Forum on the Professions

PARTICIPANTS:

Rachel Katz-Sidlow; Michelle Friedman

and Rachel Yehuda; Roy Simon; Erica Brown

EDITOR’S NOTE:

I thank Lawrence A. Kobrin

for his participation in preparing this forum.
FORUM ON THE PROFESSIONS

RACHEL KATZ-SIDLOW

The “Sick Visit”

(Bikkur H. olim):
A Model for Medical
Humanism

“At the conclusion of all our studies we must try once again to experi-
ence the human soul as soul, and not just as a buzz of bioelectricity;
the human will as will, and not just a surge of hormones; the human
heart not as a fibrous sticky pump, but as the metaphoric organ of
understanding.”
Melvin Konner MD, PhD1

R
ecent advances in modern medicine have proven beneficial to the
healthcare of ill patients, prolonging life and reducing morbidity.
Nevertheless, while providing answers for physicians and patients,
these new technologies have generated many questions for discussion
among ethicists and religious leaders. Contemporary ethics texts cover
wide-ranging subjects such as genetic and reproductive advances, abor-
tion, transplantation, and end-of-life issues. Yet the attention garnered
by these exciting technological advances has overshadowed an important
ethical problem faced daily by physicians: an erosion of humanism in
physician-patient relations.
Medical humanism has been defined as physicians’ “attitudes and
actions that demonstrate interest in and respect for the patient, and that
RACHEL J. KATZ-SIDLOW, M.D., is an Assistant Professor of Clinical Pediatrics at the
Albert Einstein College of Medicine of Yeshiva University, where she is a pediatri-
cian in a city hospital and works with students and residents. She also holds an
M.A. in English and Comparative Literature from Columbia University.
224 The Torah u-Madda Journal (11/2002-03)
 Rachel Katz-Sidlow 225

address the patient’s concerns and values.”2 While multiple definitions

of the term exist, there can be no doubt about humanism’s critical role
in patient care. As Francis Peabody declared in 1927, “One of the essen-
tial qualities of the clinician is interest in humanity, for the secret of
good patient care lies in caring for the patient.”3 More recently, William
Branch noted a similar connection between a humanistic approach to
patients and a successful outcome: “For patients depending on their
doctors, the attitudes with which those doctors deliver care—their
attentiveness, kindness, and compassion—are in many cases as thera-
peutically important as the curative treatments.”4 Despite agreement
among medical institutions on the importance of humanistic patient
care, contemporary medical training may actually impede its implemen-
tation.5 There is increasing evidence that humanistic behaviors among
physicians, especially those in training, are on a decline.
The problem originates in the pre-clinical years of medical school,
when students immerse themselves in the basic sciences. As alluded to
by Dr. Konner’s quotation above, the formal teaching of pathophysiolo-
gy and molecular biology in medical schools tends to reduce the human
body to quantifiable units and systematic pathways, displacing the lay
person’s metaphysical understanding of the human form. Dissecting a
human cadaver, performing experiments on animals, and learning
pathology from autopsy samples (“man in the pan” sessions), similarly
strain the student’s humanistic tendencies by forcing the student to dis-
tance him- or herself from the inherent sacredness of the experience in
order to examine such “specimens” in a clinically dispassionate manner.
While the “formal curriculum” of a medical school may stress the
importance of eliciting patient emotions during an interview and assur-
ing the dignity and privacy of the ill person, many factors in a physi-
cian’s education promote the opposite behavior. In addition to formal
coursework, each medical institution unwittingly teaches a “hidden cur-
riculum,” 6 consisting of the subtle lessons that medical students and
residents absorb daily over the course of their training; this “hidden
curriculum” likely exerts a greater influence on a physician’s approach
to patient care than any formal didactic teaching.7 For example, despite
being explicitly taught to elicit psychosocial aspects of a patient’s illness,
interns are routinely pressured to complete historical intakes on hospi-
talized patients quickly, not to delve into emotions. There is often sim-
ply too much to do, no time to eat and few opportunities for needed
sleep. As insurance companies continue to press for shortened lengths
of stay for hospitalized patients, a proportionate increase in paperwork
226 The Torah u-Madda Journal

