(2009/5770)

Last week we began our discussion of choices involved in national health care in Israel where the government provides medical insurance for all of its citizens.  We noted that Halacha does not seem to obligate a Jewish government to provide health care for its residents.  However, we noted that a community or nation should decide how best to grapple with challenges associated with health coverage and that the decision should be made for the betterment of the community and not of individuals’ self-interests.  Israel has historically chosen to provide health care for its residents despite the lack of a Halachic obligation to do so.

We began to discuss the question as to whether Halacha permits the Israeli government to include in the “basket of medicines” covered by the national health insurance, those medicines that resolve severe but not life threatening illnesses such as psoriasis and blindness over medicines that will briefly extend lives (but do not cure disease).  We cited Rav Eliyahu Bakshi-Doron who rules that Halacha always requires choosing the life-extending medicine in such circumstances.

On the other hand, we also noted that Rav Yuval Sherlow seeks to marshal arguments that would permit the government to choose the medicine that relieves ailments that greatly detract from quality of life over certain life extending treatments.  We noted that Halacha permits or might even require a government to choose an option that will cost lives of some in the near-future but will save the lives of many more people in the future.  

An example of such conduct is Rav J. David Bleich’s approving (Tradition Spring 1992 p.66) the reported action of British Prime Minister Winston Churchill during World War Two.  It is alleged that Churchill had the knowledge that the Germans would be bombing Coventry a few hours in advance yet did not warn its residents to seek shelter.  He reasoned that this would inform the Germans that the British had broken their communication codes.  He felt that this would cost many mores lives in the future, having lost this major advantage.  Rav Bleich is willing to consider “ignoring the imminent danger to a smaller number in order to prevent future danger to a larger number of people” if “it is certain or virtually certain that the future danger will become actual.” 

Rav Sherlow cites Rav Yitzchak Zilberstein (Chashukei Chemed, Pesachim 69b s.v. Yachid Nami) who writes: “In regards to the priorities government authorities must assume, and the question is whether to develop a transplant department or the emergency room department, I understood from my father-in-law [the eminent Rav Yosef Shalom Eliashiv] that the needs of a community are also considered Pikuach Nefesh.  Indeed the Halacha essentially obligates us to save as many sick individuals as possible and to invest the money into emergency care and not in the transplant unit.  However, it is impossible to either close or not develop the transplant unit, because the needs of a community are also considered Pikuach Nefesh.  If the transplant department would close, it will strike fear in the community, and people will not want to live in this country as it states in tractate Sanhedrin (17b) that it is forbidden for a Torah scholar to live in a city which does not have a doctor, and people will feel as if they live in a desert.  Therefore, even though a transplant unit requires more investment and with that money more lives could be saved, nonetheless the very existence of such a unit calms the community with the knowledge that in case of necessity transplants are available.  This is considered Pikuach Nefesh.”

Nedarim 80b – Life vs. Laundry

Our dilemma depends to a great extent on the resolution and explanation of a somewhat puzzling Tannaitic dispute recorded in the Gemara (Nedarim 80b).  The Tanna Kamma (first recorded opinion) asserts that if one town has sufficient water for both washing clothes and drinking and a neighboring town has no water even for drinking, the first town must give of its water it would use for washing clothes and give it to the neighboring town to drink.  Rabi Yosi astonishingly disagrees and rules that the first town need not share their water for washing clothes even to save lives.  The Gemara explains that the first town has priority since if they do not wash their clothes, they will lose their sanity. 

Rav Sherlow derives from this Gemara that one need not sacrifice one’s medicine to alleviate severe pain or prevent blindness in order that another should have his life briefly prolonged.  Rav Yisrael Rozen, in an editorial critique of Rav Sherlow, cites Beit Shmuel (80:15) to demonstrate that mainstream Halacha accepts the opinion of the Tanna Kama instead of Rabi Yosi.  In addition, he cites Teshuvot Achiezer (Y.D. 2:23, Teshuvot Igrot Moshe Y.D. 1:145 and Rav Unterman, B’Tzomet HaTorah VeHamedina 3:313) as limiting even Rabi Yosi’s ruling to where the residents of the neighboring town would suffer more than the first town but would not die. 

Rav Sherlow’s Conclusion

Based on above, Rav Sherlow presents the following nuanced approach, which contrasts sharply with Rav Bakshi Doron’s absolute stance regarding this difficult dilemma: “The Halacha permits, and possibly might obligate, to include in the basket of medicines that redeem patients from excruciating pain, despite the fact that as a result medicines that briefly prolong life (but do not cure disease) will be excluded from the basket.  The community is obligated to take extra precaution in these decisions, due to the danger of denigrating the importance of every moment of life.  The stature of the Torah’s view of the holiness of life teaches that despite the permission to include medicines that improve the quality of life, the importance of life saving medicines and medicines that lengthen life should enjoy priority over other medicines.”

Rav Sherlow, following in Rav Eliashiv and Rav Zilberstein’s footsteps, is concerned that Israel would be rendered an undesirable place to live if its national health insurance did not offer medicines to prevent blindness and alleviate painful skin diseases such as psoriasis. 

We pray that the individuals entrusted to resolve the difficult dilemmas concerning health care coverage, whether in Israel or elsewhere, do so in the spirit of the Halacha which seeks to balance the needs of individuals and community without one necessarily outweighing the other.  In addition, we pray that all involved in the decision making process do so with intelligence, sensitivity and for the sake of long term interests of the country.