Robert Payton

1997

It is the fashion these days to cry alarm or to attack the Bad Guys or to expose the unsuspecting weakness. This is my version. The point of this essay is that the stewards of health care and philanthropy have lost touch with the moral values of the society that calls them into being and that sustains them as institutions and as practitioners.

What is missing from health care and philanthropy these days is the notion of an ideal. What we have instead is the voice of the expert. The expert, as someone commented in the Times Literary Supplement many years ago, is someone who knows everything about a subject except what it is all for.

I began to make the connection between philanthropy and health care a long time ago. It came up again when I read the feature article in the Chronicle of Higher Education¹ about the trials of the academic centers on philanthropy and the state of research. In it, one of my colleagues, Dwight Burlingame, lamented that most of the new centers are in business schools. Terry Odendahl, a friend with whom I often disagree, complains that foundations don't want to support research that might reveal the flaws of foundations, and scholars can't criticize those who support their research. Peter Dobkin Hall, an expert if there ever was one, reports that he will recast the mission of the Program on Non-Profit Organizations at Yale, the first of the academic centers, to something presumably more marketable.

A perfect academic blend of angst, schmaltz, and chutzpah. The Chronicle headline concludes that academic interest in philanthropy is increasing but that research support is declining.

For the moment, let the Chronicle report represent the received academic wisdom about the condition of philanthropy in the university. I want to reflect on the state of philanthropy and the state of another quite similar and closely-related new field, that of healthcare ethics and professionalism.

I serve on the organizing board of a new center on healthcare ethics and professionalism at Indiana. The center began about eight years ago with the appointment of the first specialist in medical ethics at the Medical School. The small nucleus of faculty members at the new center has hammered out an ethics curriculum for medical students, and organized a series of conferences and a newsletter for healthcare practitioners around the state. Very recently the focus has begun to shift somewhat from the ethical side of the health care agenda to the professional side (not that the two can be separated in reality).

The effort at Indiana follows similar efforts begun earlier at universities like Chicago and Virginia, all of which must look to the pioneering work of the Hastings Center a generation ago.

The reasons why such centers have come into being are obvious to everyone except the community of academic medicine. That there is an urgent need for study and education in ethics and professionalism in health care will come as a surprise only to those who thought healthcare provision had become a business, having only recently ceased being a failed bureaucracy. The general public, and especially the interested public dealing with immediate problems of illness and its costs, both personal and financial, has known for a long time that the gap between the public myths of health care and the realities of health care was growing wider all the time. Only the medical schools and their associated hospitals seem to have been attending to other things. The cost of medical malpractice insurance is hardly the first item on the public agenda.

Indeed, many of us believe that academic medicine lost its way quite a while ago. It became preoccupied with its own interests and problems and needs and seemed to turn its back on the larger society. For a while, as I recall from my service on a hospital board in the 1970s, the debate was between the claims of research and those of patient care. Research won out. The next issue was the research-related competition for technological leadership: which medical centers were going to have which machines, if you'll pardon the pun, to do cutting-edge surgery or transplants.

The progress was dramatic and undeniable. The technical capacity of health care expanded at a rapid rate. At the same time, the strong traditional link between the community and its health care institutions and practitioners became more awkward and distant.

What happened to health care? It became a business. What happened to professionalism? It became an artifact of a sentimental and righteously self-serving past. The moral common ground that was once thought to be shared by the community and its health care practitioners was invaded by people with other priorities.

Philanthropy has an important role to play in this crisis of health care and professionalism. The most important role is not financial but moral: voluntary associations concerned with the public good must serve as voices of the public conscience. Because the "public good" and the "public conscience" are problematic at best, the third sector of voluntary action becomes the arena in which moral issues are argued and new moral alternatives explored.

Philanthropy can also subsidize and sustain the professional ideal as a model of public life. Contemporary capitalist society exalts the private life and its values, but society needs people whose careers are committed to public and not simply private needs. A generation ago a wise and thoughtful sociologist named Philip Selznick said that professionalism is "the basic answer that society has evolved for the protection of institutional integrity."²

It is a continuing struggle to bring healthcare ethics and professionalism and the study of philanthropy into the university because the university is an uncertain host. Once the university has its act in order - once the university rediscovers and reanimates its mission - the support will be forthcoming.

The public wants to support such things. The public wants to believe universities have ideals and are committed to them. Obtuseness about such matters can be terminal.

1 The Chronicle of Higher Education, 28 November 1997, pp. 37-8.

2 Philip Selnick, Leadership in Administration, Harper & Row, 1957, p. 132