Responsibilities for the Provision of Health Care

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March 1, 2003
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By Elliot N. Dorff and Aaron L. Mackler

The provision of health care represents a chal-lenge of great and growing importance. In recent years, the number of U.S. citizens without health insurance has increased to over 43 million and is continuing to grow. Furthermore, studies confirm that lack of coverage leads to impaired health status. Even patients with insurance worry about gaps in coverage, uncertain quality of care, and lack of choice. After a brief pause in the 1990s, health costs again are increasing rapidly. Employers are therefore paring back the insurance they offer employees or dropping it altogether. In the meantime, physicians and other health care professionals complain of administrative and financial pressures, and less time to spend with patients, even as their income declines.

Three related teshuvot (responsa) on the responsibilities of individuals, health care providers, and communities for the provision of health care have been accepted by the Conservative movement’s Committee On Jewish Law and Standards. These responsa provide limited but important guidance from our halakhic tradition, recognizing that prudential judgment as well as compassion must be used in applying our general guidelines to complex real life situations and that new issues arise all the time. Both halakhah and theological reflection support a duty for individuals to care for their own health and for health care professionals and others to provide medical care when needed. Halakhic sources are clear that members of the community are obligated to perform the mitzvah of bikur cholim, visiting the sick. Visitors are expected not only to engage in conversation and prayer, attending to spiritual needs of the sick individual, but to care for the tangible needs of the patient as well.

Traditional sources, though, have relatively little discussion of the extent of the community’s responsibility to care for ill individuals. This is not surprising, as both the effectiveness and costs of medical treatments were much more limited in past centuries than they are today. Traditional sources, however, more extensively discuss the extent of the community’s responsibility to provide for individuals in other contexts, of which two are especially relevant to health care: tzedakah, support for the poor; and pidyon shvuyim, redeeming captives. Extrapolating from precedents of tzedakah would require the provision of at least a “decent minimum” of health care, sufficient to meet the needs of each member of the community.

The redemption of captives provides a precedent even more closely analogous to at least some types of medical care. This category of acute needs is seen to take precedence even over general obligations of tzedakah. Health care shares the characteristics that justify the priority accorded to pidyon shvuyim: both concern individuals who are suffering and may be in immediate danger. Further, both categories entail special needs that vary greatly among individuals. Jewish law and ethics understand the community to have a fundamental obligation to save lives whenever possible, diverting funds from other projects as required.

To what extent are individual patients and their family members responsible for providing health care? Individuals have the primary responsibility to care first for their own health and then for family members, either directly or through insurance. When they cannot do so, they may and should avail themselves of publicly funded programs to acquire the care they need. In any case, one should seek to prevent illness rather than wait to cure an illness that has already occurred.

To what extent are physicians and other health care providers responsible for providing health care? Based on halakhic precedent, physicians and other health care professionals must treat patients in case of emergency. They also have some responsibility more generally to make health care available to those who cannot afford their normal fees. At the same time, health care professionals legitimately may expect compensation for their efforts and should be able to earn a living.

To what extent is the community responsible to provide health care for those who cannot afford it? Halakhic sources indicate that such an obligation is a matter of justice as well as a specific halakhic obligation. In contemporary countries such as the United States and Canada, though, which “community” is responsible for health care – the Jewish community or the general society? We argue that, given the expenses and complexity of health care provision in our day, the responsible “community” must be the national society, through its government, health care institutions, insurance companies, and private enterprise. Jewish citizens should support (by lobbying and other means) societal institutions that will fulfill the responsibility to ensure access to health care. The Jewish community, through federations, synagogues, and other institutions, should support these efforts. It must also assess whether and to what extent it should support hospitals and other forms of health care. It should balance that purpose against its commitment to other important Jewish needs, such as Jewish education and social services.

The guarantee to provide needed health care does not extend to all desired treatment, or even all that might provide some benefit. Even needed treatment might be limited when it is so extraordinarily expensive that its provision would deprive other patients of needed care. Still, possible limits to interventions must be weighed against the value of human life and healing, and the injunction that a physician who fails to provide needed health care is considered as one who sheds blood.

Thus, in sum, patients and family members, health care professionals, and national societies and their citizens all have areas and degrees of responsibility in providing the health care required by Jewish law and ethics. Only through effective and accessible health care, both preventive and curative, can we fulfill our fiduciary responsibility to God to safeguard our bodies.

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Rabbi Elliot N. Dorff is Rector and Distinguished Professor of Philosophy at the University of Judaism in Los Angeles. He is also Vice Chair of the Conservative Movement's Committee on Jewish Law and Standards.

Rabbi Aaron L. Mackler is Associate Professor of Theology at Duquesne University in Pittsburgh, and Associate Director of Duquesne's graduate program in health care ethics. He is a member of the Rabbinical Assembly's Committee on Jewish Law and Standards, for which he serves as Chair of the Subcommittee on Bioethics, and has been ethicist for the New York State Task Force on Life and the Law. This essay draws on the authors' "Responsibilities for the Provision of Health Care," published in Life and Death Responsibilities in Jewish Biomedical Ethics, ed. Aaron L. Mackler. For more on this and related topics, see Elliot N. Dorff, Matters of Life and Death: A Jewish Approach to Modern Medical Ethics.

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