Jewish Medicine

[Jewish medicine prayer]

Moses' Prayer for Healing (Numbers 12:13)


Introduction

What is Jewish medicine anyway? Mention "Jewish medicine" and you may elicit smirks, laughter, or retorts like Does that mean taking care of chronic complainers? or You mean treating with chicken soup? After all, what is Judaism? Isn't it just a culture, a race of people with some sort of tribal connection who enjoy eating chopped liver and lox and who take pride in how "successful" they are? Well, no on all counts. It is neither a culture, race, nor tribe; it does not sanction gluttony or hedonism; and Jews are neither proud nor do they define success from a materialistic standpoint but rather in terms of how well one has improved oneself in order to be better able to help make the world a better place in which to live. A cardinal value and virtue of Judaism is histapkut bamuat, living simply, unpretentiously, and unostentatiously and deriving satisfaction from having just a little, in short, inconspicuous consumption, the antithesis of materialism (as symbolized by the major holiday of Sukkot, in which Jews assume a minimalist lifestyle for one week by living day and night in a sukkah, a temporary, flimsy, loosely thatched hut open to the elements). Judaism is not a mere religion but rather a way of life encompassing all aspects of being. Jews need not seek ways to bring Judaism into their lives or to make it relevant to their lives: they live Judaism; Judaism is their life. Jews are a people, yes, but a people defined by the religion and way of life they have chosen to follow: they are the "choosing people," not the "chosen people." Judaism is open to people of all colors, races, ethnicities, and cultures. Someone who "looks Jewish" is someone who is actively and avidly pursuing a Jewish way of life.

Rabbi Dr. Isidore Epstein, the editor of the first complete translation of the Babylonian Talmud into English (Soncino Press), described the world view and social structure of the post-exilic Jewish communities in his 1962 introduction to the tractate Bava Metzia: With the Torah as supreme guide in communal life, the primary end and aim of communal organization had moral and religious purposes. This does not mean that the economic and social functions of organized society were ignored. But it does mean that all was looked upon as subordinate to the moral functions. In other words, morality was made the dominating factor of communal life, and the underlying principle of all legislation regulating social and economic relations. Rationalizing things for the sake of money is not kosher. Furthermore, throwing money at a problem is not always the best solution, contrary to what some people believe. Epstein's take on social legislation in the Talmud is consistent with the fact that Judaism is anything but consequentialist in its weltanschauung: the ends do not justify the means, and the process takes precedence over the finished product. Contrast that with the approach of abetting and rewarding unscrupulous real estate and stock investors as a means of facilitating economic recovery from downturns caused by unbridled self-interest and greed.

Medicine is a vocation imbued with a holiness requiring scrupulous attention to and adherence to the highest ethical standards. To a few people who are cognizant of the reality of the current health care environment, the disparity is self-evident: regardless of their religious background or orientation, when they hear the words "Jewish medicine," they nod their heads knowingly.


Jewish Medicine: What It Is Not

What, then, is Jewish medicine and what isn't it? It isn't some quackish, fraudulent form of medicine or some compilation of traditional folk medicine practices. On the contrary, with its respect for educated opinion and legitimate authority, Judaism is in complete accord with evidence-based scientific medicine, which, unlike most "alternative" methods, is anything but conventional but rather open to all modalities of healing, so long as there is reasonable evidence for their efficacy. Folk remedies appear in the Talmud, but the great physician and scholar Rambam (Maimonides) felt we should ignore them lest we lose our faith when we see that such remedies are not really effective. Judaism has always taken a dim view of dubious medical practices based on specious reasoning, such as homeopathy. As the Torah commands (Exodus 23:7), Keep yourself far from a false matter (midvar sheker tirchak). Jewish medicine does indeed provide an alternative to secular medicine, not scientifically but rather philosophically.

Jewish medicine is not a specialty area of medicine in the same sense that disciplines like cardiology or ophthalmology are. Contrary to the secular world in which physicians generally limit their practice to one esoteric area and may often be uninterested in and unknowledgeable about other specialty areas, the practice of Jewish medicine requires an encyclopedic and continuously updated knowledge base incorporating all of medicine. In light of this, how do we apply the pedagogical advice When you hear hoofbeats, think horses, not zebras, which is akin to the medical aphorism Uncommon presentations of common diseases are more common than common presentations of uncommon diseases? Those who practice Jewish medicine, while taking the likelihood of various diagnoses into consideration, keep all diseases, whether of the horse or zebra variety, in mind so as not to miss anything. Uncommon diseases are often more common than is generally believed: they tend to be underdiagnosed because doctors are not thinking of and looking for them. Maintaining the broadest view of all of medicine allows one to become a rosh gadol, someone who incorporates a holistic, or biopsychosocial, approach to medicine in which all aspects of a patient's health and being are considered simultaneously and in the context of each other (not to be confused with the contemporary use of the word "holistic," which often denotes quackery). The concept of not confining oneself to one narrow area may fly in the face of strictures sometimes imposed on physicians by the narrow-minded roshim ketanim of governmental bodies or of insurance companies. Nevertheless, to paraphrase the old Hebrew National commercial, those who personify the values inherent in Judaism answer to (and are answered by) a higher authority: From the narrow place I called out to God; God answered by expanding the confines of my being (Psalms 118:5).

