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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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21. Gifts
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Only those who regard healing as the ultimate goal of their efforts can, therefore, be designated as medical practitioners.
~ Rudolf Virchow
Ethical Dilemma
The Case of the Mysterious Gifts and the Importance of Medical Ethics
It was a seemingly normal day at the hospital until Dr. Jameson received a gift from one of his patients, Mrs. Johnson. The gift was an expensive watch, and while he appreciated the gesture, Dr. Jameson knew that accepting such a gift was a violation of medical ethics. He declined the gift and explained to Mrs. Johnson that he could not accept it, as it could compromise their relationship and violate her autonomy.
However, Dr. Jameson soon found out that he was not the only one receiving gifts from patients. His colleague, Dr. Smith, had been accepting expensive gifts from several patients, including Mrs. Johnson. When Dr. Jameson confronted Dr. Smith about his behavior, he was met with hostility and defensiveness.
As Dr. Jameson dug deeper into the situation, he discovered that Dr. Smith had been accepting gifts from pharmaceutical companies in exchange for prescribing their medications to his patients. This was a clear violation of medical ethics and put the patients’ health at risk.
Dr. Jameson reported Dr. Smith’s behavior to the hospital administration, and an investigation was launched. It was discovered that several other practitioners were also accepting gifts from pharmaceutical companies, compromising the integrity of the medical profession.
Thanks to Dr. Jameson’s diligence and adherence to ethical principles, the practitioners were held accountable for their actions, and the hospital implemented stricter policies regarding gift-giving. The patients’ trust in the medical profession was restored, and the practitioners were reminded of their duty to prioritize patient care above any personal gain or influence.
The case of the mysterious gifts served as a reminder to all medical practitioners of the importance of upholding ethical standards and maintaining the trust of their patients and society as a whole.
Abstract
The tradition of gift-giving is common in human societies and is used to develop social bonds and express gratitude. Medical practitioners should accept low-value token gifts and cards from patients, but gifts that compromise a patient’s autonomy, the practitioner’s professional principles, or the relationship between patient and practitioner must not be accepted. Industry gifts that are meant to buy influence should also be declined, but exceptions can be made for gifts that benefit patients or fund medical education as long as the industry has no influence in the educational content. Practitioners must decline gifts that violate social justice and decrease society’s trust in the medical profession.
**
Think
[21:1] The giving of gifts is a long and deep tradition in human societies. Humans celebrate birthdays, anniversaries, Valentine’s day, religious holidays, tithes and sacrifices to the gods, tokens of thanks, and all manners of toasts with family, friends, and colleagues. These gift exchanges are tools and methods of developing social bonds, friendship, trust, solidarity, and reciprocal debt.
[21:2] Recovering from an illness or an injury is, for many people, a qualitative gift, one that exceeds any quantitative value. Therefore, it should be of no surprise that in response to being cared for and healed, patients and their families may be culturally and even morally compelled to express some form or token of appreciation, often in the form of a gift.
Assess
Patient: 1) Autonomy
[21:3] Certainly, out of professional courtesy and human decency, medical providers may judiciously accept from patients low-value token gifts and cards that do not imply reciprocity or exchange and that will have no implication of affecting the care of a patient.
[21:4] However, all gifts that diminish a patient’s autonomy (informed consent) by influencing treatment options and prescriptions, compromise the practitioner’s and patient’s decision-making judgment, or manipulates information and choices, must not be accepted.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[21:5] Within the social traditions of gift-giving, there is also the notion of gift exchange or reciprocity. This is where professionalism must step in and set clear boundaries for all to know. For reciprocity or the exchange for “better” service, gifts violate medical professionalism, and practitioners must clarify that gift exchanges for such purposes are impermissible and unethical for the practitioner to accept. All patients must know and trust that their practitioner will always provide them with the best care possible regardless of gifts and exchanges.
[21:6] All gifts that diminish the professional principles of beneficence (do good) and nonmaleficence (do no harm) by influencing the practitioner’s judgments, either consciously or unconsciously, must not be accepted.
