Marshall Kapp presents us with a case that raises an ethical dilemma of significance to the Jewish community and all religious institutions, particularly those in the healthcare arena: how to balance the needs of an individual and the welfare of the community. Dr. Kapp's presentation of this case asks us to investigate the limits of the community's obligation to one individual. Jewish law and ethics assert that both individuals and the community have an obligation to provide and support health care. In this case, the Jewish community has supported a long-term healthcare facility, which can provide quality nursing and rehabilitation services to Miriam.
Unfortunately, Miriam is unable to provide for herself or to be her own advocate. Her estrangement from her husband and brothers and the fact that her children are minors have left her with no financial recourse. There is no question that under Jewish law her family has an obligation to pay for her care or provide the necessary information to permit payments by Medicaid. However, since membership in the Jewish community is voluntary, the Jewish community cannot compel the family to meet its obligations, short of the threat to discharge Miriam. As Dr. Kapp points out, legally the JLTCF can discharge Miriam, but would Jewish ethics permit it?
In Jewish law, the saving of human life takes precedence over all other obligations, even the observance of the Sabbath. It is my presumption that without rigorous rehabilitation, Miriam will have little chance for independent existence, and even with such care she will have certain significant disabilities. There is little question that Miriam's life would be endangered by her being discharged. Therefore, her needs have a high degree of priority on communal resources. In addition, we might consider her to be in the category of "the poor, the stranger, the widow, and the orphan," whose rights we are specially commanded to uphold. To discharge her would be an impermissible act of oppression. It is, therefore, the obligation of the community to provide for Miriam's care while vigorously pursuing her family to meet their obligations.
However, Dr. Kapp asserts that providing the long-term intensive care that Miriam needs may place the JLTCF in financial jeopardy and therefore harm the JLTCF and its current or potential residents. This is a serious issue and one which has important implications for the allocation of healthcare resources in general. In every community there are more needs than the community can fully meet. Therefore, it is important to establish a hierarchy of priorities for using limited resources. Feeding the hungry takes precedence over clothing the naked because starvation is usually a greater threat to life than inadequate clothing. A threat to an individual who is identified as being at risk takes precedence over threats to those who are potentially at risk. Jewish texts further give priority to the needs of those who are nearest over those who are farthest away.
Miriam's circumstances could require that the community represented by the Jewish Federation, synagogues, and individual donors consider reducing allocations to other communal institutions or entities and increasing support of the JLTCF. A certain percentage of Federation funds are usually allocated to national and international needs. The local JLTCF would have a greater claim on local Jewish funds than, for example, Hadassah Hospital in Jerusalem. In a world of limited resources, our highest priority must be given to those most at risk in our local community.
Peter Knobel is Rabbi of Beth Emet the Free Synagogue in Evanston, Illinois. He serves as chair of the Liturgy Committee of the Central Conference of American Rabbis and is a corresponding member of the CCAR Responsa committee.
