But medicine is an art as well as a science. In part two of this editorial, I propose that as an art, medicine creates connections of a special kind, "gift relationships," a network of tight social bonds that have traditionally tied the entire medical care system together. I propose, further, that because commercial trading is fundamentally alien to gift relationships, the spread of managed care is progressively destroying medicine's network of gift relationships, providing a second major source of professional anger and anxiety.

People generally think of the art of medicine in intellectual terms, as something associated with the decision making of experts, a kind of special power "derived from background experience and training; it has been described as intuitive and is therefore difficult to articulate and describe to others" [3]. But it is a less familiar property, the art of medicine as a gift, that creates the social bonds with which we are concerned here.

As scholar and essayist Lewis Hyde has pointed out, the concept of art as a gift is both subtle and essential, manifesting itself in two different ways. First, artists are "gifted"; that is, they are persons to whom gifts of insight, imagination, energy, creativity, and the like have been given. And second, a work of art is truly art only if the spirit in which the artist creates it is principally one of giving, rather than selling, it to the world. Art done principally for sale may be well crafted and may be successful in the marketplace, but it is commercial art, not really art at all. At the extreme, it is the difference between Walt Whitman's Leaves of Grass and romance novels written according to a formula [4].

Art is, of course, only one special kind of gift among the many kinds that people can exchange. Over time, gift giving in large, complex, market-oriented societies has become vestigial; it survives largely in the form of "threshold gifts," tokens given to mark key life passages, such as births, holidays, and marriages. But in other times and places, gift exchange rather than commercial exchange served as almost the entire basis for social relationships, particularly in smaller, less technologically oriented societies. In this social context, a gift is not simply a nicely wrapped package accompanied by a card; rather, as Hyde points out, the concept has a set of specific social, even anthropological, meanings. First, a gift is something that must be given away. It cannot be kept by the recipient as capital for personal gain; that automatically converts a gift into an investment and takes it into the entirely different realm of commercial exchange. Second, when a gift is given, nothing is expected in the way of immediate return. Third, a gift received must soon be passed on, in turn, by the recipient to others. Fourth, gifts so exchanged gain in amount as they move from hand to hand, as a natural fact (as when seeds grow into crops), a natural-spiritual fact (as when the spirit of the gift survives the consumption of its individual embodiments), or a social fact (as when successive owners add materially to a gift, creating a community out of individual expressions of goodwill) [5]. And, finally, it is understood that the gift, increased in size or value, will ultimately return to the original giver, at which point it will again be given away.

The gift nature of western medicine is not new. Writing some 2500 years ago, the poet Pindar made it clear that from its earliest beginnings, the care of patients was to be both given and received, unequivocally, as a gift. Pindar tells of Asklepios, "that hero who gave aid in all manner of maladies," who allowed himself to be "seduced by a splendid fee of gold displayed upon the palm, to bring back from death one who was already its lawful prey." Jupiter promptly destroyed both physician and patient with a thunderbolt [6]. In contrast, any attempt to characterize the art of medicine today as a gift, even in the strict anthropological sense, might seem naive. After all, with the costs of a medical education equalling tens, even hundreds of thousands of dollars, it is hard to claim that medical skills are acquired as a gift, and practicing physicians are now among the better paid members of our society. But on reflection, characterization of today's medicine in gift terms may not be naive at all [7]. The fact is that medicine, for all its financial encumbrances, is still shot through with gift relationships. Consider the following.

1. Until recently, we always talked about "giving medical care," never "selling medical care." As is so often true, language reflected an important social reality: that medicine was not to be thought of as a commodity.

2. Not everyone has the talents, skills, and personality needed to practice medicine well; there is an element of being "gifted" in medicine that is somewhat analogous to that seen in the arts.

3. People can and do earn much more money, and with a considerably smaller personal investment, in careers other than medicine. At some level, then, the giving (in contradistinction to the selling) of care apparently matters to almost everyone who goes into medicine, even those to whom money matters a great deal.

4. Teachers in medicine have rarely been paid to teach; they have supported themselves by caring for patients, becoming researchers, and doing administration. Although this is beginning to change, teaching is still largely "stolen" from these other activities and hence is given as a gift to the profession rather than put up for sale. The professional obligation to teach was clearly recognized in the Hippocratic oath (with its exhortation "... to teach them [the offspring of one's teachers] this art, if they shall wish to learn it, without fee or stipulation ..."). The oath also made it clear that such teaching creates powerful and exclusive social bonds (medicine is to be taught only to the physician's own sons, sons of his teachers, and disciples bound by oath, but to no others) and brings important reciprocal social support (a physician must, for example, reckon his teacher as dear to him as his own parents) [8].

5. The physician-patient relationship was, until recently, a covenant rather than a contract. Although the relationship certainly has both financial and legal implications (particularly when things go wrong), expectations about the exchange of care for money have generally been set forth in loose terms rather than in rigid, legally binding language.

6. Until the early 1960s, salaries for residents in training were minimal. Although unreimbursed time and effort can be seen as investments on the part of residents, they were and to some degree still are at least partly given rather than paid for (witness the outrage against the "shift mentality" that many feared would be created by the regulation of housestaff hours inspired by the Libby Zion case).

7. In return for giving care, physicians of course receive money; until recently, however, most physicians' incomes were relatively modest (in 1937, for example, the average annual income of U.S. physicians 20 years out of medical school was estimated to be about $7500, or roughly $60 700 in 1997 dollars, considerably less than half of what it is today) [9], and payment was sometimes received as gifts, rather than cash. The reimbursement Equation has been written in this way in part because of the difficulty in putting a monetary value on many services that physicians provide, the recent obsession with such things as resource-based relative value scales and quality-adjusted life-years notwithstanding. But the Equation also reflects the "unreckoned gift increase" expected of gift relationships as much as the "reckoned market interest" of commerce because physicians individually also receive many important nonmonetary benefits in return for their services: intellectual satisfaction from clinical problem solving; emotional satisfaction from managing patients' medical conditions well; the gratitude of patients and families; presents; donations given in their names to worthy causes; respect; status; and credibility. Collectively, in return for the care they give, physicians ultimately receive the right as a profession to regulate their own affairs [10].

8. Blood and organs are still largely donated, at least in the United States; that is, they are given as gifts, not sold [11]. Indeed, the sale of organs, tissues, and reproductive services is still looked on with a certain degree of horror. Participation in clinical research is also still almost entirely voluntary, a gift to other people who may benefit from the results, not something to be paid for.

9. Ideas, reagents, and data are often shared among researchers without the expectation of payment in return (although this, unfortunately, is beginning to change). Moreover, the results of medical scholarship are submitted for publication as gifts to the research and clinical communities and to the public, not as commodities to be sold [12].

10. Physicians and hospitals give, and have always given, care gratis to those who can't afford it. And until recently, physicians generally also provided care gratis to other physicians (professional courtesy), a gift that strongly reinforces the social bonds within the profession.

11. The reaction of physicians to malpractice actions may be one of the most telling reflections of the depth of gift relationships in medicine. Physicians who have been sued speak of the experience as devastating, a social and psychological nightmare that is hardly explained by the inconvenience and financial damage involved. It is much more likely that the deep sense of injustice that accompanies violation of a gift relationship is what lies at the root of this reaction; a physician gives care in good faith and receives in return a smack in the face: blame, disrespect, and vengeance.

What is it about commerce that that runs so deeply counter to gift relationships? The answer lies in the fragmenting nature of trading. Thus, for example, commerce requires investment, and investment requires capital. Gifts converted to capital are, however, no longer gifts, because they are kept by the "owner" and no longer passed along to the group. Moreover, lending with interest and commercial trade are both acceptable practices only when they involve "outsiders." Thus, the same cultures that long ago outlawed usury within their own cohesive social groups felt that usury was acceptable, even useful, in dealing with strangers. Making loans with interest and setting up commercial trade therefore actually define people as "outsiders," as "others"; they cut, rather than create, close social ties. More generally, as Hyde suggests, gift cultures are associated with imagination, synthetic thought, gift exchange, use value, and gift-increase, all linked by a common element of relationship, a "shaping into one." The elements that underlie commerce, on the other hand, are analytic or dialectic thought, self-reflection, logic, market exchange, exchange value, and interest on loans, all of which share the property of "differentiating into parts" [13].

Looked at from the "gift" perspective, then, it should come as no surprise that the extension of commerce into medicine has created so much professional distress because it is so destructive of the social context in which healing has always taken place. At the same time, we need to be careful in using such perspectives because seeing the world through the single lens of gift relationships can seriously distort the broader social realities. As Hyde puts it, "Neither of these poles [gift or commercial relationships], the joining or the splitting, is more important or more powerful than its opposite. Each has its sphere and time of ascendancy, and it is not impossible to strike a balance between the two" [13]. Thus, even artists need to eat and must find ways to tie themselves to the commercial sector in order to do so. This creates a dilemma, however, because the closer the tie, the greater the risk that artists will shift their modus operandi from "unreckoned gift increase" to "reckoned market interest"; that artists' creations will "melt down" into commodities (recall that the French refer to EuroDisney as a "cultural Chernobyl").

Artists have dealt with this dilemma, and still do, in various ways: They acquire patrons (or, nowadays, grants); they temporarily step out of their artistic role and into the commercial sector to earn enough to support their artistic "habit" (for example, writers and painters drive taxis); and they sell their art (usually through an agent, which helps the artist stay out of the art "business"), although it is the rare artist who can live entirely on income from that source. The crucial common element among these various strategies is maintenance of the boundary between art and commerce: hence, the integrity of art as a gift rather than a product.

The giving of medical care has obviously moved far from being an art, in the sense of being a gift given; it has reached the point where it makes no sense to pretend that we can restore the impermeability of the boundary between medicine (as an art) and commerce. Large, complex societies are not sustained on gift relationships alone. Medicine is a trillion-dollar part of our economy; there is no going back. But it is equally crucial for everyone involved in health care to recognize that the essential core of medicine involves gift relationships and that beyond a certain point, the conversion of gift relationships into commercial ones would be so destructive of its social nexus that medicine as a healing art might well disappear.

If the general experience of artists translates to medicine, however, it should be possible to mitigate the corrosive effects of commercialism on the art of medicine. The actions needed to protect the gift nature of medicine are strikingly similar to those needed to minimize the corruption of medicine's guardian moral precepts [1]: Stake out clear boundaries-or, as Robert Frost put it, make "good fences"-between medicine as a gift and medicine as a commodity and never lose sight of the distinctions between them. Does this mean that in dealing with the commercial world, the health care professions should retreat defensively behind its fences? On the contrary. The medical profession will need to be right in the thick of it over the coming years, playing an increasingly tough, intelligent, activist role in a heavily technological and fiercely commercial world. How we will manage not to be thrown off course by the awesome leverage of the marketplace isn't clear to me; what is clear, however, is that we absolutely must work from a base of care given rather than sold. Good fences are important precisely because they make it possible to create an effective symbiosis between medicine, both as art and science, and commerce, and to do so without losing either our moral or our social compass [1, 2].