By Harofei Yaakov Ben Ben-Tzion Halevi - Jay B. Lavine, M.D.
Last revised 10 Nisan, 5768; April 15, 2008
1. Everything possible must be done for every patient in terms of preserving life, treating illness, and relieving suffering. All therapeutic decisions must be in the patient's best interests. The safest, gentlest treatment for a given condition must always be the preferred one. To ensure optimal care, physicians must constantly strive to maintain and improve their knowledge and abilities through continuous study.
Comment: Numerous sources in Judaism stress the supreme value of life. We are commanded to guard ourselves most diligently (Deuteronomy 4:15) and to choose life above all (Deuteronomy 30:19). In terms of Jewish medical ethics, the rest is merely commentary, to paraphrase Hillel. Physicians are given permission to heal and, moreover, are obliged to heal the suffering. Likewise, the sick must seek healing to preserve their lives.
2. Prevention is the highest form of healing. Drugs and surgery have their place in the holy art of healing, but the need to resort to invasive treatment must also be regarded as a failure in prevention.
Comment: We know that prevention is the highest form of healing from Exodus 15:26: "If you will listen carefully to the voice of the Lord your God, and do what is right in His eyes, and keep all of His commandments, I will put none of the diseases upon you that I have put upon the Egyptians, for I am the Lord your physician." God is saying here that He is preventing disease. Since, in preventing disease, we are emulating God, prevention is the highest form of healing. In light of Principle 3, Rashi's midrashic explanation of this verse is very interesting: he states that God in this context is like a physician who says to his patient, "Do not eat this food or it will make you sick."
Physicians do not usually discuss lifestyle changes with their patients. Prevention is on the back burner, and someone has to get burnt to get treated. Our secular society deems it reasonable to pay tens of thousands of dollars for coronary bypass surgery but unreasonable to pay a few dollars for prevention.
3. Nutrition is the primary determinant of health and the backbone of preventive medicine. Nutritional management should also play an important role in the treatment of disease. In this regard, a vegetarian diet, the ideal diet from medical, ethical, and Torah standpoints, should be offered, with various modifications, to every patient. Physicians themselves should be vegetarians, not only to serve as exemplars to their patients but also to develop and reinforce a respect for the sanctity of all life and a desire to prevent suffering in the world.
Comment: Maimonides held that "from a practical standpoint, knowledge of nutrition is of the greatest usefulness to the practice of medicine..." The influence of diet in such areas as immunity and coagulability of the blood is usually ignored in patients with infectious, neoplastic, cardiovascular, cerebrovascular, and other problems. Its role in prevention, as noted above, is neglected as well. The Torah tells us (Genesis 1:29) that in the ideal world of the Garden of Eden, God created man to be vegetarian. Subsequent permission to eat meat was a concession from the ideal state. When the Israelites lusted for meat in the desert (Numbers 11), God smote them with a plague "while the flesh was still between their teeth," and this plague continues to this day. Modern medical studies have confirmed the wisdom and ideal nature of a vegetarian diet. Lifestyle change incorporating a low fat vegetarian diet can reverse coronary atherosclerosis and prevent most myocardial infarctions. All the major forms of cancer, including lung, prostate, breast, colorectal, pancreatic, ovarian, lymphatic, and bladder, are linked to dietary factors. Increasing the consumption of fruits and vegetables to over five servings a day would lower the cancer death rate twenty years from now by over 50%. The incidence of hypertension, gallstones, kidney stones, obesity, non-insulin-dependent diabetes, and other diseases would decline drastically. Maimonides justified shechitah (ritual slaughter) based upon his mistaken belief that meat was necessary for health. If he had the advantage of today's medical knowledge, he would never sanction the consumption of meat.
Traditional Jewish thought supports the concept that our everyday actions influence our behavior. The observance of the laws, including those for which we do not know the reason, implants important messages in our psyche, helping to prevent the hardening of our hearts as Pharaoh suffered. As Maimonides indicates (Guide for the Perplexed 3:48), the Torah teaches us that nonhuman animals feel the same pain as humans do, and by learning and practicing compassion toward nonhuman animals, we become more compassionate toward our fellow humans. When we consume a product of violence, that violence then becomes internalized.
4. Jewish prayer should be recognized as a most important and powerful healing tool. Jewish prayers of healing are an integral part of patient care and should be further evaluated to determine how they may be used for optimal effectiveness.
