Community Magazine April 2012

the word “ with you ” connotes subservience. “You” are the primary focus, and your brother, who is secondary to you, will come along “with you.” 3 How Much is Too Much for a Captive? There are two Talmudic sources that discuss limited resources on a communal level. In Masechet Gittin (45a) , the Mishna establishes that communities should not redeem captives for more value than they are “worth,” due to the concern for tikkun ha’olam (the benefit of society) . The Gemara investigates the precise intent of the Mishna’s reference to tikkun ha’olam , asking whether the concern is to avoid the undue hardships the community would face if it must redeem all captives at any cost, or to avoid encouraging kidnappers to continue their criminal behavior. The Gemara tries to solve the question by bringing the case of Levi Bar Darga, who ransomed his daughter for 13,000 golden dinars – an exorbitant sum of money. This would seem to prove that the reasoning of the tikkun ha’olam refers to the undue hardship caused to the community, and thus allows for individuals to personally ransom captives for exorbitant prices. But the Gemara rejects this proof, noting that Levi’s payment of this sum was not necessarily sanctioned by the rabbis, and thus cannot be used as a halachic precedent. The Gemara leaves the question unanswered. 4,5 The third source in the Talmud that discusses limited resources is found in Nedarim 80b, where the Gemara addresses the case of a natural spring that supplies water to two towns, the second of which is downstream from the first. What would happen if there was a drought, and there was only enough water for one town? The Gemara posits that when it comes to human life, a person is obligated to ensure his own survival before considering the lives of others, and thus the first town should use whatever water is needed to sustain the lives of its people before considering the lives of people in the town downstream. The Gemara then proceeds to discuss different 3 See the aforementioned commentaries of the Maharsha and Hazon Ish who address this case further, addressing questions such as whether the halacha would be different if the jug belonged to both of them, or to a third party. 4 Which understanding is the decisive one? Additionally does it matter who is the captive, and what are the conditions of the captivity? There are different opinions as to which reasoning applies. See the Tur (Yoreh De’ah 252:4), and the accompanying Beit Yosef, Rabbi Yosef Karo, for further discussion as to which reasoning is the accepted rationale, and what the practical differences might be. 5 See Rabbi Moshe Hershler’s Halakhah U’refuah vol. 3, where he discusses whether and how the kidnappers’ motives might affect the halacha in this case, and if it matters whether they plan on killing or merely tormenting the captives. permutations of the above scenarios, suggesting that even the future needs of the first town can take precedence over the current needs of second town. A fourth possible Talmudic source relating to the discussion of limited resources is quoted by Rabbi J.D. Bleich 6 , within a halachic investigation of medical insurance. The Talmud in Baba Batra (7b) discusses the responsibility of individuals toward the needs of their society. The Mishna establishes that the townspeople may compel one another to contribute to the cost of erecting a wall and fortifications as protection from bandits and military assault, even in times of peace. In other words, “financial cooperation can be compelled even though there exists no imminent threat.” Here, the issue is the obligation upon individuals to contribute from their own limited resources toward the needs – both present and future – of the community. 7 From Babylonia to Capitol Hill Can we broadly apply the aforementioned sources to the healthcare crisis that is looming on the horizon? The Gemara’s discussion in Gittin concerning the ransoming of captives demonstrates three principles relevant to our subject: 1) we recognize society as an entity; 2) this entity has limited resources; 3) most importantly, we must refrain from bankrupting the government. From the Gemara’s discussion in Nedarim concerning the stream of water , we could make several applications. It would seem that anyone currently receiving medical care should continue with that level of care, even if it would be at the expense of other individuals who currently have a need that is being unmet. Eliminating necessary medical procedures, drugs, or tests does not seem to be a possible option. Also, present concerns take precedence over future concerns, and as such the government should not limit the current level of care to save for future needs. Additionally, we could extrapolate that spreading the current level of resources over a greater population, which could compromise the care of those already receiving healthcare, would not conform with Talmudic policy. 8 One of the conclusions that we can make is 6 Bioethical Dilemas: A Jewish Perspective . 7 This concept of compelling individuals to contribute for future expenditures is akin to tax contributions towards the Social Security and Medicare programs. 8 This is similar in concept to the Gemara’s discussion about water in the desert in Baba Messia as well, and one of the central points of “Obamacare.” that the government must eliminate wasteful expenditures, or cut spending in other areas in order to offer healthcare to more people. In theory, the government can also increase revenue by raising taxes on individuals, similar in concept to the Gemara’s ruling in Baba Batra, however, there too, waste must be eliminated prior to compelling individuals to give more to society. For me, both as a physician and an observant Jew, a certain internal dichotomy exists. As a physician, everyday I see individuals who are uninsured, and as a result, probably refrain from visiting physicians, leading to poor health, and just as importantly, more costly treatment in the future for ailments that potentially could have been prevented. On the other hand, if we try to insure everyone simply by dividing the funds among a greater pool of patients, then medical care suffers for everyone. Insurance companies will be ever more difficult, doctors will be forced to see more patients and spend less time with each of them, and patients will find it harder to see the doctor of their choice when they want to see them. As a result, the patient will be the one to suffer from all sides. As a religious Jew, it should be obvious that our sacred Torah recognizes the responsibility of society for less fortunate individuals, as well as the individual responsibility we all have for the greater community. On the other hand, we also each bear a religious responsibility to, first and foremost, take care of our health to the best of our ability, something that will become more difficult if “Obamacare” goes into effect. These are but a few of the different perspectives that emerge from the Talmudic sources. Clearly, twomillennia ago theTorah had already addressed the modern issue of limited resources. While a sound solution to the current political conundrum remains elusive, the timeless Torah principles of societal needs versus individual needs, and that of individual precedence versus equality, form the basis of this debate and will, hopefully, form the basis of its ultimate resolution. 9, 10 This essay was written as a theoretical analysis of the issues, and is not intended to establish halachic norms nor dictate how one should vote on Election Day. 9 For further discussion, the reader is referred to Encyclopedia of Jewish Medical Ethics, Rabbi Avraham Steinberg M.D., Bioethical Dilemmas: A Jewish Perspective, Rabbi J.D. Bleich, and The Schlesinger Institute for Jewish Medical Ethics website for articles on Priorities in Medicine. 10 These sources are also quoted within discussions regarding limited medical resources on the individual level, such as cases of two critically ill patients and one intensive care unit bed, a triage of victims of terrorist attacks and their treatments, and priorities in medicine generally. NISAN 5772 APRIL 2012 23