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What Is Jewish Medical Ethics? from Jewish Medical Ethics/Assia, vol. 1, no. 1, May 1988 German-born Avraham Steinberg studied at Yeshiva! Mercaz Ha'Rav Kook in Jerusalem before entering the Hebrew University-Hadassah Medical School. From 1973-76 he served as a medical officer in the Israeli Air Force and in 1976 became a resident at the Department of Pediatrics at the Shaare Zedek Medical Center in Jerusalem, where he still works. Since 1988, Steinberg has directed the Center for Medical Ethics at the Hebrew University-Hadassah Medical School in Jerusalem, where he also teaches general pediatrics and pediatric neurology . The winner of five prizes, such as the Abramowitz-Zeitlin Prize in 1976 and the Katz Prize in 1990, Steinberg is listed in the International Who's Who of Intellectuals (1987), the Dictionary of International Biography (1989-1990), and Who's Who in Israel (1991-1992). Steinberg edited the first four volumes of Assia (1976, 1979, 1982, and 1989), the Hebrew publication of the Schlesinger Institute for Medical and Haiachic Research of the Shaa;e Zedek Medical Center. He has authored and coauthored a vast and profound range of over 90 articles on neurology, general medical ethics, Jewish medical ethics, and medical history. His book titles include Chapters in Pathology in the Talmud (in Hebrew), Encyclopedia of Jewish Medical Law, volumes I and II (in Hebrew), and Neurologic Manifestations of Systemic Diseases (in progress). Steinberg lives in Jerusalem with his wife and three children. by A vraham Steinberg, MD Ethics constitutes the branch of general philosophy which deals with moral problems and judgments. It attempts to define human conduct in terms of its property; it evaluates man's desires and the results of his actions as good or bad. Ethics (derived from the Greek ethos, meaning "manners" or "habit ") deals with the fundamental, theoretical aspects of these values, while morals (derived from the Latin mos, meaning "custom" or "usage") deal with the actual and concrete aspects of conduct. These two terms are, however, often used interchangeably. Taken in their precise, historical meaning, medical ethics form a code that governs the physician's conduct vis-a-vis colleagues and patients. Historically, such codes were formulated by physcians (e.g., the Hippocratic Oath, the Oath of Assaf Ha'Rofeh, the codes of various medical associations). In the accepted modern meaning, medical ethics constitute the application of general ethical theories and principles to the problems of clinical practice and medical research. Medical ethics are the systematic analysis of morals and values in the medical and behavioral sciences . Those principles and their application to medicine derive from a wide spectrum of 14 Jewish Medical Ethics knowledge of the humanities and social sciences, not exclusively from medicine itself. Concern with the moral problems of medicine originated early in history with laws, edicts, guidelines, and oaths formulated for or by physicians. Among the ancient peoples exhibiting such concern we find the Code of Hammurabi, Egyptian papyri, Indian and Chinese cultures, and the classical cultures of Greece and Rome. In its modern form , general medical ethics are based on a multidisciplinary and pluralistic approach to philosophical, sociological, and legal outlooks. This approach was developed during the last thirty years, starting with the publication of Joseph F. Fletcher's seminal book Morals and Medicine (Boston: Beacon Press, 1954). Since then the field has developed quickly, and we have witnessed the forming of bioethical research and teaching institutions, the introduction of bioethical programs in medical schools, and the involvement of ethicists in arriving at difficult moral decisions in hospitals. There is a continually growing interest on the part of academic societies, as well as on the part of the public at large, together with the development of specialized parallel literature - books, journals, surveys, and articles in both medical and popular frameworks. It must be emphasized that from an ethical point of view there is nothing special about medical ethics. Ethical theories and principles are universal in nature. It is their specific application to medical questions that gives rise to a special viewpoint. There are several primary declared goals of medical ethics: first , increasing the sensitivity and awareness of medical practitioners and researchers to the moral problems connected with ·treatment and research; second, imparting basic philosophical and legal knowledge related to moral B'Or Ha'Torah problems; third, forwarding national analysis and debate regarding moral medical matters; fourth , encouraging the union of technical medical knowledge with humane sensitivity , morality , and justice; and fifth, improving the moral conduct of medical practitioners and, perhaps, improving their moral character. Noble though these goals be, the pluralistic and multidisciplinary nature of medical ethics has proven unable to achieve a normative consensus in many areas of medical practice. The first to speak about the specifically Jewish aspects of medical ethics was Rabbi Immanuel Jakobovits in his Jewish Medical Ethics (New York : Bloch Publication Co., 1959). There are, however, three factors that characterize and distinguish these Jewish aspects, as compared with general medical ethics. I. Range General medical ethics deal with diverse subjects, including the patientphysician relationship, confidentiality, informed consent , disclosure of information, attitude toward the patient's family , public medicine policy, limited medical resources, triage decisions, labor strikes , biomedical experimentation on human and animal subjects, attitude toward the terminal patient, congenital defects, abortion, artificial insemination, in vitro fertilization, organ transplants, definition of death, and involuntary hospitalization . Jewish medical ethics deal with all these as well as many more subjects that are no less important from the point of view of halacha (Jewish law), for example: medical treatment on the Sabbath and Yom Kippur, gynecological examination, B'Or Ha'Torah the laws of family purity and kosher food, kohanim (members of the priestly class) as patients or physicians, circumcision under specific conditions. II. End Point Being pluralistic, general ethics does not generally aspire to absolute, normative decisions. Jewish medical ethics, on the other hand, are essentially based on a halachic (Jewish legal) approach to medical problems. Their solutions are thus as binding as halachic decisions in any other field, such as dietary laws, the Sabbath, or theft. Ill. Method of Analysis Whereas general ethics is based on philosophical analysis, Jewish medical ethics are based on halachic analysis. These two fields exhibit differences in their mode of discourse and in the relevant cognitive background pertaining to the medical problem under analysis. These differences typify two divergent approaches to all areas of human endeavor. The common aspect of both general and Jewish medical ethics is their application of general principles and theories to actual medical problems. The differences between the two fields arise from their respective sources of authority. General ethics is based on theories deriving from human thought and variable opinions, whi e Jewish ethics are based on halacha and Jewish thought , which are of Divine origin, as they were interpreted and applied by the Talmud Sages and subsequent authorities in the direct line of tradition. Let me emphasize again that Jewish medical ethics do not profess morally possible or desirable Jewish Medical Ethics 15 modes of conduct. Rather, they profess halachically normative, obligatory conduct. The same halachot (Jewish laws) which determine the parameters of prohibited gossip may be applied in medical contexts. This method of applying general halachot to specific medical problems is just as valid with regard to the allocation of rare medical resources, defining the moment of death , and induced abortion as it is with reference to medical problems of the Sabbath, the kashrut of medication , or nidda (family purity). When asked about medical ethics , our poskim (leading rabbis) are guided by exactly the same modes of thought and analysis, the same considerations which guide them in responding to any other halachic problem. It is therefore impossible to solve moral problems in medical practice on the basis of the patient's or the physician's proclivities or personal feelings. Rather, it is essential to be guided by an authoritative rabbi (posek), whose decisions will be reached on the basis of relevant halachic considerations. Familiarity with the halachic sources is, by itself, insufficient for halachic decisions . In addition, one must have a complete grasp of all the relevant facts and their ramifications . Only the combination of thorough comprehension of relevant halachic sources with profound understanding of relevant data can lead to the desired solution of moral problems. In summary, proper use of the term "Jewish medical ethics" is limited, requiring an awareness of the factors which distinguish it from general medical ethics. Used properly, it refers to the halacha governing physicians and medical practice. In effect, Jewish ethics is halacha and it is only in this sense that the term should be used with respect to actual medical problems, just as it is used in all other fields.