The clinical practice of secular medicine is conducted on a battlefield. The language is telling. Treatment is frequently described in militaristic terms. Therapies, especially pharmaceutical, constitute an "armamentarium." The goal is to use the "weapons" or "arsenal" at our disposal to "fight off" disease; to "conquer," "battle," "beat" or "win the war on" cancer; and to "defeat" heart disease and other ailments -- the "shock and awe" approach. And if we can "kill two birds with one stone," all the better. This mentality fosters the outlook that killing or destruction is the solution to most problems and has undoubtedly had a negative effect on patient care and on medical progress.

In contrast, Jewish medicine takes a more positive approach. Prevention is emphasized. As per Rambam's exhortation in his Treatise on Asthma, the physician should treat the patient, not the disease. The priority is the individual, not the system, and the individual is to be treated as an individual, that is to say, in a personalized manner, not according to a one-size-fits-all paradigm. An attempt is made to help the patient deal with his disease in positive, supportive ways whether a cure is feasible or not. Medical scientists are now catching on to this approach: realizing that the "war on cancer" was not being won, they are now looking for ways to turn cancer into a chronic disease that the patient can live with for many, many years, perhaps indefinitely, with a good quality of life. By employing the biopsychosocial model, Jewish medicine tries to make patients whole by paying attention to the spiritual, emotional, and social aspects of each person's being (refuat hanefesh urefuat haguf - a healing of the spirit and a healing of the body). Included among the benefits of spiritual healing are a bolstering of immunity, stimulation of the body's reparative processes, and restitution of a sense of well-being. Delving into a patient's social circumstances - living conditions in the neighborhood, problems with the habitat, access to sources of healthful foods and to community programs, personal relationships or lack thereof, mobility, financial resources, attitudes toward medicine and toward eating, etc. - can make a major difference with respect to therapeutic outcomes. In the current health care environment, however, it is rarely done, much less acted upon.

In Jewish medicine, success is not measured by the size of one's practice, by the volume of surgery performed, by the location of one's office, or by the renown enjoyed by or the acclaim heaped upon the physician. Rather, it relates to the degree to which the physician has been able to conform to the norms of Jewish medicine.


Jewish Medicine: What It Is

Jewish medicine, then, is a philosophic field of practice based on Jewish moral and ethical values, including but not limited to those laws dealing specifically with how a physician is to ply his trade (the focus of this website). According to the Biblical account of Creation, we were placed on this earth to serve rather than be served (Genesis 2:15), and the calling of physicians is to serve in their supremely holy vocation -- to serve God and "serve the people." A sense of service (think Chiune Sugihara) as the basis for practicing medicine represents a much higher level than does a desire to help people that is fueled by a craving for self-admiration or by self-satisfaction derived from patient gratitude and from societal esteem. Self-service is better suited for the Automat.

Jewish medicine is based on an infinite respect for the value of all life. Everything must be done in the best interests of the patient (beneficence), and everyone in the system knows his bounds: non-physicians are not co-opting or being asked to assume the proper role of physicians in the examination of, diagnosis of, treatment of (including dietary and physical therapy), and post-operative care of patients, for example. Of course, if physicians are to maintain their role, they must think and act like physicians, not like technicians. Jewish medicine does not acquiesce to the facile introduction of the term "health care provider" into the lexicon by the insurance industry. The term, used as a substitute for "physician," denies the uniqueness of each individual and implies (falsely, of course) that all who provide a service do so with equal skill. The goal of this duplicitous word substitution is for patients to accept the very limited choice of physician provided by some insurance companies or even accept non-physicians in lieu of physicians.

Doing what is in patients' best interests means constantly questioning the accepted or traditional way of doing things. Jews theologically accept a considerable degree of uncertainty, for example, in their understanding of the afterlife and of what it takes to achieve salvation. Moreover, it is okay, by and large, to question and to doubt. For those who can accept uncertainty as part of life, there are some benefits. Uncertainty helps one avoid complacency and spurs one on to question the status quo and search for answers that help advance our knowledge and improve the quality of our lives. Despite the scientific basis of modern medicine, many time-honored treatments have not been adequately investigated and are more or less accepted on faith. For example, we've always been told to cleanse minor cuts and scrapes with warm water, but reviews of studies performed have failed to demonstrate any reduced risk of infection. Simple corneal abrasions were always treated by patching, but now it appears that we may be better off just leaving the eye open and instilling a little antibiotic ointment. For over a hundred years, oxygen has been administered to patients who have suffered myocardial infarctions (heart attacks), but recent studies suggest it doesn't help and may even be harmful in terms of how much damage the heart ends up with. Thus, questioning, challenging assumptions, probing, and questioning again, always in an educated and respectful way, are intrinsic to Jewish medicine.

With regard to therapy, the risk/benefit ratio must be minimized with the gentlest treatment preferred, and so doing may sometimes make "tincture of time" (allowing an illness to recover on its own) the preferred treatment. Although a patient's input is always an important part of the decision-making process, sometimes a physician may need to go against a patient's wishes, e.g., refusing to perform surgery that is not indicated or to prescribe an antibiotic for an obviously viral infection (or, for that matter, any inappropriate drug requested by a patient who has been influenced by direct-to-consumer advertising by the unscrupulous drug companies). The rationalization "if I don't do it, the patient will just go down the street to the guy who will" does not even enter the mind. However, there exists in Judaism the concept that sometimes a person may intrinsically know more about what is occurring inside his body than others do and may therefore be entitled to some degree to act as his own physician! This concept derives from Proverbs 14:10: The heart alone knows its own bitterness. The Talmudic sages (Yoma 83a) ruled that, if a person thinks he can fast on Yom Kippur but the physician disagrees, then the physician is boss because the person may not be thinking clearly and may be overestimating his own stamina. On the other hand, if the physician feels the person is well enough to fast but the person thinks otherwise, then the person should not fast. We know when we're hurting! Despite their inherent limitations, physicians can best "get inside" a patient by taking a careful and thorough history (an "endangered species" nowadays), starting out by giving the patient adequate time to speak freely about his problem and by not questioning him prematurely.

A physician must personally spend as much time as is needed to get to the root of a patient's problems and treat the patient properly and optimally, whether obtaining a comprehensive history; counseling or instructing; washing hands and disinfecting stethoscopes and other instruments and removing and replacing face masks between patients; performing all indicated testing and not cutting corners, e.g., obtaining bacterial cultures whenever feasible before initiating antibiotic therapy; refracting for eyeglasses; researching the medical literature when faced by unfamiliar problems; or helping patients in any other way, even if it doesn't involve "doing things" to people. Forcing a physician to spend less time per patient or pressuring him to "make his numbers" is opprobrious and impermissible.

Respect for patients is also de rigueur, whether scheduling appropriately to avoid excessive waits, responding to telephone queries promptly and personally whenever possible, relaying both positive and negative test results in a timely fashion, or any other office procedure affecting patients. Above all, empathy, as embodied in the commandment to be loving to one's neighbor as oneself (V'ahavta lerei'acha kamocha - Leviticus 19:18), is essential. The motto attributed to the 19th century physician Dr. Edward Trudeau, to cure sometimes, to relieve often, to comfort always, is not just for nurses! Easy to fall short of the mark, of course, in today's social environment, unless one remembers Hillel's famous admonition (Pirkei Avot 2:6), now more apropos than ever: Where there are no menschen, try to be a mensch. Regrettably, it is sometimes impossible to be a mensch in such a place, in which case one must extricate oneself from the noxious environment and evacuate, as Abram did when God commanded him to leave Ur Kasdim (Lech lecha! - Genesis 12:1). It is all too easy to rationalize ethical dereliction by falling for that weakest of non-Jewish arguments, But everyone is doing it.

Accomplishing all of this involves subordinating one's own personality, inclinations, and vested interests to the best interests of one's patients. As Rabbi Yosei urged (Pirkei Avot, Chapter 2), May everything you do be for the sake of heaven. Indeed, belief in a higher power may help attain this state of mind, as illustrated by a story that appeared in a nursing magazine. A nurse of religious bent was caring for a debilitated patient, and near the end of her long and arduous shift the patient soiled himself for the umpteenth time. Her immediate response was one of anger toward the patient for doing this to her. But within seconds she recalled the higher purpose in her sanctified role as the patient's caretaker, and she then cheerfully and speedily went about the job of cleaning him up. Even the most menial of tasks are joyfully performed when they are imbued with holiness. Such behavior represents the apotheosis of Jewish medicine.


Prevention, the Highest Form of Healing

Patients and physicians are partners in prevention. From the standpoint of patients, the Torah commands (Deuteronomy 4:15), You shall guard yourselves most vigilantly. From the standpoint of physicians within the sphere of Jewish medicine, prevention is the highest form of healing, in contrast to the secular world, where doctors who perform complex procedures are idolized and paid exorbitant sums of money. This point is illustrated by a story about Rambam, who had become the personal physician to the sultan of Egypt. One day the sultan asked him, "How do I know you're the great physician you're reputed to be? After all, in all the time you've been taking care of me, I've never been sick, so you've never had the opportunity to demonstrate your skills on me. Rambam replied that in the Torah (Exodus 15:26) God promised the children of Israel that, if they did what was right in His eyes and followed all of His commandments and statutes, He would protect them from all the diseases (plagues) He had visited upon the Egyptians, concluding, I am the Lord your physician (the only place in the Tanach [Bible] where God is referred to as a physician!). In other words, God, acting as a physician, is preventing disease (the preeminent commentator Rashi here compares God to a physician who says, Do not eat this food or it will harm you). Therefore, when we prevent illness, we are emulating God, and this means that prevention is the highest form of healing and the main role of a physician. Rambam went on to explain that, when a patient follows his physician's advice and does not get sick, this is the greatest proof of a physician's abilities.

In contrast to this philosophy, some scientifically uneducated commentators, usually of conservative bent, have attempted to discredit the evidence for the value of prevention out of a desire to reduce government spending. Jews, by the way, do not fall at any one point on the secular conservative-liberal spectrum because of their deontological outlook: they subordinate their own personal tendencies to the Jewish tradition, which in some cases is very conservative, e.g., in the preservation of traditional values, while in other cases is very liberal, e.g., leveling the playing field and seeing to it that everyone in the community has the opportunity to provide for himself and is not taken advantage of. Worshiping an ideology foreign to that of Judaism and regurgitating its distortions, deceptions, and lies for self-validation purposes might even be considered akin to idolatry (avodah zarah), replete with the immorality the term connotes: You shall not deviate from the things I command you today, either to the right or to the left, to go after other gods to worship them (Deuteronomy 28:14). I have coined the portmanteau word "ideolotry" to refer to the phenomenon of having one's ideology become one's religion.

One should not confuse the Jewish concept of prevention with the activities of what might be dubbed the prevention industry, or, more accurately, the early detection industry, or, more accurately still, the overdiagnosis industry. Emerging from the sea of unbridled medical entrepreneurship like a Hydra, it has fed on the fears and misconceptions of the average layperson, who has been led to believe that screening and even early detection are more successful in preserving life and health than they often are.

A study published in the February 2015 issue of the journal JAMA Internal Medicine (Patients' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review) found that the majority of patients overestimated the benefit to be derived from such procedures as mammography, PSA screening for prostate cancer, and bowel cancer screening. Possible reasons include lack of accurate and balanced information from physicians, many of whom profit from the misinformation; one-sided, deceptive, and dishonest advertising and marketing practices by cancer centers and screening services and by the news media that promote these buccaneer entrepreneurs; and even most politicians, who, while making a show of support for lower health care costs, are undoubtedly numbered among the unscrupulous investors who enrich themselves from the overuse and misuse of the system.

The result is the infliction of needless worry and suffering as well as the tremendous depletion of financial resources caused by the numerous procedures, including surgeries, that are done to act upon questionable findings uncovered in the screening tests. Perverting preventive medicine in this manner flies in the face of the concept of non-maleficence (prīmum nōn nocēre: above all, do no harm) and may even constitute malevolence. Some screening procedures, such as Pap smears at appropriate intervals, are certainly indicated, but testing recommendations must not be biased by vested financial interests and should not be one-size-fits-all but rather personalized, that is to say, based on each individual's unique risk profile, and the same applies to preventive procedures such as immunizations.

With regard to prevention, physicians, in the conduct of their own lives, should be exemplars for the community. So doing contributes to the fulfillment of the prophecy (Isaiah 42:6, 49:6) that Israel is to be an "or goyim," a "light of nations," that is to say, a luminary or guiding light visible to all who allow their eyes to be opened (not a "light unto the nations," in other words, beaming, perhaps with pride, like an illuminant projecting its light into others' eyes and minds, as the phrase is commonly mistranslated). Physician education in this regard should begin in medical school and in residency training programs, with such institutions encouraging and facilitating the adoption of healthful lifestyles incorporating ideal dietary habits, adequate rest and sleep, and strategies and mechanisms for stress reduction and coping. Tikkun olam, correction of the imperfect world to make recompense for past misdeeds, begins with self-correction.


Nutrition, the Main Determinant of Health and the Backbone of Preventive Medicine

As noted in the preceding section, Rashi presciently compares God preventing illness to a physician telling his patient what not to eat. Even in the present technologically advanced age, it is clear that nutrition remains the main determinant of health and the backbone of preventive medicine. Despite the amassing of a vast body of scientific data relating the dietary inclusion or exclusion of specific foods to the incidence of specific diseases, patients rarely receive such information. Physicians' lack of knowledge (including not knowing what they don't know) and indifference are the likely reasons in a system that rewards procedures, not prevention. The first rule put forth in the Torah is a dietary one: only vegetarian food shall be eaten (Genesis 1:29). Modern medical science has confirmed that a vegetarian diet, the ultimate plant-based diet, meets all nutritional needs and represents the standard for health maintenance and disease prevention.

Jewish medicine is ethically based, and, in Judaism, ethics is inextricably intertwined with everything else in life, so the ethics behind the Jewishly prescribed diet is quite relevant. Expounding on the clause "satisfy us from Your goodness" ("vesabeinu mituvecha") found in one nusach (version) of the Shemoneh Esrei prayer, the 18th century rabbinic authority Jonathan Eybeschutz, author of Yaarot Devash, explains that we ask God to satisfy us from His goodness, that is to say, from that which is good to Him, because, as rendered by the ArtScroll prayer book, Food acquired in a tainted manner lacks the holiness to nourish the soul. In a similar vein, Rashi, commenting on Leviticus 26:5, opines that, when the food inside ourselves is blessed because of our having followed the Torah way of life, we experience spiritual nourishment that makes us feel satiated even after eating just a small amount. This, of course, has implications with regard to moderation in food intake, but also implicit is the idea that assimilation of the spiritual aspects of sustenance allows us to experience deeper, more sustained pleasure than we can derive from the sensory aspects of food, thereby facilitating dietary change.

The kinship of moderation with pleasure has deep roots in Jewish thought. Judaism recognizes that self-control can be the key to happiness and to the avoidance of temptation. Youngsters brought up without proper direction and discipline are often unhappy children and grow up to be unhappy adults. As Virginia Woolf so aptly put it, "To enjoy freedom we have to control ourselves." Non-Jews sometimes view the Jewish way of life as hopelessly restrictive, but observant Jews often view it as a source of pleasure.

