Joshua Star-Lack
Sylvia Star-Lack

August 14, 2009

A Jewish Perspective on Healthcare Reform

The U.S. is now embroiled in a heated health care debate. As patients or caregivers or both, we all will be affected by its outcome. I am a scientist who works for a company that makes radiation therapy systems to treat cancer. Our machines save many lives but are also expensive. Sylvia is a childbirth educator and labor doula (birth coach). My family, like many of yours no doubt, has recently has had its share of medical successes and setbacks. Happily, my mother just emerged from a successful and complicated surgery to treat a life threatening disease. Remarkably, just last month she was able to attend our family reunion and play with her grandchildren at the beach. On the other hand, my father’s health is in rapid decline from an illness for which there is no treatment. Could more research funding have found a cure?

Of course, we are the lucky ones. My family has a good insurance policy and the wherewithal to navigate the system. Not all are so lucky. The U.S. is the only major industrialized nation without universal coverage. There are 50 million uninsured. Yet we spend more than any other country on health care (17% of our GDP vs 10% in Europe) and have worse outcomes including higher infant mortality rates and lower life expectancy. Health care costs are rising at 7% a year, which is way beyond inflation.

While people of good faith can debate how best to fix the situation, it is hard to argue that the status quo is sustainable. As such, we thought it would be interesting to ask, from a Jewish perspective, what should be the guiding principles of a national health care policy?

The Torah portion this week, R’eih, in Deuteronomy touches on some of the larger issues. The Israelites are getting ready to enter the Promised Land and God is instructing them to conquer the cities and cleanse them of all practices of polytheism. The Israelites must “beware of being lured into (the pagan) ways” and avoid being trapped into evil practices, one of which is that they “perform for the gods every abhorrent act that the Eternal detests; they even offer up their sons and daughters in fire to their gods”.

Another way to translate the sentence “they even offer up their sons and daughters …” is “they also offer up their sons and daughters….” . The Hebrew word ‘gam’ lends itself to either meaning alluding to the fact that, in addition to children, it was common to sacrifice the elderly. In many of these cultures, infirmed parents were abandoned to wild animals or otherwise disposed of. Thus, God is saying that we, as a nation, have a duty to care for our sick and elderly as consistent with the fifth commandment of honoring thy father and mother.

So let’s try to briefly address the following questions as they pertain to more modern healthcare issues. Under Jewish law,

- What are our moral obligations to provide health care to all members of society?

- How should it be distributed?

- How much should be spent?

For some answers we turned to a wonderful book – ‘Matters of Life and Death, a Jewish approach to Modern Medical Ethics’ by Elliot Dorff, which was recommended to us by Rabbi Janet.

It turns out that there is not a lot of commentary in the Mishnah and Talmud on healthcare per se. This is mainly because, before the discovery of antibiotics in the 20^th century, physicians were not terribly effective healers. The average person’s life span was less than 45 years, and, in fact, in one passage of the Mishnah, it is written that physicians can “go to hell”. Nevertheless, they must have been doing some good since a doctor was one of the 10 elements considered to be essential for building a Jewish community (among the others were a synagogue, a court, an educator and a kosher butcher).

Given the lack of writing on health care, the approach that Dorff takes is to look at Rabbinic passages on saving lives, which, as we know in Judaism, is the most important commandment or mitzvah.

Consider a scenario where two men are wandering in the desert with only enough water for one of them to make it back safely. Who should get the water?  Should they

a) Share the water and hope for the best.

b) Flip a coin.

c) The person who owns the water is saved.

Raise your hand if you vote for a) share the water, b) flip a coin, c) the person who owns the water is saved.

 According to Rabbi Akiva, the answer is (c). It is generally accepted that whoever owns the water deserves it. The logic is that at least one person should live and that, while an individual certainly has an obligation to look after others, his first priority is to look after himself. The next priority is to take care of his family.

Dorff examines rabbinic sources dealing with captives in order to tease out Jewish values on how far a community must go to save a life.  He argues that being held captive by an illness is similar to being taken prisoner for ransom.  There is extensive commentary as to how a community is obligated to redeem (or free) any of its members that are taken hostage. To start with, it’s interesting to note that, while there are limits to the amount a community is obligated to pay in ransom, a person may pay any amount to free himself.

While permission is thus given to look after number one, the larger portions of the text address our obligations to each other. The mitzvah to save lives is paramount and, in fact has precedence over other community duties including feeding the poor and education. Nevertheless, because of resource limitations, difficult prioritizations may have to made.

Consider this scenario. Two members of the community are taken captive and there is only enough money to redeem one. One passage in the mishnah bases preference on social and religious hierarchy. A Kohen would take precedence over a Levite. A scholar over a non scholar, and …. a man over a woman. Actually, a deeper reading of the text states that this priority relates only to Beth Am men.

Of course, in modern times, these hierarchies are considered abhorrent and, in actuality, there is strong evidence that even then the Rabbis did not like to make decisions in this way and often ignored such edicts.

The more enlightened and egalitarian threads in the Talmud are based on the premise that all of humankind is descended from a single person, Adam, who was created in the likeness of god. The reasoning is that no person is inherently more important than another, and everyone, no matter her station in life, can claim, “for me the world was created.”

Under these teachings, need trumps status. If two community members are taken into captivity, the one whose health is worse or is most threatened is to be redeemed first. If a man and woman are taken into captivity then the woman is to be redeemed first because she is more vulnerable.

Limits to the community’s obligations are also addressed. As mentioned previously, an upper limit may be set on ransom so as not to encourage future kidnappings and extortion. If a person is partly responsible for being kidnapped (say they owe money to the kidnapper) then the community still has an obligation to redeem them once but not multiple times unless their life is threatened.

So, how do we interpret these various texts in the context of today’s health care debate? There is a strong community obligation to fulfill the mitzvah of saving a life. Priority should be based on need rather than status or wealth and, from a medical perspective, would include preventive care. There is a strong, though not limitless, community obligation to treat people who may be partly responsible for their illnesses (e.g. smokers with lung cancer or alcoholics with liver disease).  At the same time, as individuals, our first priority is to take care of our families and ourselves. Thus, while it is not necessarily a Jewish value that everyone have the same care, according to our tradition, society is obligated to provide a basic level of care for everyone.

So, as a childbirth educator, I leave you with the following thought. As our nation seeks to give birth to a more moral, equitable and financially stable health care system, we would do well to remember that holding our collective breath is the opposite of what we should do.  I hope we can breathe (everyone take a deep breath) and work to get the job done, all the while marveling at the miracle of life.