An online discussion had a wonderful post by the important Jewish Medical Ethicist, Alan Jotkowitz MD. In the post he gives five programmatic directions for the future of medical ethics. Some are statements of his different starting points and others are open questions (1) To recognize the lack of precedents for Jewish medical ethics and its reliance on aggadah and Jewish thought. (2) To encourage that it serve as a source for the general ethical discussion. (3) We need a greater recognition of the role of patient autonomy is needed, similar to Western medical ethics. This goes with a lesser rabbinic presence. (4) Does the lack of consensus undercut the discipline? (5)There is a greater need to focus on the sources of confession and death bed to develop an ethic of empathy and altruism. I hope he finds time to write a book soon.
His approach breaks the denominational and legalistic straitjacket of the field in the last twenty years. I discussed some of these issues when I posted on Immanuel Jacobovits here and here.
A Dialogue on Jewish Medical Ethics – Alan Jotkowitz MD,
Associate Professor of Medicine, Ben-Gurion University of the Negev, Beersheva, Israel
There has been an explosion in interest in Jewish Medical Ethics since the publication of Lord Rabbi Immanuel Jakobovits monumental work Jewish Medical Ethics and culminating in Avraham Steinberg’s Encyclopedia of Jewish Medical Ethics. Scholars and Rabbis have over the last fifty years developed a particular Jewish bioethics and given an authentic Jewish response to such questions as end of life care, artificial reproduction and abortion. Notwithstanding these achievements I think there are five fundamental areas that future Jewish bioethicists have to pay particular attention to.
- An authentic Jewish ethical response is heavily dependent on Talmudic sources and precedent. However many modern ethical questions simply have no precedent in the Jewish sources as Louis Newman has pointed out in his landmark article On Woodchoppers and Respirators The Problem of Interpretation in Contemporary Jewish Ethics. (1) For example, how does develop a Jewish approach to such questions as cloning and the development of human-animal chimeras (not to mention the rapidly growing fields of public health ethics and bio-environmental ethics) where there is a paucity or absence of halakhic material. Jewish ethicists in the past have relied on aggadda and Jewish theology to help answer these questions but this also raises the methodological question of how to use these sources to develop normative law. (2)
- Another question related to Jewish medical ethics is what is the relevance of the field to general medical ethics? In other words why should a non-Jew care about what the Jewish tradition says about a particular area? Daniel Callahan has argued that for the benefit of an extensive exposure “to the accumulated wisdom and knowledge that are the fruit of long established religious traditions. I do not have to be Jewish to find it profitable and illuminating to see how the great rabbinical teachers have tried to understand moral problems over the centuries.”(3) From a different perspective David Novak has long claimed that halakha and particularly the seven universal commandments, from which most of JME is derived, are rooted in natural law and therefore have universal applicability. (4)
- In modern secular medical ethics there is a consensus that the ultimate decision maker should be the patient or their surrogate. Autonomy is one of the four basic principles of modern bioethics (and some say the ultimate principle) and the Charter on Medical Professionalism, which states as one of its cardinal principles “Physicians must be honest with their patients and empower them to make informed decisions about their treatment.” (5) Traditionally, from a Jewish perspective the Rabbi has been the ultimate authority and the question arises in the modern healthcare environment if that is still a tenable position. Rabbi Emmanuel Rackman has even gone as far as to suggest in relation to triage that “”when one must choose between two persons, who will live and who will die, the decision must be that of the person who will act upon it and not that of the state or any of its duly authorized agents. ….the rich legal literature of Judaism provides him with no imperatives. No court will authorize his action in advance and no functionary of the state will or should be his surrogate to decide for him. The only sanction he may suffer will come from his conscience and public opinion. His problem is exclusively ethical and not legal in character…. It seems to me that human beings who are confronted with the problem of making a choice must evaluate all the circumstances and make their own decision”.(6)
- The question also arises of whether there can even be a Jewish bioethics due to the lack of consensus even among ultra-orthodox authorities not to mention inter-denominational differences of opinions. For example Rabbi Moshe Feinstein and Rabbi Eliezer Waldenberg, two of the greatest poskim of the twentieth century, have widely divergent opinions on such fundamental questions such as abortion and end of life care. An esteemed halakhic authority can come to the same conclusion as the Catholic Church regarding abortion and an equally distinguished authority can rule that even late term abortion is permitted in certain instances. If this is indeed the case then what is the meaning and significance of a Jewish bioethic?
- JME has traditionally been focused on the relatively straightforward clinical questions such as how aggressively to treat a patient at the end of life or in which cases an abortion is permitted. However, there should be much more to a Jewish approach to these questions reflecting the traditional concern with character development and supererogatory behavior. For example, beyond the question of whether an elderly demented patient should be fed which relates to the question of quality of life versus sanctity of life, the commandment to respect your parents and the obligation to feed them should enter into the discourse. (7) The requirements of Bikur Cholim and confession before death and how they are done appropriately should be a factor in the Jewish discussion of the doctor-patient relationship and professionalism. (8,9) However this perspective has been missing in may modern presentations of JME which tend to focus more on the dry legal issues and less on how these dilemmas relate to the development of an altruistic and empathic personality. These latter concerns have been a staple of those concerned with virtue ethics and should also play a role in JME.
- Newman L.E. Woodchoppers and Respirators: The Problem of Interpretation in Contemporary Jewish Ethics. Modern Judaism 10:2 (February 1990):17-42.
- Alan Jotkowitz Nomos and Narrative in Jewish Law: The care of the dying patient and the prayer of the handmaid Modern Judaism in press
- Callahan, Daniel. 1990. ” Religion and the Secularization of Bioethics” Hastings Center Report , Special Supplement: “Theology, Religious traditions and Bioethics” 20, no 4. (July/August): 2-4.
- David Novak The Sanctity of Human Life Washington DC: Georgetown University Press 2007.
- “Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002 136(3):243-6.
- Emanuel Rackman Priorities in the right to life Tradition and Transition: essays presented to Chief Rabbi Sir Rabbi Immanuel Jakobovits to celebrate twenty years in office Ed. Jonathan Sacks London: Jews College Publication 1986. pp235-244
- Jotkowitz A, Clarfield AM, Glick SM The care of patients with dementia. A modern Jewish ethical perspective Journal of the American Geriatrics Society. 2005:53:881-4
- Jotkowitz A. Clarfield AM The Physician as Comforter. European Journal of Internal Medicine. 2005; 16:95-6.
- Jotkowitz A , Glick S. Confession at the end of life: A Jewish perspective. Journal of Palliative Care. 2005; 21:57-8.
“(3) We need a greater recognition of the role of patient autonomy is needed, similar to Western medical ethics. This goes with a lesser rabbinic presence.”
Why? That’s like shooting the arrow and then drawing the bull’s eye around it. He is clearly less interested in ethics and more in rationalizing an a priori utilitarian desire. Let him argue why patient autonomy should be an important priority in Jewish medical ethics and see whether that is generates a halakhic consensus.