There is a rich literature about physicians accepting gifts from patients. One commonly referenced article is Lyckholm's 1998 JAMA publication (1). Although the acceptance of gifts remains somewhat controversial, there is nevertheless general consensus on what constitutes acceptable versus nonacceptable behavior. However, this is not the case on the subject of gifts from physicians to patients. A PubMed literature search returned fewer than a dozen articles on the topic, which are discussed in some detail below. I myself faced a clinical dilemma while working at a county mental health clinic. A synopsis of the case follows.

Mr. R is a 43-year-old single, Hispanic man. His pathology is dementia due to head trauma, which has left him permanently disabled with global cognitive deficits. His psychiatric history includes polysubstance dependence and antisocial personality disorder. His medical history includes several strokes, which have left him completely debilitated. He has complete right-sided hemiplegia and must walk with a cane. He lives in a group home, where he requires assistance for even basic activities of daily living. It is always hard for me to see him slowly and painfully twisting his dilapidated body toward my office. He is invariably pleasant—even jovial—on contact, although he frequently complains of depression. He is clearly demented, with poor memory, poor concentration, and blunting. But I always look forward to seeing him, because he is funny and fairly optimistic.

Several months before the holidays, Mr. R asked me if I was going to get him a Christmas present. I asked him what he wanted, and he said he wanted cigarettes. Smoking is one of his only pleasures. I said I would get him cigarettes for Christmas. He came for his bimonthly visit just before Christmas and immediately asked whether I had gotten him his present. Fortunately, I had purchased several cartons that morning in case he should remember. He was delighted with his gift and gave me and my family his blessings.

To round out the picture and anticipate several logical questions: I did not give gifts to any other patients. I know as well as anyone else that cigarettes are carcinogenic, and my prime directive is to first do no harm. The ethical issues here are several. Should a physician give patients gifts? If not, are there patients who are somehow special and deserve exception from the general rule? Even if it were ethical to give a patient a gift, wouldn't it be the physician's duty to give a wholesome one?

A number of articles address these issues. These articles fall into two categories: those that address directly the ethicality of health care providers' giving gifts to patients, and those that address more specifically the things that health care providers give patients that might be construed as gifts, such as medication samples, special services or accommodations, and money.

The first category contains three articles, which focus on different issues, all taken from guidelines. The main principle is that providers should not use their position to gain an advantage that is not available to others. Palmer (2) argues that it is "sometimes acceptable for psychiatrists to give patients small gifts to celebrate milestones." She adds that gift giving may help forge the therapeutic alliance with "adolescents or severely regressed adults." The Texas Medical Association (3) warns that "many patients find over-familiarity offensive," noting that giving gifts "may lead to a decrease of a physician's objectivity." The association's gravest concern is that a patient might be "burdened by a sense of obligation that can never be openly discussed with the physician." Finally, the Alberta Association of Registered Nurses warns that although gift giving may or may not be appropriate, one must question very closely one's motivation for giving a gift, asking questions such as, Do I give all my patients such items or special treatment? Are toiletries and clothing available as needed, or just for patients of whom I am fond? (4)

The second group of articles, focusing on specific gifts, includes an article by Nelms (5) that beautifully articulates all that we "give" to patients in terms of family education, helping them have healthier lives, and helping them use their common sense to make decisions. In another article, Miksanek (6) asks the question, "Should I give money to my patients?" While acknowledging that the literature on the topic is scarce, he observes that the practice of giving money to patients is probably uncommon, that practitioners who do it "tend to keep it a secret," and that most do not feel comfortable, because "they are uncertain about the professional boundaries." He further outlines a number of drawbacks to giving money to patients: there is no guarantee that the money will be spent for legitimate needs, the gift might result in expectations about future gifts, it might violate the principle of equal access, there might be legal consequences, giving money is often a short-term fix that fails to address a long-term need, and it often oversteps the boundaries of the physician-patient relationship. He concludes that giving money is rarely recommended: "it is almost always more preferable to supply the actual item or service needed."

Finally, Zambri (7) reports that providers who offer items or services at a discount "must be increasingly cautious." This advice is based on an opinion rendered by the U.S. Department of Health and Human Services Office of the Inspector General that states "patients that are required to pay even a small portion of their care will select items or services because they are medically needed, rather than simply because they are free." Thus the core question seems to be one of management of limited resources.

In light of these arguments, it is unlikely that my gift would pass a strict review of ethical boundaries. However, it is unlikely that my gift in any way damaged my relationship with the patient. But the seed of another question is planted in the choice of gift. True, the patient had specifically requested cigarettes. But was this gift the wisest choice for him? A colleague observed that my giving a potentially harmful gift might suggest something about my ambivalence toward this patient. The basic meta-communication might be interpreted as, "Thank you for prompting me to provide you with an instrument for your quick demise so I no longer will have to see your twisted body ambulating into my office as a constant reminder of the deformity and injustice in life that I most fear." Seen in this light, my countertransference is the central issue.

When confronted with an ethical or countertransference conundrum, it is always wise to consult Glen O. Gabbard. In a 1995 JAMA article, Gabbard and Nadelson (8) addressed the issue of "Professional boundaries in the physician-patient relationship." Although concerned mostly with boundary violations and physicians' acceptance of gifts, these authors had the following to say about physicians who give gifts, which can include not charging a fee: "Although done with the best of intentions, the patient may feel burdened by a sense of obligation that can never be openly discussed with the physician." It is unlikely that my patient felt any sort of obligation toward me other than to give me and my family his blessing; this was his practice at every session, though. Furthermore, the session described above was my final session with the patient, which raises an interesting question about whether boundaries must be strictly maintained under special circumstances—for example, during a patient's final session or during ongoing sessions with a patient who is dying. My feeling is that such instances must be taken on a case-by-case basis and that there are no simple, ironclad guidelines that address every possible situation.

So, at the risk of being labeled "that cigarette-giving psychiatrist" or "that psychiatrist who wears his destructive fantasies about his patients on his sleeve," I submit these questions to you my colleagues and shall be most interested in your feedback.

The author thanks A. A. Howsepian, M.D., for his invaluable feedback and guidance and Cynthia Meyer for her assistance with literature searches.

Dr. Krassner is chief resident in psychiatry at the Psychiatry Residency Program, UCSF-Fresno Medical Education Program, University Medical Center, 445 South Cedar Avenue, Fresno, California 93702-2907 (e-mail, david.krassner@ucsfresno.edu). Marcia Kraft Goin, M.D., Ph.D., is editor of this column.