V. ISRAEL

Medicine in Israel, like the country itself, is a blend of contrasts and contradictions, of compromises between tradition and modernity, between myth and reality. Israel, a tiny country made up of a dominant religion and culture (18 percent of the population are non-Jewish), is neither homogeneous nor monolithic. Over fifteen political parties are represented in the Knesset (parliament), and many Israelis are concerned about an ever-impending Kulturkampf between religious and secular factions.

Like all else in Israel, healthcare has been shaped by diverse inputs from a variety of lands of origin, and by the dialectic between the Mosaic and rabbinical tradition and modern Western secular humanism. Each of these major streams is itself heterogeneous. Lip service is paid to myths violated in practice, while traditions overtly denied and rebelled against often provide the spiritual sustenance in which rebels' values are rooted.

The ties that bind Jews to medicine are powerful and deeply rooted. Rabbinic leaders in the Middle Ages often practiced medicine for their livelihood, Maimonides being perhaps the best known in this tradition. In almost every society, Jews have been disproportionately represented in medicine. The most recent example is the 2.5 to 3 percent of Jewish immigrants to Israel from the former Soviet Union who are physicians, a ratio ten to fifteen times higher than that encountered in developed Western countries. The extraordinary value that Judaism places on human life explains in part the attraction of Jews to medicine. The Talmudic statement "He who saves a single life is regarded by the Scripture as if he saved an entire world" (Babylonian Talmud, Sanhedrin 37a) has led to the useful myth that life is of infinite value and to the "sanctity of life" concept that so permeates Jewish tradition.

The foundations of healthcare in modern Israel were laid by Zionist pioneers several decades before the creation of the State of Israel. These individuals were largely secularist, socialist ideologues with deep roots in the social justice ethos of Judaism and in the value placed on human life. Workers in 1912 created a "sick fund" for mutual assistance and healthcare insurance, similar in many ways to the Krankenkasse of Central Europe from which they had emigrated. But the principles underlying this Jewish institution were derived no less from the traditional principles of gemilut hadisim (loving charity or mutual aid) so clearly spelled out in the Torah, whose rituals the pioneers had often discarded or drastically modified. All were to be equal in the receipt of health care, and money was not to be collected from a person in time of need and distress. This nongovernmental Histadrut labor union sick fund continues to be the major healthcare provider in Israel today. It is both an insurer and a provider of healthcare, owning and operating hospitals and community clinics, and insuring about 80 percent of the population. Smaller sick funds, also funded by mandatory employee and employer contributions, cover the rest of the population.

During the last few years, as healthcare financing has become problematic worldwide—with citizens often placing a higher priority on such personal amenities as choice of physician and attractive waiting rooms than on the concept of equality—the egalitarian foundations of the healthcare system in Israel have been threatened. Gaps in the public sector are being met by a growing fee-for-service private sector. Nevertheless, Israel has managed to maintain both a respectably high level of healthcare and reasonably equal availability of this care, in spite of a relatively low national expenditure. Israel currently spends about 7.5 percent of its gross national product on health care, but since its GNP is considerably smaller than those of most Western European countries, the absolute per capita expenditure is modest.

Manifestations of the strong ethos for saving human life at all costs include the relatively high renal dialysis rates in Israel and the intense efforts made by the military medical corps to provide physician coverage virtually at the battle line, in order to enhance every possible chance to save soldiers' lives. Public appeals by private individuals regularly raise tens of thousands of dollars to send patients abroad for complex surgical procedures that are not performed in Israel.

Yet, simultaneously, there is much evidence that the myth of the infinite value of human life is often shattered in the face of economic realities. Open-heart surgery is rarely offered to those over eighty, and long waiting periods for critical surgical procedures are not uncommon because of limited resources. The distribution of physicians and facilities is not even, with development towns and Arab villages sometimes at a disadvantage compared with the major metropolitan areas. The continued public tolerance of preventable deaths due to smoking and traffic accidents also exposes the mythical nature of the commitment to human life "at all costs." Recently, however, there has been improvement in all these areas.

Consonant with the high priority given to life, the Jewish tradition, unlike Anglo-Saxon law, requires the physician to respond to a patient's call for help. This requirement to render assistance to someone in distress is not confined to the physician; it obligates any individual to come to the aid of a fellow human being. To refuse would fall under the prohibition "Neither shalt thou stand idly by the blood of thy fellow" (Lev. 19:16). A physician who does not respond to a sick patient's request is regarded as one who spills blood. This attitude is incorporated into Israeli secular law, under which a citizen's failure to render assistance at the scene of an accident is a criminal act. Just as the physician is obligated to render care, so is seeking of care by the patient mandatory. The reason for this obligation is that in Judaism, human beings do not possess full title to life or body. Humans are but the stewards of the divine possession they have been privileged to receive. The terms of that stewardship are not of human choice but are determined by the Almighty's commands. Jewish law forbids suicide and requires that all reasonable steps be taken to preserve life and health. When beneficence conflicts with autonomy, the former is given precedence by Jewish tradition, a view clearly in conflict with the modern Western consensus (Beauchamp and Childress).

While such a violation of autonomy for the patient's good is not enforceable in modern pluralistic societies, it is sanctioned in the Jewish tradition; and were Jewish courts fully empowered, they might force medical treatment on a patient if it were indisputably indicated. In modern Israel, in contrast with most Western countries, the courts have not always decided unequivocally for autonomy over beneficence. There has been at least one case where the Israeli Supreme Court permitted a surgical procedure against the expressed will of the subject in order to prevent danger to his life (Kortam v. State of Israel 40 [III] P.D. pp. 673–698).

