Accepting, rejecting patient gifts: A delicate proposition

Motive, value, appearance all come into play

If a grateful patient presented you with one of his Aunt Mary’s special fruitcakes during the holidays, it was probably pretty obvious that such a gift presents no ethical dilemma.

But what if your patient is injured in an accident that later comes with a sizable monetary settlement, and wants to share a portion of the award with you out of gratitude for his medical outcome?

So long as the gift is not too large — and you had nothing to do with it in terms of giving court testimony or depositions — you are probably ethically in the clear to accept the gift, according to the American Medical Association’s Council on Ethical and Judicial Affairs (CEJA); but other authors on the subject feel the line is much more difficult to draw.

Use good judgment, consider motives

CEJA largely leaves the acceptance or declination of gifts from patients or their families to physicians up to the physician — with some cautionary advice.

"Gifts from patients may be an important means for some patients or their family caregivers to express gratitude for the care a physician has provided," the CEJA opinion states. "However, physicians should be aware that gifts may be offered for many different reasons, and that acceptance of certain gifts may compromise the patient-physician relationship."

Likewise, turning down a gift might have a negative consequence to the patient-physician relationship, the council notes.

Gift giving and receiving is a complex interaction of relational rules. Depending on the relationship and the intention, to reject a gift might offend the giver; on the other hand, accepting a gift intended to secure preferential treatment may be required to maintain the appropriate respect and objectivity key to the patient-physician relationship.

The council’s bottom line recommendation? There can be no set rule for most situations. "Physicians need to think carefully and exercise judgment when deciding whether to accept or refuse a gift," according to the CEJA opinion.

In deciding whether to accept a gift, a physician should consider the giver’s motive. Often, the gift springs from generosity, simply because the patient derives pleasure from giving gifts. The gift might be a sign of appreciation only, not as a means of influencing the physician-patient relationship. In those cases, CEJA suggests, gifts are a "manifestation of goodwill" and not a threat to the professional relationship.

When gifts are a means of influencing care, however, there could be a threat to the patient-physician relationship. If the gift is refused, the patient might be offended; if the gift is accepted and the desired effect (favorable treatment, etc.) is not achieved, the patient might become resentful; or, accepting the gift might cause the clinician to feel obligated and to question his or her ability to make treatment-appropriate recommendations.

Value not the determining criteria

A hundred-dollar gift certificate from a patient of limited means can represent a gift of much greater relative value than a million-dollar faculty chair donated by a wealthy client. Therefore, judging the value placed on the gift by the giver is an important factor in deciding whether to accept it. A large gift from a wealthy donor may not be considered by the patient to be of much value, but might be interpreted by the physician, or his colleagues, as a request for special treatment. The reverse may be true of a gift from a less wealthy patient that may seem insignificant to the physician, but represents a large gift with serious meaning from the patient.

A commonly quoted rule of thumb is to ask oneself, "Would I feel comfortable if my colleagues or the public were to know about this?"

What does it mean when patients give their doctor a gift?, asks British physician Sean A. Spence, MD, who wrote on the topic in the British Medical Journal in 2005. In "Patients bearing gifts: Are there strings attached?" (2005; 331:1,527-1,529), Spence suggests that even though many gifts merely convey a "thank you" sentiment from the patient, within the medical practice, the main argument against accepting gifts from individual patients is the need for justice and equity when dealing with all patients. "So, even in the most sincere interaction, the doctor is on a slippery slope when accepting a gift," Spence writes.

Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency, Spence adds.

Another author, Laurie J. Lyckholm, MD, writes in the Journal of the American Medical Association that regardless of the intent of the giver, a large or expensive gift to a physician "is a serious boundary transgression." She suggests accepting or acknowledging the gift appropriately, to let the patient know the sentiment is appreciated, but to then direct the gift to a charity or foundation. This is true whether the gift is a $1 million gift from a wealthy patient or a $100 gift from a patient who is not well off. ("Should physicians accept gifts from patients?" JAMA 1998; 280:1,944-1,946.)

One author who believes physicians should not accept gifts at all from patients is Charles Weijer, a professor at Dalhousie University in Nova Scotia, who wrote in the Western Journal of Medicine that "gift giving debases the true value of the care that physicians give to their patients."

"The gift of life is simply too precious to be acknowledged by a bottle of scotch, no matter the make or vintage," he concludes. ("Gifts debase the true value of care." West J Med 2001; 175:77.)