the jewish patient in a non-jewish hospital

Journal of Religion and Health, Vol. 25, No. 4, Winter 1986

The J e w i s h Pa t i en t in a Non- J e w i s h Hosp i ta l

FRED ROSNER

ABSTRACT: The healing of the sick is a Jewish religious precept. The present paper discusses the special needs of a hospitalized Jewish patient, describes a "Jewish Patient 's Bill of Rights," and suggests that the needs of Jewish patients, such as kosher food and religious services in a hospital environment, be provided wherever possible.

Basic tenets of Judaism

In Judaism, a physician is given divine license to practice medicine.' Accord- ing to many rabbinic sources, a physician is in fact obligated to heal the sick and is guilty of wrongdoing if he refuses. Similarly, the patient is obligated to seek healing from a physician. Judaism teaches that life is a gift of G-d to be held in trust. One is duty bound to care for one's life and health. Only G-d gives life, and hence only G-d can take it away. Man does not possess absolute title to his life or to his body. It is given on loan to be used but not abused. Man is charged with preserving, dignifying, and hallowing his life. This individual responsibility for the preservation of one's life and health is apart from the duty of one person (including a physician) toward another's life and health and soci- ety's responsibility concerning the life and health of its citizens.

Another cardinal principle of Judaism is the infinite value of human life. Jewish law requires the physician to do everything in his power to prolong life, but prohibits the use of measures that prolong the act of dying. The value at- tached to human life in Judaism is far greater than that in Christian tradition or in Anglo-Saxon common law. To save a life, all Jewish religious laws are au- tomatically suspended, the only exceptions being idolatry, adultery, and murder. In Jewish law and moral teaching, "the value of human life is infinite and beyond measure, so that any part of l i fe--even if only an hour or a second--is of precisely the same worth as seventy years of it, just as any fraction of infin- ity, being indivisible, remains infinite. Accordingly, to kill a decrepit patient

Fred Rosner, M.D., is Director of the Department of Medicine, Queens Hospital Center Affilia- tion of the Long Island Jewish Medical Center, and Professor of Medicine in the Health Sciences Center of the State University of New York at Stony Brook.

316 �9 1986 Institutes of Religion and Health

Fred Rosner 317

approaching death constitutes exactly the same crime of murder as to kill a young, healthy person who may still have many decades to live . . . . -2

Jewish medical codes

Although no separate codes of Jewish medical ethics exist, the classical codes of Jewish law, including the Mishneh Torah of Moses Maimonides and the Shulchan Arukh of Joseph Karo contain sections dealing with medicine and the t reatment of patients. Such codes are, in nature and scope, roughly comparable to the corpus of canon law. The rabbinic Responsa li terature also con- tains numerous questions and answers specifically dealing with medical ethics and practice. Several recent books specifically address the issues of medical ethics from the Jewish viewpoint. 3 These publications, however, are not binding upon individuals or hospitals, since Judaism has no central authori ty like the Vatican, and therefore, by definition, there is no contemporary code of Jew- ish medical ethics comparable to the "Ethical and Religious Directives for Catholic Health Facilities." Since Jewish hospitals, unlike their Catholic counterparts, are usually administered as secular institutions, those contemporary codes would in effect serve mainly as guidelines and be regarded as binding only by those individuals and hospitals that conscientiously submit to certain traditions of Jewish religious law.

An at tempt to provide some authoritative guidance on Jewish teachings related to medical theory and practice is the compendium Medical Ethics published by the Committee on Religious Affairs of the Federation of Jewish Phi- lanthropies of New York. 4 This compendium provides a concise summary of the rulings of traditional Jewish law on the religious and moral issues encoun- tered in the practice of medicine. It is intended as guidance to the boards of di- rectors and hospital administrators who establish hospital policy, the individual physician, and to all concerned with health care.

It is important to recognize the interface of medical ethics and religion. Ju- daism does not intrude into the physician's medical prerogatives, provided the considerations in question are purely medical in character. However, modern medicine has moved into new areas in which great moral issues are involved. Organ transplantation, hemodialysis, genetic engineering, abortion, contraception, euthanasia, and drug addiction raise serious moral issues. In those areas Judaism offers a message and an opinion. It emphatically insists tha t the norms of ethical conduct may be governed neither by the accepted notions of public opinion nor by the whims of the individual conscience. Moral values are not matters of subjective choice or personal preference: Right and wrong, good and evil are absolute values that transcend the capricious variations of time, place, and environment as well as human intuition or expediency.