Comment: Jewish law requires that we not rely on the occurrence of miracles. Therefore, we do not forsake medical treatment and rely on prayer alone. But medical treatment and prayer go hand in hand, and, in past years, many rabbis were also physicians. Prayers for healing are recited thrice daily on weekdays, and special prayers for healing are recited when the Torah is read. Such prayers should be recited with the proper spirit and intention, based upon a personal relationship with God and the belief that He can bring about change in our lives. Some Jewish physicians have also composed special prayers to help bring about healing in their patients. As the great physician Ambroise Pare said, "I treated him, God cured him." Recent studies have confirmed the beneficial effects on health and longevity accruing from either a religious lifestyle or from regular attendance at religious services.
5. The physician's office environment should promote good health. All office personnel should be non-smokers and waiting room magazines should be free of cigarette advertisements. Since people who care about their own health will care more about the health of others, and since empathic concern for patients depends upon strong ethical convictions regarding the prevention of suffering, office personnel should manifest a reverence for all life as well.
Comment: Doing everything possible to preserve life means helping patients make the right lifestyle choices to prevent illness. It has been shown that the acceptance of cigarette advertisements by magazines affects the content of the articles in those magazines. Although the American Medical Association has recommended that physicians keep only cigarette ad-free magazines in their waiting rooms, a negligible number of physicians have done so. Since medical office personnel can also have a major influence on patients, they should share the medical ethical convictions of the physician.
6. The physician should be regarded as the ultimate authority in all medical matters and should be the person primarily responsible for every patient's care. Ancillary medical personnel, such as physician's assistants, nurses, dietitians, and technicians, should be involved in the diagnosis, treatment, and prevention of illness only when under the direct supervision of a physician or when following the orders of a physician, as in the administration of medications or in the carrying out of dietary orders.
Comment: All health care personnel play key roles in healing. In recent years, however, non-physicians have been allowed to examine, diagnose, prescribe medication, and make major therapeutic decisions without even consulting a physician. They often make medical determinations for insurance companies as well. Optimal patient care requires that those best qualified make the decisions and carry out the care.
7. Medical quackery, which constitutes some but not all of what is commonly termed alternative medicine, must not be integrated into scientific medical practice, in accord with the Jewish tradition of respect for educated opinion and legitimate authority.
Comment: Medical treatment should incorporate all useful modalities, including some that have been ignored, such as acupuncture and the use of herbal preparations. Physicians should also recognize the mind/body connection and attempt to give patients the expectation of success in their treatment. Although Jewish law tends to be liberal with regard to unproven remedies, modalities such as homeopathy that epitomize the "emperor's new clothes" should not be used in place of proven therapies. There should be at least some evidence for the safety and efficacy of any therapy employed.
8. Managed care as generally practiced should be abolished as it works contrary to the patient's best interests. Limitation of patient choice of physician is especially unethical. Health insurance companies should maintain relationships with their clients and not with physicians.
Comment: Managed care (health maintenance organizations and the like) has profited only the insurance industry. Patients are often lost in the system and prevented from consulting the physician best suited to treat their particular problems. Managed care does not effectively reduce unnecessary surgery. It either limits all surgeries, hurting people who really need surgery, or it lowers reimbursement on all surgeries, playing into the hands of the high volume entrepreneurial surgeons and forcing ethical doctors out of the picture. We need some management of care to prevent abuse of the system, but such management should not be in the hands of the insurance companies. There are superior ways of reducing unnecessary surgery under the traditional fee for service system of medicine.
9. Tort reform is essential if physicians are to practice optimal medicine, treating each patient according to his unique needs without the fear of lawsuits.
Comment: While Jewish law recognizes the need for justice for those who are truly harmed as a result of negligence, it does not want to discourage good people from becoming physicians or inhibit the development and use of novel means of therapy. The current malpractice situation may be nothing more than a "business expense" to the unscrupulous, high volume surgeon, but it is an unbearable financial and emotional burden to the ethical physician who really cares about his patients.
10. A physician may not become wealthy from medical practice but is entitled to earn a good living. Medical fees should be determined by each physician and adjusted according to patient need. In accord with the societal importance of healing and the extensive educational background required for the practice of medicine, physicians' fees should be substantially higher than those currently allowed by insurance companies and other institutions. Emphasis on preventive care, competent treatment of illness, avoidance of unnecessary surgery, and honest billing practices will cause a substantial decline in health care costs even with higher payments to physicians for specific services.
