Gift Giving or Influence Peddling: A Practice That Needs Critical Review

Dear Editor,

The giving of gifts in medicine has long been an issue of ethical approach, mainly in specialties such as neurosurgery. This practice may cross the limits as it may become influence peddling, which can indirectly intervene in the personal doctor's decision-making. According to Łuków,[1] altruistic donation based on anonymity, in any aspect of medicine, is defective and unproductive and that notion must be changed by human practices of giving and receiving, in a regulated manner and without additional interests. He mentions that this can become something unpayable and that the neurosurgeon is practically forced to have debt burdens with the patient and family due to the gratitude that this entails. However, it is mentioned that the giving of gifts altruistically is not motivated exclusively by the expectation of direct or indirect gain, in which it is not intended to benefit another. However, the aim is almost always to benefit an anonymous person. According to Ferraro,[2] the extent of the feeling of indebtedness makes the person who has accepted it feel inferior and will seek to free themselves from the obligation through reciprocity.

The gift-giving value or the type does not matter. There is always a reward waiting. It has been shown that it does not matter if the gifts are small or large. According to Katz et al,[3] sometimes small gifts surpass large ones in persuasive influence, also imposing a sense of debt, which shows that the feeling of obligation is not related to the size of the gift. Also, it is not just the type or brand that influences; sometimes, the gifts have symbolic messages, which can be very relevant. Giving a necklace with a spiritual symbol or something that carries a powerful message can have a great influence. However, the giving of gifts is not the same as an act of courtesy or selfless charity. It plays an important role in the functioning of society and seeks to obtain a benefit from the one who gives it, expecting something in return from the recipient, which is why, according to Łuków, they may correspond to instruments of social connection.[1] But as Graycar and Jancsics[4] mention, gifts can have other connotations and in certain cases. It may cross the boundaries of being a bribe. However, the former is accepted and the latter is condemned, when, in certain situations, there is no clear limit to this, since gifting to a neurosurgeon can negatively influence the results, decrease efficiency, and alter trust. But gifts do not always have to be tangible. According to Larsen and Watson,[5] other ways can be used such as providing meals. The sky is the limit in certain cases. What we want to highlight in this aspect is that there are great similarities between gifts and other less acceptable terms, even if society sees them differently. It can be said that the giving of gifts triggers a feeling of reciprocity and imposes a quid pro quo.[5]

Although in many places it is seen as something benign, a good example is the phenomenon known as potlatch, which is a gift ceremony practiced by the people of the northwest coast of the United States, being normal in that culture.[6] However, in many parts of the world, strict regulations are being taken regarding gifts in the medical field. “Altruistic” gift giving has important regulations in the United States and the European Union.[1] Some states have banned gifts from pharmaceutical companies to doctors and others require them to disclose the gifts they receive.[7] These regulations can have legal repercussions that can damage the neurosurgeon's reputation. Public online web information sites like https://openpaymentsdata.cms.gov/ help society to know the details of the types and total value of gifts in U.S. dollars given to individual medical doctors (MDs). This is based upon the Physician Payments Sunshine Act of 2010.

Furthermore, colleagues could view these gifts as suspicious behavior, with some suspicion and mistrust, which can alter the work environment. It should be noted that trust is essential to establish a good doctor–patient relationship. Therefore, patients trust that their neurosurgeon is being objective, without the external influences of gifts, which can erode trust and alter this relationship. Not only trust, this can also influence clinical results, because decisions such as the choice of a certain tool or procedure can be made due to a gift from a provider, not always being the best option for the patient. Giving gifts in these instances can generate a loss of income and undermine bureaucratic processes and the trust of these processes.[5]

One of the most important examples is when pharmaceutical companies invite doctors to conferences with full payment. Neurosurgeons are not exempt from this and these practices have been found to increase the prescribing of promoted medications. According to King and Bearman,[7] the pharmaceutical industry spends about US$15 billion annually offering gifts, samples, trips, honoraria, and other incentives to prescribe its medications. In the study performed by these authors, it is evident that the acceptance of expensive new medications was lower in states with regulation than in areas that do not have restrictions, which is associated with these practices.[7] The neurosurgeon must be based on commitment to the patient, thinking about their well-being and professional integrity, which can be interrupted by gifts that can create conflicts of interest. Therefore, it is best to be free of these external influences, basing clinical decisions on objectivity, away from influences. It has been shown that even small gifts can create a feeling of obligation, leading to biased decisions being made favoring certain devices or medical treatments, due to the feeling of debt to the donor.

Therefore, the recommendations are to adopt a strict policy of not giving gifts or receiving gifts, including all interested parties such as patients, family members, and providers. Additionally, training about medical ethics and conflicts of interest can be provided to keep neurosurgeons informed about legal guidelines, reinforcing the importance of maintaining professional integrity. Institutions must be an important part, having mechanisms to transparently report on any gift received, regardless of what it costs. This helps maintain consistent accountability and identify conflicts of interest. In summary, there are more and more doctors and organizations who are advocating for a complete ban on receiving gifts. Partial limitations are not respected and are often forgotten. That is why it must be regulated in a very effective way. Gifts, influence peddling, and conflict of interest correspond to important ethical challenges in neurosurgery. Clear policies and a culture of transparency and integrity must be adopted to maintain the highest standards of professional conduct, guaranteeing the well-being and best outcomes for patients. In this way, the neurosurgical community can continue to preserve the high trust that patients have placed in them.

Conflict of Interest

None declared.

• References

• 1 Łuków P. Pure altruistic gift and the ethics of transplant medicine. J Bioeth Inq 2020; 17 (01) 95-107
• 2 Ferraro E. Owing and being in debt. A contribution from the northern Andes of Ecuador. Soc Anthropol 2007; 12 (01) 77-94
• 3 Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth 2003; 3 (03) 39-46
• 4 Graycar A, Jancsics D. Gift giving and corruption. Int J Public Adm 2017; 40: 1013-1023
• 5 Larsen D, Watson JJ. A guide map to the terrain of gift value. Psychol Mark 2001; 18 (08) 889-906
• 6 Lanoue G. Gift giving, reciprocity and community survival among central Alaskan indigenous peoples. Humans 2023; 3 (01) 47-59
• 7 King M, Bearman PS. Gifts and influence: conflict of interest policies and prescribing of psychotropic medications in the United States. Soc Sci Med 2017; 172: 153-162

Publication History

Article published online:
06 December 2024