Green Eggs and Ham

Strategies to Address the Growing Phenomenon of Selling a Medical School’s Name

Abstract

In 2008, the authors published a review that highlighted an emerging trend for medical schools to change their names to those of wealthy donors. Since 2008, the names of ten benefactors have been added to the medical schools receiving their gifts. Twenty-three of the 141 U.S. medical schools accredited by the Liaison Committee on Medical Education are currently named after donors. Large donations have the potential to positively affect all stakeholders by improving the resources that are available for research, teaching, and clinical care, but the rapid increase in the naming of medical schools after wealthy benefactors raises important concerns for those same stakeholders. In this perspective, the authors explore such concerns and identify mitigating strategies that institutions facing these issues in the future can use to ensure that the benefit associated with a gift outweighs any adverse impact. The authors argue for a strong presumption of impropriety when a donor possesses a conflict of interest with the potential to affect clinicians’ judgment. They go on to assess how donors’ control of funds may have an impact on institutional mission and research agenda, and analyze the right of an organization to remove a benefactor’s name for alleged wrongdoing. The perspective considers how renaming may negatively affect brand recognition and the associated impact on students, residents, faculty, and alumni. Finally, it concludes with an analysis of taxpayer-funded organizations and the concern that educational renaming will lead to a slippery slope in which other public goods are effectively purchased by wealthy donors.

In April 2012, Dartmouth Medical School changed its name to the Audrey and Theodor Geisel School of Medicine. The late Theodor Geisel was a 1925 Dartmouth graduate known worldwide as “Dr. Seuss,” an imaginative children’s author whose 46 books include Green Eggs and Ham. By honoring Theodor Geisel and his wife, Dartmouth joined several other Ivy League institutions in naming their medical schools after a generous donor. Harvard, Yale, and Columbia represent the residual minority of Ivy League medical schools without a benefactor’s name.

In 2008, two of us (E.C.H. and J.S.L.) published a review that highlighted an emerging trend of medical schools changing their names to those of wealthy donors, and offered preliminary insight into the negative consequences of such renaming.¹ Since 2008, the names of Lewis Katz (Temple University), Sidney Kimmel (Thomas Jefferson University), Theodor Geisel, Paul Foster (Texas Tech University), Herbert Wertheim (Florida International University), Charles Schmidt (Florida Atlantic University), Raymond and Ruth Perelman (University of Pennsylvania), Frank and Carol Morsani (University of South Florida), Frank Netter (Quinnipiac University), Michael and Susan Dell (University of Texas at Austin), and Carl Icahn (Mount Sinai) have been added to the names of the medical schools that received their gifts. Nine of the eleven changes occurred after 2010. Excluding schools bearing the name of a donor after whom the entire university (Duke/Harvard) or a preexisting medical system (Carilion-Virginia Tech) was named, 24 of the 141 U.S. medical schools accredited by the Liaison Committee on Medical Education are currently named after donors—a 85% increase since our 2008 review.

Large donations have the potential to positively affect all stakeholders by improving the resources that are available for research, teaching, and clinical care. However, the rapid increase in naming medical schools after wealthy benefactors raises important concerns for those same stakeholders. In this Perspective, we explore these concerns and identify mitigating strategies that institutions can use to ensure that the benefit associated with a gift outweighs any adverse impact. We developed these strategies through a careful analysis of past institutional renaming and sequential consideration of all stakeholders. Table 1 summarizes the advantages, concerns, and potential solutions associated with the sale of a medical school’s name.

Table 1: Advantages, Concerns, and Mitigating Strategies Associated With the Sale of a Medical School’s Name

Assurance of unbiased training for medical students and clinical care for patients is a paramount concern of all academic medical centers. Many institutions therefore limit participation in speakers’ bureaus for drug companies and cap compensation for serving on boards of directors.² Similar concerns about bias can arise in the context of institutional renaming, as indicated by the University of Iowa’s decision to reject a $15 million gift from the Wellmark Corporation to rename its School of Public Health.³ Because bias often interjects itself subtly and subconsciously,⁴ any name change reflective of a donor with financial interests tied to physician decision making (e.g., pharmaceutical companies, equipment manufacturers, insurers) has the potential to adversely affect both academic and clinical care missions. As a threshold rule, such transactions should be viewed with extreme skepticism, regardless of the degree to which they conform to the other guiding principles.

Institutional objectives may also be compromised if benefactors retain control over donated funds. Donors understandably want to ensure that the money is directed toward endeavors that they personally find worthwhile, or that are likely to solidify a legacy. However, assuming that medical schools rationally appropriate funds, charitable contributions are maximally beneficial to an organization when they are not earmarked for specific purposes. Heightened attention to this concern is appropriate for large gifts, where the institution’s research agenda may be so substantially redirected that it functionally entrenches the university in an alternative research path. Medical schools may therefore wish to expressly limit the conditions that can be placed on gifts, as well as benefactors’ ability to serve on institutional boards. Universities enamored with the prospect of a large donation may be poor judges of a conditional gift’s downstream effect, as well as the donor’s ability to exert influence on appropriation of the funds. Thus, in cases where the organization’s mission is presumed to remain intact and donor influence to be minimal, it is reasonable to secure confirmation of this expectation from a neutral third party.