Comment: In our secular society, which does not hold physicians in the same esteem as in traditional Jewish society, attempts are often made to "punish" physicians, who are perceived as making too much money, by reducing their reimbursement. Although the unethical physicians survive by spending minimal time with each patient, by having other practitioners see patients, and by performing unnecessary procedures, the conscientious, ethical physicians can barely make a living and are forced out, to the detriment of their patients.
11. An ethical physician earns money by providing services, not by selling products. All drugs, supplies, and other items provided to patients must not be sold for profit.
Comment: The sale of drugs and supplies by physicians for a large profit is unfair to the patient, who does not have the benefit of comparative shopping. The Talmud (Taanit 20b) relates that Rav Huna would dispense medications at no charge. Although such an action is not obligatory, Jewish law does place limits on the price of medicines. One who dispenses medication must charge no more than its actual value.
12. A physician and his employees may not accept gifts or gratuities of any kind, including utilitarian articles bearing product or company names, free dinners, and free services, from any individual, pharmaceutical company, optician, medical supplier, or other business to whom patients are referred or whose products are used in patient care. The need to maintain objectivity in patient care is self-evident.
Comment: Drug and other companies provide gifts such as these to influence physicians' prescribing patterns. A physician who prescribes a particular drug because of such an influence is not acting in the best interests of his patients. The Torah (Deuteronomy 16:19) warns judges not to take a gift, "because a gift blinds the eyes of wise men and distorts the words of the righteous." If this injunction applies to judges, how much more so should it apply to those entrusted with the care of human lives.
13. Advertising of a physician's services is unethical. An ethical physician acquires new patients by his reputation and by referral from other physicians and from patients. Advertising is, by its nature, deceptive, places a stepping stone before the blind, and causes patients to seek care from those who are not best suited to treat their individual illnesses.
Comment: Rashi felt that physicians who engaged in excessive commercialism were among those to whom the Mishnah was referring when it stated, "The best of physicians are destined for hell!" In the modern era, advertising has been used by unscrupulous physicians to lure the gullible into their lairs, where they are pressured into having unnecessary surgery and other procedures. Coincident with the lack of respect for reputation and for educated opinion which is now so prevalent in our society, people are no longer wary of the advertising doctor. Eliminating advertising would protect the gullible and lessen the problem of unnecessary surgery.
Comments by Jay B. Lavine, M.D.
In the eight years since its inception, the Jewish Medicine web site has served as a resource to its numerous readers, both Jewish and non-Jewish alike, who have inquired about Judaism and about its perspective on medicine. This epilogue is now offered to answer many of the questions about the intent and content of the site.
Who is Harofei Yaakov Ben Ben-Tzion Halevi? Every Jew has a Hebrew religious name that includes his or her first name, that of his or her father (and sometimes mother), and a designation indicating descent from the Levites or from the priests in ancient Israel, if appropriate. "Harofei" is simply the title "doctor." Thus, the Thirteen Principles are not the creation of an ancient sage but rather that of the present-day author of this site, yours truly, Jay Lavine, M.D. This revelation may be a bit of a letdown to some people, but it should not be. The principles of the past must be integrated with the reality of the present to deal with the problems in our current health care environment.
Why thirteen principles? The title is a takeoff on The Thirteen Articles of Faith, which were written by Maimonides, one of the greatest religious scholars of all time. In Judaism, thirteen is not an unlucky number, not that there is such a thing.
Conferences on Jewish medical ethics became fashionable about fifteen years ago, although the trend has diminished over the past few years. They have tended to focus on the standard medical ethical issues, such as brain death, organ transplantation, in vitro fertilization and surrogate motherhood, and other esoteric issues. However, the role of prayer in healing, important in any faith, has received short shrift, so to speak. The main weakness of these conferences is that they have failed to see the forest through the trees. The importance of the issues discussed pales in comparison to the main problem: the destruction of the health care system caused by greed and self-interest.
Unnecessary surgery has become the rule, not the exception. Many patients' medical problems are ignored or go undiagnosed, either because they see fee-for-service physicians who are only interested in persuading people to have surgery or because they go to HMOs that have a vested interest in limiting the care provided. Few people outside the sphere of medicine are truly aware of the situation. People have been brought up to trust their doctors, and, indeed, such trust is an important component of the patient-physician relationship. The gullible public likes to think that their doctors are the best, because it gives them comfort to believe that, but such blind trust is misguided in this day and age. They fail to realize that they are incapable of judging the competence of their doctors. They mistake the well-rehearsed appearance of competence and the likability of the doctor and his or her staff for true competence.
