Understanding how communities respond to COVID-19: experiences from the Orthodox Jewish communities of Antwerp city

BACKGROUND

The importance of community involvement in the response against disease outbreaks has been well established. However, we lack insights into local communities' experiences in coping with the current COVID-19 pandemic. This study explored both the impact of, and response to, COVID-19 within the Orthodox Jewish communities of Antwerp (Belgium) during the first lockdown period (March 2020 - May 2020).

METHODS

We conducted an explorative qualitative study using a participatory approach. First, we performed a community mapping to identify relevant stakeholders. Through the active involvement of a community advisory board and based on qualitative interviews with key-informants and community members, we elicited lived experiences, attitudes, and perceptions towards COVID-19. Interviews were conducted both face-to-face and using online web conferencing technology. Data were analyzed inductively according to the principles of thematic analysis.

RESULTS

Government-issued outbreak control measures presented context-specific challenges to the Orthodox Jewish communities in Antwerp. They related mainly to the remote organization of religious life, and practicing physical distancing in socially and culturally strongly connected communities. Existing community resources were rapidly mobilized to adapt to the outbreak and to self-organize response initiatives within communities. The active involvement of community and religious leaders in risk communication proved to be of great importance to facilitate the coverage and uptake of pandemic control measures while protecting essential community values and traditions. Creating bottom-up and community-adapted communication strategies, including addressing language barriers and involving Rabbis in the dissemination of prevention messages, fostered a feeling of trust in government's response measures. However, unmet information and prevention needs were also identified, such as the need for inclusive communication by public authorities and the need to mitigate the negative effects of stigmatization.

CONCLUSION

The experiences of Orthodox Jewish communities in Antwerp demonstrate a valuable example of a feasible community-centered approach to health emergencies. Increasing the engagement of communities in local decision-making and governance structures remains a key strategy to respond to unmet information and prevention needs.

Psychiatry, Cultural Competency, and the Care of Ultra-Orthodox Jews: Achieving Secular and Theocentric Convergence Through Introspection

Several socio-cultural factors complicate mental health care in the ultra-Orthodox Jewish population. These include societal stigma, fear of the influence of secular ideas, the need for rabbinic approval of the method and provider, and the notion that excessive concern with the self is counter-productive to religious growth. Little is known about how the religious beliefs of this population might be employed in therapeutic contexts. One potential point of convergence is the Jewish philosophical tradition of introspection as a means toward personal, interpersonal, and spiritual growth. We reviewed Jewish religious-philosophical writings on introspection from antiquity (the Babylonian Talmud) to the Middle Ages (Duties of the Heart), the eighteenth century (Path of the Just), the early Hasidic movement (the Tanya), and modernity (Alei Shur, Halakhic Man). Analysis of these texts indicates that: (1) introspection can be a religiously acceptable reaction to existential distress; (2) introspection might promote alignment of religious beliefs with emotions, intellect and behavior; (3) some religious philosophers were concerned about the demotivating effects of excessive introspection and self-critique on religious devotion and emotional well-being; (4) certain religious forms of introspection are remarkably analogous to modern methods of psychiatry and psychology, particularly psychodynamic psychotherapy and cognitive-behavioral therapy. We conclude that homology between religious philosophy of emotion and secular methods of psychiatry and psychotherapy may inform the choice and method of mental health care, foster the therapist-patient relationship, and thereby enable therapeutic convergence.

Frequency of use of the religious exemption in New Jersey cases of determination of brain death

BACKGROUND

The 1981 Uniform Determination of Death Act (UDDA) established the validity of both cardio-respiratory and neurological criteria of death. However, many religious traditions including most forms of Haredi Judaism (ultra-orthodox) and many varieties of Buddhism strongly disagree with death by neurological criteria (DNC). Only one state in the U.S., New Jersey, allows for both religious exemptions to DNC and provides continuation of health insurance coverage when an exception is invoked in its 1991 Declaration of Death Act (NJDDA). There is yet no quantitative or qualitative data on the frequencies of religious exemptions in New Jersey. This study gathered information about the frequency of religious exemptions and policy in New Jersey that was created out of respect for religious beliefs.

METHODS

Literature and internet searches on topics related to religious objections to DNC were conducted. Fifty-three chaplains and heads of bioethics committees in New Jersey hospitals were contacted by phone or email requesting a research interview. Respondents answered a set of questions about religious exemptions to DNC at the hospital where they worked that explored the frequency of such religious exemptions in the past five years, the religious tradition indicated, and whether any request for a religious exemption had been denied. This study was approved by the Northeastern University Institutional Review Board (IRB #: 16-03-15).

RESULTS

Eighteen chaplains and bioethics committee members participated in a full research interview. Of these, five reported instances of religious exemptions to DNC occurring at the hospital at which they worked for a total of approximately 30-36 known exemptions in the past five years. Families sought religious exemptions because of faith in an Orthodox Judaism tradition and nonreligious reasons. No failed attempts to obtain an exemption were reported.

CONCLUSIONS

Religious exemptions to DNC in New Jersey do occur, although very infrequently. Prior to this study, there was no information on their frequency. Considering religious exemptions do occur, there is a need for national or state policies that addresses both religious objections to DNC and hospital resources. More information is needed to better understand the impact of granting religious exemptions before new policy can be established.

