Avraham Steinberg, M.D.
Rapid developments in medicine and medical technology during recent years have created a variety of ethical dilemmas including the allocation of limited or scarce resources such as money, instruments, medications, health-care facilities, time and manpower.
No country in the world can provide all medical needs for all its
citizens. Therefore, public policy relating to priorities in allocation must be
established. The issue is both economic – how to allocate the limited resources
most beneficently, and ethical – how to allocate these limited resources in the
most equitable and just manner.
There are two aspects to this issue: macro-allocation, involving the
society as a whole; and micro-allocation, involving individual health care
providers.
This section deals with macro-allocation, namely the ethics of limited
public resources, general health-care policies, and the effects of budgetary
and economic decisions on medical practice.[1]
B. Past
and Present
In the past if a particular medical treatment was considered useful, it
was given. The questions at that time were whether the procedure was
beneficial, safe and widely accepted. Nowadays, because of rapid advances in
medicine, there are additional questions of feasibility and cost, because much
of medicine is now based on technology, instrumentation and manpower, all of
which are very expensive.[2]
The equitable and just distribution of limited medical resources has
become very difficult, since in situations of poor health standards a small
investment may produce significant benefits, whereas in situations of high
health standards large investments may produce little benefit.
Modern medicine has increased people’s life expectancy,[3] correspondingly
increasing the corresponding number of patients with chronic and debilitating
physical and mental disabilities. Modern medicine has rendered possible the
survival of many defective and premature infants, requiring long and expensive
therapy. Modern medicine has made available complicated and expensive new
technologies and treatments such as resuscitation and ventilation, organ
transplantation, and in-vitro fertilization. It is based upon complicated,
prolonged and expensive basic and clinical research, and necessitates
large-scale preventive measures.
All these are very expensive and obviously require a system of
priorities. In addition, there are worldwide budgetary and economic restraints
which have negative effects on the ability of all countries to provide adequate
and universal health care for their populations. Among poor nations there are
serious problems of hunger, un- employment, lack of housing and population
explosion in addition to medical needs. In developed countries people aspire to
a very high and expensive standard of living; hence medical expenses are only a
small portion of the total societal needs.
In recent years, the fraction of gross national product (GNP) devoted to
medicine has risen substantially, more than any other economic aspect, as shown
in the table:
Year |
Country |
% of GNP for medicine |
1960 |
USA |
5.2 |
1991 |
USA |
13.2 |
1960 |
Germany |
4.8 |
1991 |
Germany |
8.5 |
1960 |
Canada |
5.5 |
1991 |
Canada |
10.0 |
1960 |
France |
4.3 |
1991 |
France |
9.1 |
In 1990 in the United States an
average of $2,400 was spent for each citizen for health care,[4]
although only a small fraction of the population had government insurance, most
having private insur- ance or none at all.
The following are some examples of expenditures for medical care in the
United States: the cost of hemodialysis is two billion dollars annually; in
1980, more than 100,000 coronary bypass procedures cost two billion dollars;[5] the
cost of heart transplants is close to three billion dollars annually;[6] the
average annual cost of caring for a patient with AIDS is $30,000-40,000
annually;[7] for a
patient in intensive care (ICU) it is about $3,000-4,000;[8] and the
cost for caring for a child born below 1,500 grams is nearly a million dollars
over a 100 day period in an ICU.[9]
C.
Possible Solutions
Undoubtedly no country in the world can afford to provide for all the
medical needs of all its citizens in an equal manner. Every country must,
therefore, ration health care and provide for a system of priorities of public
or national health insurance.
