When is it ethical to accept a gift?

AAOS guidelines make clear that support from industry must have educational value and improve patient care.

Issue: July 2004

ByDavid F. Apple, MD

Guest Commentary
	David Apple is the medical director of the Shepherd Center in Atlanta, which he also helped establish. He is the editor of the Rehabilitation section on the Orthopedics Today Editorial Board.

The dictionary defines a gift as something that is bestowed voluntarily and without compensation. Gifts are often given in appreciation, as thanks, or in response to a favor. Many gifts are given freely and with no strings attached; however, with some gifts there may be an expectation for something in return.

Accepting such gifts frequently or carelessly can lead to abuse and an ethical dilemma for physicians. Test your “Ethics IQ” on accepting gifts by answering the following true/false questions:

When attending a drug company dinner and educational presentation, you can accept a Mont Blanc pen as a favor.
True or False?
An equipment company sponsoring a course offers to pay your fellow’s expenses to the course. You cannot accept the offer.
True or False?
You are invited to lunch and a tennis game to discuss a new NSAID. You can accept the invitation.
True or False?
You are invited to be an all-expenses-paid lecturer at a company-sponsored course. You will also receive an honorarium. You can accept the invitation.
True or False?
A company representative volunteers to bring lunch for your staff if the physicians attend. You can accept the offer.
True or False?

The correct answers

False: Attending a drug company dinner with an educational presentation is within ethical guidelines, but accepting a Mont Blanc pen, which has a value of around $100, would be unacceptable.
False: A company can provide money for an educational course that can be designated for resident and fellow attendance, but the entity developing the course content also must maintain the authority to determine those who may attend utilizing funds provided by the company.
False: A reasonably priced lunch with a discussion of a new NSAID would be acceptable, but adding a recreational event would make this ethically unacceptable.
True: An invitation to be a lecturer with all expenses paid for a company-sponsored course that also provides an honorarium is acceptable under the guidelines of the academy’s statement on ethics as well as AdvaMed’s Code of Ethics, the ethical consortium for industry.
True: It is acceptable for a company representative to bring lunch for the office staff if the physicians attend as long as the lunch is of reasonable value and the educational content will benefit the patient care.

Gifts can undermine integrity

Gifts can compromise AAOS’s Principles in Medical Ethics of Professionalism in Orthopedics by undermining the physician’s integrity and challenging his or her honesty regarding the use of the knowledge or equipment being highlighted at a company-sponsored “educational” course. Gifts also can produce a conflict of interest in deciding the most appropriate care to be provided to the patient.

At the center of the ethical concern is that the orthopedic profession exists for the primary purpose of caring for the patient and thus the patient’s well-being is central to all orthopedic ethical decisions.

The AAOS opinion on gifts and the orthopedic surgeon’s relationship with industry states: “Generally, the Academy believes it is acceptable for industry to provide financial and other support to orthopedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopedic surgeons and industry should benefit the patient and be able to withstand public scrutiny.”

Gifts should benefit patients

The academy’s guidelines emphasize that any gift or other financial support accepted by an orthopedic surgeon should include a benefit for his or her patient. Under no circumstances should an orthopedic surgeon accept gifts with conditions attached.

For instance, it would be unethical to attend an educational meeting in which there was an understood or implied requirement that products highlighted at the course must be utilized by the attendees. Social functions may also take on the appearance of a gift if there is no educational value attached to the event — such as a sporting event, evening at the theatre, golf outing or gourmet dinner. The absolute ethical “no-no” is acceptance of monetary gifts.

In review, there are basically two times when gifts from industry are ethically permissible. One is for subsidies to underwrite the cost of educational events. CME credits must be awarded at these events, and the purpose of the event must be to improve practitioner knowledge, thus improving patient care. Furthermore, support for the educational opportunity must be acknowledged, and the content of the educational experience and the desired attendees should be determined by the sponsoring organization and not by the industry providing the subsidy.

The other occasion when a gift from industry is appropriate is in relationship to expenses and honoraria for faculty. Providing an educational experience to an industry-sponsored conference is ethically sound as long as the sponsoring organization controls the content and attendance.

The orthopedic surgeon must remember that the welfare of the patient is paramount in any ethical dilemma. Surgeons should diligently avoid industry incentives intended to influence treatment choices or use of devices or diagnostic approaches that are contrary to the best interests of the patient.