Six values receive special emphasis within Judaism and have been applied directly to medical practice: life, peace, justice, mercy, scholarship, and sincerity of intention. These values are showcased based on the first author’s own immersive experience learning among multiple Jewish denominations. We do not assert this list as exhaustive, but only as especially prominent and well-attested among the applicable values in Jewish religion and overall culture. These select values will be considered within the structural context of Jewish practical ethics, or halakhah from the Hebrew word “to walk” (as in, to walk the ethical path; see Table 1), as well as two direct codes, the Oath of Asaph (a Jewish cousin to the Hippocratic Oath, circa third–seventh century CE)11 and the Prayer for Physicians (eighteenth century; though often called the Prayer of Maimonides, and inspired by the twelfth-century rabbi-philosopher-physician, it is notably of much later German origin).12,13 A glossary of Jewish/Hebrew terms is also provided in Box A.
Categories of Halakhic Sources in Rabbinic Judaism.
Box A. Glossary
||Exegetical parables and homilies; non-legalistic (cf. halakhah).|
||Life, considered sacred in Judaism.|
||Mercy; see also G’milut chasadim.|
||“Defiling the Name”—refers to blasphemy through actions unbecoming of a Jew, which thus “defile” the reputation of the Jewish God.|
||Acts of loving kindness (from root chesed meaning mercy).|
||Stranger, foreigner, or convert (for nuance, see Table 2).|
||Jewish principles and precedents of ethics and religious law (see also Table 1).|
||Intention or sincerity; often noted in contrast to empty ritual, or as a necessary complement to prevent empty ritual and preserve the emotional or spiritual intent of such actions or prayers.|
||Translates as “Learning;” valued as a life-long pursuit in Judaism.|
|Lo bashamayim hi
||“It is not in heaven;” a precept of halakhah referring to the Talmud story in which miracles fail to overrule the professional standards of a rabbinic majority.32|
||Local custom (see Table 1).|
||Main canonical text of the Oral Torah, providing a traditional Jewish understanding of the Five Books of Moses, further expounded upon by the Talmud (see Table 1).|
||Closely translated as “learning of the saints” (or more roughly but contextually appropriate, “expertise of the pious”); refers to moral standards of exemplary persons, stricter than the religious law for the everyday person.|
||Commandments (see also Table 1).|
||Halakhic principle “to save a life.”|
||Rabbinic legal replies (see Table 1).|
||Peace; includes connotations of harmony.|
||Two canonical commentaries (Jerusalem and Babylonian) on the Mishnah (see Table 1).|
||“Fixing the World” through social justice and acts of kindness.|
||Five Books of Moses (“Written” Torah) and later Talmudic material (“Oral” Torah) (see Table 1).|
||Charity (for nuance, see Table 2).|
Life is sacred in Judaism, as expressed by the halakhic
principle of pikuach nefesh
(saving a life)—actions which save a life from danger, or prevent such danger, override other Commandments. Halakhah
has a legalistic style, allowing nuanced exceptions, case rulings, and circumstantial sub-clauses to carefully qualify what might otherwise be taken as absolute obligations. Obligatory mitzvot
(Commandments) therefore become sinful (prohibited
rather than obligatory) if performed contrary to pikuach nefesh
. Sabbath laws against work must
be violated to save a life. Fasting on Yom Kippur (Day of Atonement, the holiest of High Holy Days) is forbidden
if it would seriously endanger health (e.g. for uncontrolled diabetics). Only the most serious prohibitions (idolatry, adultery, and murder) stand in exception to this rule (i.e. religious martyrs are allowed this self-sacrifice since the alternative would have been forced idolatry).14,15 Pikuach nefesh
thus prioritizes sanctity of life while also permitting resistance against violent tyrants, even in the face of personal danger.
