Introduction
Medical schools and affiliated hospitals in the United States are highly dependent upon the generosity of philanthropic donors to support their educational and research missions. A significant percentage of these large gifts come from alumni or individuals with deep ties to an institution, earmarked for endowed professorships or specific fields of inquiry.Footnote 1 The vast majority of these donations generate minimal controversy. However, some donations do prove highly controversial when they occur, while others appear so in hindsight. These controversies may stem from the public views of the donors, from a donor’s private conduct, or from the source of the donor’s funds. On occasion, institutions even choose to relinquish such funds. In one notable example, the Mount Sinai Health System announced on August 23, 2019, that it was “contributing a sum equal to the donations we received from” financier and convicted sex offender Jeffrey Epstein “to a charity focused on preventing human trafficking and sexual exploitation.…”Footnote 2 The media has reported this sum to be at least $10,000, a relatively modest total by major donor standards.Footnote 3 Other institutions will likely take similar actions regarding Epstein-donated funds. Nevertheless, the underlying ethical questions transcend any donor or public relations crisis.
These issues are particularly relevant in the current political climate. Medical schools, often prodded by their own students, are increasingly devoting their attention to the relationship between healthcare and social justice. Curricula have branched beyond anatomy and pathophysiology to incorporate patient narratives and the social determinants of health. Heightened awareness surrounding racial bias, sexual harassment, LGBT rights, and structural inequities have permeated the intellectual lives of medical students and faculty. This internal transformation of the medical community reflects larger cultural currents, such as the efforts of TIME’S UP Healthcare to address many of the gender inequities underpinning the #MeToo Movement. One of the consequences of this transformation is that donations from controversial figures are far less likely to go unnoticed or unchallenged than they were only a few years ago. Unfortunately, at present, such donations appear to be handled on an ad hoc basis by development offices with one eye toward optics and another toward the bottom line. Nonprofit institutions, including medical schools, require an ethical structure for evaluating such donations.
The goal of this paper is to outline a framework for analysis that medical institutions and their stakeholders can use in addressing proposed donations from contentious or divisive sources, and in managing those donations that subsequently appear controversial.
Historical Background
Donations historically occurred in an environment of minimal public scrutiny and limited oversight. Politicians have long been attuned to the optics of campaign donations. As early as the first decade of the twentieth century, Presidential candidate William Howard Taft made national news by rejecting and returning donations from corporations.Footnote 4 However, the major impetus toward transparency in the political arena resulted from the Federal Election Campaign Act of 1971 (FECA) and subsequent amendments post-Watergate Scandal that imposed broad transparency upon political campaigns (much of it since watered down by Supreme Court decisions in Buckley v. Valeo (1976) and Citizens United v. Federal Election Commission (2010)).Footnote 5, Footnote 6 Public outcry surrounding the ABSCAM bribery scandal, which witnessed criminal convictions for twelve public officials including US Senator Harrison A. Williams of New Jersey and six congressmen, also generated more widespread interest in the origins of campaign contributions. Initially, politicians concerned themselves primarily with the legality of contributions, such as in the notable episode when New York City Mayor Ed Koch returned funds from police groups, an action that happened to be prohibited by statute in 1981.Footnote 7 By the second half of the decade, politicians were returning perfectly legal campaign contributions on purely ethical grounds, such as when gubernatorial candidate John F. Russo in New Jersey returned a Ciba-Geigy Corp donation after the company was penalized for pollution.Footnote 8 The decision by Presidential candidate Bob Dole to return donations from a gay Republican organization in 1995 marked a watershed moment in candidates’ willingness to reject donations based solely upon the viewpoint of donors, as opposed to past improprieties.Footnote 9 Today, returning controversial campaign donations—whether actually objectionable or perceived to be so—has become a staple of political life. Such campaigns have only recently began creating and publicly announcing standards for their donations, often declaring their refusal of donations from sources.