Some authorities have suggested optimal criteria for a morally defensible
health care system. They include the following character- istics: the health
care system must be clear and understandable to the citizens; health insurance
has to cover all citizens without discriminatory considerations which are based
on income, employ- ment, age, or social status; medical coverage should be
compre- hensive, to include psychiatric, geriatric, dental and preventive
services; the health care system should include measures for a possible cost
containment, such as incentives for cheaper treat- ments, and counter
incentives to avoid unnecessary diagnostic and therapeutic measures; the system
of payment for the health insurance should be fair, and result in satisfaction
both for the patient and the health care providers.[10]
In any case, an optimal health care system should secure a standard of
care for individual patients to prevent the danger of sacrificing individual
patients for the common needs.[11]
In addition to creating an optimal health care system there are ways to
reduce cost even within the existing systems: educate health care providers to
consider the economic impact of their actions, and use the most cost-effective
strategies in diagnosis and treat- ment. Indeed, practical lists have been
developed to help treat their patients with cheaper measures without reducing
the quality of care.[12]
Further measures include avoidance of defensive medicine, coupled with
awareness of the damaging effect of too many malpractice suits and high awards
to litigants; reduction of adminis- trative expenses and manpower, and
elimination of duplicate medical services, careful allocation of limited
resources, as well as efficacious use of manpower, location, time and medical
supplies.
We must distinguish between vital medical services and other essential
needs of general health, versus the aspirations for maxi- mal medical benefits
to improve convenience and quality of life.
In the first category full and complete equality is an ethical
imperative, whereas the other category is no different from housing, clothing,
education and the like, in which no equality exists even in any western
society. Hence, one has to distinguish between pain relief medications for
transient minor illnesses and medic- ations for life threatening diseases;
elective plastic surgery to improve external appearance differs from heart or
cancer surgery.
Indeed, health is an important goal, and, in the eyes of the public more
important than others. However, even within the health care system some needs
are greater than others. Many health care needs are actually those of general
well-being. Hence, society should be obligated to supply basic and vital health
care needs for all its citizens equally. Although services for well-being should
theoretically be equally accessible for all citizens, the actual delivery of
these services is in practice the personal responsibility of individuals
according to their own priorities and means.
A general public health approach must provide the following: medical
intervention in situations of danger to life, serious illness, significant
disability, or great suffering; preventative medical ser- vices in all its
aspects including those of environmental hazards and infectious causes of
disease; preferential consideration for the poor and the underprivileged; and
applied practical research.
On the other hand, other health care needs (which are basically no
different from housing, clothing, education, etc.) should be provided for by
adequate payment or private insurance, although this would result in
non-equitable distribution. Such social non- equitability results not only from
the economic differences between people, but also from individual preferences
and importance attrib- utable to various different needs in life. Such
inequalities exist in all spheres of life, and there is no ethical reason to
exclude them from health care services, provided they are of no vital
importance.
D.
Current National Solutions
Many western countries have revolutionized their health care systems.
Complete and equal national health care insurance for all citizens is provided
by only a few countries. Such complete health coverage has lowered the death
rate, but at the same time, has increased suffering and morbidity, and has increased
dissatisfaction among patients because of the inherent lowering the standard of
care, and lengthy waits for diagnostic and therapeutic procedures, including
surgery. Hence, despite varied health care plans and attempts to design and to
secure health care insurance – whether national, public or private – none has
so far fulfilled the desired aspirations.[13]
Two countries, the United States and Israel, are now in heated debate
over reform in their health care systems.
In the United States there is at present no national health care program
for all citizens. There are only two national programs which give medical
coverage to a minority of the population —Medicaid, which covers patients below
the poverty level, and Medicare, which covers people over the age of 65.[14]
A system that has become popular in the United States is the health
maintenance organization plan (HMO), in which families or individuals pay a
fixed amount for which they receive medical services according to their needs.
Another approach advanced in the United States is to make employers responsible
for providing partial or full health insurance coverage for their workers and
their dependents, and the government responsible for the poor and the
unemployed.[15]
An attempt in America to control unjustified costs related to
hospitalized patients is the system known as diagnostic related groups (DRG). A
list of diagnoses was developed and a price tag for the diagnostic and
therapeutic expenses as well as for length of stay in the hospital for each
diagnosis was developed. A hospital is reimbursed at a predetermined figure as
cited in the list of diagnoses for each individual patient, regardless of the
actual cost to the hospital for the care of that patient. Hospitals and doctors
are thereby forced to reduce the length of stay in the hospital for many
patients, to limit diagnostic tests and therapeutic inter- ventions to those
absolutely essential, so as to keep hospital costs down to the level of
reimbursement for that DRG. Only in exceptional circumstances do insurance
carriers pay more for a specific DRG than the listed reimbursement. Another way
to limit costs is to require a second opinion before an insurance carrier
allows payment for a surgical or expensive medical procedure.