Special needs of the Jewish patient

The healing of the sick is a Jewish religious precept. Any person who has the power to save life and does not exercise it, but stands idly by, violates the bibli-

318 Journal of Religion and Health

cal command: "Thou shalt not stand idly by thy neighbor's blood." The religious and moral obligations of the physician necessitate that he perform his duties without regard for the financial, social, or religious status of his patient.

The task of the healer is to help his patients regain their strength and confi- dence, as well as their physical well-being. Anything that strengthens the will to live facilitates the patient 's recovery. Consequently, during this trying pe- riod of illness, the religious needs of the patient may assume particular impor- tance. The provision of kosher food, Sabbath and Holy Day observance, and general regard for the religious scruples of the patient can be of inestimable help in the healing process.

Hospital administrators and staff should be sensitive to these needs and should bear in mind that there is no automatic dispensation to suspend these precepts and practices, except in life-threatening situations. A patient who has always adhered to Judaic precepts and practices and is suddenly thrust into a hospital environment which tempts or compels violation of these Judaic laws, may suffer severe emotional stress. Such a patient may feel harried and threatened, not only by the underlying disease process, but also by hospital au- thority and personnel, and may develop deep feelings of guilt if he succumbs to unwarranted violations.

One of the most pervasive and inclusive of Judaism's requirements is the system of dietary laws. Jewish law regulates the type of food the Jew may eat and the procedure to be followed in its preparation. These regulations are basic to daily routine and are as operative and essential in the hospital as in the home environment. Every effort should be made by hospitals to provide kosher food not only for patients but also for observant Jewish staff members. In- creasing numbers of observant men and women are serving on the health team, including physicians, nurses, social workers, technicians, psychologists, and the like. Making kosher food available demonstrates concern for the needs of staff members, and is a common courtesy which every institution should be expected to extend.

The Passover regulations forbidding the consumption of any item containing an admixture, however small, of unleavened grain product known as chometz are among the most stringent of the dietary laws. Hence, during the Passover week, Jewish patients may be given only food sanctioned for Passover use. This excludes many drugs and medicines, such as those containing chometz or potable alcohol, even for external use, unless these are urgently needed for seriously-ill patients and adequate substi tutes cannot be found.

The Sabbath is a basic institution of Judaism. With the commencement of the Sabbath before sundown on Friday evening until its conclusion after dark on Saturday night, actions and thoughts are consecrated to the service of G-d and His worship. Workday activities and creative procedures are forbidden. When a Jewish patient is hospitalized on the Sabbath or one of the Holy Days, his religious scruples should be given every consideration. The hospital administration is asked to appreciate the binding nature of these religious commit- merits. The Jewish patient should not be compelled to produce documents, sign application forms or admission documents, or be pressured for advance pay-

Fred Rosner 319

ment. If emergency surgery on the Sabbath is required, oral consent in the presence of witnesses may suffice.

Jewish personnel, physicians and nurses, should be offered similar consideration. Observant Jewish doctors and nurses may and, in fact, must involve patients in all life-saving procedures for the benefit of the patient. They do, however, find that routine chores, such as the writing in charts of histories and physical examinations may become a point of contention between themselves and the hospital administration.

Jewish hospitals: Is there a need for them?

The early purpose of Jewish hospitals in the United States was the t reatment of Jewish patients who, it was believed, needed a medical environment tha t was Jewish. After approximately 1920, when Jewish patients needed the Jew- ish medical environment less and less as they began to lose their foreignness, the Jewish hospitals tended to find, as a rationale, the necessity of providing opportunities for Jewish physicians who were victims of severe discrimination in hospital staff appointments elsewhere. When medical discrimination de- clined after about 1950, the Jewish hospitals, many of which by then had only ten to twenty-five percent Jewish patients, tended to be rationalized once again, this time as a Jewish service to the community at large. 5 There is thus no specific need today for a Jewish hospital, since the needs of the Jewish pa- t ient and staff member can be met in most general hospitals or related medical facilities.

