Extract
T.D. is a sixty-three-year-old woman who fell and fractured her wrist. She
underwent a closed reduction and application of a short arm cast. Following
removal of the cast, she was enrolled in a physical therapy program. She
progressed slowly but eventually did well. Upon completion of treatment, she
sent two bottles of wine to her physician. Two weeks later, T.D. made several
requests of her physician. Despite nearly normal functioning of the wrist, she
asked her doctor to prescribe additional physical therapy and to complete
forms that would justify additional time off from work. She also asked for
letters supporting suspension of her gym membership and alteration of her
vacation plans.
T.D. is a sixty-three-year-old woman who fell and fractured her wrist. She
underwent a closed reduction and application of a short arm cast. Following
removal of the cast, she was enrolled in a physical therapy program. She
progressed slowly but eventually did well. Upon completion of treatment, she
sent two bottles of wine to her physician. Two weeks later, T.D. made several
requests of her physician. Despite nearly normal functioning of the wrist, she
asked her doctor to prescribe additional physical therapy and to complete
forms that would justify additional time off from work. She also asked for
letters supporting suspension of her gym membership and alteration of her
vacation plans.
Patients often demonstrate their gratitude for the medical care that they
have received by bringing gifts to the treating physicians. Usually, these
tokens are cards, baked goods, articles of clothing, or handcrafted
items—modest items given to physicians as gestures from appreciative
patients or their families. As the above scenario illustrates, however, gifts
can raise ethical issues of which we need to be aware. The potential problems
usually involve the nature of the gift and the expectations of the
patient.
Certain gifts can create problems in and of themselves. Gifts of an
exceedingly personal nature are usually inappropriate. Gifts of intimate items
may be inconsistent with the maintenance of the doctor-patient relationship.
They can certainly make the treating physician feel uncomfortable and
interfere with the requisite boundaries of professionalism. Furthermore, the
acceptance of such a gift by the physician may signal a departure from
professionalism as well as the professional relationship.
Similarly, gifts of excessive monetary value or cash gifts are usually
improper. These types of gifts can be interpreted as payoffs or
"tips" for the care rendered. Extravagant gifts are often
disproportionate to the services provided by the physician and to the nature
of the relationship.
In some societies, gifts from patients or family members are expected. In
those environments, regardless of the fact that payment for the patient's
treatment is covered by a national health-care program, it is well known that
without the gift the patient will not receive appropriate medical care. These
arrangements amount to extortion, and such demands are anathema to
medicine.
In our society, gifts to physicians are neither required nor expected. Yet,
there may be office arrangements that signal some financial expectation that
goes beyond paying the bill. Some patients may interpret the prominent display
of patient gifts around the physician's office as a declaration that gifts are
encouraged. A printed or posted request for donations to a physician's
research fund, or even a declaration that one exists, could convey the message
that a contribution is expected. Deliberately or even inadvertently
communicating a demand for further payment can compromise the doctor-patient
relationship, lead patients who cannot afford the gratuity to mistrust the
care that they receive, and induce patients to extend themselves beyond their
financial means to ensure that they receive the care to which they are
entitled.
The vast majority of gifts from patients are offered with no strings
attached. Patients are happy that their treatment went well, and they wish to
demonstrate their gratitude. Such tokens are given with no presumption of
further recompense. Some patients, however, may expect special treatment in
return for their gift.
To paraphrase Thoreau: If I knew someone was coming to my front door to do
me a favor, I would have fled out the back. As the case above illustrates,
T.D. may have assumed that her gift entitled her to numerous letters and
prescriptions. Some of her requests clearly exceeded the time frame and
activity restrictions that would normally have followed her type of injury.
Yet, it is easy to see how the treating physician would find it more difficult
to turn down her requests after having accepted the two bottles of wine than
if no gift had been accepted.
Patients such as T.D. expect that their gifts will ensure that they receive
special treatment. They may anticipate that a gift will elevate them above the
status of the ordinary patient and allow them to receive more specialized or
personal care. They may envision their physician spending extra time with them
or being more likely to remember them because of the gift. They may even count
on being allowed extra consideration with regard to making appointments,
having their phone calls returned, or having their insurance paperwork
completed. They may view a small gift as going a long way in expediting
medical services.
Patients can also expect their gifts to change the nature of their
relationship with the physician. With the presentation of a gift, a patient
may hope to gain a social friendship or a professional colleague. In such
circumstances, offering a gift can be very different from offering
gratitude.
Other expectations of patients can be more appropriate and benign. Gifts
may provide a way for patients to satisfy their own sense of worth and need
for relationships. A widow who brings baked goods to the doctor's office may
gain a sense of purpose and belonging through her giving, and the office staff
may, in fact, develop an attitude of familial friendship toward the patient.
We have several patients in our practice who routinely bring baked goods or
other food items every time they visit the office. They will often stay and
chat with the office staff, inquiring about children, school, and family. The
food that they bring helps them to express gratitude. I am certain that their
presentations also enhance their self-esteem and provide them with personal
contact in what can otherwise be a very impersonal medical care system.
When a patient's gift is simply an appropriate gesture of gratitude, it
should be accepted with grace. The patient's goodwill and appreciation should
be acknowledged with warmth and respect. Often, a simple expression of thanks
is a fitting reply.
An inappropriate gift should be politely declined, and the reason for doing
so should be explained to the patient. In this communication, the physician
should try to avoid offending or embarrassing the patient. Explaining the
rejection of the gift in terms of a general policy can help the patient to
avoid seeing the refusal as a personal rejection. In some circumstances, it
may be appropriate to offer an alternative. The physician can explain that
while he or she cannot accept the gift, it would be well appreciated if it
could be shared among others in the office.
For patients who insist on bestowing monetary or expensive gifts, an
invitation to a fund-raising event to support an activity of an academic
medical department or a medical institution may solve the dilemma by placing
some distance between the gift and the personal interest of the physician.
This distance makes it less likely that the physician will know precisely how
much a patient has contributed and less likely that the funds will have much
of an impact on the behavior or judgment of that physician, thus protecting
the physician's professionalism as well as the integrity of the doctor-patient
relationship.
It must be made clear to patients and staff alike that the acceptance of
gifts does not confer any change in relationship, treatment level, or office
privileges. Physicians must never make patients feel that the care that they
receive will be less than optimal if they do not present gifts. Rather,
physicians should endeavor to make patients understand and trust that
treatment and care are based solely on the medical considerations of need and
urgency and that, beyond those differences, every patient will receive an
equal amount of care and compassionate attention.
When considering how to respond to gifts from patients, as a general rule,
physicians should use the same standards that they use in dealing with gifts
that they receive from industry. Is the gift modest in nature? Does it come
with any strings attached? Will the gift alter the physician's medical
judgment? Can the gift stand up to the scrutiny of other patients, staff,
colleagues, and the general public?