Gifting

‘Non nobis solum nati sumas.’
(Not for ourselves are we born.)

—Marcus Tulluis Cicero

When I was still in clinical practice, I had many farmers as patients. There is, however, one I will always remember. He came to all his preoperative, surgery hospitalization and postoperative visits in clean overalls. I asked his wife if he ever wore anything else. She said, “No, but he keeps a special set for church on Sundays.”

On some occasions, when I mildly teased this patient about his attire, he smiled in return. Several years after his successful surgery, he came to follow-up clinic with a gift for me, carefully wrapped in brown paper. He and his wife had conspiratorial smiles on their faces as I unwrapped my gift—a new, starched, blue denim pair of overalls. We all laughed. Then the farmer gave me his second gift as he shook my hand—his silent look of gratitude. I have kept the overalls, and, in my mind’s eye, that moment of gifting.

Many times I have been on the other side of the occasion of gifting, that is being the giver. One such event goes back to my childhood. I graduated from public school at age 12. My class had a remarkable teacher, Ms. Feil, whom we loved, and who gave most of us—in our tough, working class, immigrant neighborhood—the impetus to seek a college education. We gave her a surprise party, gifted her with a corsage, and gave little speeches of thanks and affection. She beamed at us in turn, and I believe she may have remembered that day as I remember the day of the overalls. My memory of the event is of the perfect joy I felt in gifting my gratitude to this extraordinary teacher.

The verb “to gift” is derived from Old Norse, but the act goes back to the beginnings of our species and its expression can be found in the animal kingdom. Chimpanzees and crows have been recorded engaging in gifting to establish bonding. Cave drawings depict gifting, perhaps as peace offerings. Tomb hieroglyphics of ancient Egypt chronicle the presentation of gifts to their gods, and to one another. The Romans made gifting a holiday celebrating the Saturnalia—a week of riotous drinking, eating and gift giving. Gifting has become more sedate in modern times, but gifts are still given to express gratitude, friendship and betrothals, as well as promoting peace, appeasing heavenly gods or earthly rulers, and to bring joy—but also to deceive, bribe and shame.

The importance of gifting in human affairs has been incorporated into religious practices. Gifting has been lauded by emphasizing its remarkable reciprocity, benefiting the giver as well as the receiver. Essentially all religions prescribe or encourage gifting, particularly during their holidays. In the story of Christmas, the three magi came bearing gifts, and 2 Corinthians (9:6-8) tells us to “gift cheerfully and voluntarily.” In Judaism, Hanukkah—a celebration of freedom—gifting represents gratitude for liberation, replacing the ritual of sacrifice. In Islam, gifting is considered a Sunnah (a way of life) of the prophet Mohammad in the name of Allah—the one constantly bestowing gifts. Buddhism teaches that the Buddha stated that the highest motivation for giving is to attain Nibbana (enlightenment) by non-clinging loving kindness and concern for others. In Hinduism, the practice of dana means to give away something you own without expecting anything in return.

The words of the officiant at the funeral rite for a family loved one has best defined the role of gifting in religion for me. During a solemn moment of prayer, an infant gave a hearty, room-filling cry. The attendees looked annoyed, possibly even angry, at the mother of the child. The officiant smiled and said we had heard the voice of a new birth to replace our loss, a gift of hope, of renewal.

In my research of gifting, I was fascinated by betrothal gifting as tokens of affection and commitment. In our culture, we practice the offering of a jeweled ring, usually containing a diamond. This custom started in Austria in 1477, when Archduke Maxmillian proposed to Mary of Burgundy with a ring set with diamonds in the shape of the letter M. Rings for engagement, made of stone and other substances, however, date back at least as far as ancient Rome. A gift of a comb in China denotes bái tóu xié lao, meaning that the couple will be together until their hair turns white. Tea, with or without an ornamental pot, is a gift of engagement in Japan. In ancient Africa, the gift of a cow or cows denoted a proposal of marriage. In our Indigenous American communities, the custom of engagement gifting usually was not between the couple, but between the families of the couple. The groom’s family presents a piece of jewelry, a basket of food or a prized animal hide to the bride-to-be’s family.

