Jewish tradition says safety trumps privacy when it comes to mental health

The deadly rampage and paranoid ravings of Seung-Hui Cho in Virginia last week cast an uncomfortably harsh light on the issue of mental illness, particularly untreated or undiagnosed mental illness among young people.

While Cho had some initial psychological counseling in 2005, it appears that he opted out of follow-up care, an option the law affords adults who do not pose immediate danger to themselves or others.

In the Jewish tradition, while privacy is valued, a greater emphasis is put on healing the person who is ill and protecting those around him.

“I think that both as Jews and as Americans we have a strong sense of privacy and of the right to individual privacy, but at the same time that does need to be balanced so that we report issues when we see them,” said Rabbi Elliot Dorff, professor of philosophy and co-chair of the bio-ethics department at the American Jewish University (formerly University of Judaism).

Jewish law considers mental illness as serious and real as physical illness, he says, with an accompanying obligation of treatment.

The laws against lashon hara (gossip) are suspended when a person’s safety or well-being is at stake, Dorff points out, and Judaism requires bystanders to become active participants in ensuring a person’s well-being.

At the same time, Judaism does recognize that human dignity often lies in the right to privacy. God himself is only partially revealed, Dorff said. And he points to the Biblical laws that require a lender who is collecting a pledge to wait outside the door, and not invade a person’s home. Rabbinic laws prohibit opening another person’s mail, and tzedakah (charitable giving) is considered to be at a higher level when it is given anonymously.

But the emphasis on privacy can be taken too far, Dorff says, such as when there is a reticence to report domestic abuse.

“Health and safety trump privacy rights,” he said. “It’s a hard balance to strike, but one we need to strike.”

Some Jewish mental health professionals believe American law errs too far on the side of individual rights.

“There are those who say that someone has a right to be disheveled and pushing a shopping cart and muttering to himself and living under a bridge, as long as he doesn’t hurt anyone. They say he has a right to do that, and giving him that right is what embodies a vision of human dignity,” said Dr. Abraham Havivi, a psychiatrist and ordained Conservative rabbi.

“Others would say that what embodies a vision of human dignity is to take control of that person against their will and force them to have treatment, and that it doesn’t respect their dignity to allow them to be that way,” said Havivi, who runs a private practice and teaches pastoral counseling at the Ziegler School of Rabbinic Studies at the American Jewish University.

Havivi points to the biblical injunction of “Lo ta’amod al dam re’echa,” to not stand idly by when a person is in danger, which includes getting a person help when necessary.

Traditionally, he says, families — Jewish and non-Jewish — have taken care of those who are struggling, no matter their age.

Havivi points to a situation where an 18-year-old patient has been hospitalized for his first psychotic breakdown, a common occurrence since psychosis such as schizophrenia or mania often manifest during the late teens or early 20s. If the patient refuses to tell his parents, the treating professional is precluded by law from calling the family, even though the patient’s decision-making capabilities are compromised.

In that situation, Havivi sees the law butting up against his ethics.

“There are times when a mental health professional is faced with a dilemma,” he says. “Do I essentially violate the law and break confidentiality to notify someone’s family? If I were this young man’s parents, I would want to be notified and want to try to take care of my child,” Havivi said.

Jewish Family Service (JFS), an agency of the Jewish Federation of Greater Los Angeles, works hard to maintain that balance as it offers counseling in its several storefronts and onsite at public high schools and Jewish day schools. Assessment by several people is a big part of the process, and serious cases get referred to in-patient facilities or intensive out-patient programs.

Having the services in the schools makes it more likely that students and parents will get help, said Margaret Avineri, director of clinical and disability services at JFS.

JFS helps teachers identify behavior that should be referred to mental health professionals, and presents workshops to students, parents and teachers on issues such as substance abuse, relationships or safety on the internet.

“A lot of the programming promotes good communication, which I think can prevent rather than react after serious situations,” Avineri said.

Milken Community High School also takes a proactive approach, according to Roger Fuller.
A unit on mental health is included in the ninth-graders’ curriculum, and those students, in groups of six to 12, are matched up with advisers. The groups stay together through the four years of high school, and the students check in with their adviser for 15 minutes four times a week.

Staff counselor Georgie Cutter is available for academic as well as social needs, and next year two more counselors are coming on board.

Some Milken students also volunteer for Teenline, a hotline staffed by trained teen volunteers, who field anonymous phone calls and online messages from teens who have issues with anything from boyfriend problems to suicidal thoughts.

While the vast majority of mental illness does not lead to violence such as Cho’s, Dorff — a past president and current board member of JFS — encourages those who have issues to seek help, and for others to get help for those who need it.

“One of the important things to recognize is that just as physical illnesses range from a cold to cancer, so too mental problems range across a spectrum,” Dorff said. “People can have real problems that one has to deal with, and they are not always going to be life-threatening.”

