Are We Obligated to Provide Medical Care?

Parshat Tazria: The Challenge of Wealth
Are We Obligated to Provide Medical Care?

The Negaim or various physical forms of impurity that form the subject of this parshah as well as that of the following one, Metzorah, could be construed as being caused solely by natural causes like other human diseases or health problems. This is indeed the opinion of Ralbag and Abarbanel. Most of our commentators, however, disagreed, saying that this would make the Torah merely a medical textbook. It is interesting to note that Maimonidies, the physician and arch-rationalist is among them. Sforno and S.R. Hirsch both point out that the disease leprosy does not constitute ‘tumah’ and that the examination by the Cohen only commences when symptoms of physical disease have disappeared. Furthermore, the quarantine imposed by the Torah does not apply during such periods of large scale public gatherings such as the Pilgrimage Festivals or the 7 days celebrating a wedding, when contagion would be most likely. In regard to the distinction between kosher and non-kosher animals, birds and fish, however, the Ramban sees only a spiritual reason whereas the Rambam considers the medical reason as legitimate.

Irrespective of the reasons for this difference of opinions, they can serve as evidence of concern for the provision of medical services and public health. The provision of medical care is considered an essential part of Jewish religious living, since the saving of a life [pikuach nefesh] takes precedence over many religious obligations. There is no question in Judaism that a man may, and should, avail himself of the services of a physician for medical care: the Rabbis understood that G-d had enabled the doctor to perform his services, making him a human agency for His healing powers. So a city that did not have a doctor was considered by the Talmudic sages to be unfit for a Jew to dwell in. However what concerns us here is how the services and costs of this medical assistance were to be financed.

The fundamental question with which the Jewish sources are concerned is the medical costs of the poor – since the wealthy are able to provide for these services, just as they do in the case of other goods or services that they need or desire. Halakhicially, a Jewish community or society, can, if it wishes, legislate free medical care for all; it cannot, however, escape its obligation to provide for the medical needs of the poor, even if it so desires. If, for example, they decided to change a publicly financed medical system to one based strictly on self-insurance, it may be assumed that halakhic authorities would require the community or society to bear the cost of insurance premiums for the poor, to be funded by the tax system.

The physician’s work was considered to be an obligation placed on the doctor by a Divine source, to be provided free of charge, since G-d alone was the real Healer. This is obviously not an economically sustainable system, and therefore permission was given to the physicians to take money. However, such payment was not for the specialized knowledge of the physician, but solely for his time, that is the loss of the alternative employment. While this may seem not to be of any practical importance, it does put the doctors’ work in a different category from all others. So for instance while strikes by workers are permitted halakhicaly, they are not permitted in the case of the doctors. Writing to his physician son, Samuel, the medieval Jewish physician Yehuda Ibn Tibon provides a guide for a personal solution to this problem that was typical of many Jewish doctors. “While you take your fees from the rich, heal the poor gratuitously. The Lord will requite you.” There is a halakhic opinion that the Bet Din can force a doctor to treat poor patients free of charge if there are no other doctors available (T’shuvot Mei Ahava, part 3: Yoreh De’ah, sections 336, 408).

Irrespective of this, the councils of many autonomous Jewish communities made decisions for providing for public financing of medical care. In Padua, Italy, in 1585 for instance, we find the following decision of the council: “It is decided to raise further funds in order to provide for the medical care for Shimon Levi Ginsberg. This shall be done both from the funds raised by [the Parnas] on every Tuesday [from the members of the various synagogues]; and also further funds are to be raised from a general charity [tax]”.

A further example of the use of communal funds to cover the costs of medical care is contained in an enactment of the community of Krakow in 16th century Poland: “Regarding a domestic who became ill, the employer is required to pay the costs of her hospitalization up to a period of two weeks. If she requires further treatment, the costs are to be shared equally between the employer and the employee for a fortnight. After that, all the costs are to be born by the communal charitable funds”. This enactment refers to the sick domestic as being hospitalized in the hekdesh, the communal hospital maintained by the community. We find many references to such hospices maintained by many Jewish communities throughout the Diaspora, which often served a dual purpose, that of inn for travellers and that of a hospital. Josephus Flavius mentions the synagogue erected in Jerusalem before the destruction of the second Temple, which served both as a hospital and an inn. In Talmudic days we hear of the cheder hashaysh that served as a place for the care of the sick. In 1373 the Nurenberg Memor book describes the bequest of one Samuel ben Natan Ha-Levi of 50 pounds to the hekdesh in that city, while in 1765 we learn that there were 18 patients in the Vilna hekdesh.

Effective medical care, however, involves not only the cost of the physician and hospitalization, but also requires a support system to alleviate the effects of illness on the peace of mind of the sick person and on the family unit. Modern medicine recognises such a support system as an intrinsic part of health care, and therefore expects it to be funded either by the patients’ health insurance or by the State. In the Jewish world, for 2000 years such supports have been part and parcel of our welfare system. The following ruling of Maimonides shows this support system to be halakhically binding and not just something desirable. “It is a Rabbinic commandment incumbent on all, to visit the sick and this may be done many times in the day. He who does not visit the sick, it is as though he has shed blood. It is a fulfilment of the Torah’s commandment, “You shall love your neighbour as yourself” [Leviticus, 19: 18]” (Hilkhlot Eivel, chapter 14, halakhot 1-5).

This support system like most moral and ethical injunctions in Judaism is not left to the choice of the individual but is a communal obligation, that the members should be coerced to fulfil, either through taxation or by personal effort. So we find the community of Avignon in 16th century France, enacting a statute that made it obligatory on all its members, men and women alike, to visit and nurse the sick. Those who did not were fined.

Even a society that accepts responsibility for providing medical care, in whatever form and scope, is faced with the problem of rationing scarce medical resources such as expensive drugs, hospital space and sophisticated machines. Obviously if these facilities are available as needed, there is no problem. Unfortunately, in real life scarcity does exist and therefore answers have to be provided. Contemporary halakhic authorities have addressed this for example in dealing with the allocation of scarce medical resources such apportioning intensive care units. Rabbi Waldenberg writing in present day Jerusalem, rules that the basis for allocation has to be medical criteria. This would mean that those with greater potential for cure would have preference (Tsitz Eliezer, part 9,sections 17 and 18).