In a recent essay, a practicing internist remembers the gifts her orthopedist father received from his patients and wonders why she does not receive such gifts from hers. She reasons that since the leveling of the power differential between physician and patient has made the professional boundaries more indistinct, gift giving may further blur those boundaries, creating an awkward situation for the patient, the physician, or both.¹²

How do physicians decide whether it is ethical or appropriate to accept patients' gifts? Should physicians guess at the motivation? Should clinicians consider the cost, the character of the gift, or the giver? As in any ethical calculus, risks and benefits to the patient should be considered, and justice-related issues explored. Also to be considered are the size and nature of the gift, such as large donations to the physician's institution.

Best Interest of the Patient?
The best interest of the patient is a fundamental parameter by which to measure whether an action is ethically acceptable. It is easily conceivable that a physician often acts in the patient's best interest when he or she chooses to accept a gift, especially considering the alternative—rejection. Acceptance of the gift can be acceptance of the giver. It is acknowledgment of the person's autonomy and worth as a fellow human being and affirmation of the genial nature of the patient-physician relationship. Declining a gift actually may cause more damage than any potential harm done by accepting it. If a physician rejects a gift, it may be interpreted by the patient as a lack of regard for the patient's wishes, and may hurt the patient's feelings, irrevocably fracturing the patient-physician relationship. Should my colleague have rejected the silver paperweight that conveyed so much meaning to him from his patient? I think not.

Potential Ethical Problems With Accepting Gifts
A physician may reciprocate a patient's gift with inordinate medical attention, or a patient might expect such treatment in exchange for a gift. Other patients may perceive their treatment by the same physician as inferior to that given to the gift-bearer and may feel that they, too, need to give the physician gifts to receive more attention or even adequate care.

It is inescapable that physicians will give disproportionate attention to some of their patients, perhaps because those patients are charming, demanding, exceptionally young or old, or have endured a particularly difficult plight, among other reasons. But medical attention in exchange for gifts is not ethical. It reduces the delivery of medical care to a service that can be bought rather than one that is given justly, according to a patient's need rather than his or her ability to "buy" extra services. This is not consistent with the professional ethic of medicine.

A formal study of the impact of managed care on the practice of gift giving could provide some understanding of the effects of gifts on the patient-physician relationship. Davidoff has noted: "the spread of managed care is progressively destroying medicine's network of gift relationships."¹³ The idea of medical care as commodity, impersonal and businesslike, runs counter to the type of patient-physician relationship that is conducive to gift exchange as a form of affection and appreciation. But might the constraints of managed care encourage some patients to give gifts to gain advantage in the form of longer visits, easier referrals, and more personal care?

Hospitals, medical schools, and other health care institutions traditionally have been the beneficiaries of patients' gifts. When a patient has donated considerable amounts of money to an institution, he or she should receive a formal, sincere, and possibly public acknowledgment of gratitude from both the physician and the institution. However (as in the second scenario), the physician should not feel pressured or obligated to give the patient special attention in the form of inordinate amounts of time, priority scheduling of surgery and examinations, and medical care provided by physicians other than the regularly scheduled attending physicians and house staff.

The danger inherent in this type of activity not only is the real or perceived compromise of just treatment of other patients but also is that such preferential treatment may actually interfere with care of the patient. Critical information may be missed for fear of asking personal questions, such as those regarding sexual activity or substance abuse, or by foregoing performance of uncomfortable procedures or physical examination of intimate parts of the patient's body. If the usual house staff team does not care for the patient, standard procedures and orders may be overlooked, and the patient's care could be compromised. Physicians must help such patients understand that it is in their best interest to be treated in a similar manner as other patients.

Cost and Nature of the Gift
Sometimes, it is difficult to deem which gifts are too personal or too extravagant, or otherwise inappropriate. Although there are no specific guidelines, some limits exist that most people would recognize, such as when a gift is extremely intimate (a nightgown), too extravagant (an all-expenses-paid vacation), or a gift obviously beyond a patient's means.

Money in particular appears to be so much more of a direct payment or "tip" than a gift that has some personal meaning. Whether given directly or through a will (such as in the first scenario), the physician should never accept money for personal use. Monetary gifts should be designated for a specific use such as an endowment, charity, or foundation.

