National Health Care Choices
By Rabbi Chaim Jachter
Parashat BeReishit
Vol. 19 No. 3

The staggering cost for quality health care constitutes a major problem for many countries today. The Israeli government has dealt with this problem since its inception by adopting a national health care system in which the government provides health care for all its citizens. Health care constituted 7.8% of Israel’s 2008 budget, costing $2,065 per person. Despite what appears to be a generous allocation, it is insufficient to pay for all of the medicines that are very much needed.
Thus, painful decisions must be made as to the medicines that will be included in what is referred to as the “basket of medicines.” These dilemmas include choices between medicines that will briefly extend the life for very ill patients and medicines that will prevent serious illnesses such as blindness, alleviate very painful skin diseases such as psoriasis and medicines that ease nerve pain. A special committee representing the various sectors of Israeli society is convened by the Israeli government to decide these issues. Rav Yuval Sherlow, the Rosh Yeshiva of the Yeshivat Hesder of Petach Tikvah, is a member of this committee. He explains his approach to some of these dilemmas in an extensively footnoted article that appears in Techumin volume twenty eight (pages 383-391).

Must the Government Provide Health Coverage?
Rav Sherlow very briefly raises a most basic issue in a footnote early in his article – “the responsibility of a government to its citizens” in terms of providing health care. As of this writing, Americans are intensely debating this issue. Rav Sherlow leaves this question unanswered but refers to the remarks of Rav Itamar Warhaftig (Techumin 1:485) who notes that in the time of the Gemara the government did not assume responsibility to provide health care, but rather was paid for privately as is done currently in the United States.
Rav Warhaftig notes that as times have progressed and government organization has become more sophisticated, it is obligated in his opinion to provide health care just as it is obligated to provide roads and courts. He argues that government-paid health care “facilitates essential services to all levels of the population at a lower cost than in a private market.” Rav Warhaftig admits, however, the downside of this approach “when individuals abdicate their responsibilities and rely on the government to care for them.”
One may explain Rav Warhaftig’s view based on the Shulchan Aruch (Choshen Mishpat 163:1), which states that the leadership of a city may coerce each member to contribute payment for essential services such as a wall to protect the city from marauders. National health insurance may be compared to a wall as it protects all the residents of a country from illness.
However, the matter is not a simple one. Although socialized medicine provides more affordable health care than private service, since the government controls costs, nonetheless, the question is whether the quality of medical services becomes diminished in governmental clinics. Indeed, the Gemara (Bava Kama 85a) in a celebrated statement asserts that “the service of a doctor who is not paid is worthless.” This is essentially the dilemma that the American people are currently grappling with.
Rama (ad. loc.) writes that debates regarding public expenditures to service and protect the community are resolved by “convening all the tax paying members of the community and everyone will express their opinion for the sake of Heaven (i.e. considering the best interests of the community and not personal needs) and the majority opinion will be followed.” The health care dilemma in the United States should also be resolved by our elected officials who should reach a decision by a process where each side in the debate voices his opinion for the sake of the entire country and not focus simply on narrow concerns.

Does Halachah Resolve National Health Care Dilemmas?
Rav Sherlow writes that since the Israeli government has assumed the responsibility to pay for health care for all, difficult decisions must be made as to what will be paid for. However, he raises a most intriguing question: does Halachah allow the community to decide such matters in the democratic manner described by Rama’s aforementioned statement or must decisions be made by Halachic authorities based on Halachic sources? Rav Sherlow cites from Rav Yosef Dov Soloveitchik’s Halachic Man to illustrate the opinion that “everything is subject to Halachic adjudication”: “There is no phenomenon that Halachic man does not relate to…..He is interested in sociological creations such as the state, society and the relationships of individuals within the matrix of the community. The Halachah encompasses business issues, damages caused by neighbors, monetary disputes, partnerships, agents, workers, artisans and watchmen. It encompasses family life – marriage, divorce, levirate marriage, Sotah, Mi’un, rights of husbands and wives – their obligations are clarified by Halachah. War, supreme courts, lower courts and punishments – these are among the topics of the Halachah which are as numerous as the sand by the sea. The master of Halachah grapples with psychological problems such as sanity versus insanity, whether it is appropriate for a couple to remain married, Migo and assumptions, judicial discretion, and presumptions of deceit and suspicion.”

Paying for Medicines that Save Lives or that Alleviate Excruciating Pain?
Assuming that Halachah resolves national health care allocation dilemmas, Rav Sherlow proceeds with his analysis. He notes that Rav Eliyahu Bakshi Doron argues that the Halachic position regarding this matter is absolute, in that it always favors life saving medicine over medicines which improve quality of life. This approach seems quite logical for if one has a choice between saving one person’s life and another individual from psoriasis, the answer would appear to obviously prefer saving a life.
Rav Sherlow, however, develops an approach for a community to think otherwise. Rav Sherlow’s fundamental point is to distinguish between the dilemmas of a community and the dilemmas of individuals. An individual, who has to make the choice whether to save someone’s life or restore another individual’s vision, should obviously choose to save a life. However, the considerations of a community are different. At times, the community may or even must overlook the needs of certain individuals in order to further the greater benefit the community.
For example, the Mishnah (Gittin 45a) states that we are forbidden to pay excessive ransom to redeem captives. One reason for this, says the Gemara (ad. loc.), is because excessive ransom is too oppressive for the community. Rashi (ad. loc. s.v. Mipnei Duchka DeTzibura) explains “We do not have to pressure the community and to impoverish it for these [captives].” Some opinions believe this Halachah applies even when the lives of the captives are in grave danger (see Shulchan Aruch Yoreh Deah 252:4 and commentaries as well as Techumin 4:108-116). Another example is that Halachah (Sanhedrin 20b) permits a king to wage a Milchemet Reshut (discretionary war) to further the national interest, despite the danger it poses to soldiers.
On the other hand, we must recall that Halachah does not disregard individuals either and does not teach that the needs of the community always outweigh that of the individual. An example of where the individual takes precedence over the community is the Talmud Yerushalmi (Terumot chapter eight) which states: “A group of individuals on a journey and are encountered by evildoers who said to them ‘Give us one member of your group or we shall kill the rest of you’ – let them all be killed and we must not release even one Jewish soul (Yemsaru Kulam VeAl Yismasru LaHem Nefesh Achat BeYisrael).”
What emerges is that Halachah requires a balance between the needs of a community and the needs of the individual. Rav Sherlow argues that the Israeli government is not required to spend all its money on basic necessities such as security and health care and not allocate money to economically develop the society. One could argue that in the long run the Israeli government will be able to better serve the society and widen the basket of medicines if it develops further economically.
Moreover, the government must do its best to make the country attractive so that more people will be willing to move there and also not to leave. The flight of highly talented individuals from Israel could in the long run also endanger the population on a whole. A government is obligated to consider Pikuach Nefesh in the long run and not merely the short term (see Shevuot 35b and Gray Matter 3:222).
Next week we will conclude our discussion of this vitally important issue.