Duty and Healing: Foundations of a Jewish Bioethics (review)

Duty and Healing: Foundations of a Jewish Bioethics. By Benjamin Freedman. New York: Routledge, 1999. Pp. 368. $24.49.

In this posthumously published book, Benjamin Freedman, who died in 1997, brought together two projects that occupied him during his tragically short life: his passionate devotion to clinical medical ethics and his religious commitment. He envisioned a bioethics based on duties, rooted in Jewish tradition, which starkly contrasts with the prevailing Western rights-based approach. Freedman's final book provides a challenging and intriguing look at a bioethics that sheds the seemingly self-evident rights structure that encases our legal and political institutions.

The problem with bioethics today, in Freedman's view, is that it focuses on social ethics, which adjudicates conflicting rights claims within society, and largely ignores personal ethics. In contrast with this effort to achieve consensus on social ethics, Freedman elaborates an ethic that places medical choices within the context of "living a dutiful life."

In his clinical ethical practice, Freedman noticed that discussions over moral issues focused mostly on claims of duties, as participants tried to figure out the right course of action for the patient. Under the rights model, the only duty is that freely chosen. Not so in the duty model. A doctor takes on obligations as part of the "moral baggage" of his profession. For Freedman, relations between brother, parents, and neighbors are not chosen, they are divinely ordained. Under the duty model, one doesn't expect or hope to be proven right: one wants to know "the right thing to do."

In four chapters Freedman explores the practical and theoretical implications of his duty model for bioethics. Drawing on cases from his practice as a clinical bioethicist at the Jewish General Hospital in Montreal, he skillfully weaves Jewish commentary on medical decision making into his analysis of moral dilemmas that commonly face doctors, patients, and families in a modern urban setting.

Freedman first analyzes the family's role in making medical choices, and rejects the standard view that allows doctors to disqualify families from decision making on flimsy evidence of "conflict" between family and patient interests. Rather than ground a family's participation in medical decision making on a notion of rights, Freedman examines Jewish teaching that children have a duty of respectful service to parents. Where there is a close question, with no convincing arguments on either side, the family's strong feelings should be granted precedence.

The next chapter reveals a sharp fault line between the conservative rabbinical view of informed consent and the standard approach in Western law and bioethics. A Jewish patient has an obligation to care for his body and cannot waive life-saving treatment, which doctors must decide. This view destroys autonomy as a foundational principle. Seeking accommodation, Freedman argues for a gentler version of this dogmatic view. A Jewish patient--and by implication others who hold similar ethical or religious views--must seek out and utilize that information which would be demanded by the average, reasonable patient and must make a reasonable decision. But where there is medical uncertainty as to outcome of proposed treatment, as is often the case, life-saving procedures may be refused. While incorporating a version of informed consent into a Jewish framework for medical decision making, Freedman's approach offers a corrective to the prevailing strict adherence to a form of autonomy that often ignores broader social, familial, and personal dimensions of medical decision making.

Chapter 3 deals with the issue of competence. It is not enough that a patient exhibit "capability," i.e., basic communication skills, an understanding of the benefits and risks of proposed treatment, and the ability to choose. Another question is whether society should authorize choice. Freedman would require "recognizable reasons": the patient must provide reasons for her choice, and the reasons must bear some relation to the choice made and must not be based on provably false propositions...