Toxic Charity: When Doing Good Does Harm

"Most of us would rather avoid challenging our own motives or pointing out the negative effects of actions we'd rather hold as proof of unmitigated generosity."

- Jonathan M. Katz

One of the story lines in a 1998 episode of the TV show Friends involves Joey challenging Phoebe to perform a selfless good deed, one that is only for the benefit of someone else and does not benefit her in any way. After failing multiple times to meet the challenge, Phoebe makes a donation during a PBS telethon for which Joey is volunteering. She eventually realizes, however, that the good feeling she has about how this contribution helped Joey's career actually proves him right. Most people can relate to Phoebe's sense of satisfaction when contributing money or time to a charitable effort, and most would also agree that this good feeling does not render the good deed inherently selfish. A good deed can benefit the person it is intended to help, and also give us a sense of satisfaction for having performed it. It is worth considering, however, whether good feelings influence our good deeds more than the actual outcome of that benevolence. An even more serious concern is whether our efforts to help those in need actually have negative effects that we may not be aware of. Could our sense of satisfaction for doing good blind us to the limitations of our efforts and the negative outcomes that may result? This is the first of two articles examining the uncomfortable reality that our efforts to help others can actually do harm. This article focuses on how charity can harm those it is intended to help. A future article will consider how doing good can damage our own capacity to continue those efforts.

Toxic Charity Though Bob Lupton, PhD, earned a doctorate in psychology, no one can accuse him of living in an ivory tower. For decades he has lived in inner-city Atlanta, developing neighborhoods by bringing resources to hundreds of his neighbors. His interest in helping others began during his tour of duty in the Vietnam War, when he developed relationships with young men who had been raised in inner cities. He then worked with juvenile delinquents and the families of troubled youth, and eventually within communities to provide housing and other human services. 1 These years spent working closely with individuals and families in need and organizations providing resources have given him a special insight into how to be most effective in offering help, and how some attempts to do so can actually cause harm. In 2011, he published a book titled Toxic Charity–How Churches and Charities Hurt Those They Help (And How to Reverse It).

One of Lupton's primary concerns is that despite a "compassion boom" in which "almost 90 percent of American adults are involved personally or financially in the charity industry" the outcomes of many of these efforts are not sufficiently examined and harmful effects are overlooked. 2 Lupton uses evidence from his extensive experience within the United States and statistics on international compassion efforts to make the case that charity often has the effect of creating dependence, destroying personal initiative, and disempowering others. (Jonathan M. Katz, a correspondent with the Associated Press in Haiti when the 2010 earthquake devastated that country, addressed similar themes in his account of the disastrous effects of international aid provided before and after this event. 3 ) A deep personal faith and religious conviction has guided Lupton's efforts, but he does not hold back criticism of faith-based charity: "Many people legitimately fault the government for decades of failed social programs, and yet frequently we embrace similar forms of disempowering charity…. And religiously motivated charity is often the most irresponsible." 2

The Importance of Relationships Lupton distinguishes between emergency aid in the wake of a crisis and resources intended to support long-term development, which require a deeper partnership with individuals in need. "We respond with immediacy to desperate circumstances but often are unable to shift from crisis relief to the more complex work of long-term development. When relief does not transition to development in a timely way, compassion becomes toxic." 2

Lupton suggests that becoming personally involved with the recipients of assistance is the only way to provide long-term assistance effectively: "There is no simple or immediate way to discern the right response without a relationship." 2 Not only does a relationship allow more accurate assessment of specific needs and outcomes, it also changes both parties in important ways. One-way giving often involves no knowledge of the recipients' situation other than the immediate need for a particular resource. The giver can leave the encounter with a sense of satisfaction that this need is met, but without any real understanding of important side effects of the assistance. Resources provided without any long-term relationship or commitment can foster resentment in both the giver and recipient. For example, the giver may become frustrated that their generosity is underappreciated, and the receiver may feel condescended to and inferior rather than empowered to make improvements in his or her own life. According to Lupton, "Authentic relationships with those in need have a way of correcting the we-will-rescue-you mindset and replacing it with mutual admiration and respect…." 2 Every person, regardless of socioeconomic status, craves this reciprocal respect. Lupton identifies the following progression in response to one-way giving, "give once and you elicit appreciation; give twice and you create anticipation; give three times and you create expectation; give four times and it becomes entitlement; give five times and you establish dependency." 2 If a primary goal of charity is to improve the lives of the recipient, maintaining a cycle of dependency begins to look like something other than compassion.

Lupton asks and answers a key question that is reminiscent of the debate between Joey and Phoebe: "Why do we miss this crucial aspect in evaluating our charitable work? Because, as compassionate people, we have been evaluating our charity by the rewards we receive through service, rather than the benefits received by the served. We have failed to adequately calculate the effects of our service on the lives of those reduced to objects of our pity and patronage." 2 Feeling good about doing good does not make our good deeds inherently selfish, but judging the effectiveness of our charity based on that good feeling rather than meaningful outcomes, while ignoring negative side effects, comes frighteningly close. Genuine and effective compassion is focused on real benefit to those in need, rather than simply whether we feel good about what we've done.

O&P Service Trips It seems hard to argue that providing a prosthesis or orthosis to improve function could ever be anything but beneficial to the recipient. Greater mobility results in improvements in overall health and function, as well as in participation in society, particularly in cultures where severe stigma surrounding disability presents insurmountable barriers. O&P charity may not involve as much risk as a larger-scale efforts, but the importance of measuring outcomes and recognizing the potential to do harm should not be overlooked. " Providing Evidence-based Care in Low-, Middle-income Countries ," The O&P EDGE, May 2016, describes the need for outcomes data to assess the effectiveness of O&P service trips, and includes an extreme example of a misguided charitable effort. At the very least, providing short-term solutions with no plan for sustainable, long-term follow-up care does significantly less good than is assumed based on the feelings of participants.

Short-term service trips may also be a less effective use of resources than other models of providing care. A comparison with food distribution may be helpful. Food pantries prefer financial donations, because this allows them to leverage their buying power with suppliers and purchase items at a much lower cost than individuals who donate food items pay for items they've purchased at full price. Dropping cans of soup in a donation bin is certainly charitable, and may make us feel good, but it has much less positive impact than donating an equal amount of money to a food pantry. Similarly, providing donations and other resources to organizations and facilities experienced in providing O&P care in under-resourced regions is likely to be more effective than making trips to provide that care. In some locations, the lack of trained care providers necessitates that qualified practitioners travel from outside the region, but even in those situations, devoting more resources to develop training programs may be a more effective way to meet the long-term need. Spending thousands of dollars per person to send individuals with limited experience and qualifications to remote locations may result in good feelings, but it is questionable whether this is the best use of resources. It is less likely that these individuals would donate funds without the personal benefit of a taking the trip, and in that case, it is understandable that aid organizations use this circuitous method for raising funds. Individuals can spend their money on whatever they choose, but if their choice is to do good, it is worth considering how that can be accomplished most effectively. Lupton suggests: "Isn't it time we admit to ourselves that mission trips are essentially for our benefit? Would it not be more forthright to call our junkets ‘insight trips' or ‘exchange programs'? Religious tourism would have more integrity if we simply admitted that we're off exploring God's amazing work in the world." 2 I've had the privilege of joining students on an O&P service trip through an organization that provides responsible, sustainable care in an under-resourced region. The way that experience matures the students' desire to provide meaningful long-term help to others over the course of their careers is likely to be the most significant effect of that trip.

Charity Closer to Home In many O&P practices, practitioners encounter patients on a daily basis who require significant financial assistance to obtain the required items and services. It is uncommon to see the same level of interest in domestic charity as in that requiring travel to exotic locales. Perhaps it is easy to assume that foreign need is a result of lack of opportunity or resources, while the domestic need is a result of personal irresponsibility and choices. In these cases, proximity may breed contempt. Companies may (gladly or grudgingly) provide services and items at a reduced cost if third-party payment is insufficient, and in some cases, a prosthesis or orthosis may be provided at no cost to someone who has no ability to pay. The personal relationship that naturally develops between practitioner and patient when providing long-term care provides the opportunity to develop a fuller understanding of the individual and his or her specific needs. This understanding can form the basis for a partnership that affirms the recipient's dignity and self-efficacy and empowers the patient to improve his or her own situation. It will undoubtedly take more time and energy to do this than to simply give away free stuff, but our patients are worth that added investment. Early in my career, I was surprised to learn that some business owners continued to provide services to patients with large unpaid balances, as long as the patient paid a nominal amount per month towards the bill. This practice seems to be consistent with Lupton's oath: Even though the full amount owed may never be paid, giving the patient the opportunity to make some contribution to the cost of care is more empowering than providing the services at no charge.

Should I Give, or Not? The purpose of this article is not to discourage giving and other good deeds, but to encourage close scrutiny of our motives and the outcomes of our charitable efforts. Charity is hard work and requires thoughtful consideration of how resources can be used most effectively. Collaborating with individuals and organizations who are experienced in determining and meeting specific needs and have a track record of sustainable impact is essential to do the most good. Asking them what they need and how they would prefer their efforts be supported is a good starting point. Doing good in a responsible, sustainable manner will not only result in positive feelings about our contribution to the world, it will make more of a positive difference in the lives of individuals who require our care, which is really the point.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education. References 1. Focused Community Strategies. https://www.fcsministries.org/founder (accessed August 29, 2019).

2. Lupton, R. D. 2011. Toxic charity: How churches and charities hurt those they help and how to reverse it. Harper Collins.

3. Katz, J. M. 2013. The big truck that went by: How the world came to save Haiti and left behind a disaster. St. Martin's Press.

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