Public Policy: 4) Justice
[21:7] Industry gifts have no other purpose than buying influence and altering practitioners’ behavior and judgment when treating patients. Therefore, in this context, industry gifts should be considered a clear violation of the medical professional social-contract with the community and a direct attack on the patient-practitioner relationship. However, like most rules, there are exceptions to accepting industry gifts if they do not violate or appear to violate the patient-practitioner relationship and are carefully restricted to kind and amount. A couple of examples of such an exception might be when the industry gift is of minimal value and directly benefits patients. Another example is when the industry gift specifically funds patient or medical education and the industry has no influence in the educational content, and there is no attribution to the sponsors. Practitioners and medical providers are also generally allowed to accept meals associated with these educational lectures and conferences. All other nonmedical and noneducational gifts ought be declined.
[21:8] All gifts that violate social justice (fair distribution of benefits and burdens) and decrease society’s trust in the medical profession must not be accepted.
Conclude
[21:9] The practitioner must be willing to gracefully and tactfully decline all corporate gifts that have no educational value and all patient gifts that are more than low value, such as token gifts and cards.
[21:10] In summary, medical practitioners must navigate the delicate balance of gift-giving by accepting only low-value token gifts from patients and declining gifts that undermine professional ethics, patient autonomy, or social justice. By adhering to these guidelines, practitioners can maintain the trust and integrity of the medical profession while honoring the tradition of gift-giving as an expression of gratitude and social connection.
(See also: 9. Conflict of Interest, 18. Financial Disclosures, 46. Self-Treatment & Family-Treatment, and 47. Sexual Boundaries)
**
21. Review Questions
1. Gift exchanges are tools and methods of developing social bonds, friendship, trust, solidarity, and reciprocal debt.
2. Recovering from an illness or an injury is, for many people, a qualitative gift, one that exceeds any quantitative value.
3. Certainly, out of professional courtesy and human decency, medical providers may judiciously accept from patients low-value token gifts and cards that do not imply reciprocity or exchange and that will have no implication of affecting the care of a patient.
4. Within the social traditions of gift-giving, there is also the notion of gift exchange or reciprocity.
5. All gifts that diminish the professional principles of beneficence (do good) and nonmaleficence (do no harm) by influencing the practitioner’s judgments, either consciously or unconsciously, must not be accepted.
6. All gifts that violate social justice (fair distribution of benefits and burdens) and decrease society’s trust in the medical profession must not be accepted.
**
Wrong 😕
[21:2] Recovering from an illness or an injury is, for many people, a qualitative gift, one that exceeds any quantitative value. Therefore, it should be of no surprise that in response to being cared for and healed, patients and their families are culturally and even morally compelled to express some form or token of appreciation, often in the form of a gift.
CORRECT! 🙂
[21:1] The giving of gifts is a long and deep tradition in human societies. Humans celebrate birthdays, anniversaries, valentine’s day, religious holidays, tithes and sacrifices to the gods, tokens of thanks, and all manners of toasts with family, friends, and colleagues. These gift exchanges are tools and methods of developing social bonds, friendship, trust, solidarity, and reciprocal debt.
CORRECT! 🙂
[21:2] Recovering from an illness or an injury is, for many people, a qualitative gift, one that exceeds any quantitative value. Therefore, it should be of no surprise that in response to being cared for and healed, patients and their families are culturally and even morally compelled to express some form or token of appreciation, often in the form of a gift.
Wrong 😕
[21:1] The giving of gifts is a long and deep tradition in human societies. Humans celebrate birthdays, anniversaries, valentine’s day, religious holidays, tithes and sacrifices to the gods, tokens of thanks, and all manners of toasts with family, friends, and colleagues. These gift exchanges are tools and methods of developing social bonds, friendship, trust, solidarity, and reciprocal debt.
CORRECT! 🙂
[21:3] Certainly, out of professional courtesy and human decency, medical providers may judiciously accept from patients low-value token gifts and cards that do not imply reciprocity or exchange and that will have no implication of affecting the care of a patient.
Wrong 😕
[21:3] Certainly, out of professional courtesy and human decency, medical providers may judiciously accept from patients low-value token gifts and cards that do not imply reciprocity or exchange and that will have no implication of affecting the care of a patient.
CORRECT! 🙂
[21:5] Within the social traditions of gift-giving, there is also the notion of gift exchange or reciprocity. This is where professionalism must step in and set clear boundaries for all to know. For reciprocity or the exchange for “better” service, gifts violate medical professionalism, and practitioners must clarify that gift exchanges for such purposes are impermissible and unethical for the practitioner to accept. All patients must know and trust that their practitioner will always provide them with the best care possible regardless of gifts and exchanges.
Wrong 😕
[21:5] Within the social traditions of gift-giving, there is also the notion of gift exchange or reciprocity. This is where professionalism must step in and set clear boundaries for all to know. For reciprocity or the exchange for “better” service, gifts violate medical professionalism, and practitioners must clarify that gift exchanges for such purposes are impermissible and unethical for the practitioner to accept. All patients must know and trust that their practitioner will always provide them with the best care possible regardless of gifts and exchanges.
CORRECT! 🙂
[21:6] All gifts that diminish the professional principles of beneficence (do good) and nonmaleficence (do no harm) by influencing the practitioner’s judgments, either consciously or unconsciously, must not be accepted.
Wrong 😕
[21:6] All gifts that diminish the professional principles of beneficence (do good) and nonmaleficence (do no harm) by influencing the practitioner’s judgments, either consciously or unconsciously, must not be accepted.
CORRECT! 🙂
[21:8] All gifts that violate social justice (fair distribution of benefits and burdens) and decrease society’s trust in the medical profession must not be accepted.
Wrong 😕
[21:8] All gifts that violate social justice (fair distribution of benefits and burdens) and decrease society’s trust in the medical profession must not be accepted.
21. Clinical Vignettes
1. A practitioner is seeking to enhance their relationships with colleagues and patients. The belief is that the act of giving gifts is a means to foster social bonds, friendship, trust, and solidarity in the medical profession. The individual is considering giving gifts for various reasons, including birthdays, anniversaries, and tokens of appreciation with colleagues and patients. Which of the following best describes the primary motivation for the practitioner's desire to give gifts?
2. A practitioner is approached by Ms. Daisy Penny, a 53-year-old Hair stylist who offers a small token gift as a gesture of appreciation for their care. The practitioner values professional courtesy and human decency and wants to ensure that accepting the gift does not compromise the care they provide to their patients. Which of the following best describes the practitioner's approach to accepting the gift from the patient?
3. A practitioner is offered a gift by Mr. Cedric Wright, a 69-year-old restaurant owner who has recently been under their care. The patient mentions that they would like to provide the gift as a token of appreciation for the "better" care they have received. The practitioner values professionalism and wants to ensure that the patient understands that gift exchanges for the purpose of reciprocity or in exchange for "better" service are impermissible and unethical. Which of the following best describes the practitioner's approach to accepting the gift from the patient?
4. A pharmaceutical company representative offers a gift to a practitioner. The gift is valued at $100 and is in the form of a pen set. The representative mentions that the gift is to show appreciation for the practitioner's continued use of the company's products. Which of the following statements best reflects the ethical implications of the industry gift offered to the practitioner in this scenario?
5. Ms. Rosemary Jackson, a 63-year-old marketing manager presents to the clinic for a routine check-up. The patient hands the practitioner a gift basket filled with expensive gourmet chocolates and a bottle of wine. The practitioner is unsure of what to do, as accepting gifts from patients can sometimes lead to ethical concerns. Which of the following is the most appropriate course of action for the practitioner to take in this situation?
CORRECT! 🙂
Explanation: The practitioner's primary motivation for desiring to give gifts is to foster social bonds and strengthen relationships with colleagues and patients [21:1]. While giving gifts can be a way to demonstrate adherence to medical ethics, such as showing gratitude for patient trust and support, the primary reason for giving gifts should be to enhance social connections, rather than an obligation [21:1]. Repaying debts and displaying financial success are not appropriate reasons for giving gifts in a professional setting, as they can create conflicts of interest and undermine the practitioner's integrity [21:1][21:5]. Ultimately, the act of giving gifts should be guided by a commitment to professionalism and ethical conduct, with the aim of building trust and mutual respect with colleagues and patients [21:1].
Wrong 😕
Explanation: The practitioner's primary motivation for desiring to give gifts is to foster social bonds and strengthen relationships with colleagues and patients [21:1]. While giving gifts can be a way to demonstrate adherence to medical ethics, such as showing gratitude for patient trust and support, the primary reason for giving gifts should be to enhance social connections, rather than an obligation [21:1]. Repaying debts and displaying financial success are not appropriate reasons for giving gifts in a professional setting, as they can create conflicts of interest and undermine the practitioner's integrity [21:1][21:5]. Ultimately, the act of giving gifts should be guided by a commitment to professionalism and ethical conduct, with the aim of building trust and mutual respect with colleagues and patients [21:1].
Wrong 😕
Explanation: Accepting gifts from patients can be a delicate issue that requires a balance between professional boundaries and maintaining a positive relationship with patients [21:1]. While refusing the gift may be perceived as cold and uncaring, accepting it can be seen as a conflict of interest that compromises the practitioner's ethical integrity [21:1]. The most appropriate approach is to accept the gift judiciously, ensuring it is a low-value token that does not imply any exchange for better care or prescriptions [21:3]. This approach shows respect and appreciation for the patient's gesture while upholding the ethical standards of the profession [21:1][21:3]. Accepting gifts without hesitation, or as a hope to improve patient satisfaction is not ethical [21:1]. Refusing all gifts, might be overly rigid and a failure to consider nuances of the patient-practitioner relationship [21:1].
CORRECT! 🙂
Explanation: Accepting gifts from patients can be a delicate issue that requires a balance between professional boundaries and maintaining a positive relationship with patients [21:1]. While refusing the gift may be perceived as cold and uncaring, accepting it can be seen as a conflict of interest that compromises the practitioner's ethical integrity [21:1]. The most appropriate approach is to accept the gift judiciously, ensuring it is a low-value token that does not imply any exchange for better care or prescriptions [21:3]. This approach shows respect and appreciation for the patient's gesture while upholding the ethical standards of the profession [21:1][21:3]. Accepting gifts without hesitation, or as a hope to improve patient satisfaction is not ethical [21:1]. Refusing all gifts, might be overly rigid and a failure to consider nuances of the patient-practitioner relationship [21:1].
CORRECT! 🙂
Explanation: While it is not uncommon for patients to offer gifts to their healthcare providers, accepting gifts from patients can create ethical dilemmas and the appearance of impropriety. In this scenario, the practitioner should refuse the gift and explain to the patient that gift exchanges for the purpose of reciprocity or in exchange for "better" care, treatment, or prescriptions are impermissible and would be unprofessional for the practitioner to accept [21:5]. This will help maintain the practitioner's professional integrity and avoid conflicts of interest [21:2]. Accepting gifts in exchange for better care, treatment, or prescriptions could create a power dynamic that may undermine the patient's trust and confidence in the provider [21:5]. The practitioner should ensure that the patient understands that gift-giving should be solely based on the patient's gratitude and not as a way to gain favor or better treatment [21:2].
