Megan Rich, MD MEd
Program Director, The Christ Hospital/ University of Cincinnati Family Medicine Residency
Learning objectives
- Describe the ethical issues encountered in free care settings (e.g. student-run free clinics, community based free clinics)
- Discuss the challenges associated with service and learning in an under resourced environment.
- Discuss how the four ethical principles of autonomy, beneficence, non-maleficence, and justice apply to the free clinic setting.
- Describe the role free clinics play in caring for those un/underinsured
Please consider some of your own experiences and examples reflecting on the following quotes for discussion:
Ethics of Free Clinics
Quotes to reflect on:
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
“Charity care, certainly in its current configuration, represents a failure of imagination. While some good may come of these well-intentioned stop-gap measures, they are ultimately not good enough.”
It sounds like someone here volunteers at a free clinic located at a pantry where they helped to create a service project looking at the healthcare needs of the patients/customers. I love the point you ended your first paragraph with, the education is a component of both the recognized emergency room/hospital and the SRFC, one is just villified for it and the other has this fact swept under the rug.
“To be clear, patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.”
I think Katie brought up a great point in her post about the opportunities for education throughout the medical system, not just at a SRFC. I think the more pressing issue here is what the trainees are expecting to get from the encounter. It is important for medical students to recognize that just because you have the chance to practice medicine under supervision at a free clinic, that does not mean that you have the clinical skills or medical knowledge to be a doctor yet. In my experience, UC does a great job with this but I often think back on my experiences at Duke. I had a close friend who started our local chapter of RAM (Remote Area Medical). This is a national organization that puts together pop-up healthcare clinics in the more rural areas of the US. I was not privy to what the national organization expected from the Duke undergraduate students, but the leader of the student organization pitched it as an opportunity to get clinical experience as an undergraduate as part of this mission. RAM certainly did not offer this opportunity, but most likely used the administrative or logistical support of the students. Nevertheless, this is still damaging to the reputation of the students and the clinics that they had this different approach. Students everywhere should understand the limitations of their skillset, so that people who come to free clinics enter with fair expectations about who they are getting care from.
Again, I agree with Katie that charity care is a band-aid. Whether it’s a global health experience abroad or at home, or a SRFC, separate but equal is inherently unequal. There are certainly benefits to a more informal setting, and there are difficulties getting providers to go to remote areas without making it a global health experience, but these same environments could be established with adequately compensated physicians and adequately established and then maintained healthcare systems. Unfortunately, the blame here is so nebulous that it is hard to get the political motivation to make substantive changes. I’ve been reflecting a lot about political capital lately, and I simply don’t think that there is political capital to change these systems because it is too long-term of a task. Politicians have their term limits, and their constituents want results. Good healthcare is a lifelong process, and one where the best result is that you don’t see any problems. Political capital prefers big, flashy problems with simple, quick fixes that a politician can point out to their constituents. (I’ve been thinking about this a lot because of the tree-lined sidewalks in Mendoza, Argentina. The shade is incredible for such a warm place but you would have to have foresight for 30+ years to be willing to put money into this. It worked in Mendoza because there was an earthquake that leveled the town so they built back up with an eye for the future, generations ago.) Until we find a quick, substantive fix that is better than a band-aid, SRFCs and other charity care will persist.
Megan, I really appreciated your point about trainee expectations and humility in these settings. The ethical issue is not simply that students are involved in free clinics, but how they understand their role in those encounters. Patients come to these clinics because they need care, not because they want to help educate trainees. That makes it essential for students to recognize the limits of their training and approach these experiences with humility and transparency. If trainees frame the encounter primarily as a chance to gain experience, it risks undermining patient trust and the integrity of the clinic.
I also found your reflection on charity care and political capital compelling. Free clinics often function as necessary stopgaps for patients who have no other access to care, but they also highlight deeper structural failures in the healthcare system. Like your Mendoza example, meaningful solutions often require long-term investment and foresight that our political systems do not always reward. Until those broader structural changes occur, free clinics will likely continue to play an important role, even if they are not the ideal solution.
Your reflection in the second paragraph put into words so nicely the daily process of encouraging healthy habits: good healthcare is a lifelong process, and one where the best result is that you don’t see any problems. It is very difficult for the human mind to think about all the things that could have gone wrong if certain safeguards weren’t in place. Thinking about vaccine hesitancy, it is clear that people have forgotten or choose to ignore the loss of life and health that used to occur without vaccines. Instead of seeing vaccines as a massive win for the entire world, many people in our communities see vaccines as causing problems rather than mitigating them. Our minds are focused on the tangible bad outcomes without realizing that numerous bad outcomes more have been avoided. It is difficult to conceptualize have important “charity care” is unless it’s erased. Maybe then we would appreciate what it does.