Although most people think mainly about which foods they are eating when they think about nutrition, scientific research has shown that how much we eat may be just as important as what we eat. For example, studies on non-human animals have shown that those consuming a reduced quantity of food are much more vigorous and live longer than those fed the usual amount. There is evidence that such caloric restriction can reduce blood pressure and cholesterol levels, lower the risk of diabetes, strengthen the immune system, and perhaps prevent certain cancers. Therefore, being able to reduce one's intake while at the same time experiencing the pleasure and satiation propounded by Rashi could benefit us tremendously. Eating slowly and mindfully, savoring each tiny morsel that enters our mouth, can facilitate the process. We can augment the spiritual pleasure associated with eating 1) by acknowledging that our food is the result of God's beneficence and providence; 2) by remembering and appreciating the role played by all the farmers, field workers, packers, distributors, truckers, and others, each of whom played a pivotal role in seeing to it that the food reached our plate; and 3) by taking into consideration the effect of our food choices on all our fellow creatures and on the earth.

Learning moderation in food intake begins in childhood. Putting food in its proper Jewish context as a form of both nourishment and pleasure means never using food as a reward. When children are rewarded with sweets or even favorite foods, they will often feel the need to reward themselves as adults whenever they feel anxious or depressed, and overeating is the result. A second problem involves the way pleasures are viewed. In our society, it is common for tasty foods to be referred to as decadent pleasures. Such terminology probably derives from a non-Jewish theology that considers many pleasures to be inherently sinful, a concept far removed from Jewish thought. In Judaism, permitted pleasures are encouraged, and, although ascetic streams do exist, their adherents would probably never refer to pleasures in moralistic terms. When children are brought up in an environment where certain behaviors, such as alcohol consumption, are forbidden, they often end up engaging in those activities, sneakily at first and later in excess. Thus, the Jewish philosophy on pleasure may help people keep the act of eating in its proper perspective.

To many, the vegetarian diet originating in the Garden of Eden is an ideal but no more than that. However, to the late Rabbi Joseph Ber Soloveitchik ("the Rav"), whose reputation speaks for itself, vegetarianism was not just an abstract ideal but rather a dietary lifestyle toward which we should all be striving. Although the Rav was very traditional from a religious standpoint, he was a rational, scientifically-oriented scholar who was not reticent about thinking for himself, even if so doing ruffled a few feathers. In these respects, he resembled Rambam.

In contrast to some traditional ways of thinking, the Rav, while not equating man with non-human animals, did not place man in a separate category all by himself. In fact, he considered all life, including plants, to be divine and to be part of one continuum. In a book of his writings that was published posthumously (The Emergence of Ethical Man, Ktav, 2005), he describes one aspect of the corruption of mankind before the Flood as the exploitation of animals for food: Man created a new demand, a sinful existence upon something which by right does not belong to him, namely, on life equal to his, on flesh that is not different from his own. In discussing sacrifices performed in the desert during the journey to the land of Israel, he says that someone who killed an animal for any other purpose was guilty of murder and that under a certain aspect, the life of the animal has been placed on an equal plane with that of man. He points out that the Torah describes the craving for meat as a "lust, illicit demand" in reference to the plague visited upon the Israelites as punishment for their demand for meat (Numbers 11:4-34). He continues, Animal hunters and flesh-eaters are people that lust. Of course, it is legalized, approved. Yet it is classified as ta'avah, lust, repulsive and brutish. This kind of permission by the Torah to engage in something of which it strongly disapproves as a concession to human weakness and to the yeitzer hara, the evil impulse, is not unparalleled. Eishet yefat to'ar, permitting a soldier who lusts after a female captive to take her and ultimately marry her (Deuteronomy 21:10-14), is just such an example.

The Rav describes the commonalities, both physiologic and cognitive, between humans and the other animals. Rambam also did so in his Guide for the Perplexed: he stated that the pain of a mother animal upon seeing her offspring killed is very great, adding, there is no difference in this case between the pain of man and the pain of other living beings. Rambam also questioned why man was permitted to slaughter animals for food because he acknowledged the suffering involved. He concluded that the killing of animals for food was necessary because animal flesh was deemed part of a healthful diet. One can only speculate what he would have said today now that we know that this supposition is not true.

The fact that the Rav was not vegetarian in no way militates against his advocacy of vegetarianism. In Orthodox social circles, especially during his lifetime, it was very difficult to go against the grain by abstaining from eating meat. Many people, when faced with someone exhibiting a higher level of conduct than their own in some respect, will deprecate or even depreciate the other person. It is a testament to the greatness of the Rav that he did not stoop to such behavior but rather extolled those who were able to achieve the level he, in fact, advocated even if he was not able to achieve it himself.


