For a patient's perspective on gift-giving, click here.
Joel Dunnington, MD, a radiologist who retired in 2014 from the University of Texas MD Anderson Cancer Center in Houston, is a regular Father Christmas. Last year, he baked and distributed 50 fruitcakes (using his mother's recipe) and 150 cupcakes to faculty and staff at Anderson.
But when it comes to gifts from grateful patients, Dunnington is a regular Ebenezer Scrooge. He just says no to any gifts.
"Gifts from patients generally only create a conflict with that patient and his/her physician," he said. He worries that gifts can result in patients getting preferential treatment.
The countdown on the number of shopping days until Christmas has begun, and doctors and other health professionals may find themselves on their patients' holiday shopping lists.
Should doctors accept gifts intended as expressions of gratitude? If so, what is a reasonable monetary value? Or should you politely decline?
It depends on whom you ask.
"There are no definitive regulations regarding accepting gifts from patients, and opposing views exist. Some believe physicians should never accept gifts because it might influence the standard of care or weaken the fiduciary relationship. Others believe that accepting gifts in certain circumstances allows patients to express gratitude and strengthens the physician-patient bond," said psychiatrist Lara Hazelton, MD, of Dalhousie University in Halifax, Nova Scotia.
She and Andrew Caddell, MD, a cardiology resident at Dalhousie, wrote about the dilemmas of gifts in Canadian Family Physician in 2011.
Dunnington, a delegate to the American Medical Association in the late 1990s, testified in favor of banning all gifts from patients, which he feared could lead to such inequities as queue jumping by the super-rich, including foreigners -- like the Saudi royals who got first crack at kidney transplants in the 1980s at the Presbyterian-University Hospital in Pittsburgh.
But he said some of his colleagues are "greedy" and don't want to refuse gifts on ethical grounds.
Should There Be Limits on Gifts?
Patients giving gifts to their physicians and other health professionals apparently is not uncommon. A 1980 survey of nearly 400 British physicians in a variety of specialties found that 20% received gifts in the previous three months. The average value of the gifts was less than $15, with alcohol being the most common gift, followed by chocolates and cash. Bounty from the garden and baked goods are other popular gifts, but sometimes the gifts can be extravagant, such as cruises and season tickets to a professional sports team or orchestra, or intimate gifts, like lingerie -- posing clear ethical dilemmas.
Hippocrates, who seemingly had something to say about everything, was silent on patient gifts. Likewise, many codes of ethics don't touch the topic, with the AMA being an exception in its Principles of Medical Ethics.
The AMA's Council on Ethical and Judicial Affairs adopted those updated principles in 2016 following an eight-year revision of all ethical policies. The document allows physicians leeway in deciding to accept or decline a gift on a case-by-case basis.
But as to when a gift becomes a bribe? There are no sweeping policies on this.
The AMA principles set no dollar limits on the value of a gift, though some institutions set such limits. Dunnington said MD Anderson, which operated under state government rules, limited the value of gifts to $50.
He joked: "I have an intrinsic bias since most patients do not give radiologists gifts after their barium enemas. Physicians who take care of patients for longer periods of time tended to get more gifts. The radiation oncologists received a lot of gifts."
George Annas, JD, a medical ethicist at Boston University, said there ought to be limits, but the issue can become fuzzy. "What if your patient gives you a smoked salmon, can you take that? That's probably worth $25-$50. I really think that's not worth fighting about. But I'm sure some people are purists, who would say no."
He said the basic issue is whether patients are buying special treatment with their gifts: "That's the question for the patients. Do you need to do more than have your insurance company pay the bill to actually give your doctor something to expect decent care. And that, of course, is very distasteful even to the AMA. They're thinking, no, doctors can't do that."
The AMA council ruled that physicians should "decline gifts that are disproportionately or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted."
What Are Docs Getting, and Do They Accept?
Hazelton said she experienced a boundary issue from a quite elderly patient who gave her cookies and other baked goods, books, and then insisted on "doing something special" for the psychiatrist. Hazelton suggested that the woman and her physician husband make a donation to the hospital when the treatment ended.
"I insisted on not knowing how much it was for," she said. "The baked goods and books I politely expressed my thanks for, and said quite firmly that I would be giving them to the office staff or donating them to the patient library. Halifax is a fairly small city, and our social spheres did overlap somewhat, which made it more challenging."
Martha Howard, MD, a Chicago family physician, feels that physicians ought to refuse gifts from patients to maintain the integrity of their relationship, but she made an exception to her no-gift rule when she was working for the National Health Service Corps in Chicago.
"My wonderful Mexican patients sometimes brought me tamales because they could see I didn't have time for lunch. I gratefully ate them," she said.
Paul Speckart, MD, a long-time general practitioner and endocrinologist in a more than 100-year-old practice in San Diego, faced a dilemma with an offer of a high-value gift.
He said he and his partners have close bonds with patients, who often seem like family. Patients often come bearing gifts.
"Most of the gifts originate in our patients' kitchens or gardens. We commonly get a sack of avocados or tomatoes. One of our special joys is that we care for a lot of Italian patients, some of whom own local Italian restaurants. We often get an 'extra dish' of pasta or sauce. One of my Sicilian patients brings a wonderful lasagna and some homemade sausage to my house on Easter and Christmas each year. Two of my patients own craft beer establishments and will bring in samples from time to time."
"One of my patients feels that I have a major deficit in culture and he brings me two tickets to an opera each year. At Christmas time, I will get six or eight gift certificates to local restaurants -- usually from patients who are physicians. Over a year's time I may get one or two books from patients who feel I need to broaden my horizons. Two of my patients send me 'fruit by mail' each month."
Then came an offer of $40,000.
A patient who was a retired businessman and also a personal friend knew that Speckart's income in primary care was about $150,000 a year.
His son was accepted at Stanford University, which in 1991 had a $40,000 annual tuition (about $75,000 in today's dollars), beyond the doctor's means. The friend felt the opportunity to attend prestigious Stanford was one Speckart's son should not miss because of money.
To Speckart's shock, his friend brought him a grocery bag filled with $10,000 in $100 bills. The friend offered $10,000 per year for each of the three following years to help pay the Stanford tuition.
Speckart, a former member of the Board of Regents of the American College of Physicians, knew that cash gifts generally were not appropriate and one that large seemed on the surface unseemly. But after consulting with his partners, he accepted the gift -- from a friend.
In doubt about a gift? The AMA says a charitable contribution would be a good option.