BA MA PhD
Senior Lecturer in Medical Ethics and Law
Centre for Medical and Healthcare Education
St George's, University of London
Deborah has been an academic since 1991, having worked at Queen Mary College, University of London, the Open University, postgraduate deaneries, and as director of her own ethicolegal and medical education consultancy business. Since 1999, she has been a member of the Medical and Healthcare Education Centre at St George's, University of London, where she is Senior Lecturer in Medical Ethics and Law, as well as Associate Dean for Widening Participation
The sight of a surgery office decorated with "thank you" cards, coffee rooms crammed with biscuits, cakes or chocolates, and consulting room shelves bearing bottles of wine are familiar to most staff working in general practice.* Patients commonly offer gifts as a means of conveying their appreciation.(2,3)
Indeed, sometimes gifts can be proffered after a patient has died, in the form of a bequest. But while provision of food and drink to hardworking staff might appear to threaten little more than their dietary good intentions and waistlines, the issue of gift-giving to clinical staff is rife with ethicolegal dilemmas.
Why think about gifts from patients?
Therapeutic relationships depend on boundaries† and professionalism.(5) In order for the patient to trust the doctor, he or she must believe that the GP or nurse will work without bias or favour in facilitating access to appropriate healthcare. The Royal College of General Practitioners (RCGP) and General Medical Council (GMC) express it thus:
"You must act in your patients' best interests when making referrals and providing or arranging treatment or care. So you must not ask for or accept any inducement, gift or hospitality which may affect, or be seen to affect, your judgment"(6)
"Your decisions about the treatment of patients must always be based on their best interests. Financial inducements, gifts, or hospitality must not colour those decisions"(6)
That the doctor–patient relationship is not one of friendship (and there is a distinction between being friendly and a friend), intimacy or personal involvement allows for the sharing of confidences, disinterested assessment and fair response.
The ethical premise therefore for reflecting on gifts from patients is that such gifts potentially threaten the boundaries and professionalism on which the cornerstone of trust is built. Specifically, the gift may be perceived as indicative of a shift from professional concern to personal involvement, and concomitantly can distort patient expectations.(1)
Of course, the gift may be a perfectly innocent expression of thanks,(7) but the difficulty for the professional is that it is impossible to know whether a gift is a genuine token of appreciation or a sign that a patient's expectations are compromised, or indeed signifies something else entirely (in primary care relationships are longitudinal and distinct(8).(3)
GPs use talk as much as tablets as a therapeutic intervention, with the concomitant transference and counter-transference.(9–11) Once a gift has been accepted and expectations changed, future contact will occur through an imbalanced lens in which a patient may seek special treatment and the professional may struggle to regain his or her nonpartisan approach.(12)
Presents and probity in practice
Most readers are probably unsurprised by this article so far, and are likely to agree that there is an important line to be drawn with regard to patient gifts. The real ethical challenge lies in determining when, how and by whom that line should be drawn. A blanket "yes" or "no" to gifts may seem clear, but is neither grounded in reflective practice nor practicable.(13)
Should practices have a policy on gift giving or should it be up to individual nurses and GPs to decide what they will accept? Does the ethical acceptability attach to the gift itself, the value of the gift, the identity of the donor or the perceived impact of the gift on future practice?
Should practice managers ensure that their employing surgery has a policy on gift-giving and, if so, what should it say? A policy implies that there is ethical value in consistency among staff. A policy is a very practical mechanism, by which practice managers can facilitate the development of an institutional or organisational ethic that is internally coherent, transparent and explicit. Fairness and accountability are prioritised such that all staff and all patients work to the same normative framework.
So far, so ethically satisfying. However, it is worth considering the instant appeal of the policy on gift-giving a little closer if it is to be valuable and practicable. On what moral and legal bases would such a policy rest? What gifts, if any, are acceptable and why? And what would the status of a policy be? Is it for guidance or part of the contractual terms of staff? The apparent ethical clarity of a policy quickly becomes mired in complexity.
Yet a policy should not be dismissed too readily. It is argued that if practice managers use the development process imaginatively to facilitate ethical reflection in which perspectives are shared and flexible guidance develops, then a policy may be immeasurably valuable. Different practices and different practice managers reading this article may well give contrasting, but equally ethically valid, answers to the questions posed in the last paragraph, depending on the culture of their individual practice.
The important point is that there is no inherent moral magic in the mere construction of a policy on gifts from patients. However, a policy that is well constructed and suits the needs and values of the practice can be invaluable. A policy is hastily conceived by an overworked staff, and, if neither inclusive nor collectively owned, will fail.
In contrast, a policy that is thoughtfully created in an environment of structured and reasoned nonhierarchical discussion is likely to serve a practice well in most situations.(14) What, then, should a practice manager considering the development of a practice policy on gift-giving do to so achieve this ethical nirvana?
A starting point might be to agree that all gifts will be declared to other practice staff. Such a requirement need not be onerous, and could be achieved by means of a simple written register that is reviewed regularly by the practice manager to identify cases where further discussion seems to be indicated.
The act of declaring gifts facilitates a transparent system in which collective consideration is integral and there is an opportunity to build up an informal sense of "precedent". The potential for individual staff to allow feelings of flattery to impede their professional judgment is kept in check by the routine scrutiny of all gifts.
Furthermore, if subsequent questions arise in relation to a gift or conflicts of interest are perceived, everyone in the practice will be familiar with the circumstances of the gift giving and able to explain why it was or was not accepted.(15)
If a practice established a system whereby gifts were declared, what sort of criteria might a practice manager employ when deciding whether a gift was unproblematic or warranted further discussion?