Nonprofit and educational institutions have been slower to return controversial donations, at least publicly, likely because they face less scrutiny and do not stand for election. Of course, in the absence of transparency, one does not know how many such donations were rejected or returned sub rosa. One of the earliest documented public instances of reversing course in the modern era was Georgetown University’s decision to return $600,000 in contributions from Muammar Gaddafi’s Libya in 1981 because of that nation’s “growing support of terrorism as a tool of government.”Footnote 10 Yale returned $20,000,000 in contributions to alumnus Lee Bass in 1995, driven in part by student activism, when he allegedly sought to impose his own views on hiring in the Western studies curriculum.Footnote 11 Yet until very recently, universities and medical schools have proven willing to accept controversial gifts with little input from their stakeholders. For much of the twentieth century, Wake Forest University’s medical school boasted the name of Bowman Gray, former head of tobacco giant R.J. Reynolds.Footnote 12 The Mount Sinai School of Medicine rebranded itself the Icahn School of Medicine at Mount Sinai in 2012,Footnote 13 embracing the name of controversial corporate raider Carl IcahnFootnote 14—a decision that was later the subject of student objections and a widely-circulated petition.Footnote 15 Loeffler and Halperin observed that any American medical school was likely to “refuse to accept money to rename its medical school the Benito Mussolini School of Medicine.Footnote 16 Until recently, the bar did not stand much lower. For donations without prominent naming rights, standards were largely nonexistent. For instance, junk bond guru Michael Milken, sentenced to ten years in prison and fined $600 million for securities-related crimes, later became a major contributor to medical research and education in the United States.Footnote 17
The tide has started to shift. Attention to the Epstein donations and several other recent controversial donors have caused institutions of higher education to grapple more actively with the ethics of donation. Unfortunately, there is minimal guidance in the medical literature to assist them.
Evaluating Donations
All medical institutions should have clear guidelines regarding the terms under which they accept or reject donations, as well as a relatively transparent process for doing so. Ideally, medical schools should have a specific process for evaluating major and controversial donations regarding potential taint or disqualification. Such a process would ideally include a review body reflective of relevant stakeholders: students, faculty, clinical and nonclinical staff, medical school administrators, representatives of affiliated hospitals where appropriate, patients, and leaders from the local community or catchment area. Such a body should be demographically, experientially and ideologically diverse. In addition, if an individual or group is likely to be adversely impacted by a donation—either directly or indirectly—that individual or group should be invited to present his/her/their concerns.
In recommending whether to accept a gift, the evaluative body should consider the source of the controversy, the nature of the donation, the underlying motivation for the donation and the impact upon the medical school and surrounding community:
Source of controversy.
The vast majority of controversial donations will raise concerns for one of three reasons. First, the donor may have expressed views or taken actions in the public sphere that run contrary to the mission of the medical school or that have potentially negative public health implications. At one extreme of this continuum are those potential donors who have expressed views that target historically marginalized or vulnerable populations, such as a donor who advances positions that are overtly racist or sexist. At the other extreme are those figures who have advocated for positions on controversial matters of public policy—from reproductive choice to gun control—that stand in contrast to those of leading professional bodies or many medical school stakeholders. Between these two poles are donors who express views that are demonstrably false and deleterious to the public health—such as advancing a connection between autism and vaccination—but who do so without malice and speak in the proverbial public square. The standard by which evaluating bodies assess such speech or conduct is inherently subjective; there will often be disagreement regarding how objectionable is too objectionable. Allowing speech in the public square is not the equivalent of stamping the imprimatur of one’s medical school upon it. Evaluators should not lose sight of fact that accepting a donation is not tantamount to an endorsement of every view a donor has ever expressed. Factors to consider might include whether the donor is known for a particular view or the objectionable view is an incidental part of a larger body of expression, whether the controversial ideas are an attempt to contribute meaningfully to civic discourse, and whether they are views regarding which reasonable people of good will might disagree. Assessment of a donation from a Klansman or neo-Nazi leader might reach a far different conclusion that a similar assessment of a civil rights advocate who also, on occasion, has voiced concerns about a purported connection between autism and vaccination.