Animal Experimentation in Medical Research

It is a given that halacha (Jewish law) permits the use of animals for the benefit of humans when it serves a legitimate human need. But this only represents a minimum standard of conduct and not necessarily the preferred approach. Jews are enjoined to go beyond the minimum of the law and assume a higher standard that embodies the spirit of the law, a Talmudic principle known as lifnim meshurat hadin (Bava Metzia 30b). The sages of the Talmud, in fact, cite the failure of the people to act in accordance with this principle as one reason for the destruction of the Temple. Further, tsa'ar ba'alei chayim, causing unnecessary suffering to animals, is prohibited, a law whose importance is underscored by the fact that it is d'oraita -- derived directly from the Torah. Samson Raphael Hirsch, another rabbi who needs no introduction, writes in his classic work Horeb (transl. by Isidor Grunfeld, Soncino Press, 1962):

There are probably no creatures that require more the protective divine word against the presumption of people than the animals which, like human beings, have sensations and instincts, but whose body and powers are nevertheless subservient to people. In relation to them, human beings so easily forget that injured animal muscle twitches just like human muscle, that the maltreated nerves of an animal sicken like human nerves, that the animal being is just as sensitive to cuts, blows, and beating as people. Thus the human being becomes the torturer of the animal soul...

Here you are faced with God's teaching, which obliges you not only to refrain from inflicting unnecessary pain on any animal, but to help and, when you can, to lessen the pain wherever you see an animal suffering...

Medical authorities acknowledge that advances have accrued from animal research, although not to the extent that the public has been led to believe. It is also clear that a great deal of the animal research currently being performed could be eliminated without adversely affecting human health. One halachic authority, Rabbi Mordechai Yaakov Breisch of Zurich, is cited (Responsa Chelkat Yaakov 1:30) by Rabbi Immanuel Jakobovits (Jewish Medical Ethics, Bloch Publishing Company, 1959, p. 294) as concluding that, while there was no basis in Jewish law for a legal ban on such experiments, they were morally indefensible. In other words, although halacha permits it, machshava, the philosophy behind the law that directs us to observe the law according to its true spirit, does not and, in accordance with the principle of lifnim meshurat hadin, behooves us to avoid such experiments. Most would not take this as an absolute, however, just as the directive to the physician to "do no harm" cannot be completely fulfilled, given that virtually all medical treatments entail at least a little risk. But it does mean that vivisection should be performed only when there are no viable alternatives, when the expectation of a meaningful result is significant, and when the human malady being studied causes sufficient suffering to justify the suffering to be endured by the animals.


Relationship with Other Physicians

In secular medicine, physicians often view others, especially those in the same specialty, as competitors. In Jewish medicine, there is no place for feelings of competitiveness. Everyone in the health care system is working together for the benefit of the patient, all with that higher purpose in mind. Further, there is no vested interest in one's own specialty and no deriding of physicians in other specialties. Commonly, in secular medicine, doctors favor their own specialties. For example, a radiation oncologist might recommend radiation therapy as the best alternative for a cancer patient, while a medical oncologist might recommend chemotherapy. In Jewish medicine, on the other hand, there should be consensus whenever possible. In secular medicine, physicians, fearful of possible repercussions, are often reluctant to say anything if they see another doing something in a suboptimal way. In Jewish medicine, as in all spheres of life, correcting one's colleague (You shall be sure to reprove your associate - Leviticus 19:17) should be done whenever feasible, and such corrections should be not only tolerated but greatly appreciated by the one being corrected.


Patient Referrals

Jewish medicine requires that a physician refer a patient to another physician when he feels that another would be better suited to diagnose or treat some aspect of a patient's problem. To whom should he refer the patient? To the physician whom he feels would be best for the patient, not to someone from whom he expects something in return, such as friends or individuals who will refer other patients to him. In practice, doctors typically have certain individuals to whom they refer patients, and those individuals are often not selected for reasons that are in the patients' best interests. The process of searching for an appropriate physician for consultation or referral is most challenging in the current health care environment, however, and the outcome usually reflects ethical compromise.


The Problem of Patient Exploitation and Its Solution

The most blatant and egregious example of harmful self-interest is the glut of unnecessary surgery and other procedures performed in entrepreneurial, fee-for-service environments, as in the United States. The risk/benefit ratio alluded to earlier may approach infinity in such cases: there may be significant risk and little to no benefit. It amounts to battery or even butchery performed on innocent people, and it drains society's financial resources as well. Since most patients are medically unsophisticated, it goes without saying that recommending unnecessary procedures is a flagrant violation of the commandment not to place a stumbling block before the blind (Leviticus 19:14). The primary motivation is undoubtedly financial, although one should not discount an underlying sadistic aspect to the personality of some surgeons who gain some kind of satisfaction from "doing things" to people. The problem was exacerbated in the U.S. when the Federal Trade Commission gave doctors the green light to advertise, resulting in an opening of the floodgates and dealing a veritable coup de grâce to the health care system. The Mishnaic principle Ein machzikin yedei ovrei aveirah - One may not aid and abet transgressors (Mishnah Gittin 5:9) clearly applies here. Medicine today does do some good in curing and alleviating the effects of illness, but if one were to weigh the good against the bad, viz., the substandard care and the unnecessary surgery and other procedures, the good being done would not outweigh the bad by very much.

Obviously, this phenomenon is foreign to Jewish medicine, but the fact that it exists greatly impacts anyone who would like to practice in the Jewish way. The ultimate solution to this problem would be the creation of a medical community consisting of God-fearing (literally or figuratively) or, even better, God-loving individuals whose only motivation is doing what is best for the patient. Religious leaders could play an important role in restoring holiness to the defiled sanctuary of medicine, but most lack the medical expertise and inside knowledge to understand what is going on in the system and many undoubtedly harbor ulterior motives that keep them from doing anything that might rock the boat.

