Yasir I. Abbasi  ( Sheffield Care NHS Trust, United Kingdom )
Amin A Muhammad Gadit  ( Memorial University of Newfoundland, Canada )

Patients generally express their gratitude towards the doctors and many a times would offer gifts as token of thanks. This gesture of appreciation in the form of gift can vary from a simple, relatively inexpensive item to an expensive one. Should the doctor accept gifts from patients? Are there any guideline from our regulatory authority that is Pakistan Medical and Dental Council (PMDC)? Is this practice common in Pakistan? Had there been cases reported where this issue has raised serious and significant concerns with respect to patient-doctor relationship? The answer to the first question is debatable, for the second question, we do not have any guideline for sure and yes to the third question but the answer is based on anecdotal evidence and not on an empirical study in the local context. Regarding the fourth query, we do not have any scientific evidence for this fact but personal communications, media reports and some ethics committees have indicated the existence of this problem. The debate regarding the first issue revolves around the idea of evaluation on a case to case basis keeping in view the ethical connotations, nature and cost of gift and therapeutic relationship. There is a word of caution for psychiatrists though not exclusive to them but also applicable to all medical practitioners is the issue of transference which may lead to relationship boundary violations.¹  In some cases, not accepting a gift can be counter therapeutic. However, it is advisable for the doctor to judge the value of the gift and the intention of the patient before making a personal decision of acceptance. Gifts to clinicians are neither expected nor required; therefore ethical problems may arise regarding the nature of the gift and expectation of patients.² According to Spence³ gift giving by adult patient can provide some insight into the patient's thought processes from a psychoanalytic perspective.  Weijer⁴ argues that the gifts should not be accepted for reasons that physician-patient relationship is fiduciary and therefore acceptance may violate physician's fidelity to the patient, the motivations of the patient cannot be judged correctly, it would reflect as an attempt to purchase the physician's favour with more expectations by the patient and there are other more meaningful ways to express gratitude. It is a difficult area in the local context. The exchange of gifts is more acceptable culturally but coming from patients may raise some concerns. In many instances, gifts from patients have been a first step towards boundary violations. The matter of transference and counter transference in this context can lead to potential complications. It also becomes difficult to differentiate between a simple respectable gesture and underlying vested interests. It can lead to feeling of rejection by the patient if the gift is not accepted and the value of gift is also an important factor to take into consideration. Capozzi and Rhodes² suggests that an inappropriate gift should be politely declined and the reasons should be explained to the patient, if the patient insists upon giving expensive gifts then he/she should be advised to support an academic activity or charity, moreover, it should be made clear to the patient that acceptance of gift will not confer any change in attention to the medical condition. Viewing the issue with a different perspective, in our society at times gifts are in a non-material form, like doing favours. A certain patient will pass on their business card to the physician, outlining their higher social standing and influence the doctor's decision by promising personal favours. There also arises the question of patient abuse. If such a practice (taking gifts from patients) is made acceptable then there could be physicians who may be misusing the vulnerable under the premise of patient's altruism.
But on the other hand different societies have a cultural tradition of exchanging gifts amongst people who are respected. Takayama⁵ describes the Japanese gift giving tradition of oseibo and ochugen during winter and summer respectively. He goes on further to describe that orei which is another type of gift left by patients or family members of 10,000 yen ($100) or more of cash. This token of appreciation is often provided in advance of major surgical procedures. The General Practitioner in the UK proudly displays the different cards given to him over the years and a scarf knitted by one of his patients for him in his room. During a ward round a patients family leaves a cheque of £100 after their son completed an alcohol detoxification. This was given to the ward manager to be used for buying different board games for future inpatients. A box of chocolates given by a patient is usually distributed among the staff and other patients on the ward.
There can also be gifts which could carry a more sinister tone to it. Some patients might be attracted to the treating physicians for one reason or the other. Personal gifts like flowers, jewelry or wallets should alert the doctor and the possibility of stalking by patients cannot be ruled out. They should be discouraged from the very beginning and if the advances are deemed inappropriate, then the professional contact should immediately be severed.  Such events can lead to a lot of anxiety and if they are not handled properly then at times the consequences can be grave.
Likewise, in the local context, we believe that it is wiser to discourage personal gifts from patients while educating them, encouragement for donation to a patient welfare project if a rich patient is adamant about giving gifts and in rare circumstances the doctors may accept a photograph with family, hand drawn picture or a letter of thanks. It will be even more appropriate to request the patient for 'prayers (dua)' as an expression of gratitude. 
There is a clear need for a guideline devised by the PMDC which could incorporate the following suggestions:
-         A clear definition should exist of what gifts are in clinical practice.
-         There should be identifiable monetary labels of what comprises of a small, medium and large gift.
-         Any gifts (if at all) accepted by the physician should primarily be of benefit to the patient and should not be of substantial value.
-          A doctor should keep an official record of all the gifts accepted and their disposal.
-         Physicians should be given mandatory training in medical ethics and law.
Some can argue against having a code of conduct as no one can guarantee its implementation .Why would we want to criminalize an innocent act of appreciation? Sarkar et al⁶mention that the existence of a code of research ethics had little effect or no on the practice of medical members of the Nazi party and there is little evidence that having such a code can prevent unethical practice. While these ideas have some veracity in them, it cannot be denied that a code of ethics is another way to maintain standards, even if it cannot ensure ethical behaviour. But above all the main aim of such a code of ethics would be to protect the rights of the most vulnerable individuals of our society that is the physically and mentally ill patients.
The Canadian born physician Sir William Osler (1849-1919) once said "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish."

1. American Medical Association Council on Ethical and Judiciary Affairs: Code of Medical Ethics, Current Opinions with Annotations 2000- 2001. Chicago, IL, American Medical Association 2000; pp 45.
2. Capozzi J, Rhodes R. Gifts from patients. J Bone Joint Surg Am 2004, 86, 2339-40.
3. Spence S. Patients bearing gifts: are there strings attached? BMJ 2005; 331: 1527-9.
4. Weijer C. Point-Counter Point: Should Physicians Accept Gifts from Their Patients? No: Gifts debase the true value of care. West J Med 2001; 175: 77.
5. Takayama J I. Giving and receiving gifts: one perspective. West J Med. 2001; 175: 138-9.
6. Sarkar SP, Adshead G. Protecting altruism: a call for a code of ethics in British psychiatry, Br J Psychiatry 2003; 183: 95-7.