Whether or not we are believers in the Obama plan, or any of the particular plans for universal health care currently winding their way through Congress, support for universal health care is an imperative in Jewish law. Although what is available in medicine and its cost have changed radically, particularly over the past century, the fundamental right to receive good care — and to be compensated for giving it — goes very far back in our heritage, though perhaps, ironically, not all the way to the Torah or even the Mishnah.
When physicians could not do much to heal a sick patient, their services were easily attainable, relatively cheap, and, frankly, not much sought after. “The best of physicians should go to hell,” the Mishnah says, reflecting people’s frustration in the second century C.E. with doctors’ inability to cure.
With the advent of antibiotics in 1938, as well as other new drug therapies, and, especially, new diagnostic and surgical techniques, however, there has been an immense increase in the demand for medical care, precisely as it has become much more expensive. This raises not only the “micro” questions of how physicians should treat a given person’s disease, but also the “macro” questions of how we, as a society, should arrange for medical care to be distributed. It is precisely this argument that is taking place in town halls and in the halls of Congress these days, sometimes in rational arguments but all too often in shouting matches that are clouding the real issues.
Jewish tradition imposes a clear duty to try to heal, and this duty devolves upon both the physician and the society. Jewish sources on distributing and paying for health care are understandably sparse, however, because before the 20th century, medical care was largely ineffective and inexpensive. The classical sources that describe distribution of scarce resources and apportioning the financial burden for communal services deal instead with questions like providing for the needy or rescuing someone from captivity, from highway robbers or from drowning. Still, those discussions raise moral problems and suggest solutions that are often similar to those associated with scarcity and cost in modern medical care.
One set of issues is this: Who should get what when medical interventions are scarce and/or expensive? The other set of questions is this: Who should pay for health care? I discuss at some length the answers that emerge from the Jewish tradition to both of these questions in Chapter 12 of my book, “Matters of Life and Death: A Jewish Approach to Modern Medical Ethics” (Jewish Publication Society, 1998). I will share here a general sense of how the Jewish tradition responds to these questions, which are at once so ancient and so contemporary. (For specific source references, visit this article at jewishjournal.com.)
The Distribution of Health Care: Five Criteria for Triage
If particular forms of medical treatment are scarce or expensive, who should get them? Although this question of triage is most dramatic when the decision is one of life or death, it affects the quality of people’s lives in less threatening situations as well. Who, for example, should get a hip replacement when society cannot afford to provide one for everyone who needs one? Who should have the benefit of a heart bypass operation or transplant, and who shall be denied that? Which AIDS patients should get the regimen of drugs now available to lengthen their lives, and for whom is that just too expensive? In the High Holy Days liturgy, “who shall live and who shall die” is God’s decision; but with the benefit and responsibility of today’s technology, we find ourselves all too often in the uncomfortable position of having the responsibility to decide that ourselves.
The rabbinic passages that might give us some guidance about triage go in five different directions:
Social hierarchy. One passage in the Mishnah determines priorities on the basis of the victim’s position in the hierarchy of society — with knowledge of Torah trumping all other social stations.
Close relationship. Jewish laws on charity provide a second reservoir of precedents that may guide the provision of health care. In concentric circles, you are most responsible for yourself first, then for those closest in relationship to you, then for the rest of your local Jewish community, then for all other Jews, and then for all other people.
A hierarchy of social needs. A third set of sources we might use as the basis for a Jewish ethic of the distribution of health care concerns the prioritizing of the community’s duties to fund specific needs. The Shulchan Arukh specifies the order of preferences as follows: “There are those who say that the commandment to [build and support] a synagogue takes precedence over the commandment to give charity [tzedakah, to the poor], but the commandment to give money to the youth to learn Torah or to the sick among the poor takes precedence over the commandment to build and support a synagogue.
One must feed the hungry before one clothes the naked [since starvation is taken to be a more direct threat to the person’s life than exposure]. If a man and a woman came to ask for food, we [Jews acting in accordance with Jewish law] put the woman before the man [because the man can beg with less danger to himself]; similarly, if a man and a woman came to ask for clothing, and similarly, if a male orphan and a female orphan came to ask for funds to be married, we put the woman before the man.
Redeeming captives takes precedence over sustaining the poor and clothing them [since the captive’s life is always in direct and immediate danger], and there is no commandment more important than redeeming captives…. Every moment that one delays redeeming captives where it is possible to do so quickly, one is like a person who sheds blood.”
The Shulchan Arukh recognizes the varying needs of the community — physical, educational, religious and social. Each can be easily justified in terms of broader Jewish commitments to life, human dignity, worship and other religious expression, education, economic solvency and close social ties. Consequently, if one were to create a contemporary list based on these Jewish values for funding communal projects in the United States, it would probably closely resemble the Shulchan Arukh’s list. Saving people who are threatened by human attackers would clearly come first, followed by providing food and clothing to prevent disease, followed by some order of curative health care, defense, education, culture and economic infrastructure.
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