After reading this chapter, the nurse will be able to:
Identify how the religion of Judaism affects the cultural behaviors of Jewish Americans.
Identify some of the differences between health-oriented behaviors demonstrated by various religious groups within Judaism.
Identify how the various ethnic backgrounds of Jewish Americans affect their cultural behaviors.
Describe attitudes and beliefs affecting health care within and across individuals in various Jewish groups.
Identify how the verbal and nonverbal communications of Jewish individuals may affect health care.
Identify implications or precautions for providing effective nursing care to Jewish Americans.
Recognize those health care practices that are mandated by Jewish law for people who are Jewish.
Explaining what it means to be Jewish is not easy. It is more than just belonging to a religious organization; it is also being a part of a specific people ( ; ; ). It is a shared feeling of “Jewishness.” Jewish people are linked together by a common history, common ethical teachings, a common language of prayer (Hebrew), a vast quantity of literature, common folkways, and, above all, a sense of common destiny ( ). Jewish people share centuries of history as a minority subjected to hostility wherever they go.
The Jewish-American culture has many subcultures because of the different areas of the world in which Jews live as well as a diversity of religious observances. Jews came to the United States predominantly from Spain, Portugal, Germany, and Eastern Europe. There are four main religious groups: Orthodox, Conservative, Reform, and Reconstructionist. Within the orthodox group are the Chassidic (or Hasidic) and Lubovitch subgroups, which are the largest subgroups in the United States today.
Despite differences, there are some cultural similarities that are indigenous to this group of people. To understand the culture, one must have knowledge of some of the religious dictates. Through a discussion of the six common variables found within and across cultural groups as they apply to Jewish Americans, this chapter attempts to clarify some behaviors that are commonly found among Jews in order to assist nurses in developing an effective plan of care for the Jewish-American client. Attention is also placed on Jewish rituals and the effects of assimilation on their cultural traits.
Overview of the Jewish People in the United States
The history of American Judaism encompasses three distinct waves of immigration. The first wave of people, who began arriving in the middle 1600s, was relatively small. They were Sephardic Jews from Spain and Portugal, and they had little effect on the development of modern American Judaism ( ). The beginning of the nineteenth century saw a steady German immigration, which swelled after 1836, when Jews sought to escape persecution in Bavaria and other German states ( ). The last tide of immigration began slowly in 1845, when Polish Jews began arriving in the United States, but swelled to tens of thousands in 1881 as a result of a wave of pogroms and a series of new anti-Jewish decrees in Russia. This last wave, consisting of Eastern European Jews and German Jews, has had a profound effect on modern Jewish-American culture and religious practices.
To understand Jewish-American culture today, it is necessary to consider Europe during the Middle Ages. At that time, most of the internal law in European Jewish communities was strongly controlled by the Talmud (the Rabbinic code). Talmudic law governed not only the religious behavior of Jews but also almost every other aspect of life, such as birth, marriage, and death, as well as the proper foods to eat and the proper clothes to wear. The Jews were kept separate from the general population not only by persecution from others but also by the boundaries set by these laws.
In the nineteenth century, not all German Jews were isolated in their communities; some were involved in non-Jewish communities. Many of these Jews were embarrassed by the ancient laws and found them distasteful, especially if they desired the status of full members of the German nation ( ). To maintain their beliefs and yet not appear different from the general culture, German Jews of high social status attempted to start the Reform movement. The freedom experienced in the United States allowed the Reform movement to flourish. The German Jews who immigrated to the United States and wished to become part of the American community were willing to rid themselves of the old traditions and become increasingly “Americanized.” They were insistent, however, that the Jews be maintained as a people.
The Eastern European immigrants came predominantly from Russia, Romania, Poland, and Austria. In contrast to many of the German Jewish immigrants who had lived in nonsegregated areas, most of the Eastern European Jews came from all-Jewish villages, known as shtetls, where a Jewish culture was created that was almost totally unaffected by the cultures of the people around them. Life was dictated by the religious traditions Eastern European Jews followed and was much the same as it had been during the Middle Ages.
Along with these pious Jews came the radical political and socialist Jews, who believed that the only way to survive was through complete abandonment of religion. A third group who immigrated during this time represented the “middle-of-the-road” Jews, who were both religious and radical ( ).
It is important to understand the differences in religious behavior when caring for Jewish clients. All Jewish beliefs derive from the Torah (the five books of Moses) and the Talmud (the Rabbinic code). From the Torah come 613 commandments. The combination of the Torah and Talmud results in codes of law. Rather than referring to a body of doctrine, Judaism refers to a body of practices ( ).