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Opinions Conflict on Ending Life Support

The Florida case of a woman on life support for 13 years has put issues of how we die and when and how doctors and others should intervene on the front page. Whatever the courts say about that case, however, will only apply to federal and Florida law.

What would Jewish law say about such a case? That question is important because the issues raised in that case confront Jews often as they care for their parents, spouse and other loved ones and as they contemplate their own dying process.

The basic Jewish principle about these matters is clear: We are, on the one hand, not allowed to hasten the dying process, but on the other, we are not supposed to prolong it either.

Until just a few decades ago, it was easy to adhere to that prescription, because there was little, if anything, that doctors or anyone else could do to prolong or reverse the dying process. Now, however, we are faced with the old Kantian problem: specifically, as Kant pointed out, as soon as one can do something, then one has to ask whether one should.

Our ancestors, of course, could never have contemplated these new powers that we have. As a result, we cannot just look up the answer as if we were looking up a recipe in a cookbook. We, instead, must use judgment in applying Jewish laws, principles and sensibilities to the new situation.

When we examine the tradition, we find that there is a strong imperative to save life and health when we can, but there is also a clear recognition that we are not immortal, that Adam and Eve could not eat from the Tree of Life and that, in the words of Kohelet (Ecclesiastes), "There is a time to be born and a time to die."

Medieval Jewish sources also announce that we must do what is in the best interests of the patient, and while they assumed that that always meant trying to save the patient’s life, in our own day, when that can mean years in a coma supported by machines, that is not always as clear.

Most Jewish authorities from all movements would agree that we may and, in some cases, should remove machines or medications that are not curing the patient, whether dying or earlier in life, for every medical intervention has side effects and both emotional and financial costs.

Rabbis differ, however, regarding artificial nutrition and hydration. Some — for example, Conservative Rabbi Avram Reisner and Orthodox Rabbi Moshe Tendler — understand them to be the equivalent of food and liquids, for they function to nourish the patient. These rabbis assert that if a person cannot eat normally, we need not insert feeding tubes but may rather let nature take its course. If we do insert feeding tubes, however, we may not remove them.

I, however, maintain, as I did in a ruling approved by the Conservative movement’s Committee on Jewish Law and Standards, that artificial nutrition and hydration should be classified as medicine. That is because it does not come into the body in the usual way food does and thus lacks all the qualities associated with food, such as taste and varying temperatures and textures. Furthermore, one of the natural features of the dying process is that the person stops eating, and so by using tubes, we are effectively force-feeding a patient and thus prolonging the dying process.

Thus when Jews face these issues, they should think carefully about whether they should permit feeding tubes to be inserted into their loved one in the first place. If they do and the patient does not recover, they may, in my view, take the tubes out and let the person die a natural death, making sure that comfort care is administered.

In such cases, it is not the person removing the feeding tubes or the one who authorizes that who is killing the person; the underlying disease is. And they should do this as soon as it becomes clear that nothing can be done to bring the person back to independent functioning — long before the 13 years that it has taken the Florida courts to resolve this issue.

That is not only the wisest way to spend our limited health care dollars; it is also the most humane and theologically correct way to acknowledge that God has made us mortal.

Rabbi Elliot N. Dorff, rector and distinguished professor of philosophy at the University of Judaism, is the author of "Matters of Life and Death: A Jewish Approach to Modern Medical Ethics" (Jewish Publication Society, 1998).

Spin Cycle

By J.J. Goldberg

Spin Cycle

A spate of new polls shows Jewsdivided, Arafat unpopular and pollsters getting rich

Some startling revelations have emerged aboutAmerican Jews and the way they view the Middle East, following lastweek’s publication of parts of a new American Jewish Committeesurvey.

First, the statistics prove that fascination withJewish opinion has reached an all-time high, at least amongpoll-takers. No fewer than four major surveys of American Jews havenow been released since the Hebrew year 5758 began last September.This breaks the previous record of three polls in a six-month period,set in 5752. And we’re not even halfway to Yom Kippur. Don’t cancelthose vows yet.

Second, opinions on the Middle East are evenlydivided. Of the four latest polls, two support aggressive U.S.intervention, while two warn against it.

Of course, this is a silly way to interpretsurveys. It doesn’t tell what American Jews actually think. Butnobody cares about that. The point of all this expensive pollingisn’t to explore Jews’ beliefs. The point is to influence policymakers by scaring them with imaginary Jewish bogeymen.

Why now? Because Washington and Jerusalem are on acollision course over how to break the yearlong deadlock inIsraeli-Palestinian peace talks. Having tried quiet diplomacy, theClinton administration now plans to announce its own peace plan.Israeli Prime Minister Binyamin Netanyahu hates that idea. He saysthat it amounts to America pressuring Israel into concessions. Toblock it, he is playing every card he has, from toasting theChristian right to threatening angry Jewish politicalretaliation.