In the United States malpractice litigation is common, and courts not
uncommonly award large sums to patients. As a result, physicians of necessity
insure themselves, and these high costs are added to patients’ medical bills.
In addition, physicians protect themselves by practicing defensive medicine,
performing more tests than necessary from a purely objective medical point of
view, thereby further raising the cost of health care.
In general, American physicians have developed a tendency to perform many
and expensive diagnostic tests which do not con- tribute to better medical
results. Attempts are being made to reduce overutilization of expensive medical
technology, and to relieve pain and suffering resulting from some invasive
tests without reducing the quality of care.[16]
A novel approach to controlling health costs and to resolve the problem
of limited medical resources is that of the state of Oregon in the United
States.[17] The
goal of the Oregon Plan is to provide the basic medical needs of all Oregon’s
poor by restricting the amount and the type of medical services rendered by the
govern- ment to the general population. This was achieved by encoding a list of
priorities for all medical services based on their medical importance, their
cost and/or the resultant quality of life.
The list was prepared after in-depth discussions and consult- ations with
medical experts, as well as public input through an opinion poll and numerous
public meetings. In 1991 a priority list of 709 specific medical services was
published by the State of Oregon. The State agreed to cover the medical
expenses for the poor for the top 587 items. The Oregon Plan, however, has been
strongly criticized from practical and ethical viewpoints. It was found that
there are insufficient data for setting priorities in medical services based on
cost/benefit considerations. Indeed, distortions in the priority listing were
enumerated by many investigators.[18]
In Israel the health system is primarily operated and admin- istered by
two major providers:
(a) The Ministry of Health is responsible for general health policies,
for the control of other health care delivery systems, and for subsidizing
shortfalls in budgets by various health agencies. The Ministry is directly
responsible for half of the acute hospitalized cases in Israel, one-fifth of
the chronic care patients and half of the psychiatric inpatients.
(b) The main health care provider of medical services is the Kuppat
Cholim (Sick Fund) of the Labor Union (Histadruth). About 75% of all
Israelis are insured through the Kuppat Cholim. In addition to its role
as medical insurer for most Israeli citizens, Kuppat Cholim also
provides basic medical and preventive medical services to all people in rural
areas, irrespective of their member- ship in Kuppat Cholim. This Sick Fund
is also directly responsible for about one-third of the acute care beds in
Israel.
About 20% of the Israeli population have other health insurance, while
about 5% are uninsured.
In 1989 Israel spent 7.6% of its gross national income on health care, yet
the annual expenditure per capita was only $472.[19]
The health care system in Israel has been colored by a socialistic
approach, and represents a public, almost complete population health insurance.
The system nearly went bankrupt because of increasing costs of medical care,
and poor policy and administrative adjustments.
In 1988 the Israeli government appointed a National Inquiry Committee to
investigate the Israeli health care delivery system.[20] This
Committee discovered a variety of substantial deficiencies in the existing
operational systems, to include poor health care services to individual
patients, inappropriate and inefficient allo- cation of existing resources,
poor doctor-patient relationship, malfunction of the Ministry of Health,
unsatisfactory distribution of health care personnel, inappropriate health and
financial policies, poor administrative procedures, and poor overall
functioning of the health care system. They also found low morale and poor
motiv- ation among public health care workers.
According to the Committee, all this contributed to an infant mortality
rate higher than in Europe, a higher than expected mortality from cardiac
diseases, greater frequency of infectious diseases, and significant problems in
the area of dentistry.
The main recommendations of the Committee were to pass a national health
care law to provide universal medical coverage for widely specified medical
services. These services should include preventive medicine, ambulatory care,
hospitalization, rehabil- itation services, medications, medical appliances,
geriatric and dental services to the elderly, preventive dentistry for
children, and provide for such medical treatment as is not available in Israel.
Additional insurance could be purchased voluntarily.
Such a law should enable individuals to choose freely between the various
medical insurance providers, increase competition among medical insurance
providers, define the minimal level of universal medical coverage, define the
maximal waiting period for medical services, set the budget for the health care
system, and allow governmental inspection of service providers.
The Committee also proposed establishing a National Health Authority to
reorganize the Ministry of Health, so that it can properly function to improve
general health policies, to privatize all hospitals, to introduce private
practice into public hospitals, to use financial incentives for increasing
productivity and efficiency, to award professionals for high standards of
performance, and to invest in scientific research.
These recommendations as well as other political forces have brought
about heated debate in Israel. The proposal for a National Health Care
Insurance Law has been enacted by the Knesset.
E.
Jewish Approach
Issues of scarce medical resources have not been directly dealt with in
Jewish sources.[21]
From a philosophical viewpoint, one of the fundamental questions
concerning the allocation of scarce medical resources is whether society is an
entity and as such has its own interests, or whether it is but the sum of all
the individuals that comprise it. If the latter is true, each individual has
the right to demand that all its needs be met, even if society must therefore
make large expen- ditures while abandoning other goals. If, however, society is
a separate entity, it may ethically have the right to allocate resources for
the public good, including highways, parks, museums etc., even though many
individuals may thereby suffer from insufficient medical services.
In halacha, society is indeed considered to be a separate entity, and has
its own set of ethical and legal standards.[22]
E. 1.
Primary Halachic Sources
The main talmudic source concerning the allocation of limited resources
is the law that captives should not be redeemed for more than their worth “mippnei
tikkun ha’olam” (for the good of society).[23]
The Talmud justifies this ruling for two reasons: a) so that society
should not become impoverished by paying expensive ransom demands and thereby
not leaving adequate funds for other needs; b) so as not to encourage
kidnappers to take more captives and demand ransom from society.[24]
In applying this talmudic ruling to the question of allocation of scarce
public medical resources it is important to answer two questions: (1) Which of
the two reasons is the decisive one? (2) What are the conditions and the
characteristics of the captives?
1. Some authorities hold that the Talmud left unanswered the question as
to which of the two reasons is decisive[25] and,
therefore, both are operative.[26] Others
adduce talmudic sources to prove that the main reason is to discourage
kidnappers;[27] there
are those who hold that the main concern is to avoid impoverishment of society.[28]
2. Concerning the condition and the characteristics of the captives, some
authorities distinguish between the individual and society in that the former
is obligated to expend all possible resources in order to ransom a relative but
society can not be so obligated because impoverishment of society would be a
form of danger to the lives of the public versus that of an individual.[29]
Some halachists hold that where the life of a captive is in danger,
society has an obligation to pay ransom beyond the consideration of “worth.”[30] However,
other authorities disagree,[31] on the
basis of the biblical injunction ‘Do not stand idly by the blood of thy fellow
man’ which applies only to the individual but not to society as a whole.[32]
Another talmudic source of reference is the case of two towns with a
single water supply. According to one opinion, the closer town is allowed to
use the water, not only for drinking but also for washing laundry in order to
prevent sickness of its inhabitants, even if it, thereby, deprives the other
town of its drinking water supply.[33]
Thus, society (i.e., whole town) must take into account its own possible
future needs even if it thereby may harm or interfere with present needs of
others,[34] since
societal needs can involve situations of danger to life in a much broader sense
than with individuals.[35]
E. 2.
Current Halachic Opinions
A recent rabbinic opinion states that society should give priority to
basic needs of all its citizens, particularly needs that relate to danger to
life. Such immediate needs take priority over medical research and development.
Accordingly, society is allowed to set new policies for allocation of its
resources even if it changes current policies, and even if citizens may in the
future not receive certain benefits currently being provided. However, society
may not take away or terminate benefits and services already being supplied to
patients, such as closing wards or hospital beds currently occupied by patients
who need those services. It may establish policies that might affect future
patients, but it may not ignore present and immediate danger to patients in need
of medical care.
Society must first be concerned with its own preservation before that of
the individual. Society should also allocate resources for preventive medicine,
including education about smoking and good eating habits. Also, screening
programs for the early detection of serious illnesses take precedence even if,
thereby, funds for future medical and surgical therapies may not become
available, because preventive measures may save many more lives than the
treatment of individual future patients.[36]
F.
General Ethical Considerations[37]
The ethical foundation of distributive justice can be character- ized
either by the principle of equity or by various modes of utilitarian approach.[38]
There is no doubt that humanistic nature tends to favor absolute equality
among individuals. In a society where equality is the guiding ethical principle
in all spheres of life, every citizen should have the right to any required
medical therapy. However, no modern society can afford to provide every medical
need for every citizen.
