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To the Editor: In their social science perspective on biases in the practice of accepting gifts from drug companies, Mr Dana and Dr Loewenstein¹ understated their case by focusing narrowly on self-interest bias. They overlooked a large body of literature that suggests gifts may influence physician behavior in more ways than they suggested.²

Across cultures and over time, it has been observed that gift exchange stimulates social advancement by creating networks of obligation. Giving a gift is more than a nicety—it creates a social contract. Gifts create reciprocal obligations, even if the gift is unwanted and the giver is distrusted or disliked. To refuse a gift is socially awkward and refusal is often considered a declaration of conflict. This pressure to accept gifts reduces individuals' abilities to choose to whom they are indebted. Furthermore, the form of reciprocation is often determined by the giver. Because it is distasteful to receive . . . [Full Text of this Article]

Dana Katz, MBe
Department of Medical Ethics
University of Pennsylvania School of Medicine
Philadelphia

Peter Mansfield, BMBS
Healthy Skepticism Inc
Willunga, Australia

Robert Goodman, MD
Division of General Medicine
Columbia University College of Physicians & Surgeons
New York, NY

Leonore Tiefer, PhD
Department of Psychiatry
New York University School of Medicine
New York

Jon Merz, JD, PhD
Department of Medical Ethics
University of Pennsylvania School of Medicine

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