The role of doctors, nurses and physicians in general is to help out their patients and make them healthy. The patients pay for their treatment, but some may feel that their payment is not enough or may want to give extra. This exchange of money for service is extremely personal since this service is the provider of their continued health, or at least genuine attempts to do so. Since it is so personal, patients may feel that they are still in debt to their healthcare providers even if proper payment was done. These patients may give their healthcare professional a gift to show their thanks.
Should the healthcare professional accept or reject these gifts? Currently, it seems that the decision is up to the healthcare professional’s discretion. To begin with, some sort of loose definition must be set for the types of gifts that are being discussed. Gifts that would be deemed as just a thanks between a healthcare professional and a patient are also the most common types of gifts (Spence). These are chocolate and liquors, which have low monetary value and cannot be exchanged easily for their face value; meaning, once the healthcare professional receives these gifts they are most likely stuck with them.
This is important, because gifts other than money usually have some thought process behind them and requires more effort to go out and acquire them. This would mean that the patient is thinking about the doctor and that their thanks are most likely genuine. There can still be hidden motives behind these ‘genuine’ gifts, but both sides of the argument have to be laid down before it can be further discussed. If a gift were to be accepted it may taint the rest of the healthcare procedure.
As Weijer writes: “The physician-patient relationship is a fiduciary one; that is, the physician owes an obligation of fidelity to the patient” (Weijer). He goes on to say that profiting from outside the established monetary channels that pay for the doctor to do his job interferes with his obligations to his patient. It may also give the patient the idea that since they gave their doctor a gift, that the doctor now is in a sort debt to them. This debt would of course need to be paid in the form of extra attention to the patient.
If the debt is not paid the patient may resent the doctor and think of him as greedy or ungrateful. This resentment may lead the patient to hurt the doctor in ways he or she does not deserve. It could lead to the slandering of the doctor, which could deny him potential clients all for a reason that has nothing to do with the doctor’s ability to supply a comfortable atmosphere for his practice, or his ability to perform his general duties as a doctor. Some doctors or health professionals get into their profession, because they get pleasure from helping people.
They might see these gifts as gratitude from the patients to whom they have provided such good service that the patients want to express their thanks in additional ways such as gifts. In some cases this could be true, but in cases such as the one being discussed where the patient has ulterior motives, it could end up hurting both the patient and the doctor. The patient would be hurt because he or she gives this gift with the expectation of increased attention which the doctor does not deliver.
The doctor sees that they have upset the patient instead of helping them like he or she thought he or she would, and he or she becomes upset too. Nobody wins in this situation, and it only causes pain. There is also the possibility of a ‘corruptible’ doctor who does see all these gifts as bribes, and gives increased attention to those willing to imburse him additionally. In this situation the doctor-patient relationship becomes completely corrupted and the fidelity (that Weijer stated as so important) is almost non-existent.
The doctor may feel no obligation or duty to help patients that do not imburse him additionally, and therefore give them less attention than needed for adequate healthcare. These bribes may also extend past the conventionary gifts like chocolate and liquor to lump sums of money and cars. The slippery slope argument comes into play here and asks: how long before the physician is willing to completely sell him or herself out? Some big pharmaceutical companies pay doctors to sell their specific drug over others to patients over generic or other medicines (Spence).
This of course is extremely ethically wrong, illegal and breaches the trust between the doctor and the patient, but it may become justified in the doctor’s mind if he or she starts accepting gifts from patients. This case or type of doctor may not be common, but there are so many other laws and ethics (as set out by governments) that protect against possible slippery slopes (such as laws against racism) that it begs the question: why not protect against this one?
Why not elaborate on the Code of Ethics of the Canadian Medical Association so that it states clearly that no gifts of any kind may be accepted? Well, there are downsides. Turning down gifts may also carry with it more sting than just the denial of a doctor to his or her sweet tooth. It also has the ability to hurt the patient, and with it the doctor patient relationship. First of all if this present is a genuine thanks from a patient who feels him or herself in debt from the care provided by the doctor, turning them down keeps them in this debt with no possibility of ever paying it off. Refusal of a gift may also make the patient feel insignificant.
The doctor has helped them in their dire time of need which, depending on the case (for example a risky surgery), could make a huge difference in their lives, and for the doctor to refuse the patients thanks may make it seem to the patient that this possibly life-altering event meant nothing to the doctor and was so insignificant that the doctor does not even feel deserving of a small gift. As Andereck writes: “some people are simply generous by nature. Gifts to the mail carrier, the newspaper carrier, [etc. ] and others in their lives are just a part of their personality.
