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Journal ofmedical , 1983, 9, 109-112 J Med Ethics: first published as 10.1136/jme.9.2.109 on 1 June 1983. Downloaded from

Jewish - a brief overview

Sir Immanuel Jakobovits ChiefRabbi ofthe Brintish Commonwealth

Editor's note Emphasis on ethics This paper outlines the traditionalJewish approach to Paramount throughout this long and highly creative medical ethics, as perceived by the ChiefRabbi ofthe association between and has been British Commonwealth, himselfan academic specialist in the emphasis on ethics as their common denominator. thisfield. It is based on a 'St Paul's Lecture' given to the Building materials for the imposing edifice of Jewish London Diocesan Councilfor ChristianJewish medical ethics came from all strata of our religious understanding. literature, while the architects were legal experts, who, In medical ethics converge two of the Jewish people's as already noted, often combined rabbinical and most notable contributions to the progress of hum- medical experience. The provided the foun- anity: medicine and ethics. From the beginning, our dations: the sanctity and of human life, the people have shown a special concern with the healing religious duty to preserve health, an uncompromising art. Already the Bible includes in its religious legi- opposition to superstition and irrational cures, in- slation some revolutionary concepts of preventive cluding faith-healing, a rigid code of sexual , medicine and public health. In the we find, and many basic definitions of moral imperatives in among the numerous medical references almost 2,000 medical practice, including the of the dead. years ago, the earliest mention of such innovations as By the way, these rights, as defined in Deuter- artificial limbs, some form of artificial insemination, onomy, expressly extend even to executed criminals, oral contraceptives and Caesarian operations on living and I need hardly stress how significantly this provision http://jme.bmj.com/ mothers. Many authors of the Talmud themselves alone contrasts with the callousness of other legis- practised medicine. They were succeeded by what lations, ancient and modern, which treats the bodies of became, in the Middle Ages, the common pheno- such criminals and of so-called 'unclaimed persons' as menon of the -physician. Indeed, it is estimated res nullius and denies them the claim to dignified burial. that over one-half of the best-known rabbinical The impact ofthe biblical tradition on the development scholars and authors - philosophers, poets, exegetes, of medical ethics in Western society may be un- grammarians as well as - in medieval times were derstood when it is contrasted with the Code of on September 25, 2021 by guest. Protected copyright. physicians by occupation; men like , Hamurabi and other ancient legislations which pro- , the Ibn Ezras, Ibn Tibbons and vided, for instance, for the amputation of a doctor's countless others. arm if he proved unsuccessful in an operation on his These historical antecedents no doubt contributed patient! significantly to the extraordinary predilection among On these biblical foundations, the Talmud (the for a medical career in modern times. Only an depository of the 'Oral Law' finally edited about attitude conditioned by centuries ofnurture could have 500 C E) established the legal framework in virtually produced such a disproportionate preoccupation with all fields ofmedical ethics, setting forth the main prin- medicine as to have enabled Jews to receive some 20 per ciples on such problems as , , con- cent of all Nobel prizes for medicine - a proportion traception, sterilisation, malpractice claims, etc. The more than 40 times the ratio of Jews in the world! Talmud, followed by the great codes of Jewish law, Likewise most leading medical historians were Jews; even enacted certain eugenic laws against marriages one recalls names like Max Neuberger, Arturo Cas- suspected to result in physically or morally diseased tiglioni, Charles Singer of this country, and Joshua children. Anyone who has read the famous Oath of Leibowitz and Sussman Muntner ofIsrael. Asaph Judaeus (7th century) or the medical writings of other early Jewish notables in the history of medicine Key words will recognise at once how profoundly the spirit of the ; history of Jewish medicine; abortion; Bible and the Talmud suffused their ethical outlook. contraception; euthanasia; experiments on humans; genetic Little wonder that there never existed a Jewish form of engineering; medical ethics trining. the Hippocratic Oath, though there were Christian and 110 Sir ImmanuelJ7akobovits J Med Ethics: first published as 10.1136/jme.9.2.109 on 1 June 1983. Downloaded from

