A woman brought a very limp parrot to a veterinarian. As she placed her pet on the table, the vet pulled out his stethoscope and listened to the bird's chest. After a moment or two, the vet shook his head sadly and said, "I'm so sorry, Polly has passed away."

            The distressed owner wailed, "Are you sure? I mean, you haven't done any testing on him or anything. He might just be in a coma or something."

            The vet rolled his eyes, shrugged, turned and left the room, returning a few moments later with a beautiful black Labrador. As the bird's owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the dead parrot from top to bottom. He then looked at the vet with sad eyes and shook his head.

            The vet petted the dog and took it out, but returned a few moments later with a cat. The cat jumped up and also sniffed delicately at the ex-bird. The cat sat back, shook its head, meowed and ran out of the room.

            The vet looked at the woman and said, "I'm sorry, but like I said, your parrot is most definitely 100% certifiably ...... dead." He then turned to his computer terminal, hit a few keys and produced a bill, which he then handed to the woman. The parrot's owner, still in shock, took the bill.

"$150!,” she cried, “$150 just to tell me my bird is dead !!"

            The vet shrugged. "If you'd taken my word for it the bill would only have been $20, but what with the Lab report and the Cat scan......"

While the joke is not likely to be read into the Congressional record any time soon, it does conjure the issue of health care, an issue much on our minds at Congress moves toward legislating systemic changes. Changes, we hope will leave us with the non-animal versions of lab reports and cat scans, or, come to think of it, pet scans.                 

I am not a health care provider, nor a health care economist, but I do have some significant first hand experience of our health care system. About four years ago, I became a big time health consumer. A fall down a long flight of stairs led to ten hours of surgery, after which I was left with substantial pain and a pretty much useless right arm. With the assistance of the Sinai community, in tandem with a network of friends and family, within four months I found a surgeon in Indianapolis with the requisite training and experience to perform a full elbow replacement. Newly bionic, I returned to Milwaukee, where, free of pain, I soon regained full range of motion and function.

I learned a number of lessons over those four months: first, that chronic pain can be unbelievably debilitating and those who live with it deserve our utmost understanding and rachmones, or sympathy. I also discovered how fortunate I was to have the wherewithal to navigate the confusing and, at times, capricious world of American health care. I repeatedly saw firsthand what happens to those who can’t, who are left to drift with the currents, unaware of how to go about locating expertise or adequate insurance coverage.  They are, as the Yiddish expression goes, “Auf Tzuris”, in a heap of trouble.

In contrast, I was lucky enough to have the help of friend who helped me appeal the insurance company’s decision to withhold coverage for the surgery in Indianapolis, which was, as the non-Yiddish expression goes, “out of network.” In short, I was very, very lucky.

Our nation is now embroiled in a heated health care debate. We all will be affected by its outcome, as patients or caregivers or, most likely, both. My story is one of the lucky ones.

Not all are so lucky. There are, as of last year, close to 47 million uninsured Americans. As a country, we spend more on health care any other country on earth (17% of our GDP vs. 10% in Europe). And despite that enormous outlay of resources, we have worse outcomes, including higher infant mortality rates and lower life expectancy, depressing statistics that might otherwise be surprising, where it not for the fact that the U.S. is the only major industrialized nation without some form of universal coverage.[1]

Lest we think that these problems affect only a small number of Americans, try this experiment: raise your hand:

• If you know someone who doesn’t have health insurance?
• If you know someone who is paying for COBRA coverage that will be coming to an end?
• If you know someone with a preexisting condition who can’t get individual coverage?
• If you know a business owner who is struggling to keep up with rising health care costs?

I could go on with this list, and I bet you could too.  Every week, people tell me stories about what happens when families and individuals fall through the supposed safety net of health insurance.

• Children in need of inpatient mental health services that families can’t afford and insurance will no longer cover.
• Cancer patients who lose their jobs and then can’t afford the COBRA payments and then even if they could afford the COBRA payments, have little of nothing left over for co-payments and treatment costs.
• Middle income families who are well off enough to be ineligible for Medicare or Wisconsin’s Badgercare, but not well off enough to pay the premiums, or the co-pays, or the costs of medication.

And these are examples I heard about just in the past two weeks.

Yes, safety nets like Medicare and Badgercare do exist to take care of the most indigent patients, but in reality those nets are strung so close to the ground that people hit bottom and bounce before the net can soften their landing.

While reasonable people can debate how best to fix the situation, it is hard to argue that the status quo is sustainable. Yet, finding a solution seems to be nearly impossible. I will leave it to the Op-Ed page of the Newspapers to explain why that might be. As a non-expert, however, it strikes me that one challenge we face is that the health care crisis is a classic example of NMBY – not in my backyard. We know there is a problem but we’re worried how solving it might negatively affect us. By calling it a NMBY I don’t mean to trivialize. I suspect I speak for others when I share my own inner struggle between wanting to do the right thing and the fear that my own health care will suffer.

In response to those concerns, Judaism teaches that inaction is not an option. “Tzedek Tzedek Tirdof, we learn in Deuteronomy. Justice, justice shall you pursue.” Commenting on the unusual repetition of words, our sages explained that the first tzedek refers to doing justice when the outcome will be to your benefit, while the second tzedek insists we do justice, even when the outcome will not redound to your personal benefit. Moreover, indifference to the pain of others is a serious sin. As Rabbi Abraham Joshua Heschel taught: Indifference to evil is more insidious than evil itself. Or as the Torah succinctly states: Al Ta’amod al dam re’echa – do not stand idly by as your neighbor bleeds.

And we are bleeding. Of the sixteen percent of Americans, those nearly 47 million who are not covered by health insurance, twenty million might be covered if they could afford it. The other thirty aren’t eligible.[2] To put those numbers in perspective, 47 million is greater than the population of the 24 smallest states combined. And that number continues to rise. In 2001 it was 41.2 million. And of the 47 million who are currently uninsured, 72% are employed in some form, and of those 56% are working full time.

The cost of insuring a family has far outpaced inflation, rising from 6,300 dollars in they year 2000 to nearly 11 thousand today. How many of your salaries have kept pace? Minorities in America lack health care at rates much greater than the general population: One in five African Americans, one in four American Indians, and one in three Latinos lack health insurance of any kind. In addition, 8.3 million children are uninsured a number that seems incredible given the presence of programs like S-CHIP which are in place to make sure no child is without coverage.

In addition to those who lack health insurance, a significant number of Americans – an estimated 12 million elderly families and 11 million younger families, have inadequate coverage and spend more than ten percent of their annual income on health care.[3] These 23 million Americans face the greatest challenge because the government doesn’t consider them at risk. Yet, because of high premiums and co-pays, many under insured Americans are forced to choose between feeding their family and buying their medicine.

Thankfully, congress is grappling with these issues as we speak, but the outcome is far from determined. Given the gravity of these concerns, I want to address the question, from a Jewish perspective, what ought to be the guiding principles of a national health care policy?

Specifically, under Jewish law,

- Are we morally obligated to provide health care to all members of society?

- If so, how should it be distributed?

- And how much should be spent?

It turns out that the second century c.e. Mishnah and the 6^th century Talmud don’t have a lot of commentary on healthcare. This is mainly because, before the advent of antibiotics in the 20^th century, physicians did not excel at healing. The average person’s life span was less than 45 years, and, in fact, in one passage of the Mishnah, it is written that physicians can “go to hell”. Nevertheless, they must have been doing some good since a doctor was one of the ten things one needed to have to build a worthwhile Jewish community (among the others were a synagogue, a court, an educator and a kosher butcher).[4]

Given the Torah’s lack of specifics on health care, it makes sense to look at other Rabbinic passages related to saving lives, which, as we know, is Judaism’s most important commandment or Mitzvah.

            Even in the pre-penicillin age, Judaism taught a system of values that placed the preservation of life at its apex. Created in God’s image, we are of infinite value. Descended from Adam and Eve, we are all co-equal with one another. Taught to love our neighbors as ourselves, we are, in a very real sense, our brother’s keeper.

            Yet, real life is complicated; how ought we to apply such values?

Consider a scenario, found in the Talmud, in which two men are wandering in the desert with only enough water for one of them to make it back safely. Who should get the water?  Should they:

a) Share the water and hope for the best.

b) Flip a coin.

c) The person who owns the water is saved.

Raise your hand if you vote for a) share the water, b) flip a coin, c) the person who owns the water is saved.

 According to Rabbi Akiva, the answer is (c). It is generally accepted that whoever owns the water gets to drink it. The logic is that at least one person should live and that, while an individual certainly has an obligation to look after others, his first priority is to look after himself. The next priority is to take care of his family.