The Jewish Patient's Bill of Rights

To assist hospital administrators in treating Jewish patients, Agudath Israel of America, an orthodox Jewish organization tha t sponsors diversified pro- grams for Jews, has published The Jewish Patient's Bill of Rights. Patterned after an American Hospital Association Patient 's Bill of Rights, the Agudath Israel publication lists what a Jewish patient can expect from a hospital administration but is not legally binding.

The Bill of Rights includes such things as being served kosher food, deferred advance payment until the close of the Sabbath or a festival, observance of Jewish rituals, refusal of outpatient appointments scheduled for the Sabbath or festivals, and the right to consult with spiritual advisers before deciding whether to undergo medical procedures tha t might pose religious questions.

Specifically, the nine items listed in the Jewish Patient's Bill of Rights are as follows:

. The Jewish patient can be admitted to the hospital in an emergency on the Sabbath or a Festival, by making an oral s tatement of authorization suitably witnessed. No patient may be forced to sign an admission form in violation of religious scruples.


2. The Jewish patient has the right to be served kosher food of proper qual- ity, quantity, and variety to assure meeting his nutrit ional needs.

3. The Jewish patient has the right to medical attention, and to defer any advanced payment that may normally be required until the close of the Sabbath or Festival.

4. The Jewish patient has the right to engage in observance of Jewish rit- ual where not medically counterindicated. This includes prayer, provi- sions for Sabbath candles, Chanukah Menorah, kosher-prepared wine, Esrog and Lulav, Matzoh, Megillah reading and Shofar, where appropriate and possible. The hospital should recognize the psychological value of these activities in the same spirit as recreational and other amenities that are offered to the patient.

5. The Jewish patient has the right to refuse out-patient appointments scheduled for the Sabbath and Festivals, the eve of such days, or fast days. This refusal should not prejudice the patient's right to a suitable alternative appointment.

6. The Jewish patient has the right to consult with his own spiritual advisor--or allow family to do the same when patient is incapable of doing so--before deciding on procedures involving abortion, sterilization, prostate surgery, contraception, artificial insemination, circumcision, euthanasia, autopsy, withdrawal of life-supporting therapy or appli- ances, hazardous procedures, or any other procedure posing religious questions. The name of the family rabbi should be entered on hospital admission cards, as a matter of routine, so he may be called upon to serve as consultant when religious problems arise.

7. The Jewish patient has the right to expect the hospital to consider con- sultation with a spiritual advisor as professional guidance, which can assist immeasurably in the t reatment of the patient as a complete en- tity. The rabbi should be considered an integral part of the healing team.

8. The Jewish patient has the right to psychiatric, psychological, genetic, sex, and other counseling by individuals attuned to patterns of behavior which are the norm among observant Jews. The medical team should welcome the participation and advice of the patient's spiritual advisor.

9. The Jewish patient has the right to request such considerations as those listed above for visitors whose presence is deemed supportive of the patient's health and well-being.

The Bill of Rights concludes with the following statement addressed to the patient:

We are confident that a polite but forceful request for any or all of these rights will be honored by hospital administrators. While these rights may not be legally binding, they are certainly ethically and morally binding. Efforts are now being made to secure endorsement of these rights by hospitals across the country. Show- ing this statement to attending personnel will help you in stating your claim for the right to all that the medical profession has to offer you, without compromising your religious convictions.

Fred Rosner 321

The example of autopsy

The Medical Ethics Committee of the Federation of Jewish Philanthropies of New York has succinctly summarized the biblical, talmudic, and rabbinic views concerning autopsies.

Since Judaism teaches that man is created in the image of G-d, every dignity must be extended to the human body in death as in life. It is for this reason that the body must be regarded as inviolate. Except in certain limited circum- stances, Jewish law does not sanction the performance of autopsies. It is, however, the consensus of rabbinic opinion that postmortem examinations may and sometimes must be performed for the purpose of gaining specific information of immediate benefit in the t reatment of other patients already afflicted by a life- threatening disease. A case in point would be a person with cancer who died after receiving an experimental drug or drug combination. Postmortem examination to ascertain possible toxicity, foreboding potential harm to other patients on the same course of treatment, or for purposes of obtaining information concerning the therapeutic efficacy of the drug or drug combination, would be warranted according to Jewish law when such information is deemed to be essential in the t reatment of other patients already suffering from the same illness.