Mohammedan as well as pagan versions of it. Jews law), is inclined to permit the abortion ofan embryo in simply fell back on their own ethical heritage. the earliest stage of gestation if the mother has And it was left to the voluminous rabbinical res- contracted German measles, the late Chief Rabbi ponsa, issued in increasing profusion over the past Unterman ofIsrael adamantly opposed the destruction 1000 years, to interpret and apply these in of any potential human life unless the mother's life the light of contemporary conditions and the advance were in jeopardy. of medical knowledge and techniques. There are now But virtually all recognise only a strictly being published annually, notably in Israel, hundreds medical motivation for abortion, and they would not of such rabbinical responsa or verdicts - ranging over sanction the termination of a pregnancy unless there the entire gamut ofethical problems in medicine, from were some grave physical, or even psychiatric, hazard transplants to artificial insemination, and from ex- to the mother's life, however remote, provided every perimentation on humans or animals to autopsies. The such capital judgment - which literally determines responsa serve as case-law in the evolution of modern whether a human life is 'to be or not to be' - is most Jewish law. As a consensus gradually emerges from the scrupulously considered on the strength of the best many often conflicting judgments given, this consensus available medical evidence and in consultation with is recognised as a valid precedent and embodied in the competent moral experts. accepted corpus ofrabbinic law. Similar considerations govern the attitude to birth control. Where genuine fears exist, attested by reliable medical opinion, that a renewed pregnancy might pos- Abortion and contraception sibly cause some serious risk to the mother, rabbinical verdicts on the use of contraceptive precautions would Let me give just one example to illustrate this process in generally be liberal. Once again, of course, each case rough outline. The Bible does not specifically deal with would have to be judged on its own merits, and Jewish either criminal or therapeutic abortion. But in legi- law would make some distinction between different slating on the liability for assaulting a pregnant mother types of devices, oral contraceptives being regarded as and causing a miscarriage, the text in the Book of the least objectionable. But purely social or economic Exodus (21:22) implies that the destruction of an reasons, let alone considerations ofsheer convenience, unborn child is not culpable as murder, and that the would never be regarded as a valid indication for the fetus does not, therefore, enjoy the same absolute title artificial frustration ofthe act and duty ofprocreation. to life as an existing human being. The Talmud takes For legal purposes, ie to override or modify religious this an important step further by ruling in favour ofan laws, Judaism would therefore not unreservedly accept embryotomy where a difficult delivery otherwise the World Health Organisation (WHO) definition of http://jme.bmj.com/ threatens the mother's life. In any mortal conflict health 'as a state of physical, mental and social well- between mother and child, the ruling insists that her being'. While it naturally seeks to promote the social life enjoys priority, if necessary at the deliberate health of society and its members, by numerous laws expense of the child, provided its head or the greater and enactments designed to advance human welfare in part of its body has not yet emerged from the birth- every sphere, social and economic considerations by canal (which is the legal definition of birth). Judaism, themselves do not automatically suspend religious or therefore, in contrast to Catholic teaching, would moral imperatives in the same way as purely medical regard it as a grave offence against the sanctity oflife to factors do. on September 25, 2021 by guest. Protected copyright. allow a mother to perish in order to save her unborn The most popular argument commonly advanced in child. In other words Jewish law distinguishes between connection with both abortion and birth control, that potential (unborn) life and existing or independent is, the artificial prevention or termination of a preg- (born) life, only the latter being absolute in and nancy, is the fear of 'population explosion'. Quite therefore inviolate, rendering its destruction an act of frankly, ifthe nations affected - maybe the Indians, or murder. Nevertheless, the unborn child, in different the Chinese, or some South American peoples-were to stages from the moment of conception, enjoys a very ask me as a rabbi for moral advice on how to cope with sacred title to life which can or must be set aside only in their very real problem of a teeming population out- the most exceptional circumstances. running available food supplies, I would not find it too This and some other Talmudic principles were then difficult to provide an answer. The fear ofstarvation is used in the numerous rabbinical responsa of the past certainly a threat to life which could easily justify cer- few centuries (and especially of very recent times) to tain measures to control population growth. But so far provide judgments in more complicated circum- these nations have not asked me for my advice, and I stances, for instance, in cases of rape or , or of would be quite happy if I succeeded in prevailing on suspected deformities in the child resulting from the Jews to accept the directives ofJewish ethics. effects of rubella (German measles) or drugs like Jews are facing today, and have always faced in the thalidomide during early pregnancy. Often differences past, numerous problems and difficulties. But popula- ofopinion still remain unresolved. For example, while tion explosion is not one of them. On the contrary, we a leading member of the Israel Chief Rabbinate, a face the opposite problem of population shrinkage. specialist on medicine in the Halacha (Jewish religious Our birth-rate both here and throughout our dis- Jewish medical ethics - a briefoverview 111 J Med Ethics: first published as 10.1136/jme.9.2.109 on 1 June 1983. Downloaded from persion, and notably in Israel, is appreciably lower than we would rob all human beings