falls on the intern, who must work at a dizzying speed to facilitate

patient admissions and discharges.8 Significant financial debts accumu-
lated from medical school, decreased confidence in obtaining jobs after
training, and threats of closings of academic centers also contribute to
resident stress.9
Economic pressures further add to the agenda of the “hidden cur-
riculum,” as managed care models place ever-greater premiums on
“productivity” and “efficiency.”10 Growing numbers of attending physi-
cians are now being required to meet specific “productivity require-
ments” in order to earn a salary. Physicians may consequently have less
time to spend with individual patients; house calls are essentially extinct
in urban practice settings. In addition, as student and resident teaching
is usually an uncompensated activity and “detracts” from patient care
sessions, even dedicated doctors are finding such teaching responsibili-
ties increasingly burdensome. Physicians who must rush to get back to
their offices to see patients may not have sufficient time to improve the
patient-relating skills of the trainees on their medical team. Harried fac-
ulty members who speak derogatorily about patients, or who refer to a
patient as “the pancreatitis in Room 213,” rather than “Mr. Smith in
Room 213,” only further worsen the situation. Needless to say, role
models for medical trainees are becoming harder to find, and existing
ones may be growing increasingly cynical.11
Marcus notes that although medical students arrive with “an
empathic identity,” the “classic rites of passage of medical education
currently produce a characteristic developmental pattern of emotional
and psychological adaptations that delay the development of mature
emotional empathy and humanistic attitudes until after residency.”12 In
other words, “medical education sometimes beats students’ ability or
willingness to care right out of them.”13 Medical training has been com-
pared to the wartime experiences of soldiers; both groups are witness to
gruesome life and death situations, and individuals in both fields may
struggle unaided with resulting emotions.14 At the extreme, these strains
lead some physicians to suffer “burnout” and emotional impairment,
further alienating them from their patients.15
Medical institutions traditionally depend heavily on faculty physi-
cian role models,16 as well as on formal medical school courses and initi-
ation ceremonies, to teach medical ethics and humanistic behavior to
students and residents.17 As already mentioned, inspirational role mod-
els for medical trainees are becoming harder to find, and formal ethics
courses and initiation ceremonies may not be effective in producing
 Rachel Katz-Sidlow 227

humanistic physicians.18 As a result of the pressures described above, the

education provided by the “hidden curriculum” routinely contradicts
the lessons taught in formal ethics coursework. After experiencing the
culture of medicine, students too often come away with a cynical view
of their formal medical humanism sessions, perceiving these courses as
not in tune with the “real world” of medical training, and as draining
precious time from “important” medical subjects.19
Despite curricular reforms and attempts to reduce resident stress,20
studies over the last decade continue to demonstrate an ongoing decline
in humanism in the medical environment. In a survey of second-year
residents by D.C. Baldwin et al., over 25% responded that they had been
required to do something they perceived to be “immoral, unethical, or
personally unacceptable.”21 C. Feudtner and others found that 98% of
medical students had heard physicians refer derogatorily to patients,
61% witnessed “unethical behavior” by other medical team members,
and of these, 54% felt like accomplices. Sixty-two percent stated that at
least some of their ethical principles had been eroded or lost.22 A 1998
survey by Virginia Collier et al. found that 61% of medicine residents
reported increasing cynicism during residency, and 23% reported a
decrease in their humanism.23 Tait Shanafelt et al. surveyed internal med-
icine residents in 2001 and found that 75% of residents met criteria for
physician burnout. Thirty percent of respondents in this study said they
“paid little attention to the social or personal impact of an illness on a
patient” and 18% said they “had little emotional reaction to the death of
one of my patients.” Burned-out residents were more likely to report
delivering suboptimal patient care, including “discharging patients to
make the service ‘manageable’ because the team was so busy,” “not fully
discuss[ing] treatment options,” and “not perform[ing] a diagnostic test
because of desire to discharge a patient.”24
Such statistics are unfortunately not shocking to those training in
the contemporary medical environment. One medical student recently
recounted to me a story about a patient she had cared for on a medical
ward, and with whom she had developed a close relationship. The elder-
ly gentleman was admitted to the hospital for treatment of a disfiguring
rash on his abdomen and groin. Several times each day, medical stu-
dents, attendings and consultants paraded through the room, and, often
forgetting to pull the curtain around the patient, would repeatedly
remove the patient’s dressings to take a look at his “interesting findings.”
Several days into his hospitalization, the patient began crying when the
student entered the room, and he admitted to her that he felt depressed
228 The Torah u-Madda Journal

