‘Business Dilemmas’

To accept or not to accept? Dr Ellie Mein explains what you should do if you receive a gift from a patient. 

 

 

 

 

 

Dilemma 1

Do I accept this costly present?  

QA patient has gifted me an expensive watch as a thank-you present following a recent course of treatment. While this is extremely kind and I am very flattered, I am not sure if I should accept it. Is this a conflict of interest? 

What should I do? 

A While it can be nice to receive a gift from a patient, it is worth bearing in mind that accepting gifts from patients can be misinterpreted. 

In Financial and commercial arrangements and conflicts of interest (2013), the GMC states that ‘you must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you’.

However, unsolicited gifts from patients and their relatives can be accepted as long as this ‘does not affect, or appear to affect, the way you prescribe for, advise, treat, refer, or commission services [and] you have not used your influence to pressurise or persuade patients or their relatives to offer you gifts’, but you should ‘consider the potential damage this could cause to your patients’ trust in you and the public’s trust in the profession’. 

Small gifts such as chocolates or wine are unlikely to raise alarm if accepted from a patient.

But you must be wary of more pricey items such as expensive watches, property or large sums of cash. 

Sometimes even small gifts can ring alarm bells in the context of other behaviour. For example, a Valentine’s present or a gift from a patient you suspect has romantic feelings for you. In such situations, it might be better to politely refuse the present.

In the MDU’s experience, bequests can also put doctors in a difficult position, not least because they might raise questions from relatives about your relationship with the deceased patient. 

Think twice if the bequest is large or if the patient was particularly vulnerable. If you are unsure, it’s a good idea to seek an objective opinion from a colleague and get advice about the ethical implications from your medical defence organisation.  

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An injection of the law

A consultant’s questions about a patient with severe needle phobia highlights some big issues raised in a court case. Dr Ellie Mein gives her view

 

 

 

 

Dilemma 2

What if she won’t have blood test?  

Q I am a consultant gynaecologist with a private practice who recently saw a woman who was five weeks pregnant who had attended me in my NHS capacity due to a threatened miscarriage. However, she and her baby remained well after the initial review.  

Nevertheless, I am concerned about how her pregnancy might be managed going forward, as, during our discussion, she disclosed that she had a severe
needle phobia and would be unable to have blood tests or an IV infusion even if she needed it.

What do you suggest?  

A It is estimated that approximately 10% of the UK population suffer from a degree of needle phobia. This can impact on care in various ways and it has been found that pregnant women with severe needle phobia may be more likely to register late for antenatal services and delay or refuse their antenatal blood tests. 

The difficulties in treating pregnant woman with needle phobia have previously made it to court, with perhaps the most notable being the 1997 case of MB . 

MB was about 40 weeks pregnant but her foetus was in the breech position. She was told that a vaginal delivery carried a high risk to her child of death or brain damage. 

As such, she agreed to have a Caesarian section, but later refused to undergo anaesthesia by way of injection at the last minute, as she was needle-phobic. 

The hospital obtained an urgent judicial declaration that it would be lawful for the doctors to proceed with the anaesthetic for a C-section, a decision that was later upheld by the Court of Appeal. 

The basis for this ruling was that MB temporarily lacked capacity to refuse consent, as her fear had prevented her from taking in the information she had been given about her condition and treatment.

While the above case required urgent legal intervention, most of these cases do not reach this point. In this case, the severe phobia has been identified at an early gestation and consequently the following should be considered:

Identifying needle phobia and its potential impact on a patient’s care early on may avoid last-minute, rushed interventions. This may also provide time in which the patient can receive cognitive behavioural therapy to help them manage their phobia in advance of necessary blood tests, cannulations or suturing.

Use a multidisciplinary approach by including senior input from psychiatry, as necessary, and the anaesthetic team, who may be able to discuss treatment strategies with the patient. Discuss the case and phobia implications within the wider obstetric team to obtain senior opinions on how this woman could be managed.

If the patient currently has capacity, she may wish to donate Lasting Power of Attorney (LPA) for health and welfare to her birth partner to make decisions on her behalf should she lack capacity in the future. The Mental Capacity Act 2005 means that, should a scenario similar to MB occur now, the patient’s health and welfare LPA could authorise treatment such as anaesthesia and a C-Section on her behalf. The GMC encourages us to engage with patients about such advance care planning. 

Involve the trust’s legal team early because, as the case of MB demonstrates, occasionally these cases do require urgent court involvement.

Dr Ellie Mein is a MDU medico-legal adviser

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