Cruel to Be Kind and Kind to be Cruel


I received an email from a woman named Irma. She wants to become a health advocate, to assist people in her community who have Alzheimers. (Bless her for that.) But she was laid off from her job, and doesn’t have any money. She asked me if I would let her join Alliance of Professional Health Advocates for free so she could “learn how to do it.”

Irma’s request was not the first I’ve received over the years. I am also asked to give people free copies of my books, and even loan or donate money to help them get started with their practices.

In the early years of building this patient advocacy profession, I used to struggle over the answers to these requests. Should I support these folks to help them get started when they didn’t have the means to do it themselves? If I said “yes” – would that really help them? If I said “no” – would I be hurting them, and would I feel guilty? How much did I owe to the profession to build a strong foundation? How much did I owe compassionate people who want to help others? How could I even determine which answer served the requester, the profession, the organization, or me the best? Would one answer serve them all?

It took a lot of soul searching…..

And ultimately I came to one conclusion, one point of view that helps me answer them all.

The answer is always “no.”

Here’s why:

Irma represents the requests for free membership very well. I am sorry for her circumstances, and I am impressed that she is trying to move forward in a new profession. I give her props for picking herself up and trying to figure out what to do next.

But her plea gives an excellent clue as to why her wish to become a private advocate isn’t good for her, and isn’t good for our profession either. That is, that AS A PRIVATE ADVOCATE she will not be able to help the people she says she wants to help – elderly people with Alzheimer’s. Because, unfortunately, Irma has no money, and helping them AS A PRIVATE ADVOCATE is expensive.

Expensive? Yes. For starters, in order to own a private advocacy practice and charge money for her services, she will need to be insured with E&O and/or professional liability insurance. That insurance may cost her between $400 and $1500 or more for just her first year.

In addition, in order to help these folks as a PRIVATE ADVOCATE she will need to get a contract signed by both the elderly person, and whomever oversees that person’s financial health, like an adult child or a designated caregiver. Where will she get that contract? How will she afford to hire a lawyer to draw one up? Of course, she could get a sample contract from an APHA Premium membership – but that costs $200 more than the PACE membership she has asked me to waive. Is she going to ask me to donate a $289 membership? Even then, she’ll still need to have the contract reviewed by her own lawyer – more money.

The list of costs goes on from there. There are business licenses to purchase, there are communications costs like internet access and phones, there are costs to setting up a website – and many more. In The Health Advocate’s Start and Grow Your Own Practice Handbook I put together a projected sample budget for getting started of more than $20,000. Yes, it can be done less expensively, I’m sure, but there is a huge gap between nothing and $20,000.

Then there’s the opportunity cost – as I learned in Econ 101 in college, “Opportunity cost is opportunity lost.” That is – as Irma struggles to make a go of a new advocacy practice, she won’t have the time or opportunity to find a new job which, for this time in her life is probably a better idea than falling further into the money hole.

Irma has other options for working with people with Alzheimer’s. She can become a home health aide, or she could work in a nursing home with a memory unit. I applaud and appreciate her recognition that there is a role for someone with her interests that can serve people with a need.

Is it up to me to make these choices for Irma? No. Of course not. But it’s also not up to me to subsidize her either. But when she asks me for something free, or discounted, then she’s forcing me to judge.

I also feel as if I am protecting our advocacy profession. Especially in these early years, we need people to become the masters of advocacy as full-blown, invested, focused professionals. Worrying about how to cover the cost of insurance, or how to pay next month’s bills is a natural part of starting any new business, of course. But starting in the hole, on the “defensive” of sorts, means that attention will be pulled in negative directions, instead of investing gung-ho into the actual services that are being applied to help clients. An unfocused professional is barely professional at all.

Finally – suppose I said yes – and was willing to donate a free membership to her. It would not be only me making the donation. In fact, it would be every member of APHA doing so, because the cost of doing business remains the same – and that cost gets covered by membership dues. So for APHA to make that donation to Irma would be the same as you, a member, making the donation, too. As your representative, I must also say no.

So now you understand my answer to Irma. A definitive “no” with a brief explanation not unlike what I have outlined above. It may seem like a harsh answer, but it’s the right answer for Irma, for APHA’s members, for the profession, and for me.

Yes, I consider this cruel to be kind, and kind to be cruel. I truly hate being put in such a position as to have to make this kind of judgment. But no, I do not feel guilty about it, for all the reasons outlined above.

In your practice, you may be asked to make these kinds of judgments, too. You may be asked to perform your services for free, or to donate some of your time for one thing or another.

I implore you to ask yourself the hard questions. Even if you will be serving the client-patient who could use your help in the short-term, what will the long term, or ripple effect be? What will the impact be on the rest of your work, on other clients, and your ability to maintain your practice? If you continue to donate your time, to do the work for free, how will you earn enough money to sustain a business?  Further – if you continue to donate your time, and it does force you to give up on your practice – what will happen to those potentially hundreds of other people you MIGHT have helped?

It’s not easy. There may be times you say yes, and there may be times you decide against it. But I can tell you that if you think it through, and you know your reasons are solid, you will be able to make the right decision AND sleep at night, too.

It’s not about feeling guilty. It’s about making tough – but smart – decisions.

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Share your experience or join the conversation!


3 thoughts on “Cruel to Be Kind and Kind to be Cruel”

  1. Thje old saying is NOT true that if one does good heaven will provide. Unfortunately, there are few opportunities for the poor to help the needy. There are volunteer positions for her with her local counsel on aging, the alzheimer’s foundation, and/or her local chapter of AARP. Very few people are paid to serve as ombudsmen. Without the right connections, it will be difficult for her to get a paid position at a local charity. She can be like me by working paying positions while being an advocate. However, please advise not to whine like me. It is not effective.

  2. I appreciate you taking this tough love stance, Trisha. It is a good lesson for all of us. And I completely agree.
    Here’s an idea from a different field – I have a dear friend who has been a proposal developer/writer and fundraising professional for well over 25 years. You can imagine how often she gets requests to do it on a percentage (not ethical!) or donate her services. What she finally decide to do was take 2 pro bono clients a year and turn down anyone else who was looking for free or discounted services. She explains to them what her policy is and even tells them who the pro bono clients are for the year as well as how they can be considered for this status in future years. This way she feels good about giving back but also can maintain her business and the income level she needs to support it and herself. And she is also helping maintain the professionalism of her career field and the pay rate for it.

    1. Michele – thanks for sharing your friend’s idea – an excellent one. A nice balance between helping those who need the help, but making sure her business stays healthy, too.

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