Cases of professional misconduct and unethical behavior have been reported in which physicians apparently have taken advantage of their patients' generosity and vulnerability. One such case involved an elderly patient with cancer whose surgeon became a benefactor of her property shortly before he was to perform an operation on her from which she was not expected to survive. Two years later he "allegedly proposed changes that would help him acquire her estate." She complained to the College of Physicians and Surgeons of Ontario, who found the surgeon guilty of professional misconduct.¹¹

A question may arise about the appropriateness of accepting gifts from patients who give them regularly. However, this practice is a good example of having to look at each situation individually, attending to both ethical principles and to common sense. Several of the patients in my practice bring gifts of baked goods each time they visit. Rejection of such gifts would be embarrassing and hurtful to them. However, if monetary gifts or other more expensive gifts are given regularly, they may be interpreted as payment for care and should not be accepted or expected by the physician. For the physician, a simple expression of "Thank you but I can't accept that" is probably all that is necessary unless the patient persists.

Should there be a limit to the value of the gift a physician may accept from a patient? Gabbard and Nadelson¹⁴ suggest that a large or expensive gift is a "serious boundary transgression." The best course of action is to acknowledge any such gift formally and direct it to a charity or foundation. The actual monetary value of a gift is relative. It may be entirely legitimate to accept a $1 million chair from a wealthy philanthropist, but acceptance of a $100 check from a patient of few means may be questionable. In such a case, a physician may still want to accept the gift, in the interest of the patient's autonomy, but with a tactful reminder that gifts are not expected or necessary for the patient to receive appropriate care. This communication may prevent the patient from giving more gifts that he or she may not be able to afford.

Accepting or Declining Gifts
In many instances, the decision whether to accept a gift is easy and requires little ethical analysis, such as in the third scenario, in which acceptance of small tokens of gratitude and remembrance complement and sustain the patient-physician relationship. Other decisions must be considered more rigorously from the standpoint of risks and benefits, such as in the first scenario, in which a physician was given a substantial sum of money in a patient's will. In that case, rejection of the gift would be hurtful to the patient's family, especially considering the patient's specific wishes. Acceptance of such a gift could potentially change the way the physician treated future patients, especially those from whom he stood to benefit financially and also could change the patients' perceptions of what was necessary to obtain appropriate treatment from that physician. In this case, the real threat to the best interest of the patient's family trumps the potential risk of conflict of interest. However, any remaining doubts about the influence of the gift on the physician's treatment of others could be tempered by the physician's insistence on contributing the money to a charity of his or her choice, perhaps one that the physician feels would have been meaningful to the patient.

In the case of large gifts, such as in the first and second scenarios, formal guidelines and protocols must be created to protect the physician, the gift-giving patient, and other patients from conflicts of interest, inappropriate care, and real or perceived infringements of justice. The physician should provide the gift-giving patient with medical care in the same manner as other patients, and the institution should not pressure the individual physician to do otherwise.

If a physician has a difficult time accepting gifts without feeling significant indebtedness and need to reciprocate, it may be best for him or her to make a formal policy of never accepting gifts so that a particular patient does not feel singled out or rejected. In the case of a clearly inappropriate gift, or one with which the physician is for any reason uncomfortable, the physician not only should say "No, thank you, I appreciate your generosity," but also, "I don't feel comfortable taking this." The physician may want to consider the patient's motivation for giving the gift. Is the patient feeling desperate, neglected, or becoming too close to the physician? The inappropriate gift may be a wake-up call that something is amiss with the patient or the patient-physician relationship.

In conclusion, patients give gifts to their physicians for many reasons. Whether large or small, most gifts are simply gracious tokens of affection and gratitude. Physicians must be sensitive to the patient's motivations for giving the gift. If it seems more than simply a gift, a physician should act accordingly. The acceptance of a gift must never interfere with the care of the patient, and if the physician judges that it may, he or she should sensitively and tactfully redirect the gift. A few guidelines may be considered, such as never accepting personal cash gifts or obviously extravagant or intimate gifts and never letting a gift dictate or influence treatment. In the ancient words of Seneca, "The spirit in which a thing is given determines that in which the debt is acknowledged; it's the face-value of the gift that's weighed."