Introduction
In the coming years, Jewish medical ethics scholars will probably be required to address cuttingedge challenges, such as in neuroscience or genetics. Therefore, one dimension of the future of Jewish medical ethics is related to the innovative halachic response to these external scientific and clinical challenges. However, in this paper I do not intend to mention any of these anticipated challenges.
Rather, this paper is limited to my personal thoughts regarding the way I would like to see the future of the intersection between Judaism and Medicine, not as a response to external stimuli but rather as part of an internal renaissance of the field.
I intentionally prefer to talk about the broader field of "Judaism and Medicine", instead of using the term "Jewish Medical Ethics", since to my view, the term "Jewish Medical Ethics" conveys only one dimension of the potentially rich and broad realm of "Judaism and Medicine".
This paper begins with a descriptive analysis of contemporary Jewish Medical Ethics; its characteristics, strengths, and limitations. Then, the concept of "Judaism and Medicine" will be introduced, including its complementary role to "Jewish Medical Ethics". This will lead me to present my vision pertaining to a future in which Jewish Medical Ethics expands and evolves to become Judaism and Medicine.
Jewish Medical Ethics
Contemporary Jewish medical ethics is halachically-guided. The basic halachic approach, in terms of methods and principles, is the same for questions relating to universal medical ethics issues, such as abortion and brain death, as for questions relating to specific medical issues that affect only the Jewish community following the precepts of the Torah, such as the treatment of patients on the Shabbat. Once the accepted rabbinic authority has reached the halachic decision, physicians and patients must follow that ruling. In other words, for the "Jewish consumer" - usually orthodox Jews - the halachic ruling is obligatory, not optional. Hence, the term "Jewish Medical Ethics" is a misnomer since for the "Jewish consumer" it is not considered "ethics" in its ordinary sense but rather it is akin to law.
Another characteristic of Jewish Medical Ethics is that it is a problem-oriented field.
It is interested in finding practical solutions to well-defined problems arising from medical practice via the application of halachic principles. Each problem is like a puzzle that the rabbinic authority has to solve. The most stimulating and intriguing questions are those that relate to dramatic situations, mostly life-and-death issues, or intellectually demanding dilemmas that require a deep or innovative analysis of halachic resources. Jewish Medical Ethics seeks "what to do" solutions, as the focus of its inquiry is mostly on actions. Its curriculum consists of an accumulation of halachic solutions of many different problems.
Jewish Medical Ethics is built upon a rule-based reasoning. Usually, the halachic decision is provided through the question-answer format. The question is first identified, presented to the rabbinic authority and ultimately answered. The halachic authority attempts to apply the most relevant halachic rule pertaining to the case in hand. Although the halachic discussion is always bounded to specific situations and agents, the formalistic nature of the halachic discourse detaches the question from its personal and particular context and attempts to reach a pure conceptual formulation that could be applied to similar cases.
The role of physicians in the Jewish Medical Ethics system is quite limited and peripheral; they often raise the questions, they may provide scientific and clinical background pertinent to the dilemma but they have no role in the halachic decisionmaking process. Of course, physicians may also be rabbis. In their rabbinic capacity, physicians may function as halachic authorities, similar to nonphysician rabbis. However, most of the leading rabbinic authorities on medical ethics issues are nonphysicians.
Academic Jewish Medical Ethics scholars usually limit their contribution to a secondary analysis of the halachic text, while the primary halachic analysis is the exclusive domain of the rabbinic authorities. Some academic scholars present the content of the convoluted halachic texts in a much friendlier and systemized form for the benefit of the academic community. Other academic scholars may offer a critical or complementary analysis of medically- related halachic issues from various disciplines, such as history, psychology, sociology, and anthropology, among others. Jewish Medical Ethics in its halachic form is determined only by rabbinic authorities who apply the traditional methods of halachic analysis to the halachic text.
For orthodox Jews, the first and foremost objective of Jewish Medical Ethics is to deliver the voice of the Torah via the rabbinic authorities to the everyday medical practice. For the orthodox community, there is no qualitative difference between the content of the laws of Shabbat and the laws pertaining to the medical arena. To many orthodox observers, the Halacha is divine and the halachic decision-making process is sacred; therefore by following the Halacha the agent implements God's will.
Jewish Medical Ethics covers almost every conceivable practical aspect that relates to any medical conditions, such as infertility, dementia, and terminal illness, to name a few. Immense intellectual effort has been invested to develop criteria to determine parenthood and motherhood in genetically challenging situations; to determine the intellectual capacity which is required for different mental activities; and to set priorities in situations in which there is a conflict between the wish to prolong life and the desire to minimize pain and agony. This is certainly a major achievement for any ethical theory.
Can Jewish Medical Ethics, in its halachic form, be relevant and useful to non-orthodox Jews or even to non-Jews? I think the answer is affirmative. The halachic reasoning pertaining to several general medical ethics questions is not so alien to "universal" moral reasoning. Therefore, there is sufficient common ground for inter-cultural ethical discussion within the halachic zone.
Moreover, if one perceives the Halacha in a non- positivistic way, namely, that law is not separate from morality, then Halacha is a system in which moral values and principles are transformed to practical behavior via legal reasoning. Therefore, regardless of its particular content, Halacha can be an inspiring model for ethicists that look for a viable methodology that applies abstract moral values to everyday professional practice. Understanding Halacha as a system may be a major contribution to the field of applied ethics.
However, the many merits of Jewish Medical Ethics in its halachic form should not make us blind with regard to its limitations.
Halachically-based Medical Ethics is in fact legally-oriented. As a legal system, Halacha attempts to give final and practical decisions to well-defined concrete problems. As a result, the halachic discussion excludes dimensions that are not related to actions since these aspects are considered irrelevant with regard to the halachic method. At times, especially when a major conceptual issue is at stake, the discussion or the suggested solution may feel too practical. There is a sense that even though the practical puzzle has been successfully solved and there is a tangible manual for action, something is still missing; some important dimension concerning the problem is still beyond our reach.
In addition, under the halachic form of Jewish Medical Ethics, ethical, existential or philosophical dilemmas that do not impinge upon halachic principles are ultimately absent. Accordingly, significant dimensions of everyday medical practice do not exist within the halachic discourse. On the other hand, lengthy discussions have been offered with regard to relatively uncommon questions that pertain to a few physicians on rare situations.
Another limitation of Jewish medical ethics in its halachic form relates to the nature of Halacha as a rule-based and an action-directed system. As with other rule-based ethical theories, the inclination to meticulously examine the morality of actions according to certain rules renders the agent's character irrelevant, since obedience to the rules is the key component of morality. As a result, virtue-based dimensions of morality that relate to the character of the physician are not as developed as other areas of Jewish Medical Ethics.
A few examples may illustrate the limited scope of Jewish Medical Ethics:
One of the major questions in the philosophy of medicine, which has tremendous clinical implications, relates to the ontology and epistemology of illness and health. Namely, what is the definition of disease and health? Who decides what is considered a disease, the patient or the physician? Is the definition of disease objective or subjective? I am sure that many physicians have been puzzled by this question at least once during their professional career. This question is a philosophical one; it is not linked to any concrete problem or action and it does not challenge any halachic principle. Therefore, this abstract question has never been explicitly dealt within the traditional halachic discussion. Jewish Medical Ethics, in its halachic form, does not provide answers to these questions.
Let us take another example. As mentioned above, Jewish Medical Ethics covers ample practical aspects that relate to medical conditions, such as infertility, dementia, and terminal illness. At the same time, Halacha barely touches other significant issues that relate to the suffering that is a part of these medical conditions, and to the emotional challenges of treating them. For instance, what does it feel like to be infertile? What emotions and thoughts involve this condition? What does it feel like to suffer from dementia? What does it feel like to suffer from a terminal illness? What kind of spiritual comfort can be offered to a person who is gradually declining cognitively or physically? What should be said and done for the benefit of these patients' families? And from another perspective, what kind of spiritual support and encouragement can be offered to medical health providers that continuously confront the challenge of treating an incurable disease? Again, these questions are not legal in their nature. They are too abstract to be dealt within the confines of Halacha. Jewish medical ethics, in its halachic form, does not - and indeed is not expected to - provide answers to these questions.
Judaism and Medicine
Anyone who is familiar with the wealth and depth of Jewish lore knows that Judaism is brimming with useful insights beyond the halachically-oriented practical solutions which Jewish
Medical Ethics
offers. During my personal clinical work, I find myself troubled far more frequently by questions of the
sort mentioned in the examples above than by the problematic situations more commonly dealt with in the halachic literature. Under these situations I maintain an internal dialogue with Jewish texts that I find relevant to the situation. This continuous dialogue provides me with a meaningful and useful tool to appropriately handle this sort of situation. Therefore, I find it disappointing that these valuable dimensions of Jewish wisdom are almost unknown to the greater medical community. In order to enable this embedded Jewish wisdom to shine in full and to transcend its particular Jewish origin, we need to stretch Judaism beyond the horizons of Jewish Medical Ethics. A new paradigm should be added: Judaism and Medicine.
