ProPublica recently released a story that Supreme Court Justice Clarence Thomas has been secretly from billionaire GOP donor Harlan Crow for years. Thomas these gifts because of long-ago conversations with fellow jurists who claimed disclosures regarding "personal hospitality" were not reportable. The purpose of gift disclosure is to inform others of one's possible conflict of interest. If instead, Thomas had disclosed, would his role as an arbiter of the law be necessarily fairer?
Physicians also struggle with conflicts around the receipt of gifts by, for example, pharmaceutical companies. such gift-giving from pharma companies will indeed induce physicians to alter prescribing practice in favor of the company giving the gift. To understand the deeper problem with billionaire donors and billion-dollar pharmaceutical companies, it is necessary to understand the biology of fairness, the anthropology of gift exchange, and the potential sinister applications of both.
Fairness is likely a hard-wired behavior, as even kids tend to understand it from a young age. No one needs to teach a child the rules of the "you cut; I choose" exercise for fair division of the last slice of chocolate cake. In , psychologists had kids choose between an option where they would get fewer tokens than another child or an option where both children get fewer tokens but the same amount. Children generally chose the second option -- the same number of tokens each -- so they wouldn't get less than someone else. Interestingly, in another part of the same study, children demonstrated an aversion to getting less but not an aversion to inequality -- they were OK with being the one to get more tokens. Our desire for higher social status at the expense of others powerfully drives us.
In 1925, French sociologist and anthropologist Marcel Mauss published his seminal work entitled The Gift: Forms and Functions of Exchange in Archaic Societies. Mauss studied how the exchange of objects between people build relationships. Fundamental to this activity is the idea of the obligation to give, receive, and -- most importantly -- reciprocate. What is the power of an object that causes the recipient to pay it back? For Mauss, the power of the gift lay in the idea that the giver and the gift are indissolubly bound together. The giver does not merely give an object, but a part of themselves. This is the glue that forms the social bond between giver and receiver and to not reciprocate is to risk the loss of honor and status.
on gift receipt have shown a correlation towards the owed reciprocity based on the gift monetary value. In physician gift disclosure, exemptions may be based on the degree of monetary value. Indeed, the American Medical Association draws this distinction by permitting gifts of . Just a free lunch sponsored and branded by Big Pharma at a conference? Perhaps we won't mention.
According to Mauss, this reasoning is deeply flawed. Pharmaceutical companies people to give the gift. Attaching a face and handshake to the gift is the core of the problem. When physicians know the product they prescribe may be based on conflicted pharmaceutical company-generated evidence, the power of the obligation to reciprocate and write that prescription can still feel overwhelming. Reciprocal gift exchange likely also draws from our deeper need to be fair.
Fairness allows a certain degree of cruelty. Let's unpack this. The well-known psychological experiment "" illustrates a surprising finding: in a scenario where only one of two parties can win, people would rather no one win as the only fair solution. Our desire for fairness can override our self-preservation. In an extreme example, in scenarios where two people have the same interests, we might act as if we prefer that both die instead of one surviving by . However, people like Justice Thomas may be acting on the belief that they have a privilege that comes with high office or some other form of status. This privilege entitles them to a greater weight on the balance of fairness. This may contribute to his belief that he has done no wrong. The hard-working doctor believes this too. Traffic laws like speeding don't apply to them when on the way to the hospital -- no matter if it was a real emergency or not.
In the case of Thomas, receiving gifts from Crow would, in theory, instill a need to reciprocate, but Thomas may lack the enormous wealth to be able to return monetary gifts in kind. Instead, Thomas describes Crow and his wife Kathy as "dearest friends." The implication of this statement is clear: Crow gives Thomas monetary gifts and Thomas reciprocates with friendship -- namely, status. In the book Railroaded: The Transcontinentals and the Making of Modern America, author Richard White analyzes the concept of "friends" and how this term used between railroad men was understood as a euphemism for bribery. Specific quid pro quo has long been illegal, and "friendship" can circumvent this.
Pharma spends a considerable amount of time and money giving gifts to physicians for one specific reason: it works. For the physician, the problem is the need to gift back -- and the only practical commodity to give back is an action that favors the interests of the party that gave them the original gift. Very large gifts may make it paradoxically easier for the physician to feel little obligation to reciprocate. Such large gifts lack the individual human touch. The small gift from the drug rep gains much more power through the building of the rep-physician relationship. The danger here is when physicians are unable to see what might be plain to everyone else -- it is the personal relationship that creates the most powerful obligation to reciprocate. Even children know what's fair.
is an associate professor of anesthesiology and surgery at Emory University School of Medicine in Atlanta. He is also a senior fellow in the Emory Center for Ethics, and has held an adjunct appointment in the Emory School of Law.