On the more homiletic side (the less formalistic counterpart of halakhah, called aggadah), the story of Genesis reinforces this value. Adam is portrayed as the single progenitor of all humanity in order to affirm that the life of each individual human is associated with the inherent worth of all—“anyone who destroys a life ... destroy[s] the world; and anyone who saves a life is as if he saved an entire world.”16
Because life is so infinitely holy by these teachings, an ironic quandary for professional medicine arises. One is not supposed to profit from the per-formance of commandments (and protecting life is always commanded), so it would seem that an economically sustainable profession would be banned, as most medical services should be provided as a matter of more general obligation and not for a fee. This can be thought of as a hyper-inflated version of the secular Rule of Rescue, or “the imperative people feel to rescue identifiable individuals facing avoidable death.”17(p2407) Being pragmatic, halakhah does allow medical practices to charge based on a carefully carved out exception, but the allowance is genuinely exceptional in intent and practice—described by one set of commentators as existing only by “a variety of legal manipulations”—and hence heavily hedged in with caveats and regulative restrictions.18(p662) Even with the permission to charge reasonable amounts, Jewish doctors cannot turn away patients for inability to pay without committing a sin “almost tantamount to murder.”18(p662) In some interpretations, this charge for medical services is not even characterized as direct fee-for-service, but as compensation for the many hours of study required of the physician to make practice possible.19
The contrast to the economic rationales of Third Reich medicine speaks for itself. Judaism fears turning away patients unable to pay, whereas T-4 charged the patient’s insurance for involuntary euthanasia, which itself was performed to rid the state of the economic burdens posed by societally defined patient populations.1 The German-Jewish philosopher Moses Mendelssohn forecast an opinion on this concept of “public health” in 1842:
“People expendable to the State; useless to the State,” these are statements unworthy of a statesman ... No country can dispense with even the humblest and seemingly most useless of its inhabitants without seriously harming itself. To a wise government not even a pauper is one too many; not even a cripple is altogether useless.20(p175)
Shalom can also be translated as wholeness or harmony, and prayers for it constitute the bulk of Jewish liturgy. This value encompasses not only an internal sense of cohesion within and among the Jewish people; it explicitly includes respect for foreigners. Regardless of differences in religious belief or tribe, non-Jews who demonstrate a basic level of morality are considered righteous under a separate covenant with God (defined by seven Noahide Commandments). An act religiously required of a Jew might even defile
the Name of God (“chillul Hashem”
in halakhic terms) if its performance would threaten peace between Jewish and righteous Gentile communities. There is a second and third part to the exegesis about Adam cited above, that the Genesis story is also told “to promote peace among the creations, that no man would say to his friend, ‘my ancestors are greater than yours’” as well as to link human diversity to divine grandeur:
A man strikes many coins from the same die, and all the coins are alike. But [God] strikes every man from the die of the First Man, and yet no man is quite like his friend. Therefore, every person must say, “For my sake the world was created” [and we might add, for the sake of every other as well].16
Hence the sanctity of life and multicultural peace are not easily separated in Judaism.
The Prayer for Physicians also interweaves chayim and shalom (life and inclusive peace) by expressing to physicians the value for all human life. Its preface praises God for creating the human body “with infinite wisdom,” describing the intricate harmony of “ten thousand times ten thousand organs” working in concert;12 disease is likewise portrayed as purposeful, to warn the patient of the dangers to be averted through medical knowledge, rather than as a punishment to be accepted blindly or as a test to be healed through unassisted faith. Learning to identify and combat illness is necessary for patients “to succeed” not only in their healing process, but in life generally.12 The prayer makes no distinction between patients based on background, since all human beings experience suffering.12 This endorses the opinion of the historical Maimonides, that medicine—particularly through preventive and holistic care—is instrumental to healing, spiritual growth, and worship.21 Maimonides treated all patients in his multicultural environment in accommodating terms. For example, in a letter to a Muslim patient, Maimonides quotes the Koran instead of the Torah.22 Another patient famously praised Maimonides above the Greeks: “Galen’s art heals only the body, but [Maimonides’] art heals body and soul,” because the patient is valued in body, mind, and soul.22(p550)
As the Prayer for Physicians and Maimonidean practice in general suggest, Jewish ethics would not support eugenics as a premise for practicing medicine. While it would be consistent with Maimonides to consider cases of medical futility, the reference point for this determination must be the patient’s own good, not the patient’s social “worth” based on eugenic evaluations of ethnic difference. No concern for “public health” or community beneficence has encroached on even the most permissive rabbinic opinions regarding cessation of care or euthanasia.23,24 In fact, the emphasis is toward restoration of health or a reduction in suffering.
