Caution urged over patient gifts

CHRISTMAS is fast approaching and what better time of year for a patient to give their doctor or dentist a gift to thank them for their care? So what harm could there be in accepting that box of chocolates or bottle of wine from the grateful patient you have dutifully treated over the years?

As most healthcare professionals will know, the issue of accepting gifts from patients can raise difficult ethical dilemmas. In some cases it might be entirely appropriate to accept a small token of recognition or gratitude, but there are times when a gift can represent something more. The recipient may feel that by accepting a gift, they are giving the patient some kind of hold over them, encouraging favouritism or influencing their clinical judgement.

The General Medical Council’s Good Medical Practice advises doctors not to “ask for or accept any inducement, gift or hospitality which may affect or be seen to affect your judgement,” adding that doctors “must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.” The General Dental Council’s Standards for the Dental Team says that dentists must “never ask for, nor accept, any payment, gift or hospitality, or make or accept any referral, which may affect or appear to affect your professional judgement.”

There is no clear-cut solution to this issue as it is not always easy to enforce a strict “no gifts” policy in any practice. But you must consider whether accepting a gift could be seen to influence your decision-making, so make sure you can show that it hasn’t.

You should make it clear to any gift-giver that their gesture will not have any impact on the care you provide. Be prepared to discuss the offer of a gift with the patient, and perhaps also their family, and consider refusing or returning it if you feel it is inappropriate. It is advisable to keep a record of any such conversations or correspondence surrounding the offer of a gift and note your reasons for accepting in some form of gift register.

The size of the gift is also relevant when deciding whether it is appropriate to accept. Section 23 of the Health and Social Care Act 2001 requires practitioners to declare financial interests and the acceptance of gifts and other benefits. It states that NHS employees should not accept “substantial” gifts from patients or others and monetary gifts are not allowed. When assessing what constitutes a “substantial” gift, you should consider the gesture in relation to the patient’s means. If a patient offers more than they could obviously afford, then it would be wise to respectfully refuse it. This rule can also apply if a gift is too intimate (lingerie, for example) or too extravagant.

When any offer of a gift is made it is important to gauge the underlying reason for why the gesture is being made. In an article for the RCGP’s The New Generalist publication in 2005, GP and medical ethicist Dr Paquita de Zulueta described several reasons for patient gift-giving, including:

• 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.

Dr de Zulueta said patients generally tend to act on a combination of two or more of these reasons, but there are occasions when a gift may be given for no secondary gain. She said: “Correctly gauging the underlying motive helps to shape the response, but may not always be easy in practice.” She also makes an important point in saying that the power balance should always be kept in mind. This is particularly relevant if your patient is vulnerable and the recent case of psychiatrist Dr Peter Rowan raises some important points. He was criticised for “losing sight of professional boundaries” when he appeared before a fitness to practise panel of the General Medical Council in May.

He admitted receiving gifts of £50,000 and £100,000 as well as a bequest of £1.2million from a "lonely and isolated" female patient whom he treated privately in London. He admitted that accepting the cash gifts "could be open to misinterpretation" but said his patient had become angry when he initially refused her gifts. He said he had spoken to her solicitor to ensure the woman was able to afford the gifts and that she was aware of the implications.

While some practitioners might feel obliged to accept a gift for fear of offending a patient, it is crucial to carefully consider such offers. The size of the gift, the motive behind the offer and any perceived or actual impact on your professional judgement must all be taken into consideration. If in doubt, seek advice from MDDUS.

ACTION: Carefully consider 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.