In many ways, the Jewish approach to medicine is the opposite of the secular approach. As I described in my in my previous article, many ethical lapses over the past century have been the result of placing the good of society before the good of the individual. In Jewish theology, the individual is of paramount importance. This is aptly stated by Rabbi Jonathan Sacks, current Chief Rabbi of the British Commonwealth, in his book, A Letter in The Scroll, regarding the contribution of the Jews to the world's concept of morality. He writes: "In eras that worshiped the collective- the nation, the state, the empire- they (the Jews) spoke about the dignity of the individual." In another section, Rabbi Sacks crystallizes the crux of the Jewish contribution to civilization:
"In terms of ethics, Judaism was the first religion to insist upon the dignity of the person and the sanctity of human life. For the first time, the individual could no longer be sacrificed for the group. Murder became not just a crime against man but a sin against God."1
This lesson is apparent from the first chapters of the Torah where we learn about the circumstances of man's creation. The Torah2 tells us that "God created man in His own image" to teach us that every individual person is Godly. If every person has the spark of God within him, how could we ever contemplate treating any individual with anything less than the utmost respect and dignity?
The Talmud teaches that the Almighty first created mankind as a single individual, rather than a group of people, to teach us that one who saves a single life saves a world, and one who destroys a single life, destroys an entire world.3 According to the Jewish view, the individual is a microcosm of the entire world.
We see that the individual is of intrinsic importance manifested in Jewish law in a multitude of areas. For example, an innocent person's life may never be sacrificed to save someone else or even a group of people. Nevertheless, although we recognize the validity and necessity for triage and rationing in some situations, we do not sacrifice one person's life to save someone else's life. If two people are drowning and we can only save one, or if several people need a medicine and we only have enough for one, what do we do? Mainstream Jewish law would have us save one even if others will die. Although we choose to save a particular individual and others may die, we have not directly caused their deaths. However, we could not kill one person in order to save another, unless the party we are killing is a rodef, someone pursuing another to kill them (see: Abortion in Jewish Law).
Regardless of how sick an individual may be, we may never harm him to save someone else. While the secular word entertains the idea of removing organs from very ill patients by obtaining consent to withdraw life-support, halacha unequivocally rejects the idea of sacrificing the life of even the sickest patient to save the life of another. This does not imply that halacha bars cadaveric or live organ donations, only that one may not kill one person to save another.
A General Approach
1. Good ethics start with good facts. 2. There is no distinction between Jewish law and ethics.The Jewish approach to any ethical question relies on two important concepts: that good ethics start with good facts and that in Judaism, there is no distinction between Jewish law and ethics. Judaism does not deal with armchair philosophy; it deals with real, practical cases. I learned the first rule after speaking at the International Conference on Jewish Medical Ethics in San Francisco several years ago. At that time a major scandal had just come to light in Israel. It was revealed that the Magen David Edom, the Israeli version of the Red Cross, was throwing away the blood of Ethiopian blood donors without informing them, for fear that the blood was tainted with HIV. There were angry accusations of racism. Dr. Avraham Steinberg, a pediatric neurologist at Shaarei Tzeddek hospital in Jerusalem and prolific author on Jewish medical ethics, was asked whether it was ethical to secretly discard the Ethiopians' blood. He replied: "Good ethics start with good facts." He explained his analysis of the situation in a most ingenious way. If the HIV rate in the Ethiopian population is not significantly higher than the general population, then discarding the blood is immoral. But if the HIV rate in the Ethiopian population is significantly higher than the general population, then other factors come into play. It must be understood that testing donated blood was expensive and there was a window of time between HIV infection and conversion to a positive HIV test. If the yield of clean blood after expensive testing for HIV is so low that it is not economically viable to test, and the risk of HIV tainted blood entering the blood supply is high enough, then secretly discarding the blood is not only prudent from a medical and economic point of view, but shows respect for the Ethiopians by not publicly labeling them as diseased.
If one questions the wisdom of such an approach, one need only look to the American Red Cross. After a potential donor is finished donating his or her pint of blood, the donor chooses a bar code that indicates whether their blood should be used or should be discarded. Why should such a system be necessary? Why would someone donate blood and then ask to have it discarded? Because the drive to avoid embarrassment could force a person to donate due to peer pressure even if they know that their blood is, or could be, tainted. So the Red Cross offers a tactful, confidential way out that prevents embarrassment to the donor.
What is ethical is not always obvious. The question of whether an action is ethical can only be made with respect to the exact facts and merits of each specific case.
The second rule, that there is no distinction between Jewish law and ethics, is more straightforward. From a traditional Jewish approach, Jewish Law, halacha, defines ethics. Halacha is the code of conduct by which the traditional Jew leads his or her life. Extra-halachic ethics is somewhat of a non-sequitor. We apply Jewish law to each case and the answers that we reach should represent an ethical paradigm. For this reason, Jewish medical ethics is merely the application of Jewish law to medicine, just as kashrut is the application of Jewish law to food, or Jewish tort law is the application of Jewish law to monetary damages.
How are medical ethics questions approached?
Every day, new medical and technological breakthroughs occur, widening the panorama of therapeutic options. While the march of technology continually improves our health, it creates new scenarios and novel questions. How does the Torah approach what sometimes appear to be unprecedented situations?
Regardless of how unique as situation may appear, the approach of the halachic system remains unchanged.
Regardless of how unique as situation may appear, the approach of the halachic system remains unchanged. As the book of Ecclesiastes states: "There is nothing new under the sun." 4 Infertility treatments (including IVF and surrogacy), artificial prolongation of life, abortion, rationing, self-endangerment, and a myriad of other contemporary ethical issues have been dealt with in Jewish law for millennia. The challenge is to appropriately recognize the salient issues in order to properly apply Jewish law.
