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Treating Orthodox Jewish patients

Modesty, tradition and preservation of life at all costs are key to understanding Jewish patients, writes Dr Joseph Spitzer

Of the 300,000 Jews in the UK, fewer than a third would describe themselves as Orthodox and of those a much smaller proportion as strictly Orthodox. This group regards Judaism not as a 'religion' but an all-encompassing way of life. They lead an insular lifestyle very different from the society in which they live but in which they receive their health care. Less Orthodox and non-Orthodox Jews will follow many of the facets of the Orthodox way of life; the extent to which they follow this may vary considerably.

The traditional way of life

Strictly Orthodox Jews tend to be conspicuous because of their way of dressing. Men cover their heads at all times as a reminder that they are constantly in God's presence, most have beards and some have long sidelocks. Women dress modestly and don't expose much bare skin. They wear their sleeves and skirts long with high necklines and legs are covered with stockings or tights. