Patients bearing gifts: are there strings attached?BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7531.1527 (Published 22 December 2005) Cite this as: BMJ 2005;331:1527
- Sean A Spence, professor of general adult psychiatry ()
- Academic Clinical Psychiatry, Division of Genomic Medicine, University of Sheffield, Sheffield S5 7JT
- Accepted 4 October 2005
The love embodied in the gift outlives the giver, affirms his life drive, and adds a sense of beauty to the endurance of life.1
It was Christmas Eve and the elderly man had walked in his pyjamas through the sleet and snow, until he reached the accident and emergency department. He already knew that he had cancer, but now he was in acute urinary retention. As luck would have it, the house surgeon who came to see him was the one he knew from the ward; they exchanged banter as the younger man sited a catheter. A few nights later, when the house surgeon was back on the ward, the elderly man called him over. He had a gift for him. It was a bottle of champagne. In his working life he had been the head waiter at a famous restaurant; this champagne was the favourite drink of a celebrity who had dined there. The houseman was speechless with emotion; he liked the man and knew he was about to die. It was the first gift he had received from a patient.
The meaning of gifts
What does it mean when a patient gives their doctor a gift? Often, it means “thank you for being there,” especially at a difficult time.2 3 The elderly man had walked through the snow, despite being in great pain. Perhaps his gift was offered in thanks for relief from that pain. Perhaps it was an attempt at being understood on another level: as someone who was not always old and ill, but who had worked long hours and earned respect as a head waiter. A single gift may have many “meanings.”1 4 5
Although gifts from patients to doctors are common,2 4 6 they have attracted little systematic research. Most of the available literature comprises case reports and series from the world of psychotherapy1 5 7; cautionary, anecdotal tales from general practice3 8; and small surveys of hospital doctors.4 6 These data are derived largely from the industrialised West, as reflected in the gifts most often reported: bottles of alcohol and boxes of chocolates.3 6 No one has surveyed the impact of gifts on doctors' health, but their impact on nurses' wellbeing has been investigated.9
The giving brain
What does a gift tell us about the patient's mind and brain? At the very least, in an adult, it indicates that they thought about the doctor before their meeting, during the performance of a purposeful act (the acquisition of a gift). Hence, in the language of psychoanalysis, the gift indicates that the doctor persists in the patient's mind as an internal “object” (that to which action or desire is directed… that to which the subject relates himself).10 Indeed, if the gift is taken at face value, then the doctor constitutes a “good object,” one eliciting kindness. Alternatively, from a cognitive neurobiological perspective, the acquisition of the gift implies the working of higher, prefrontal, brain regions engaged in the formulation of intentions, so called “memories of the future”11; the patient has shown that he or she can plan ahead. So the proffered gift carries information, but is it always good news?
A mixed blessing
According to the Oxford English Dictionary, a gift is “something, the possession of which is transferred to another without the expectation or receipt of an equivalent; a donation, present,”12 so it might seem churlish to “look a gift horse in the mouth.”6 7 However, consider some alternative definitions, such as “a fee for services rendered,” “something given with a corrupting intention; a bribe.”12 Similar ambivalence can be traced back through many languages and cultures.1 Things may not be all that they seem.
Here are two questions for doctors receiving gifts from patients: (1) Should any gift be accepted? (2) Should this gift be accepted?
