Medical Education

A Syllabus for Jewish Medical Ethics in the Context of General Bioethics*

Department of Bone Marrow Transplantation and Immunobiology Research Center, and 2Department of Radiology, Hadassah-Hebrew University Medical Center (Ein Kerem Campus), Jerusalem, Israel

Key words: medical ethics syllabus, Jewish medical ethics, Avraham Steinberg, bioethics education in medical schools

Abstract

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 Steinbergs 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. Steinbergs 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.

IMAJ 2008;10:397400

Medical ethics has existed side by side with the practice of medicine from the very start, but has become especially important due to new issues raised by the huge advancements in medicine and medical technology in recent years [1]. In the 20th century the basic values of the medical profession suffered severe blows, the most devastating of which was the murderous contribution of Nazi physicians during World War II [2-4]. This led to the formulation of internationally recognized ethical rules for the first time, following the Nuremberg trials (1947) of the physicians involved in the most heinous violations of their profession. Since then, there have been extensive developments in the field of bioethics, and it has achieved honorable standing in many medical faculties

[5]. Many universities have integrated the teaching of bioethics in various areas of study, allowing for specialization in this subject. Bioethics publications include a comprehensive encyclopedia of bioethics [6], journals that relate exclusively to medical bioethics [7], and many websites dealing with medical ethics on the internet [8]. In addition, bioethical topics relating to different areas of medicine are discussed in the professional literature. There are three major sources on the subject [Figure 1]. Dr. Julius Preuss (1861-1913), in his book Biblical and Talmudic Medicine, was the first to research historically and comprehensively the abundance of Jewish sources relating to medical ethics [9]. In the book Jewish Medical Ethics, Lord Immanuel Jakobovits, late Chief Rabbi of Great Britain (1921-1999), made a comparative and historical study of the Jewish religious attitude to medicine and its practice, referring to the rabbinical literature from the time of the Talmud to the present day [10,11]. With the publication of the Encyclopedia of Jewish Medical Ethics by Prof. Avraham Steinberg (born 1947) in both Hebrew and English [12], research in this field reached new heights. It contains many references to scientific, rabbinical, ethical and legal literature, and relevant documents are often appended. As Prof. Steinberg is in clinical practice, he is fully aware of all aspects of the practical problems involved. Due to his extensive command of these issues and his thorough approach, Prof. Steinberg has contributed immensely to modern bioethics. This is manifest in The Dying Patient Act (Steinberg Law), promulgated in 2006 [13,14]. Prof. Steinbergs

* In honor of Prof. Avraham Steinberg on

Biblical and Talmudic Medicine 1911 (German); 1978 (English)

Dr. Julius Preuss (1861-1913)

Jewish Medical Ethics a Comparative and Historical Study of the Jewish Religious Attitude to Medicine and its Practice 1959 (English); 1966 (Hebrew)

Rabbi Dr. Lord Immanuel Jakobovits (1921-1999)

Prof. Avraham Steinberg (born 1947)

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Encyclopedia of Jewish Medical Ethics, which connects the world of medicine with the Jewish heritage and Hebrew law, is an exceptional work suitable for both researcher and layman. Rabbis, physicians, historians, ethicists, as well as people in other fields can find a wealth of information in this monumental work. Furthermore, the encyclopedia provides rich sources for the intercultural discussion of bioethical topics also for non-Jews. The literature on both general bioethics and Jewish medical ethics throughout the ages is an invaluable source for educating young physicians in the profession's basic values. A syllabus incorporating practical and professional material is a prerequisite for teaching the subject, for its definition as a discipline within the framework of professional pre- and postgraduate training in medical schools, and as a field of research. A course of medical ethics relating to Jewish sources and values would widen the students' cultural and moral horizons and develop their sensibilities to basic humanitarian issues in medicine, thereby improving their medical performance in the long term.