Shalom shows up in remarkably subtle and diverse ways in medical responsa as well. For instance, Rabbi Jakobowitz argues that observant Jewish patients have no right to refuse physician advice (by pikuach nefesh above, to protect life), but he also asserts Jewish doctors should acknowledge the right for Gentiles to refuse treatment.25 It is not the doctor’s place to impose religious rules on those of other faiths, not even out of beneficence, as doing so could drive a wedge between communities, and thus be regarded even as blasphemy (chillul Hashem noted above, or, in more secular terms, a violation of the public trust in a health-care system that serves their needs). Thus, a physician promotes shalom between people by the same route as promoting shalom within the person, through a respectful, holistic, and patient-centered approach.
By way of caveat, there is no perfect faith or ideology immune from cultivating in-group biases, and Judaism is no exception, though such ambivalent counterpoints fall far short of the Nazis’ picture of the Jew as anti-healer. The same tribal thinking which entails that a Jewish doctor should not impose Judaism on Gentiles also entails, in several places, that protective measures which apply to Jews would not apply to Gentiles. In particular, rules referring to “your brother” customarily meant only a fellow Jew (e.g. the return of lost persons).26 In more extreme cases, commentaries imply Jewish lives are more valuable, as in the Talmudic reading which paradoxically interjects “a life from Israel” into the Mishnaic discussion which derived “anyone who saves a life is as if he saved an entire world” from the Adam story.27 Disturbing structural parallels come to mind—such as Rudolf Ramm’s emphasis that general ethical precepts in his textbook only apply to Aryan patients,2 or the proactive Nazi policies of supporting employment and medical care for Germans and amputee veterans even while initially discriminating against and eventually exterminating Jews.3(p40) However, it is notable that both Maimonidean medical ethics and the later German-authored Prayer for Physicians follow the majority readings (in both the Mishnah and Jerusalem Talmud) which lack “from Israel” and instead apply value to life in an unambiguously universal manner. This choice can be explained two ways. One way is descriptive: the Maimonidean version simply follows the more attested trend both in terms of ancient sources,28 and in post-Enlightenment Germany—in sermons of universal brotherhood by the early reformer Israel Jacobson29 and neo-Orthodoxy founder Samson Raphael Hirsch20(p190) (both early nineteenth century). To portray racially supremacist views as a matter of canonical Jewish Law (as Nazis in fact did)3(p41) would misread not only the tradition in its full retrospect, but these German-born movements in particular. The second way is normative: an inclusive stance was simply seen as more fitting for a physician to encourage, in order to serve all patients without discrimination. Again in comparison to Ramm and the case of Nazi medical curricula, the shift between inclusion and exclusion may be gradual, but not passive—it was the physician faculty (not solely or even primarily appointed party ideologues) who explicitly chose which norms to endorse and which to condemn when training the next generation of German doctors.2
Justice (Tzedek) and Mercy (Chesed)
In Judaism, distributive justice (tzedakah
, righteous giving) and acts of loving kindness (g’milut chasadim
) are expressed through social action (tikkun olam
, “fixing the world”), based both conceptually and grammatically on the balance of the two general values, justice and mercy. The Torah and prophetic writings stress the needs of vulnerable populations in particular—the poor, orphans, widows, and “strangers” (Table 2
). The Talmud finds so many Torah verses protecting the stranger, in fact, that any mistreatment involves double jeopardy: verbal abuse counts as three sins, plus two for more material harms.32
Tzedakah can refer to any charitable donation, but in medicine it requires that poor and marginalized groups receive treatment as a matter of social justice, essentially corresponding to modern post-WWII secular principles of justice, universal health-care systems, and global health improvement initiatives.18
