Archive for the 'Medical Ethics' Category

No strings attached?

With Christmas just around the corner, doctors may find themselves being handed boxes of chocolates, fruit baskets and wine from appreciative patients. Charlotte Hudson examines the ethical issues surrounding accepting gifts from patients.

The New Zealand wine selection at Target in Columbia Heights, DC
Photo by Jonathan Ah Kit
It is December and over the last year you have provided good care to your patients, so how nice of them to show their appreciation by giving you a present? Accepting presents, however, can create conflicts of interest and threaten probity.

Individual GP practices and most hospitals will have their own gratuities policies, but as a rule the GMC states in its ethical guidance on conflicts of interest, that GPs in particular “must not ask for or accept inducements, gifts or hospitality which may be seen to affect judgements, nor should these be offered to colleagues”.

The guidance also states that GPs “must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit them”.

Pallavi Bradshaw, MPS medicolegal adviser, says that all doctors need to be sensible and objective when accepting gifts from patients.

“GPs, in particular are more likely to be given presents as they have known their patients for longer. Care needs to be taken when deciding whether to accept or decline a gift as you don’t want to break the professional boundaries of the doctor-patient relationship.”

If you accept a gift from a patient you should say thank you and record it in your practice/hospital’s gift register. Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency. All GP practices should have a gift register and some individual trusts will have their own policies – so always check.

If you decline a gift be polite and explain the reason why you cannot accept it, and record in the gift register what you were offered.

Do not leave wine bottles in doctors’ rooms – this can look unprofessional and give the wrong message to patients.

In an article in the BMJ Dr Sean Spence wrote that the most appropriate advice is to take nothing for granted and reflect upon the gift and its timing. A polite refusal may be preceded by reference to the ethics of medical practice or could emphasise that declining a gift does not equate to rejecting the patient. He adds that whatever the outcome, a thank-you note is appropriate.

What if I am given an expensive gift?

Under the General Medical Services (GMS) contract GPs are obliged to declare any gift from a patient worth more than £100 to their local commissioning body. This rule also applies to gifts received by spouses of partners or staff. If you work in a hospital and a gift is of particular value, you should discuss this with your departmental manager.

“If you are given cash by a patient, I would be reluctant to accept it,” says Dr Bradshaw. “I would also encourage the sharing of gifts given to you with the rest of your practice, for example, a box of chocolates. There have been cases when patients have left large sums of money in their inheritance to their GP. I would advise you to be cautious about this, and if you do decide to keep it then maybe invest the money into the practice or give it to charity.”

Treat those patients who give you gifts the same as any other patient, but a nice gesture would be to send thank you letters to patients who brought you presents during the festive period.

Section 23 of the Health and Social Care Act 2001 requires practitioners providing family health services (GPs) to declare financial interests and the acceptance of gifts and other benefits. It also states that doctors and other NHS employees in the hospital sector are required to refuse all gifts from patients except those which are of low intrinsic value, such as diaries or chocolates.

NHS employees should not accept “substantial” gifts from patients or others and monetary gifts are not allowed.

What is the intention of the patient?

It is advisable for a doctor to judge the intention of a patient before making deciding whether to accept it or not. Some patients may attempt to influence care or secure preferential treatment through the offering of gifts or cash. Acceptance of such gifts is likely to damage the integrity of the doctor-patient relationship. Doctors should make clear that gifts given to secure preferential treatment compromise their obligation to provide services in a fair manner.

The nature of the gift itself must also be considered. Accepting a gift, such as lingerie would be inappropriate, as would gifts of large sums of money. Giving either of these gifts may represent an attempt to equalise the power structure of the relationship, or may be a conscious or unconscious bribe. Giving a gift to influence an outcome is a bribe, and as such, it is unethical. In most organisations the demands of probity require that employees decline gifts that might be seen to influence their judgment.

If you are in doubt about whether to accept a gift, seek advice from MPS.

Dr. Sean Spence (BMJ, December 24, 2005).

Revalidation is Coming to Doctors in Training

No sooner than finishing medical school, british Graduates will begin to be introduced to the subject to revalidation, in a process due to start in December 2012.

It will apply to fully registered foundation year 2 doctors, and all speciality trainees. The trainees will officially have to report to different representatives of the General Medical Council (GMC) depending on where they live. For example in England, this will be the postgraduate dean.

This process may be confusing already confused junior doctors! This from an ST doctor from the West Midlands:

“We are already operating in a highly structured system of mandatory training, appraisal and work place based assessments. I’m not really sure how this revalidation applies to us, it seems to be an assessment of what we are doing already.”

Early indications from the GMC suggests that this opinion may largely reflect the truth for doctors in training. It seems the responsible officers will review evidence already collated at the annual review most doctors have (ARCP or RITA), but can also take into account other information ‘from employers’. As an ARCP or RITA can already do this, we don’t anticipate the system will produce dramatic changes for trainees.

So, the process of certifying doctors are at an appropriate standard continues. We feel this area may be particularly important for undergraduates being called to any interview process in the coming months, due to it being a topical issue. Further information can be found from the GMC here.

Broadening your horizons

A medical qualification equips you with a passport to the world – it enables you to transport your skills anywhere, with opportunities to enhance them. Having appropriate indemnity is essential before you pack your bags.

Photo by the russians are here
Before practising in a new country it is important to protect yourself: new countries may bring new risks. Having indemnity and access to 24-hour medicolegal advice is vital, and this is where MPS can help.

MPS can protect you whether you are relocating permanently, for just a year, or working on an expedition or voluntary project. The NHS indemnity scheme, which is limited to clinical negligence claims arising from NHS hospital care and claims made against the trust, does not extend to doctors working abroad.

