- Orit Navot, Ph.D.
Faculty of Health Sciences,
Ben Gurion University of the Negev,
P.O.B. 221, Omer, Israel 84965
Eubios Journal of Asian and International Bioethics 13 (2003), 52-53.
This culture developed concurrently with the development of modern medicine in Israel, with the arrival in 1840 of the first university-educated physicians. Israel was in those days a part of the Ottoman Empire, a remote, poor and miserable place. These doctors, equipped with modern medical equipment, were sent to the Holy Land from Jewish European communities to organize and establish medical services that until then were essentially nonexistent.
Actually, their arrival was a response of the Jewish community to British Missionary efforts to provide medical services to the Jews of the small and suppressed Jewish community of Jerusalem. The first modern clinic in that city was opened by 'The London Society for Promoting Christianity among the Jews', which embarked for Jerusalem in 1840, "the year of the Messiah's redemption". To the dismay of Jerusalem's rabbis, when the Missionary Hospital opened, its stated purpose was to care for Jewish patients only.
The Jewish response came with the help of Montefiore, an honorable philanthropist, who sent a doctor and equipment for a clinic - the first physician, arriving in 1843. Four hospitals were established during the next fifty years.
The Jewish physicians who staffed these hospitals fulfilled a crucial role in creating both a medical and moral culture. These university-educated doctors had to compete with and overcome many primitive but popular medical practices, such as healers who dealt in whispers and charms as a means for curing illness. Their efforts and their professional success paved the way for present-day medicine. However, their professional academic education could not bridge the wide cultural gaps that existed between Eastern and Western cultures, between Eastern conservatism and European modernity and some of these gaps are reflected in some of today's conflicts in Israeli medical ethics.
The pathway of the modern physicians was interwoven with power struggles to establish their social standing and professional autonomy. They were sent to the Holy Land by the Orthodox Jewish communities in Europe in order to facilitate Jewish communal life as prescribed by Halacha (the Jewish regulations). Consequently, they were expected to conduct themselves according to religious tradition. Since the physicians earned their living from these communities, and their salaries were dependent upon them, they pledged to practice medicine according to traditional Jewish values even if this conflicted with their best professional judgment.
The conflicts and power struggles between secular physicians and the religious authorities that hired them were not the only significant contributors to the medical ethics culture that prevails today. Conflicts with ethical overtones also arose between medical practitioners and governmental authorities responsible for regulating and licensing physicians. Ethical problems regarding rights and obligations and financing inevitably arose when doctors' organizations interacted with patients' cooperatives and communities to provide both public health and personal health services.
In this paper, the developing medical ethics culture of Israel is examined under four major topics:
1. Sanctity of Human Life
2. Primacy of Jewish Law
3. Medicine under Society's Scrutiny
4. Organized Medicine
The Sanctity of Human Life. The dilemma regarding the value of human life arose in all its severity when spiritual life came in conflict with physical life. For example, although the British Mission could provide medical assistance when Jewish physicians arrived were unavailable, seeking treatment at the British Hospital met with strong rabbinical objection - to the point of ostracism, denial of income from the 'Haluka' (donations of the European Jewish community), and being forbidden a proper Jewish burial. The dilemma was between saving life at any cost and facing the risk the missionary trap, and risking life while retaining spiritual safety.
How much risk to his own life is the physician obligated to take to save another? This was not a theoretical question facing the physician who rode to widely dispersed and distant villages by horseback in all kinds of conditions, and there were those who died doing so. The physicians' dedication was especially remarkable during epidemics. While the governors of cities and heads of consulates fled in fear of contamination from the spreading epidemic, the Jewish doctors would not leave their posts and risked their own lives. Some died or lost their families as a result of the epidemics.
Is refusal to treat a patient ever justified? Treatment was sometimes disrupted when physicians were prevented from accepting patients because of bureaucratic conflicts between farmers and clerks or workers in the settlements, conflicts between different congregations, financial disputes, etc. Some doctors agreed to treat patients despite the threat of dismissal if they should do so, and there were those who conceded to the heavy social pressure.
The general conception was one of equality and justice for all, and the right to receive medical treatment without discrimination. Foreign patients were also cared for by Jewish physicians. The poor as well as the rich were granted treatment, according to Jewish perspective. Each clinic had office hours for poor patients, and a special fee for house calls. In the hospitals, the community subsidized hospitalization fees in order to ensure recovery.
The Primacy of Jewish Law This was part of the struggle regarding the character of the renewed society in Israel. The objection to Jewish non-religious physicians was greater than the objection to non-Jewish doctors, for fear of their influence and ability to sway patients away from tradition. A constant struggle existed between the rabbinic leadership and the physicians concerning the proper amount of modernization that should penetrate the ranks of the community.
Jewish Law contains explicit instructions regarding the keeping of the Sabbath (no work is allowed on Saturday). This became a continuing ethical dilemma. Physicians that were required to visit patients during the Sabbath day encountered difficulties in preparing medications, riding to patients, performing certain medical procedures, or receiving pay for their work. Some physicians chose to avoid visiting patients on the Sabbath; others found other ways to solve religious dilemmas.
The Jewish religious laws offered a majority of the answers to questions concerning the treatment of the deceased, doctors' fees and their responsibility, non-maleficent, beneficence, etc., and the physicians acted accordingly.
Medicine under society's scrutiny - The Jewish society in Israel deeply honored the position of the physician. Doctors received great respect and appreciation for their efforts to benefit the population. Their source of social power stemmed from their involvement in social matters. The doctors stood apart from the rest of the community with regard to their broad education, knowledge of languages, their financial ability, and their customs. The conservative urban settlement displayed greater reservations toward the physicians than did the villages. In the villages, doctors received full appreciation, and the importance of their medical aid was tested daily by the many patients suffering from malaria, typhus, and other diseases.
The authorities of the Ottoman Empire required that the physicians sit for special licensing exams in Kushta, the Empire's capitol, and present certificates verifying their education. This was another stage on the way of removing healers and seers from the medical system. At the beginning of the 20th century, physicians' societies were established in Jaffa and Jerusalem, whose role was to promote cooperation regarding medical and professional matters among physicians.
Doctors' responsibilities towards their patients also came under public scrutiny, and physicians who deviated either stood trial or were removed from their positions. The social criticism toward physicians was displayed by publicizing patients' complaints and by patients' rights. For many years, there was an ongoing struggle between doctors and public leaders, since the latter wanted to maintain control over the management of health services.
The physicians, on their part, showed a growing involvement in the society, so that their influence was felt in every area. Doctors helped establish schools, and they were involved in education and various cultural subjects.
Organized medicine - Medical services were organized in Israel according to the laws of the Ottoman Empire. The Ottoman law provided public health services mainly during epidemics, but also carried out inoculations and engaged in the prevention of diseases. Apart from this, the law entrusted the organization of medical services to the community itself, with the exception of compulsory reports concerning contagious diseases, autopsies for legal purposes, and examinations to certify laboratories. Under the physicians' management, organized medicine engaged in health education, compulsory preventative treatments, statistical management of diagnoses and medical, epidemiological, and laboratory research. During the same period, with the assistance of the physicians, a patients' organization was also getting underway in the framework of medical insurance for workers. The doctors took on the responsibility for the sanitary conditions of the cities and villages, including the extermination of vermin that could cause disease, hygiene in food service establishments and 'Mikveh' (ritual bath). The idea of mutual assistance and the 'duty of visiting the sick' came to fruition independently.
It might be significant that many medical ethics values, considered to be integral to Western medicine and dealing with individual autonomy were not of great concern to the physician that practiced in Israel during the period we deal with. We hardly find in the 19th century in Israel such topics as respecting patients' rights, informed consent, confidentiality, or speaking the truth to a patient. The uncompromising regard for the sanctity of life led to forced medical treatment, and the determination to avoid causing distress prevented physicians from disclosing medical details to patients and their families.
The growth of the Jewish settlement during the years 1840 - 1914 was made possible by the physicians' determination to settle and remain in Israel despite the many difficulties they faced. Only the bravest of doctors could confront a culture so strange to them, a community so poor and destitute, a conservative leadership that opposed their activities, and diseases so deadly that they put themselves at such great risk. The great appreciation felt towards these physicians is made even clearer when one considers their isolation and personal and professional hardships.
Despite varying conditions in unpredictable historical circumstances, the first university-educated physicians brought the Jewish ethical cultural tradition to Israel and set standards of morality accordingly. These became the foundation for the standards of medical ethics practiced today.
This article is an abstract of a PhD research, submitted to Ben-Gurion University in Israel, 2001. This work was carried out under the supervision of Prof. Velvel Greene and Dr. S. Schwartz.