Stage 1. As students acquire preclinical knowledge, they should study the basic concepts and principles of medical ethics. They should clarify their personal motivation and commitment to medicine by studying ethical codes and the history of medical ethics, and by understanding the historical and clinical need to consolidate the basic values of medical ethics. Discussions on the patients status, doctor-patient relations, and formation of the physicians personality and image, all fall into this section of medical studies. Stage 2. In this phase of their medical studies, students are exposed to clinical medicine, including rotating clerkships in the hospital departments. At this level, they should deal with ethical problems arising in the different areas of medical training. Discussions on fundamental issues relating to the life cycle should provide students with extensive knowledge in a chronological fashion, within the framework of the medical ethics course. In this way students should become familiar with the bioethical approach to clinical topics during their clerkship in the different departments. Stage 3. At this point, the medical student is preparing for the final examinations and is considering the direction his or her professional future will take. Their bioethical training at this stage should focus on their field of medical interest within the framework of writing and defending their theses. This goal should encourage them to become familiar with the professional literature. They should learn to identify, approach and analyze bioethical problems in the field close to their heart. Their presentation of the subject to a small class would prepare them to discuss ethical concerns, to involve colleagues in such subjects in the future, to cope with problems in their work, and to gain ethical awareness in the profession in the long term [16].

The proposal After reviewing the literature, surveying the internet sites relating to the teaching of medical ethics and the compilation of methodological study programs [8,15] and drawing on personal experience, we present a proposal for a comprehensive and multifaceted program for the teaching of medical bioethics. The medical ethics syllabus should be an integral part of the general medical study curriculum and not an isolated discipline. Prof. Avraham Steinbergs encyclopedia can serve as the basic textbook for both general and Jewish bioethics. Over 100 entries on key topics furnish wide-ranging data on most bioethical issues. The syllabus should be drawn up in a logical and practical manner, in parallel to the basic medical study program. Consequently, we have divided bioethical topics into three stages [Table 1].
1. Preclinical phase at start of medical training Basics of medical ethics, ethical code, and personal motivation

Table 1. A three-phase Medical Ethics syllabus based on Steinberg's encyclopedia

Basics of medical ethics

Patient

Beginning of life

The patient

End of life

Secular ethics Jewish ethics

Patient Visiting the sick, suffering

Medicine Study of medicine Health Danger to life

Physician Medical negligence Self-endangerment

Fertility and infertility Sexuality Contraception Artificial insemination In vitro fertilization Pregnancy Fetus Abortion and miscarriage Childbirth Parents Paternity Twins Newborn Nursing Circumcision

Illnesses physical and mental Disabilities amputee, blindness, deafness, lameness, muteness Treatments medical, surgical, risk assessment Genetics

Elderly Suicide Confession Terminally ill Definition of the moment of death Autopsy Mourning and deep mourning

Written assignment or oral presentation to the group according to the field of interest of the students

Hospitals Allocation of scarce resources Priorities in medicine

Informed consent Disclosure of illness to the patient Confidentiality

Human experimentation Human cloning Cruelty to animals

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Table 1 presents the ethical topics relating to the three stages of medical studies and refers to the entries in Prof. Steinbergs encyclopedia, where they are dealt with in detail. Entries relating purely to practical religious observance according to Jewish tradition (Sabbath observance, fasting on Yom Kippur, etc.) are not included in the Table, since the focus of the syllabus is bioethical topics, appropriate medical decision-making, and proper conduct of physicians towards patients. On the other hand, subjects of general bioethical importance that are not dealt with in Prof. Steinbergs encyclopedia should be incorporated, such as stem cell research, global health issues and others. In addition to Steinbergs landmark work, other sources of both Jewish and general bioethics warrant inclusion, so that the student can appreciate the differences of opinion within Jewish tradition of contemporary rabbis (poskim) and modern Jewish ethicists. Furthermore, comparing Jewish tradition with secular bioethical attitudes will ensure a balanced view for a comprehensive Jewish medical ethics syllabus. Last but not least, regular updates, including relevant literature and bioethical controversies, are crucial for the maintenance of a meaningful syllabus.