not only about his illness, but more so over the loss of dignity he was
experiencing on a daily basis. In another recent encounter, an over-
worked resident admitted that constant exhaustion was eroding her
humanism. She was horrified to find herself wishing late one night that
a terminally ill patient would “hurry up and die” so that she might not
have to work quite so hard. Such examples occur even among the most
conscientious and dedicated medical trainees.
Religious medical students may also be losing their way. Orthodox
students are subjected to the same stresses as all others, if not more so, as
they must balance medical practice and observance. Because of the com-
plex interplay between halakhah and medicine, Orthodox students may
find themselves preoccupied with “pure” ethical issues, to use Avraham
Steinberg’s terminology. 25 Examples of so-called “pure” dilemmas
include many important questions, including what medical students may
do for patients on Shabbat, whether a particular individual should apply
for a “shomer shabbat” residency, whether a student may participate in
clinical rotations in which patients undergo reproductive procedures or
abortions, how to deal with obtaining autopsies on patients, and how to
approach end-of-life issues. Questions about humanism may remain
unformulated in light of the day-to-day “practical” ethical struggles of
the observant medical student.
The problem of eroding humanism in the profession has not gone
unnoticed by the medical establishment. Over the last decade, a number
of professional organizations (including the American Board of Internal
Medicine) have called for greater emphasis on the humanistic dimen-
sions of medical education.26 Clinical educators and medical training
institutions have worked to develop programs geared toward instilling
compassion and humanistic behavior into harried medical students and
residents. Some strategies focus on training attending physicians to
actively and passively model humanistic skills for trainees.27 Other pro-
grams are aimed directly at students, including problem-based learning
sessions, small group sessions, resident retreats and mentoring ses-
sions.28 Some of these approaches formally teach humanistic behav-
iors,29 while others emphasize “personal awareness” strategies intended
to develop the students’ understanding of factors in their own back-
grounds, cultures and religions that may influence their treatment of
patients.30 Many medical schools have added a course in which students
read and discuss works of literature, case studies and poetry that focus
on the experience of being ill.31 In addition, numerous schools have
instituted memorial services for cadavers dissected in medical student
 Rachel Katz-Sidlow 229

anatomy courses, as well as “white coat ceremonies” intended to foster a

sense of responsibility and professionalism among medical students.32
Jewish medical ethics literature, replete with valuable discussions
about the Jewish physician’s license to heal and about halakhic approach-
es to scientific advancements in areas such as transplantation, reproduc-
tive medicine and end-of-life issues, says less about the specifics of the
Jewish doctor’s halakhic responsibility to treat patients with dignity and
respect. Nevertheless, it seems clear that the Jewish doctor, as David
Feldman and Fred Rosner note, “should maintain the self-respect of the
patient.” They point out that “Many medical procedures may compro-
mise a patient’s dignity, unless the psychological impact is taken into
account. For example, proper draping and privacy, rather than undue
exposure, allow the patient to retain a sense of self-esteem.”33 Julius
Preuss notes that the Jewish physician has a “moral” obligation to feel
compassion toward patients; he writes that unlike other languages,
which derive the word for physician from “magician” or “knowledge,”
the Hebrew designation “rofe” arises from a root meaning “alleviate,
assuage.” 34 Along these same lines, Ramban’s locating the source of the
physician’s license to heal in the verse, “And you shall love your neigh-
bor as yourself,” 35 seems to underscore the intrinsic humanistic essence
of Jewish medical practice.
Examples of humanistic behavior by physicians exist in Jewish liter-
ature (although these passages are not usually explicated from their
physician-patient relationship standpoint). One example that stands out
is from Bava Mez.i‘a, 85b, and is quoted by Fred Rosner in his Medicine
in the Mishneh Torah of Maimonides:36
Samuel was Rebbi’s physician. Rebbi [R. Judah the Prince] contracted an
eye disease. Samuel offered to bathe it with a lotion, but Rebbi said, “I
cannot bear it.” Samuel then said, “I will apply an ointment to it.” Rebbi
objected: “This too I cannot bear.” So Samuel placed a vial of chemicals
under Rebbi’s pillow, and the latter was healed.
Rosner uses this passage to illustrate that Mar Samuel, an eminent
talmudic rabbi and physician, was famous for his special eye salve,
whose vapors alone evidently were potent enough to treat eye illnesses,
sparing the ill person the pain of a topical medication. In addition to
highlighting Samuel’s clinical expertise, this passage also demonstrates
his humanistic attitude. Instead of exhibiting frustration with his patient,
Samuel incorporated his patient’s wishes by prescribing an alternate, yet
effective, therapy. Significantly, the passage concludes that R. Judah
“was healed,” healed in a way that was both therapeutically acceptable to
230 The Torah u-Madda Journal

