For an appreciative patient, giving gifts to a competent, caring doctor or nurse may seem only natural.
But should health workers accept such tokens from patients for whom they provide care? And what if it's more -- much more -- than a token? Should doctors, nurses and others ever encourage patients to name them as beneficiaries in a will?
These ethical issues arose in a big way in the care of Huguette Clark, who inherited a titanic fortune from her father, one-term U.S. Sen. W.A. Clark. Her dad made money on par with the Rockefellers, Morgans, Vanderbilts and Carnegies in mining copper and other metals throughout the American West at the turn of the 20th century.
And the questions loom large for readers of a new book about Clark, a reclusive heiress who was worth about $300 million at the time of her death in 2011 at age 104.
Released this week, the new page-turner is "Empty Mansions: The Mysterious Life of Huguette Clark and the Spending of a Great American Fortune," by NBC News investigative reporter Bill Dedman and Paul Clark Newell, Jr., a cousin to the heiress.
Huguette Clark owned fabulous properties in New York City, New Canaan, Conn., and Santa Barbara, Calif. -- and she had not set foot in any of them for decades.
Starting in 1991 at age 85, after some successful surgery, she chose, despite excellent health, to live in a relatively small room at a small, little-known hospital overlooking Gracie Mansion, the mayor of New York's official residence in upper Manhattan.
When she entered Doctors Hospital, later to become Beth Israel Medical Center, she had an even bigger fortune. She chose to give a good deal of it away to some of her caregivers, their children, institutions she cared about, friends, employees who watched over her homes and some former employees.
And these were not small amounts. Clark's favorite private duty nurse, Hadassah Peri, received more than $31 million in gifts during 20 years of service, including enough money to buy five homes, jewelry and other luxuries. Clark gave lavishly to Peri's husband and children, too.
Other caregivers also got gifts, although not in those amounts. Still others got nothing. Was it ethical for those who got gifts to accept them?
Clark's personal staff members were not the only ones with an eye on her fortune. The hospital where she lived pushed hard to get Clark to make a substantial gift, using their development staff to try to pry a promise from her, the book reports.
In 2004, Dedman and Newell write, hospital officials threatened Clark with having to move from her beloved room if she did not make a contribution of $125 million to forestall the sale of the building.
So what is the ethical deal? Can wealthy patients bestow gifts of whatever amount they choose on whomever they wish -- including those who provide their care? And if not while they are alive, what about after they are dead?
The American Medical Association's code of ethics pretty much leaves the decision about accepting gifts to the individual doctor.
"One criterion is whether the physician would be comfortable if colleagues or the public knew of acceptance of the gift," the code says.
Those who got millions from Huguette Clark said they never requested she be generous to them. However, the book makes clear they were quite willing to let her know that their rent had gone unpaid, their kids needed medical or dental care, their cars had broken down or their apartments were too small. That kind of behavior seems nothing less than a solicitation which, coming from a care provider, seems highly unethical.
But what if a fabulously wealthy patient voluntarily chooses to shower her nurse or doctor with unsolicited cash? Again, this seems to be wrong.
Patients pay their bills and those bills are often steep. Gifts do not have a role in that equation. It seems strained to argue that that gift-giving flows out of the doctor-patient relationship while the patient is still in the care of those getting the presents.
Allowing a patient to give millions to the health-care team -- even if she wants to -- seems morally suspect if only because the patient is reliant on the care and vulnerable to even the slightest hint of financial need.
Well, then, what about bequests? Plenty of hospitals and development folks keep an eye on their wealthiest patients or their families in the hope of getting funds in a will or trust to build a new wing for a building or a new cancer center.
Here the ethics seem less clear. Trying to shake down patients with threats unless they include you in the will is an obvious problem. But following up once they have left the hospital to see if they want to donate, attend fund-raisers or purchase naming rights to the Hospital for Very Crippled Children seems less ethically troubling.
Bequests for research, helping medical students or paying for care for the poor seem far more ethically seemly than a direct post-mortem gift to a doctor to spend as he or she sees fit, be it on a yacht or a catheter lab.
But that wasn't Huguette Clark's point of view. From what we read in the book, she loved being generous to those she liked -- but she was also perfectly capable of rejecting requests that didn't suit her.
She may have been an odd duck, but she knew the value of money and enjoyed the pleasure of gift-giving well past her 100th birthday.
Medicine gets antsy around the subject of gifts. It is not likely that a lot of health-care providers or systems will simply put them off limits. Nor do they yet agree on how to handle bequests from appreciative patients. I think there ought to be tougher rules. Ironically, as "Empty Mansions" suggests, Huguette Clark would not agree.
Arthur Caplan, Ph.D., is the head of the Division of Medical Ethics at NYU Langone Medical Center.