of their absolute claim that of the general population around us. In fact, we to life, making it merely relative-to their expectancy of hardly produce enough to maintain our existing life, or their state of health, or their usefulness to numbers, let alone to replenish the calamitous losses we society, or to any other arbitrary criterion. No two sustained in the Nazi Holocaust with the destruction of human beings would be equal in value. For their one third ofour people. And out ofthe sparse numbers worth, being reduced to a fmiite scale, would depend on that we do produce we lose too many, through drift and any variety of physical or social means tests. Con- assimilation. The result is that, for the first time in our sequently, Jewish law brands direct euthanasia as millennial history, we are facing and widely discussing murder. But under certain carefully defined con- the problem ofJewish survival. ditions, it might not require the physician to prolong Hence, for us the problem of abortion and contra- the agony by artificial or 'heroic' methods, permitting ception, quite apart from the intrinsic moral considera- him to withdraw such treatment in completely hopeless tions involved, is of paramount demographic cases of lingering life. But on the precise verdict in significance to the future ofour people. these cases there is still some debate in current rabbinical writings. Sanctity ofhuman life And just as infmity cannot be reduced by division, making 'half a life any less valuable than a full life, so In more strictly professional terms, Jewish medical infinity cannot be increased by multiplication, making ethics is also often at variance from the norms devel- a million lives any more precious than one life. We oped in secular law and common practice. To take a would therefore never be justified in sacrificing or classic example, ifone sees a two-year-old child drown- deliberately risking a single life however many others ing in a foot of water, neither a doctor nor any other may thereby be saved, and it is wrong to subject people, passer-by is under an obligation to help the child, at even with their informed , to possibly hazard- least not in British law. In Jewish law, such conduct ous medical experiments, unless the subjects them- violates the Biblical precept: 'You shall not stand upon selves might be helped in a gamble to save their lives in your neighbour's blood'. Hence, the Shukhan Aruch the absence of any tried cures. In other words, experi- (the final codification ofJewish law ofthe 16th century) ments involving possible risks of life must not be per- rules that to engage in medicine is a , a religious formed even on volunteers who are healthy; such risks precept or , and any doctor who refuses to attend could only be justified ifthe subjects themselves would to those in need is guilty of bloodshed, just as a quali- be the beneficiaries were the experiment to succeed. fied rabbi who fails to practise his vocation is held responsible forthe spiritual victims slain by his default. Similar considerations apply to the present state of

transplant surgery. While Jewish law raises no objection http://jme.bmj.com/ Worse still - dare I mention this- theShukhanAruch to corneal grafts, with certain safeguards, nor indeed to debars physicians, engaged as they are in the fulfil- any organic transplants, in , it views with grave ment of a religious duty, from receiving payment for concern the indecent haste with which doctors and their skills, just as rabbis were expected to give their hospitals have competed in these premature operations religious services free - a practice commonly observed at the cost ofscores oflives and offalse hopes raised and until the rabbinate became professionalised in fairly dashed in thousands of sufferers. Jewish law insists, recent centuries. But doctors may derive some relief - firstly, that no vital organ be removed from a donor - and profit from the omission of this rule about until is defmnitely established by the actual on September 25, 2021 by guest. Protected copyright. physicians in the code of Maimonides who was, of cessation of all essential life functions, including par- course, himself making a lving from medicine because ticularly respiration and pulsation, and not merely by he refused to be paid for his rabbinical work. what is termed 'clinical death', such as irreversible Physicians and rabbis are also treated alike in respect of brain damage. It insists, secondly, that such operations their liability for caused by negligence or must not be continued unless they have passed the errors ofjudgment. purely experimental stage and offer recipients a reason- In a brief historical survey of such wide-sweeping ably hopeful prognosis. dimensions and subject matter, I am forced to limit my It would be wrong, therefore, to manipulate one life, references to some more modern issues to the barest even if only maintained by artificial life-supports, for outline ofthe principal conclusions. the sake of another - for instance, by switching off the In the matter of euthanasia, for instance, any respirator sustaining the 'clinically dead' donor (whose deliberate act to hasten death, whether with or without heart is still beating) when the recipient is ready to the patient's consent, is incompatible with the Jewish receive the former's organ. One would have to await understanding of the . Judaism regards complete death either by allowing the machine to run every human life (from the moment ofbirth) as being of out on