Boundary issues between physicians and industry regarding the giving of gifts have been widely debated and written about over the last decade or so. Most hospitals, medical organizations and journals now have well-developed policies in place to help safeguard against the blurring of these boundaries.

But what about gifts from patients? Much has been written on this subject, and most commentators suggest that the acceptance of presents from patients is wrong. In one study dentists were asked what they would feel comfortable receiving and 51% said they wouldn’t accept a gift worth over $100. But
do their words accurately reflect their actions? Do the platitudes appearing in several commentaries really ring true to most doctors?

What’s the appropriate action for a doctor who is offered gifts by patients? This will happen to most physicians during their careers. Few would balk at receiving an inexpensive bottle of wine, or even a gift certificate for a restaurant. We’re gratified and also a little uncomfortable; however, the gift is usually accepted with a smile and a “Thank you for your kindness but this is quite unnecessary.” But when the stakes are higher, what is one to do? Allow us to present two brief illustrative examples from our own practices.

An elderly gentleman visited his native Europe and upon returning to Canada was pale, with a hemoglobin count of 65. He was diagnosed with bowel cancer. His family physician (FP) had always treated him competently and kindly, and now he asked the doctor what he liked to drink. “Bordeaux,” said the FP, “but who can afford it?”

On the day of admission the patient brought a shopping bag containing two bottles of wine. The physician was dumbstruck when he later opened the bag at home — the bottles were worth about $2,500. The next day, the physician went to see the patient on the ward, protesting the gift was excessive. The patient scoffed. He had a basement full of red wine that he could no longer drink, he said, his kids didn’t like it, and he was damned if it was going to go unappreciated in his lifetime. He lived four more years, and at each visit he brought the FP two bottles.

Another example

A lonely, elderly widowed gentleman, also from Europe, required surgery for a benign but painful spinal condition. At his pre-operative visit after the surgical date had been set, he handed the neurosurgeon an envelope. Later that day at home, the surgeon discovered the envelope contained a lovely card containing several crisp $100 bills. The next time the patient did it the surgeon held his hands up as if to plead “Please, no” but the patient literally stuffed the envelope into the surgeon’s coat pocket.

Obviously, we must gently tell these generous people that what they’re
doing isn’t necessary and we would prefer they not do it. But most patients are insistent and should we actually refuse them? Do we send back the bottles of wine or wrestle the envelope back into the patient’s hand? Expensive gifts, especially money itself, clearly represent the most uncomfortable position for any physician at the receiving end of a patient’s gratitude.

Eschew the “party line”

There are four options, we believe. The first is to accept the gift or money and use it as intended by the patient — for your personal use. The second is to accept the gift or money but contribute it to charity. The third is to be emphatic with the patient, tell him you can’t
accept it and send it back to him, perhaps informing him that he can make a donation to research. The fourth option is to inform the patient that you feel morally obliged to terminate the doctor-patient relationship because of irreconcilable boundary transgressions, and offer to find him/her a new physician.

We would contend that the first option is the best. Just accept the gift with thanks and use it to treat yourself, as intended by the patient. The second option is acceptable but not good. The patient has given a gift but now he has been effectively deceived — it isn’t being used as he intended. The third option represents the common “party line” but we consider it undesirable. It would cause the patient embarrassment and emotional discomfort, which could add to his pain and possibly even impede his recovery. In many cultures it’s egregiously offensive to refuse a gift, although not in modern western society, where propriety rules. The fourth option is a cop-out. It just relieves your conscience, inconveniences the patient, and off-loads the problem to the patient’s next physician.

The important challenge and the pivotal issue is how to embrace the first option (i.e. accept the gift/money), but not allow this gift to cloud your judgement or alter your treatment of this individual compared to your other patients. In our examples above, the patient must not jump the queue for investigations or treatment; he must be managed as we would any other patient; he must be discharged on the same day we would ordinarily discharge a similar patient; and ongoing care and monitoring must follow our standard practices for all such people without deviation or “special attention.”

Few doctors feel comfortable receiving presents from patients, especially money, and we ought never to become so. But the alternatives to accepting are worse. Maybe we should all just stop skirting the issue, and let our patients thank us in their own ways.