Rabbi Avi Weinstein

The Talmud and Health Care Reform: Public policy in light of great need and scarce resources

In Uncategorized on December 7, 2009 at 11:51 pm

I would like to offer an unsentimental snapshot of a public scourge that required the rabbis, the makers of public policy, to diminish enthusiasm for a great mitzvah in the interest of a greater good.

In Baba Batra 8b the Sages taught:

Rava said to Rabba Bar Mari, “Where does this notion that redeeming the captive is considered so special that the sages called it an exceptionally great mitzvah appear? As it is written: “And when they will say to you, “Where shall we go?” You will say to them, “So says the LORD, those to die will die, those to go by the sword, will go by the sword, those by famine will be by famine and those who will be taken captive will be taken captive.” (Jeremiah 15:2) And Rabbi Yochanan said, “[In this verse] the afflictions become increasingly more severe. [For example] The sword is considered more severe than death.”

Through a close reading of the verse in Jeremiah, Rabbi Yochanan sees the worst possible circumstance is to be held captive.  It follows that redeeming someone from that situation is a profound act of mercy.  Now, check out this passage:

One never redeems captives for more than they’remarket value, because of our concern for Tikkun HaOlam. One also does not help captives escape because of  our concern for Tikkun HaOlam. Rabban Shimon Ben Gamliel said, “It was a decree made especially for captives.”

All of a sudden, the exceptionally great mitzvah should not be too expensive!!??  The Talmud goes on to  query whether the limit on ransoms to be paid was because paying too much will encourage more kidnappings, or whether we are worried that it will bankrupt the community’s resources?  Either way, concern for public welfare trumps the suffering of one person, even in the case where it is acknowledged that a captive’s life is worse than dying by famine.

John Marshall a respected oncologist wrote a heart wrenching article in the Washington Post over a week ago.  He spends his life fighting cancer and lives with the knowledge that eighty per cent of his patients–regardless of the expense and relentless toxicity of the treatments–will not have a positive outcome. He reports:

My patients seek state-of-the-art therapy, access to clinical trials and new treatments, all of which we provide at our institution. Almost all of them have insurance, and most have some form of prescription drug coverage; their access to care is virtually limitless. We employ the latest diagnostic tests, targeted chemotherapy, minimally invasive surgical techniques and incredibly precise radiation. Yet, despite the many recent advances in detection and treatment, of the 50 patients, 40 of them are likely to lose the fight.
Because insurance will pay the price tag for the patient, the patient and the patient’s family will go to heroic efforts in hopes for a miracle. I would be no different. In most of those lucky twenty per cent, it probably can’t be certain that the interventions provided the outcome.  If they can’t explain why the eighty per cent weren’t as lucky, then who knows why the twenty per cent survived?
Fifty billion dollars are being spent on the last two months of the patient’s life.  Fifty billion that might be spent on finding cures, that might be spent on prevention, that might be spent on insuring all those who use emergency rooms for primary care.
The Talmud teaches that the good of community comes before the good of the individual, and even if saving one life is as if one saved the world–saving many lives translates into many of them.
Our Sages  courageously acknowledge the pain and suffering of one being held captive, but they also remind us that the needs of the individual should not be met if doing so would completely deplete community resources.
The reluctance to make these hard decisions has brought us to where we are now; a system that provides the most expensive care for the most pathetic results.  We can’t avoid these decisions anymore. The Talmud taught this eighteen hundred years ago, and it’s about time we learned it as well.
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