In the secular world, the solution would require governmental intervention. One possible approach might be the use of undercover agents ("mystery shoppers"), as employed by the California Bureau of Automotive Repair, to catch the miscreants. But, in the presence of the vacuum in moral leadership as it exists today, with politicians who think or pretend that they are knowledgeable about medicine and health care when they are not and who, moreover, don't really care about the debacle they helped create, the prognosis for the sick system is grave. These politicians, who worship the money idol, tend to fall into two camps: the first, the penny-pinching, would deny you a glass of water even if it would keep you from dying of thirst; and the second, the pound-foolish, want to extend "care" to all but are oblivious to the deluge of unnecessary procedures that would be inflicted on the unsophisticated, lower socioeconomic populace in the current health care environment.

With respect to regulating medical practice in general, Rambam held that sanctions against malfeasant physicians should be neither too lenient nor too strict: the former would be insufficient to prevent malpractice and the latter would dissuade ethical physicians from engaging in the practice of medicine. Many modern day bureaucratic enactments are easily circumvented by the unscrupulous but create unscalable hurdles for the ethical.


Advertising, Self-Promotion, and Self-Aggrandizement

Let your praise come from a stranger and not from your own mouth, from someone you don't know and not from your own lips (Proverbs 27:2).

Advertising by physicians has already been alluded to, but it cannot be emphasized enough: it was probably one of the main factors contributing to the destruction of the U.S. health care system. Advertising allowed the unscrupulous to proliferate as never before, creating a hostile environment in which no one decent wants to participate. Jews have always established their reputations by dint of their knowledge and demonstrated accomplishments, not by self-promotion, and they describe themselves in an honest and evenhanded way. It is now commonplace for doctors to engage, to use an alliterative euphemism, PR/marketing hirelings to promote them (dishonestly) and to procure patients for them. They lie by saying that advertising provides useful information to patients; in fact, it only serves to deceive and lead people to the wrong doctors, who, like the Sodomites, see people only in terms of how they might take advantage of them. A typical ruse is to claim that they were named one of the top doctors in the country by a leading organization. Often, the "organization" turns out to be some entrepreneurial company that markets and sells such honorary plaques to almost any breathing, actively licensed doctor who is willing to fork over a couple of hundred dollars for one. Another variation on the theme is the deceptive ploy of citing mass media-conducted surveys in which one has been named one of the "best doctors." To those in the know, such survey results are primarily a reflection of business relationships and professional "friendships," not of medical competence.

The language used in the ads is telling. The doctors frequently describe themselves as "nationally and internationally renowned or (eek!) renown [sic]," as if "nationally and internationally" is different from "internationally" and as if being well known is more important than excelling at what one does. And, if they were indeed famous, why would they need to advertise themselves as such, or even advertise at all for that matter? Their treatment is often "cutting-edge." Well, they do like to cut on people. Their practice is "world-class." They must compete in the Medical Olympics. They've perverted the meaning of the word "institute," which has always referred to an organization devoted to education and research but has now come to mean a house of ill repute, not that "repute" means anything anymore. They are frequently said to have trained or served at "prestigious" institutions: modifiers like "Harvard-educated" are used to convince those who confuse social prestige with real substance of the worth of those whose work cannot stand on its own merits. As a result of their attainments, Jews always enhanced and augmented the reputation of the institutions in which they served, not vice versa. The use of superlatives such as "foremost," "leading," "premier," and "number one" is even more problematic not only because it is usually dishonest but also because it might be construed as idolizing oneself literally, that is to say, setting oneself up as an idol in place of the One who is truly number one. For those who take the words of the Shema (Deuteronomy 6:4) to heart, "looking out for number one" takes on a whole different meaning.

Being deceptive toward those with whom one does business and creating a false impression constitute geneivat da'at (literally, theft of one's mind), which many authorities consider a violation of the commandment You shall not steal. The sages (Tosefta Bava Kamma 7:3) deemed it the worst form of theft because it harms the victim personally besides taking his money - how much more so in medicine where violation of the body and worse may also result. Further, it is still another example of placing a stumbling block before the blind.

The remark by Rav Yehuda in the name of Abba Guria (Mishnah Kiddushin 4:14) that the best of physicians are headed for Gehinnom (hell) may well refer to doctors who deceptively use superlatives such as "best" in describing themselves (here we are not talking about physicians who acknowledge to themselves their greatness in certain areas, because, if they did not do so, they would not come to use their talents maximally in the service of mankind). When one says something often enough, one soon starts to believe it, and that is when one can become dangerous. For example, as the Talmudic commentator Maharsha (Rabbi Samuel Eliezer Edels) suggests, such physicians may decline to consult with or refer to other physicians who may have a better idea than they do or who may be able to do something better than they can. Further, they may perform surgery that is not indicated because they may discount the possibility that well-documented complications of a procedure would ever occur in their hands. Exponents of Jewish medicine avoid engaging in egregious self-aggrandizement and unethical self-promotion, such as advertising. Rather, they try to embody the characteristics attributed to Moshe Rabbeinu (Moses), the epitome of humbleness (Exodus 3:11, Numbers 12:3), and to the angelic, mystical figures known as the lamed-vavniks, on whose merit the world is saved: simple, humble, modest, unpretentious, unsung, and shunning recognition (Do not covet honor - Pirkei Avot 6:5). All of the actions of such physicians are meant to serve as a kiddush hashem, a sanctification of God's name, not their own. Pride is not part of the Jewish psyche; self-respect tempered by humility is.


Gifts and Conflicts of Interest

A physician and his or her employees should not accept gifts or gratuities of any kind, including utilitarian articles bearing product or company names, free dinners, or free services, from any pharmaceutical company, optician, medical supplier, business or other entity, or individual to whom patients are referred or whose products are used in patient care. The need to maintain objectivity in patient care is self-evident. Pharmaceutical and other companies provide gifts to influence physicians' prescribing patterns, and this is not in patients' best interests. The Torah (Deuteronomy 16:19) warns judges not to take a gift, because a gift blinds the eyes of wise men and distorts the words of the righteous. If this injunction applies to judges, how much more so should it apply to those entrusted with the care of human lives.


Physician Compensation

How should doctors be compensated in Jewish medicine? Since the practice of medicine is holy work, the fulfillment of the mitzvah (commandment) to provide care to patients, physicians' fees are technically not for healing people but rather to compensate doctors for all the time they have spent learning and practicing medicine when they could have been earning money from another occupation. Having special skills or abilities does not justify higher fees. Jewish doctors are entitled to make a good living but are prohibited from becoming wealthy from their profession - a far cry from the secular world in which some high volume surgeons may earn hundreds of thousands of dollars a year. Physicians earn money by providing services, not by selling products such as drugs for a profit, because their patients do not have the benefit of comparative shopping. The Talmud (Taanit 20b) relates that Rav Huna would dispense medications at no charge. If a physician does charge for medications dispensed, he must charge no more than the actual value. Reflecting this concept, the American Medical Association in 1999 adopted a policy stating that physicians should not sell health-related products such as supplements or over-the-counter medications for a profit but may dispense them free or at cost.

As for remuneration for services performed, either fee for service or a straight salary arrangement is theoretically permissible. Both systems have been criticized, the fee for service system for promoting unnecessary treatments and the salary (or capitated) system for encouraging doctors not to give needed care or even preventing them from doing so.

A problematic situation arises in the fee for service system when insurance is allowed to cover 100% of expenses. Unscrupulous physicians might be tempted to file fraudulent claims, knowing that someone who is making no financial contribution of his own will be less likely to complain to authorities. This instance provides another application of the principle mentioned earlier, One may not aid and abet transgressors.

Some health maintenance organizations (HMOs) pay exorbitant salaries to medical directors who excel at limiting access to care. They may also employ the principle of "purposeful incompetence" - purposely hiring incompetent, inefficient employees whose blunders and plodding work to the company's financial advantage and to the detriment of the patient. An obvious conflict of interest is that, if the patient dies, the HMO can profit through saved costs.

Both systems can succeed, however, if those who lead them and the doctors in them are motivated not by the remuneration they receive but rather by the holiness of their work and by a deep desire to act in the best interests of their patients. And that is what Jewish medicine is all about.

In contrast, when today's physicians elaborate on their dissatisfaction with the health care system, they typically rattle off a litany of complaints having to do with the compensation they receive, how they are treated, the paperwork, the bureaucratic red tape, and the insurance companies. What we don't hear about are the serious compromises in patient care that they have willingly accepted and in which they engage. They see the system mainly in terms of how it affects them, not the patient.


Conclusion

Jewish medicine -- with its infinite respect for the sanctity of all life, its compassion, its prioritizing the individual, its biopsychosocial approach, its preoccupation with study and knowledge, its emphasis on prevention, its focus on cooperation and consensus, and its insistence on answering to a higher authority -- provides the basis for a rebuilding "from the ground up" of a broken health care system that is now beyond reform or rehabilitation.


[Jewish medicine prayer]


About the Author

Jay Lavine, M.D., wears several yarmulkes, one of which is that of a physician exemplar, having ceased practicing clinical medicine in the United States when he felt it was no longer possible to do so according to Jewish ethical standards. An independent scholar in Jewish medicine who has taught classes on the subject, he writes about the ethics of medical practice and about preventive nutrition. He authored The Eye Care Sourcebook (McGraw-Hill, 2001), which emphasizes prevention and which he calls a "self-defense manual for today's health care environment." His classic letter "Chicken Soup or Jewish Medicine" appeared in the medical journal CHEST (2001 Apr;119:1295). He has published in many other journals, including The New England Journal of Medicine, The Lancet, and The American Journal of Clinical Nutrition.

Dr. Lavine attended the Central Hebrew High School of the Jewish Education Association of Essex County (New Jersey), graduating as valedictorian and as recipient of the Simon Chasen Memorial Award for excellence in Hebrew studies. He was a summa cum laude graduate of Pomona College, where he was granted "distinction" in chemistry and was elected to Phi Beta Kappa. He received his M.D. degree from the School of Medicine of the University of California, San Diego, and served his residency in St. Louis at the Washington University Affiliated Hospitals, which included Barnes Hospital, The Jewish Hospital of St. Louis, and St. Louis Children's Hospital, among others.


Last modified: 28 Cheshvan 5777; November 29, 2016
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