to the training of future physicians [21], enabling them to acquaint themselves with the basic concepts of medical ethics and to apply in their future work. This project constitutes a unique opportunity and challenge for cooperation between students and faculty members. Where there is no established syllabus for medical ethics, lecturers and students could use the suggested syllabus or develop an alternative framework according to their interests, experience and understanding. The bioethics teaching program within the framework of the medical curriculum should be reassessed regularly by teachers and students [22,23] in order to ensure its ongoing relevance [24]. Study material: A short and concise textbook should be compiled that relates to updated professional literature. Such a book should include case histories with a methodical analysis. Abstracts and clips of selected films would help improve and perfect the teaching of medical ethics. An internet site that is updated constantly could collect lectures, references to literature, films, forum, etc., on the subject, as well as suggestions and ideas for teaching the subject in an interesting and meaningful way. Sources from Jewish tradition may provide a useful literary platform to analyze bioethical topics [25] including various historical aspects [26-28]. Training of lecturers: Lecturers from different professional fields should present real-life cases from their departments and their personal experience, including discussions based on up-to-date literature relating to the cultural, legal and religious considerations of the populations involved. An interdisciplinary approach is essential for the understanding of many bioethical topics, such as questions regarding the dying patient [29,30] and transplantation medicine [31,32]. Cooperation between specialists in the different areas and departments of the faculty would allow for analysis of different approaches to the subject and enhance inter-disciplinary and inter-professional learning [33]. Regular meetings of physicians, health care providers and faculty members to discuss relevant bioethical topics might serve as an appropriate platform to study medical ethics systematically [34] and enrich the professional skills of physicians [35]. Inter-cultural research: The State of Israel encompasses communities and traditions from the entire world, and the teaching of bioethics offers the opportunity to become familiar with the diversity of religions and cultures in our society. Steinbergs Encyclopedia of Jewish Medical Ethics primarily provides Jewish sources that have important historical and legal implications for Israel. However, a comprehensive medical ethics syllabus in Israel should compare and analyze these Jewish values in relation to general ethical considerations, including also Christian and Muslim attitudes and values. Bringing traditional Jewish perspectives to clinical bioethics would broaden and deepen the contents of this field. By dealing with this inter-cultural challenge through the teaching of medical ethics, Israeli medical faculties could become a model for other medical faculties throughout a world that is increasingly being faced with similar problems.
A Syllabus for Jewish Medical Ethics

Discussion The inclusion of bioethical subjects in an orderly syllabus is a prerequisite for defining the field of bioethics and for increasing awareness to these subjects, with a view to integrating this discipline in the formal medical training program. The syllabus proposed here could serve as a basis for the teaching of medical ethics as part of the regular faculty curriculum in medical schools in Israel and abroad, either as an integral part of the study program or as an elective course. This program could contribute significantly to the widening of horizons and to the teaching of humanistic values [17,18]. Integrating these subjects into the academic framework would improve the quality of medical care on both human and qualitative levels [19], and ensconce medical ethics more firmly into patient-oriented clinical practice [20]. Prof. Avraham Steinbergs monumental encyclopedia is a comprehensive and multifaceted textbook for both lecturer and student that offers the reader and researcher information on clinical topics, and a historical and ethical background together with relevant classical Jewish sources throughout the ages, including discussions and documents relating to modern Israeli legal procedures. Since the entries present diverse aspects of each topic with relevant references, the encyclopedia forms a wide professional base and rich source of information for both beginners and specialists. The syllabus for medical ethics proposed here could serve as a framework for a richer and more detailed curriculum to be developed in the future according to the needs and interests of doctors, lecturers and academic staff on the one hand, and students on the other. In order for the program to be successful, improvements will have to be made in many areas in the future:
Development of a syllabus by lecturers and students: A broad and interesting syllabus created with the active participation of the medical facultys teaching staff and students could contribute

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Conclusion Incorporating the teaching of bioethics in medical schools would contribute significantly to the profession by opening the horizons of young physicians to fundamental cultural, ideological as well as Jewish values, and developing their humanitarian sensibilities. Since the basic principles of bioethics will accompany physicians throughout their professional careers, the integration of bioethics into the medical syllabus would contribute greatly to the fundamental principles of medical practice. Avraham Steinberg's Encyclopedia would be a good start for such a project.
Acknowledgments: Our thanks go to Nadine Gesundheit, Lilly Schaechter and Jacob Bar (all from Jerusalem) for helping in the preparation of this article, and to Prof. Shimon Glick (Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva) for his helpful comments.

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Correspondence: Dr. B. Gesundheit, Dept. of Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, P.O. Box 12000 Jerusalem 91120, Israel. Phone: (972-2) 677-8357 Fax: (972-2) 677-7540 email: gesund@hadassah.org.il