As mentioned previously, four main religious Jewish groups exist today: Orthodox, Conservative, Reform, and Reconstructionist. The Orthodox Jew maintains a strict code of interpretation of the law, the Conservative Jew maintains a less strict code of interpretation, and the Reform Jew follows a more liberal interpretation of the law. Reconstructionist Judaism is a little difficult to explain. Reconstructionists do not necessarily believe in God as a personified deity or that God chose the Jewish people. If they follow the laws of Judaism, they do so because of their cultural value. An example of the differences deals with the head coverings worn by men: the Orthodox Jew is obligated to keep his head covered at all times in reverence to God, the Conservative Jew keeps his head covered during times of worship, and the Reform and Reconstructionist Jews are not obligated to keep their heads covered.
The division between Jewish practices started in Germany in the nineteenth century, but it was not until Jews experienced the religious freedom of the United States that the Conservative and Reform movements thrived. The freedom experienced in the United States allowed the Jewish immigrant to question the narrow confines of orthodoxy and led to a desire to express religious beliefs and traditional practices in a less confining environment. The German Jews had begun to practice Reform Judaism. However, to the Eastern European Jew, Reform Judaism seemed empty ( ). A movement known as “Conservatism,” which had begun in nineteenth-century Germany, had a small beginning but appealed to the children of many Eastern European immigrants. According to , Conservatism offered a compromise between the blind religious teachings of the Orthodox Jews and the scholarly endeavors of the Reform movement to break from tradition completely. Today, Reform temples are moving toward more traditional practices but maintain the belief that a person should be able to make choices based on knowledge of customs and their meanings.
In regard to religion, Jewish identity has changed through the generations. In the United States today, the sense of Jewish identity does not lie in the Old World religious observances. Most Jewish Americans do not observe the traditional Jewish Sabbath, nor are they active in their temple or synagogue. According to , their identity lies not with the historical religious aspects of Judaism but with their ethnic or racial identity.
Changes in immigration laws have decreased the number of Jews entering the United States. However, since the time of the large immigration of Eastern European Jews, Jews from other countries have come to the United States under different circumstances. There are Jews who escaped or lived through the Holocaust, Jews who have emigrated from Communist Russia, Russian Jews who were able to leave after the collapse of the Communist party, and Jews who have arrived from many other countries of the world, including Ethiopia and Israel. Each group has added to the cultural diversity of the Jewish people. All have brought with them the culture of the land from which they emigrated. Because of the close ties that have developed between Jews of all nationalities, cultural traits have begun to blend. For example, descendants of Eastern European Jews talk about eating falafel, a food made from ground chickpeas, which originated in the Middle East.
A fear of many Jewish Americans is the effect of assimilation on their children. Jewish-American people do not want to appear different from other Americans because being different has led to thousands of years of persecution. However, many Jewish Americans do not want to lose the common thread that binds them to one another.
Although Jewish Americans make up only about 3% of the U.S. population, they are visible in many areas of U.S. culture. Today, an estimated 6,544,000 Jews reside in the United States ( ). Jewish Americans are distinguished members of the arts, academia, the sciences, medicine, law, and the political arena. Education is a large part of the Jewish culture, which has helped Jews in the United States succeed as they never could in other countries.
The desire to succeed, plus intermarriage, has caused some loss of Jewish identity. Some Jews today in the United States do not wish to be identified as Jewish for fear of discrimination in the workplace. Discrimination against Jews does exist in the United States, and many Jews are sensitive to anti-Semitism.
Today the primary language of Jewish Americans is English. In the late 1800s the primary language of the Jews was Yiddish, which is a combination of German, Slavic, Old French, Old Italian, and Hebrew languages (Languages of the World, 2015; ). The children of first-generation Jews, born to Eastern European parents, wanted to be accepted by the other children. Although Yiddish may have been spoken in the home, these children spoke English outside the home. Very few second-generation Jewish Americans understand Yiddish. However, almost all Jewish Americans know some Yiddish, and many Jewish conversations are sprinkled with Yiddish words. Some of these words have become a part of American English, such as shtick (or shtück ) and tush .
Hebrew, which is the language of Israel, is rarely spoken by most Jews who do not live there. However, Hebrew is the language of the Torah, and many Jews can read it. An important part of Jewish religious education is the reading, speaking, and writing of Hebrew. Shalom is a Hebrew word that is commonly used by Jewish people to mean “peace,” “hello,” or “good-bye.”
The Sephardic Jews have a language of their own, Ladino, which is similar to Old Spanish. It is not commonly spoken in the United States today.
When communicating, Jewish people tend to be highly verbal and expressive, using hand gestures to punctuate their communication. They have a sharp sense of humor and usually prefer language that is direct and frank.
By changing the emphasis on certain words, the Jewish person changes the meaning of the message being conveyed (Languages of the World, 2015; ). This change in emphasis is done easily in Yiddish and has been carried over into English. As an example, changing the emphasis on the words “Him you trust?” changes the meaning: “Him you trust ?” versus “ Him you trust?” The first questions a person’s judgment; the second implies that anyone who would trust the character of such a scoundrel must be an idiot.
