AMA offers guidelines to answer hard questions on patient gifts

Thoughtful consideration is required when deciding whether to accept a present from a patient.

Editorial. Aug. 18, 2003.

A patient's gift to a doctor also can present that physician with an ethical problem. The AMA House of Delegates recently adopted guidelines covering that potentially awkward situation. The new standards are both sensitive to the situation and comprehensive, though they may leave physicians longing for the simplicity of a previous set of gift guidelines -- one that outlined the ethics of accepting gifts from pharmaceutical representatives.

Although those guidelines may not be roundly loved, or perhaps not even roundly followed, they are pretty clear-cut: nominal gifts only, that's all.

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The guidelines on patient gifts, written by the AMA Council on Ethical and Judicial Affairs, are much more nuanced. That's not surprising given the intricacies that surround gift giving and receiving in society in general. Whether and how a gift is received -- or rejected -- can have a profound, lasting effect on the interpersonal relationship between the giver and the receiver.

The stakes are even higher when the two involved are in the already delicate dance that is the patient-physician relationship.

The council decided to take on the topic after numerous calls, mostly around the holidays, from physicians and patients seeking guidance on the topic. But it soon realized that gifts are offered up year round by patients who have a variety of illnesses, come from diverse cultural backgrounds and live at varying income levels.

The council was wise to recognize that the gift-receiving scenario did not lend itself to a one-size-fits-all approach. Instead, CEJA advocates a case-by-case approach and advises physicians to think carefully and exercise sound judgment when offered a gift from a patient or a patient's family.

But the CEJA report does not conclude there. The council offers further guidance, addressing some considerations that should import their sound judgment.

First, consider the giver. Many patients are likely to give a gift simply because they derive pleasure from doing so or want to express gratitude. For some patients, their desire to give a gift stems mostly from cultural traditions.

For others, however, gift giving could be less benign. These patients may be trying to make up for being difficult or even noncompliant. Some gifts could be an indicator of a psychological need that should be addressed by the physician. And some patients may use a gift as an attempt to secure preferential treatment. In the last case, CEJA advises that physicians make clear to the patient that that type of gift compromises their obligation to provide services in a fair manner.

Next consider the gift. While CEJA does not set an amount over which a gift becomes inappropriate, it does indicate that the gift should not be disproportionate to the patient's or the physician's means. CEJA suggests one criterion for accepting a gift is whether the physician would be comfortable if acceptance of the gift became known to colleagues or the public. Physicians also should consider whether the gift transgresses the boundaries of a professional relationship and whether it is offered before or after a patient has made a special request.

What if the gift is in the form of a bequest? If the patient announces that intent in advance, CEJA recommends the physician suggest a donation to a charity or foundation not associated with the doctor. If the bequest only becomes known after the patient's death, the physician should not accept the gift if it appears extravagant in comparison to the family's means or causes a conflict within the patient's family.

Accepting or declining a gift from a patient may not always be the most difficult step in the patient-physician waltz. But as the CEJA effort highlights, it could be one with potential for considerable unintended problems. The right course of action is to dance carefully and to try to avoid your patients' toes while not bumping up against the ethical principles of the medical profession.