Unfortunately, it’s unclear how angry Jews mightget. Netanyahu wants President Clinton to believe that they’d behopping mad. Clinton wants Netanyahu to believe they wouldn’t.Everyone has polls to prove it. If nothing else, it’s a great time tobe a pollster.

The polling frenzy began last September, when thedovish Israel Policy Forum released results that showed strong Jewishbacking for U.S. pressure. Its most publicized figure was 84 percent,the number supporting pressure if applied equally on Israel and thePalestinians (a detail lost in most reporting). The findings werereleased days before a crucial White House meeting, where a forumleader presented them directly to Clinton as Israeli officialswatched helplessly.

In reply, the hawkish Middle East Forum conductedits own survey in January. It found Jews opposing American pressure,65 percent to 24 percent. “President Clinton is on a collision coursewith a majority of American Jews,” Middle East Forum director DanielPipes said, savaging the Israel Policy Forum survey as “garbage in,garbage out.”

In February, yet another poll was released, thisone by the Jewish Council for Public Affairs (JCPA), whichcoordinates the policies of the main Jewish organizations. The JCPApoll was a two-tiered affair, questioning community leaders and therank and file to test whether the mostly liberal leaders are in stepwith their constituents (they are, except on welfare reform andaffirmative action). JCPA found that 70 percent favored equalpressure on Israel and the Palestinians.

Now comes the American Jewish Committee’s annualsurvey, widely considered a reliable, objective resource on Jewishopinion. The AJC, like the Middle East Forum, found Jews against U.S.pressure. The margin was 52 percent to 45 percent.

The score, if you’re following: two favoring U.S.pressure, two against, all claiming to be the latest news on Jews’views. Is there anything believable in this morass of statisticalblather?

Actually, yes. The original surveys, devoid ofspin, are more alike than their sponsors let on. Studied carefully,allowing for differences in method, all four paint a similar pictureof American Jewry: devoted to Israel; suspicious of Arab intentionsbut none too fond of Netanyahu; hopeful that the peace process can besalvaged; and willing to see the Clinton administration do somethingabout it so long as Israel isn’t the fall guy.

Differences in method are important, though. TheAJC and Israel Policy Forum surveys worked with reliable nationalsamples of more than 1,000 interviews each. The other two were morelimited. The JCPA simply mailed a questionnaire to federationactivists, a narrow spectrum. Results reflect the views of those whobothered mailing it back.

Most limited was the Middle East Forum survey,which interviewed only 600 “likely voters” (“unsure” voters weredropped) in just nine states. How representative is its sample? Well,15 percent were Orthodox and 28 percent Reform; every other surveyshows about 7 percent Orthodox and 35 percent to 40 percent Reform.Researchers have long known that Jews’ political conservatism riseswith traditional observance. It seems the forum found the results itwanted to find.

Still, the four polls’ results are strikinglysimilar. Dislike of Palestinian leader Yasser Arafat runs from 81percent in the Israel Policy Forum’s survey to 84 percent in theMiddle East Forum’s. Asked if Arafat really wants peace, answersranged from AJC’s 55 percent “no” (up from 31 percent “no” a yearago), to the Middle East Forum’s 60 percent “no,” to 70 percent “no”in the JCPA survey (which asked about the PLO, not Arafat).

But Netanyahu doesn’t do too well either. Hescores high on basic questions such as “what are your feelings towardhim,” a cue to praise Israel’s leader. But with probing, his numbersdrop. His Likud Party is viewed far less favorably than the Laboropposition, 39 percent to 59 percent in the AJC poll. When the MiddleEast Forum asked respondents to choose between Arafat and Netanyahuas “someone I admire,” Netanyahu got 43 percent. “Neither” got 44percent.

The one question where comparison is hardest isthe big one: U.S. pressure. Different polls phrased this differently,seeking different responses. The Israel Policy Forum and JCPA askedif Washington should pressure both Netanyahu and Arafat, and foundstrong support; support for pressuring only Netanyahu was much lower.The Middle East Forum and AJC polls didn’t ask about pressuring bothsides, because they didn’t want to know. Naturally, they found theJews against pressure.

But how strongly against? The AJC found that 52percent opposed the United States pressuring Netanyahu, and 45percent supported it. With the survey’s 3-percent margin of error,that could also be 49 percent to 48 percent. It’s a virtualtie.

The truth, if anyone cares, is that American Jewsare a complicated lot. They are deeply devoted to Israel — 74percent told the AJC that “caring about Israel” was a “very importantpart of my being a Jew,” and nearly 40 percent have visited — butare troubled about its future and divided over what to do. They trustClinton more than Netanyahu, but they’re wary of blaming Israel. It’san amber light for Clinton, and a “hazard” sign for Bibi.

It’s not clear who should be happy with thesepolls. Besides the pollsters, that is.