Medicine and Commerce. 2: The Gift

Science has helped transform medicine from social function into marketable commodity, catalyzing the recent intrusion of commerce into medicine, most visibly through the development of managed care. As noted in part one of this editorial [1], that intrusion has begun to fragment the guardian moral syndrome-the set of moral precepts-that has traditionally governed the medical profession, paving the way for the metamorphosis of the health care system into a moral “monstrous hybrid.” One major source of the angst over managed care now abroad in the profession thus seems to be our increasing perception that the integrity of the guardian moral syndrome in medicine is in danger of being intractably corrupted [1, 2].

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 …