For a few months this spring I found, wherever I walked, paths covered in pastel chalk, offering gratitude and lauding essential workers as “heroes.” The same message was audible overhead as people leaned out their windows at seven each spring evening in New York City, clapping and sounding bells and horns repurposed from sports games past. The number of times that I personally have been thanked for working as a physician in this city during COVID-19 is lovely and staggering. At the same time, some US medical residents who merely inquired about hazard pay have been told that such questions were “not becoming,”1 and could lead to career penalties. I think it is likely that these individuals were trying to define professionalism for themselves and their families.

Something feels flimsy and tautological about the current state of affairs for healthcare essential workers. Doing the work renders us heroes. The society thanks us by giving us, again and again, this title of “hero,” and we reciprocate that gift by in turn giving more of our heroic work, without asking whether the type of work or the limitations of the work conditions we are experiencing go beyond our commitments to serve our patients trustworthily.

Let me digress a moment for this: I love being a doctor. Moreover, I willingly undertook a career with significant occupational hazard—from unpredictable hours, to patients whose illness might cause volatility or aggression, to communicable diseases. This was the deal, in exchange for a career that brings such wonder and joy. I love meeting and listening to patients, solving diagnostic puzzles, devising therapeutic regimens, and working under fast and sometimes heart-racing conditions. I even love the bitter privilege of ministering to a patients’ suffering or death, because it is so rare to accompany another human being in that way, and moreover so rare to have had mentors who taught me, I hope, how to be useful, self-effacing, and awed when I do so. I see these actions as part of my professionalism, and among the gifts that patients bestow on me, because they go beyond the specifics of my work contract.

Much of my work, however, falls within my work contract. When someone’s blood culture grows Staphylococcus aureus and I prescribe a dose of vancomycin, I am not giving a gift; I’m doing my job. When an administrator assigns me to a particular shift date and I arrive at that shift, neither of us is giving the other a gift; we’re at work, in accordance with contracts that bind us to each other and our institutions by firm pacts. I am willing to go beyond the specifics of my contract because I love and respect my role as a physician. Ongoing extreme risk without appropriate compensation or risk reduction should not be expected of healthcare workers, however, under the label of gifts or heroism. Instead, efforts should be made to improve work circumstances.

As a faculty physician, I am well paid, have reasonable job security, and receive benefits such as health insurance and vacations. For medical residents, some benefits will only be experienced in the future. For other essential healthcare workers, compensation and benefits are much more limited. Yet less-compensated workers are bearing a share of the COVID risks and demands that is often equal to or greater than those experienced by higher paid professionals. This raises issues of justice, a fundamental ethical principle. A better distinction is needed between the heroism or giving-of-self necessary to meet unanticipated temporary job conditions, and the enforced “giving” or “heroism” that simply becomes an ongoing, uncompensated or unremediated job expectation.

The early twentieth-century sociologist Marcel Mauss observed gift-giving practices around the world to tease out the difference between gifts and other transactional contracts. In his 1925 The Gift: Form and Reason for Exchange in Archaic Societies, he writes that contracts are easier to define: they are quantitative and specific, with precise and predetermined mutual profits for each party when the contract is upheld, and equally precise penalties if broken.2 Gifts, on the other hand, tacitly (sometimes explicitly) demand reciprocity, but their enforcement mechanism is through the honor and selfhood of people and their communities. There aren’t legal penalties for lack of gift giving. However, the stakes of not giving are high: one’s very self is on the line. And a loss of “honor,” such as was experienced by the residents who questioned the breadth of their work commitments, can have long-term consequences.

“What is wrong with the so-called free gift is the donor’s intention to be exempt from return gifts coming from the recipient. Refusing requital puts the act of giving outside any mutual ties,” says anthropologist and Mauss scholar Mary Douglas.3 True gifts are those that prompt cycles of action that “engage persons in permanent commitments.” When we construe labor as “gifts” and expect the giver to continue giving freely, without tangible reciprocation, we break these cycles of action.

There is danger in gifts. When someone’s working conditions become abruptly unjust or untenable, for instance, then there is no longer a valid contract governing that work, and whatever a worker chooses to continue to do in accordance with that prior, no longer pertaining, contract shades into the realm of gift. For those who work for reasons of need, precarity, and vulnerability, or who have limited options for changing jobs, being expected to continue gifting not only may be unjust but also may lead to a diminished sense of accomplishment or self-worth.

In everyday life, we use the gift-related words “thank you” and “you’re welcome” even when non-gift transactional work is involved—handing someone a syringe or mopping a hospital corridor, for instance—mostly, I think, because we recognize that the particular style, grace, or personal presence that an individual brings to that work is indeed a gift, one worthy of esteem and prompting future exchanges. And gifts are, in Lewis Hyde’s words, “social faith,” sorely needed at present.

But it can be dangerously easy for hoped—for “gifts” to become “expectations”—obligatory, quasi- or pseudo-contractual. This is what struck me as the evening vuvuzelas and cowbells, the soundtrack of World Cups and marathons, greeted me as I entered the hospital to begin my night shifts this past spring. Turning my work into a “gift” binds my honor and integrity into the exchange. It’s flattering, but as the months go on, it’s also harder to call attention to the need for workplace improvements if one has internalized this view of one’s higher-risk or unprecedented work as a gift to society. Moreover, converting one’s particular, idiosyncratic self into a “hero” can make one believe over time in the attendant expectation to be “ungrudging” and “strong” rather than (perhaps appropriately) inquisitive, pragmatic, or skeptical. I am fortunate to work under fair and reasonable conditions. But I know this is not the case for many essential healthcare workers. I fear that the pervasive gift/hero mentality makes it harder to fight for justice for them—and harder to convince oneself of what one deserves.

Shifting our attention from the “gifts” of individual “heroes” to a discourse of protections and rights is a necessary move, one which mirrors the evolving definition of “medical professionalism.” As Frederic Hafferty and Dana Levinson have written, for too long the concept of “professionalism” focused on a view of medicine that privileged “individual motives and behaviors,” while a more useful redefinition should call our attention to “how systems and structures affect individuals and how organizations themselves might embody professional principles.”3 We know, too, that long before the pandemic, burnout has been pervasive in American medicine.4 Clarifying what can and should be asked of doctors and their teams, versus what constitutes taking advantage of our “hero” complex, might be helpful. Most healthcare professionals see going above and beyond written contracts in times of need as part of the work. No one, however, wants to foolishly continue to carry excessive burdens in perpetuity. Simply making it possible to discuss and address such issues might go far in improving the health of the workplace.

Since the pandemic began, I’ve found myself consciously smiling more, saying “thanks,” trying to make sure I explicitly notice the infinite forms of labor that construct the world I live in. And I should—we should—be grateful. I am grateful to those who encouraged me during a difficult time with their communal displays of thanks, and I appreciate and am warmed by the community spirit that prompted those displays. At the same time, it’s important to remain wary of excessive use of displays of gratitude to reinforce the ongoing behavior of accepting excessive or remediable work risks or demands. Long after the pandemic is over, this striving for conceptual clarity will remain a cornerstone for building a more just and a healthier healthcare workplace.