Another aspect to consider is the possible influence of the gift’s timing—whether it occurs during treatment or after medical care has been completed. If it is given before treatment is over, “a certain kind of conflict of interest comes up,” said Dr. Hester. “It could act as an inducement for special treatment, for going above and beyond, and it could influence the physician in a way that makes him or her act differently.” However, the same concerns apply if treatment may need to resume at a later time, and it’s tough to always predict when and if a patient will call upon your services again, he said. There is no denying “the psychology of reciprocity,” Dr. Hester added. “We know from research that humans are moved to reciprocate when given even as little as a dime from someone else. So, even the well-meaning gift-giver may unintentionally receive special treatment.”
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December 2012
“We’re all human beings and we can be influenced, but again, in the ideal world, you need to treat everybody equally.”—Daniel Samadi, MD, pediatric otolaryngologist in Hackensack, N.J.
AMA Guidelines
The American Medical Association (AMA) has established ethical policies on gifts to physicians from patients and industry. The policy states:
“Gifts that patients offer to physicians are often an expression of appreciation and gratitude or a reflection of cultural tradition, and can enhance the patient-physician relationship. Some gifts signal psychological needs that require the physician’s attention. Some patients may attempt to influence care or to secure preferential treatment through the offering of gifts or cash. Acceptance of such gifts is likely to damage the integrity of the patient-physician relationship.”
The AMA also urges physicians to “make clear that gifts given to secure preferential treatment compromise their obligation to provide services in a fair manner.” Nonetheless, the group offered “no definitive rules to determine when a physician should or should not accept a gift.” It added that “no fixed value determines the appropriateness or inappropriateness of a gift from a patient; however, the gift’s value relative to the patient’s or the physician’s means should not be disproportionately or inappropriately large.”
Among the issues highlighted by the AMA is whether a physician would feel comfortable if colleagues or the public knew about the gift’s acceptance. The policy advises caution if patients mention gifts in the context of a will, insisting that these conversations must not influence medical care. “If, after a patient’s death, a physician should learn that he or she has been bequeathed a gift,” the policy states “the physician should consider declining the gift if the physician believes that its acceptance would present a significant hardship (financial or emotional) to the family.” The AMA noted that “the interaction of these various factors is complex and requires the physician to consider them sensitively.”
“Recently, I received a gift card, and I sent it back to the family, saying, ‘I really appreciate the sentiments and your good wishes, but I’m not able to accept this by our hospital regulations.’ ”—Steven Handler, MD, pediatric otolaryngologist in Philadelphia
Determine Where to Draw the Line
Even with this guidance, physicians aren’t entirely sure where to draw the line or how to assign monetary value to a gift, said Paul Helft, MD, an associate professor of medicine at the Indiana University School of Medicine and director of the Charles Warren Fairbanks Center for Medical Ethics at Indiana University Health in Indianapolis. Dr. Helft has looked after very wealthy patients for whom giving a set of theater tickets or an elaborate gift basket presumably wouldn’t pose financial hardship. Still, regardless of a patient’s net worth, “if somebody said, ‘I want to give you a car,’ that would be a gift that I feel I had to refuse,” he said. “Refusing such a gift would be understood as a matter of principle.”