Second, the private conduct of a donor may prove controversial. The #MeToo movement has brought considerable public attention to matters of personal and private misconduct. Obviously, certain behaviors should not be tolerated in the workplace or society. However, the standard for accepting a donation is not necessarily the same as that for terminating an employee or judging private conduct. A private act may disqualify an individual from serving in public office, but it does not follow that the same act ought to disqualify a person as a donor. At the same time, some conduct may prove legal, but still ethically objectionable to the point that one would not want one’s institution to embrace a contribution from those engaged in it. In addition to the nature of the conduct, evaluators should consider (1) the length of time that has elapsed since the conduct, with some reasonable deference afforded those who acted inappropriately or criminally when minors; (2) whether the party has ‘paid a debt to society’ and/or expressed amends; and (3) whether the victims of an offense, in cases with victims, have embraced those amends, and where possible and relevant, what these victims’ views might be on accepting a donation. Justice and mercy are both important values and our society has set up mechanisms outside the philanthropic process for offenders to be penalized and aggrieved parties to seek redress. Accepting a donation need not signify tolerating the conduct of the donor, a concern often blurred by the context of #MeToo-related offenses. For instance, accepting a major gift from an industrialist convicted of driving while intoxicated as a teenager may or may not be objectionable, but is unlikely to justify claims that a medical institution is endorsing or tolerating drunk driving. In other circumstances, however, accepting a gift may be read as a dismissal of ethical concerns or a tacit condonation of the controversial or offensive conduct.
Third, the cause of controversy might not be a public act or private action of the donor, but rather the source of the funding itself. Often the two will prove inextricably linked. Donations from the Sackler family, owners of Purdue Pharma, have generated controversy for a number of nonprofit institutions, owing to the purported role of Purdue in propagating the opioid crisis.Footnote 18 In this case, the source of the funds may be tainted, but the donors themselves may also prove objectionable for their role in the crisis. If the Sacklers donated funds obtained from a different source, one might still argue against accepting the donation. However, cases will arise where the donor is not inextricably linked to the controversial source and the source itself is problematic—such as the heir to a tobacco or asbestos fortune who seeks to undo the damage rendered by their forebears by donating to medical causes. To some critics, this is ‘blood money.’ At the same time, it could be viewed as meaningful reparation. Evaluators must grapple with both the degree of objectionable conduct underlying the source—what one might term the ‘immorality factor’—and the distance removed from that source. Should the heirs to an American company that did business with Nazis or operated segregated facilities be precluded from philanthropy? And for how long? A meaningful assessment requires a review of both the ‘immorality factor’ and the ‘removal factor.’ As sources of funds become more objectionable and more closely tied to the underlying objectionable conduct, institutions should be less willing to accept their money. Institutions might even choose to establish red lines: banning funds directly derived from human rights abuses, for example, or from companies inextricably linked to foreign governments that refuse to respect the most fundamental rights of their citizens.
Finally, some donors may wish to restrict funds to specify purposes. Although many of such requests are morally benign—such as wanting to fund research in a particular branch of medicine—these gifts may occasionally arrive with more focal and potentially concerning strings attached. A recent investigation into medical school donations revealed that the majority of major medical school donations are earmarked for specific causes, disciplines, or departments.Footnote 19 For instance, a donor might wish to provide funds to include a specific topic in medical school curricula or to endow a chair in a very narrow field. Sometimes the goals of such funding are biased and obvious, such as a course on the merits of abstinence-only sex education. However, even when restricted donations appear neutral on the surface, as they become increasingly focused, they should be evaluated with added scrutiny, because setting the agenda is a powerful tool. Funding a lecture on adoption services, for instance, may impact the space for other reproduction-associated materials in the curriculum.
Nature of Donation.