The most curious, or perverted, example of gifting is the potlatch tradition, practiced by the indigenous peoples of the Pacific Northwest. At a communal gathering, the participants witness the giving away or destroying of items of value to demonstrate the host’s wealth and power, with the host expecting reciprocation. Potlatch gifting included slaves and sheets of ornamental beaten copper, shield-like in appearance. Canada outlawed the practice in 1884, but later rescinded the law in 1951. Potlatches are still practiced occasionally today in commemoration of an ancestral culture. If I attended such an event, I would be reminded of the words of Ralph Waldo Emerson: “We do not quite forgive a giver.”

‘Health is the greatest gift.’

—Buddha (563-483 BCE)

Gifting has long been integral to healthcare. Hippocrates, a contemporary of Buddha, in his oath prescribed the following: I will reverence my master who taught me the art. Equally with my parents …

Translated to modern times, this oath seems to prescribe the gifting of professional courtesy. Sir Thomas Percival, in 1807, in his Code of Professional Conduct, stated the Hippocratic admonition in the clearest of terms: All members of the profession … should be attended gratuitously.

In 1847, the American Medical Association in its Code of Medical Ethics reiterated this admonition for the American physician and emphasized gratuitous services for the indigent: Poverty, professional brotherhood … should always be considered as solid claims for gratuitous services.

Living by these moral precepts no longer exists in today’s world of corporate medicine. The lawyers who represent most members of both houses of Congress, and, who for themselves mandate 50 hours of pro bono work annually, and have no coded ceilings for their charges, have passed laws forbidding the gifting by doctors of professional services and free patient care. A physician offering his services per gratis, even waiving a copayment, may violate the Anti-Kickback Statute of 1972, and even the False Claims Act of 1863. Such a practice can also be charged as defrauding the contracting healthcare provider organization. Maximum available penalties under these laws for civil lawsuits are up to $50,000 per violation, as well as loss of contract and loss of licensure; criminally as a felony, the fine can be as high as $100,000, as well as up to 10 years in prison. Today there is no publicized case of a physician taken to court under these laws; there is only the threat. Perhaps we, via our professional societies, should challenge these prejudicial laws in court.

My great-great uncle was a rural doctor and made his rounds in a horse-drawn carriage or a sledge in winter, providing free care to his farmer patients when they had a bad season or accepting a chicken or two as payment. Today he would be breaking the law.

It is usually enlightening to follow the money trail. Lawyers can use expenses in pursuing a client’s case pro bono as a tax write-off. In some states, they can also obtain a tax benefit for performing pro bono work. The lawyers in Congress who passed the anti–physician gifting laws receive major contributions from big medical care conglomerates that would lose some of their income if their doctors (today most doctors are employees) do not charge for a service.

I was also intrigued, and actually distressed, by the perversion of gifting inherent in “concierge medicine,” which is legal today, and in my opinion a violation of equal access to care. Because the big medical service entities, hospitals and academic institutions are part of corporate management that regulates doctors’ practices, affluent payors can “gift” (bribe) specific physicians to answer the phone and care for them when needed or desired. The medical provider accepts this gift (bribe) purely to be available to the patient, not for any medical services, for which he or she can charge insurers separately.

Although gifting can be perverted, this holiday season let us honor the splendor of the gift of gifting—the power of reciprocity. I choose to end this column with several quotes on the power of gifting—sacred and secular—to bring joy and benefit to both giver and receiver. I quote from a man of poverty, a man of wealth, a former slave and a great scientist:

‘For it is in giving that we receive.’

—St. Francis of Assisi

‘Think of giving not as a duty, but as a privilege.’

—John D. Rockefeller Jr.

‘Those who are happiest are those who do the most for others.’

—Booker T. Washington

‘Only a life lived for others is a life worthwhile.’

—Albert Einstein

As physicians, as surgeons, we are privileged to gift as part of our calling. Almost every time we step into the operating room, we are bestowing a gift of health, perhaps the gift of life itself. In turn, we receive the intangible gift of happiness that is gifted to the giver.

Happy Holidays in the joy of gifting.

Dr. Buchwald is professor emeritus of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery, at the University of Minnesota, in Minneapolis. His articles appear every other month.