What does halachah say about how to improve American health care? Not much.

Someone skeptical about halachah might ask, "Does Jewish law have anything useful to say about a public policy debate as complicated and multifactorial as health care?" Unfortunately, after reading the chapter devoted to health care in Rabbi Jill Jacobs' There Shall Be No Needy, I have to say no.

I wanted Jacobs' book to provide halachic metaphors to help me understand better what it means to support health care reform - and, ideally, to help me judge the relative ethical benefits and risks of various alternatives, even in a general way. I don't need halachah to tell me about the necessity of health care, the critical role of the health care provider, or the community's role in providing such care: these are relatively uncontroversial, things that even opponents of health care reform support. Halachah should be a source of Jewish wisdom and  something more than the deployment of righteous cliches. It should provide a particular perspective, not a reinterpretation of universalist principles which can be found in any liberal ethos.

Rabbi Jacobs' chapter is a skillful summary of the general principles of Jewish law regarding the provision of health care to the individual and community. She discusses the well-known arguments about the healer's permission to "interfere" in Divine creation when healing the sick, the need for the physician to be remunerated for their services; and the requirement inumbent on the community to provide for medical care. In an esthetic and moral sense, the passages she cites are useful - as Jacobs herself points out, they serve as a troubling reminder of the inefficiencies of the American health care system. (1)

After these summaries, however, Jacobs seems to get lost. She acknowledges that "today's system presents us with many more players than the doctor, the patient, and the immediate community" and goes out to find what halachah will tell us about these multiple factors. Unfortunately, there isn't much there (when has there been a health care system on earth as fragmented, oversized, and inefficient as ours?), so she has to limit herself to an unsatisfying historical aside on the history of Jewish hospitals and an unsurprising teshuvah by Rabbi Shlomo Goren holding that the Israeli government is required to provide health care. (2)

Jacobs acknowledges in passing that most Americans today receive health care through their employers (though she neglects to mention that veterans and Native Americans also are cared for by a national system), a state of affairs which has no halachic precedent. What then is there to say?

This is where the rubber meets the road. If there are no exact parallels in halachah to the matter at hand, perhaps there are at least useful metaphors, engaging stories, gripping ultimatums, solid philosophies. Jacobs: "From a Jewish perspective...a major problem with the American health care system is the lack of community oversight over the distribution of funds." This is disappointingly tepid and unfocused.

"Community oversight," like Mom and apple kugel, sounds good on its face. (I supported a public option and I think that a single-payer system is the way to go - I assume this is what Jacob is reaching towards with her "community oversight.") But what we need is help with a hard question: what kind of community oversight is needed, and at what level of government? Do we need more state control of apportionment of Medicare and Medicaid, or less (both could be called "community oversight")? Do we need Congressional interference in decisions about comparative effectiveness research? Should the Federal government have a role in deciding what health care should be available to which doctors? Democracy is all about the conflict of different communities, and "the Jewish perspective," at least as Jacobs is presenting it, has nothing whatever to say about these conflicting priorities.

In a concluding chapter which is useful in understanding her overall approach, Jacobs lays out her vision for how Jewish law and tradition should inform public policy (or the "public sphere," as she vaguely calls it). Unfortunately, this vision is not convincing.

Why unconvincing? Her "essential principles" ("the dignity of human life," "the inherent disparity of power" between different classes, and the reciprocal responsibilities of individual and community) are not unique to Judaism. This would not be a problem if halachah provided a unique perspective on issues of public policy - but I don't see any evidence of that here either. How, according to Jacobs, should Jewish law inform our discussions? "Jewish sources should help us to see various sides of an issue,challenge our assumptions, and enable us to formulate a response that takes multiple factors into account." Again, this is nothing we need halachah for - only a liberal cast of mind and general civic virtues of tolerance and open inquiry. (3)

It is not inspiring to say that halachah offers us no guide in some areas of life, but I think that's the case. I will not ask a posek the next time I prescribe an antibiotic and I don't think I need one either when considering various aspects of health care reform. (4) General moral guidelines about the importance of health care are available in halachah, should one choose to seek them there (though they can be found nearly everywhere else in a liberal society). For practical approaches to systematic reform, we should look elsewhere.

Update: See Rabbi Josh Yuter's shiur on the topic here, which I haven't listened to all of yet.

1. Jacobs says that our country's systematic inefficiencies and profit-driven nature "prevents many patients from being able to afford needed medical care." This is undoubtedly true, but another issue - which Jacobs does not explicitly address - is that Americans want too much medical care: too many labs, tests, and procedures, which drive up costs without improving care. This, among many other complications of the health care system, is something which our halachic predecessors simply could not envision, although I am sure one could, by stretching some precedent to the breaking point, find a proof text of use.


2.  Jacobs calls this teshuvah influential, but I suspect she is mixing up the chicken and the egg. Surely more determinative in today's halachic world is the fact that Israel is a democracy. Democracies legislate and administer national health care. Were Israel not a democracy, or not able to administer health care, the Goren teshuvah would be forgotten.


3. In fact, one could argue that Jewish law - in many places - does not place a premium on tolerance or open inquiry. There is the apikores and the min, after all.


4. In this regard, Rabbi Jacobs' philosophy bears a surprising (and disquieting) resemblance to Charedi daas Torah: that rabbis have a variety of expertise which equips them to offer advice even in practical situations far afield from their formal erudition.