Name changes also place medical schools at risk insofar as a donor may be later implicated in wrongdoing or otherwise fail to live up to the institution’s standards. Wake Forest University removed Bowman Gray’s name from its medical school in order to distance itself from the former tobacco executive, and Dr. Paul Dishner’s name was dropped from East Tennessee State University when rumors of sexual impropriety arose.¹ In such cases, removing the benefactor’s name is reasonable to protect the brand equity of the organization and ensure a commitment to ethical behavior among students, alumni, and faculty. As long as the institution is acting in good faith and there is no contract to the contrary, the institution should not be obligated to return any of the donated funds. The good will of the benefactor’s name is part and parcel of the transaction.

Some donors may attempt to secure a guarantee that their money will be returned if the institution later decides to remove the philanthropist’s name because of alleged impropriety. Although there is no ethical reason to ban such refund policies, medical schools should be reluctant to entertain them. Because information about past indiscretions can surface even postmortem, medical schools face an omnipresent risk that the money will have to be returned. Thus, institutions would have to perpetually maintain sufficient liquid assets to fulfill their contingent refund obligations, effectively devaluing the donation and increasing the threshold required for renaming. Moreover, money-back guarantees may encourage individuals with unscrupulous but presently clandestine pasts to donate, increasing the likelihood that the funds will be returned and further driving up the price for a name change. In essence, refund provisions are likely to be prohibitively expensive for all but the most generous philanthropists.

Even the sale of a medical school’s name to an upstanding donor has the potential to adversely affect the school’s brand. Institutions with a reputation for excellence may regress toward the mean, as renaming can cause confusion among the public. On the other hand, large transformative gifts may lead to greater research opportunities, more productive faculty through augmented salary and research support, and brighter, more socially conscious students through scholarships.

Ideally, organizations such as the Association of American Medical Colleges, American Council on Education, or Association of Academic Health Centers would empirically examine the impact of medical school renaming. This could be done through surveys of affected stakeholders and the public, including analyses of perceived prestige before and after the donation. If institutions’ public perceptions are adversely affected by renaming, medical schools might consider appropriating a percentage of the donation to counteract this effect through scholarships, publicity surrounding new research endeavors, or other targeted marketing activity.

An institution’s renaming may also communicate the wrong message to its potentially impressionable students, who fail to appreciate the implicit or explicit tradeoffs the organization considered before accepting the donation. Instead, students may interpret the name change as an endorsement of a “finance first” or “everything is for sale” mentality—a sign that even medical school personnel, who have devoted their lives to improving the health of others, view wealth accumulation as the most important goal.

It is therefore advisable for medical schools contemplating or experiencing a name change to incorporate frank discussions of wealth and competing personal goals into their curricula. Students should understand that name changes are preceded by a complicated cost–benefit analysis, and appreciate the fact that neither wealth nor the ability to have one’s name attached to an institution is indicative of contribution to or standing in society.

Medical schools’ tax-exempt status means that even the private institutions are indirectly funded via public coffers. Taxpayers deserve protection by ensuring that the benefit of a donation outweighs any risk to the institution’s mission or brand. In the case of state-funded public universities, a separate cost–benefit analysis should be conducted for state citizens that includes the risk of diminished funding from state legislatures.

There could also be concern about a “slippery slope” phenomenon, in which other public goods become unduly privatized. Athletic arenas (e.g., Gillette Stadium) and academic buildings (e.g., FedEx Global Education Center at the University of North Carolina at Chapel Hill) are increasingly emblazoned with corporate names; is there a legitimate concern that one day we will wake up to the “Bill Gates Statue of Liberty”? Such fears appear unfounded as public parks and monuments tend to rely more directly and extensively on a tax base, whereas medical schools are funded largely through philanthropy. Thus, benefactors’ evolving expectations regarding renaming place disproportionate financial pressure on universities compared with other governmentally owned property.

Only 15% of medical schools are named after donors compared with 80% of ranked U.S. business schools. Although the absence of comprehensive information on donation amounts makes it impossible to prove, it appears that medical school deans understand the special concerns associated with renaming their institutions and attach a premium that comparatively fewer philanthropists will pay. In this Perspective, we explored the policy concerns associated with naming medical schools after wealthy benefactors and articulated strategies that institutions can use to protect the interests of patients, students, trainees, faculty, alumni, and society. Large gifts have the potential to advance the interests of the institution and society, but great care must be taken to ensure that all stakeholders are adequately protected.