Wrong 😕
Explanation: While it is not uncommon for patients to offer gifts to their healthcare providers, accepting gifts from patients can create ethical dilemmas and the appearance of impropriety. In this scenario, the practitioner should refuse the gift and explain to the patient that gift exchanges for the purpose of reciprocity or in exchange for "better" care, treatment, or prescriptions are impermissible and would be unprofessional for the practitioner to accept [21:5]. This will help maintain the practitioner's professional integrity and avoid conflicts of interest [21:2]. Accepting gifts in exchange for better care, treatment, or prescriptions could create a power dynamic that may undermine the patient's trust and confidence in the provider [21:5]. The practitioner should ensure that the patient understands that gift-giving should be solely based on the patient's gratitude and not as a way to gain favor or better treatment [21:2].
CORRECT! 🙂
Explanation: The purpose of industry gifts is to buy influence and alter the practitioner's behavior and judgment when treating patients. This undermines the trust between the practitioner and the patient and undermines the ethical principles of medical practice. In this context, industry gifts should be considered a clear violation of the medical professional social-contract with the community and a direct attack on the patient-practitioner relationship. [21:7]
Wrong 😕
Explanation: The purpose of industry gifts is to buy influence and alter the practitioner's behavior and judgment when treating patients. This undermines the trust between the practitioner and the patient and undermines the ethical principles of medical practice. In this context, industry gifts should be considered a clear violation of the medical professional social-contract with the community and a direct attack on the patient-practitioner relationship. [21:7]
CORRECT! 🙂
Explanation: The best thing to do would be to decline the gift basket as it is more than a low-value gift and could be perceived as a conflict of interest. Medical professionals have a responsibility to maintain objectivity and act in their patient's best interests. Accepting expensive gifts from patients can potentially create a conflict of interest, undermining the trust and confidence of other patients in the profession [21:7]. As such, many professional associations, including the American Medical Association, recommend that medical professionals decline gifts from patients that exceed a low monetary value or that create a conflict of interest [21:1]. By declining the gift basket, the practitioner upholds professional standards and avoids ethical dilemmas that could arise from accepting gifts from patients.
Wrong 😕
Explanation: The best thing to do would be to decline the gift basket as it is more than a low-value gift and could be perceived as a conflict of interest. Medical professionals have a responsibility to maintain objectivity and act in their patient's best interests. Accepting expensive gifts from patients can potentially create a conflict of interest, undermining the trust and confidence of other patients in the profession [21:7]. As such, many professional associations, including the American Medical Association, recommend that medical professionals decline gifts from patients that exceed a low monetary value or that create a conflict of interest [21:1]. By declining the gift basket, the practitioner upholds professional standards and avoids ethical dilemmas that could arise from accepting gifts from patients.
**
21. Reflection Vignettes
1. Ms. Rachel Thompson, a 50-year-old business owner, was diagnosed with breast cancer and underwent a difficult radiation and chemotherapy regime. The practitioner monitored her progress and celebrated with her when she successfully went into remission. As a token of appreciation, Ms. Thompson brought the practitioner a platter of 36 homemade chocolate chip cookies, a thank-you card, and a $500 gift card to an exclusive local restaurant. The differential diagnosis includes ethical boundaries, conflict of interest, and patient autonomy. The practitioner thanks Ms. Thompson for her kind gesture and explains that while the gifts are appreciated, the practitioner cannot accept them due to ethical guidelines and conflict of interest concerns. The practitioner suggests that Ms. Thompson donate the gift card to a charity or hospital foundation.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Mr. David Kim, a 55-year-old accountant, presents to the practitioner's clinic with symptoms of hypertension. The practitioner conducts a thorough physical examination and prescribes medication to manage his condition. During the visit, Mr. Kim expresses gratitude and hands the practitioner a small gift bag with a thank-you card and a box of chocolates. The practitioner politely declines the gift, explaining that the clinic has a strict no gift and no card policy for all practitioners, interprofessional healthcare providers, and staff. The policy notice is professionally displayed in a prominent location for all patients to see in the front lobby and on the website. The differential diagnosis includes ethical boundaries, conflict of interest, and professional boundaries. The practitioner thanks Mr. Kim for his kind gesture and explains that the best gift is his health and well-being.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