the physician, and tolerable for the patient. Feldman and Rosner under-
score this image of the humanistic Jewish physician in their statement
that an “emphasis on the spiritual and moral counterparts to the physi-
cal elements in the human personality, [and] the stress on maintaining
the dignity of the patient . . . are among the basic contributions of
Judaism to the practice of medicine.”37
In general, however, it is difficult to identify explicit references to
medical humanism in Jewish thought. Jewish law does not mandate a
specific personal code of conduct in the realm of physician-patient rela-
tions. Halakhic problems with oath-taking aside, it is telling that Jewish
physicians never committed themselves to an equivalent of the Hippo-
cratic Oath, and there is no mention of a such an oath for physicians in
rabbinic literature.38 In fact, Immanuel Jakobovits points out that “For
physicians, there are no specific ethical directives on the lines set out in
the Hippocratic Oath.39 [The Oath’s] principal provisions—on the
respect due to teachers, the protection of human life, abortion, steriliza-
tion and chastity—are in any case covered by laws which are incumbent
on any Jew, and which could not, therefore, be designated as profession-
al rules of conduct.”40 Such a code for Jewish doctors would be redun-
dant; “For one who has foresworn at Sinai to observe the tenets of
Judaism in their entirety, a subsequent oath to fulfill any specific reli-
gious obligation would be superfluous.” 41
The obligation of a practicing physician to deliver humanistic care
thus derives from the general dictates of behavior required of all Jews,
rather than from a code designed explicitly for the physician. Jako-
bovits notes that “Strictly speaking, a Jewish code of medical ethics (in
the technical sense of professional rules of etiquette and moral con-
duct) cannot be said to exist at all. Jewish law lays down special moral
qualifications only for religious officials.” 42 Maimonides notes in
Hilkhot De‘ot that a Jewish person is commanded to emulate God;
“ ‘Just as He is called Gracious, so you too should be gracious; just as
He is called Merciful, so you too should be merciful; just as He is called
Holy, so you too should be holy’. . . . These are good and just paths, and
a person is obligated to conduct himself by them and to emulate Him
as much as one can.”43 Similarly, in a dispute with Bet Shammai on the
issue of truth-telling (Ketuvot 16b-17a), we accept Bet Hillel’s approach:
“Let a man’s disposition always be considerate of the feelings of
others,”44 a practice that highlights a “principle of sensitivity to the
needs of others.”45
 Rachel Katz-Sidlow 231

Bikkur H.olim as a Model for Humanistic Care

Despite the general mandate for all Jews to behave in a humanistic way
toward others, Jewish (and non-Jewish) physicians’ efforts to provide
such care are challenged daily. While medical establishments continue
to debate the most effective ways to increase humanism among students
and residents, Jewish tradition provides a unique model for humanism
in physician-patient relations in its explication of “bikkur h.olim,” the
precept of visiting the sick. The practice of bikkur h.olim is highly
esteemed; in fact, the Talmud (Shabbat 127a), in a passage recited by
religious Jews in daily prayers, lists visiting the sick among a number of
precepts for which a person is rewarded in both “this world” and the
“world to come.” In addition, just as God visited Abraham when he was
recovering from his circumcision (Gen. 18:1), so too are Jews required
to visit the sick.46
Bikkur h.olim is referred to here as the “sick visit,” in order to distin-
guish it from the “doctor visit,” a term used in this essay to describe a
physician’s interaction with an ill person. It is unlikely that a doctor on
traditional medical rounds fulfills the miz.vah of bikkur h.olim. While a
visit from the physician may distress the patient, the “sick visit” is
intended to provide solace. Historically, these two visits were considered
separate entities as well; bikkur h. olim societies were organized and
administered by the lay community, not by the medical establishment.47
The distinctness of these two visits is illustrated clearly by a passage
from Midrash Kohelet Rabbah 5:6 “Said Hezekiah to Isaiah: “Normally,
when a man visits the sick, he says, ‘May God show compassion to you.’
And when a physician visits a patient he tells him, ‘Eat this and not that,
drink this and not that.’”48
The contemporary “doctor visit” is physician-centered, with patients
waiting to be seen either in their hospital beds or at an office at a sched-
uled time. Such a visit, orchestrated by a clinician with a white coat and
medical instruments, is often much more anxiety-provoking than com-
forting to the sick person. In addition, except in the case of a poor person,
who should be cared for without charge, the physician generally receives
monetary compensation; “a doctor for nothing is worth nothing.”49
In contrast, all Jews are enjoined to participate in bikkur h.olim, and a
visitor to the sick should not accept payment for the visit (Nedarim 39a).50
Unlike the typical “doctor visit,” the “sick visit” is patient-centered, a
notion underscored by the laws pertaining to its practice.51 Among other
things, these laws dictate appropriate hours for such visits, times that
232 The Torah u-Madda Journal

