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updated 6/23/2011 6:57:44 PM ET 2011-06-23T22:57:44

When the wealthy and reclusive copper heiress Huguette M. Clark died recently at the age of 104 , she left $30 million to her personal nurse and $100,000 to her doctor, among other gifts bequested to charities and her accountant and lawyer .

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The nurse, Hadassah Peri, was thrilled. She said in a statement to the media that said, in part, “I saw Madame Clark virtually every day for the 20 years. I was her private duty nurse but also her close friend.”

So what's the problem? A nurse who spent years caring for an elderly heiress got a great windfall. But there are serious ethical challenges when patients are the source of big gifts directly to their health care providers.

While hospitals allow gifts to the institution itself, most have strict rules against a doctor or a nurse personally accepting anything more than a small gift from a patient. And those rules make good sense. Patients ought not be put in the position of trying to bribe their nurse to get attention. And doctors and nurses must not shower favors on those they think might make them personally wealthy. And when a life hangs in the balance, you don’t want your doctor thinking about whether it is better for his bank account if you live or die.

Story: Heiress Huguette Clark's will leaves $1 million to advisers

When it comes to big gifts to home caregivers, personal nurses and physicians and those who work outside hospital settings, the ethics are just as sticky but the rules are slim.

A patient, particularly an elderly and frail one, can get very dependent on a caregiver, particularly if they have few, if any, other social contacts. And a caregiver can be in a good position to start to influence the patient simply because they are there — never mind that they are paid to be, not because they necessarily have a strong emotional relationship to the patient.

Years ago, a private physician asked me if it would be appropriate to be named the conservator of his wealthy elderly patient’s estate. She wanted him to be in charge of her fortune, and he told me that she trusted him over anyone else she knew to do the right thing with her money. I thought this was a bad idea. If he was in charge of her medical care knowing that he stood to control a huge sum of money should she die, it would create a mountain of conflict of interest. If he had been at a hospital, that relationship would have been frowned upon — but out in the community there was nothing to prohibit it. In the end he became the conservator but stopped being her doctor.

People like Huguette Clark have the right to do with their money as they wish. Heck, when Leona Helmsley died she left $12 million dollars to her dog ! But the bequests that patients make directly to doctors and nurses who care for them in their old age in their homes or in private settings need close scrutiny by courts.

Special report: Huguette Clark, the reclusive heiress, and the men managing her

It is not always clear how competent a frail elderly patient might be when leaving big sums of money to one of the only few people may have seen for decades. Nor is it certain that ideas about how to make a gift were not suggested by those who might stand to benefit. And doctors and nurses are not above trying to alienate a patient from their families when the stakes are high.

Ideally, no doctor or nurse should allow a grateful patient to make them rich. In a non-ideal world, courts need to treat large personal gifts to healers as possibly in need of a legal cure.

Huguette Clark’s nurse promised in a statement to “devote a substantial portion of this bequest toward making the world a better place for all people.”

The ethical choice is for her, and Clark’s doctor, to donate all of their windfall.

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.

© 2013 NBCNews.com  Reprints

Video: Who will inherit heiress’s $500M estate?

  1. Closed captioning of: Who will inherit heiress’s $500M estate?

    >>> one of the richest and exclusive heiresses has died. she passed away on tuesday. prosecutors were looking into how her vast fortune was being handled. nbc's jeff rossen has the latest. hey, jeff. good morning.

    >> reporter: hi, ann. good morning to you. just to give you an idea how much money we're talking, she owns the largest apartment on all of manlt's fifth avenue. inside this building behind me, 42 rooms worth about $100 million. that's just the beginning of it. she herself is worth about half a billion dollars by some estimates. when she died this week, big questions started. what will happen to all of her money, especially considering her closest advisers are under investigation for stealing millions from her. she pass added away this weekend at a new york city hospital living under an alias. reclusive until her final breath. she leaves behind three massive estates. this one in santa barbara hugs the california coast. its value, over $100 million. clark 's estate in connecticut is worth over $20 million. and, of course, the prestigious fifth avenue property filled with dolls and fine art worth over $100 million. clark hadn't seen any of them in 20 years. instead she was living in seclusion in what would be her final home, the medical center surrounded by her french doll collection. clark 's lifestyle is so mysterious, this is the last known picture ever taken of her in 1930 . her death two weeks shy of her 105th birthday means the battle begins for her riches.

    >> she was buried wednesday evening the way she had lived, alone, no ceremony, no funeral mass , no priest. it was a strange life that came to a strange ending.

    >> reporter: new york prosecutors have launched a criminal investigation into her inner circle . her lawyer wally and her accountant irving.

    >> the gfters want to know if she was taken advantage of all those years. they have a roomful of documents to go through.

    >> reporter: wally quietly arranged his sell, a stradivarius violin for $6 million and a rpainting.

    >> as we say, follow the money. it goes some place. the court may freeze the money, put it someplace, lock it up, and have someone other than these two people in control of it until they can sort out the facts.

    >> reporter: clark who divorced young and had no children inherited her wealth from her wealthy father, a copper king . she reportedly has a will, too, but it remains unclear who's in it. the mystery stretches beyond the grave. we reeved out to both her attorney and the accountant. the accountant never called us back yesterday, but we did hear back from a spokesman for the attorney wally . he told us, cloak, madame clark 's passing is a sad event for everyone who love and respected her over the years. she died as she wanted with dignity and prove sichl we intend to continue to respect her wishes for privacy. it's important to note, ann, they would not comment on the ongoing criminal investigation against them, and we should mention this apartment is so big behind me if it does end up going on the market depending on what's in her will, it would make a huge splash here in the always business new york real estate market .

    >> jeff rossen , thanks.

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