A COMPARATIVE ANALYSIS OF BIOETHICAL ISSUES FROM VIEW POINTS OF RELIGIOUS AFFAIRS ADMINISTRATION IN TURKEY, ROMAN CATHOLICISM AND ORTHODOX JUDAISM

The arguments set forth by religious authority are important since they play a crucial role in shaping the social values of the public and influence the decision of individuals in practice pertaining to bioethical issues. The Religious Affairs Administration (RAA) was established at the inception of the Republic of Turkey in 1924 to guide religious considerations moving out of the Ottoman caliphate to a secular bioethical framework. In this article, the bioethical views of the RAA under Islamic tradition is examined and contrasted with those influenced by the Roman Catholic and Orthodox Judaic traditions. On bioethical deliberations related to the beginning and end-of-life, all three religious traditions justify sacredness of life and that of God's will in its preservation it. Assisted reproduction techniques between spouses is considered to be appropriate, although third party involvement is explicitly forbidden. Organ transplantation is approved by all three religious traditions, except uterine transplantation. Contraceptive practices are approved under certain conditions - views differ most on approaches to contraception and the appropriateness of methods. The RAA judgement on cloning is to prohibit it, like Roman Catholicism and Orthodox Judaism. In other topics, cosmetic surgery and gender determination are approved only for treatment.

The Care of the Ultra-Orthodox Jewish Patient

The Ultra-Orthodox Jewish community embraces a system of values and a rigorous behavioral code that are deeply rooted in religious tradition and history. Here we describe some of the unique challenges that stem from the encounter between modern medical practice and the Ultra-Orthodox world. Through examples of clinical and ethical scenarios ranging from prenatal care to end-of-life decisions, we illustrate problems related to observance of age-old practices in a modern hospital setting, balancing acceptance of Divine will with standard risk assessment, reconciliation of patient autonomy with deference to rabbinic authority and fear of stigma associated with mental illness in a traditional society. We also offer a generalizable model where inquiry precedes pre-formulated judgment to help clinicians provide enhanced care for this population.

Extracorporeal membrane oxygenation as a bridge to chemotherapy in an Orthodox Jewish patient

OBJECTIVE

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as "a bridge to recovery," involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA-ECMO in patients who, in the absence of recovery or transfer to longer-term therapies, might assert religious or cultural objections to the terminal discontinuation of life-sustaining therapy (LST). We present a novel case of VA-ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes.

PATIENT

A 40-year-old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA-ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patient's religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA-ECMO.

INTERVENTIONS

Meetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA-ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor.

CONCLUSION

Traditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA-ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA-ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology.

Revisiting the problem of Jewish bioethics: the case of terminal care

This paper examines the main Jewish sources relevant to end-of-life ethics, two Talmudic stories, the early modern code of law (Shulhan Aruch), and contemporary Halakhaic (religious law) responsa. Some Orthodox rabbis object to the use of artificial life support that prolongs the life of a dying patient and permit its active discontinuation when the patient is suffering. Other rabbis believe that every medical measure must be taken in order to prolong life. The context of the discussion is the most recent release of the "Steinberg Report," which proposes a law regulating end-of-life issues in Israel. It is argued that the Orthodox rabbis base their views on a strongly positivist concept of religious law. The rabbis deliberate the law as a manifestation of the will of God and try to stretch the law as much as possible in order to benefit the patient, even when it is good for the patient to die. Direct and active actions that kill are prohibited; certain forms of passive euthanasia and contrivances that terminate life support without needing direct human action are accepted.

Jewish and Roman Catholic approaches to access to health care and rationing

In addressing issues of access to health care and rationing, Jewish and Roman Catholic writers identify similar guiding values and specific concerns. Moral thinkers in each tradition tend to support the guarantee of universal access to at least a basic level of health care for all members of society, based on such values as human dignity, justice, and healing. Catholic writers are more likely to frame their arguments in terms of the common good and to be more accepting of rationing that denies beneficial and needed health care to some persons. Jewish writers are more likely to consider individual responsibility for illness in allocation decisions and to accept differences in health care that different members of society receive. The article considers the relevance of both shared and complementary perspectives for deliberations in nations such as the United States.

Reaction to truth telling among Israeli physicians

This inquiry centers on the issue of truth telling from a physician's perspective. Thirty-two doctors practicing in a large general hospital in Israel responded to a questionnaire on truth telling. Findings suggest that physicians who are Orthodox Jews are less likely to inform patients of their illness in contrast to doctors whose orientation is Conservative Judaism or nonreligious. The rationale for a number of these responses and teachings is based upon Jewish religious Halacha (Law). Findings indicate that doctors judge patients individually based on their physical and psychological state. We also suggest that physicians convey hope, involve the family, and view truth telling as their exclusive right. Tentative observations suggest that Israeli doctors tend to be more liberal in truth telling than their American counterparts.

Approximation and negotiation: clinical pragmatism and difference

When addressing cultural and religious differences in the clinical setting we need to be realists. Despite our public homage to pluralism and good intentions, it is just not possible to overcome all the differences that might exist and achieve perfect understanding of others. Try as we may, we will never be able to see perfectly the world through another's eyes. Instead of reaching for such perfection, we should instead reach for an approximation of shared understanding that will promote discourse and civility when peoples of different races, genders, cultures, religions, and sexual preferences interact in the clinic.

Barriers to organ donation in the Jewish community

It has long been recognized that members of the Jewish community generally do not sign organ donor cards or consent to the donation of the organs of their family members. In order to address this issue, the position of Jewish law on organ donation was examined and a sample of the Jewish population of Toronto was surveyed in an attempt to better understand the reasons for the observed reluctance to donate within this community. The results confirmed that the rate of signing organ donor cards was much lower in the Jewish community than in the general population, and although other reasons do exist, the major barrier to donation was a perception that Jewish law prohibits such action. The study of Jewish law revealed that organ donation is permitted and, in fact, encouraged by all branches of modern Judaism. Finally, in response to these results, a guide titled "Organ Donation: A Jewish Perspective" was compiled to help explain both the religious and medical aspects of organ donation for Jewish people and transplant personnel.

Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations.