Edition: U.S. / Global

Ambiguous Gifts: When Patients Give and Doctors Take

Published: January 11, 2004

A LAWSUIT last week evoked a distressing image of the former Beatle George Harrison, weak and exhausted, near the end of his life, being coerced into signing autographs by the doctor who was treating his cancer.

Dr. Gilbert Lederman of Staten Island University Hospital has denied through a spokesman that any coercion took place, saying that he and his patient had become close and that Mr. Harrison had freely autographed a guitar belonging to Dr. Lederman's son.

Dr. Lederman has now offered to donate the guitar to charity. But the lawsuit, filed by Mr. Harrison's estate, also said the doctor had violated his patient's privacy by giving repeated television interviews within hours of Mr. Harrison's death. The episode, however it is resolved, raised the uneasy question of how far doctors and hospitals can go in accepting gifts, gestures of friendship or endorsements from their patients. The question becomes particularly fraught in the cases of severe or fatal illness, when a desperate and vulnerable patient may feel powerless to say no to a doctor.

''Talk to any doctor, and they'll tell you a patient gave them a signed book, and it will go all the way up through much more expensive things,'' said Dr. Jeffrey P. Kahn, director of the center for bioethics at the University of Minnesota.

Dr. Kahn, who is not a doctor, added: ''It's called exploitation if it goes too far, like deathbed wills: 'Sign here, Grandma, and everything will be fine.''' The Web site of the American Medical Association (www.ama-assn.org) includes a section on patient gifts (much more space is devoted to corporate gifts), reflecting the ambiguity of the entire subject:

''Gifts that patients offer to physicians are often an expression of appreciation and gratitude, a reflection of cultural tradition, and can enhance the patient-physician relationship.

''Some gifts signal psychological needs that require the physician's attention. Some patients may attempt to influence care or to secure preferential treatment though the offering of gifts or cash.''

With regard to revealing details to the press, Dr. Kahn said most hospitals make special arrangements to help famous people protect their privacy, like admitting them under a pseudonym. He said that was done successfully at his university's hospital for a locally prominent minister who was H.I.V. positive.

''People here were told that any leaks would be dealt with in a harsh manner,'' Dr. Kahn said.

Another expert, a cancer specialist at a major hospital, who spoke on the condition that he not be identified, saw Mr. Harrison's case as an illustration of forces that can come into play when celebrities need care. There may be a tacit quid pro quo, he said, between elite hospitals and patients who are rich or famous: the celebrities may gain quick access to top specialists, providing in turn endorsements, priceless free advertising or donations.

''There's enormous competition for these kinds of patients,'' the specialist said. ''Celebrities become sort of a marketing vehicle. It's not the most savory of activities, I think.'' The system can backfire. Prominent patients may suffer if doctors and hospitals are reluctant to let go of them even though they need specialized treatment best provided elsewhere. ''Unfortunately, this goes on a lot,'' the specialist said. ''I've seen some major celebrities get very poor medical care because of these issues. It's paradoxical. You'd think someone with this kind of money and access would get the best care.''

But hospitals take a special risk if they openly admit a famous patient, because their every move will be under a spotlight, and the death of a prominent person, particularly if there is a question of error or substandard care, can be the worst possible publicity.

''I would think they might equally want to refer a person on because they don't want to deal with the notoriety or risk of taking care of someone who is high profile,'' said Dr. Lawrence M. Shuer, chief of staff at Stanford Hospital and Clinics in Stanford, Calif. ''At our institution, we treat everyone the same, and a person should be in the hands of the person who can give them the best possible treatment.''

Photo: George Harrison at a concert in 1995. (Photo by Associated Press)