The resources and values of philanthropic organizations greatly shaped the institutions of modern academic medicine (¹, ²). When Johns Hopkins University was established, the benefactors sought to formally link a graduate school in medical science with a sophisticated teaching hospital, and the multimillion dollar bequest required that only individuals with college degrees, including women, be permitted to matriculate (³). Nearly a century ago, the Carnegie Foundation commissioned Abraham Flexner to evaluate the state of medical education, with the highly influential Medical Education in the United States and Canada, which was published in 1910 (⁴). The efforts of John D. Rockefeller and Reverend Henry T. Gates helped establish and determine the missions of the University of Chicago, Rush Medical College, and the Rockefeller Institute for Medical Research, which, in turn, directly or indirectly influenced the work of other medical and scientific institutions across the United States and Canada (¹, ⁵). More recently, major philanthropic organizations (e.g., the Commonwealth Fund, the Ford Foundation, the Kellogg Foundation, the Macy Foundation, the Markle Foundation, the Henry J. Kaiser Foundation, the John D. and Catherine T. MacArthur Foundation, the Howard Hughes Medical Institute, the Gates Foundation, and especially the Robert Wood Johnson [RWJ] Foundation), have funded initiatives that have guided the course of the development of major academic medical institutions in the United States and Canada (¹, ², ⁵).

With notable exceptions, such as the commitment to altruism and mental health shown by Anna Harkness in establishing child guidance centers "for the welfare of mankind" in 1918, psychiatry received little early attention as a target for philanthropy in this country and elsewhere (¹, ⁶). In the past few decades, innovative organizations such as the National Alliance for Research on Schizophrenia and Depression (NARSAD), the RWJ Foundation, the MacArthur Foundation, as well as the Foundations Fund for Research in Psychiatry (no longer in existence), and newly emerging organizations have sought to build the field of psychiatry through support for research, curricular development, community outreach, and ethical inquiry (², ⁷—¹⁰). These visionary and generous efforts have helped launch the careers of psychiatrist-scientists and scholars, led to valuable insights in public and community health, built major centers and endowed chairs and professorships in academic psychiatry, and enriched educational activities pertaining to mental health.

Nevertheless, philanthropy in the field of academic psychiatry has failed to develop steadily over the years, in contrast with the robust, often quantum-leap advancement of some other medical specialty fields (¹¹, ¹²). This observation is particularly poignant and troubling when one considers that mental illness affects one in five individuals in the United States and that mental illness is the leading cause of disability in economically established countries and, globally, is second only to infectious disease as a cause of disability (¹³, ¹⁴). Moreover, the resources for academic psychiatry are both limited and threatened at this point in our history, increasing the importance of possible development of philanthropy as an important source for future evolution of our field (⁶, ¹²). Thus, it is worthwhile to examine the reasons for philanthropic languishment in the field of academic psychiatry and to explore possible steps for its growth in the future.

Philanthropy is inherently relational. It involves a committed, intentional, trusting, and goal-directed relationship between a benefactor and a potential recipient. Remedying the underdevelopment of philanthropy in academic psychiatry will require a careful look at diverse factors influencing both partners in this unique dyad. Historically, with respect to benefactors, relatively few organizations have identified the field of mental health as an important priority (¹¹). This neglect may result from a lack of knowledge or understanding of the field, e.g., the misimpression that psychiatric treatment is ineffective or even "futile," the erroneous notion that mental illness is not prevalent, or the belief that efforts in the area of mental illness should be supported solely by resources in the public sector. The mass media is the most important source of information regarding mental illness for the public (¹⁵, ¹⁶); this information is predominantly negative and commonly associates mental illness with violence (¹⁷—¹⁹). The neglect of mental illness as an important priority for philanthropy may also relate, therefore, to a fear of mental illness, or to a fear of being stigmatized through association with mental illness (¹²).

Education is a key strategy for enabling mental illness to become better appreciated as an important priority for philanthropy. This could include education on patient vulnerability, unmet biopsychosocial needs, priorities and potential for research and for preventive and treatment interventions, and on the richness and diversity of opportunities across specialties and disciplines. Additionally, we need to counter negative stereotypes of mental illness and continue to develop evidence-based strategies for doing so.

On the recipient side of the partnership, there are many sensitivities (read "obstacles") related to academic psychiatry’s mission within medical institutions and to academic psychiatry’s stigmatized populations (¹¹, ¹²). Relatively few medical schools have chosen to undertake philanthropic programs to help support mental illness initiatives and have failed to build psychiatry’s goals into the routine procedures of institutional development offices and fundraising activities. For example, medical school offices for fundraising typically have not sought to develop "grateful patient" lists, as they do for other departments, out of respect for the confidentiality of potential donors (¹²). We agree with this approach. This special attention to the distinct issues faced in the care of people with mental illness is welcome and sound. Nevertheless, it is a concern that there appear to be few companion or compensatory efforts to find appropriate routines for fundraising in psychiatry, for example, working in partnership with advocacy organizations, creating venues for those interested in fundraising for mental illness-related areas to step forward, etc. (⁶, ¹²).

The profession of psychiatry also faces challenges in entering philanthropic partnerships. Our profession has rightly identified ethical concerns about accepting gifts and potentially exploiting the vulnerability of those who might choose to donate to causes related to mental illness (¹²). Recently, altruistically-oriented gift-giving to psychiatry has become confounded with business-oriented "gift-giving" by the pharmaceutical industry to psychiatry, which has raised the specter of grave conflicts of interest and has had a chilling effect on the dialogue on philanthropy in psychiatry. As a profession, psychiatry has not sufficiently examined the hard ethical issues in philanthropy and academic psychiatry, nor has it examined adequately conflict of interest issues in academia, industry, and their points of interface. A nuanced, shared understanding of ethical gift-giving in psychiatry does not yet exist, and professional guidelines for ethical philanthropy in academic psychiatry are only at an early stage of development (¹²).

