Gifting Season Can Present Ethical Dilemma for Physicians

It’s that time of year when tasty treats, handmade crafts and other tokens of appreciation are more likely to infiltrate your practice. Some patients opt to express gratitude in a manner they feel is more pronounced than a verbal or written thank you.

As potential receivers, physicians sometimes find themselves in an awkward position during the winter holidays and on other occasions. While accepting a gift, even with the most innocuous season’s greetings, may compromise the professional code of ethics, refusing it can hurt the giver’s feelings in an irreparable way. Whether you should accept the gift depends, in large part, on its monetary value and whether it can be shared with your staff. A tactful explaination of this rationale helps the giver understand why you’re politely declining.

Obligation

Physicians walk a fine line in acknowledging gifts from patients, said D. Micah Hester, PhD, chief of the medical humanities division in the College of Medicine at the University of Arkansas for Medical Sciences and clinical ethicist at the Arkansas Children’s Hospital in Little Rock. “A typical best practice is to respectfully and kindly refuse any gift. However, there is no question that just like any gift-giving situation, this could cause some tension,” he said. Being sensitive to the possibility that the giver could feel rejected is important. “People sometimes give simply out of generosity of spirit, and to deny somebody the ability to give a gift out of that can seem rude or cold. The challenge physicians have is to be friendly without becoming a friend,” he said.

“You can’t throw any gift back in their face,” said Steven Handler, MD, MBE, a professor of otorhinolaryngology-head and neck surgery at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia. “The danger is in not communicating properly. You need to tell them that you really appreciate their gift and their generosity, but you’re not able to accept it.”

One concern is that a gift may make the physician feel obligated to care for one patient in a different way than for other patients, and the giver may expect different care for giving the gift, said Dr. Handler. “It also may make other patients feel that they may get different care because they didn’t give a gift, or make them feel that they have to give a gift,” he said.

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.”

“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.”

On the other hand, Dr. Helft, an oncologist, recalls accepting a handcrafted pen a decade ago from a patient who had completed treatment for esophageal cancer. The patient had made the pen by turning wood on a lathe in his own workshop. Rejecting something special that someone took the time and effort to create could be perceived as a real snub, said Dr. Helft, who stores the pen as a keepsake in his desk at work. “Obviously, patients are free to make gestures or give gifts as they see fit or as their feelings drive them to do. In general, it’s okay to accept gifts when they amount to tokens. The problem, of course, is that it raises the question of whether these gifts could be construed as some sort of quid pro quo.”

At The Children’s Hospital of Philadelphia, where Dr. Handler works as a pediatric otolaryngologist, hospital policy states that any gift of more than nominal value must be turned down. While that actual value is left up to the physician’s discretion, “if someone made a craft—a little handmade thing—I imagine it would be acceptable,” Dr. Handler said. And when it comes to baked goods, he sincerely thanks the giver and responds, “I’m accepting this for my team.” He then shares it with his office or hospital staff. Patients “realize that whatever I do, I don’t do it on my own,” he said.

“This is a professional relationship, and that role has certain parameters or limitations.”

—Micah Hester, PhD, clinical ethicist in Little Rock, Ark.

For Daniel Samadi, MD, a pediatric otolaryngologist in private practice in Hackensack, N.J., gifts flowed in this fall from patients congratulating him on the birth of his son. A steady stream of presents also followed his daughter’s birth two years earlier. To acknowledge Dr. Samadi’s dedication, the families of young patients brought in or sent baby clothes, toys, flowers, trays of cookies, cupcakes and chocolate.

Still, Dr. Samadi maintains that he doesn’t accept any gifts personally, and he tells patients and families that doing so would violate medical ethics. If they insist, he opens the presents in front of them. “I thank them profusely,” he said, while asking for permission to offer the items to his staff members, many of whom also have young children or nieces and nephews. This usually resolves the issue.

“I don’t want the patient to feel like I’m dismissing what they’re trying to do,” Dr. Samadi said. “But at the same time, I want to appreciate the staff for their support and care, and for really being the backbone of my practice.”