Introduction
Gift-giving from patients to health professionals is a common expression of gratitude and cultural tradition in healthcare settings. While often well-intentioned, these gestures present ethical challenges and practical dilemmas for providers. Accepting gifts can strengthen the therapeutic relationship and acknowledge care, but may also risk conflicts of interest, perceived favoritism, or emotional attachments that could influence clinical judgment (1,2). Public perception often regards healthcare professionals as influenced by financial incentives, as compromised individuals prioritize personal gain over their professional obligations. Nevertheless, empirical evidence indicates that the effects of conflicts of interest are frequently unconscious and may inadvertently divert even the most ethical practitioners from their primary objective of delivering optimal patient care (3). To our knowledge, there are no universal rules governing patient gift acceptance; ethical scrutiny, institutional policies, and professional judgment must guide responses. Small, inexpensive tokens of appreciation are generally considered acceptable, especially when given after care is completed and without expectations of preferential treatment. In contrast, costly or extravagant gifts, or those given during ongoing treatment, often raise concerns and should be declined politely with clear communication to preserve trust (4,5).
Physicians often rationalize the acceptance of such conflicts by citing a sense of entitlement derived from their dedication and self-sacrifice. For instance, one study demonstrated that physicians who responded to questions about self-sacrifice before inquiries about gift acceptance were twice as likely to accept such gifts (increasing from 21.7 to 47.5%) (6). Another common justification is the belief that gifts do not influence impartial clinical decision-making, despite substantial evidence to the contrary (7).
Disclosure of conflicts of interest remains a widely endorsed strategy to mitigate their impact, enabling patients to make more informed decisions (8). However, disclosure may inadvertently pressure patients to comply with physicians’ recommendations. Research has shown that following disclosure, patients tend to place less trust in medical advice and experience apprehension about declining such recommendations (9).
The most effective approach to managing conflicts of interest involves consulting an unbiased advisor. Seeking a second medical opinion has been shown to reduce bias; however, studies reveal that primary consultants may provide more biased recommendations when aware that a second opinion will be sought, possibly due to a perceived increase in ethical latitude (10).
The lack of explicit hospital policy or guidelines regarding gift-giving creates ambiguity regarding the ethical permissibility of accepting or rejecting such gifts (5). Additionally, to avoid any appearance of conflict of interest, healthcare professionals should carefully evaluate each situation and ensure that the public is well-informed about hospital policies regarding the ethical complexities of accepting gifts. Distinguishing between a simple gesture of gratitude and underlying ulterior motives can be challenging. While most patients offer gifts as spontaneous expressions of appreciation, some may do so with the expectation of gaining higher social status or preferential access to specialized or personalized care. In some cases, patients may attempt to use gifts to influence the professional relationship, seeking personal or social connections with healthcare providers. Generally, patients’ intentions are harmless and stem from a desire for personal satisfaction and meaningful social interaction (11). On the other hand, performing good acts and appropriately repaying someone’s kindness are cultural expectations. The cultural acceptability of gift-giving is enhanced by its intrinsic role in the community dynamic (12).
The acceptance of gifts by healthcare professionals raises ethical concerns, potentially influencing clinical judgment and undermining public trust. Such practices can foster bias and compromise patient care integrity (5). Understanding how health professionals respond to patient gift-giving is essential for developing clear guidelines that balance respect for patient generosity with the imperative to uphold ethical standards and equitable care. This study is the first of its kind conducted in Iran to explore healthcare professionals’ responses to patient gift-giving, providing insights specific to the cultural and healthcare context of this region. 

Materials and Methods
This research employed an analytical cross-sectional design to assess healthcare professionals’ responses to receiving gifts from patients. The study was conducted at Razi Hospital in Rasht from January 2024 to June 2024. This study included physicians, nurses, and residents in various hospital departments who had received or been offered gifts from patients. Exclusion criteria included non-medical staff, those without gifts, and those with familial or personal relationships with the patient. 
Convenience sampling was used to recruit physicians, nurses, and residents. After obtaining informed consent, participants completed questionnaires detailing gift types, timing, motivations, and responses to gift offers. The questionnaire was specially designed based on literature review and expert consultation to capture healthcare professionals’ responses to patient gift-giving. To ensure validity, the study employed the Content Validity Index (CVI) and Content Validity Ratio (CVR) for assessing content validity. Regarding the CVI, all questions across three sections demonstrated simplicity, clarity, and relevance scores exceeding 0.7, while the CVR for all questions was also above 0.7. To evaluate the scientific reliability of the questionnaire, it was divided into sections, and the correlation coefficient was calculated using Cronbach’s alpha, yielding a value of 0.8.
The Ethics Committee of Guilan University of Medical Sciences approved the study protocol on 15 November 2023 (IR.GUMS.REC.1402.413), and researchers maintained the confidentiality of the evaluated files.
The study population included all healthcare staff at Razi Hospital. The sample size was calculated based on the primary study objective, with an additional 10% to account for potential attrition. The final sample consisted of 97 healthcare professionals. 

After obtaining informed consent, eligible participants completed a pre-designed questionnaire and checklist to document their responses and attitudes toward gift acceptance. Data was collected anonymously to encourage honest responses and minimize social desirability bias.

Statistical analysis
Statistical analysis was performed using SPSS Package 16.0 software (SPSS Inc., Chicago, IL, USA). All demographic parameters were reported as mean, standard deviations, minimum, maximum, and frequency values as absolute and percentages. 

Results
This study included 97 healthcare staff. The sample comprised 45 female (46.4%) and 52 male (53.6%) participants. The respondents ranged from 30 to over 60 years, with the largest proportion being between 40 and 49 years (43.3%). The mean age of the participants was 43.6 years, with a standard deviation of 8.11. Most participants were nurses (67%), followed by those specializing in internal medicine (20.6%). Regarding employment type, 41.2% were formally employed, 28.9% were contractual, and 29.9% were temporary staff (Table 1).
Analysis of gift presentations revealed that goods were the most frequent gift received or offered (45.6%), followed by cash gifts (39.2%). Service-related tasks accounted for 12.3% of gift types, while influence and connections represented 3.1%. Gifts were most often presented before hospitalization (67%), with fewer instances during (17.6%) or after hospitalization (8.2%), and after complete recovery (7.2%). The primary motivation behind gifting was gratitude (71.1%). Other motivations included receiving non-attendance services like prescriptions (18.6%), encouraging task performance (5.3%), obtaining illegal medical certificates (4.1%), and encouraging unlawful activities (0.9%) (Table 2).
Regarding the response to gift offers, 46.4% of healthcare staff accepted the gift, whereas 42.3% rejected it because it was prohibited, 5.2% because they did not need it, and 6.1% out of fear of the consequences of accepting it. Among the 45 participants who accepted the gifts, the most common type was cash (53.3%), followed by goods (24.4%), service-related tasks (17.8%), and leveraging influence (4.5%) (Figure 1). Most of these participants were nurses (71.2%), with the remainder from the medical staff (28.8%), and all indicated that the primary motivation for the gift was gratitude.