There are two ways to solve the problem. Either society must equally
reduce the level of medical care for all its citizens, or it must reduce some
level of equality in order to provide high-tech medicine to some “more chosen”
citizens.
Several proposals have been put forth to accomplish a certain level of
equality in health care:
(a) Providing equal access to all possible medical needs in order to
achieve a reasonable level of health care while requiring every individual to
purchase his needs according to his economic ability.[39]
Justification for this system is provided by the fact that society has no
obligation to provide free health care services to all its citizens; rather,
its obligation is to provide full and equal access to all available medical
means. The problem with this system is the practical definition of the
philosophical concepts: What is just distribution? What is an appropriate level
of care, and who determines it?
(b) Provision by society of appropriate medical care to each individual
in order to achieve a level of medical care equal to others.
The problem with this system is that the sicker the patient, the greater
is the benefit received in order to achieve health equal to others. The result
is that a small group of patients with serious chronic illnesses may consume
the bulk of the societal resources. Therefore, some limitations must be
applied, depending on the resources available.[40] This
approach also has similar difficulties of practical definitions.
(c) Provision of the same level of care for all patients with the same
illness.[41]
This approach emphasizes illnesses rather than patients. Here, too, the
problem is that a small number of patients use up a disproportionate share of
the resources.
(d) The approach which deviates the most from principles of equality is
the provision of equal health care only for limited and well-defined
health-care areas, in which strict equality must be kept.
This method attempts to conserve the idea of equality with a practical view
on societal limitations. A minimum package of health care benefits is to be
provided equally to all citizens, and every individual can purchase additional
care depending on his economic means and other personal priorities.[42] It is,
however, very difficult to determine what this minimal package of medical
benefits should be.[43]
The
Principle of Utilitarianism
The basis of the utilitarian approach is to insure the greatest benefit
and greatest happiness for the largest possible number of people. This approach
avoids equality and approves of any system which accomplishes utilitarian
goals.
There are several significant ethical and practical problems with this
approach: Are benefit and happiness the only standards of ethics? Does the goal
justify the means? How does one measure happiness and benefit in complicated
situations? This approach gives priority to the young and healthy over the
elderly or disabled, to the educated and politically well placed over the poor
and underprivileged, and to patients with acute illness over the chronically
ill.
Economic concepts of cost/benefit ratios are based upon the principles of
utilitarianism. These economic theories convert all benefits and costs into
monetary values.[44]
The cost/benefit or utilitarian approach has a number of marked
disadvantages: It is a purely economic system which is difficult to apply in
medicine where one has to take into account human values that cannot be
measured in financial terms; many variables in health cannot be precisely
calculated in economic terms;[45] the
absolute cost itself is not always the main problem but how much money and
resources are diverted from other basic needs, or whether the savings in
economically less important plans is indeed diverted most efficiently to
alternative, more important plans.
Ethically, the utilitarian system significantly interferes with equality
and primarily undermines those who are in greatest need of health care
services.
Additional ethical problems regarding the just allocation of scarce
medical resources are whether an individual has an absolute right to health
care and whether society has an obligation to provide it.
The recognition of some kind of individual rights within a society was
already recognized in the Magna Charta in 1215. The Declaration of Independence
of the United States in 1776 reco- gnized human rights, stating that all men
are created equal and are endowed by their Creator with certain inalienable
rights which include life, liberty, and the pursuit of happiness. The National
French Assembly in 1789 adopted a declaration of human and citizen rights.
None of these declarations, however, specifically mentions the right to
health care. Only in 1948, in the Declaration of the United Nations, do we find
a specific human right for adequate standard of living amongst thirty other
human rights. This statement is rather general but it specifically recognizes
the individual’s right for basic health.
Two rights relate to the issue of allocation of limited resources: the
right to health, and the right to health care.
The right to health is a sweeping and all-encompassing right. However, from a practical viewpoint it has major problems because the implementation of this right places an unbearable and im- possible obligation on society. Thus, for instance, society should forbid smoking, alcohol consumption, overeating and their like because these are all harmful to health. Such rules, however, would severely interfere with the principle of individual privacy and liberties. Furthermore, the definition of health is difficult. The World Health Organization defines health as the complete physical, psychological, and social well-being of an individual. If the right to health would include all that, society’s resources would never suffice to provide it all.