G’milut chasadim are acts of loving kindness which relate directly to caring for the sick on an individual level. This concept is linked to the early origins of Jewish nursing professionals.33 Mercy as “loving kindness” is both patient-centered and life-centered when used in the medical context. The Prayer for Physicians states: “May I never see in the patient anything but a fellow creature in pain ... In the sufferer let me see only the human being.”12 The ancient physician Asaph exhorts: “do not harden your heart against the poor and the needy; rather have compassion upon them and heal them.”11(p319) A doctor’s fiduciary duty is to heal the patient burdened by society, not to heal society burdened by the patient (still less to heal society burdened by a vulnerable population of patients, in violation not only of the value of life but also of justice). This contrasts with Brandt’s misapplication of the concept of mercy in the T-4 program, wherein “the essential question was not whether the programme was ... in itself humane, but whether the method of killing was humane,”9(pp137–188) or with Ramm, who had relocated the physician’s mercy towards the body of the German Volk, seeing patients as potential pathogens to that reified collective.2
Scholarship, as a virtue, is encouraged both culturally and in explicit homilies. For instance, study is described as the greatest Commandment, in the sense that it leads to knowing how to perform all the others.34
Intensive study and intellectual curiosity support one’s efforts in leading a moral life, and scientific observation can become a basis for illuminating truth.
Scholarship is obviously relevant to medicine. Explicit codes such as the Prayer of the Physician emphasize life-long learning, intellectual humility regarding the scope of one’s knowledge, and scientific objectivity; in that same spirit, Maimonides practiced critical appraisal of all medical teachings, whether from Jewish, Greek, or Islamic authors.22,35 His appreciation of diverse sources of knowledge stands in marked contrast to the Nazi ethnocentric science, which banished Jewish scholarship from sight (literally and figuratively).
Objective scholarship requires careful avoidance, or at least identification and management, of conflicts of interest.36 Asaph denounces bribery twice: once in reference to doing harm for a bribe and again for becoming an accomplice to sexual misdemeanors,11 suggesting that he appreciated conflict of interest not as an abstract idea to be spoken of in generalities, but in terms of the specifically lucrative transgressions and erosions of commitment which deserved direct address. “Do not lust” and “do not shed blood” go without saying to a pious audience, but do not lust after a patient or “shed blood by ... dangerous experiment in the exercise of medical skill”11(p319) are specifically medical temptations.
According to some interpreters,19,37,38 the Talmud directly addresses physician objectivity with the provocative line, “The best doctors go to hell.”39 The line stands in stark contrast to an otherwise pro-medical tradition, so the commentaries read “best” with some nuance. The sort of ideological doctors who seek the “best” for themselves over the patient, or who forget intellectual humility and fail to place their “best” practices under scrutiny, are the more sensible culprits for this verse, rather than physicians who are truly effective at saving lives. On a historical reading, however, “best doctors” likely refers not to biased or compromised doctors but to literal witch-doctors, because the Talmud pre-dates any modern distinction between medicine and magic.40 Asaph’s Oath (which is contemporary or near-contemporary to the Talmud) also dwells on the illicit use of idols in medicine.11 Maimonides enjoyed the emerging proto-science of medieval Islamic medicine and could therefore apply at least some common empirical standards across medical authors of different faiths. Aside from some medieval apologetics against heresy,40 Maimonides associated the practice of good, scholarly medicine with careful methodology, whereas bad medicine was marked by superstition or dogmatic metaphysical speculation, better resembling a modern epistemic distinction.