Table 1. The healthcare staff characteristics

Table 2. The gift characteristics and information about motivation

Discussion
This study aimed to explore the health professionals’ responses to patient gift-giving. The findings reveal that nearly half of healthcare staff surveyed had accepted gifts from patients, while a similar proportion rejected them, most commonly due to institutional prohibitions. Goods and cash were the most frequent types of gifts, and the primary motivation cited was gratitude. The high prevalence of gift acceptance (46.4%) and the fact that cash gifts were most commonly accepted among recipients (53.3%) highlight the complexity of navigating professional boundaries in clinical practice. The present study findings align with international studies revealing common acceptance of patient gifts driven by gratitude, yet highlight cultural nuances in timing and types of gifts accepted. Unlike some global settings, cash gifts were notably common in the present study sample (53.3%), underscoring the need for context-specific policies (11-13).
 Professional guidelines consistently advise that healthcare professionals should avoid accepting gifts that are or appear to be excessive, that could influence clinical judgment, or that might be perceived as a form of bribery. The timing of gift presentation—most frequently before hospitalization—raises further ethical considerations. Gifts given prior to care may be interpreted as attempts to secure preferential treatment, even if the patient’s stated motivation is gratitude. This underscores the importance of transparency and clear communication when responding to such offers. When gifts are declined, providing a respectful explanation that emphasizes institutional policy and professional ethics can help preserve the therapeutic relationship and avoid patient distress. The study also found that nurses were the most frequent recipients of gifts, reflecting their close and sustained interactions with patients. This is consistent with literature suggesting that the nurse-patient relationship often carries emotional layers and cultural expectations that may prompt expressions of thanks through gift-giving. However, nurses and all healthcare staff must remain vigilant to the potential for conflicts of interest or boundary violations, particularly in cases where gifts are accompanied by requests for non-standard services or documentation. Meanwhile, declining gifts that present an ethical dilemma could lead to an unfavourable perception on the part of the giver. Accepting gifts could violate a healthcare professional’s fiduciary duty to the patient (13). This is because gift-giving could be interpreted as an attempt by the patient to win the staff’s favour in return for higher expectations. Frequently, patient gifts have served as a precursor to boundary violations. It is appropriate to respectfully decline inappropriate gifts and explain the reasoning behind the decline (5).
However, as indicated by the students’ feedback in a study by Napiah et al (11) declining the gift might be interpreted as disrespect and devaluation, consequently impacting the rapport between the patient and the nurse. Accordingly, this may result in awkward encounters, impede the development of rapport, pose challenges to delivering high-quality care, and evoke feelings of remorse, especially when the carer is working with an elderly and long-term patient population.
In contrast, patients may experience feelings of rejection if the gift is declined, and the value of the gift is also a significant factor. Also, the patient should be informed that accepting the gift will not necessitate modifying treatment for the illness. A common occurrence is that healthcare professionals lack knowledge regarding the patient’s ancestry, which includes their public status. Hence, healthcare professionals must always uphold the standards of professionalism while refusing gifts. This is because the conduct of healthcare professionals can impact the reputation of the healthcare sector, whether favourably or unfavourably (13). 
The motivations behind gift-giving in this study were predominantly positive, with gratitude accounting for over 70% of cases. However, the presence of gifts intended to encourage task performance, secure non-attendance services, or obtain illegal certificates, though less common, highlights the need for ongoing ethics education and robust institutional policies. Healthcare professionals must be able to distinguish between genuine appreciation and attempts to influence care or circumvent regulations.
Cultural context also plays a significant role in shaping attitudes toward gift-giving and acceptance. In some cultures, gift-giving is an integral part of expressing respect and appreciation, while in others, it may be viewed with suspicion or as inappropriate. Sensitivity to these nuances, combined with adherence to ethical standards, is essential for maintaining professional integrity and patient trust.
To address ethical risks, the authors suggest healthcare institutions implement clear policies including monetary thresholds for acceptable gifts, transparent disclosure protocols, and regular ethics training to help staff navigate these complex situations.

Limitations
This study has certain limitations. Firstly, since the research was conducted solely within Guilan province, the results may not be applicable to other regions or healthcare systems that operate under different practices or cultural norms. Secondly, the analytical cross-sectional design only provides a snapshot of attitudes and behaviors at one point in time, which limits the ability to assess trends over time or establish causal relationships. Third¸ the participant group consisted of a varied mix of healthcare professionals such as physicians, nurses, and residents whose data were combined for analysis. This aggregation might have reduced the ability to precisely identify differences in behavior and attitudes among the different subgroups. Therefore, future studies are recommended to perform more detailed, subgroup-specific analyses to gain clearer insights into each group’s distinctive traits and behaviors. Additionally, the evaluation of patients’ motivations for gift-giving was indirect, relying solely on input from the healthcare recipients rather than surveying patients themselves. This method was chosen due to practical challenges in directly surveying patients. While recipients can offer useful perspectives regarding patient motivations, their viewpoint is indirect and might not fully capture the patients’ true attitudes or behaviors.

Conclusion
In summary, this study demonstrates that patient gift-giving is a nuanced phenomenon that requires healthcare professionals to balance gratitude and empathy with ethical vigilance and institutional guidelines. Clear policies, ongoing ethics training, and open communication with patients are essential to ensure that expressions of appreciation do not compromise professional standards or the quality of care. Also, the results indicated, many healthcare staff accept gifts, often cash, driven by patient gratitude. These findings underscore the need for clear policies and ethical training to mitigate conflicts of interest and maintain public trust in healthcare.

Acknowledgement
The authors are thankful to the researchers and staff of the Razi clinical research development unit, Rasht, Iran. This study was approved by the Ethics Committee of authors’ institute (ethical number: IR.GUMS.REC.1402.413).

Conflict of Interest
There was no conflict of interest in this manuscript.