Video Abstract

Video Abstract

Gift giving is psychologically and culturally complex. In any context, a gift can have multiple meanings. In the context of the doctor-patient relationship, the giving of gifts and decisions about whether to accept gifts raise complex ethical issues. In this essay, a number of pediatric oncologists discuss the ethical considerations that should guide physicians as they decide how to respond to an extravagant gift from a family.

Patients and families are often profoundly grateful to doctors. Sometimes, they want to express their gratitude by giving a gift. The impulse to give a gift can reflect an admirable generosity. It can also have more complex and sometimes troubling ethical implications. Gifts may be attempts by patients or families to ensure that they will receive preferential treatment. They may be attempts to sway the doctor’s clinical judgment. They may lead to other, unforeseen, and perhaps even unintended consequences. In this Ethics Rounds, we present a case in which a family tries to give the child’s oncologist an extravagant gift, and the family won’t take “no” for an answer. We then ask a group of pediatric oncologists to discuss the ethical issues raised by the case.

Diamond is a 2-year-old girl who was diagnosed with acute myelogenous leukemia 6 months earlier. She was ill at diagnosis and spent an extended time in the ICU. Her parents are grateful for the care she has received from her oncologist. The family owns a successful jewelry business and has repeatedly asked the oncologist if she would like any jewelry. The physician has repeatedly declined the offer and also said she could not accept such a gift. Recently, the family gave the oncologist a bag of homemade brownies. She accepted them gratefully. She later realized that the bag included a diamond-and-ruby pendant necklace from the family’s business. The physician spoke to the family and said the gift was generous, but she could not accept it. They are not willing to take it back. The value of the necklace is above the limit in the professional boundaries policy, and the physician is not sure what to do. She reported the donation to her department chair, who wonders if it should be donated to the hospital charity, or should the employee be allowed to keep it? The physician will be working with this family over the course of at least the next year. If the family were to learn the necklace had been donated, it is possible they could react negatively, which could strain the dynamic between the patient, the patient’s family, and the clinical team.

Gift giving is a common social practice and an acceptable medium for people to express their feelings. Gift giving is common in cultures. However, this simple act of appreciation and kindness by a patient’s family to a physician can sometimes have complex ramifications. It is usually reasonable and polite to accept small tokens of appreciation from grateful patients. Refusing a much thought-out gift may not only cause embarrassment and disappointment to the patient but could also potentially hurt the therapeutic relationship.

On the other hand, gifts of high monetary value raise contractual and ethical conflicts in a physician-patient relationship. Several views exist on whether physicians may accept such gifts from their patients. Professional society recommendations are not always clear.

The American Academy of Pediatrics (AAP) maintains that gifts from patients carry a far more symbolic value compared with real material content. The AAP policy statement on the pediatrician-family-patient relationship states that generally accepting “modest gifts from patients does not involve a serious conflict; in fact, refusal of a gift may constitute a social or cultural affront.” The policy argues that if a “pediatrician feels uncomfortable with a gift that a family insists on delivering, he or she must voice the concern and suggest acceptable alternatives, such as a charitable donation in the pediatrician’s name.”1 The American Medical Association (AMA) asks that physicians “decline gifts that are disproportionately or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted.”2 This leaves a void in the definition of what constitutes an unacceptable gift.

To guide their respective employees, several institutions have developed their own policies in this regard. For example, a hospital may prohibit employees from accepting gifts with a monetary value >$25 or items of >$100 when a department or a service shares them. But in a society riddled with a wide economic divide, the same monetary amount might have a different value for different patients based on their financial status. What seems modest for some families can be extravagant for other families. This puts the onus on the physician to reasonably assess whether a gift is within the means of the patient.

The doctor should also consider the reason why a patient is giving a gift. Although it is impossible to know the exact intent behind an action, past or subsequent behavior may give a clue as to motives:

  1. Some patients are just generous and derive pleasure from the act of giving without any underlying desires or expectations. Gift giving may be a customary component of some cultures, especially around festivals and anniversaries, and patients may just be following their traditional or personal values.

