Grateful patients often offer gifts to their family physician, a seemingly simple gesture that can raise complex issues in the therapeutic relationship. There are no definitive rules regarding acceptance of gifts from patients and opinions on this matter are divergent. Some believe that doctors should never accept gifts because this gift could influence standards of care or weaken the fiduciary relationship. Others are of the opinion that accepting gifts in certain circumstances allows patients to express their gratitude and strengthen doctor-patient ties.
In previous studies, it was found that 20% of physicians who responded to the survey had received gifts of which the most common were chocolate, pastries, alcohol and money 1 , 2 . While the supply of gifts is fairly common in clinical practice, literature on the subject is scarce and sample sizes are limited 1 , 3 – 5 . In addition, there is not much material to guide physicians in deciding whether or not to accept gifts. The Canadian Medical Association does not address the offer of gifts by patients in the Code of Ethics or in the Charter of Physicians. The American Medical Association suggests only that every gift should be evaluated case by case 3 . The Provincial Orders in Alberta 6 , Manitoba 7 and Quebec 8 allow the acceptance of “symbolic” or “insignificant” ill-defined gifts. Provincial Orders in Ontario 9 , Nova Scotia 9 , 10 in Newfoundland 11 and Prince Edward Island 12 recognize that acceptance of gifts may constitute a potential crossing of boundaries that can be interpreted as Professional misconduct. Orders in Saskatchewan, New Brunswick and the territories do not explicitly mention patient gifts, while the British Columbia order 13 allows the physician to be responsible for the decision in practice. Trainees also mentioned the need for better guidelines to know when we can accept gifts 14 .
It is not surprising that opinions vary as to whether gifts should be accepted from patients 2 , 4 , 15 , 16 . The argument may be made, however, that under certain circumstances, accepting gifts is acceptable to most physicians. There are 3 different common practices regarding the acceptance of gifts: never, always and a conditional acceptance. Among these, conditional acceptance (with objective measures to define such acceptance) might be the most appropriate.
Accepting gifts under certain circumstances
Some doctors choose not to accept gifts from their patients. The guidance document for Ontario physicians suggests that gifts could be considered “border crossing”, potentially leading to “breach of boundaries”, including professional misconduct 9 . By refusing all gifts, physicians adopt a coherent approach that eliminates all potential sources of crossing limits. Furthermore, in the same document recognizes that many boundary crossings are benign and do not become major problems 9 .
Others are of the opinion that accepting a patient’s gift can be beneficial. This gesture can strengthen the friendly relationship between doctor and patient 2 , recognizes patient independence 2 , adds to patient self-esteem 17 and builds trust . 15 People can take great satisfaction in giving gifts 15 and if a gift is refused, the donor may feel hurt 2 or offended 18 . In some cultures, gift giving is an important part of community dynamics and rejection of a gift can be perceived as rudeness 16 .
There is a general consensus that accepting all gifts is not appropriate. In reviewing the literature, it appears that there are no practice guides, opinion pieces, or primary research that advocate indiscriminate acceptance of all gifts. Rather widely recognized that doctors should refuse gifts when they are extravagant or inappropriate, given the dynamics of the doctor-patient relationship 2 , 17 – 19 . Selective acceptance (or conditional acceptance) recognizes the benefits of accepting gifts from patients while applying criteria that assess the potential of the unethical implications of offering a gift. When offered a gift by a patient,
Is the gift given to guarantee preferential treatment?
The American Medical Association has a clear policy, reflected in many opinion articles, regarding the denial of gifts aimed at obtaining preferential treatment 2 , 17 , 18 , 20 . Improper care 2 or “jump the queue” 21may have negative repercussions for both the person giving the gift 20 than for other patients 21 . The complex expectations and interpersonal dynamics present in each therapeutic relationship add a dimension that doctors may not always recognize. It is important to be aware of the possibility of changes in the relationship after the acceptance of a gift 5 , 18 . The particular characteristics of the gift giver (factors related to personality, personal limitations, vulnerability) can also influence the approach of the doctor 5 . Gifts that are changing the doctor-patient dynamic can complicate the physician’s objective discussion of sensitive issues such as non-adherence to medication, sexual history or dependencies 2 , 20 . Conversely, if the doctor accepts a gift but does not change the standard of care, the patient may experience a grudge 20 .
Is the gift intimate?
Gifts of intimate or personal nature should be rejected for not crossing the limits required by the professionalism 17 . Others have argued that the acceptance of personal gifts (such as lingerie) for would-cause removal of the professional relationship that would hurt patient care 3 , 17 . It is clearly in the doctor’s interest to avoid accepting such items.
Is the gift extravagant or excessively expensive?
The excessive value of a present presents another difficulty 2 , 17 , 20 . Homemade gifts or those of nominal value are benign and can be accepted without any likely negative impact 20 . On the contrary, cash gifts can be considered as “tips” or “a bribe” to the doctor 2 , 17 . Cases where doctors have accepted large sums of money have attracted media interest and, by extension, have undermined public confidence 2 , 5 . Gifts of money or funds transmitted by will should be refused or redirected to an appropriate charitable work, After explaining the reason for the refusal 2 , 5 , 17 . In addition to deny or redirect gift excessive value, there is also appropriate not to accept those known to be above the patient means 20 . If the doctor does not know or can not accurately assess the patient’s means, it would be prudent to refuse his gift.
One might wonder what constitutes excessive value. Usually, this judgment is left to the discretion of the physician. Some centers define an acceptable maximum gift value (eg, $ 50) 3 . The doctor may also ask the question whether it would be comfortable that the acceptance of the gift is made public or discussed 17 .
When is the gift offered?
The moment the gift is offered is also important. Gifts given after an identifiable action can be an expression of gratitude 18 . Similarly, gifts given during the holiday season may reflect cultural traditions 18, 20 . Gifts given impromptu should deserve special attention because they might mean that the patient expects to receive more than the standard of care in the future 18 .
Accepting gifts remains a matter of controversy among doctors. Establishing an upper limit on the value of gifts could help determine objectively whether or not a gift can be accepted. Cash gifts should be given to appropriate charities. If a doctor feels uncomfortable or can not gauge the motivation behind the gift, he should refuse it. Any gift accepted or refused should be documented 5 , 9 , 10 , 19 . When a gift is denied, an explanation of the decision could spare the feelings of the patient and maintain the therapeutic alliance 5 .
It might be useful to have more explicit guidelines on ethical and practical aspects of accepting gifts from patients. However, most doctors can navigate without problems in this common situation by using a flexible approach that takes account of its inherent complexities.
This article has been peer reviewed.
The English version of de cet article est disponible à www.cfp.ca on the table of contents for the December 2013 issue on 1259 page .
The opinions expressed in the comments are those of the authors. Their publication does not imply that they are sanctioned by the College of Family Physicians of Canada.