In an article in New Doctor, the risks are discussed in more detail.

Dr Pallavi Bradshaw, MPS Medicolegal Adviser, says: “Junior doctors must be alive to the ever-increasing risks of clinical practice. Doctors travelling abroad should be alert to the current legal and ethical climate within a particular country. Being aware and managing these risks will safeguard you for the future.”

MPS protects the interests of members when concerns are raised about their practice, in any form – claim, complaint, medical council investigation. With members practising in more than 40 countries, if you are planning to work overseas MPS membership can often be arranged.

Talk to a membership adviser before travelling if you are planning to work overseas. Use the helpline number 0845 718 7187, or email You should provide details of your scope of practice and where you intend to work, so we can confirm the correct subscription rate for your work.

Read more about the service here, and read the New Doctor article in full here.

Hit the target

Wrongly inserting a nasogastric tube can have deadly consequences. A recent Casebook article outlines how to avoid these risks

Nasogastric tube
Photo by St. Murse
In 2010 75-year-old Maurice Murphy died in hospital as a result of a misplaced nasogastric tube. He was being treated for liver failure and required a nasogastric (NG) tube to be inserted. Unfortunately this ended up in his right lung instead of his stomach and feeding commenced, resulting in fatal pneumonia.

At the inquest it emerged that a junior doctor was challenged by a nurse to confirm that the tube was in the right place. The doctor in question overruled her, saying: “You don’t have a brain to remember that I told you to start the feed as the tube is in the right position.” It also emerged that there was an x-ray flagging the error. So why hadn’t anyone seen it? It would appear that a combination of factors led to the death of Mr Murphy – the misplaced confidence of the junior doctor, the fact the standardised procedure for inserting a tube was not followed, and that the x-ray was not reviewed.

This case report highlights just how careful you have to be. There are big risks associated with NG tubes, and if a misplaced tube is not spotted before feeding, patients can suffer complications like pneumonia, which can be fatal.

Avoiding the risks

Individual clinicians should consider the following before going through with the procedure:

  • Is nasogastric feeding right for this patient?
  • Does this need to be done now?
  • Am I competent to do this?
  • How can I check the right amount of tube has been inserted?
  • Do I know how to test for correct placement?
  • What is a safe pH level?
  • When should I get an x-ray?
  • What should I look for on the x-ray?
  • What about repeat checks?

Did you know?

  • The ‘whoosh’ test is unreliable in detecting the placement of NG tubes. The NPSA recommends pH testing using pH indicator paper as a first-line check – pH levels between 1 and 5.5 are safe.
  • The NPSA was notified of 21 deaths and 79 cases of harm due to misplaced NG tubes between 2005 and 2011. The single greatest cause of harm was due to misinterpretation of x-rays. A chest x-ray is required if the first-line check fails to prove the NG tube is safe for use.
  • Flushing NG tubes with water before placement can cause a pH reading of below 5.5 because of the mix of water and lubricant – this can cause practitioners to assume that NG tubes are correctly placed, when they are not.

The National Patient Safety Agency (NPSA) has issued many warnings about the dangers of nasogastric tubes over recent years. The most recent alert was in March 2012, when they issued Rapid Response Report, Harm from flushing of nasogastric tubes before confirmation of placement [1]. The NPSA is aware of two patient deaths since March 2011 where staff had flushed nasogastric tubes with water before initial placement had been confirmed. This is extremely dangerous and all medical staff should be aware that gastric placement must be confirmed before the tube is flushed.

The NPSA states that “misplaced nasogastric tubes leading to death or severe harm are ‘never events’.” Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place.

The full Casebook article, Nasogastric tube errors, can be read here –


[1] NPSA, Harm from flushing of nasogastric tubes before confirmation of placement, accessed 14 September 2012 –

Foundation doctors using MPS for vital support

12/52 : La crise de la vache folle - Mad cow crisis
Photo by Eric Constantineau
All doctors want to avoid making mistakes, but none more so than foundation doctors who are just starting out.

Knowing what to do when things go wrong – such as the unintended harm to a patient, or a complaint being made about you – is something that is not taught in medical school. The sooner you seek advice about an ethical or legal dilemma, the sooner the matter can be resolved.

The MPS can support you with any problems you may encounter now or later on. An article in New Doctor, “Collateral damage” points out the most common reasons why foundation doctors call MPS’s medicolegal helpline. In 2010 and 2011 820 calls were received from foundation doctors.

The main reason

The main reason foundation doctors called MPS during this time was to receive advice on inquests or fatal accident inquiries, with one in five calls relating to this. MPS can support foundation doctors by advising on draft reports to give to the coroner, which could also later be reviewed by an appointed educational/clinical supervisor. MPS may be able to assist by providing legal representation if there is a conflict of interest between a foundation doctor and their trust.

Other top queries

The second most common call related to complaints, and the third, the GMC regarding fitness to practise. Other top calls related to writing reports, employment issues and confidentiality.

Top three comedy calls

On occasions, foundation doctors will call MPS for advice on matters that are not ethical or legal dilemmas. Below are the top three comedy calls MPS has received:

  • “I’ve just burnt the mess carpet!”
  • “The library has issued me with a massive fine – can I fight it?”
  • “Can we hire strippers for the rugby AGM?”

As a foundation doctor, it is comforting to know that should you encounter difficulties there are organisations available to provide support and expert advice, and educational material to prevent medicolegal problems in the future.

Read the full text of “Collateral damage” in the latest issue of New Doctor.