Some people do complain about some aspects of the health care system, but they do not realize that their own attitudes have made it what it is. The vast majority of the public thinks that doctors are highly paid, a delusion in stark contrast to the reality of the situation, which is that highly ethical doctors who refuse to compromise their standard of care in response to the demands of our health care system are barely able to make a living. When people see a doctor with an expensive car or other signs of wealth, they tend to think that he must be an excellent doctor, not that he's an unscrupulous one who is only interested in money. The Jewish ethic that doctors may not become wealthy from their medical practices is unknown to most.
If doctors are thought to be so wealthy, then there is no perceived need for tort reform with regard to malpractice issues. In many states, such as Arizona, referenda to effect tort reform have been turned down, and people are only too willing to be swayed by the deceptive trial lawyers. High malpractice premiums have contributed to the exodus of many ethical physicians but are just considered a business expense by the entrepreneurial surgeons.
Managed care, which has lowered payments to doctors for specific services, has also had a major detrimental effect, not on the high volume operators but on the ethical physicians who insist on spending enough time with each patient to properly assess each problem. They can hardly afford to do so any more. But, again, the public hasn't objected because of the perception that doctors make so much anyway.
Arizona, a state in which those in business must pay yearly property taxes on their equipment and other property, was the scene of another remarkable referendum some years ago. Voters approved a referendum to exempt cattle ranchers from paying property tax on the cattle they owned, but ethical physicians struggling to make a living still had to pay this onerous tax. What does this say about public attitudes toward health?
People may complain about waiting times in doctors' offices, but they tend to think more highly of those who have busy waiting rooms than they do of doctors courteous enough to space out appointments in an appropriate manner. Which doctors benefit from this mistaken belief?
A change in public attitude toward advertising by physicians has greatly contributed to the demise of the system. In modern times, advertising by physicians has been considered unethical. Physicians are supposed to build their practices based upon reputation. Most people, especially those in urban areas, grew up sharing these beliefs. But the advertising industry is able to change beliefs. Many patients now do not hesitate to patronize doctors who advertise, and, in so doing, they are supporting the most unethical and unscrupulous ones and pushing the ethical ones out.
Taking charge of one's health is a good idea but not when it means telling a doctor what to do. That is what is occurring when patients tell a doctor they want a certain drug advertised to them by the drug companies or even a surgery they think they should have. Most doctors today will give patients what they want even if it's the wrong thing. I once attended a continuing medical education lecture by a university physician who lamented the fact that 40% of antibiotic prescriptions given are unnecessary, resulting in our major problem of antibiotic resistance. Yet he admitted that when a patient with an obvious viral infection comes to him he often prescribes an antibiotic because he's afraid the patient will change doctors if he doesn't. A few decades ago, a well-known surgical ophthalmologist from California came to a major medical center in the Midwest to speak about the new field of intraocular lens implants. When asked what his indications were for inserting an implant in a cataract patient, he reportedly replied, "Because if I don't do it, the guy down the street will."
We have seen how the beliefs and behavior of the public have had a Darwinian effect in selecting out the worst and eliminating the best our health care system had to offer. Yet, The Thirteen Principles of Jewish Medical Ethics address only physicians. The reason for this is very simple. Even if the public by and large does not appreciate optimal medical care, physicians are still morally and ethically obligated to provide care in this manner. If they feel that they cannot do so in the current medical environment, then they should not be practicing medicine at all. It is sad indeed that many physicians who lacked a strong moral basis to their lives but nevertheless still practiced medicine with some semblance of ethics have fallen to the lowest common denominator, rationalizing their actions on the basis of the belief that if everyone does something it must be okay. The practice of medicine is holy from a Jewish standpoint and should not be defiled.
Over the years this web site has received many wonderful E-mails from its visitors, 90% of whom are non-Jews. Their comments have been very gratifying. Many, including some outside of Medicine, do sense the ethical collapse of our system and acknowledge the importance of one's faith in following the right path in life. Jewish values are widely respected. Unfortunately, the response I receive from the average person on the street of Jewish ethnic background to the topic of Jewish Medicine is not so gratifying. Most find it incomprehensible and say, "Does that mean you treat with chicken soup?" or "Does that mean you treat only chronic complainers?" The concept of a deeply held faith that dictates a way of life is a foreign one for many. I like to think that one function of a Jew is to cry "foul!" when an injustice is being done and everyone else is oblivious and looking the other way. Where have all the Jews gone?
"You are not required to complete the task, but neither are you free to stop working on it." (Pirkei Avot II:16)