(2004; 102 pages)
1.10 What are professionals’ and patients’ attitudes to the appropriateness of gifts?
Most (55%) of the family medicine residents surveyed by Sergeant et al. said that they would attend a private dinner with a sales representative paid for by a company. Thirty-six per cent felt that gifts from sales representatives to doctors resulted in higher drug costs for patients5. The doctors surveyed by Aldir et al. felt that smaller gifts were more appropriate than more valuable ones6. Of the Canadian doctors surveyed by Strang et al.13 85% agreed that sales representatives should be able to offer free samples, but 74% felt they should not be able to offer all-expenses-paid trips to meetings organized by companies.
More than half of the residents surveyed by Keim et al.10, reported accepting gifts such as textbooks because they needed financial assistance with their education. Seventy-eight per cent of programme directors and 92% of students believed it was appropriate to accept textbooks from drug sales representatives. Keim et al. found that those who were more sensitive to bioethical issues in general were less willing to accept non-educational gifts. Twenty-five per cent of resident doctors in Virginia surveyed by Sigworth et al.32 said they would not want patients to know that they had received gifts and awards from drug companies and would try to hide this.
In a simple but clever research design, Palmisano and Edelstein33 asked 100 medical students and 100 family planning nurses about the propriety of various people accepting gifts. Of the 50 medical students who were asked, 85.4% felt it was improper for a government official to accept a US$50 gift from someone who wanted to gain a contract. Of the other 50 students, 46% felt it was improper for a medical student to accept a US$50 gift from a drug company. The nurses were divided into three groups and asked different versions of the question. Of those who were asked, 97% felt it was improper for the government official to accept the gift, 64% felt it was improper for a resident doctor to accept the gift, but only 30% felt it was improper for a nurse practitioner to accept the gift. Amongst the Turkish doctors surveyed by Güldal and Semin27 33% felt that gifts were not ethical, 36% felt they were not ethical in some respects, and 21% felt that gifts were ethical.
Sixty-four per cent of the patients surveyed by Blake and Early8 believed that gifts would increase the costs of medicines. They approved more of doctors accepting some gifts, like drug samples, medical books, ballpoint pens and conference expenses, than others, such as dinners, baby formula and golf tournaments. Men, older people and those with tertiary education were more likely to disapprove of gifts. They were more likely to disapprove of gifts (except free samples) if they felt that these influenced prescribing and increased cost. One limitation of this study was that many patients were unaware that such gifts were given, so had little time to consider their opinion of them while completing the questionnaire. In Mainous et al.’s Kentucky study11 many more people (82%) were aware that doctors received office-based gifts than personal gifts (32%). This study used a population-based sample, rather than a practice-based sample. Substantial minorities of people felt that gifts had a negative effect on health care costs (42% for personal and 26% for office gifts) and health care quality (23% for personal and 13% for office gifts). These beliefs were more common amongst respondents with higher levels of education.
Gibbons et al.34 asked doctors and patients about the same list of 10 gifts, and found that patients rated the gifts as less appropriate and more likely to influence prescribing than doctors did. Those with higher levels of education (i.e. those who had completed high school) were more likely to think that the cost of gifts was passed on to patients. Before the survey about half of the patients (54%) were aware that doctors accepted such gifts. Of those who were previously unaware of this, 24% said that learning about them had changed their perception of the medical profession.
CONCLUSION: Seven studies in the database address the question of professionals’ attitudes to gifts. The studies available suggest that there is a range of views about gifts but a tendency for gifts that were smaller or more relevant to helping patients to be regarded as more acceptable. There is evidence that professionals believe that their acceptance of gifts goes below community standards and their own standards for other people in positions of responsibility.
Three studies in the database address the question of lay peoples’ attitudes to gifts. The studies available suggest that only a minority are aware that doctors receive personal gifts, so only a minority disapprove, but people with higher levels of education were more likely to disapprove.