The right to health care is also not a universally-accepted doctrine and
is also hard to define. Some investigators postulate that society is not
obligated to provide all requested medical therapies for all its citizens.
Rather an appropriate minimum standard should be met and each individual
should decide when to supplement individual services and needs through private
means.[46]
Another ethical principle weighing on the issue of scarce resources is
autonomy[47] whereby
the individual has the right to decide what shall be done with himself.
What happens if the patient or his family demand certain treatments which
the physicians believe are futile or too costly? On the one hand, if the
patient refuses life sustaining measures, the principle of autonomy requires that
his wish must be respected. On the other hand, if he requests to prolong his
life, society occa- sionally does not respect his autonomous wishes.[48] Is it
ethical to use the principle of autonomy only in the direction which suites the
interests of society?
The issue of the allocation of scarce resources has significant impact on the provision of specialized medical services, intensive care units, life-prolonging measures, organ transplants, application of new reproductive technologies, and expensive diagnostic stings, among others.
Source: ASSIA – Jewish Medical Ethics,
Vol. II, No. 2, May 1995, pp. 14-21
1.
Concerning allocation decisions for individual patients, see “Priorities in
Medicine” in the Encyclopedia of Jewish Medical Ethics by A. Steinberg.
3.
Increased life expectancy in this century has aggravated the problem of
allocating scarce resources because people over 65 years of age now account for
12% of the population but utilize one third of all health resources in the
United States. See Jecker, N.S. and Schneiderman, L.J., Am J Med 92:189,
1992.
8.
Detsky, A.S., et al., N Engl J Med 305:667, 1981. In the United
States in 1988 there were 6556 intensive care units accounting for 7% of all
hospital beds. The cost for the care of those patients was 140 billion dollars
which was 1% of the GNP. See Bone, R.C. and Elpern, E.H., Arch Inter Med
151:1061, 1991.
9.
Stahlman, M.T., J Pediatr 105:162, 1984. See also Hernandez, J.A., et al.,
Clin Perinatal 13:461, 1986.
13. In a series of articles in the New England Journal
of Medicine J.K. Iglehart described the health care systems in the United
States, Japan, Germany, England, and Canada. See N Engl J Med 309:1264,
1983; 310:63, 1984; 315:202, 1986; 319:807, 1988; 321:1767, 1989; 322:562,
1990; 324:503, 1991; 324:1750, 1991; 326:962, 1992; 326:1715, 1992. See also
Blendon, R.J., JAMA 267:2509, 1992.
14.
The various health systems in the United States are described by Dukakis, M.S.,
N Engl J Med 327:1090, 1992; Igelhart, J.K., N Engl J Med
328:896, 1993.
17.
See Klevit, H.D., et al., Arch Inter Med 151:912, 1991; Eddy,
D.M., JAMA 266:417, 1991; Callahan, D., J Am Geriat Soc 39:622,
1991; Dixon, J. and Welch, H.G., Lancet 337:891, 1991; Steinbrook, R.
and Lo, B., N Engl J Med 326:340, 1992.
18.
See Hadron, D.C., JAMA 265:2218, 1991; Daniels, N., JAMA
265:2232, 1991; Stason, W.B., JAMA 265:2237, 1991; Klein. R., BMJ
304:1457, 1992.
19.
Ginsberg, G., et al., Isr J Med Sci 26:625, 1990. In the United
States during that year the expenditure on health care was $2,400 per capita.
20.
The five member commission consisted of Supreme Court Judge Shoshana Netanyahu
(Chairperson), Prof. Mordechai Shani (Sheba medical Center), Prof. Shmuel
Pinchas (Hadassah Medical Center), Prof. Arye Shiram (Tel-Aviv University), and
Dr. Dov Chernichowski (Ben-Gurion University). In 1990 it rendered majority and
minority reports after hearing testimony from 148 experts.
21.
Only issues of scarcity concerning individuals were dealt with. This is
discussed in the section “Priorities in Medicine” in the Encyclopedia of
Jewish Medical Ethics by A. Steinberg.
