It is that gift-giving season, so perhaps it is a moment when we can reflect upon them. Gifts are often accompanied by a silent companion, debt. Not the kind that appears on a Visa bill, but an obligation, a social indebtedness - ones that the government tracks and that ProPublica mines for tales of conflicting interests between physicians and “Industry.” To understand the exchange of gift’s silent companion, it helps to set aside their cultural or social meaning, leaving only the transfer of a commodity. Commodities have value, as ProPublica’s Docs for Dollars proclaim, but does that exchange engender reciprocity? The answer to that requires us to rewrap our present in its social context.
All of us have received a gift of little value but of immeasurable worth. A handwritten note, that handmade object with maker’s marks, that something “you can’t put a price on.” The specialness of these presents lies in the “feeling-bond” created between people; those exchanges engender reciprocity. It is in the relationship, the boundary between giver and receiver where the exchange acquires its social meanings. Gifts demolish boundaries; commodities cross boundaries without changing them.
Consider a rapidly disappearing custom, “professional courtesy,” when one physician discounts their services to another; a recognition that both are of the same “tribe;” not seeking to profit from sharing collective knowledge, and in giving, creating the obligation to pay the same courtesy forward. For the majority of patients, outside the tribe, the principal exchange is a fee for service, a transaction that leaves the boundary between physician and patient, insider and outsider, for the most part intact. Gifts obliterate the border, outsider and insider are one, there is no distinction.
It is at the border crossing that “sunshine” laws and ProPublica lose their way; confusing and conflating commodity with a gift. The majority of exchanges between Big Pharma or Big Device and physicians are commodities; my time or expertise for their cash. That giving solidifies the boundary making clear an outsider is giving, and an insider receiving. This exchange, the free lunch or speaker fee have a dollar value but little worth; more importantly, there is no obligation, indebtedness or need for reciprocity.
The surest way to destroy the bond of affection and to close the border crossing is to give a commodity in place of a gift – ask the spouses on either side of the holiday exchange of a vacuum cleaner. Analogously, Big Pharma and Device give physicians pots and pans, not hand-written cards or mis-shaped crafts from the heart.
Consider political contributions, is there really an expectation that my $10 or $1000 donation will be considered a gift, engendering a politician’s reciprocity. That kind of money doesn’t buy a seat at the dinner let along a seat at the table. Much larger donations may be perceived as a gift, certainly by the donor if not by the receiver - there is always room for those who seek to create obligation from their largesse. The interaction between industry and physicians is neither about gifts nor about reciprocity, it is about the exchange of our time and attention.
By understanding more of gift’s emotional foundation, we can separate the true meaning of gifts from the claims of the watchdogs, like ProPublica, whose importance and value is often more wrongly associated with how much they bark, than in how much they protect.
Source: An excellent discussion of gifts, gift giving societies and the role of interest and usury at the boundary between insider and outsider can be found in The Gift by Lewis Hide.
Chuck Dinerstein, MD, MBA
Director of Medicine
Dr. Charles Dinerstein, M.D., MBA, FACS is Director of Medicine at the American Council on Science and Health. He has over 25 years of experience as a vascular surgeon.