  2. Some patients may feel guilty of burdening their physicians with their care. This may be especially true for physicians in certain specialties that involve providing care for long durations and involves complex emotional situations. In those situations, doctors and nurses develop intimate bonds with their patients and vice versa. Some patients may give gifts in appreciation of the excellent care they received during a critical illness or after a successful surgical procedure. Although this motive is more focused than pure beneficence, there is no intent to change future behavior.

  3. Some patients may give their physicians a gift to gain special attention or manipulate them to get preferential services. Although this is uncommon, there are instances of institutions unknowingly promoting this habit by providing special recognition to patients who make sizeable gifts, often providing them with so-called donor badges or publicizing them on social media. This creates an impression that gifts and donations are expected. Giving a gift to influence an outcome is unethical and should be discouraged.

Practicing medicine involves a fiduciary relationship. It is the physician’s responsibility to make it clear to patients that gifts are neither expected nor desired and that any gifts or their absence will not affect the quality of care that the patient receives. When gifts are accepted, transparency and accountability are essential, especially when gifts are of a high monetary value. It is advisable to let your superiors know and discuss with colleagues if a patient wants to give such a gift. The physician should discuss this freely with families and encourage them to donate to a charity of their choice. They may donate in honor of the physician.

In this vignette, it appears that Diamond’s family is appreciative of the care she received from her oncologist and would like to give a gift to acknowledge and express gratitude to the physician. There does not appear to be any intention to change or influence future behavior or to get any special favors. In principle, although it would be reasonable for the physician to accept a gift from this family, the high monetary value makes the physician uncomfortable. The physician may feel obliged to reciprocate (knowingly or unknowingly) or be concerned about the implications if the knowledge of this gift becomes public. She may worry that this could erode other patients’ trust in her as a physician. An additional complexity in this case is the family members’ persistence in offering jewelry from their business and the ultimate decision to conceal the gift within a bag of brownies, thus placing the high-value gift within the physician’s possession without her immediate knowledge of it.

The physician rightly approached the parents first, and when she couldn’t get them to take the gift back, she informed the department chair. Together, the physician and her department chair should meet with the family, explain why the physician is uncomfortable accepting the gift, and emphasize that being unable to accept the gift does not equate to rejecting their appreciation or feelings.

If the family members continue to refuse to take the gift back, it would be appropriate to notify them of the institution’s plan for the necklace (donating it to the hospital charity). Redirecting a gift toward a charitable donation not only is honorable but also strengthens the legacy of the physician-patient relationship. It also may be helpful for organizations to develop and publicize a mechanism that allows generous contributions to be directed toward the hospital or clinic for the benefit of all children.

The oncologist here is torn between competing obligations: her need to avoid or minimize potential harm to her patient’s family (both immediate emotional harm and long-term damage to the therapeutic rapport between family and physician) and her need to respect boundaries set forth in the policies of her institution and in many professional codes of medical ethics. Such policies and codes originate from concerns that personal gifts might lead to favoritism, biasing the care of patients in favor of those who can afford such gifts over those with fewer resources, or at least contribute to expectations or perceptions of such favoritism as well as disrupting boundaries meant to protect both patients and physicians.

As a starting point, I would suggest that the oncologist and her department chair clarify their hospital policy. If the policy does not allow for physician discretion and sets forward consequences for employees who violate it, then the way forward for this oncologist is somewhat simpler. She can and should return the gift with an apologetic but firm explanation that to keep it might cost her her position. This is something that most families will understand. She might further explain that although she fully believes that the gift was given in the spirit of gratitude, acceptance of the gift might unintentionally change her behavior toward families that cannot afford such generosity.

If the hospital policy does allow for some flexibility in interpretation, then the oncologist is faced with more complex considerations. Physicians should not deceive patients and families about the extent to which their actions are constrained by policies or regulations to avoid difficult conversations. In this case, she has already said she could not accept the gift yet was pressured (and even deceived) into keeping it. She should reflect carefully on the family’s motivations as best she can perceive them. Do Diamond’s parents seem to expect special treatment or advantages as a result of the gift? Do they now perceive an inappropriately intimate relationship with the oncologist? If there are obvious concerns in this regard (for example, if, at the next visit, the family begins refusing to allow residents to examine the daughter or suddenly asks for the oncologist’s home phone number), then the gift should be returned promptly, at the same time as those concerns are directly addressed. A sensitive conversation of this nature should not be conducted in the patient’s presence.

