To Do No Harm

There is a rule in life, one that is also the first rule of philanthropy, which is to do no harm. There is another related rule, the rule of unintended consequences.

The best of intentions had dramatic unintended consequence at a time in the ‘80s when I was President of the Massachusetts Association for Mental Health, which had long led the fight for community-based care and treatment of the mentally ill. For more than a century mentally ill people had been warehoused in the back wards of large state run hospitals. The situation was awful on every level for these patients. The institutional facilities were run down, the staffing and treatment were inadequate, and patients' rights as we know them today did not exist. I had first seen those back wards while in college in the late ‘50s and will never forget how depressing and desperate they were.

The cure sold to the state legislature was the notion of community-based treatment for all but the most seriously ill. Several factors made the timing right. One was the increasingly effective use of pharmacology in the treatment of the mentally ill, which in many cases reduced the necessity for hospitalization. Another was the growing belief that more humane and effective treatment was possible in local community settings rather than dehumanizing, ostracizing, hospitals. It was also argued the state was better off not being in the direct care business and that privatizing such services would result in better care and treatment. The final argument, which won the day, was that community care would cost far less. Many of these arguments, including the wisdom and efficacy of privatizing services heretofore the province of government, are still being argued. The last assumption, however, that community care would cost less, was a complete fabrication.

No one really knew how much a community-based care system would cost. The implementation of an effective community-based delivery system proved to be much more difficult than originally thought. Finding a site became a big challenge and remains so as most neighborhoods strongly resist having these populations literally next door.

In addition, the presumptive savings from closing the old state institutions did not materialize for many years. Many of those same properties some 25 years later in 2003 are still owned by the state. It is ironic to watch the new Massachusetts Governor include in his budget the disposition of properties that were to be sold 25 years ago.

One of the most troubling unanticipated results of this policy change toward community-based care was the creation of a new and undercapitalized human service provider system. Many providers were originally advocacy organizations and only became service providers at the behest of the state. These non-profit organizations, still among the most fragile within the sector, are constantly buffeted by the vagaries of state funding and in the main have not been successful at raising resources from private philanthropy. Serious organizational and human resource issues continue to have a great impact on their ability to provide good services to their clients.

An even more troubling result of the de-institutionalization of the state mental health hospitals was and is the creation of a large, permanent, homeless population of mentally ill people.

Chronic homelessness is arguably tied to the overall crises in low-income housing that has escalated during this same 25-year period. And no one would propose a return to the dismal back wards. Nonetheless, it was irresponsible for the advocates, myself included, the Department of Mental Health and the state legislature to neglect the risk analysis and planning that would have led to better understanding of the implications of emptying those wards. There was far more attention paid to the theory of change then to the implementation of that change. In retrospect it is clear that we took a walk away from the public's responsibility for those who are among the most vulnerable in the society. It would have been better had we acknowledged and acted on the central truth that "social change is incremental at best."

There is a homeless man who wanders the downtown block where my office is. He has long, straggly hair and walks face down, muttering on his delusions. I often give him money and have learned that he is too disruptive to be welcome in the shelters. He could be a prospect for supportive housing with professional staff to deal with his needs, but there are no supported housing slots available in our city. Everytime I see him, and it is at least once a week, I think of what was done for good and proper reasons, and I regret we did not do a better job.

Whether one is doing good or perhaps doing harm is often in the eye of the beholder.

Take Ted, who is at the epicenter of the movement to provide Americans with a choice to educate their children. He and his colleagues are passionate in their view that the public schools are a monopoly, the only such monopoly in our society, and that the only solution is competition. Vouchers, charter schools, or any idea that tinkers with the existing system doesn't go far enough. This man wants a total revamping of what he views as unacceptable and un-American control over a parent's choice of where a child goes to school. He argues that the public school system as we know it is a failure and further has been corrupted by the self-interest of teacher unions and administrators. He also argues that public schools are a far cry from what Thomas Jefferson meant when he made the case for an educated citizenry.

Ted and other like-minded donors have organized a social marketing campaign of unprecedented scale. Social marketing is the term used to describe the adaptation of Madison Avenue advertising and public relations techniques to influence public opinion and behavior. It is expected to cost more than $200 million to achieve the objective: to convince 20 million American parents that the public school system, as we know it, must be dismantled or radically restructured. However, ask Ted what will take its place and his answer is "I do not know, and would not presume to suggest. I am not an education expert. But this is America and once the door is open for real competition, the market will take over and create the solutions."

I asked Ted about the rule to "do no harm." "What if the results are disastrous and a whole generation of American children fall through the cracks?" Ted thought for a moment and said, "I do not think it really is a risk, but if so, it is one worth taking."

Is that so? Ted has a libertarian perspective and is "peddling" change on a radical scale. My guess is that he will not prevail, partly because he has no discernible plan or end game and partly because his idea is so extreme.

For some people, the concern about 'doing harm' holds them back. I once asked a wealthy friend whose current giving is a fraction of his capacity to give, and whose estate plan calls for most of his fortune to go to a foundation, what prevented him from giving more now. He said "It would bother me enormously if I made large gifts and they did not work out. It would devastate me if the gifts actually hurt those I wanted to help, and when I look at the things that interest me the most, I am just not sure enough." My friend's instincts are not wrong, but the caution that keeps him from going forward is not in any sense a solution.

What are the lessons?

One lesson in all of this is that new ideas are not necessarily better ideas. Another is that it is very difficult to take ideas, even good ones, and make them happen. As T.S. Elliot wrote in The Hollow Men, "between the conception and the creation… falls the shadow." The longer one lives, in both life and philanthropy, the more one is aware of nuance, subtlety and what might be called the 'messiness' of real, not abstract, life situations. I do not suggest that taking risks—even big ones—is not wise, or that innovation and change is not needed, sometimes critically. Revolution is sometimes exactly the right and good thing. But only the foolish amateur, muddleheaded philosopher, constipated bureaucrat, starry-eyed social planner, or romantic advocate, pays no attention to the possible scenarios that could result from one's best intentions.

As in all things, it is important to ask the right questions and crucial to listen carefully to the answers.