The Jewish legal system
When one approaches a rabbi with an ethical question, whether in medicine or any other facet of life, how does the rabbi determine the appropriate answer? While the secular approach of a hospital ethics committee relies heavily upon personal feelings and experiences, the Jewish approach relies upon an evaluation of pertinent information from a rich heritage of over 3000 years of Jewish existence.
To understand how any specific question of medical ethics is answered, one must understand the Jewish legal system. The methodology for investigating any halachic or ethical dilemma is similar. The posek, or rabbi who has been extensively trained in Jewish law, gathers technical and situational information about the case at hand. He then surveys Jewish legal sources from the Bible to the 20th century, identifying precedents from previous cases that might be applicable to the current case. He then carefully traces the relevant issues through the Torah, Mishna, Talmud, Rishonim (early Talmudic commentaries), and Achronim (later Talmudic commentaries), using prior halachic literature to guide the application of Jewish law to modern problems. After tracing the path of Jewish law from the Torah to modern responsic literature, he renders an opinion.
Structure of the halachic system
The structure of Jewish law is in many ways analogous to that of Western legal systems. While the analogy is somewhat simplistic, it is instructive to give a sense of how the halachic process is organized.
Just as the written basis of the United States legal system is the constitution, the Torah5 is the basis of the halachic system. The Torah is a written Divine document that God presented to the Jewish people on Mount Sinai and which contains all of the mitzvos and other important concepts of Judaism.
American law rests on a long tradition of common law extending back many centuries to Great Britain and even to ancient Rome. This component of the secular legal tradition is much larger and more far-reaching, but is equally authoritative and comprises the basis for much of the case law generated by the courts. Similarly, the Mishnah, 6 Talmud7 and other components of the Oral Law are much more extensive than the written Torah and equally authoritative. The Oral Law is the corpus of Jewish law that traces back to the revelation at Mount Sinai and which includes later rabbinical legal decisions, which flesh out and explain the Torah. The Oral Law deals with the day-to-day practical aspects of Jewish life.
Like any Western legal system, our laws are compiled into statute books. Just as there are tomes of federal and state laws, we have compilations of Jewish law dating back over 800 years. The earliest extensive organized compilation of Jewish law was performed by Moses Maimonides, a great rabbi and physician of the 12th century. His Yad Ha'chazaka, also known as the Mishneh Torah, 8 covers all areas of Jewish law and remains one of the most authoritative legal guides in Judaism. The next great statute book, the Arbah Turim, was written by Rabbi Yaakov ben Asher9 in the early 14th century. Probably the most famous compilation of Jewish law is the Shulchan Aruch (Code of Jewish Law), written by the Sefardi posek Rabbi Yosef Karo who lived in Safed, Israel, with glosses by the Polish Ashenazi posek Rabbi Moshe Isserles. 10 This seminal work was completed in the late 16th century, and while hundreds of subsequent commentaries have been written, it remains the preeminent guide to Jewish law.
Where do we find the final decision?
Probably the most useful halachic literature for evaluating medical ethics issues from a Jewish perspective are the many thousands of responsa written over the last thousand years that deal with every conceivable aspect of life. This is akin to the corpus of Western case law dating back many centuries that has formed the precedents for modern court cases.
While many great rabbis dealt with a broad range of issues, some were considered to be particularly expert in the area of medical ethics. 11 In America, Rabbi Moshe Feinstein (1895-1986), author of the multivolume Igros Moshe, was widely accepted as the preeminent posek in all areas, but particularly in the area of medical ethics. His decisions span all areas of medical ethics. In Israel, Rabbi Shlomo Zalman Aurbach (1910-1995), author of Minchas Shlomo, was accepted by many as the greatest authority in these areas. Of course there are many other great rabbis who deal with medical ethics. Among the greatest living experts are probably Rabbi Yosef Shalom Eliashiv, author of Kovetz Tshuvos, and Rabbi Eliezer Yehuda Waldenberg, author of the 20 volume (so far) Tzitz Eliezer.
Judaism has very rich tradition of medical ethics. Questions that the rest of the world finds novel have been dealt with in a variety of ways in halachic literature for hundreds, if not thousands of years. We have a comprehensive system that has been field-tested for reliability and which does not bend to the transient whims of society or the changing winds of fashion. Without a gold standard for comparison such as the Torah, situational ethics can become a very slippery slope. Murder becomes "mercy killing," destruction of fetal life becomes a "personal choice," and the basic rules of human dignity upon which society should be grounded erode beneath our feet. With our extensive, proven track record of morality that stems from a Divine source and that stresses the nobility of all human beings, we are highly qualified candidates to enter the societal debate over public policy issues involving medical issues.1 Sacks, Rabbi Jonathan, A Letter in the Scroll, p. 75
2 Genesis 1:27
3 Sanhedrin 4:5
4 Ecclesiastes 1:9
5 The Torah was presented to the Jewish people in 1313 BCE
6 The Mishnah was compiled by Rabbi Yehuda HaNasi in approximately 190 CE.
7 The Babylonian Talmud was compiled by Rav Ashi and Ravina.in approximately 500 CE. The Jerusalem Talmud was compiled by Rabbi Yochanon in approximately 350 CE. Exacts dates vary.
8 The Mishneh Torah was written around 1180 CE. Maimonides lived from 1135 to 1204 CE.
9 Rabbi Yaakov ben Asher lived from 1270 to 1343 CE.
10 Rabbi Yoseph Karo lived from 1488 to 1575 CE and Rabbi Moshe Isserles lived from 1530 to 1572 CE.
11 See Fred Rosner, Pioneers in Jewish Medical Ethics, Jason Aronson Press, 1997