Several medical ethical issues have attracted public attention in Israel over the years and provide interesting insights into the dynamics of Israeli society. For several decades, the issue of postmortem examinations and the laws regulating them were a major public and political issue (Glick). Judaism emphasizes respect for the human body in death as well as in life, and mandates early burial with integrity of the body preserved. Autopsies are permitted only if the information may contribute directly to the saving of a human life. With the creation of the first Israeli medical school, the rabbinate reached an agreement with the medical profession whereby autopsies would be permitted if three physicians attested that the cause of death was unknown. This exclusion of the deceased person's family from decision making and the subsequent frequent performance of postmortem examinations, even over strenuous family objections, turned the issue into a source of festering conflict. Subsequently, with a change in the political constellation that gave more power to religious parties, the law was changed radically as part of a backlash against the previous "liberalism." Not only is family consent now required, but other provisions, such as veto power for any member of the family, have led from one extreme to another. In all likelihood, the last word has not yet been said on the subject.

In spite of the religious limitations on postmortem examinations, the use of organs from the dead for life-saving transplants is religiously acceptable and even mandated. For many years, the hesitation of the rabbinate to accept brain death as the end of human life created difficulties for heart and liver transplants. After careful study, Israel's Chief Rabbinate in 1986 officially permitted heart transplants when donors' total brain death can be assured. This view has not been accepted by all rabbinical authorities, but religious objections now play a relatively minimal role in the limitations on organ transplantation.

Another area of conflict, as in most Western countries, has been abortion policy. Many factors lead to a restrictive policy in Israel. The Jewish tradition accords major rights to the fetus. The demographic and geopolitical situation of the Jewish people, particularly after the Holocaust, would seem to favor a strongly pronatal and antiabortion approach. Yet the Israeli public is quite permissive sexually, and its youth is very much a part of Western society.

The Israeli compromise, meant to satisfy all parties, includes a law forbidding abortions except for a "valid" medical or social reason, as determined by a hospital committee. These indications are liberally interpreted. Abortions performed outside this framework are illegal, thus satisfying religious sentiments. But no physician has ever been prosecuted for such illegal activities, thereby soothing the libertarians. This precarious balancing characterizes many of Israel's solutions to such conflicts.

Israel has a national committee appointed by the minister of health that advises the minister on many of the more complex and controversial areas in medical ethics, such as in vitro fertilization, genetic engineering, and the like. The committee, called the Supreme Helsinki Committee, is an outgrowth of a committee originally charged with the regulation of research in human subjects according to the Helsinki Declaration. It includes physicians, nonmedical scientists, jurists, philosophers, and clergy. It prefers to work by consensus rather than by vote, and makes every effort to weave its way through the maze of potential legal, religious, and sociopolitical conflicts. In the area of reproduction, the problems are great, since—unlike most areas of law that are adjudicated by the secular courts—marriage, divorce, and family law are largely in the hands of rabbinical courts (Shapira, pp. 12–14). Permissive decisions in the area of new reproductive technologies, unacceptable under religious law, might label the offspring of such practices as bastards, with serious consequences for them in their attempts to marry.

Israeli medical schools now have courses in medical ethics. Most provide the largely secular students with philosophical as well as religious approaches. The Israel Society for Medical Ethics serves as a forum for discussion, for the issuing of position papers, and for raising the consciousness of healthcare professionals regarding medical ethics.

Some militant secular Israelis, chafing under the restrictions of Jewish tradition, have taken a number of bioethical issues to the courts in attempts to force rulings in favor of their position. Cases pressing the right to die have been brought before the courts without clear-cut resolution. Similar suits have been brought with respect to the restrictions placed on surrogate motherhood. These and other court decisions may bring about changes that legislators have been reluctant to press because of their hesitance to upset the "status quo"—which, in this case, refers to a freezing of the situation regarding the influence of the Jewish religion within Israel's public life prior to statehood.

In summary, Israel is a relatively young country that sees itself as part of the modern Western world, yet is the heir to an ancient and wise cultural tradition dating back thousands of years. Jewish tradition is characterized by a strong duty ethic, with emphases on both physician and patient responsibility; a high value on human life; and a strong sense of justice. Time will tell how successful Israeli society will be in distilling and blending the best of both these worlds.

shimon m. glick (1995)

BIBLIOGRAPHY

Babylonian Talmud, Sanhedrin 37a. 1969. London: Soncino Press.

Beauchamp, Tom L., and Childress, James F. 1983. Principles of Biomedical Ethics, 2nd edition. New York: Oxford University Press.

Glick, Shimon M. 1985. "Health Policy Making in Israel—Religion, Politics and Cultural Diversity." In Health Policy, Ethics and Human Values: An International Dialogue, pp. 71–74, ed. Z. Bankowski, John H. Bryant, and Robert Veatch. Geneva: Council of International Organizations of Medical Science.

Jakobovits, Immanuel. 1959. Jewish Medical Ethics: A Comparative and Historical Study of the Jewish Religious Attitude to Medicine and Its Practice. New York: Bloch.

Kortam v. State of Israel. 40 (III) P.D., pp. 673–698. (In Hebrew.)

Shapira, Amos. 1987. "In Israel, Law, Religious Orthodoxy and the Reproductive Technologies." Hastings Center Report 17 (supp.): 12–14.