Free clinics and student-run free clinics occupy a complex ethical space in the American healthcare system. They provide essential care to vulnerable populations while also highlighting structural gaps in access to healthcare. Reflecting on the ethics of these settings requires considering both the clinical environment and the broader social conditions that make free clinics necessary.
One ethical concern arises from the dual mission of service and education. Student-run free clinics allow trainees to gain valuable clinical experience while caring for underserved populations. However, this educational role can create tension. As the quote suggests, “patients do not choose SRFCs for the opportunity to educate students, they end up at the clinic for lack of other options.” Patients who are uninsured or underinsured may have little choice but to accept care in environments where trainees participate in their care. This reality makes transparency and strong supervision essential to protect patient trust and safety.
Providing care in under-resourced environments also presents challenges. Free clinics often operate with limited funding, volunteer staffing, and restricted access to diagnostic testing or specialty care. Providers may face difficult decisions about how to allocate scarce resources. These constraints can create moral distress when clinicians know that the care available may fall short of what patients would receive in better resourced settings.
The four ethical principles help frame these challenges. Autonomy requires that patients understand the nature of the clinic, the involvement of trainees, and the limits of available services. Patients should be able to make informed decisions about their care.
Beneficence motivates clinicians who volunteer in free clinics. Providers work to improve access to preventive services, chronic disease management, and health education for patients who might otherwise receive little care.
Non-maleficence requires careful supervision of trainees and honesty about the limits of what a clinic can safely provide. When patient needs exceed available resources, appropriate referral becomes critical.
Justice is especially central in this context. Free clinics attempt to address inequities by offering care to uninsured and underinsured patients. At the same time, their existence reflects deeper structural failures in the healthcare system. As one quote suggests, charity care may represent a failure of imagination. While free clinics provide important services, they do not resolve the underlying inequities that create the need for them.
Despite these tensions, free clinics play an important role in the safety net. They provide primary care, preventive services, and chronic disease management to patients who might otherwise rely on emergency departments or go without care entirely.
For trainees, working in these clinics offers meaningful exposure to the social determinants of health and healthcare disparities. These experiences can foster empathy and a stronger commitment to advocacy.
Ultimately, the ethical challenge is not whether free clinics should exist, but how they should function within a more equitable healthcare system. They provide important care in the present while also reminding clinicians and trainees of the need for broader systemic change.
Not sure why, but it looks like my response from March never posted!:
Without a doubt, most people, if given the option, will choose the best for their care. If there are 2 hospitals, they want the better one. If there are 2 doctors they want the more experienced one. If more than one option exists, people will usually seek out the superior one. And in the case of SFRCs, almost all options are superior. Not because SFRCs are necessarily or inherently bad, but because they are among the lowest levels of care. If access to care wasn’t the systemic issue that is, the patients that utilize SRFCs would cease to need them. So patients go not because it’s the best option, but because it’s the best available option accessible to them. I once volunteered at the UC Open School (interdisciplinary) Free Clinic and remember speaking with patients there because they didn’t have insurance or weren’t able to get in with a specialist. On top of the fact that the Open School Free Clinic doesn’t provide patients with prescriptions, it doesn’t provide patients with referrals either. There is still benefit in providing guidance for patients in lieu of medical advice, but it does beg the question: who is benefitting more from this structure? The medical students who can choose from an array of free clinics to volunteer at and gain experience from or the individual seeking medical attention that settles for the most accessible option for them?
This quote encapsulates a sentiment that I have felt in different instances throughout medical school. However, I would challenge the author’s use of the word “imagination” and propose it be replaced with “investment”. I have had the opportunity to witness and be a part of care that reflects investment. At Foot Care for the Souls through St. Francis Seraph Ministries, volunteers made up of retired folks (medical professionals and otherwise) provide intensive foot care for individuals experiencing housing or financial instability. Though not necessarily medical care, the individuals cared for still receive “treatment” they could not easily get elsewhere for free. Many of them don’t have insurance or the ability to see a podiatrist or dermatologist. The organization could’ve been more focused handing out free nail files, or doing exams on people’s feet to let them know what conditions they may need to see a doctor for, but instead volunteers provide care they can. And what’s more, each individual also receives a free pair of socks and shoes up to once a year. The free shoes and socks aren’t part of the treatment, but are evidence of investment. As the quote says, these measures aren’t good enough and the end goal is equitable access to care, however when the investment is made, the impact on patients is clear.