I would not suggest that this oncologist donate the necklace, especially not without discussing it with the family. Although this gift may not be so obviously personal as vegetables from a child’s garden or a hand-knit sweater, it may nonetheless hold deeper significance for the patient’s parents. Perhaps, as jewelers, they designed it themselves or chose the stones to represent their child’s name, birth date, or other qualities. Regardless of other ethical concerns that must be addressed, the generosity and symbolism of the gift should not go unacknowledged. I might also consider the child’s prognosis in this light: If she is unlikely to survive, the risk of the family receiving preferential treatment over others might be small compared with the potential psychological harm of returning the gift. The family’s act of giving the necklace may be 1 way in which the parents are attempting to exert social control over a situation in which they feel powerless. They may feel that the oncologist has gone above and beyond what they expect of a health care provider, and thus, they seek to correct an imbalance in the relationship.3,4 In addition to impeding these objectives, the oncologist’s refusal of the gesture may result in feelings of humiliation or rejection. These concerns do not justify accepting gifts in every circumstance but are worthy of consideration and should guide the discussion with the family.

Finally, although some institutions may suggest steering such families toward a grateful patient program as a more palatable alternative to acceptance or outright rejection of personal gifts, I would caution against treating this as a simple solution for an ethically complex situation.5 Physicians and institutions should be careful to avoid drawing a bright ethical line between refusing smaller gifts, such as this necklace, and accepting vastly larger ones in the form of monetary donations. The potential for benefit to other patients does not negate the risks of biasing care in favor of a select few whose families are wealthy enough to support entire programs or facilities. Furthermore, such efforts have the potential to create environments in which all families are viewed as potential donors or investors, and children are viewed not as individuals but as assets. Even if treatment decisions themselves are not directly impacted, such an environment will always be in tension with ideals of justice in medicine and medical ethics, and subtle advantages accumulate to those labeled important persons because of their potential investment in a hospital or clinic.

A gift is an object willingly given by 1 person to another without expectation of payment or reciprocation. Gift giving is a universal practice common across cultures just as accepting or receiving a gift is part of the social fabric. Conventional wisdom advises us not to look a gift horse in the mouth. Thus, at first blush, receiving a gift does not raise ethical concerns. However, within the medical setting, gifts take on additional significance, and the expectations associated with a gift require close ethical scrutiny. Gifts may influence the patient-physician relationship and challenge professional boundaries. In some cases, it is inappropriate for a physician to accept a gift.

The AMA notes that gifts from patients can both enhance and damage the patient-physician relationship.2 The former occurs when a gift reflects gratitude or stems from a particular cultural tradition, whereas the latter occurs when a gift is meant to secure preferential treatment. Lyckholm6 recounts the advice of 1 cancer survivor, “Charm your doctor…differently than others charm them so they see you as their special patient. If you can entertain them, they will want to help you.” Before accepting or declining a gift, the AMA counsels physicians to tread lightly and carefully consider the gift’s value commensurate to the patient’s means while assuring that their treatment of the patient does not change because of the gift. The AMA advises physicians to decline inappropriate gifts as well as gifts that are disproportionally large. Physicians’ role as trusted caregivers with a strong moral foundation informs the AAP’s position toward gifts from patients. Specifically, the AAP is concerned by boundary violations.1 Accordingly, the AAP advises that although it may be appropriate to accept a modest gift, pediatricians should exercise caution when a gift causes the pediatrician to feel uncomfortable or when the gift could be viewed as compromising the pediatrician’s judgment. The Canadian Medical Association is largely quiet on the issue of patient gifts, whereas local Canadian provincial colleges offer differing counsel.7 

Gift giving is common within the medical setting. Levene and Sireling8 found that 20% of junior physicians in the United Kingdom had received a gift from a patient. Typical gifts included alcohol, chocolate, and money. Studies of internal medicine physicians in the United States found that 2.3% of residents and 17% of attending physicians reported patients had attempted to give them an expensive gift.9,10 Of the residents, 58% perceived expensive gift giving by patients as having a negative impact on the patient-physician relationship.

