Spence Sean A. Patients bearing gifts: are strings attached? BMJ 2005; 331:1527-1529

Summary

The giving of gifts is an ancient and ubiquitous human activity. However, when a patient gives the gift to her/his doctor, ethical considerations may arise. The author begins the article with the story of an elderly man who walks into the emergency department of a hospital in severe pain. The doctor on call treats him, promptly and kindly. A few days later the patient gives the doctor an expensive bottle of champagne.

The author attempts to analyse what the patient may have wanted to convey to the doctor through this gift. It could mean a simple thank you for being there and for providing relief. Maybe the patient wanted to remind the doctor that he was not just an old man and that he had had a profitable career once when he handled such expensive wines.

According to the Oxford English Dictionary, a gift is “something, the possession of which is transferred to another without the expectation of receipt of an equivalent.” Alternative definitions say a gift can be “a fee for services rendered” or “something given with a corrupting intention; a bribe.”

The author says that doctors receiving gifts from patients must ask if any gift should be accepted. If the answer is “yes”, they must ask if this particular gift can be accepted.

The main argument against accepting gifts from individual patients is the need for justice and equity when dealing with all patients. If doctors accept gifts from patients who can afford them, will they treat patients who cannot afford gifts, differently? Will doctors play “favourites” and spend more time on gift-giving patients? Will they bend rules? The doctor who becomes a “friend” is no longer impartial and may sacrifice critical judgment or even violate boundaries through inappropriate intimacies.

The author contends that, “… even in the most sincere interaction, the doctor is on a slippery slope when accepting a gift … towards the bottom of that slope are … exploitative actions such as bribery for favourable reports or preferential treatment in lieu of charitable donations.”

The British General Medical Council’s (2001) Good Medical Practice warns doctors against soliciting gifts: “You must not encourage your patients to give, lend or bequeath money or gifts which will directly or indirectly benefit you. You must not put pressure on patients or their families to make donations to other people or organisations.” The document advises against deliberately seeking gifts but it gives no advice on accepting those that are offered. Classical psychoanalytical teaching says that gifts from patients conceal unconscious motives.

However, refusing a gift may offend a patient. “The requirement that a doctor should never accept a gift from a patient may make life difficult in small or isolatedcommunities, where private and professional lives are hard to dissociate. For example, should a doctor’s child accept a present from a friend at the village school when the friend’s parents are the doctor’s patients?”

Most organisations require employees to decline gifts that might be seen to influence their judgement. Most doctors feel that culturally appropriate gifts of low monetary value are relatively “safe”. When thinking about accepting a gift, the doctor must ask why is the patient bringing the gift now? Gifts are often given after specific medical intervention.

Surgeons receive more gifts than physicians. The gift is a “tip” for “more than standard” service. “This is why doctors do not automatically reciprocate—implicitly or explicitly they understand that the “gift” of their treatment initiated the process. That is, they ‘gave’ first.”

A gift arriving unexpectedly must be seen with suspicion. The gift may be a way of balancing power: patients humiliated by their sick role may demonstrate, by their largesse, their importance in the outside world. Alternatively, the gift may constitute a “sacrifice”, offered to the “power” of the doctor to heal, which is a kind of belief in magical powers to keep away misfortune.

Commentary

In many societies, significant moments in a person’s life are marked by an exchange of gifts. Every illness that results in a medical encounter is a significant event in a patient’s life. Indeed, the provision of medical services is a gift from the physician to the patient where the fee paid is not equal to the “value” of the gift received (1). It is therefore not surprising that physicians receive gifts from their patients.

Charles Weijer gives four reasons why a gift from a patient is problematic: it interferes with the fiduciary relationship between patient and physician; it is difficult to judge the motivation with which a gift is given; it raises doubts about the physician’s impartiality in the minds of other patients; and the gift attempts to put a monetary value on something which is priceless. He writes, “The gift of life is simply too precious to be acknowledged by a bottle of scotch, no matter the make or vintage” (2).

However, it is generally recognised that most gifts from patients are probably innocuous. Therefore the code of medical ethics of most countries hardly addresses this issue. This is in sharp contrast to the strict rules that govern gifts from pharmaceutical and medical technology industries to physicians, where the intent to bribe for particular favours is obvious.

Arguing in favour of accepting gifts from patients, Andereck says there should be the space for expressing sentiment in a doctor-patient relationship. This recognises personal values and creates a bond. Rejecting a gift could be interpreted as rejecting the giver. By accepting a gift the physician acknowledges the patient’s autonomy and worth as a fellow human being and affirms the genial nature of the patient-physician relationship (3).

Even if no gifts were involved, physicians often give more attention to some of their patients. Perhaps those patients are charming, or demanding, or have endured a particularly difficult medical illness, etc. But medical attention in exchange for gifts is unethical. It reduces the delivery of medical care to a service that can be bought rather than one that is given justly, according to a patient’s need rather than his or her ability to “buy” extra services (4).

The most appropriate advice is to take nothing for granted and reflect upon the gift and its timing. A polite refusal may be preceded by a reference to the ethics of medical practice or an emphasis that declining a gift is not equal to rejecting the patient. Whatever the outcome, a thank you note is appropriate. Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency.

Hospitals, medical schools, and other health care institutions are often the beneficiaries of patients’ gifts. When a patient has donated large sums of money to an institution, he or she should receive a formal, sincere, and possibly public acknowledgment of gratitude from both the physician and the institution. However the physician should not feel pressured or obligated to give the patient special attention in the form of inordinate amounts of time, priority scheduling of surgery and examinations, etc (4).

Medicine has turned into a business and some unsavoury practices have crept in. Not only do hospitals accept gifts with gratitude, some even resort to cultivating a long-term relationship with a potential donor. Rumour has it that a hospital in Chicago had assigned a young, good looking clerk to scan the hospital’s daily admission lists and identify wealthy widows to woo in order to ensure a hefty bequest in their wills.

In the Indian context, gifts may also be given in lieu of fees. Patients invariably pay for their medical consultations from personal funds. When a doctor or her/his immediate family member consults another doctor, the consultant often refuses to accept payment for the service saying that it is part of the medical profession’s ethics to provide free service for one of their own. The recipient often tries to reciprocate by giving an appropriate gift to the treating doctor. This practice can be quite hazardous to the financial health of a doctor because the Indian concept of “immediate” family is quite stretchable. I have come across physicians who have faced financial hard times because their practice involved a disproportionately large numbers of extended family and friends.

Perhaps some doctors yearn for the good old days when gifts from patients were the norm especially during the holiday season (5). In the current setting, where medicine is a commodity, gifts are rare (1). Perhaps the return of the friendly gift will tell us that medicine has become human again.