August 26, 2009
Why We Must Support Universal Health Care
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In addition to paying for his own health care, a man assumes an explicit obligation in marriage, according to Jewish law, to pay for the medical care of his wife, children and other relatives if they cannot care for themselves. Once again, the precedent for this comes from the laws of redemption from captivity: A father must redeem his son if the father has money but the son does not. A gloss, by Rabbi Moses Isserles: “And the same is true for one relative redeeming another, the closer relative comes first, for all of them may not enrich themselves and thrust the [redemption of] their relatives on the community.”
In today’s more egalitarian society, this would presumably mean that spouses of either gender have responsibility for the health care of each other and of their children.
The immediate implication of these teachings is that one may not preserve the family fortune and make the Jewish community or the government pay for one’s health care, except to the extent that the government itself makes provision for all sick, elderly citizens in programs like Medicare without restrictions as to a person’s income or estate. Options can include using one’s own assets or buying a health insurance policy, either privately or through one’s employer. Public aid, though, is limited to when and if one qualifies for aid to the poor through programs like Medicaid, or for the elderly, like Medicare.
The individual also has a duty to contribute to the medical care of others besides one’s family. Although this is never spelled out in just those words, the Rabbis, as we have seen, see the absence of health care as shedding blood. Since the physician alone cannot be expected to bear the costs of health care for those who cannot afford it, this duty devolves upon the community, and the costs of health care for the poor become part of the charity one must give. Maimonides asserts: “If a person wants to give no charity at all, or less than is fitting for him, the court compels him and flogs him for disobedience until he gives as much as the court estimates is proper. The court may even seize his property in his presence and take from him what it is proper for that person to give. It may pawn possessions for purposes of charity, even on the eve of the Sabbath.”
Thus, with donations from, or taxes on, its members, the community as a whole has the duty to pay for the health care of those who cannot afford it themselves. In medieval Spain, for example, Jews played a prominent role in the state’s program of socialized medicine, while in other places, Jewish communities, on their own, hired surgeons, physicians, nurses and midwives among their staff of salaried servants. Whatever the arrangement, the community as well as individual doctors were under the obligation to heal, and that was taken very seriously.
In turn, the community must use its resources wisely, a demand that can serve as the moral basis within the Jewish tradition for some system of triage. The community must balance its commitments to afford health care with the provision of other services. The Talmud lists 10 such services: “It has been taught: A scholar should not reside in a city where the following 10 things are not found: (1) A court of justice that can impose flagellation and monetary penalties; (2) a charity fund, collected by two people and distributed by three [to ensure honesty and wise policies of distribution]; (3) a synagogue; (4) public baths; (5) toilet facilities; (6) a circumciser (mohel); (7) a surgeon; (8) a notary [for writing official documents]; (9) a slaughterer (shohet); and (10) a school-master. Rabbi Akiba is quoted [as including] also several kinds of fruit [in the list] because they are beneficial for eyesight.”
Several items here are relevant to health care. Since there was no indoor plumbing then — actually until the 19th or even 20th century in many places — it was important for purposes of public health to have public baths and toilet facilities. The “surgeon” mentioned in the list was the person who could perform the most important form of curative care known at the time — letting blood. Finally, Rabbi Akiba’s addendum concerns one’s ability to procure healthy foods in the town, recognition that our choice of food is important on a preventive basis in assuring health. Because no community’s resources are limitless, and because social needs other than health care must also be met, the community must ensure that those who receive public assistance for health care deserve it.
Thus, if a person repeatedly endangers his or her health through practices known to constitute major risks, such as smoking, drug or alcohol abuse, or overeating, the community may decide to impose a limit on the public resources that such a person can call upon to finance the curative procedures she or he needs as a consequence of these unhealthful habits. The legitimacy of the community enforcing such limits is established in Jewish sources with regard to captivity, the case that has served as the paradigm for many of the rules of assessment of cost throughout this essay: “He who sold himself to a non-Jew or borrowed money from them, and they took him captive for his debt, if it happens once or twice, we redeem him, but the third time we do not redeem him…. But if they sought to kill him, we redeem him even if it is after many times.”
Everyone is assisted in overcoming the consequences of the first and perhaps even the second indiscretion that endangers the person’s life, but beyond that the community no longer has the duty to act.
Even when the person will definitely die unless something drastic is done, the community has the right to assess the chances of success before deciding to expend the resources. The Shulchan Arukh assumes that a high enough ransom will surely redeem the captive, even after many times, but some medical procedures do not carry that certainty. So, for example, smokers cannot rightfully expect the community to pay for repeated lung transplants, and alcoholics may not call upon the community to pay for repeated liver transplants. Indeed, in light of the shortage of organs for transplant, the cost of the procedure, and the bad prognosis for smokers and alcoholics to benefit significantly from such transplants, current medical practice denies them even one transplant. This policy is warranted from the standpoint of Jewish law: Individuals must take responsibility for the consequences of their behavior, especially after being duly warned through captivity, sickness, or, in our time, education.