They derive pleasure from the act of giving itself. Such behavior is inspirational and should not be thwarted” (Andereck). It does not necessarily hurt the patient to turn down these gifts, but doing so you are denying an act of appreciation and sentiment. Andereck goes on to discuss what is expected out of the doctor-patient relationship. He dismisses the idea of a relationship based on objectivity and presents one that is a special type of friendship as first described by Pellegrino and Thomasma (Ibid). This relationship would include compassion and trust, and would not be cold like one of objectivity (Ibid).
Andereck closes by stating that if: “patients are not trying to influence their relationship with their physician, the doctors should accept the gift with a smile, send a thank-you note, and move on” (Ibid). His model for accepting gifts is ideal, but has one glaring problem; how is one to truly able to distinguish the motives of a patient? Sean Spence believes that the time at which a gift is given may give some insight as to why it was given (Spence). For example a gift given on a major holiday such as Christmas is less suspect than one given at the beginning of a treatment.
History is also important in discerning motives, as if no gifts were given up until this Christmas the doctor must reflect to see if anything has changed in the past year that might warrant an ill motive for the patient to give (Ibid). The type of gift may also show meaning. Spence gives a humorous example of disgruntled patient giving a doctor a medical textbook. The motives in this example are clear, and in some cases gifts may allow doctors to further help their patients. For example a suicidal patient giving the doctor something sentimentally precious so the doctor can take care of it.
Spence also states that whatever action you do take in accordance with a gift, a thank you note is always required (Ibid). This would eliminate problem or help to alleviate the pain as discussed earlier of the patient getting hurt over the rejection of their gift. As for Judaism’s approach on this dilemma the first place to look is the Torah. In Deuteronomy 16:19 it states “Thou shalt not wrest judgment; thou shalt not respect persons, neither take a gift: for a gift doth blind the eyes of the wise, and pervert the words of the righteous. ” It states that a judge who takes a gift or bribe may be blinded and change his words or actions.
Surely this can also be applied for doctors as well; they can both at times make decisions that could affect people’s lives, and a gift given to them can impact on their decision (Lavine). This disdain for gifts continues throughout Jewish texts and applies not just to those with power like judges or doctors, but to everyone in general. Proverbs (15:27) says, “A greedy person corrupts his house, but one who disdains gifts will live,” and as Rabbi Meir points out, “in the Shulchan Aroch it tells us: It is a mark of piety not to accept gifts, but rather to trust in God to provide enough for his needs” (Meir).
Meir goes on to list sages that also refused gifts (such as Rabbi Elazar refusing gifts from the Exilarch) and cited proverbs as an explanation for their refusal. Meir believes that Elazar turned down this gift because it was meant as a bribe to cloud his judgement and turn him against his own people. Meir then brings up a story of Rabbi Yehuda and Rabbi Pinchas. Rabbi Yehuda invited Rabbi Pinchas to dinner, but Pinchas refused. This perturbed Yehuda to which Pinchas explained: “do you think I have forsworn benefiting from other Jews? Israel are a holy people!
[The problem is that] some people are willing but don’t have [means], while others have and don’t want [sincerely] to give… You want to and also have [means], however right now I’m in a tremendous rush” (Ibid). Pinchas denied gifts from those he thought were trying to impress him and were not sincere, and also those he thought did not have the means to follow through (comfortably) on their promise. This can be applied to physicians in the sense that one can accept gifts but must be humble in doing so. The gifts must be sincere and must not be an imposition on the giver.
Meir further interprets this story and says: “Rebbe Pinchas ben Yair acknowledged, accepting a gift is a way of recognizing the status and beneficence of the giver; refusing one may show that you are unwilling to owe a favor to someone” (Ibid). The idea of owing a favour to someone is interesting, and flies in the face of reasons discussed to deny gifts from patients. To refresh, if a patient gives a gift before say a surgery, there might be the expectation that the doctor is now in their pocket, and must perform the surgery precisely.
This may cause problems if the doctor, for whatever reason, fails to repay the favour. One may argue that the connection Meir intended to draw is between friends and acquaintances and has no application to a professional relationship like doctor-patient. However, inability to repay a favour to a friend also holds the potential to ruin relationships, which brings a general conclusion: although gifts are defined as objects given without the obligation to pay them back, do not accept them if you cannot.
Gifts in the doctor-patient capacity have the ability to do serious damage to both parties, and so there is no simple guideline as how to handle them. Gifts must be analyzed situation by situation, and even then the right course of action may still not be clear. Letting the patient know they are appreciated is important, and being careful not to overextend the relationship by accepting gifts that may not be able to be paid back in the form of continued health to the patient. A doctor must not only look a gift horse in the mouth, but give it a full physical.