Supreme Court justices and physicians share a commonality: they both receive gifts from individuals who have a vested interest in their decisions. However, they mistakenly believe that these gifts don’t influence them. Gifts serve as more than just gestures; they establish and maintain relationships by creating a sense of obligation. This indebtedness is a universal social norm and an essential aspect of human interaction, as discussed by sociologist Marcel Mauss in his essay “The Gift.”
The power of reciprocity is subconscious and influential, and it doesn’t always necessitate a direct exchange. A material gift doesn’t always have to be reciprocated with another material gift; it can be reciprocated in other ways, such as showing favor towards a particular company, group, or individual. The manipulation of feelings and choices using gifts has intrigued me for many years. As a physician and professor heading PharmedOut, a research group at Georgetown University Medical Center, I study covert marketing tactics employed by pharmaceutical and medical-device companies. At times, I have been requested to serve as a paid expert witness for plaintiffs in pharmaceutical marketing lawsuits.
While my research primarily focuses on how pharmaceutical companies subtly shape physicians’ beliefs regarding drugs and diseases, the issue of gift-giving has now emerged within the highest court in the nation. ProPublica recently reported that Justice Clarence Thomas has enjoyed at least 38 destination vacations funded by benefactors who share his ideological inclinations. The New York Times also uncovered that Thomas accepted favorable financing from a wealthy friend for a high-end RV and failed to disclose it. Additionally, an investigation by ProPublica found that Thomas accepted private plane trips, yacht cruises, and luxury vacations from Republican donor Harlan Crow, who has spent millions of dollars in efforts to align the judiciary with his conservative beliefs.
In response to the controversy, Thomas issued a statement claiming that he sought guidance and was advised that personal hospitality from close friends, without any business before the Court, did not require disclosure. Crow stated that they never asked about pending or lower court cases, Justice Thomas never discussed them, and they never attempted to influence him on legal or political matters. Justice Samuel Alito made a similar argument when criticized for accepting luxury vacations from billionaire Paul Singer, who had cases before the Court. Alito defended himself, stating that they never discussed Singer’s businesses or any case or issue before the Court.
However, influence is rarely overt or obvious. Meals, trips, and exclusive accommodations can instill a sense of gratitude in recipients and gradually increase their openness to the interests of the gift-givers. Crow’s defense that Thomas and his wife never asked for this hospitality is irrelevant because no explicit request was necessary.
A close friend of mine began working for a prominent foundation where she would have the power to decide which organizations receive funding. A colleague told her, “Say goodbye to true friends and bad meals.” I wish someone had imparted a similar sentiment to the justices.
Gifts can impact behavior in ways recipients are unaware of. A classic study showed that giving individuals a soft drink before asking them to purchase raffle tickets for a good cause increased ticket sales, regardless of the likability of the giver. In his op-ed, Alito emphasized the “modest” nature of the lodging Singer provided during a luxury fishing vacation, describing it as a comfortable but rustic facility with homestyle fare. However, numerous studies have demonstrated that even modest or insignificant gifts have a disproportionate influence. The branded trinkets given to physicians by drug representatives were not only intended to keep specific brand names in mind but also to maintain relationships. Although pharmaceutical companies voluntarily stopped providing these “reminder” items in 2009 due to public criticism, they were effective marketing tools.
Our research shows that accepting a single meal from a pharmaceutical company can lead to physicians prescribing more expensive drug options and prescribing more drugs per patient. Many other studies have demonstrated that the industry’s promotional tactics increase the prescription of targeted drugs. Interestingly, physicians acknowledge that promotional efforts can sway their colleagues’ drug choices, but they believe they are immune to such influence themselves. This self-serving bias, known as the “bias blind spot” in social psychology, causes people to readily identify biases in others but not in themselves.
The truth is that nobody is impervious to persuasion tactics. Professionals, whether physicians or justices, may believe that their professionalism prevents them from acting unprofessionally. Acknowledging the possibility of acting unprofessionally creates cognitive dissonance, which is the discomfort generated by holding opposing beliefs simultaneously. Cognitive dissonance is mitigated by rationalizing the conflict, deeming one factor irrelevant, or, less frequently, by changing attitudes or behaviors.
Alito’s protestation that the seat on Singer’s private airplane would have otherwise remained empty is an example of resolving cognitive dissonance through rationalization. The private plane trip, valued at over $100,000, falls into the category of expensive gifts. To resolve the dissonance between being an ethical Supreme Court justice and accepting a potentially bribe-like expensive gift, Alito discounts its value. He rationalizes that the trip’s cost would remain the same whether or not his seat was occupied. However, as a Supreme Court justice, occupying that plane seat made it the most valuable on the aircraft.
Similarly, physicians justify accepting industry-sponsored meals and favors by arguing that their opinions cannot be swayed by a free lunch. Yet, they are mistaken. The modesty of the food validates their belief that their prescribing decisions are unbiased. As they cannot fathom their professional judgment being influenced by a sandwich, physicians rationalize that they prescribe a targeted drug because they genuinely believe it is the best option.
This bias blind spot might explain why Thomas, Alito, and many physicians see no issue with accepting gifts from those who stand to benefit from their decisions. However, gift recipients should question whether their relationships would persist without gifts, favors, services, and adoration. Would doctors meet with pharmaceutical representatives if they only offered sales pitches without food, gifts, services, or opportunities to boost income? Would justices engage in conversations with billionaires if they met at a local coffee shop and everyone paid for their cappuccinos?
A friend’s father, a businessman, believed he had close friendships with vendors with whom he conducted business. They went fishing, attended sports events, and shared countless meals. However, upon his retirement, he was shocked to discover that these relationships abruptly ended. The annual invitation to the Kentucky Derby disappeared, and his “friends” became permanently unavailable. Because Supreme Court justices have lifetime appointments, individuals who aim to influence them have a long-term strategy. Unless they step down from the bench, these relationships with benefactors will continue to influence Supreme Court justices.
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