Many patients want to recognize their physicians’ compassionate caring and view a gift as a natural and grateful gesture, nothing more, nothing less. Even in circumstances with less than desirable clinical outcomes, patients often thank physicians for their dedicated care, so it should come as little surprise that Diamond’s parents want to acknowledge her oncologist for her role in saving Diamond’s life. In some cultures, it is customary for patients to give their physicians a gift. I would like to know more about Diamond’s parents’ cultural background. Although not determinative in the ultimate decision to accept or reject their gift, it lends important context to their motivations and how they may respond should their gift be refused. It may be culturally appropriate for Diamond’s parents to give her physician a gift, but should the doctor accept it?

In considering whether to accept a gift, clinicians must consider a host of circumstances, including the patient’s motivation(s) for giving the gift; the nature of the gift; the gift’s material, relational, and sentimental value; the timing for giving (why now?); and how the patient, other patients, and colleagues will react to the gift. A gift may come without expectation of compensation, but even without expectation, it can influence behavior. A gift may lead a doctor to spend more time with a patient, offer a more desirable time for a clinic visit, or even omit sensitive components of the history or physical examination to avoid embarrassing the patient. How might Diamond’s oncologist or the hospital development team respond were she to experience a setback and require services available only at another center, such as bone marrow transplantation? One would like to believe that her parents’ gift would not influence clinical decision-making, and Diamond would be treated like any other patient and her care transferred appropriately. However, in their effort to maintain the relationship either out of a sense of obligation or possibly in the hope for a future gift (to the physician or the hospital), one might imagine a delay in transfer, resulting in substandard care and ultimately harm.

In deciding whether to accept a gift, it is important to weigh the patient’s disease course. A gift given at the end of an illness may have a different meaning than a gift given in the context of ongoing treatment. In Diamond’s case, she and her parents will continue to see her oncologist for acute care and, should she be cured, for a long period of follow-up care.

In the absence of an institutional policy, physicians need to use their judgment in deciding whether to accept a patient’s gift. One consideration is the cost or type of gift. Expensive and extravagant gifts, money, and intimate gifts blur boundaries. They may lead to unfair treatment of some patients either by prioritizing patients who give gifts over those who don’t or by causing patients to believe they must offer their physicians a gift to ensure appropriate care. Therefore, such gifts should be respectfully declined. Modest gifts offered with the intent to secure preferential treatment should also be refused. On the other hand, simple gifts, such as food, crafts, or a framed picture, typically do not present a problem and should be graciously accepted. Clearly, there is a difference between a plate of chocolate chip cookies and an expensive piece of jewelry.

Weighing all these complex considerations, I believe it was appropriate for Diamond’s oncologist to decline the gift; but now, Diamond’s parents have refused to yield. Gift giving is only half of the equation; for the transaction to be complete, the recipient must willingly accept the gift. Hence, negotiation seems reasonable in such a case. Diamond’s oncologist should suggest that the gift be donated to the hospital or to a childhood cancer charity. She can politely inform the parents that she has a policy of not accepting gifts from patients and that doing so would violate her personal ethics. Such an explanation may allow the parents to view the refusal less as a personal rejection and more as a general matter of principle. If all else fails, the department chair should intervene. The chair should meet with Diamond’s parents, gratefully acknowledge their generosity, and respectfully explain that professional ethics and hospital policy preclude such extravagant gifts. They could then explore mutually agreeable alternative approaches for the parents to express their gratitude.

The doctor-patient relationship is unique and fragile. It is asymmetric in many ways. The doctor has power and knowledge. The patient and family are frightened, dependent, and vulnerable. The doctor has many patients. The family cannot know whether the doctor is competent, loyal, or honest. In such circumstances, it is natural for families to offer gifts as a way of trying to equalize and normalize the relationship. But, the doctor-patient relationship can never be normalized or made similar to other relationships. When families give an inappropriate gift, doctors have an excellent opportunity to clarify the unique boundaries that must govern doctor-patient-family relationships. Such clarification is a gift that we can give back to families.

     
  • AAP

    American Academy of Pediatrics

  •  
  • AMA

    American Medical Association

All authors contributed to the design of this article, the drafting of the manuscript, and the review of the manuscript, and approved the final version as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.