Jewish humor may be viewed as sarcastic, and often the humor is directed at themselves. This self-directed humor has led to comments that Jewish humor comes out of self-hatred. Although Jewish humor may appear to be self-critical and sometimes self-deprecating, it does not stem from a form of Jewish masochism. One of the most popular beliefs is that Jewish humor arose as a way for Jews to cope with the hostility they found around them, sometimes using that hostility against themselves. It appears as if a Jewish person is telling enemies, “You don’t have to attack us. We can do that ourselves—and even better” ( ).
Jews today are sensitive to humor from “outside” sources. Jokes that are not appreciated when told by non-Jews include “JAP” (Jewish American Princess) jokes and those about “Jewing people down” (referring to Jews being cheap or unmerciful at bartering).
As Jews become more acculturated with each generation, the communication styles change. Jewish people who are third- or fourth-generation Americans are more likely to demonstrate the same communication style as their neighbors rather than that of their parents, grandparents, or great-grandparents. This type of acculturation is part of the history of Jews all over the world ( ).
The use of touch varies among Jewish people; however, the use or nonuse of touch can be a critical issue with Orthodox Jews and must be carefully considered by the nurse. Because of Jewish laws regarding personal space and touching others of the opposite sex, it is important to ascertain to which religious group the client belongs. If the client is Orthodox, he or she will be very modest. Overexposure of or touching the parts of the body associated with sexual activities can cause a great deal of distress. When caring for strict Orthodox Jewish clients of the opposite sex, the nurse should use touch only for hands-on care. To touch the client at any other time could be offensive because of the sexual connotations attached to casual touch. It is also important to note that, according to Jewish law, religious observances are not to be followed if doing so will endanger the person’s health.
Implications for Nursing Care
Because older Jewish clients may be very verbal about what and how they are feeling, they may appear to be chronic complainers. Although it is difficult to remain nonjudgmental with a client who is considered a chronic complainer, it is important to remember that letting others know feelings is part of the Jewish culture. It may be difficult to assess pain levels of Jewish clients because they are very emotional when expressing their discomfort, and it may take persistence and patience to pinpoint the problem and its extent. Younger Jewish clients may be more articulate and may also complain less than their parents or grandparents as a result of acculturation.
Jewish communication style may lead to analytical sparring. Because of this tendency, teaching may be best accomplished using a question-and-answer style and open discussion.
The Orthodox Jew is keenly aware of religious dictates regarding personal space that may or may not be invaded by members of the opposite sex. Many Orthodox Jewish men and women will not shake hands with a member of the opposite sex. This practice stems from the ruling in the Code of Jewish Law that forbids a man to smell the scent of a strange woman, to look upon her hair, or even to gaze upon her little finger ( ; ). An ultra-Orthodox Jewish man will not usually touch his wife in public.
Traditionally, Jewish people have also had practices about personal and social space. In times of sickness and during their elderly years, Jewish individuals have an acute desire to have members of their family and other Jews around them. This desire has been illustrated in studies of the elderly that indicate that elderly Jewish people in nursing homes adjust better if they have other Jews around them ( ; ).
Implications for Nursing Care
Judaic laws can lead to some misinterpretation by nurses and other health care providers. For example, during childbirth, if an ultra-Orthodox Jewish husband decides to participate in the delivery, his participation will be only verbal. He will not touch his wife during labor. This practice is associated with the laws of separation that dictate that avoidance is necessary during the time a woman has any vaginal bleeding. He will not view the birth because he is not permitted to view his wife’s genital area. After the birth, he may lean over his wife (being careful not to touch her), smile, and say, “Mazel tov” (good luck, congratulations) ( ; ; ). Some ultra-Orthodox husbands elect to participate only spiritually. If this is the case, they will sit with their prayer book and recite from the Book of Psalms. It is important to remember that this practice does not mean the man loves his wife any less than the man who actively participates.
Among the Orthodox Jews there are different groups. The “modern” Orthodox Jew cannot be distinguished by his or her dress, although some traditional Orthodox Jews are often recognizable by their appearance. The men usually have long earlocks and beards and wear a yarmulke (skull cap) or large black hats and long black frock coats. The women are modestly dressed in long-sleeved dresses and have wigs or scarves covering their heads.
With the increase of male nurses, the question arises regarding the assignment of a male nurse to a female Orthodox Jewish client. The Code of Jewish Law ( ) states that “a male is not permitted to attend to a woman who is suffering with a belly ache . . . but a woman may attend to a male who is so suffering. . . .” This passage may be interpreted to mean that a male nurse should not be assigned to care for a female client. If, however, only male nurses are available, this law would probably be waived because all laws are suspended in the case of severe illness. A law that addresses attendance of a male physician with a female client states that a physician is permitted to let blood and to feel the pulse or any other place of a woman, even if she is married, even the pudenda (external genital organs), as is customary with physicians, because he is merely following his profession ( ; Periara, 2015).
