Israel Medical Association Journal

Since the beginning of medical history, ethics has interested medical practitioners. The subject has become particularly important in recent years due to the huge advancements in medicine and medical technology and has elicited much public interest. While international ethical principles and guidelines have been established, classical Jewish tradition has always placed great emphasis on bioethics. Prof. Avraham Steinberg’s monumental Encyclopedia of Jewish Medical Ethics presents the subject comprehensively and in depth. We propose a bioethics syllabus, to be integrated into the medical curriculum in three stages: i) preclinical – covering basic ethical concepts and principles, relevant history, and ethical codes; ii) clinical  – covering bioethical topics relating to the human life cycle; iii) prior to students' final examinations and further specialization – covering bioethical topics relating to their personal interests. Steinberg’s Encyclopedia is an ideal basis for the development of a professional course, including Jewish traditional aspects. Such a course would provide future physicians with a varied cultural and intercultural background, help shape their image, and improve the quality of medical care.

It is common knowledge that in addition to the slaughter of millions of innocent civilians, Nazism caused direct damage to patient care by euthanasia of the handicapped, gruesome human experimentation, and ethnic cleansing of German medical schools. In gastroenterology, 53 prominent academicians living in Nazi-occupied Europe were persecuted by the Nazis. Prior studies analyzed this persecution as it related to gastroenterologists rather than to patient care. What is not known, however, is that Nazi persecution led to a delay of more than one generation in the clinical application of major inventions by these gastroenterologists. These included flexible fiberoptic endoscopy, which was delayed from 1930 to 1957. Fiberoptic transmission was invented by Heinrich Lamm in 1930. Lamm was exiled from Nazi Germany in 1936, and this technique was clinically applied to endoscopy by Hirschowitz only in 1957. Another innovation was fecal occult blood testing for early colon cancer detection, which was devised by Ismar Boas before 1938. Boas committed suicide under Nazi oppression in 1938 and this modality was clinically applied by Greegor only in 1967. The acceptance of refugees from Nazi Germany or Austria into America or into the future State of Israel helped mitigate some of this damage. For example, eight eminent academic gastroenterologists who fled Nazi-occupied countries to then mandatory Palestine made major contributions to the development of academic gastroenterology in the soon-to-be established State of Israel.

The Israel Health Ministry is preparing legislation that would allow a person to receive monetary compensation in exchange for donating a kidney for a lifesaving transplant. Such a bill would be the first of its kind, and would seem to establish a policy that is in contrast with both existing international professional ethics and major Christian and Islamic religious ethics. In an attempt to investigate the extent to which such a bill would be consistent with traditional Jewish ethics, we reviewed the opinions of major traditional Jewish ethicists/halakhists, with emphasis on contemporary opinions, and found that compensating an organ donor for his or her time, discomfort, inconvenience, and recovery is fully consistent with traditional Jewish law and ethics.  While non-altruistic sale of kidneys might be theoretically ethical from a Jewish perspective, ultimately its ethical status is inextricably connected to solving a series of pragmatic issues, such as creating a system that insures that potential vendors/donors are properly informed and not exploited; controlling and supervising medical screening and support of the donors to insure that their health is not permanently endangered; protecting minors and incompetents; and regulating payments so that they reasonably reflect compensation for pain and suffering.

How to place medical ethics more firmly into medical practice continues to be a central concern of physician training and practice. One strategy is to make medical ethics an explicit focus of attention in the medical record. A separate section of the medical chart, one integral to clinical evaluations and ongoing progress notes, should be devised to articulate both the obvious and less apparent ethical issues pertinent to each patient. This so-called Ethical Concerns section is designed to proactively identify such problems and thereby raise these issues as part of routine evaluation and care. The historical developments and ethical challenges leading to the need for such a revision in record-keeping is reviewed.