Imagine trying to perform a delicate surgical procedure with a set of lawn shears and some baling wire – wielding such blunt instruments, it would be difficult to complete any operation, and the amount of damage inflicted on the patient would likely exceed the benefit. As is often the case in educational philanthropy, this is precisely what has happened in the case of several recent high-profile donations to US medical schools, including gifts by billionaires Ken Langone to New York University and Michael Bloomberg to Johns Hopkins University, which make medical education tuition-free for admitted students. 

Such donors intend to attract a more diverse pool of students, to enable more students to choose careers in relatively low-paying primary-care fields such as family medicine, and to encourage graduates to locate in medically underserved areas. Yet there is little evidence that they are achieving such results. In fact, according to a recent article in The Atlantic, they appear to be producing the opposite effects. At NYU, admission now demands even higher grades and test scores, favoring the well-to-do, and the proportion of financially disadvantaged students has actually fallen. 

The percentage of NYU medical students who went into primary care was about the same in 2017 and 2024, according to an analysis by Chuck Dinerstein, the medical director at the American Council on Science and Health. The locations of the hospitals where students do their residencies — often a clue about where they will end up practicing long-term — also remained essentially unchanged. And although applications from underrepresented minority students increased by 102 percent after the school went tuition-free, the proportion of Black students declined slightly over the following years, according to data from the Association of American Medical Colleges and provided by Jared Boyce, a medical student at the University of Wisconsin. (The share of Latino students grew by a few percentage points.) Perhaps most alarming of all, doing away with tuition appears to have made the student body wealthier: The percentage of incoming students categorized as ‘financially disadvantaged’ fell from 12 percent in 2017 to 3 percent in 2019.

To see why, it is necessary to turn to the nature of philanthropy, and especially its most essential virtue, generosity. In the Nicomachean Ethics, the Greek philosopher Aristotle argues that givers do not qualify as generous merely according to the magnitude of their gifts. Giving generously requires far more than writing a large check. We must also give the appropriate amount to the appropriate person at the appropriate time in the appropriate way and for the appropriate reason. If these criteria are not satisfied, we end up wasting money, achieving little or no good by our efforts. 

In fact, we may even inflict real harm. Consider, for example, how in decades past philanthropic efforts to provide support for single mothers instead ended up boosting out-of-wedlock births and creating more fatherless families. To act in a truly generous fashion, we must understand and intend the good of the person or group to which we are giving. This requires that we must know them and their circumstances well, a test that educational mega-philanthropists often fail. 

If wealthy donors wish simply to make medical education tuition-free for students, all they need to do is write checks of sufficient magnitude to cover such costs. But if they want to achieve subtler purposes, such as drawing more students from disadvantaged backgrounds into medicine or encouraging more graduates to locate their practices in underserved areas, they need to target their efforts with more precision. 

Instead of making medical school free for all, they might offer aid only to students from disadvantaged backgrounds or offer stipends only to students who pledge to locate their practices among the underserved. The idea that making medical school free would prompt more students to choose primary care practices in rural areas, thereby foregoing hundreds of thousands of dollars in annual income, fails to take into account the kind of education elite programs such as NYU and Hopkins are offering, which tends to be tilted toward research-focused, high-tech subspecialties and takes place in urban environments. 

Yet the bluntness of the instrument is only part of the problem. There is a much deeper misconception at work in contemporary healthcare that is undermining the morale of physicians – namely, the notion that the best way to influence behavior is through money. It is easy to see how many contemporaries, especially the wealthy, might acquire such a notion. After all, they have devoted most of their lives to pursuits that made them rich, and they naturally suppose that being so grants them greater influence than those who lack such means. 

Yet there are limits to what money can buy, and systems are often more complex than they initially appear. For example, wealth can provide a new medical school building or new equipment, and it can increase the size of a medical school class or fund the hiring of more faculty members. But money’s capacity to influence what we might call intrinsic motivation, to shape what a person is most dedicated to and most deeply aspires to contribute, may prove to be both quite limited and fraught with considerable great peril. 

Suppose, for example, that we started paying our fellow citizens and neighbors for things they ought to want to do for their own sake. We pay people to marry, to have children, to speak regularly and lovingly to their spouses, and to cuddle and read bedtime stories to their children. It is quite possible that such monetary incentives would achieve some effect, increasing marriage rates and enhancing youth literacy.  

Yet it is also likely that we would be replacing intrinsic motivation with extrinsic motivation – people would stop doing things because they recognize them as good and genuinely want to do them for their own sake, and instead begin doing them more and more because they expect to be rewarded. When this happens, a withdrawal of the monetary reward is typically accompanied by a substantial decline, even below initial levels, in the desired conduct. Offering financial incentives may, over time, merely undermine the intrinsic motivation of physicians and other health professionals to do what they – and we – need to believe in and act on for its own sake. 

My own experience leads me to believe that sacrifice has an important role to play in professional motivation. Medical students, residents, and practicing physicians sometimes grumble about long hours, sleepless nights, and the cognitive, emotional, and even spiritual demands of our profession, but many of us also find fulfillment in the fact that we are proving ourselves worthy to serve the suffering. To cut open a patient’s chest in an effort to restore blood flow to the heart, to administer toxic drugs in hopes of curing a cancer, or to tinker with a patient’s neurochemistry in order to lift them out of a major depression – these are not trivial matters.  

It can be deeply reassuring to know that we have paid the price and continue to pay the price to be entrusted with the lives of our fellow human beings. We cannot take full responsibility for the outcomes of medical care – too many other factors, such as the patient’s underlying state of health, willingness to partner in care, and sheer good fortune or perhaps even the will of God are involved – but we encounter the patient with the confidence that we have done everything we could to be ready and to deserve to be there. 

There is also the issue of the money itself. To be sure, the average medical student graduates with a debt totaling in the hundreds of thousands of dollars, which typically requires many years to repay. Yet even physicians in the least remunerated fields earn more than enough to discharge such debts. In doing so, we are regularly reminded of the price we have paid to practice medicine – a privilege made all the dearer by the financial sacrifices we have made to secure it. For most of us, it is a boon to the spirit, even a blessing, to have sacrificed.  

A world where entry into professions such as medicine were free might not be a better place. For one thing, many would-be entrants might move forward with an ill-grounded sense of entitlement. For another, many might operate with a diminished sense of gratitude, feeling that we are merely seizing what we have earned. Worst of all, we might develop the habit of expecting much while paying little, forgetting to rejoice and give thanks for our hard-won opportunity to serve the suffering.