The nurse should be aware that since elderly Jewish clients in non-Jewish hospitals or nursing homes may adjust better with other Jews around them, it may be advantageous to have Jewish clients room together or at least be in proximity. This closeness will allow for increased comfort and offer the Jewish client the chance to interact with someone who “understands” him or her.
The foundation of the Jewish culture is the nuclear family and the greater Jewish community. Controversy exists as to whether the Jewish community or the Jewish family has had the bigger influence on maintaining the Jewish faith and the Jews as a people ( ; ).
Jewish families tend to be close-knit and child oriented ( ; ). Jewish parents tend to “want better” for their children than they had themselves. It is not unusual to hear parents say that they have given up something they really wanted for the “sake of the children.”
Family life of the Jewish Americans has changed through the years. The earlier Jewish family was male dominated, and the father made the major decisions. The mother’s job was to care for the home, the children, and her husband. Today the delineation of duties is more obscure. Usually both parents work, often at jobs of equal financial and professional status.
The Jewish family structure is seen as protective. The Eastern European mother of the past got the reputation of being overbearing and overprotective. In the shtetls of Europe, the mother was the cohesive force in the home. This is still the case today, although younger women are not considered as overbearing or overprotective as their mothers and ancestors were.
In the Jewish family the child is seen as the means of maintaining Jewish existence. Therefore, education of the child in the Jewish faith and traditions is often seen as the most important thing a community, as well as the family, can do. In small Jewish communities, even communities too small for a rabbi, religious education of the children is seen as a priority. The fear of assimilation and annihilation increases the importance to the community of “sticking together” and educating the children.
Among the commandments that Jews are expected to follow are those that dictate the social relationships of family and community. These commandments dictate expected behavior toward parents and people within the community, such as the poor, teachers, rabbis, neighbors, ill people, the dying, and the dead.
Social orientation has helped maintain the Jewish people. When the Eastern European immigrants arrived in the United States, they were an embarrassment for the German Jews. However, commandments that control social behaviors dictated that the German Jews reach out to help the newcomers. This sense of kinship was so strong that Jews felt obliged to help one another, both in the United States and abroad. Today, this dictate is seen in the assistance offered Russian Jews, as well as other smaller groups of Jews from other countries, who immigrate to the United States.
Eastern European Jews brought with them a strong sense of community, which arose from their restricted lives within the shtetls. Furthermore, they were often held responsible for political events that occurred outside the Jewish quarters. Even though each Jew developed his or her own individuality, there was an intense feeling of “groupness,” an identification with a common cultural heritage ( ).
When the immigration laws of the 1920s resulted in decreased numbers of Eastern European Jews entering the United States, increased assimilation began to occur. Several significant events have helped slow the rate of Jewish American assimilation. The event that seems to have had the largest effect was the rise of Nazi anti-Semitism and its American counterparts. The Holocaust caused all Jews to realize that they were indeed brothers ( ), and the memory of the Holocaust continues to have this effect on Jewish people. Other events that have had an effect on Jewish identification were related to the development of the state of Israel and the struggle of Israel to continue to exist despite a hostile environment. When Israel won the Six-Day War in 1967, the feeling of pride in the Jewish state was almost tangible. There seemed to be a stronger sense of “Jewishness” and an increased willingness to admit to being Jewish. Today, the tension in the Middle East continues to unite Jews.
Today, the Jewish American community is much more mobile than it was in the past. It is not unusual for the children to move away when they leave for college or marry. When a Jewish individual moves, often one of the first things he or she may look for is a Jewish affiliation. A Jew may not join a synagogue until the children are ready for religious school, but often he or she desires the company of other Jews despite the inability to join a synagogue until that time.
Implications for Nursing Care
When a Jewish person becomes ill, family and community resources are mobilized to assist the client. The Jewish faith contains a commandment to visit the sick. Therefore, friends, relatives, and neighbors will visit an ill Jewish client. If the client is very ill, the visitors will act as client advocates. It is important for the nurse to recognize the cultural implications of these visitors and to expect them to ask about the client.
Because of the protective attitudes of Jewish parents, they will often make arrangements to have someone with their child at all times if the child is hospitalized. Jewish parents may appear demanding and aggressive if they believe their child is not getting the care he or she “deserves.” Handling the concerns of the parents may take patience on the part of the nurse. The nurse needs to remember that this cultural group highly prizes their children and sees the survival of the Jewish people as a responsibility of the next generation. This view places a large responsibility on the child to get well and on the parents to see that the child does get well.
