Is it better to give, receive, or decline? The ethics of receiving gifts from patients

Consider this hypothetic case: A patient comes in to see his PA, who assisted with an extensive emergent surgical procedure due to multisystem failure. The prognosis was poor at the time of surgery, but the patient has made a full recovery and has returned for a 6-month follow-up visit.


The patient brings his family along, and they are all very excited to meet the surgeon and the PA, whom they credit with saving the patient's life. The patient and the PA have had numerous personal conversations in their time working together, and the patient learned of the PA's fondness for professional baseball and other sports. The patient is a wealthy business owner and has secured four season tickets for the local major league baseball team. At the follow-up visit, he tearfully presents these to the PA, along with a team jersey. The estimated value of these gifts is $5,000.


BACKGROUND AND POLICIES


Physician assistants and others who practice medicine develop undeniably intimate relationships with patients in a variety of settings. Because clinicians are human, such relationships are inevitable, and they may in fact have therapeutic benefit for patients. But the provider can be challenged with forming an appropriate response when a grateful patient offers a gift out of appreciation to the provider.


There has been little sustained discussion of the ethics of receiving gifts from patients, a fact noted by Weijer in 2001¹ and still true today. For example, the American Academy of Physician Assistants ethics policy makes no mention of this issue.² Although the American Medical Association (AMA) has related ethics policy intended to provide some guidance to clinicians on receiving gifts from patients, it is vague and lacks directive stances or positions.³ The AMA policy and a related paper frame the issue in a general fashion, leaving decisions related to receipt of gifts from patients almost entirely up to case-by-case consideration: "There are no definitive rules to determine when a physician should or should not accept a gift. No fixed value determines the appropriateness or inappropriateness of a gift from a patient."³ 


CONFLICT OF INTEREST?


In the absence of direction from the AMA and other such organizations, many health care institutions have developed their own policies. The University of Washington Medical Center and Harborview Medical Center, related institutions of the umbrella organization UW Medicine, have policies in place that prohibit acceptance of gifts from patients that are greater in value than $50. These policies allow for receipt of gifts to providers greater than $50 in value provided that such gifts are directed to the institution and away from the individual clinician.⁴


Like the AMA ethics policy, institutional policies consistently frame the issue of patient gift giving to clinicians as one involving conflict of interest. This framing generally evaluates whether such practice may influence clinicians in some way and typically implies that if the receiver can be sure that influence is not an issue, this ends the ethical consideration. The University of Washington policy notes:


For example, UW faculty may not receive, accept, take, seek, or solicit, directly or indirectly, anything of economic value as a gift, gratuity, or favor from a person if it could be reasonably expected that the gift, gratuity, or favor would influence the vote, action, or judgment of the officer or employee, or be considered as part of a reward for action or inaction.⁴ 


Similarly, the AMA's ethics policy related to gifts from patients also frames the issue as involving a conflict of interest:


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. Physicians should make clear that gifts given to secure preferential treatment compromise their obligation to provide services in a fair manner.³


BROADER FRAMING


A more nuanced look at the issue can be found in the Ethics Primer of the American Psychiatric Association, which was developed in 2001 as a tool for psychiatrists teaching ethics as well as for residents. The primer offers a more complex examination of issues related to patients giving gifts to clinicians and moves beyond the traditional view that "if it doesn't impact your behavior, then it's probably okay."


The nature of the gift itself must also be considered. Accepting an extremely intimate gift such as lingerie would be unethical, as would gifts of money for the physician's personal use. In such cases, we begin to suspect that a patient's motivation for giving a gift is not so innocent. Giving the gift may represent an attempt to equalize the power structure of the relationship or to seduce the physician, or may be a conscious or unconscious bribe (Lyckhom 1998). It is important that the treating psychiatrist be aware of transference issues present in the therapy as a possible basis for the patient's gift. In some instances, accepting a gift could perpetuate an erotic or other transference and could be quite harmful to the therapeutic relationship—and ultimately to the patient. Accepting gifts in such instances is unethical.⁵

In a piece from 2001, Weijer also moves beyond the typical conflict of interest view and offers a much broader analysis and perspective of ethical challenges related to receiving gifts from patients. Weijer argues that physicians should never accept gifts from patients and offers four reasons:¹


The clinician has a fiduciary obligation to the patient, and this is violated when the care provider receives items of value from patients other than through established reimbursement and payment systems. Thus, "accepting gifts erodes the special moral character of the physician-patient relationship." 
It is difficult, and perhaps even impossible, for the clinician to fully understand the possibly complex reasons why the patient may offer a gift. Weijer calls this "unavoidable uncertainty" and argues that it necessitates refusal of all gifts from patients. 
Even if gifts are given for what are "purely altruistic motivations," others may perceive or suspect that gift giving may lead to preferential treatment of the patient. This may contribute to a belief that the way to curry favor from physicians and other medical practitioners is with gifts. 
Weijer describes the threat to the value of care clinicians provide to patients, noting:


Fourth, and most importantly, 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. More meaningful and appropriate ways exist to express gratitude, such as a heartfelt "thank you," a letter recounting the family's joy, or a photo of the patient enjoying a moment of life that my medical care allowed him to experience. These gestures mean so much more than a gift precisely because they cannot be purchased.¹