The ethical significance of donors’ motivations

The works of Abraham Maslow and others who followed him help to explicate the deontologic component of the ethics of philanthropy. In his 1943 paper “A Theory of Human Motivation,” Maslow attempted to explain human motivation using his hierarchy of needs, which postulated that people are motivated to take action because they have needs to be fulfilled. Some individuals are motivated to philanthropy from a need for self-worth and recognition by others, which is on the lower end of Maslow’s hierarchy. Some individuals achieve Maslow’s highest level, which is a kind of self-transcendence in which one goes beyond oneself to be of service to and contribute to others and who does not require self-reward or recognition by others. Having used the fundamental teachings of Maslow, we have discovered certain connections that allow viewing donor motivation as a continuum of altruism.

In truth, seldom is any gift entirely self-serving or selfish or entirely selfless or completely altruistic. We therefore show it as a continuum, recognizing that perhaps all gifts have different underlying motivational factors: for example, a selfless desire to help someone less fortunate or some personal acknowledgment during a recognition dinner.

At one end of the continuum are donations that are entirely self-serving and also provide a significant and beneficially valuable exchange to the donor. This end of the spectrum represents philanthropy in a very limited sense, because it is much more like a business transaction that is mutually beneficial. Self-serving gifts can also distort the organization’s mission and, when they do so, should not be accepted. Conversely, donations on the entirely selfless end of the continuum are given without any expectation of a beneficial financial exchange or purchase. They are selfless gifts, at least in respect to finances, comfort, or recognition exchange. The anonymous gift epitomizes this selflessness. Many donors in all ranges of altruistic motivation expect a type of “return on investment”; they want to know in advance and be assured after the gift is made that the money was used appropriately to address an area of their passion. Thus, it would be appropriate to host an event at which scholarship recipients are able to meet and express their gratitude to a donor. Insistence by a donor on accountability for the use of a gift is not inconsistent with a selfless gift.

In understanding medical philanthropy, it is essential to know that many life-changing experiences happen in medical situations, whether birth, illness, or death of a loved one. These experiences can create transcendent needs; for many people, the only way to fulfill those needs is through philanthropy. Self-transcendence is achieved through a singular, occasional, or unusual experience that changes one’s view of the world; that experience creates a need of expression, whether in a perfect poem, a magnificent work of art, enthusiastic volunteerism, or a philanthropic contribution.

We must look at the experience itself to understand the underlying motivation. Some events that lead to self-transcendence are happy, joyful, even ecstatic, such as the birth of a child. Other events are excruciatingly painful, such as the lingering illness and eventual death of a child. Therefore, we recognize that there are 2 extremes of emotions that result in self-transcendent philanthropy: on the one hand there is great joy, appreciation, and gratitude; on the other hand, there is frustration, helplessness, and anger. Let us explore first the joyful emotions to discover this aspect of transcendent philanthropy in medicine; then we’ll look at the other extreme: anger.

These are the words of a grateful donor who made a million dollar gift, and that gift represented a great deal of her overall financial capacity (recorded by M.F. and J.G.).

“First, I lost color vision in my left eye, and then my central vision was so distorted that everything I saw looked crumpled. Everything was blurry and very, very distorted, and that just was so tragic to me. The thought of not being able to recognize faces or to read or to drive, it was very frightening.

“And now, as a result of my treatment here, I have such wonderful recovery of vision. All my color vision is back, and there’s virtually no distortion. That’s really a phenomenal result. And I feel very, I just feel extraordinarily grateful, and I have to say that the impact that Paul [her physician] has had on my overall life is equally dramatic.

“When I got my color vision back, the first thing I wanted to see was a sunset. I’ve always loved the sky, and to be able to look at that and to see all the brilliance of the colors, it just means a lot to me.

“I feel a strong need to give back because I just feel so grateful. I am just overwhelmingly thankful and grateful. It is a real privilege to be able to make some contributions; it just gives me a lot of pleasure. It is just really very meaningful to my life knowing that, at the end of the day, some of my life’s earnings may encourage someone to be the kind of doctor Paul is. It has just been very meaningful to me to make this legacy gift.”

This donor expresses well the overwhelming desire that many patients feel as a result of a positive experience. For many patients, especially those whose other, more basic clinical needs have been met, such experiences drive great passion and desire to express gratitude in a selfless, right-end philanthropic way.

In contrast to the earlier story, here are the words of a physician recalling a patient of his (recorded by M.F. and J.G.).

“He had a lot of money, and was relegated to the kind of helplessness that you’re relegated to with amyotrophic lateral sclerosis. And he wanted to do something about it. It was clear that he wasn’t happy about what was going on. And that unhappiness can be best thought of as either depression or anger. Anger is depression expressed outwardly, and depression is anger expressed inwardly. The quietness that you perceived in him was not just the disease, but the fact that he was profoundly depressed and damned angry about what was happening to him.

In making contributions, he was using the only thing he had left. He couldn’t get up and be around. He couldn’t talk to people about it. The one thing that he could do is use the money that he had collected to try and fight the disease that was killing him.”

This story illustrates the overwhelming desire that many patients or family members feel as a result of a negative experience. The helplessness, fear, and anger are powerful emotions that cause some people to want to engage in a battle or change an outcome that was devastating to them. They recognize that their outcome cannot be changed, but their contribution may make a difference for someone else.

The deontologic and consequentialist components of the ethics of philanthropy elucidate the ethical significance of donors’ motivations. Selfless donors are acting deontologically, insofar as they are giving without concern for consequences for themselves but purely from the praiseworthy motive to help others. By contrast, self-serving donors are acting as consequentialists, using philanthropy to advance their self- interest.

The ethical significance of donors’ directiveness

It is essential that the physician leader also understand the degree of directiveness of the philanthropic gift. Directiveness will occur along its own continuum of ethical significance.

Some donors want complete control and attempt to exercise this by establishing specific conditions surrounding the gift. They specify clearly the individual or unit for which the gift is intended, and they clearly specify purposes and conditions. Sometimes such donors may express to a physician or physician leader an intent to make a directed gift, but not to that physician or that physician leader’s unit. By contrast, donors with unrestricted intentions are willing to defer to the physician leader’s needs assessment and do not place restrictions on their gifts to a unit or to the organization. From the perspective of physician leaders, donors with unrestricted intentions are prized, because their gifts provide the physician leader maximum flexibility (eg, to cover functions of the organization that are important but may not be attractive to donors). Unrestricted gifts should not be used for basic operation without the explicit permission of the donor.

There may or may not be an association between the motivation of the donor and where he or she is on the continuum of directiveness. For example, a selfless individual may be either highly directed or unrestricted on the directiveness continuum. A selfless donor might be insistently directive. Conversely, a self-interested donor may be either directive or nondirective. In particular, a self-serving donor might make an unrestricted gift because he or she is indifferent to how the money will be used. From the perspective of physician leaders, nondirective gifts are prized independently of the donor’s motivation.

The deontologic and consequentialist components of the ethics of philanthropy elucidate the ethical significance of donors’ directiveness. Because directiveness is about the results of a gift, the continuum of directiveness should be interpreted ethically in terms of the consequentialist component. Viewed only from the perspective of organizational interests, nondirective donors may be more prized than directive donors.