The best way to classify Jewish people in relation to time orientation is to say that they are past, present, and future oriented. Jews are aware of their past—all 5000-plus years of it. They are also concerned about the present and are very involved with current social concerns, both Jewish and non-Jewish. One of the main precepts is tikkun olam, or repairing the world. They also look toward the future by insisting that their children be educated, religiously and secularly, and by participating in philanthropic activities to help the future of Israel.
The Jewish concern with the past is very obvious in American society, especially in relation to the Holocaust. Every Jewish person believes that this kind of atrocity should never happen again. By continuing to remind the world of the horrors that happened, not only to Jews but also to people of all faiths and ethnic origins, the Jewish people hope the world will never again let that type of event occur.
During happy occasions, such as a wedding, there is always something to remind Jews of their past. As an example, at the end of the wedding ceremony, the groom breaks a glass. One reason for this custom is to symbolize the destruction of the Jewish temple during the Roman invasion.
Past orientation is also seen following the death of a loved one (such as a parent, sibling, or spouse). On the anniversary of the death each year, a candle is lit and a prayer, the kaddish (meaning “holy”), is recited in honor of that person. In addition, the kaddish is recited at special times during the year for a loved one. In some congregations the kaddish is recited by the whole congregation in memory of those who have recently died or those who have no one to say the prayer for them. In relation to present-time orientation, Jews tend to be very social minded and are often involved in social movements. In many communities, Jewish congregations help run soup kitchens. In one southwestern city a rabbi was involved with the sanctuary movement.
From the Talmud comes the requirement that Jews care for all who are in need whether they are Jewish or non-Jewish. Because the concepts of charity and righteousness are so intertwined, the Hebrew word for “righteousness” (justice), tzedaka, has become the Hebrew word for “charity” ( ). This concept has had an influence on the social system in New York City ( ).
Another way that Jewish present-time orientation is apparent is in relation to an afterlife. Although Jews may believe that the spirit continues to live or reside with God after death, they are not concerned about an afterlife. What is considered important is doing good deeds on earth. During an interview regarding the belief in a soul, one woman summed up what has been written by other authors when she stated that it is the memory of one’s good deeds that causes one to be immortalized ( ).
Future-time orientation is apparent in issues concerning the education of children. Establishing schools, supporting schools, and furthering education are top priorities. Throughout the ages, education of the children in the Torah has been regarded as a duty. Originally it was the duty of the parents; eventually it became the duty of the community ( ). Today, not only religious but also secular education is seen as important. In most Jewish households the children hear, from the time they are very young, that someday they will go to college. Education is highly prized as a way of securing the future for the child as well as for the Jewish community as a whole.
Another way that future-time orientation is apparent relates to concerns during illness. Jewish people not only want immediate relief but also worry about what the future implications of their illness will be. They worry about the effect of their illness on the future of their family members, their jobs, and their lives. According to , the intensity of their concern is greater than that of other Americans.
Many Jews tend to be punctual when it comes to appointments and become very upset when they arrive on time and have to wait for their appointment to begin. However, some Jewish people also talk about “Jewish standard time,” which is at least 10 to 15 minutes later than regular time. Although there are many Jews who are very punctual (especially when it comes to appointments), general Jewish functions, such as weddings or bar mitzvahs, often begin late.
Implications for Nursing Care
Because Jewish people are past, present, and future oriented as well as emotionally expressive, they appear to feel joy, sorrow, illness, and so on with great intensity. They become very anxious when they do not feel well and may appear to be impatient about finding a cure. Jewish people have a tendency to worry about what the illness means in the present as well as the implications it has for the future.
Patience and honesty are necessary qualities for a nurse to display when dealing with Jewish clients. Demonstrating interest and concern will convey the message that the nurse cares about the ill person and may help decrease the amount of anxiety the client is feeling. Until a diagnosis is made, trying to help the anxious Jewish client put events into proper perspective may not work because the client reasons that the nurse cannot know what the future will hold if the physician does not know what is wrong.
It is important to understand that the high degree of outward anxiety the Jewish person may feel is probably more apparent in the older generation of Jews than in the younger generation because assimilation has caused them to exhibit more “acceptable” behavior patterns.
Many Jewish people tend to be fatalistic about life. They may believe that they do have some control over their health, but God has the final say. This belief is apparent during Rosh Hashanah and Yom Kippur (the New Year and the Day of Atonement), when Jews pray to be written in the Book of Life for another year.
Health Care Beliefs
Jewish people have a religious requirement to maintain the health of the body as well as the soul. The origin of Jewish health care beliefs dates back to the Torah. Many of the 613 biblical commandments appear to be hygienic in intent. Several chapters in the Book of Leviticus (12–14), as well as other books in the Bible, are devoted to the control of disease ( ; ). The Talmud continues to stress this concern for health. There are passages that deal with proper exercise, getting enough sleep, eating breakfast, and eating the proper diet.
Physicians are held in high esteem by people in the Jewish culture ( ; ). In biblical times the priests were physicians. When a Jewish person is ill, it is a duty to go to a physician, and it is the duty of the family to make sure the individual goes. The importance of health care is so great in this culture that Talmudic scholars stated that a person should not settle in a city without a physician ( ; ).
Some researchers contend that Jewish and Arab health locus of control discovered that Jewish people had a higher internal locus of health care control than Arab participants in the study ( ; ). Jewish people believe physicians cannot heal without the participation of the client. They are also likely to question the physician if the client believes the physician is wrong about a diagnosis or treatment ( ; ; ), and the Jewish client may decide not to follow the physician’s orders. However, if the client chooses not to listen to the physician or does not agree with the physician, this individual is expected to seek the knowledge of another physician ( ; ). Seeking the best medical care, even obtaining a second opinion, is a religious dictate.
Health is one of the most frequent topics of conversation among Jewish people. With some Jewish people, especially older ones, good health is seen as an exception rather than the rule. The older individual may become preoccupied with the issue of good health because life may be viewed as a temporary lapse between one illness and another ( ; ).
The Jewish person believes that prevention of illness is important. Each family member tries to protect and warn the other members of dangers that may cause illnesses, which can make client teaching easier for the nurse. It is important to remember that client teaching in the Jewish family requires the cooperation of all the immediate family members.
There is an increased interest among Jewish adults in alternative or collaborative health care. It is not unusual to hear a group of Jews discussing the issues of fat content in food or the use of herbs to maintain health. In recent years, two healing centers that address prayer and healing have been developed in San Francisco and New York City. Healing services are held periodically in temples throughout the United States.
When a member of a Jewish family is ill, the whole family suffers with the person. Each individual is expected to become a part of the process of helping the ill person feel better.
Complaining about discomforts is expected and accepted, especially in the older generation. Complaining fulfills several important functions: it gives relief through its cathartic function, it is a means of communication, it mobilizes the assistance of the environment, and it reaffirms family solidarity ( ; ).
When Jewish clients are admitted to the hospital, they may continue to behave as though they were at home. The Jewish client may attempt to mobilize the attention and sympathy of those in the new environment by using the same methods that worked in the home, so that what the nurse encounters may be a client who complains, cries, moans, and groans. When this behavior does not result in the reactions that would be received from the family, the client may attempt to temper reactions so that feelings of acceptance and being cared for are experienced.
If the client does not verbalize pain, another member of the family will usually do so. The reasoning is that the client may be too ill to tell the physician or nurse and that it is the family member’s responsibility to communicate to obtain the attention the family member believes the loved one should have.
of first-generation Jewish Americans in pain noted that these clients responded to questions with details that sometimes seemed to relate only marginally to the topic. In the study a simple question released a flow of responses that led to information about pain, illness, anxieties, intrafamily relationships, and so on. Probing was necessary to pinpoint specific information rather than to elicit a fuller answer to a question.
Second-, third-, and fourth-generation Jewish Americans seem to be a little less expressive about their pain. However, they do consider it wrong not to express their feelings. The expressive behavior of Jews seems to indicate that Jewish people believe that one cannot get help unless a complaint is made.
If oral complaining does not result in the type of behavior the client wishes to elicit from those around him or her, crying may be used. Crying, with many first-generation Jewish Americans, is acceptable behavior and is seen as an expression of frustration or pain and often results in the attention desired ( ).
With increased American acculturation, each succeeding Jewish-American generation appears to be less expressive when in pain. The women may cry easily, but the men have adopted the American view that crying is not proper behavior for men. Second-generation Jewish American male clients tend to be less verbal about their pain than their fathers ( ). For some Jewish people, however, the meaning of pain does not change, just the outward signs. For a Jewish person, pain, discomfort, and change in the state of good health are seen as a warning that something is wrong and that the professional health care system needs to be utilized.
Jews have been noted to have higher physician utilization rates than other groups, as well as having a heightened concern for maintaining health ( ). Utilization of the health care system may involve getting the opinions of several physicians. The Jewish client recognizes that the physician is only another human, with the possibility of being incorrect. By getting at least one other opinion, the client can decide if the physician was correct or not. Before choosing the physician to see for a second opinion, the Jewish person will most likely ask a number of people who might have connections in the medical community for recommendations. Not only is a Jewish client likely to get a second or third opinion, but also this client may check the medical literature and search the Web for information about his or her condition and prescribed regimen. Schiller and Levine (1988) and have noted that some of these activities seem to be based on a feeling that the client is the final judge and authority in matters pertaining to his or her health. In this case the physician is seen in the role of consultant and advisor.
Once the Jewish client accepts the physician’s opinion, the client will also accept the prescribed treatment. The cultural belief is that to get well, one must cooperate with all therapeutic measures. Although the Jewish client will follow the prescribed regimen, the client expects the medication regimen to be individualized because illness is viewed as being individualized. Jewish patients today take a more active role in health care decisions.