Another instance where autopsy is not only allowed but probably mandated is the situation of life-threatening infectious disease such as Legionnaire's disease. At a convention in Philadelphia in 1976, several hundred Legionnaires were afflicted with a pneumonia-like illness, and many died. Jewish law would probably dictate autopsy on those who died in order to discover the offending organism (now known) and t reatment (now available) so as to save the lives of the other patients afflicted, many of whom were dying of the same illness.

The dominant consideration in permitt ing an autopsy is the immediacy of the constructive application of the findings. This "here and now" principle, once limited to the medical needs of a local community, can now be extended, through the excellence of communication and scientific reporting, to the whole medical world. Results of autopsies in New York can be available in London in a mat ter of minutes. However, a routine autopsy cannot be sanctioned, although great benefit may accrue at some distant future time.

Another area where autopsy is permissible in Jewish law is genetic disease. A child that dies of a fatal genetic disease may have a postmortem examination performed to obtain information that might save the lives of future chil- dren in tha t family that may be afflicted with the same disease. Although the baby whose life is to be saved has not yet been born or even conceived, the "here and now" principle is rabbinically satisfied in the case of lethal genetic diseases.

Where an autopsy is sanctioned in Jewish law, certain considerations must be observed. The autopsy should be done as a surgical procedure with the same dignity, respect, and consideration that would be accorded a living patient un- dergoing an operation. It should be performed in dignified surroundings. The deceased should be draped and only the area of incision exposed. Proper deco- rum should be observed, and the behavior of the surgical-pathological staff


should be appropriate to the situation. The usual autopsy involves an incision extending over the entire length of the abdominal and thoracic cavities and examination of all internal organs including the brain. Such a complete autopsy is not countenanced w h e n - - a s is often the case--a l l pertinent potentially life- saving information may be acquired by means of a much more limited incision and examination of only those organs or areas crucial for obtaining this information. For example, in Legionnaire's disease, postmortem examination limited to the chest would have provided the necessary information about the cause and cure of this disease for immediate saving of lives of patients so afflicted. Finally, organs may not be removed if they can be examined in situ. All organs and body fluids must be returned for burial.

A special autopsy consent form has been prepared by the Federation in con- sultation with a number of physicians and legal scholars. It is designed to provide for detailed specification of the nature and scope of the postmortem examination for which permission is sought. This consent form requires the physician to state in precise clinical terms the information he seeks, to specify the area to be incised and the organs to be examined in obtaining such information. The authorization signed by the next of kin limits the extent of the postmortem procedure to that which is absolutely necessary in order to secure pertinent, potentially life-saving information of immediate applicability. Use of the consent form morally and legally obligates the pathologist to respect the directives of the next of kin. It specifies the limitations placed upon the autopsy procedure and, in addition, assures that all organs, tissues, and fluids will be returned for burial as required by Jewish law.

The example of informing the patient

The practicing physician is frequently confronted with the problem of informing a patient that he has a fatal illness. Should the patient be told the nature of his illness and the expected outcome? If the answer is affirmative, at what stage of the illness should the patient be told? Who should inform the pa t i en t - - t he physician or the next-of-kin, or both; or perhaps the minister, priest, or rabbi, according to the patient's religion and the depth of his religious feeling and observance? These and related questions cry out for answers, yet no simple answers can be given.

In the Jewish tradition ~ a patient suffering from a fatal illness should not be so informed if there is the slightest chance tha t such knowledge may further impair the physical or mental well-being of the patient. Jewish ethics permit and even require that the facts concerning the true severity of the illness be withheld from such a patient. The patient should be made aware, however, that he is seriously ill, so that he may be forewarned to set his house in order, but this should be done without giving the patient a totally negative outlook. Rather, the positive side of the illness, including the chances of cure, however remote, should be emphasized. The physician should not set a maximum time to live for any patient. Such estimates may be grossly inaccurate, and may further reduce the morale and defense capabilities of the patient and his family.

Fred Rosner 323

Mention of death should be avoided, if possible, lest the will of the patient to live be undermined.