reflect the best interests of the patient, not the convenience of the visitor.
According to Nedarim 40a and Yoreh De‘ah 335:4, a visitor should not
come for the first three hours or the last three hours of the day because he
may misjudge the status of the patient and not care for him or pray prop-
erly; in the morning the patient appears better than he really is, and in the
evening the reverse is true. Patients with diarrhea, eye ailments or
headaches should not be visited, the first because the patient may be
embarrassed, and the latter two because speech is harmful for them.52
In addition, while the “doctor visit” focuses on the physician’s
knowledge and expertise, the “sick visit” highlights God as the central
healer in the person’s illness. Duties of the visitor to the sick include
praying that God should act compassionately toward the ill person and
send a recovery. The idea of prayer is so intrinsically tied to the sick visit
that one who visits a patient and does not pray for the patient’s recovery
has not properly fulfilled the miz.vah of bikkur h.olim.53 Other laws of
bikkur h.olim also emphasize the role of the Divine in the healing process.
As God Himself cares for the ill, one may pray in any language in the
presence of a patient.54 Similarly, the visitor may not sit directly on the
bed, for God is considered to be in the presence of the sick person.55
Nevertheless, as distinct as they may seem, the two visits share con-
ceptual and textual similarities. Both visits are considered to have heal-
ing properties. Just as the physician is expected to provide curative
treatment, a visitor to the sick similarly promotes healing. A passage in
Nedarim 39b states, “he who visits the sick is as if he takes away one six-
tieth of his illness.”56 Similarly, the Talmud recounts the story of Rabbi
H. elbo, who fell ill. Rabbi Akiva himself paid a sick visit, attending to the
patient’s physical needs. “My master,” said the disciple (R. H . elbo), “you
have revived me.” R. Akiva was moved by his bikkur h.olim experience to
remark that “not visiting the sick is like shedding blood.”57 This phrase
echoes a textual reference from Shulh. an Arukh, Yoreh De‘ah 336:1
regarding the “doctor visit”: “The Torah gave permission to the physi-
cian to heal; moreover, it is a religious precept and is included in the
category of saving life; and if he withholds his services, it is considered
as shedding blood.”58 While intrinsically different experiences, both vis-
its are considered so important that one who is obligated in them and
refuses to participate is considered to have erred so gravely as to have
“shed blood.” In yet another interesting textual parallel, the verse “And
you shall love your neighbor as yourself ” is cited independently as a
source text for both types of visits. While Nah.manides utilizes the verse
as the source of the physician’s license to heal (the “doctor-visit”),59
 Rachel Katz-Sidlow 233

Maimonides notes this verse to be the textual anchor for the precept of
bikkur h.olim, the “sick visit.”60
Just as these inherently distinct visits are related conceptually and
textually in Jewish thought, so too, on a practical level, the patient-cen-
tered “sick visit” may serve to inform the medical student’s understand-
ing and practice of the physician-centered “doctor visit.” The practice of
bikkur h. olim may be uniquely suited to the medical student’s needs,
offering vital insight into patients’ suffering. Many medical school cur-
ricula have a component in which first or second year students visit hos-
pitalized patients and interview them to gain a perspective on illness. In
recent years, some medical institutions have added “home visits” to
their curricula, during which students and residents visit patients’
homes with a view to understanding how the home environment affects
chronically ill, elderly, or impoverished patients.61 (In our institution,
each pediatric resident visits the home of a family he or she cares for in
the outpatient clinic. Residents gain a sense of the socioeconomic status
and cultural backgrounds of their patients and have an opportunity to
perform safety screening and health education in the home).
Yet these curricular visits are typically performed with the student
and resident wearing a white coat and/or stethoscope, in the capacity of
physician and under the supervision of an attending physician. From
the patients’ perspective, such interactions fall under the rubric of the
“doctor visit,” not bikkur h. olim. On the other hand, the “sick visit,”
modeled on the bikkur h.olim model, would require physicians-in-train-
ing to visit acutely ill patients without the trappings of the white coat
and stethoscope, and without the pressure of grades, allowing them to
focus purely on the ill person’s experience and in turn, allow the sick
person to receive them in a patient-centered setting. The rush of the
weekday clinical experience leaves little time for students and residents
to get to know the ill person; trainees generally spend their brief daily
interaction with patients involved in tasks of data-gathering and
“focused physical exam” objectives. For the Orthodox medical student
living in proximity to the hospital, Shabbat may provide the ideal
opportunity to conduct such patient visits. With the white coat left far
behind and freed from the scrutiny of a supervising attending, the med-
ical student has a unique opportunity to observe the workings of the
hospital on “off-hours,” to interact on a personal level with patients, and
to learn from the patient’s experience of illness. Whether institutional-
ized as part of a curriculum or performed voluntarily by medical stu-
dents, the regular practice of bikkur h.olim has the potential to create
234 The Torah u-Madda Journal

medical students who are attuned to assuring the physical and emotion-
al comfort of future patients, even as they attend to those patients’ med-
ical needs. In addition, for the Orthodox physician, the element of
prayer associated with the “sick visit” serves as a reminder that ultimate
healing is not from clinical medicine, but from God. While further
research is needed to clarify how such visits may best be incorporated
into medical education, a strategy incorporating elements of the “sick
visit” model may enhance the patient care skills of contemporary med-
ical students, who are struggling to maintain humanism in an environ-
ment that often encourages the opposite.

Notes
I am grateful to Dr. David Shatz for his support and guidance on this project, and to Dr.
Edward Reichman for his valuable suggestions. Thank you also to Dr. Robert Sidlow and Drs.
Monique and Mordecai Katz for their thoughtful comments on the paper.

1. Melvin Konner, “The Dawn of Wonder,” in On Doctoring, ed. R. Reynolds

and J. Stone (New York, 1991), 392.
2. William T. Branch, David Kern, Paul Haidet, Peter Weissmann, Catherine F.
Gracey, Gary Mitchell, and Thomas Inui, “Teaching the Human Dimensions
of Care in Clinical Settings,” JAMA 286(2001): 1067-74.
3. Francis W. Peabody, “The Care of the Patient,” JAMA 88(1927): 877-82.
4. William T. Branch, “The Ethics of Caring and Medical Education,” Academic
Medicine 75 (2000): 127-32.
5. Branch, “Teaching Human Dimensions,” 1067-74; see also Frederic W.
Hafferty, “Beyond Curriculum Reform: Confronting Medicine’s Hidden
Curriculum,” Academic Medicine 73(1998): 403-07.
6. Hafferty, 403-07, and Frederic W. Hafferty and Ronald Franks, “The Hidden
Curriculum, Ethics Teaching, and the Structure of Medical Education,”
Academic Medicine 69(1994): 861-71.
7. Hafferty and Franks, 861-71.
8. See Jordan J. Cohen, “Heeding the Plea to Deal with Resident Stress,” Annals
of Internal Medicine 136(2002): 394-95.
9. See Virginia U. Collier, Jack D. McCue, Allan Markus and Lawrence Smith,
“Stress in Medical Residency: Status Quo After a Decade of Reform?” Annals
of Internal Medicine 136(2002): 384-90.
10. See Eric R. Marcus, “Empathy, Humanism, and the Professionalization
Process of Medical Education,” Academic Medicine 74(1999): 1211-15 and
Jerome P. Kassirer, “Doctor Discontent,” New England Journal of Medicine
339(1998): 1543-45.
11. See Kassirer, 1543-44.
12. Marcus, 1211-15.
13. Branch, “Ethics of Caring,” 127-32.
14. Dennis H. Novack, Ronald M. Epstein, and Randall H. Paulsen, “Toward
 Rachel Katz-Sidlow 235

Creating Physician-Healers: Fostering Medical Students’ Self-Awareness,

Personal Growth, and Well-Being,” Academic Medicine 74(1999): 516-20.
15. See notes 8,9 and 14 above. See also Tait D. Shanafelt, Katharine A. Bradley,
Joyce E. Wipf and Anthony L. Black, “Burnout and Self-Reported Patient
Care in an Internal Medicine Residency Program,” Annals of Internal
Medicine 136(2002): 358-67 and Linda H. Clever, “Who is Sicker: Patients—
or Residents? Residents’ Distress and the Care of Patients,” Annals of Internal
Medicine 136(2002): 391-93.
16. See notes 2 and 6 above.
17. See Hafferty and Franks, 863.
18. Ibid., 864-66.
19. Ibid., 866.
20. See Collier, 384 and American Medical Association, Accreditation Council
for Graduate Medical Education, Graduate Medical Education Directory,
(Chicago, 1993).
21. D.C. Baldwin, S.R. Daugherty, and B.D. Rowley, “Unethical and
Unprofessional Conduct Observed by Residents During Their First Year of
Training,” Academic Medicine 73(1998): 1195-1200.
22. C. Feudtner, D.A. Christakis and N.A. Christakis, “Do Clinical Clerks Suffer
Ethical Erosion? Students’ Perceptions of Their Ethical Environment and
Personal Development,” Academic Medicine 69(1994): 670-79.
23. Collier et al (see note 9 above).
24. Shanafelt, et al, 358-67 (see note 15 above).
25. Avraham Steinberg (ed.), Jewish Medical Law, trans. David B. Simons
(Jerusalem and California, 1980), 14-15.
26. See Medical Professionalism in the New Millennium: A Physician Charter, Project
of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of
Internal Medicine. Annals of Internal Medicine 136(2002): 243-46.
27. Branch et al (see note 2 above).
28. See Joseph Engelberg, “A Program of Integrative Humanistic Study for
Medical Students,” Academic Medicine 67(1992): 455-56, S.Z. Miller and H.J.
Schmidt, “The Habit of Humanism: A Framework for Making Humanistic
Care a Reflexive Clinical Skill,” Academic Medicine 74(1999): 800-803, and
Kathryn M. Markakis, Howard B. Beckman, Anthony L. Suchman and
Richard M. Frankel, “The Path to Professionalism: Cultivating Humanistic
Values and Attitudes in Residency Training,” Academic Medicine 75(2000):
141-150.
It is important to note that the strategies currently in use by medical schools
to teach humanism may occasionally clash with the religious values of the
Orthodox medical student. While reflecting the struggle between the philo-
sophical weight given to the principles of autonomy, beneficence and justice,
these courses may give undue weight to the primacy of the principle of patient
autonomy. Although Halakhah may favor autonomy in morally indifferent
situations, there may be cases in which a patient’s will is overridden by Jewish
law. Steinberg refers to Judaism’s perspective on the physician-patient rela-
tionship as one of a “moral-religious paternalism,” to distinguish it from the
“individual-personal paternalism” of the Hippocratic model. See Abraham
Steinberg, “Medical Ethics: Secular and Jewish Approaches,” in Medicine and
Jewish Law, ed. Fred Rosner (Northvale, NJ and London, 1990), 26.
29. See Miller and Schmidt, 800-03 (note 28 above).
236 The Torah u-Madda Journal