In many cases, the client will want to know all about the prescribed treatment: what is expected of the client, what the side effects are, and, if a drug is being prescribed, the name of the drug. The client is unlikely to be content with, “It’s good for you.”
The Jewish client tends to observe carefully the effects of the drug or treatment on the system. Since many Jews believe that they are the ultimate judge of their condition, they may change the time they take a drug, increase or decrease the number of drugs taken, or reject the drug completely if they decide it is not helping or is harmful. Many times these decisions are made without consulting the physician. Careful, thorough explanations about the drug, its purpose, side effects, and why it was ordered are essential.
The future-oriented Jewish client may become hesitant to take analgesics because most drugs are viewed as “dope” and Jewish persons often fear addiction. This fear increases the problem for the client in pain who wants to receive pain relief but is afraid of addiction ( ).
Jewish-American people tend to be more educated than most other American ethnic groups ( ), and the thirst for knowledge is apparent in their wellness behaviors. They tend to be well read on issues of health, and it is not unusual to hear Jews discussing the latest information on maintaining healthy diets, preventing disease, or following health-oriented regimens.
In years past, it was rare to see Jewish children involved in physical activities. Eastern European Jews tended to de-emphasize physical activity in favor of more intellectual activities that kept the children closer to home. This practice may have stemmed from the fears of child abduction that they brought with them from the “old country” ( ). However, this trend seems to be changing. Jewish children are now involved with soccer teams, baseball teams, and other physical activities. Their parents are also more involved in physical exercise. Jogging, tennis, racquetball, and aerobics are some of the activities that are attracting more Jewish participants as the importance of physical exercise is discussed in the media.
Maintaining certain laws is included in the wellness behaviors seen in Orthodox Jewish people. Many of these laws have been incorporated into the everyday habits of most Jewish Americans because they are good hygiene or they have been proved to be medically prudent. The following are examples of these laws taken from the Code of Jewish Law ( ):
The hands must be washed on awakening from sleep, after elimination of bodily wastes, after hair cutting, after touching a vermin, and after being in proximity to a dead human body.
The proper way of washing oneself is to take a bath regularly every week.
It is advisable for one to accustom himself to having breakfast in the morning.
One is forbidden to eat or drink out of unclean vessels, and the individual should not eat with hands that are not clean.
There is a belief, although there is no empirical evidence to support it, that the custom requiring washing hands before meals has contributed to lower morbidity and mortality rates. Plus, because of better hygiene, infant and child mortality rates have been lower in Jewish than in non-Jewish populations ( ).
Kosher Diet, Religious Holidays, and Illness.
Maintaining a kosher ( kasher, “fit, proper”) diet may pose a problem for some Jewish clients. As mentioned in Chapter 7 , kosher meat is usually salted to help drain all the blood. This process presents a problem for a client on a low-salt diet unless the meat is soaked in water to remove as much of the salt as possible.
It is important for the nurse to consider what can be done for the Jewish client following a kosher diet if the hospital does not have a kosher supplier nearby. In this case it is possible to serve any fish that meets the dietary requirements of having fins and scales. It is also possible to serve dairy products as long as they are not contraindicated on the person’s diet. These meals should be served on paper plates with plastic utensils because meat and milk products or dishes prepared with milk products should not be mixed.
If, because of medical dietary restrictions and the unavailability of kosher food, maintaining a kosher diet is impossible, the client must decide to waive the dietary restrictions. All commandments are suspended whenever a life is in danger, no matter how remote the likelihood of death ( ). Food is essential to maintain life; therefore, the client would be directed by the rabbi to eat whatever the hospital could provide that would help sustain life.
Yom Kippur (the Day of Atonement) and Passover (based on Hebrew pesah, “passing over”) are two holidays that require special consideration. On Yom Kippur, Jewish people are required to fast for 24 hours. If this fast is considered physically or medically dangerous, however, the individual is required by law to put aside the law and eat. Passover requires that special foods be served. Passover, which falls in or near the spring of the year, is an 8-day holiday that celebrates the freedom of the Jews from Egypt. During these 8 days, certain foods must be “kosher for Passover” ( kasher le-pesah ). In addition, there are other foods that are forbidden, including any foods with leavening (bread, cakes made with baking soda or baking powder) or foods made with even a small amount of a grain product or by-product that is not specifically prepared for Passover. This prohibition includes many drugs and medications, such as those containing starch or grain alcohol. These drugs may be refused by the client unless they cannot be replaced and are urgently needed by the client.
