Should I accept gifts from patients?BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h617 (Published 10 February 2015) Cite this as: BMJ 2015;350:h617
- Marika Davies, freelance journalist, The BMJ
The offer of a gift from a patient may be more complicated than a simple expression of gratitude. MarikaDavies explores the ethical issues behind accepting gifts from patients
In January 2011, psychiatrist Peter Rowan was erased from the medical register as a result of having accepted a £1.2m legacy and £150 000 in cheques from an elderly patient. He had also prescribed excessive doses of benzodiazepines to the same patient and had failed to communicate with other doctors who had responsibility for her care. When the fitness to practise panel considering the case explained its decision, it said that Rowan’s acceptance of substantial sums of money had clouded his judgment. The panel expressed concern that Rowan had not realised how inappropriate it had been to even contemplate accepting the proffered gift.
Doctors often receive gifts from patients who wish to express their gratitude for the care they have been given. A survey published in The BMJ in 1980 found that 20% of UK doctors had received a gift from a patient in the preceding three months.1 Gifts range from chocolates or a bottle of wine to more unusual or personal offerings. One doctor writing on Twitter said he had been given a bag of golf balls that a patient had found while dog walking on a golf course. Anthony Papagiannis, a doctor in Greece, has written about some of the more unusual gifts he has received. These include a red woollen waistcoat that a patient knitted for him during her chemotherapy sessions.2
It may be entirely reasonable to accept a small token of appreciation from a patient. In fact, refusing it may cause embarrassment that could unnecessarily harm the relationship between a doctor and a patient. But gifts of money or items of high financial value raise contractual and ethical issues that doctors need to consider. In particular, there is a risk that accepting a gift could, or could be perceived to, impact on the doctor-patient relationship by altering the way in which a patient is treated or encouraging favouritism or preferential treatment.
In 1993 the Department of Health issued guidance to all NHS trusts on the standards of personal and professional behaviour expected of NHS employees. Although the guidance is not mandatory, NHS trusts are expected to enshrine these standards in the way they and their staff conduct their business. As a result, in the hospital sector doctors are normally required to agree to local policies that oblige them to refuse all gifts from patients. However, articles of “low intrinsic value,” such as diaries or calendars or small tokens of gratitude from patients or their relatives, need not necessarily be refused. In cases of doubt, staff are advised to consult their line manager or politely decline acceptance.
There are also particular restrictions for general practitioners (GPs) in this area. The NHS (General Medical Services Contracts) Regulations 2004 require GPs to keep a register of gifts from patients or their relatives that have a value of £100 or more. The register must include information such as the name of the donor, the NHS number or address of the patient, and the nature of the gift and its estimated value. GPs must also make the register available to NHS England on request. The BMA suggests that GPs may also need to seek financial advice about declaring large gifts or bequests for tax purposes.
The GMC’s Good Medical Practice guidelines include advice on how to deal with offers of gifts from patients. They say, “You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.” But the guidelines add that doctors may accept unsolicited gifts from patients or their relatives “provided: a) it does not affect, or appear to affect, the way you prescribe for, advise, treat, refer, or commission services for patients and b) you have not used your influence to pressurise or persuade patients or their relatives to offer you gifts.”3
Writing in The BMJ in 2005, Sean Spence, a professor of psychiatry, says that doctors are on a slippery slope when accepting gifts, even in the most sincere interaction. “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),” he says.4
Why do patients give gifts?
Understanding the reasons why a patient is giving a gift is key when considering whether to accept it. Patients may give their doctors gifts out of genuine gratitude, but Paquita de Zulueta, a GP in London and lecturer in ethics, has described several other reasons for patients giving gifts (see box).5 A patient may wish to express feelings of affection for their doctor, and a simple gift may be accompanied by a romantic letter or a more inappropriate gift. Patients may also use gifts to gain the attention of their doctor or to attempt to manipulate doctors into providing preferential services or treatment. De Zulueta suggests that doctors should try to understand the reasons behind a patient’s gift. “Correctly gauging the underlying motive helps to shape the response, but may not always be easy in practice.”
The General Medical Council emphasises that doctors should never accept a gift if there is any risk that it may influence their professional decision making. In the case of Peter Rowan, the fitness to practise panel said that the potential legacy would have been substantial and would have resulted in an even more dysfunctional doctor-patient relationship. An expert witness told the panel considering Rowan’s case that the promise of future gifts put the doctor “on notice that he had to conform in order to qualify for the future gift” and that this was “more manipulative that the outright gift.”
As well as considering a patient’s motivation, doctors should also take into account factors such as the cost of the gift in proportion to the patient’s means, the appropriateness of the gift, and whether there are particular circumstances, such as the patient being vulnerable, that may attract criticism.
The timing of the gift may also be relevant. Giskin Day, a senior teaching fellow at Imperial College London, says in her blog about gratitude in healthcare: “Gifts given at Christmas are customary, and possibly more acceptable because they form part of rituals surrounding celebration, and one need not be suspicious of ulterior motives on behalf of the giver.”6 Spence says that patients’ gifts are often given in return for an identifiable medical intervention and a gift arriving “out of the blue” should be treated with special caution, “as the doctor has done nothing [yet] to deserve it.”
Advice to doctors
The Medical and Dental Defence Union of Scotland advises doctors to consider carefully any offer of a gift. “If you have concerns over its potential influence on your professional decision-making, discuss the issue with your patient and be prepared to refuse the gift.” Pallavi Bradshaw, a medicolegal adviser at the Medical Protection Society, says it is important to maintain appropriate boundaries with patients. “Transparency and accountability are essential when considering an offer of a gift from a patient. Deciding whether it is appropriate to accept a gift should involve discussions with colleagues, the patient and, where appropriate, the patient’s family.”
Kathryn Leask, medicolegal adviser at the Medical Defence Union, says that doctors need to be careful about what they accept and how this is recorded. “If a gift is seen to be more than a token of appreciation, such as a large amount of money, or an expensive gift, there is a danger that a doctor accepting it could be criticised as taking advantage of the patient’s position.
Leask points out that thank you letters and other tokens of appreciation can provide valuable colleague and patient feedback. “We’d advise all doctors to keep a record of any gifts they receive for their appraisal and revalidation,” she says.
The General Medical Council says, “If you receive a gift or bequest from a patient or their relative you should consider the potential damage this could cause to your patient’s trust in you and the public’s trust in the profession. You should refuse gifts or bequests where they could be perceived as an abuse of trust, and must not put pressure on patients or their families to make donations to other people or organisations.”
The American Medical Association suggests a useful test for doctors offered a gift from a patient. Doctors should, the association says, consider whether they would be comfortable if acceptance of the gift were known to colleagues or the public.
Other ways to say thank you
There are other routes that can be explored when patients wish to give money to show their appreciation but doctors are uncomfortable accepting a personal gift. Many practices donate cash gifts that they have received from patients to charity or buy practice equipment that will benefit patients. The Giving Tree at the Royal Brompton Hospital allows patients to express gratitude publicly and donate money to the hospital charity rather than to an individual.6
Charles Weiger, a doctor and ethicist in Canada, considers gift giving debases the true value of the care that doctors give to their patients. He says, “The gift of life is simply too precious to be acknowledged by a bottle of scotch, no matter what make or vintage.” He suggests “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.”7
Why patients give doctors gifts 5
To show genuine gratitude
To redress the balance in terms of power sharing
Out of affection
To attract attention
To manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give
To expiate guilt for burdening the practitioner
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: I am employed as a medicolegal adviser by the Medical Protection Society.