Q. I have an uninsured patient who needs a life-sustaining medicine which is beyond his means. The family is urging me to write the prescription for another family member whose drug bills are covered by insurance.

A. Your unfortunate situation is a variation of one of the most famous and trying dilemmas in ethics. Renowned ethics researcher Lawrence Kohlberg used a version of this situation which he called "Heinz's dilemma." In Kohlberg's scenario, Heinz's wife needs a life-saving drug which he can obtain only from a local pharmacist, who demands a prohibitive price far more than the cost of the drug. Heinz must decide if it is ethical to steal the drug.

Many people have been faced with situations where the ethical obligation to save life seems to oppose the ethical prohibition on stealing. Jewish tradition provides one resolution of this dilemma. Let us present the solution and afterwards discuss its applicability to your situation.

The Shulchan Arukh (authoritative Code of Jewish Law) states: "Even if one is in mortal danger and must steal from his fellow in order to save his life, he must only take it with intention to repay." In other words, we allow a "forced loan" or a permissible tort to save a life, but afterwards the stolen object or the damage must be paid for. (1) This is based on the principle that all other prohibitions are set aside in cases of danger to life. (2)

This ruling is learned from a historical situation presented in the Talmud. The story concerns King David and his knights who needed to pass through a field where hostile Philistine soldiers were lying in ambush. They decided they needed to clear the field and consulted the Sanhedrin, the highest legal authority. The judges told them that clearing the field is permissible, but normally only on condition of payment. However, in the case of King David this condition is superfluous, since his sovereign power of eminent domain gives him the right to clear the field.

We see that in many cases the dichotomy between stealing and neglecting to save a life is not so stark; there may be an intermediate solution of some kind of "forced loan." (Indeed, one of the criticisms of Kohlberg's theories is that his focus on "pre-packaged" dilemmas leaves too little room for creative "out of the box" solutions.)

That being said, I do not think that this ruling of the Shulchan Arukh provides a valid justification for cheating the insurance company. There are a number of differences between the situations.

The first relevant distinction is that in the case of King David, it was unambiguous whose field needed to be cleared. The victim could justifiably ask, "Why did you need to destroy a perfectly good wheat crop?" But he couldn't have asked, "Why did you have to pick on my field, and not someone else's?" The road the army needed to travel, and the Philistine ambush, were specifically through that field.

But in your case, the insurance company has no particular reason for being singled out besides the fact that they are an easy target. A similar criticism could be made of Heinz's dilemma. Even if we agree that Heinz is justified in stealing to save his wife's life, why is he justified in stealing from the druggist? Wouldn't it be equally justified for him to snatch purses from old ladies?

A second distinction is that King David and his knights insisted on transparency. They consulted an authoritative legal body, whose judgment could later on have been challenged by the field's owner, and their clearing of the field was done openly, not furtively. This differs from the secretive solution your patient is suggesting.

There is a third distinction which makes the insurance company perhaps the worst candidate for this kind of deception: the money you would be stealing from them would otherwise go to some other urgent medical need. If you were to forge a check, the account holder, or bank, would lose money that might have been earmarked for some business project, like the wheat field destroyed by King David. But the insurance company is in the business of underwriting medical expenses, and practically speaking a large fraction of these are for other people with comparably urgent needs. While Judaism acknowledges that saving life overrides most transgressions, an exception is made for the prohibition of endangering others. Saving your life at the expense of endangering someone else is forbidden, for our Sages tell us, "Who says that your blood is redder than his?!" (2)

I am far too modest about my capabilities to believe that I have the authority to make life-and-death decisions for others whether stealing is or is not justified in cases of mortal danger. I pray that I should never have to face such a dilemma myself. But I am certain that stealing should not be a first resort, made attractive by expediency. I see a definite ethical an obligation to exhaust other routes: government programs, private contributions, bank loans, alternative treatments, and so on.

The law we cited from the Shulchan Arukh has a general message: The choice between outright stealing and outright neglect of rescue is seldom so stark. Thought and effort are needed to seek solutions which don't brazenly affront either of these vital ethical ideals.

SOURCES: (1) (CM 359:4) (2) Babylonian Talmud Sanhedrin 74a; Shulchan Arukh Yoreh Deah 157. (3) Babylonian Talmud Bava Kamma 60b. (The Talmudic account is based on events narrated in II Samuel chapter 23.)

IMPORTANT NOTE:

There were many fascinating responses to the recent article on cheating the insurance company to obtain a life-saving medication. A number of readers wrote that drug companies often give substantial discounts to patients needing life-saving treatment not covered by insurance and beyond their means. Therefore, they strongly recommend that someone in this tragic situation should turn first to the manufacturer of the drug to see if some compromise can be arranged.

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