We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place. Please send any cases that you would like considered for inclusion to: info@plainviews.org

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CaseConference #2 (Responses are posted below the case)

A chaplain was referred to a patient by a surgeon. The patient had just delivered her third child when she was diagnosed with breast cancer. Surgery and chemotherapy followed. Over the next three years the chaplain visited with the patient and her family whenever the patient was at the Outpatient Clinic, offering prayer support, referrals to support services, etc.

One day the chaplain visited the patient. The patient reminded her this was her last chemotherapy session and she wanted to give the chaplain a gift of a pair of earrings “in appreciation for all you’ve done for me. I genuinely love you and am so grateful you’ve been there.”The chaplain indicated that she was touched by the gesture, but wouldn’t be able to accept them. The chaplain was aware of an institutional policy against the giving of gifts to staff by patients.

The patient began to cry and became very emotional, stating, “I didn’t mean anything bad by it. I don’t want to get you in trouble. You’ve just meant so much to me and my family and I wanted to show you how much I appreciate it.”

The chaplain then received the earrings, and thanked the patient. She then contacted her supervisor, who made inquiries with the administration regarding the specifics of the policy and whether there were any exception clauses. The chaplain wanted to honor the institution’s policies, but also wondered if refusing the gift would create harm in the patient. Administration answered that there were not acceptable exceptions to the policy, and the chaplain would need to return the earrings.

Could the chaplain have handled this differently so that the patient would not have been as upset? Is there ever a time that a gift can or should be accepted? Should patients be informed in some way that the hospital has a policy of "no gifts to staff" so that this would not even become an issue?

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Responses to CaseConference #2:

I have been in this situation a few times. My answer is to inform the patient that I cannot accept gifts from patients but it would mean a lot to me if the patient would make a donation to a charity related to the patient's illness, for example, Hospice, cancer research, etc.

Gene Simco
Volunteer Chaplain
Vassar Brothers Medical Center
Poughkeepsie, New York

There is a great line in an old Charles Bronson movie called "Death Wish". The D.A. is about to enter the courtroom to prosecute some murderers. Bronson's words to the D.A. are, "Go in there and do what is right, not what is legal". Need I say more?

Alan Faulkner, BCC,
Medical Oncology Associates of Augusta

There is another option that the chaplain could have considered. It would go something like this: "Ms. [pt name], I am deeply touched by your desire to give me this gift. While we do have a policy in place that prohibits me from receiving gifts, I am also wondering if there might be exceptions. I am willing to go through the appropriate channels and consult with our administration. I think this would be beneficial not only for you and me but also for [institution's name]. Will you please let me make this consultation and contact you later?" Doing this would accomplish a few things. (1) The patient would likely not be so distressed, knowing that at least someone was willing to work with her. (2) Even if the final answer was still "no", both the patient and the chaplain could take solace in having given it their best shot so to speak. (3) There would possibly be an opportunity for the institution (and possibly its ethics committee) to revisit the issue and either clarify the reasons for the policy or define possible exceptions. (4) The chaplain would not have put herself in danger of a reprimand or possible termination.

As to the question, "Is there ever a time that a gift can or should be accepted?", my response is that because we represent the institutions we serve in our professonal practice, the question must be answered by the institution itself. Once a policy has been written, it's not up to the chaplain to decide whether or not to receive a gift. The institution has already made the decision. The chaplain can appeal to the appropriate channels and ask that a policy be reviewed, but accepting a gift when a policy explicitly prohibits doing so is like a quarterback following a different set of game rules than others on a football team. It just doesn't work.

That's my two cents.......will be interested to see other responses.

Mark Pruitt, M.Div., BCC
Staff Chaplain
Department of Pastoral Care
Centra Health
Lynchburg, VA

It seems to me that the chaplain might have acknowledged the patient's desire to symbolize an ongoing sense of connection with the chaplain, and the impending loss of that connection, by acknowledging the depth and intimacy of their journey together. The chaplain could then have affirmed that that experience would, forever, live in the hearts of both persons. The chaplain could then have interpreted the hospital's policy and invited the patient into reflection about a way that they could symbolize the journey that would honour hospital policy.

In the case, as presented, the chaplain (it seems to me) missed the patient's attempt to control her grieving of the loss of connection with the chaplain by giving a gift and also, in her (the chaplain's) anxiety about how to be ethically correct, shifted into a hierarchical place.

John C. Carr, Ph.D., Ch.Psych.
Pastoral Therapy & Education
Edmonton, Alberta, Canada

First, I would coach the chaplain on ways to keep the patient out of the policy discussion. The story indicates that the patient felt guilt by offering the gift and hurt that her gift is turned away. The chaplain might want to explore ways to deal with compliance issues elsewhere. For instance, accept the gift and acknowledge the giver’s offering of thanks. Go to the director and explain the situation and explore possibilities regarding policy. While the question is in the administrator’s court develop a couple of contingencies on what to do next. One idea is to find a close value to the cost of the earrings, buy them and donate the money to the Charitable Foundation and designate it to the oncology fund. Then send a very nicely written thank you note to the patient explaining the action. “Dear Judy, Thank you so much for your gift. I discovered that Truman Medical Center has a policy that disallows me from accepting gifts from patients. I valued your gift so that I donated an equivalent dollar value to our Charitable Foundation under your name and for oncology needs. Every time I wear the earrings you gave I pray for you and hope that each time I see you it will be at Oak Park Mall. Enjoy your days, Roy Ella."