By the Enlightenment context of the Prayer of the Physician, quackery completely replaces sorcery or heresy as the noteworthy intellectual concern. The prayer condemns both political and financial ambitions as “strange thoughts” far removed from wise scholarship and sound practice12—a phrase which, though perhaps evocative of the Biblical idea of “strange gods,” limits itself entirely to mundane examples of financial, social, or intellectual pressures to accept the advice of the less knowledgeable instead of responsibly seeking what is right for the patient. The physician must distinguish legitimately wise mentors from “conceited fools,”12 though the prayer does understate the challenge of choosing mentors, evidence, and research programs wisely—the modern distinction between science done well and science done poorly (or completely as a “pseudo”-science). Philosophers of science consider this difficulty under a special heading dubbed “the problem of demarcation.”41 Historical examples often show a “know it when we see it” basis, but more precise methodological or evidential standards tend, upon philosophical scrutiny, to include something absurd within the definition of proper science (i.e. flat-Earth model), or exclude cases too broadly (e.g. failing to account for epidemiology or germ theory as scientific).
The philosopher’s struggle is no mere theoretical concern, but impacts concrete and life-altering choices facing the professional physician. As already noted above, Brandt chose Hoche with confidence, and eugenics (however flaw-ridden in hindsight) was as promising and mainstream a research paradigm then as genomics potentially is now. The “best doctors” of Nazi Germany studied eugenics and systemically applied it as a social policy, learning their medical ethics from lecturers like Eugen Stähle.2 During the Third Reich, physicians did not separate their racial identities, academic ambitions, and ideology from a self-reflective and independent consideration of their generation’s dominant scientific paradigm. These doctors first became morally and intellectually compromised, and, in consequence, murderers, yet contemporaneously speaking—it is disturbing to admit—they followed (what had become) mainstream curricula and research agendas. Any voices that might have spoken contrary to that agenda were already “cleansed” from professional ranks.2(p593)
It may seem fanciful today to compare the intellectual challenges of medical scholarship to idolatry, as our references to the Talmud and Asaph imply. However, no matter how much the diction may change over time, the result of error remains the same: death. The practice most frequently associated with idolatry in Scripture (whether to Moloch, Baal, or unnamed deities of Canaan) is child sacrifice, typically through fire.42 Indeed these paradigm cases of idolatry mark the difference between those faiths respected by Judaism (under shalom above) and those condemned—i.e. whose beliefs harm children to protect theoretical effigies. One-and-a-half million children died in the Holocaust for the effigy of Nazi science.43 For a more recent medical example, children in the developed world have been placed at risk of measles due to a single case of research misconduct (involving, among other things, conflict of interest on the part of the researcher).44 While that was an obvious case redacted relatively quickly, others are not so obvious, and in any event may not be discovered until after review or attempted replication of (already disseminated and popularized) results. Even though modernity has replaced the mystery of discovering true versus false gods with the practice of following true over false evidence, the problem is no less mysterious and the stakes remain high.
In light of such persistent difficulty, professionals must rely on humility to avoid misapplying any knowledge learned (or seemingly learned) through scholarship, recognizing that in the end, good science can be misused just as pseudo-science can mislead. Thus, much depends on the final substantive value of our list: the sincerity and ever-constant mindfulness of a physician’s intention to treat the patient.
Sincerity of Intention (Kavannah)
Typically contrasted to keva
refers to mindfulness. Mindfulness attends to the inner meaning behind an outward action, and can be viewed as a vital, indispensable complement to any value expressed through principles or rules. One’s deeds cannot be separated from one’s inner consciousness. Roots of this concept are evident in the Mishnah,45
and were revived by the later Hasidism of Eastern Europe,20(pp161–168)
developed in philosophically sophisticated directions by modern Jewish philosophers like Martin Buber and Emmanuel Levinas.46
To these thinkers, even halakhic obligations performed in the wrong mindset are meaningless, while tying a shoelace with proper devotion could be holy.20(p163) For each Commandment, there is a rightful intention (typically one that imbues ritual mitzvot with ethical intent, e.g. using ritual handwashing to meditate upon acts of justice which truly elevate the purity of one’s hands). In medicine, the proper intent is expressed by the cardinal values discussed above, imploring the physician to treat each patient as a person; but what does this mean? To define personhood through a generalized principle would slip out of our search for intention-based kavannah by reverting back to formalistic keva. The answer is not to define people at all, but to enter a relationship with them which must frame any other definitional representations (e.g. biological or psychosocial information used to provide medical care). The Nazis defiled life through definition, allowing the category “life unworthy of life” to become possible within, rather than anathema to, the culture’s normatively permissible medical thinking. Nazi euphemisms and proceduralism created psychological retreats from any mindfulness that might recognize or resist this definition as the invasive and anti-Hippocratic move that it is, thus allowing physicians to deviate from patient-centered mercy to an amoral justification for ethnic extermination. Rule of law cannot suffice to restrain these retreats—Nazis could legislate around inconveniently protective regulations and even disregard them.47 Even values such as life (for whom?), peace (with whom?), or mercy (toward whom?) are vulnerable to misapplication or misappropriation.
