When offered a gift by a patient or a patient's family, a psychiatrist faces a significant practical challenge to negotiate "the poles of rule-bound rigor and individually tailored flexibility," the McLean Hospital Ethics Committee wrote in a recent article.1
"Gifts given to psychiatrists from patients or their families are complicated and often raise significant ethical and boundary questions," said lead author David Brendel, MD, PhD, assistant professor of psychiatry at Harvard Medical School and chairman of the Institutional Review Board at the hospital in Belmont, Mass. "Those ethical dilemmas need to be evaluated on a case-by-case basis rather than in accordance with some strict, abstract formulas or moral principles."
Brendel, a former faculty fellow at Harvard's Center for Ethics and the Professions, explained in an interview with Pyschiatric Times that the decision about whether to accept a gift should be driven primarily by considerations regarding the patient's best interests, with a focus on avoiding exploitation of the patient while simultaneously avoiding undue hurt or harm by refusing a gift.
In the recent Harvard Review of Psychiatry article, the Ethics Committee presented a pragmatic model for working through such dilemmas. Pragmatism, a philosophy developed by Charles Sanders Peirce, William James, and John Dewey, has been adapted into general medical ethics to a significant degree over the past 20 years, according to Brendel, who has also discussed its applications for psychiatry in several articles and a recent book.2 Pragmatism for psychiatry, he said, can be defined by 4 key concepts (the 4 Ps).
The first, Brendel said, is practicality. All clinical diagnoses and treatment decisions should be focused on good outcomes rather than adherence to any particular explanatory model, such as a strict psychoanalytic model or a strict biological psychiatry model.
The second, pluralism, highlights psychiatrists' need to use scientific, clinical, and ethical concepts drawn from various schools of thought as well as their need to be versed in neuroscience, psychology, and social sciences in order to devise good clinical formulations and treatment plans.
The third, participation, involves a participatory dialogue with the patient and, in many cases, the patient's family. The fourth, provisional, highlights the need to change course based on new empirical data or new clinical information coming from the patient.
Incorporating the clinical pragmatism approach, the Ethics Committee presents 6 questions to consider whenever a patient or a patient's family member offers a gift of any kind, along with clinical scenarios in which a gift is offered (based on composites of different patients). Relevant ethical principles are subsequently discussed for each scenario.
The first of the 6 questions, Brendel said, is whether the gift would be exploitative insofar as it would benefit the clinician and possibly harm the patient financially, emotionally, or otherwise. If yes, the clinician must decline the gift and strive to find a therapeutic way to discuss the refusal of the gift with the patient.
The second question is whether the gift is of great monetary or other value to the patient, the clinician, or others in the community, while the third looks at the issue of when a gift may not be of great value to an extremely wealthy family but may be of very significant value to the psychiatrist. "Gifts of great monetary value or other sorts of value should raise red flags and call for greater deliberation and probably either consultation with professional colleagues or with an ethics committee," Brendel told Psychiatric Times.
The remaining 3 questions examine whether accepting the gift runs counter to professional norms in one's practice community; whether declining the gift would be hurtful, traumatic, or otherwise countertherapeutic to the patient; and whether the clinician's deliberation about accepting or declining the gift is guided primarily by consideration of the patient's best interest.
Can a gift be just a gift?
Are there instances when a gift is just a gift, Brendel was asked.
"There are many common scenarios where we want to say in the vast majority of cases, a gift is just a gift, but we never want to slip completely into that mentality," he said. "We want to be thinking of possible exploitation and also psychodynamic meaning that may need to be explored in the best interest of treatment."
Brendel gave the example of when a patient brought him an iced coffee on a hot summer's day. "In most cases saying yes to the gift and simply drinking the iced coffee along with the patient in the session is the appropriate thing to do," he said. "At the same time, you would not want to lose sight of the fact that there can be situations where receiving a $3 iced coffee from a patient can be quite detrimental to the process."
One such situation, he added, would be if the coffee were bought by an indigent patient who doesn't have enough money to feed himself and his family. In that case, it would be appropriate to accept the coffee but then confront and address that issue during treatment.