Secondly, I believe the patient telegraphed her intent along the relationship path. As a supervisor (although I don’t have residents for 3 years) I would ask for a case presentation that explored the various times the patient hinted at her intent to give this gift. This would allow the chaplain the opportunity to explore boundary setting, transference, and ideas about when to transfer care to the patient’s clergyperson, if one exists. If the patient has a congregation, Masjid, synagogue, or other gathering of believers then three years is enough time to help the patient bond with her faith community. (I am aware that this is an assumption) The level of intensity that the patient expressed to cause the chaplain to accept the gift indicates to me that a significant level of transference was placed on the chaplain. In turn, my assumption that the same level of reliance of a faith community was not developed.

I am fairly certain that as I read the responses of others I will rethink the above and make adjustments to my opinion, for which I am grateful.

Rev. Roy Sanders, M.Div. B.C.C.
Director Spiritual Care / Clinical Pastoral Education
Truman Medical Center Hospital Hill

Your ethical walk in hospital policy is one that many of us have faced before. As a new pastor I was warned about not accepting a gift, such as after a funeral. If I rejected the gift, the parishoner might be hurt, such as in the case presented. The advice I was given was to accept the gift (which happened to be money), go to a book store or a Christian supply house and buy a book or something that would be valuable to my ministry, and then send a note to the giver explaining to them what was purchased. It ended up being even more appreciated.

However, being a hospital chaplain, the reverse is the norm. No gift may be accepted. I had a couple of thoughts.

1. Perhaps it would have been ethical to accept the gift on behalf of your department and given to a person in need (such was a case that I encountered).

2. Or maybe share with that woman, the greatest gift to you was already given through your ministry to her and her family where no material gift could compare to the sisterhood that was formed.

These are only a couple of ideas that might prove more valuable in the long run. I'm sure there are many ways to adhere to policy and still be faithful to the giver.

Yours in Ministry
Rev. Rick Hope
Chaplain, Methodist Specialty and Transplant Hospital
San Antonio, Texas

Our policy here states that one may not “profit” through receiving a gift. It is clear that occasionally a gift of limited value can be accepted as an expression of thanksgiving.

The chaplain might have suggested that a gift to a pastoral care fund would be appropriate. Or perhaps the chaplain might have expressed great gratitude – suggested that they pray together as a blessing on the earrings and then suggest that the patient keep them as a reminder of their relationship.

However – I believe that policies need to reflect exactly what is expected. If the hospital policy says “no” gifts – then the chaplain needed not to accept them.

If she could have made the policy position clear to the patient indicating that she knew this was probably new information to the patient – she might have suggested that the patient contact the senior chaplain or manager of pastoral care and negotiate an appropriate expression of gratitude.

Kathleen Ennis-Durstine
Children's National Medical Center
Washington, DC

The Ethics Committee at Gillette Children's just finished crafting a policy on gift giving. We struggled with this one for awhile, but concluded that we did not want to create a policy that would preclude the acceptance of small gifts given in the spirit of gratitude or within a cultural framework in which it is customary to share gifts with those who have helped and/or have been one's companions through a significant event. Our policy allows acceptance of gifts under the monetary value of $100 if "the staff member reasonably believes that the patient/family gave the gift without any expectation of special treatment." We
encourage disclosure of such a gift to managers/peers.

I believe our policy leaves room for the "spirit of the law." I also think it is more possible to have such a policy in a small hospital like Gillette.

Helen Wells O'Brien, BCC
Regions Hospital and Gillette Children's Specialty Healthcare
St. Paul, Minnesota

Such a rigid application of such a policy prevents patients and families from providing a sign of gratitude that may make them feel less like a "charity case" and more like a human being who wants to demonstrate appropriate thanks.

I remember being given a check for one hundred dollars from a grateful patient after supporting him through a long ICU stay. I told him that our hospital policy prevented receiving such a gift. He told his wife to keep writing the check, and told me to go to the director of my department and tell him that the patient insisted that I go to his favorite restaurant with my wife, enjoy a nice meal and tip the waitress with the amount left over (creating a very generous tip!) He said that He would be very disappointed in the hospital if he couldn't make this gift to show his gratitude. I brought the check to my supervisor, he smiled and said, "Enjoy the meal, and send a nice thank you note, telling him what you ordered."

Keeping things above board seems most crucial to me. Often, gifts of less than fifty dollars are common. What do we do with the family that sends chocolates to the nurse's station, or bagels to a break room (which happened this morning in CCU)?

I like one person's posting suggesting that the value of the gift be researched, a commensurate amount given to a hospital based charity, and a note sent to the patient letting her know what was done. In that way, the chaplain is able to honor the giver without personally benefitting.

Alex Chamberlain, BCC
Boise, Idaho

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