First, the nature of the gift is important. Large amounts of money to individual practitioners, intimate gifts and invitations are commonly identified as concerning, be it because of the distorting effect on a doctor's impartiality or because of the possible meaning of gifts.(3,16–18) Furthermore, the "value" of a gift is proportionate to a patient's income.13 In examining the type of gift, the practice manager has to make a judgment about risk that is cognisant of the timing, source and implications of the gift.(17,19)
It is suggested that it is unconvincing for staff, whatever their role in the practice, to protest that they can remain "neutral" in the face of extravagant or very personal gifts. To draw on a well-known concept from the medical-error literature, if a gift raises a practice manager's eyebrows, that would be a very powerful argument for the recipient to reflect on whether it should be accepted or not.(20)
Having decided that a gift is potentially or actually "eyebrow raising", what might the practice manager use to guide collective scrutiny of the gift to ensure that the practice acts ethically? The essence of ethical decision-making in this situation is, it is submitted, that any decision about a gift should be made in the context of human and therapeutic relationships.
That is to say that, although the value or nature of the gift may be important, ethical consideration of gifts demands a more imaginative approach. It is not simply a question of establishing some quasi-scientific formulae in which the value of the gift is quantified.
Small items, and apparently innocuous offerings, may have large and noxious effects when considered in relation to ongoing therapeutic relationships.(5)
Careful facilitation is required so that all staff, irrespective of seniority or role, can express honestly their feelings about the offer of gifts that are potentially "eyebrow raising". An environment of judgmental and moralistic hectoring or casual blindness to the implications of a gift will sabotage reflective and effective practice.
While there may be some gifts that a practice unanimously and easily decides should be either accepted or refused, this is an area of inherent uncertainty.(21) Therefore the ethical response is to acknowledge that uncertainty, and build explicit processes in which critical reflection, consistent practice and transparent decision-making are inherent.
All practice staff will bring to the table their own often unarticulated values and assumptions – the sharing of which is the first crucial step in ethical analysis.(22) As discussion about gifts occurs, so the collective knowledge base of the practice grows – perspectives are shared, normative frameworks begin to emerge, and standards are articulated.
And, in a busy surgery, that might lead to the greatest gift of all for a practice manager: content staff members who understand and appreciate each other better!
*Although it has been argued that even to display presents and cards prominently may create an environment in which it can appear that gifts and overt expressions of thanks are the norm and are expected.1
†In the psychiatric literature, some commentators have distinguished between boundary crossing and boundary violation, arguing that the former may be therapeutic but the latter is always damaging.(4)
1. Capozzi J, Rhodes R. Ethics in practice: gifts from patients. J Bone Joint Surg 2004;86A;2339-40.
2. Lyckholm L. Should physicians accept gifts from patients? JAMA 1998;280:1994-6.
3. Spence S. Patients bearing gifts: are there strings attached? BMJ 2005;331:1527-9.
4. Brendel DH, Chu J, Radden J, Lepper H, Pope HG, Samson J, et al. The price of a gift: an approach to receiving gifts from patients in psychiatric practice. Harv Rev Psychiatry 2007;15(2):43-51.
5. Gabbard G, Nadelson C. Professional boundaries in the physician–patient relationship. JAMA 1995;273:1445-9.
6. Royal College of General Practitioners. Good medical practice for general practitioners. London: RCGP; 2002.
7. Salladay S. Accepting gifts: a thoughtful "tip". Nursing 2001;31(8):66.
8. Bowman D, Spicer J. Primary care ethics. Oxford: Radcliffe Press; 2007.
9. Balint M. The doctor, the patient and the illness. Edinburgh: Churchill Livingstone; 1957.
10. Balint M. The most frequent medicine: yourself. Practical psychology for physicians 1974;July/August:62-6.
11. Salinsky J, Sackin P, Campkin M, Courtenay M. What are you feeling doctor? Identifying and avoiding defensive patterns in the consultation. Oxford: Radcliffe Press; 2000.
12. Lemmens T, Singer P. Bioethics for clinicians 17: conflict of interest in research, education and patient care. CMAJ 1998;159:960-5.
13. Polster DS. Gifts. In: Crown S, Lee A, editors. Ethics primer of the American Psychiatric Association. American Psychiatric Association; 2001.
14. Department of Health. Code of Conduct for NHS Managers. London: DH; 2004. Available from: www.dh.gov.uk/asset-Root/
15. Camilleri M, Cortese DA. Managing conflict of interest in clinical practice. Mayo Clin Proc 2007;82:607-14.
16. Miller WK, Grodeland AB, Koscenchkina TY. "If you pay, we'll operate immediately".
J Med Ethics 2000;26:305-11.
17. Spandler H, Burman E, Goldberg B, Margison F, Amos T. A double-edged sword: understanding gifts in psychotherapy.
Eur J Psychother 2000;3(1):77-101.
18. Griffith R. Generosity or stealing? When accepting a gift can be theft. Br J Commun Nurs 2003;8:512-4.
19. Lindsey C, Jones D, Holmes J, Shooter M. Vulnerable patients, vulnerable doctors. London: RCPsych; 2002.
20. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309-13.
21. Grisbrooke J, Barnitt R. Accepting gifts: a discussion of ethical issues for occupational therapists. Br J Occup Ther 2002;65:559-62.
22. Bowman D. The challenges of an ethical education in europe. Die Psychiatrie 2005;2(3):158-64.