To remain financially viable, healthcare institutions seek donations to foster financial sustainability in patient care, research and education. However, there is a growing recognition of challenges surrounding donations that are controversial due to the donor, the source of the funds or the motivation behind the donation.
To help ward off potential problems resulting from accepting donations from controversial sources, clear guidelines are needed.
Potential Controversy
The majority of donations foster little controversy; however, public conversations about institutions accepting “dirty money” raise important questions. Education, medical and healthcare institutions have been critiqued for their acceptance of philanthropic donations from individuals and families whom the public have come to revile.
There have been two high-profile cases recently of healthcare organizations removing a donor family’s name from facilities. These precedents inevitably prompt a combination of praise and backlash. The backlash usually comes from people who believe donations carry no moral valence and therefore should never be refused or returned. These views assume, either implicitly or explicitly, that donations are merely cash transfers, and that the important consideration is what an institution will do with the money rather than where the money comes from.
The praise emanates from those who see these arguments as too simplistic and feel donations represent relationships rather than mere financial transfers. When an institution accepts a donation, the act has functional value in bringing money into the organization, but it also carries expressive value. Whether the institution intends it or not, many members of the public perceive an institution’s acceptance of money as a reflection of a relationship with the donor. The relationship may or may not be controversial unto itself, but the potential for real harm to result from the perceived relationship deserves careful consideration, especially in two key areas.
First, harms may arise out of the provision of celebratory recognition to the donor: Think of the public relations benefits that cigarette companies enjoyed as a result of philanthropic giving long after their products’ health harms were known. Harms also may arise out of the provision of influence over the institution: Think of the power donors can command when they are given a board seat or the ability to set severe conditions on a donation. For an institution to take this expressive value seriously is not inappropriate; it represents an insightful appreciation of the social nature of the institution.
Guidelines Are Needed
To avoid potential harms or controversy, organizations should have clear guidelines in place to aid in decision-making regarding donations. Such guidelines could be implemented through an identified mechanism that can be called upon for assistance when the development office or institutional leaders have concerns about potential donations. The review body should include development officers, administrative leaders, board representatives, public relations officials, risk management staff and organizational ethics leaders.
The institutional guidelines should be implemented within a transparent process. A June 2020 Cambridge Quarterly of Healthcare Ethics article, “Tainted Largess: A Moral Framework For Medical School Donations,” described a moral framework for reviewing medical school donations, which is equally relevant for healthcare institutions. The article’s authors suggest that when determining whether to accept a donation, an organization’s review mechanism should consider at least three fundamental questions:
What is the donor’s expressed views, actions and conduct? If a potential donor has expressed views or has publicly acted in a manner that is contrary to the institution’s mission and values, that should trigger concern. For example, with the increasing focus on population health, would the institution feel comfortable accepting a gift from an outspoken and frequently quoted person who opposes vaccinations for children? Such expressions of concern will not always lead to a consensus regarding the acceptance of the donor’s gift; however, the institution should be aware of potential outcry when the public becomes aware of the donor’s gift.
What is the donor’s source of funding? If a donor’s source of funding is questionable or tainted, such as being obtained through illegal activities, the donation may be objectionable. Besides illegal sources of funds, there are other controversial sources. For example, should a cancer center accept money from a tobacco company?
There will be situations where the controversial source of funding is not directly linked to the potential donor such as the beneficiary of a clothing manufacturer that closed a decade ago following the public exposure of the exploitation of child labor seeking to fund a children’s hospital. The institutional reviewers of a potential donation “must grapple with both the degree of objectionable conduct underlying the source … and the distance removed from that source,” according to the Cambridge Quarterly of Healthcare Ethics article. It is reasonable, however, that institutions would be less than willing to accept funds from sources that are closely tied to objectional behavior or activities.
What are the donor’s motives for donating? When applying the donation guidelines, the review mechanism should also consider the motive and expectation behind a donation. A grateful patient may want to provide a gift to the institution’s spine center as a statement of appreciation for the care he or she received as a patient. On the other hand, is the donation being given with an expectation that the donor might gain personal benefits or derive institutional influence?
In addition to these complicated questions regarding whether to accept a controversial donation, there may also be situations when an institution accepted a substantial gift in good faith, yet it was later determined that the donor engaged in morally reprehensible activities or that the funds were derived illegally or in a highly questionable manner. Such situations clearly call for a careful review of the donation.
The review of a potential or an accepted donation is a complex process and therefore costly in terms of time and effort. To avoid situations in which the reputation and image of a healthcare institution suffers as a result of accepting a controversial donation, leaders are encouraged to cultivate and implement morally grounded guidelines for recognizing and addressing such situations.
William Nelson, PhD, HFACHE, is director of ethics and human values and professor, The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth College (william.a.nelson@dartmouth.edu). Lauren A. Taylor, PhD, is a postdoctoral fellow in the Department of Population Health at NYU Grossman School of Medicine (lauren.taylor@nyulangone.org).