            If individuals are obligated first to save themselves and then their families, how far must a community go to save a life? Former Milwaukeean Rabbi Elliot Dorf, who has written extensively on medical ethics, suggests we look at the rabbinic sources dealing with the ransoming of captives in order to tease out Jewish values on how far a community must go to save a life.  In particular, he suggests that being held captive by an illness is similar to being taken prisoner for ransom.  There is extensive commentary as to how a community is obligated to redeem (or free) any of its members that are taken hostage, a mitzvah known in Hebrew as, “Pidyon Shivuyim.”

To start with, it’s interesting to note that, while there are limits to the amount a community is obligated to pay to redeem a captive, a person may pay any amount to free himself.

While permission is thus given to look after number one, the lion’s share of the text address our obligations to each other. The mitzvah to save lives is paramount and, in fact has precedence over other community duties including feeding the poor and education. Nevertheless, because of limited resources, the challenge of rationing those resources is unavoidable.

Consider a second scenario: Two members of the community are taken captive and there is only enough money to redeem one. One passage in the Mishnah bases preference on social and religious hierarchy. A priest (Kohen) would take precedence over a Levite, a scholar over a non-scholar.

Today, we would never consider making a decision on such a basis, and there is ample evidence that even the rabbis chose to ignore those teachings when making decisions. Instead, they rely upon more egalitarian conversations in the Talmud based on the premise that all of humankind is descended from a single person, Adam, who was created in the likeness of God. The reasoning is that no person is inherently more important than another, or as the Torah puts it, “Is my blood redder than yours?”

In the rabbinic view, then, status is far less important than need. If two community members are taken into captivity, the one whose health is worse or is most threatened is to be redeemed first. If a man and woman are taken into captivity then the woman is to be redeemed first because she is more vulnerable.

Jewish tradition also asserts that the community’s obligations are not open ended; there are limits. As I mentioned previously, an upper limit may be set on ransom so as not to encourage future kidnappings and extortion. If a person is partly responsible for being kidnapped (say they owe money to the kidnapper) then the community still has an obligation to redeem them once but not more unless their life is threatened.

So, how do we apply these texts in the context of today’s health care debate? There is a strong community obligation to fulfill the mitzvah of saving a life. Priority should be based on need rather than status or wealth and, from a medical perspective, would include preventive care. There is a strong, though not limitless, community obligation to treat people who may be partly responsible for their illnesses, like smokers with lung cancer or alcoholics with liver disease).  At the same time, as individuals, our first priority is to take care of our families and ourselves. Thus, while it is not necessarily a Jewish value that everyone have the same care, according to our tradition, society is obligated to provide a basic level of care for everyone.

Such a scenario would seem a reasonable starting point in today’s debate. For it is simply inconceivable that our nation -- one that went to the moon, that offers its citizens freedoms that others in the world can only dream of, whose citizens regularly pour billions of dollars into entertainment and play, a country that spends so much money on prisons, that engages in military and humanitarian activity throughout the world -- can allow so many of its own citizens to be denied the most basic benefits of medical care.

As the legislative process continues through the upcoming months, I urge you to follow the debate and register your feelings and opinions. Otherwise the conversation will be controlled by the most extreme voices, some of whom would like nothing more than to make sure that there is no meaningful debate at all.

I hope and pray that our Jewish heritage will give structure to our deliberation, and that the values Judaism espouses come to shape the policies our country adopts.  Then, we may yet all be able to fulfill the vision provided in the Gevurot prayer: “Great is your Power, O Lord and endless your love. You are the source of life, and all that exists testifies to your love. You have taught us to uphold the falling, to heal the sick, to free the captive, to comfort all who suffer pain. In sickness and in health, in life and death you are with us. Blessed is the Lord the Creator of Life.”

AMEN

[1] Religious Action Center of Reform Judaism, “Status of Health Care in America, http://rac.org/Articles/index.cfm?id=1819&pge_prg_id=11464&pge_id=2415

[2] President Barack Obama, in a speech given the week of September 14^th

[3] Religious Action Center of Reform Judaism, “Status of Health Care in America, http://rac.org/Articles/index.cfm?id=1819&pge_prg_id=11464&pge_id=2415

[4] Moses Maimonides, Mishnah Torah