Evaluating bodies should also consider the nature of the donation and the manner in which it will be acknowledged. Large, high-profile donations require far more scrutiny, and arguably a higher standard for acceptance, than smaller, low-profile donations. At one extreme, a donor seeking a building, institute, or even an entire medical school named after himself or his family will have a significant impact on the institution and upon many stakeholders. Medical students are rightly concerned that their medical diploma does not contain the name of a highly objectionable donor. One might argue that no medical student need choose a school with an objectionable name, but as the medical school admissions process does not operate as a market and the number of slots is set artificially low, this suggestion is rather disingenuous. Indeed, even if that were a persuasive objection, additional safeguards would be needed to protect the interests of students who matriculated prior to the named donation. Similarly, faculty and staff have an interest in working in a welcoming, untainted facility. (This was a factor Yale University acknowledged in 2017 following university-wide protest and national attentionFootnote 20 in renaming a residential house named after former Vice President and slavery champion John C. Calhoun.Footnote 21) As particular donations receive less attention and the amount of funds decline, these concerns wane—although as less funds are involved, the counterbalancing good rendered by the donation also declines. Among the least objectionable donations would be one rendered anonymously. In theory, however, the donor might still be able to benefit from the institutional good will generated by insiders who know of the donation and might even reveal the donation privately or disclose their identity after the fact. Anonymous donors, after all, are not truly anonymous; nobody drops off a million dollars in unmarked cash outside a school’s development office without taking credit. Still, many donations to medical institutions are not anonymous, instead courted by development offices and personally by deans of medical schools.Footnote 22
Motive for Donation.
Evaluating bodies should also consider the underlying motive behind a donation. Determining the actual motivation—whether or not a purported motive is expressed by the potential donor—involves considerable administrative costs and may simply prove impossible. However, a meaningful effort should be made to investigate the reasons behind such a proposed donation. Is the donor deeply and sincerely interested in a cause? Or is the donation part of an effort to gain prominence and influence? If the donor is engaged in an ongoing controversy, the evaluating body should further inquire: Is the donation incidental and unrelated to any controversy or reputational crisis that has enveloped the donor? Or is it part of a targeted effort by the donor to buttress their reputation or to rehabilitate themselves? Factors to consider include (1) the historical pattern of donations, particularly one predating any current crisis or controversy; (2) the longstanding level of prior commitment to the particular receiving institution; (3) the extent to which a donor is willing to reduce the profile of (or even anonymize) such a gift or to delay it until the crisis or controversy has passed; (4) the willingness of the donor to relinquish control of the publicity surrounding the donation, such as allowing the institution to publicly disavow a donor’s views while embracing his gifts. One might prove more generously inclined toward posthumous gifts, as the potential for personal benefit is somewhat reduced, although not entirely mitigated, as many donors wish to be highly regarded after their deaths.
Consequences of donation.
Evaluating bodies should consider the consequences of a donation upon both internal stakeholders and the public more broadly. Considerable weight must be given to the views of the individuals who must work or study within the institution. The impact upon stakeholders in the local community is also an important concern. The institution might also consider the impact of a donation on potential patients; for example, some patients might feel uncomfortable seeking care at a facility named after a donor whose outspoken politics they find objectionable or even threatening. Finally, an additional concern might be the impact upon the broader society. Accepting a donation from a donor aligned with a so-called ‘toxic’ industry like fossil fuels or sweetened beverages might be read as an indifference toward the conduct of the industries concerned. Donations likely to prove internally divisive should raise red flags; those likely to raise external pressure may prove more acceptable, but recipients ought to proceed with caution.
Even conduct that might be legal and ethical might nevertheless prove so unsettling to a significant number of stakeholders as to justify rejecting a donation. In such cases, when possible, such decisions should be viewpoint-neutral and clarified in advance. Though holding any view in the controversy surrounding abortion might be neither illegal nor unethical, a medical school might choose to decline all donations from prominent advocates on either side of the issue. Accepting donations from pro-choice advocates but not anti-abortion advocates, or vice versa, would prove far more problematic.