its own or by not re-applying it, but not by an infinite value. Infmnity, by defmiition, is indivisible, so action calculated to induce death, ie turning the switch. that any fraction of life, whether 10 years or a minute, As for the recipient, such operations may only be whether healthy, crippled or even unconscious, re- carried out after they have proved successful on ani- mains equally infinite in value. By attacking the ebbing mals, and provided always that the sole object of per- life ofa terminal patient because it is deemed worthless, forming such operations on humans is to save the life of 112 Sir ImmanuelJakobovits J Med Ethics: first published as 10.1136/jme.9.2.109 on 1 June 1983. Downloaded from the patient at hand and not merely to assemble research widely-publicised statement: 'The prospect is that data and experience for the treatment of future will learn how to create a number of identical patients. In the absence of any known or proven cure, human beings exactly as you would breed prize cattle', any high-risk treatment or experiment can only be or, I might add, as you manufacture cars on assembly sanctioned if the subject himself is the intended bene- lines. This frightening statement precisely epitomises ficiary should the procedure prove successful. the challenge to medical ethics: In our blind march to Some years ago, on a visit to Cape Town, I had the mechanical perfection, shall we reduce man to prize opportunity of a fascinating discussion on the subject cattle, or to mass-produced machines? New medical with the celebrated pioneer ofheart transplant surgery, skills and insights, such as spare-part surgery and gene- Dr Christian Barnard. We found ourselves not unex- tic research, may open up a wonderful chapter in the pectedly considerably at variance in our definition of history of healing. But without strict moral controls death as relevant to the excision ofthe donor's heart. I and ethical guidelines they may also herald irretriev- found his attitude, in favour of an earlier moment of able disaster through man's encroachment upon time, certainly no less dogmatic than mine in attri- nature's preserves and the danger of assessing human buting an intrinsic value to life so long as it was not yet beings by their value as tool parts or sperm-donors or entirely extinct. living incubators or guinea pigs when they are alive, and as medical textbooks or suppliers of ersatz organs Chalienges of a technological age when they are dead. In our technological age, medicine, like science gener- In my fairly frequent opportunities to address medi- ally, threatens to turn homo sapiens into homo cal schools or professional groups on the subject, in mechanicus, treating him with his incomparable nature the UK or in America and especially in Israel I there- and dignity as if he were a soulless machine. In our fore never tire of advocating the inclusion of formal push-button world scientists, technicians and public instruction in medical ethics in the training ofdoctors, relations experts have usurped philosophers, thinkers nurses and hospital staffs. No student of medicine or and men of the spirit in determining the patterns of nursing should be deemed qualified without being human behaviour and the objectives of man's destiny. familiarised, in mandatory courses, with the ethical In this new dispensation, the physician, too, is wield- principles governing the healing art. Such training ing ever greater power. Human life is now at his should include some detailed introduction into the rele- bidding. He can generate it out of test-tubes and vant religious teachings likely to dictate the patients' terminate it out ofsyringes. He can regulate the size of commitments. Such instruction should not be left to a by contraceptive advice and feticidal opera- few haphazard extra-mural lectures or to incidental tions, and he can sway emotional responses by drugs remarks by conscientious tutors. Of course, I am par- and psychiatric treatment. Together with other ticularly anxious to see an Academic Chair in Medical http://jme.bmj.com/ scientists he will increasingly control human life, but Ethics established in the land which has inspired the the crucial question is, who will control the controllers? advance of civilisation and the moral law throughout As the delicately balanced fusion of body, mind and the world. soul and their interplay in human life, man requires a Nineteen hundred years ago our people, sustaining similar co-ordination of expert opinion in all three blows which would have proved fatal to any other fields when delicate decisions regarding his well-being nation, decided to prove that where there is life there is have to be taken. In respect ofthe soul, ifnot the mind, hope, preferring to live in abject misery and on September 25, 2021 by guest. Protected copyright. this should include moral specialists - whether rather than to choose the euthanasia of a heroic death for Humanist patients, moral theologians for Catholics, with glory which they could have had for the asking. or masters ofJewish law for Jews. Because ofthat choice, we are here today. May we now '' may soon surrender the very help a stricken humanity likewise to choose a life sus- building-blocks of life itself to the arbitrary whims of tained by the supremacy of the spirit over the body, of technical experts. Not so long ago, Dr James Shapiro, a ethics over mechanics, so that mankind may be leading researcher at Harvard University, said in a restored to universal health.