Within medical practice, the main argument against accepting gifts from individual patients is the need for justice and equity when dealing with all patients.2 3 4 If doctors accept gifts from those who can afford them will they think or behave differently around those who cannot? If doctors accept gifts they may nurture “favourite” patients, and there are risks on all sides.2 3 8 15 Doctors may expend more time and effort on selected patients, rules may be bent (for example, on waiting lists or home visits), and “special” patients may precipitate staff rivalries and divided teams.16 Doctors may spend relatively less time on other patients and favoured patients may also experience disadvantages: the doctor who becomes a “friend” is no longer impartial and may sacrifice critical judgment (for example, when excluding a neoplasm or a sexually transmitted disease) or even violate boundaries (through inappropriate intimacies).3 4 7 8 15
So, even in the most sincere interaction, the doctor is on a slippery slope when accepting a gift. Moreover, towards the bottom of that slope are more instrumental, exploitative incursions, which can originate from either side (for example, bribery for favourable reports or preferential treatment in lieu of charitable donations).3 4 8 15 In the United Kingdom, the General Medical Council's (2001) Good Medical Practice warns doctors against soliciting gifts: “You must not encourage your patients to give, lend or bequeath money or gifts which will directly or indirectly benefit you. You must not put pressure on patients or their families to make donations to other people or organisations“17 (italics added). This document advises against deliberately seeking gifts but gives no advice on accepting those that are offered. In contrast, classic psychoanalytical teaching states that gifts from patients should never be accepted because they conceal unconscious motives, which should be interpreted rather than enacted.1 5 7 Nevertheless, Freud himself accepted gifts and some contemporary psychotherapists have argued cogently for a more nuanced approach.5 Refusing a gift risks offending the patient and may seem petty when the gift is small. Also, in psychotherapeutic settings, automatic refusal of a gift may impede certain kinds of progress within the patient (for instance, among those who have difficulty giving and receiving).1 5 7 Finally, the requirement that a doctor should never accept a gift from a patient may make life difficult in small or isolated communities, where private and professional lives are hard to dissociate (for example, should a doctor's child accept a present from a friend at the village school when the friend's parents are the doctor's patients?).
Saying yes (sometimes)
Although most authors would accept alcohol and chocolates, they are more reluctant to take money and generally draw the line at intimate or transgressive items (such as pornography).2 3 5 7 8 18 So, most feel that culturally appropriate gifts of low monetary value are relatively “safe.” In most organisations the demands of probity require that employees decline gifts that might be seen to influence their judgment.7 Hence, no gift should be so valuable that it could be suspected of incurring undue influence: doctors must be seen to be above suspicion.
In addition, regardless of the value of the gift offered, the doctor might wish to reflect upon its meaning to the patient. Even an inexpensive gift might presage problems. So, it could be argued that not automatically refusing all gifts makes life more difficult, incurring a constant need for vigilance.
When exercising discretion over the acceptance of individual items, the following question is helpful: why is the patient bringing their gift now? At Christmas the answer seems obvious. However, the point remains: did they bring a present last year and the year before that? Has anything changed recently?
The scant empirical base we have suggests that patients' gifts are often given in return for an identifiable medical intervention.4 6 Hence, surgeons may receive more gifts than physicians because of the more tangible nature of their treatments.6 The sociological interpretation of this phenomenon is discomforting—namely, the gift is a “tip” for “more than standard” service. This is why doctors do not automatically reciprocate—implicitly or explicitly they understand that the “gift” of their treatment initiated the process—that is, they “gave” first.4
Irrespective of how one feels about the paternalism implied by this approach, it suggests that a gift arriving “out of the blue” should be treated with special caution, as the doctor has done nothing (yet) to deserve it. Indeed, the concept of “more than standard service” encompasses a variety of meanings: from those patients seeking to monopolise their doctor to those who are acknowledging that they can be difficult and require “toleration.”4 The gift may also be a way of balancing power: patients humiliated by the sick role may demonstrate, by their largesse, their importance in the outside world. Alternatively, the gift can constitute a “sacrifice,” offered to the “power” of the doctor to heal (a kind of magical thinking to keep misfortune away).4
The sociological critique is not as materialistic as first seems; this is just as well. For the reduction of gift giving to instrumental exchange can obscure important messages: the man relapsing into mania may bring an extravagant gift; the elderly widow, dying, might say “goodbye” with one,19 as might the suicidal patient1; the erotomanic patient might send their doctor a single theatre ticket,20 and the disgruntled patient may give their doctor a medical textbook. The wealth of meaning surrounding the gift may repay reflection.
What is to be done?
The most appropriate advice is to take nothing for granted and reflect upon the gift and its timing. A polite refusal may be preceded by reference to the ethics of medical practice or could emphasise that declining a gift does not equate to rejecting the patient. Whatever the outcome, a thank you note is appropriate.4 Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency.
Finally, doctors and their colleagues receive other “gifts” from patients all the time,21 without the donors' awareness, such as the vicarious satisfaction the doctor derives from their patients' recovery or the deep impression they leave behind when showing great courage in the face of suffering—as with the elderly man who walked in retention through snow, on Christmas Eve, until he reached the emergency department.
Competing interests None declared.