The use or nonuse of contraceptives is dictated by Jewish law, which requires one to “be fruitful and multiply.” This can cause special problems for the woman who is unable to conceive or the woman who may have physical problems, making conception dangerous. There is a lengthy discussion of this issue in the Mishnah (a part of the Talmud containing the oral law). The final analysis is that the man is commanded to procreate, but the woman is not, because, it is believed, God would not impose on the “children of Israel” a burden “too difficult for a person to bear” ( ). Since childbirth is painful and may be physically dangerous, it would be unfair for the Torah to impose the commandment for procreation on the woman.
When Jewish men were allowed two wives, this commandment was not a problem. Today, because monogamy is the rule in the Jewish community, procreation is seen as the couple’s obligation. However, outside of the very Orthodox community, Jewish couples today decide on how many children they want, and most practice some form of birth control. Within the very Orthodox community, the use of birth control is discouraged unless pregnancy or delivery would be dangerous for the woman.
Couples who have a problem with fertility are encouraged to seek medical help. For the very Orthodox Jewish man, however, a problem arises in the collection of semen. Rabbis have declared that masturbation and the use of male contraceptives such as condoms are not permitted because the Talmud outlaws the spilling of seed. For this reason, the woman is usually tested first, and then, if no problem can be detected, the man may be tested. The very Orthodox Jewish husband will have to consult his rabbi before he consents to a sperm count. Since masturbation is considered taboo, it may be emotionally difficult for the man to collect his semen. This is not a problem for most non-Orthodox couples.
It is interesting to note that the role of companionship is given an equal place with procreation in the purpose of a Jewish marriage ( ). To add to this idea of companionship, rabbis have also addressed the idea of sexual satisfaction being the right of both men and women within the bonds of marriage ( ).
According to Jewish law, all body parts should be buried with the body after death ( ; ). However, if an organ transplant would save the life of another human being, it is permissible to donate the organ ( ; ). Even removal of the heart for transplantation is allowed so long as the dying person has experienced total brain death ( ; ).
According to Jewish law, nothing may be done to hasten death; a client must be given every chance for life. However, if the use of mechanical systems would delay death rather than prolong life, they should not be used. If mechanical systems have been connected and they are not helping to prolong life but are delaying death, they may be removed ( ; ).
The Dying Jewish Client
As there are commandments that control living for the Jew, there are also commandments that control dying. These commandments are usually followed strictly only by Orthodox Jews, but some of the behaviors that the nurse may see in other Jews are a result of the cultural knowledge that these commandments have created.
According to Jewish law, a person who is very ill and considered to be dying should not be left alone. One reason for this law is that the spirit is believed to depart from the body at the time of death, and if no one were present, the soul would feel alone and desolate ( ; ; ). To satisfy this commandment, family members will often take turns sitting with the critically or terminally ill client. Asking family members to leave may cause family distress.
Jewish law also dictates that a client should be informed that death is near. However, because of two controversial passages in the Torah, some rabbis believe it is important to inform a dying individual about serious illness but not that death is near. Informing a person about a serious illness allows the individual time to put worldly affairs in order, as Isaac and Jacob did when they were told they would die (End of Life, n.d.; ; Some Modern Views, n.d.). However, to tell a person that death is imminent removes all hope, and some Jewish people fear that this information may hasten death.
Judaism teaches that it is important to lead a good, decent, and helping life on earth. Since good deeds must be done on earth, the law requires a Jew to ask God to forgive those deeds that may have been against God or not in keeping with God’s commandments. To fulfill this commandment, the dying person is encouraged to recite the confessional. If the individual is too sick to say the whole confessional, the individual is encouraged to recite the affirmation of faith, the Shma . If the dying person cannot repeat any of the confessional, the law says that it is up to the family or friends who are with the person to recite it. The recitation of the confessional is usually seen only with observant Jews.
Once death has been established, the eyes and mouth are closed by the son or nearest relative. In some Orthodox Jewish families, it is customary to remove the body from the bed and place it on a straw mat on the floor, with the person’s feet toward the door through which the body will be taken. A candle is placed at the person’s head to symbolize the “light,” or joy and love the departed brought to others while alive (End of Life, n.d.; Some Modern Views, n.d.; ). A sheet is placed over the person’s face because it is disrespectful to the dead to permit others to see the ravages of death on the face ( ; Staff, 2015). The dead body is viewed as being contaminated by Orthodox Jews and is placed on the floor because the bed is viewed as being defiled by contact with the dead body; however, the ground is not considered defiled by contact ( ; Staff, 2015). It is important to understand that this behavior is rarely seen in most hospitals or nursing homes today.
Autopsy is not allowed by Orthodox Jews unless (1) it is required by governmental regulations, (2) the person had a hereditary disease and an autopsy may help safeguard the health of survivors, or (3) another known person is suffering from a similar deadly disease and an autopsy may yield information vital to that person’s health ( ; Staff, 2015). If an autopsy is performed, all parts that are removed must be buried with the body. Autopsy does not pose a religious problem for the non-Orthodox Jew.