Tuesday, Jun 18, 2024

On Medical Priorities And Other Issues

A maggid shiur was offered two different positions. One yeshiva wished to recruit him to deliver a shiur to a group of talmidim of outstanding caliber. In that position, he would deliver advanced shiurim, and his own personal learning was bound to be enhanced by the experience. The other position was in a yeshiva where the talmidim were not as skilled, yet he would be able to offer them encouragement and chizuk. Naturally, the maggid shiur was inclined to accept the offer of the yeshiva of higher caliber. Nevertheless, he asked Rav Yitzchok Zilberstein which position he should accept.

Rav Zilberstein’s answer was terse and to the point. “Although it would be beneficial for this yungerman to go to a yeshiva for metzuyanim,” he said, “if he wishes to do the will of his Creator, he should go to the weaker yeshiva. Not only will he not lose anything from that, but he will also grow and reach great heights in his Torah learning.”

As a source to his answer, Rav Zilberstein cites a story about Rav Aharon Leib Shteinman, which was told by Rav Tanchum Fishoff, one of the roshei yeshiva of Yeshivas Ponovezh L’Tzeirim.

Rav Fishoff related that he was once asked to relay a similar question to Rav Shteinman and received a similar response. “Someone had been offered positions in two different yeshivos,” he related. “One was in a respected yeshiva where he could have achieved significant personal growth, while the other offer was in a yeshiva where the level of learning was lower. With his special approach to the talmidim, he could have strengthened and encouraged them.”

Rav Fishoff went on to describe Rav Shteinman’s response. “The rosh yeshiva’s initial reaction was: ‘In the first yeshiva he can shteig a lot, and that will certainly be good for him.’ After thinking for a few minutes, though, he reconsidered. “I am constantly approached by bochurim and yungeleit who ask me all sorts of questions,’ he said, ‘and I ask them a simple question of my own: to tell me what they want. They always tell me that they want to shteig. Tell me,’ Rav Shteinman said to me, ‘what is shteigen? Let me tell you what shteigen means. To shteig is to make advances in doing the Will of Hashem. Therefore, this is what you should tell that yungerman. I will not tell you what he should do; I will simply describe the two options to him, and he can make the decision on his own. But he should evaluate what it is that Hashem wants him to do!”

The next portion of their conversation offered an insight into Rav Aharon Leib’s mindset. As Rav Fishoff related, “Rav Shteinman went on to say, ‘Let me tell you what has been happening in recent times.’ This took place during the time when Rav Shach had become ill. Rav Shteinman said, ‘Until now, when Rav Shach was healthy and strong, the rest of us did not have any worries. We knew that he was taking responsibility for everything, that he was handling everything on his own. But he has recently become weaker, and therefore, people have begun coming to me with communal issues. What do they want from me? I am so disconnected from this and I truly do not want it; I send them all to Rav Elyashiv. But then they come right back to me and they tell me that Rav Elyashiv has sent them back to me. What should I do? I don’t want to be involved in communal matters. I want only to sit and learn! But Rav Elyashiv is constantly sending people to me. What can I do? I don’t know what to do.’”


The Doctors’ Dilemma

Rav Zilberstein is the posek of Maayanei HaYeshua Hospital in Bnei Brak and is considered the foremost expert on halachic issues pertaining to medicine. Many of these shailos involve matters of life and death.

One question deals with whether a doctor may enter a hospital on Shabbos when he will thereby cause the security cameras to be activated. Another question concerns the permissibility of establishing a hotline for dental emergencies on Shabbos. A third question came from a doctor who was disturbed by the fact that sick children had been passing away every night that he was on duty in the hospital. Another person asked if one is obligated to be treated for a medical condition that is not life-threatening, and yet another questioner asked how to kiss a mezuzah if there is a concern that it might cause the transfer of germs. A doctor related that he had been asked to testify in court about certain information that he possessed, and he was uncertain if it was permissible for him to do so. Another question pertains to a father who refused to allow his daughter to undergo a dangerous operation. There were also questions that related to mental health issues.

Perhaps the most monumental shailah in the collection pertains to what is known as the “health basket.” In Israel, every citizen must be a member of one of the country’s four health funds – Meuchedet, Klalit, Maccabi, and Leumit. There is no fee for basic membership, and patients may see a specialist in any field through his health fund. The health funds also provide patients with medications; prescriptions are issued by the doctors, and the medicines are purchased from the pharmacies of the health funds themselves, for relatively small sums. For instance, a person suffering from multiple sclerosis can receive Copaxone for 12 shekels, in spite of the fact that the health fund itself pays the manufacturer, Teva Pharmaceuticals, over $1000 for each box.