Management
For medical schools, the challenge of deciding how to reconcile their need for financial sustainability with sustaining their missions and values is longstanding; however, the complexities surrounding controversial donors are relatively new. As University President Lawrence Bacow recently explained in a letter to the Harvard community, the decentralized nature of some institutions may make tracking and monitoring such donations particularly difficult.Footnote 23 That is not to say that the complexities of such situations justify turning a blind eye, but rather that new mechanisms need be developed for addressing novel challenges.
Medical schools must decide whether to invoke the same standards for accepting an initial donation and for returning a donation. In the latter case, returning a donation may carry an extra stigma for the donor. At the same time, it may draw attention to both the donor and the institution in ways that may unfairly capitalize upon a potential initial error in judgment. For instance, the sums reportedly donated by Jeffrey Epstein to Mount Sinai were relatively small. Although addressed in the media, this aspect of the Epstein case drew little public attention. However, the institution drew positive attention to itself by distributing the donation to causes related to preventing human trafficking—thereby possibly taking advantage of its unfortunate position of having accepted funds from a convicted felon. (One might ask whether announcing the distribution of funds was the right course of action, as it made a public statement regarding the underlying conduct, or whether such a distribution, it if occurred, should have taken place without public announcement.) It is unclear based on the limited information available as to when Mount Sinai received the donation and whether they did their due diligence in investigating. More complicated are such situations where a university or medical school, acting in good faith, accepts a gift from a donor who has either engaged in immoral conduct that could not be readily discovered at the time or subsequently acts in a morally reprehensible way. While most people can agree that a major medical school ought not rename itself after a known pedophile for a multimillion dollar donation, what obligation—if any—does that same institution have to return the funds many years after the fact if the donor subsequently engages in indecent acts with children? In renaming its medical school in 1997, did Wake Forest owe the descendants of Bowman Gray money given by the family in the 1940s and 1950s?
A related question relates to what is to be done with so-called tainted money. Once an institution decides it cannot keep a donation, is its ethical obligation to return the funds to the donor? Or, assuming no legal obligation to the contrary, should it donate the funds to a cause that seeks to address or mitigate the harm caused by that donor? Again, in Harvard’s case, they are donating the “unspent” amount of $186,000, a mere 0.02% of the $8.9 million they received from Epstein prior to his 2008 guilty plea, to charities that combat human trafficking.Footnote 24 Do they have a responsibility to return the full amount of $8.9 million? Should the institution continue to benefit, based on the legacy and foundation built upon this tainted donation, as well as the decision to donate a miniscule portion to a relevant cause?
Finally, medical schools must determine—optimally, in advance—who is to be informed of decisions related to controversial donations and in what timeframe. Two related but distinct issues arise here: (1) Under what circumstances should the stakeholders be informed of a potential donation that is likely to be controversial and/or a decision to accept such funds? (2) Under what circumstances, if any, should stakeholders be informed of an initial decision to reject such funds? In the former case, at a minimum, stakeholders should be entitled to a written explanation of the basis for the decision. The latter case proves far more difficult: Once an institution becomes known for publicly rejecting donors, the effect may be that potential donors—even those not likely to generate controversy—shy away and look elsewhere, fearing excessive scrutiny or the shameful consequences, however unlikely, of a public rebuff. In order to avoid this scenario, medical schools might choose to establish an initial, confidential screening process to stave off donations highly unlikely to pass muster even before they face a formal public review.
Conclusions
Often lost in the debate over accepting or rejecting donations is that medical school donations themselves, all other factors being equal, are not neutral phenomena. Rather, they are a social good designed to further education and improve healthcare. Careful consideration ought to be given to the potential societal and institutional benefit to be derived from a gift. This benefit must then be weighed against the potential for harm or division, as revealed by a consideration of the factors enumerated above, with attention given to any disparate impact on individuals or groups who have been historically the victims of such disparate impact. There may be some situations where no amount of benefit can justify the harm: Few, if any, students would likely choose to attend the Hitler and Stalin School of Medicine. In most cases, however, the situation will call for an informed and tempered calculus in which all stakeholders are given a voice, and an insulated evaluative body renders a considered recommendation. The above framework may help that body in pursuit of these goals.
