Am Fam Physician. 2007;76(3):437-438
Author disclosure: Nothing to disclose.
Case Scenario
I have been taking care of a wealthy patient for many years. She has always given me small gifts, mostly food gift baskets that I give to my staff. However, the gifts have escalated since she was hospitalized several years ago. Soon after her hospitalization she said, “If it hadn't been for you, this wouldn't have been diagnosed,” and she gave me a card. Later, when I opened the card, I found a substantial gift certificate to an upscale restaurant. Since then, she has given me several air travel coupons, which she insists are discounts she receives through her business. I admit that I accepted the restaurant gift certificate thinking it was a one-time occurrence, but now her generosity is making me uncomfortable. Should I continue accepting her gifts?
Commentary
Social norms ingrained from early child-hood usually prescribe a polite “thank you” when a gift is received. However, the social norms that govern the relationship between the physician and patient, called professional boundaries, may require a different and more reasoned response. In the scenario, the nature of the gifts progressed from consumables that could be shared with the care team to expensive gifts for the physician's personal use. This evolution may have created a “slippery slope,” making it difficult for the physician to reject gifts after previous acceptances. Even if the physician ultimately decides not to accept future gifts, it may be challenging to find a comfortable and effective way to do so.
An American College of Physicians position paper on ethics states, “A small gift to a physician as a token of appreciation is not ethically problematic.”1 It notes, however, that consideration should be given to the nature of the gift, the potential implications for the physician-patient relationship, and the patient's probable motivations and expectations.1 When a patient offers a gift to a physician, there are several questions the physician may reflect on.
What motivated the patient to give the gift? What does the gift mean to the patient? Is it a small token of warmth and appreciation or a presumed attempt to manipulate or influence care? Is it intended to minimize the inherent power differential between the patient and physician or perhaps an attempt to transform the professional relationship into a more personal or intimate one? Is this patient from a culture in which gift-giving is the only means to ensure quality health care? Physicians should remember that patient motivations can be conscious or unconscious.
What is the nature of the gift? The refusal of a small gift may seem petty, but at what point does a small gift become something more? What if the gift is somehow too intimate? What if it is money? In general, physicians are more reluctant to take money than consumables such as chocolate.2 If a gift makes the physician feel uncomfortable, it is important to determine what about the gift or the situation contributes to that feeling.
How might acceptance or rejection of the gift affect the physician's ability to care for the patient fairly and objectively? If the gift is accepted, will the physician feel obligated to spend more time and effort on this patient than usual? Does the gift create potential conflicts of interest? How might acceptance of the gift influence the physician's relationships with other patients? Rules regarding accepting gifts from patients vary, but the most important factor to consider is how acceptance or refusal of the gift will ultimately affect the physician-patient relationship.
As with many professional boundary challenges, discussion with a mentor or supervisor can help the physician to achieve perspective and resolve the issue satisfactorily. Role-playing can help the physician find language that feels comfortable and effective. Physicians can keep a record of all gifts offered or received and discuss the matter openly with colleagues.2
The giver may easily interpret the rejection of a gift as a personal rejection, and such a concern may motivate the physician to accept a gift against better judgment. The refusal of a gift usually should include an expression of appreciation to the patient for the gesture. The physician should choose words and a tone of voice that convey that the refusal is in the best interest of the physician-patient relationship.
There are several strategies for rejecting a gift from a patient or for setting limits on future gifts:
Appeal to ethical or professional standards: a possible response to the patient in the scenario might be, “I have appreciated your generosity over the years, but I'm afraid I can't continue to accept such expensive gifts. It's an ethical issue. I don't want these wonderful gifts to influence me, and I don't want my other patients to feel obligated to give me gifts.”
Appeal to general principles: some physicians choose to draw a strict line about gifts from patients. In this case, a possible response might be: “I appreciate your thoughtfulness, but I have a general rule about not accepting gifts from patients. The best gift to me is knowing that you're satisfied with the care I've provided.”
Accept a gift on behalf of the care team: “This fruit basket is beautiful. Our office staff will appreciate having it in the break room.”
Suggest a donation to a charity: “I noticed you included $50 in your Christmas card to me, but the sentiments in the card were all I needed. I can't accept the money personally, but would it be okay with you if I donated it to a charity?”
Reassure the patient, if needed: “I know that it is common in your culture for patients to bring gifts to their physicians. I want all my patients to know that they will receive the same care from me whether or not they bring a gift.”
A guiding principle that is useful in many professional boundary dilemmas is altruism.3 Altruism distinguishes a professional relationship from other forms of human relationships and requires determining the best way to place the needs and interests of the patient before the physician's personal needs. An altruistic response might involve accepting a small handmade gift that is given when a patient has a deeply felt need to express gratitude. Other times it might involve rejecting a gift that could threaten the physician-patient relationship. Ultimately, the best interest of this relationship should guide decisions about gifts from patients.