Gifts must be evaluated within the context in which they are given, Brendel said, particularly with regard to the culture of the patient or patient's family, the community where the psychiatrist has his or her practice, and the therapeutic relationship between the clinician and patient.
Cultural expectations and norms governing gratitude and gift giving in interpersonal transactions do need to be taken into account as we make decisions about whether to accept a gift, said Brendel, who is also associate director of McLean Hospital's Pavilion unit for complex psychiatric disorders.
"If we are working with a patient or family where their cultural norm is to give a gift to someone who has been helpful to them or someone who means a great deal to them, then accepting the gift may be the appropriate thing to do under certain circumstances as long as the other criteria in the pragmatic model are met," he said. "[When] rural, small community settings [are] involved, we are into the question of dual roles. In those cases, the psychiatrist has to be very clear about the context in which the gift is given and what role he or she is playing at the time. In a small community, a gift may be given to the psychiatrist because of something that is unrelated to the clinical role (eg, the psychiatrist helped someone out in a snow storm). . . . But when the psychiatrist is fully in the role of a mental health professional, and the gift is offered, I don't see any particular differences in how the ethical analysis would go in either a large city or small rural area."
With regard to the therapeutic relationship, the Ethics Committee warned, "A gift from patient to psychiatrist may warrant more scrutiny in the context of a transference-based psychodynamic psychotherapy than in a medical-model psychopharmacological treatment."
On the spot
So what is a psychiatrist to do when offered a gift about which he has some concerns? "That question captures what can be most clinically challenging about these kinds of cases. Often it is a matter of tact and clinical acumen to be able to acknowledge in a warm way that the offer of the gift is deeply appreciated and at the same time to convey that because of certain professional norms or regulations the clinician may not be able to accept it," Brendel said, adding that ongoing supervision and consultation can help psychiatrists develop skills in being tactful.
For psychiatrists in private practice, Brendel suggested becoming part of a peer supervision group or affiliating with a professional organization that can help provide consultation and discussion about whether it is ethical to accept a specific gift.
Since Brendel introduced a 6-hour ethics curriculum to the Massachusetts General Hospital/McLean Hospital didactic program several years ago, he was questioned about training in ethics and professionalism in medical schools and residency programs.
"It is not as robust as it should be," he responded. "People are often learning these concepts on their own as part of an informal curriculum."
Some support for enhanced ethics training comes from the Accreditation Council for Graduate Medical Education, which in its 2004 revision requires training programs to ensure that the application and teaching of the American Psychiatric Association's Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry is "an integral part of the educational process."3
Additional help comes from academic psychiatry. Over the past few years, several articles about ethics education have appeared in such journals as Academic Psychiatry, Brendel said. For example, medical students and residents in New Mexico were surveyed about the need for additional training on topics pertaining to ethically important professional practices and behaviors, such as interacting with patients' families and accepting gifts from patients.4
The popular press also has become a venue for ethics discussions, as exemplified by psychiatrist Ronald Pies' "Cookie Conundrum in the Doctor-Patient Drama," which was published in the New York Times.5
Despite the increased attention, Brendel believes that ethics training in residency programs, in particular, "needs to be ramped up."
1. Brendel DH, Chu J, Radden J, et al. The price of a gift: an approach to receiving gifts from patients in psychiatric practice. Harv Rev Psychiatry. 2007;15:43-51.
2. Brendel DH. Healing Psychiatry: Bridging the Science/Humanism Divide. Cambridge, Mass: MIT Press; 2006.
3. Green SA. The ethical commitments of academic faculty in psychiatric education. Acad Psychiatry. 2006;30: 48-54.
4. Roberts LW, Warner TD, Hammond KA, et al. Becoming a good doctor: perceived need for ethics training focused on practical and professional development topics. Acad Psychiatry. 2005;29:301-309.
5. Pies R. Cookie conundrum in the doctor-patient drama. New York Times, January 2, 2007. Available at: http://www.nytimes.com/2007/01/02/health/psychology/02case.html?
ex=1188446400&en=11c8b0a8d9627a00&ei=5070. Accessed September 20, 2007.