30. See Novack et al., 516-20 (note 14 above).

31. See Engelberg, 455-56 (note 28 above).
32. See Marcus 1211-15 (note 10 above).
33. David M. Feldman and Fred Rosner (eds.), Compendium on Medical Ethics
(New York, 1984), 15-16.
34. Fred Rosner (ed.), Julius Preuss’ Biblical and Talmudic Medicine (New York,
1978), 30.
35. Lev. 19:18. Nahmanides, Torat Ha’adam in Kitvei Ramban, ed. C. B. Chavel
(Jerusalem, 1964), II, 48 (see J. David Bleich, Judaism and Healing: Halakhic
Perspectives [New York, 1981], 4).
36. Fred Rosner, Medicine in the Mishneh Torah of Maimonides (New York,
1984), 116. See also Ze’ev Metzger (ed.), “Shevu’ot u-tefillot Ha-rofe‘im,” in
Ha-Refuah Le-or ha-Halakhah, ed. H. evrei Ha-Makhon le-H. eker Ha-Refuah
Ba-Halakhah (Jerusalem, 1982) for a compilation of Jewish physicians’
prayers. Overall, these prayers highlight several shared themes, including the
acknowledgement of God as true Healer and the entreaty that He teach the
physician to care for each patient’s illness correctly; other themes include
requests for God to help the physician to retain a sense of personal humility,
to attain favor from God and fellow people, to be protected from medical
error and self-harm, and to be forgiven for personal sins. Some of these
prayers contain references to humanistic patient care (see pp. 15 and 28).
37. Feldman and Rosner, 15-16.
38. See Immanuel Jakobovits, Jewish Medical Ethics (New York, 1975), 209-210
and Bleich, 12. Examples of two Jewish physicians’ oaths, (by Asaf Judaeus in
the seventh century and by Amatus Lusitanus in the sixteenth), can be found
in Metzger (see note 36 above). Jakobovits, 389, n. 75, notes that he has dis-
regarded these oaths for the sake of his discussion because they were never
accepted for practical use by Jewish medical students.
39. There are, however, Jewish laws pertaining to ethical issues not mentioned in
the Hippocratic Oath, including the collection of medical fees, religious con-
cessions for physicians caring for patients, the extent of the physician’s
license to practice, and the physician’s liability in cases of poor outcomes; see
Jakobovits, 211-231.
40. Jakobovits, 209-210.
41. Bleich, 12.
42. Jakobovits, 209-210.
43. Maimonides, Mishneh Torah, Hilkhot De‘ot, Chapter 1:6 (translated by Fred
Rosner, Medicine in the Mishneh Torah of Maimonides [New York, 1984], 76).
44. Ketuvot 16b-17a; see Basil F. Herring, Jewish Ethics and Halakhah for our
Time: Sources and Commentary (New York, 1984), 55-56; see also Shulh.an
Arukh, Even ha-Ezer 65:1.
45. Herring, 55-56; see Nedarim 17a.
46. Sotah 14a; see Rosner, Medicine in the Mishneh Torah, 300.
47. See Jakobovits, 107.
48. Midrash Kohelet Rabbah 5:6 (translated by B.F. Herring, 50-51).
49. Bava Kamma 85a (translated by Jakobovits, 224-225). See also Yoreh De‘ah
336:2, which explains that physicians may be paid for their trouble and loss
of time, not for their medical knowledge.
50. See Rosner, Medicine in the Mishneh Torah, 300. (Jakobovits points out that
 Rachel Katz-Sidlow 237

in plague epidemics, only designated individuals, who were highly paid,

would visit these contagious patients; see Jakobovits, 108-109).
51. See Shulh.an Arukh, Yoreh De‘ah 335:1-10.
52. Ibid., 335:8. See also Fred Rosner, Medicine in the Bible & the Talmud (New
York, 1995), 176-181, and Jakobovits, 108.
53. Yoreh De‘ah 335:4 and gloss. See also Abraham S. Abraham, The Comprehensive
Guide to Medical Halachah (Jerusalem and New York, 1996), 183.
54. See Yoreh De‘ah 335:5 and commentaries there of the Turei Zahav 335:3-4
and Siftei Kohen 335:3.
55. Nedarim 40a and Yoreh De‘ah 335:3.
56. Translated by Rosner, Medicine in the Mishneh Torah, 301. See also
Maimonides, Mishneh Torah, Hilkhot Avel, 14:4.
57. Nedarim 40a; translated by Rosner, Medicine in the Mishneh Torah, 301.
58. Yoreh De‘ah 336:1 (translated by Rosner, Medicine and Jewish Law, 71).
59. See note 35 above.
60. Maimonides, Mishneh Torah, Hilkhot Avel 14:1. See also David M. Feldman,
Health and Medicine in the Jewish Tradition (New York, 1986), 32.
61. See Markakis, et al., 145 (note 28 above); see also the Arnold P. Gold
Foundation at www.humanism-in-medicine.org.