One of us (Dr. Roberts) has argued that academic medical centers should adopt a series of steps in order to promote ethical fundraising in psychiatry (¹²). These steps include establishing an advisory workgroup that helps define the boundaries of ethically justified philanthropic practices with reference to ethical principles and arguments, national ethical guidelines, and the perspectives of key stakeholders. The steps involve defining absolutely unacceptable philanthropic practices as well as defining potentially permissible practices for psychiatry. They also include thoughtful consideration of the motivation of the donor, a determination as to whether or not individual donations are acceptable, and an identification of acceptable philanthropic targets. A systematic process for decision making should be adopted exploring any potential ethical problems and the methods and level of safeguards necessary to address these concerns adequately. Safeguards include the explicit identification of potential conflicting interests, clarification of goals, motives and expectations, protection of confidentiality, attention to proper timing of the donation, and ongoing oversight (¹²).

Underlying these guidelines is our obligation to act with the strictest professionalism, with fidelity to the patient’s interests, and with committed attention to the therapeutic responsibilities of the psychiatrist-patient relationship (¹²). These are demanding standards that require psychiatrist-leaders to be critically self-observing. The virtues are essential to this work because they blunt self-interest and direct psychiatrists’ primary attention and concern to the interests of patients. Virtues are traits of character that should be cultivated so that physicians routinely discern and discharge moral obligations to patients (²⁰). For example, a commitment to altruism and putting the interests of patients first, although not explicitly framed as a virtues-based argument, underlies a proposal for eliminating the conflicts of interest that characterize the relationship between physicians and the health care industry (²¹). A virtues-based argument also complements other arguments to justify an absolute prohibition of sexual relationships concurrent with treatment of patients (²²). In the context of philanthropy in academic psychiatry, the virtues limit compromise of professional obligations by limiting the taking of personal gain.

Two professional virtues are of fundamental importance here: self-sacrifice and self-effacement. We are indebted to McCullough and Chervenak for showing us how these virtues, in conjunction with compassion and integrity and in keeping with the legacy of Dr. John Gregory (1724—1773) and others, constitute the bedrock of a clinical ethical framework (²³—²⁵). Self-sacrifice requires physicians to blunt or diminish self-interest in favor of protecting and promoting the interests of patients, even at risk to themselves. Self-effacement requires that differences between patients and physicians, such as manners, gender, ethnicity, income, and payment status, which should not factor into the professional relationship, be set aside. These are virtues which are part of medical professionalism and which educators are trying to instill and measure starting in medical school (²⁶).

In this context, therefore, self-sacrifice serves to limit the self-interest of institutions and requires psychiatrists to be rigorous in support of others’ interests in the administration of a philanthropic grant. Self-sacrifice also underpins the position that it is not considered acceptable for a psychiatrist to solicit a donation from his or her own patients (¹²). Self-effacement serves to promote a focus on the interests of patients and the public health by limiting the possibility of bias in administrative decision making when friends or colleagues are favored, or alternatively when class, gender, or ethnicity adversely biases the selection of benefactors. Self-effacement requires psychiatrists as leaders to be unaffected by these potential biases. Self-sacrifice and self-effacement in combination promote trust that psychiatrists and their institutions will be focused on advancing knowledge, education, and therapeutic and public health goals above all else.

Responsible stewardship of resources requires institutions to have the capacity to make the gift translate into something of importance and value (¹²). Psychiatrists as leaders must possess the requisite knowledge and skills in order to competently manage philanthropic contributions and to interact effectively with advisory workgroups or boards of experts. As Chervenak and McCullough have argued, however, competency in management is a necessary yet not sufficient condition for medical leadership (²⁷). This is because the virtues provide the foundation of medical leadership by creating and sustaining a moral culture of professionalism in health care organizations (²⁷). Responsible stewardship therefore allows for the protection of the institution’s economic interests so long as this advances patient care and public health goals. Alternatively, the economic interests of the institution become a primary or overriding goal of management decisions (²⁷). Responsible stewardship also demands a pursuit of a standard of excellence in clinical and basic sciences and close attention to the evidence base in patient care, while simultaneously committing to the donor’s values and intentions.

The observation that so few philanthropic organizations have identified psychiatry as a good "target" for development and so few medical schools have sought this opportunity suggests that leaders of academic psychiatry have failed to be persuasive to key stakeholders and opinion leaders regarding the importance of our field and its advancement. In response, we should raise the profile of psychiatry in order to build on the marvelous philanthropic support psychiatry has received so far. This entails providing educational outreach efforts, combating stigma, working in partnership with advocacy organizations and creating novel pathways for fundraising and philanthropy that are likely to make a real difference. A greater commitment to philanthropy in psychiatry should follow a greater understanding of mental illness, including priorities for research, leadership and clinical practice.

To this end, we should develop a national and international strategy for philanthropy to psychiatry. Goals include establishing both national and international priorities for philanthropy. Goals might also include integrating and coordinating promotional efforts, lending expertise to philanthropic organizations, establishing mechanisms for managing and disbursing funds, tracking philanthropic contributions (¹¹), and contributing to the evaluation and reporting of outcomes.

In addition, as we have indicated above, there is a need to develop further the ethical foundation of philanthropy to psychiatry. One relevant research goal is to determine the ethical and practical challenges of promoting and managing philanthropic contributions at local levels. The overall goal is to foster trust that our institutions will be responsible stewards and will behave with the utmost professionalism.