Medical ethics in an interreligious comparison: Judaism

Avraham Steinberg

Introduction

Halakhah is the generic term for the whole legal system of Judaism. lt embraces all laws, practices and customs. Orthodox Jews consider the halakhah, in its traditional form, to be absolutely binding.

Jewish ethics were set forth more than 3000 years ago, and have been tested and reconfirmed throughout the long history of the Jewish people. The methods, deliberations, values, and principles of this system, as well as their application to patients and physicians, are deeply rooted within observant Jews.

The Jewish law is filled with ethical dilemmas in medicine. In particular, over the past four decades, many books, periodicals, and articles have been published that are entirely devoted to Jewish medical ethics.

In the sense of normative Jewish law and philosophy applied to practical medical issues, Jewish medical ethics are characterized by and distinguished from secular medical ethics in at least four aspects which will be discussed individually in the following four sections.

The range

General medical ethics deal with diverse subjects. Jewish medical ethics deal with all these universal problems, but also includes many more subjects that are halakhically of no less importance.

Universal ethical issues include the following topics: abortion, addiction, allocation of limited resources, confidentiality, contraception, attitude to defective newborns, determination of the moment of death, disclosure of information, experimentation on humans and animals, genetic issues (i.e., screening, treatment, cloning), informed consent, in vitro fertilization, malpractice, sexuality, suicide, attitude to the terminally ill, transplantation of organs, and triage decisions.

Jewish medical ethics deals with all these topics, but in addition also deals with two other broad categories:

  1. The attitide toward the handicapped, disabled and vulnerable. Included in this category are: the infertile, blind, deaf, elderly, fetus, hermaphrodite, lame, mentally ill, minor, mute, newborn, pregnant, and retarded.
  2. "Pure" halakhic issues. Included in this category are: autopsy, blessings and prayers for the sick and the carers, castration, circumcision, dietary laws (kashruth), fast days (i.e., Yom Kippur), holidays (i.e., Passover), marriage and divorce, menstruation (niddah), mourning, priests (cohen), the Sabbath, and seclusion.

Hence, a Jewish medical ethicist has to deal with a much wider range of issues.

The underlying principles

Many of the Jewish moral and legal principles and rules have significant bearing upon the practice of medicine Judaism subscribes to commitments, obligations, duties, and commandments, rather than to rights, pure hedonism, and selfishness. Happiness and pleasure are considered as means rather than goals. "Rights" ethics are minimalistic ethics, sanctioning any individual's wish and conduct, as long as it does not disturb the peace of the community. This approach minimizes other socially shared values.

The aim of studying ethics is to act accordingly rather than merely to engage in intellectual exercise or academia. Judaism, in general, is opposed to absolutizing any single value; rather it subscribes to a golden path, a middle way, a balancing approach, which is always advocated and favored. No principle is construed as one that always overrides all other principles. Therefore, when conflicting values in practical medicine are encountered, each patient must be considered individually, and a solution is reached depending on the specific clinical and ethical circumstances. Obviously, this is done within the general framework of halakhic rules and regulations.

Judaism requires responsibility, mutually shared values, and a moral-religious paternalism rather than an approach of an overriding autonomy, moral anarchism, and individual-personal paternalism. The patient-physician relationship is regarded in Judaism as a covenant rather than a freely contracting relationship. In Jewish law, there is a specific obligation on the physician to heal and on the patient to seek medical help. Human life in Jewish philosophy is sacrosanct and of supreme value; hence, any precept is suspended if it conflicts with life.

The range and application of the notion of autonomy constitutes one of the most significant differences between current secular and Jewish medical ethics. The relevance of autonomy in health care decisions is undeniable. However, a zealous and unconciliatory interpretation of the right of autonomy has been severely critisized even in a pluralistic, secular society. These criticisms are particularly strong from the Jewish standpoint. It is, therefore, pertinent to cite some of the disagreeable aspects of the notion of autonomy, as stipulated by Pellegrino and Thomasma [1]. They suggest that the practical question in clinical decisions focuses on the the proper exercise of autonomy. Do we have a right to exercise autonomy when the decision we wish to make is not morally good? Are we free to make morally wrong decisions? Have we lost a common consensus on morals to such a degree that there is no longer any community of values? Are there any other values in common other than autonomy? By promoting autonomy to the extreme overriding power, are we not promoting a degradation of moral life and principles? Does this approach not educate to amoral or even immoral life? Can a society survive such radical pluralism in which there are no longer any shared values? Moreover, an extreme interpretation of autonomy may contribute to a serious educational gap in neglecting to promote the requirements for personal duty and social responsibility.

Judaism certainly acknowledges the ability of freedom of mind and of free choice. Indeed, the very approval of medicine in normative Jewish law is based on the rejection of absolute determinism. However, the mere fact that one is able to exercise free will does not give him/her necessarily the right to do so. In fact, generally, most moral principles take precedence over autonomy, unless they are very ambiguous, or significant autonomous considerations exist in the particular case. Hence, in Jewish philosophy, the right to execute autonomous decisions has significant restrictions and limitations. Autonomous decisions that do not comply with the required moral standards are overridden by higher moral values, as determined by Jewish law.

The method of analysis

General ethics is based on philosophical, social, and legal analyses, and it applies a deductive approach based on general principles. By contrast, Jewish medical ethics is based on halakhic analysis. Namely, the mode of discourse and cognitive background is based on ancient sources of authority: (a) The written law, the corpus of the five books of Pentateuch. Included in this composition are 613 positive and negative commandments of Sinaic origin; (b) the oral law, which includes the massive composition of the Talmud, as well as the magnum opus codifications (Maimonides' Mishneh Torah, Karo's Shuichan Aruch), and the enormous compilation of responsa (300 000 responsa in 3000 books of responsa). The oral law includes the interpretation of the written law, transmitted in its entirety with its details and minutiae at Sinai, as well as logical deductions, rabbinical decrees, customs, and positive and negative enactments. The precedents, rules, and regulations of these sources, as well as the general principles of Judaism, are applied to medical issues. The format of application in Jewish medical ethics is usually that of a casuistical approach. Namely, the responsum concerning a specific question is dealt with on its own merits and its specific details and characteristics. Any medical issue is analyzed according to the foundation of halakhah, much in the same way as any other issue in life is analyzed when a halakhie problem arises.

The end-point

Ethics usually does not supply definite answers because it is a pluralistic approach. "It is a central feature of contemporary moral debates that they are unsettleable and interminable.. Because no argument can be carried through to a victorious conclusion, argument characteristically gives way to the mere and increasingly shrill battle of assertion with counter-assertion" [2]. Jewish medical ethics supplies definite answers because it is a legalistic-normative method. Jewish medical ethics gives finite and decisive answers, although not always those that are accepted by all members of the community, or by all scholars and authorities. Dispute-resolution mechanisms are built into the halakhic system, so that final decisions can be reached.

The prefered model of decision-making in medical issues is composed of a triad: the physician, whose obligation is to treat the patient and to offer the best medical advice; the patient, whose priviledge and obligation is to seek medical help, and who has the autonomy to choose his medical and halakhic advisers; and the rabbi, who is required to solve any ethical/legal problem encountered either by patient or physician, based on the best available information concerning the medical condition and alternatives. Since the most qualified person makes the decisions relevant to his expertise, this triad should be able to reach the best solution to any complex medical and ethical issue concerning any individual case on its own merits and according to its specific circumstances. This model causes the patient to surrender a great measure of his/her autonomous decision-making power to others, as part of an ideological way of life.

References

[1] Pellegrino E, Thomasma DC (1988) For the patient's good. Oxford University Press, New
  York
 


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[2] MacIntyre A (1979) Why is the search for the foundation of ethics so frustrating? Hastings
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Suggested reading

Beachump TL, Childress JF (1994) Principles of biomedical ethics, 4th edn. Oxford University Press, New York

Steinberg A (1991) Jewish medical ethics. In: Brody BA, et al. (eds) Bioethics Yearbook, vol 1. Theological developments in bioethics: 1988-1990. Kluwer Acadernic, Dordrecht Boston London, pp 271-279

Steinberg A (1994) A Jewish perspective on the Four Principles. In: Gillon R (ed) Principles of health care ethics. Wiley, New York, pp 65-73

Prof. Dr. med. Avraham Steinberg
6 Shalom Aleichem
St. Jerusalem 92148, Israel