The Jewish physician is expected to have compassion for his suffering Jew- ish or non-Jewish fellow man and to share the feelings of his patient. Ancient exposition of Scriptures, known as Midrash , ciriticizes even the prophet Isaiah who, without compassion, said to King Hezekiah:

Set thy house in order, for thou shalt die and not live. Hezekiah answered: "Isaiah, it is customary that a person who visits the sick asks for mercy from Heaven [that he be healed]. When the physician visits him, he tells the patient to eat certain foods, and to refrain from eating certain other foods, to drink certain beverages, and to abstain from drinking other beverages. Even if he sees that death of the patient is imminent, he should never say to the patient 'set your house in order,' in order that the patient not further weaken, yet you told me [precisely those words]."

Once a decision has been reached that the patient should be told, then it must be realized tha t the act of telling is an art which requires experience, knowledge, and understanding. The person--physician, nurse, clergyman, or otherwise--who does the telling should be deeply committed to the patient and his family. Time must be afforded to the patient to let the facts sink in, and for him to ask questions. He must be given the opportunity to deal with his fears and apprehensions by talking. He must not feel alone.

Thus, unless the judgment of physician and family indicates that harm might be done to the physical or mental well-being of the patient if he is told of his illness, then for a variety of reasons, not the least of which is the fact tha t most patients already know without being told, it seems proper to inform the patient about his disease. Extreme care must be paid to the manner and tim- ing of the disclosure to the patient and the support and comfort required of the physician and family by the patient after he has been told.

Conclusion

Judaism is guided by the basic axiom of the supreme sanctity and infinite value of human life, and of the dignity of man as a creation reflecting G-d Him- self. To alleviate suffering, to cure disease, and to preserve heal th are religious precepts. Judaism requires the physician to heal and the patient to seek healing from authentic medical practitioners and not to rely on faith healing or medical quackery. The needs of Jewish patients, such as kosher food and religious services in a hospital environment, require careful consideration and should be provided wherever possible. A Jewish chaplain should be available in any hospital that cares for Jewish patients, however few. The same cour- tesies and considerations should, of course, be provided wherever possible to all patients irrespective of race, religion, sex, age, creed, or national origin.


Re f e rences

1. Rosner, F., and Bleich J.D., Jewish Bioethics. New York, Hebrew Publ. Co., 1979, pp. 1-55. 2. Jakobovits, I., "Medical Experimentation on Humans in Jewish Law." In Rosner, F., and

Bleich, J.D., eds, Jewish Bioethics. New York, Hebrew Publ. Co., 1979, pp. 377-383. 3. Jakobovits, I., Jewish Medical Ethics. New York, Bloch Publ., 1959, 2nd edition, 1975; Feld-

man, D.M., Marital Relations, Birth Control and Abortion in Jewish Law. New York, Schoc- ken, 1975; Bleich, J.D., Contemporary Halakhic Problems. New York, Ktav Publ. & Yeshiva Univ. Press, 1977, Vol. 2, 1983; Rosner, F., Modern Medicine and Jewish Law. New York, Bloch Publ. for Yeshiva Univ. Press, 1972; Landman, L., ed., Judaism and Drugs. New York, Federation of Jewish Philanthropies, 1973; Hankoff, L.D., ed., Jewish Ethno-Psychiatry. New York, Federation of Jewish Philanthropies, 1977; Julius Preuss'Biblical and Talmudical Med- icine, F. Rosner, trans. New York, Sanhedrin Press (Hebrew Publ. Co.), 1978; Spero, M.H., Ju- daism and Psychology. New York, Katv Publ., 1980; Bleich, J.D., Judaism and Healing. New York, Katv Publ., 1981.

4. Feldman, D.M., and Rosner, F., eds., Compendium on Medical Ethics. New York, Federation of Jewish Philanthropies, 6th edition, 1984.

5. Trainin, LN., and Rosner, F., "Religious Directives in Medical Ethics: Jewish Codes and Guidelines." In Reich, W.J., ed., Encyclopedia ofBioethics, vol. 4. New York, McMillan & Free Press, 1978.

6. Rosner, F., "Emotional Care of the Cancer Patient: To Tell or Not to Tell," New York State J. Med., 1974, 74, 1467-1469.

the jewish patient in a non-jewish hospital

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