The ethics of cultivated gratitude.

Given narrow operating margins, health care organizations are increasingly relying on philanthropy to fund operations. Since individuals provide the majority of philanthropic support, many organizations have expanded their "grateful patient fundraising" programs to include current inpatients, both established donors as well as persons of wealth. While this is legally permissible under HIPAA, it raises substantial ethical concerns for potential coercion of vulnerable patients, as well as unequal care stemming from preferential treatment and provided "amenities." While some have drawn the analogy to the additional comforts provided to first-class airline passengers, this analogy is flawed because of the potential clinical impact of the opportunities and services provided, especially to merely potential donors. From an ethical perspective, such programs should only provide non-clinical amenities to established donors, and at the same time strive for maximal transparency whereby all patients are assured of equal care and are fully informed of the specific benefits associated with any potential donation.