Q. Our hospitals can't turn away a medical emergency on the basis of ability to pay. Is it fair for local residents to bear the cost of foreigners, some of whom immigrate illegally especially to get medical treatment?

A. A number of people wrote to express concern about this problem. The problem is not only the expense but also the burden on medical resources which sometimes displaces local residents who ultimately pay for the services.

Jewish communities throughout the ages have stuck to two principles which can help illuminate this complex ethical dilemma:

1. Whenever resources permit, basic needs should be provided for every individual, including strangers.

2. When resources are scarce, residents have precedence over strangers.

Regarding the first principle, the Shulchan Arukh (Code of Jewish Law) states: "A transient poor person should receive at least a medium-sized loaf of bread. If he stays the night, he is given a mattress to sleep and a pillow for his head, and oil and beans [to eat]." (1) In other words, even a transient is provided with his basic needs including a decent place to spend the night.

Regarding the second principle, we learn that "the poor of your city have precedence over the poor of another city," even when the latter come to visit. (2)

Fundamentally, we see that Jewish communities acknowledged a responsibility to provide for even transient guests as long as resources permit this. Should we generalize that today's localities should do the same thing, providing equally for all who come?

Not necessarily. It's true that Jewish communities are obligated to aid both Jews and non-Jews. (3) But the obligation was not equal; these tiny communities did not, and indeed could not, provide for all needy gentiles. Such an obligation was not practical, and was also not reciprocal. Jews couldn't count on having all their needs taken care of by non-Jews when they were away from home.

After careful consideration of this problem, I conclude that the appropriate generalization is as follows: Just as Jewish communities have always recognized the need to provide a minimal amount of aid to all needy people, so our localities today should stand willing to provide at least a minimal amount of aid for all visitors, including indigent foreigners.

And just as Jewish communities have always undertaken to provide for all basic needs of fellow Jews, including visitors, so other close-knit communities should undertake to provide for all needs of their members. Since virtually everyone belongs to some kind of community - ethnic, religious, national, professional, etc. - the result is that basic needs are provided for all, but without creating an impersonal and unreasonable open-ended obligation on the locality as a whole.

Many countries have had variations of this regarding immigration policy. In the 1930's the United States used to accept immigrants from Europe only if they could find a sponsor to guarantee that they would not be a burden on the public. Jewish communities mobilized to sign tens of thousands of such "affidavits". This saved the lives of countless refugees including many who later made outstanding contributions to America in science, culture, government and other areas.

Putting these two elements together, I suggest the following: local governments should continue their policy of giving basic emergency medical care for all. However, part of the expense should be borne by community organizations. The entire process should be in a spirit of inclusivity, not exclusivity. In other words, the requirement to find a "community" for a needy person should not be an excuse to refuse treatment, but rather should serve as a positive impetus to encourage the formation of a variety of social service organizations committed to giving aid to their landsleit (Yiddish for "countrymen"). If a large fraction of needy people are affiliated with some organized community, then it will be relatively easy to treat isolated individuals who fall between the cracks. This can be done either at public expense -- now bearable since there are fewer eligible individuals -- or through special social service organizations financed by generous individuals who want to help specifically these isolated dispossessed guests.

A beneficial side effect of this policy is that it encourages the formation of close-knit communities which can be a partial antidote to the general atmosphere of alienation and isolation which is so common in cities, particularly those with diverse populations.

Localities should take a leadership role in making sure that all basic needs are provided for needy guests, but when resources are scarce they shouldn't have to bear all the financial burden of this provision. Rather, localities should oversee an equitable network of functional voluntary communities which undertake to bear a fair share of the expense of treating their own members.

SOURCES: (1) Shulchan Arukh Yoreh Deah 250:4. (2) Yoreh Deah 251:3. (3) Yoreh Deah 251:1

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