22.
See Rabbi U. Kalcheim, Aderet Emunah, p. 189. See also Kuzari
3:19. See further Rabbi M.D. Tendler, cited by Rosner F., NY State J Med,
83:353, 1983.
24.
The difference in practical terms concerns the question whether an individual
would be allowed to pay a large ransom to redeem a relative or friend. If the
concern is impoverishment of society, he would be allowed to do so, But if the
concern is to discourage kidnapping in general, one would not allowed to do so,
because one would thereby encourage more kidnappings. See Rif and Rosh,
Ketubbot 52b; Tosafot, Ketubbot 52a, s.v. vehayu;
Tosafot, Gittin 45a, s.v. delo; Maimonides, Ishuth
14:19; Tur, Even haEzer 78:2 and Ramah there. See also Gittin
58a, s.v. kol. See further Yadot Nedarim, Yore De’ah 252:4.
27.
Ramban, Milchamot Hashem, Berachot, Ch. 3, concerning women and
Grace after meals; Novellae Ramban and Rashba, Gittin 58a;
Maimonides, Mattnoth Aniyyim 8:12; Tur-Shulchan Aruch, Yore
De’ah 252:4. See also Rif, Gittin 58a.
29.
Responsa Chatam Sofer, Choshen Mishpat, end of #177. However, see Imrei
Binah, Kelalei ha-Torah #4. Maimonides, Mishna Commentary, Pe’ah
1:1 writes that even an individual should dispose of no more than one-fifth of
his possessions for the redemption of captives in order not to become a burden
on society. See also Rabbi S.A. Rapaport, ASSIA 49-50, 5750 (1990), pp.
5ff.
30.
Tosafot Gittin 8a, s.v. kol, in the first answer; Resp. Nachala
le-Yehoshuah, cited in Pitchei Teshuva, Yore De’ah 252:4.
31.
Novellae Ramban, Gittin 58a; Resp. Maharam of Lublin #15; Resp.
Yad Eliyahu #43. See also Pitchei Teshuva loc. cit (n. 28); Resp.
Kneset Yechezkel #38.
37.
Concerning religious views on this issue see Lustig, B.A., et al.
(eds.), Bioethics Yearbook, Vol. 1993.
39.
President’s Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research: Summing Up, p. 72, 1983.
40.
Veatch, R.M. in Beauchamp, T.L. and Walters, L. (eds.), Contemporary Issues
in Bioethics, 2nd ed., p. 410, 1982.
44.
See Weinstein, W.C. and Stason, W.B., N Engl J Med 296:716, 1977; Baram,
M.S. in Contemporary Issues in Bioethics, loc. cit. (n. 36);
Emery, D. and Schneidermanm, L.J., Hastings Cen Rep 19:8, 1989; Eisenberg, J.M.
JAMA 262:2879, 1989; Udverhelyi, I.S., et al., Ann Inter Med
116:238, 1992.
45.
Although some authors attempt to calculate costs relating to increases in the
quality or length of life, such calculations are very imprecise.
46.
See Lee, P.R. and Jonsen, A.R., Am Rev Rep Dis 109:591, 1974; Siegler,
M., J Med Philo 4:148, 1979; Sade, R.M., N Engl J Med 285:1288,
1971; Engelhardt, H.T., J Med Philo 4:113, 1979.
47.
See “Free Choice” and “Ethical Theories and Principles” in my Encyclopedia
of Jewish Medical Ethics.
48.
See Perkins, H. S., J Gen Inter Med 1:170, 1986; Ruark, J.E. and Raffin,
T.A., N Engl J Med 318:25, 1988; Veatch, R.M., Hastings Cen Rep 18:34,
1988; Brett, A.S. and McCullough, L.B., N Engl J Med 315:1347, 1986;
Tomilson, T. and Brody, H., JAMA 264:1276, 1990; Hackler, C. and Hiller, F.C., JAMA
264:1281, 1990; Schneiderman, L.J. et al., Ann Inter Med 114:169, 1991;
Jecker, N.S., Hastings Cen Rep 21:5, 1991; Paris, J.J., et al, N Engl
J Med 322:1012, 1990; Brennan, T.A., JAMA 260:803, 1988.