An alternative to Copaxone was recently developed in America; the advantage of this drug is that it is administered intravenously two or three times during the year, whereas Copaxone is delivered through a daily injection. In that sense, the new drug offers a tremendous benefit to patients. Another major benefit is that the new drug not only prevents the patient from deteriorating, but even fosters improvement. The only problem is that the medicine is not yet included in the “basket” of approved drugs.

In order for a health fund to be obligated to give a certain medication to a patient regardless of its cost, the drug must be recognized and approved as part of the official “basket” of medications recognized by the Ministry of Health. The drugs that are included in that “basket” are determined by a committee consisting of doctors and public officials. The committee meets every year to add new medications to the basket. Every year, the members of the committee are inundated by people seeking to pressure them to add specific drugs to the list of subsidized medications. Of course, the availability of a particular medication can sometimes make the difference between life and death.

The kuntres reveals that one of the doctors on the committee sought Rav Zilberstein’s guidance for the committee’s decisions. I would guess that that doctor was Professor Yonatan Halevi, the director of Shaarei Tzedek Hospital. Until recently, Halevi – who is religious – was the chairman of the committee. But that is mere speculation.


Pharmaceutical Priorities

“I am a member of the committee that sets priorities for the health services basket,” the questioner wrote to Rav Zilberstein. “Our committee faces many major dilemmas. Due to the shortfall in the budget, every decision to provide treatments for certain patients means that medical treatments will be withheld from other patients. The decisions that must be made by the committee deal with weighty moral issues and questions of life and death. As a member of the committee, I would like to ask the rov what is the order of priorities and preferences, according to Jewish law, in allocating the budget of the health basket.”

The doctor was very thorough in presenting his question. “The following is a partial list of the issues that are facing us,” he wrote. “We have a need to establish an order of priorities among the following: lifesaving medications, life-extending medications, medications that improve the quality of life, preventive medicine (such as initiatives to cure smoking addictions, exercise, and healthy nutrition), medications for rare genetic disorders, medications that will benefit only a small number of people….” At the conclusion of his letter, the doctor added an important point. “I must emphasize that according to the law, it is not possible for us to provide funding for a medication included in the health basket exclusively for the poor. When a drug is included in the list of approved medications, it is subsidized for the rich and the poor alike.”

Rav Zilberstein noted that Rav Elyashiv was once asked whether it was appropriate to invest money in establishing a unit for organ transplants. In that case, the investment had the potential to save lives, albeit only of a small number of people, whereas if the same funds were invested in a hospital, they could benefit many more individuals.

Rav Zilberstein’s response to the doctor is lengthy and highly detailed, a thorough exposition on the relevant halachos that deals with matters of the utmost gravity. In the summary of his ruling, he mentions a number of principles (for instance, that medications that can be used to save lives should take precedence over drugs that can be used to lengthen lives). He also ranks the various categories of medications and services in order of importance: Lifesaving medicines are the highest priority, followed by medications for various forms of cancer, then preventive medicine, and then tests for various forms of cancer.

Another interesting question: A diabetic who was required to measure his glucose levels by taking several blood samples every Shabbos related that a new device had been invented that could minimize the need for chillul Shabbos, but it was extremely expensive. The cost, he related, was 500 NIS every month. The questioner said he was so impoverished that the device would come at the expense of food for his family. Rav Zilberstein replied delicately, “Acquiring this device will prevent melacha on Shabbos altogether, since it can be used with a shinui. An expenditure of 125 NIS every week for the sake of preventing chillul Shabbos is not an excessive expense. It would be an affront to Shabbos if you do not spend this money to purchase the device.”


The Grandfather’s Theft

The kuntres also contains a chapter of shailos that were presented to the rov at the Lev L’Achim convention, along with his responses.

The following astounding account appears in that chapter: “A school registration activist brought a child to register in a religious school. He was accompanied by an older man who paid the registration fee. The man was the boy’s grandfather and the child had grown up in his home, since he had been unable, for various reasons, to live with his parents. When the grandfather was asked to pay for other school-related expenses, he revealed to the menahel that he didn’t actually have enough funds of his own; however, he had managed to procure the money from a different source. He explained that there was a wealthy man in the neighborhood from whom he had ‘received’ the money; he had been embarrassed to ask him for a handout, but he had obtained the money in a different way – by stealing it. ‘Don’t worry,’ he told the menahel, ‘I didn’t take much from him. I am only trying to help my grandson.’”

The menahel asked Rav Zilberstein how he should respond to that revelation. Should he accept the stolen money? Should he report the grandfather to the police? And what if the child became lost to Yiddishkeit as a result?

Rav Zilberstein related that the story reminded him of a question that he had heard from a doctor who works in Beilinson Hospital. He related that an elderly man had once been brought to the hospital suffering from fainting spells, elevated blood pressure, and dizziness. An examination revealed several severe bruises on his upper body. The patient claimed that he had bruised himself by falling out of bed, but then the doctors discovered signs of trauma on his lower body as well. After the hospital staff pressured him, he revealed that he had been beaten by his son, who was using threats and even physical violence to extort money from his father.

The doctor, who was appalled by the story, announced that he was legally obligated to report the abuse to the police, but the father pleaded with him not to do so. “I am begging you,” he said tearfully. “He is my only son, and the only support I have left. He takes care of me with great devotion. He helps me daven in shul, he goes shopping for me, and he takes care of the upkeep and cleaning of my home. If he is taken away, I will be completely alone in the world.”

Stressing that the father’s life was not in danger, the doctor asked Rav Zilberstein what he should do. Rav Zilberstein related, “I brought this shailah to the home of my master and father-in-law, Rav Elyashiv zt”l. He heard the details of the question and said decisively, ‘We must have pity on the son and deliver him into the hands of the authorities, since he becomes liable to the death penalty every time he strikes his father. As for the father, we must trust in Hashem, Who runs the world and has compassion for His creations. Just as He made sure to sustain the father and provide him with all of his needs until now, so too will He continue to care for him in the future. Hashem has many ways to aid a person.’”

Rav Elyashiv ruled that the rov of the father’s neighborhood should be apprised of the situation and should make sure that someone would take care of his needs. “A person who does not make sure to save the son from this sin will be actively violating the halacha!” Rav Elyashiv added.

As for the grandfather who wished to pay his grandson’s tuition with stolen money, Rav Zilberstein continued, “In this case, as well, since the menahel is aware that he is dealing with a thief, he is obligated to report him to the police (unless he is capable of discouraging him from sin in some other way, such as with verbal reproof). By doing that, he will prevent the sinner from stealing, and he will also save other Jews from losses, thus fulfilling the Torah’s commandment, ‘You shall not stand by the blood of your fellow.’”

In this case, though, there seemed to be another dimension: If the grandfather were taken to prison, it would become more likely that his grandson would descend into a life of sin. Rav Zilberstein’s response touched on that issue as well: “Even if there is a concern about the spiritual future of the grandson if his grandfather is arrested, that is not a calculation that we would make. If a person knows that another Jew is committing sins and he is capable of preventing him from doing so, yet he refrains from taking action, he will be considered an active partner in those sins…. In short,” the rov concluded, “the police should be informed. At the same time, someone should contact the rov of that neighborhood and ask him to become involved in providing for the boy’s needs. With Hashem’s help, the child will grow into an upstanding adult.”


An Unsolicited Ambulance Ride

I will conclude with one more fascinating question that was posed to the rov. “I have a female tenant who is not emotionally stable,” the questioner related. “She pays her monthly rent on time, and she functions reasonably well in her home. Recently, after she did not answer the telephone for a few days, her family members became concerned and sent emergency services to her. They came and spoke to her through the door and window, but she refused to cooperate with them. Consequently, they sawed through the bars on the window and entered the apartment.

“After they had done this, they saw that their intervention had not been necessary, since the woman was healthy and well. She refused to pay for the window bars to be replaced, since she claimed that she did not call the first responders. She felt that the family members who had called emergency services should be responsible for paying for the damage. Her relatives, on the other hand, argued that since she hadn’t answered the phone, they suspected that something had happened to her. “Should we now be obligated to pay for coming to her aid?” they demanded.

“A similar question was asked in the past,” Rav Zilberstein revealed. “In that case, it was about an American yeshiva bochur who drank lots of wine on Purim and became drunk. He collapsed on the sidewalk, and the passersby tried to wake him up, but he remained unconscious. They weren’t sure if he was simply drunk, and that was why they were unable to rouse him, or if his brain had been damaged by the alcohol. Finally, they decided to call an ambulance, and the bochur was transported to the hospital.

“The next morning, he became sober and found himself in a hospital bed. He immediately asked how he had gotten there, and he was told that some kindly benefactors had arranged for him to be brought there. When he was about to leave the hospital, he was asked to provide his name and identifying information. As a foreign citizen, he had no medical insurance in Israel, and the hospital wanted to charge him for the cost of his stay there. The bochur argued that he hadn’t asked to be brought to the hospital and had not benefited in any way from being there, and therefore the responsibility to pay the bill rested on those who had called the ambulance.”

Ultimately, Rav Zilberstein ruled that the answers to both of these questions should be dictated by logic and fairness. In the case of the rented apartment, if there was enough of a justification for the tenant’s relatives to summon the police and paramedics, then she would have to pay for the damage that was caused to the apartment. And the same for the drunken bochur: If there was adequate reason for the ambulance to be called, the bochur himself would have to pay for its cost.




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