A thorough presentation of my vision concerning Judaism and Medicine is beyond the scope of this limited paper. Thus, I will mention only several key points that illustrate the direction in which I hope to see Judaism and Medicine grow, develop and complement Jewish Medical Ethics.
Judaism and Medicine can be distinguished from Jewish Medical Ethics on the basis of three main pillars:
1. The scope of the problems
2. The applied methodology
3. The ethical orientation
Judaism and Medicine covers a broader range of problems concerning medical practice in comparison with Jewish Medical Ethics. Judaism and Medicine, as opposed to Jewish Medical Ethics, is interested in philosophical, psychological, sociological and existential dimensions pertinent to ordinary day-to- day medical practice. Conceptual questions are welcomed, and more than one perspective is possible.
The non-legal orientation of Judaism and Medicine enables scholars to apply various methodologies in addition to the traditional halachic reasoning. Accordingly, the discussion is open to Jewish texts that are not necessarily halachic, including the Bible and biblical commentary, Jewish Philosophy, etc. Moreover, since there is no ambition to formulate halachic decision, even the halachic text can be analyzed by more than one methodology. For example, the focus of the textual exploration may not be a search for a concrete solution to practical problem but rather the uncovering of explicit and implicit philosophical or psychological dimensions embedded in the halachic text. The non-legalistic approach to Jewish texts may enable physicians to participate in a more active and meaningful way in the scholarly process.
While Jewish medical Ethics focuses on rules and principles that define the desired ethical action with regard to a specific situation, Judaism and Medicine is more inclined to focus on virtues that promote ethical behavior among health care providers in general. The character of the physician is a key concept in Judaism and Medicine. Therefore, top priority is given to questions concerning medical education, such as: Which personality traits and virtues are most required for becoming a good physician? Can empathy be taught, and if so, by what means?
In order to better understand the characteristics of Judaism and Medicine, let us turn back to our examples which were used above to illustrate the limited scope of Jewish Medical ethics.
Although Halacha does not explicitly address the ontology and epistemology of illness and health, when halachic authorities reply to questions pertaining to different medical conditions, the sensitive reader can figure out what are the implicit definitions of disease and health which these halachic authorities had in mind. As an example, the discussion concerning whether a person is allowed to endanger himself while undergoing cosmetic surgery may serve as a test case for the legitimacy of a non-biological definition of disease.
In this case Judaism and Medicine applied a second-order non-halachic reading of the halachic text in order to address a philosophical question pertaining to the realm of medicine.
I mentioned above that the Jewish Medical Ethics approach does not give much attention to the existential, psychological and sociological aspects of the medical conditions it legalistically addresses. However, the non-halachic Jewish texts are rich with references to these conditions. For example, the fragile existential experience of being infertile is addressed with regard to several key biblical figures, such as Sara, Rachel and Hanna. Jewish biblical commentators for over two thousand years have suggested their valuable insights pertaining to various aspects involved in this condition, including the best empathetic way to approach a vulnerable person who suffers from being infertile.
In this case, Judaism and Medicine is able to examine existential questions that are related to the medical arena by reference to non-halachic texts.
Summary
The future of Judaism and medicine can be dealt with in two different orientations.
The first orientation focuses on the anticipated external intellectual challenges which will be imposed on Jewish medical ethics scholars. These ethical quandaries will probably occupy the minds of Jewish medical ethics scholars in finding the appropriate practical solutions for appropriately addressing them.
The second orientation focuses internally on the Jewish tradition, and asks how can the moral and intellectual traditions of Judaism more significantly shape the formation of physicians and other health care professionals in the future? According to this orientation, one of the future missions of Jewish medical scholars is to find the way of enriching the value and demand for Jewish wisdom among health care providers. This paper relates to the second orientation.
I proposed the addition of Judaism and Medicine as a complementary paradigm to Jewish Medical Ethics with the aim of promoting the intellectual contribution of Jewish wisdom to the medical realm. Traditional Jewish Medical Ethics, in it halachic form, will always be the irreplaceable heart of Judaism and Medicine. In fact, our capacity to think of future directions that go beyond the classical Jewish medical ethics endeavor is possible only due to the fact that Jewish medical ethics scholars have successfully established the practical foundations of Judaism and Medicine. Equipped with a broader scope, variety of methods and virtue- oriented ethics, Judaism and Medicine along with Jewish Medical Ethics can reach more medical health care providers and touch them more deeply.