Martin Buber portrayed the difference between defining and relating with the objective term “It” and subjective term “Thou.” Clinicians may also see the parallel to the dual medical stances: seeing the patient as a clinical “It” of biological lab results, a diagnostic puzzle to be solved, a research subject/guinea pig, or a pharmacologic equation to be balanced, versus recalling the mortal, vulnerable humanity of each patient as a “Thou.” Both stances are necessary—one to treat the illness, but the other to care for the patient.48–50
Contemporary philosopher Hilary Putnam attempts to illustrate the depth of this approach for the lay reader, notably invoking the Holocaust itself in his description:
The danger in grounding ethics in the idea that we are all “fundamentally the same” is that a door is opened for the Holocaust. One only has to believe that some people are not “really” the same, to destroy all force of such a grounding. Nor is there only the danger of a denial of our common humanity (the Nazis claimed that Jews were vermin in superficially human form!). [sic] Every good novelist rubs our noses in the extent of human dissimilarity, and many novels pose the question: “If you really knew what some other people were like, could you feel sympathy with them at all?” But Kantians will point out that Kant saw this too. That is why Kant grounds ethics not in “sympathy” but in our common rationality. But then what becomes of our obligations to those whose rationality we can more or less plausibly deny? These are ethical reasons for refusing to base ethics on either a metaphysical or a psychological “because.”46(p71) (emphasis added)
This approach does not deny the many obvious similarities between members of the moral community (or between those who ought to be considered equal members of the community). Rather it denies that building a theory on that similarity would ever provide a foolproof grounding for ethics. Putnam’s choice of Kant (instead of, say, utilitarianism, with its known problems of including respect and justice among its values)51 illustrates the challenge of capturing good intention through theory. Ostensibly, Kant speaks strongly of human dignity, but his criteria have been criticized for being thoroughly ableist (basing moral dignity entirely in rationality and thereby failing to situate the cognitively impaired within the moral community).52–54 Thus the Nazis did (“more or less plausibly” from a Kantian perspective) deny rationality and thereby personhood to the disabled and (implausibly but nevertheless effectively) to ethnic and political targets. From the stance of Buber and Levinas, there are no rules to abuse or to dodge by crafting exceptions—the reality of another person is basic, preceding all understanding. As long as we believe we can totally understand the Other, we can become confident enough to undermine the Other.
With kavannah, one must sincerely face the interpersonal impact of following (or disobeying) laws, engaging in research, or accepting career incentives, with the presence of the Other’s eyes always in mind. Unlike the other five values offered above, philosophies which develop this value offer no guidance or code for the medical professional, only an experience: that a moment of interpersonal responsibility situates and transforms all other tasks (no matter how mundane). Because relational ethics is taken as primary, the Self–Other relation in Levinas and the I–Thou relation in Buber have been widely used to meditate on professional–patient interactions, including hospice care,55 gerontology,50 and mental health,48 addressed to and by physicians and their medical students,49,56–58 nurses,59 and spiritual care professionals.60 Moments of interpersonal response beyond any expressible principle (other than hineni, or “I am here,” the term Abraham uses to respond to God)56 often are (and need to be) a shared experience among clinical professionals.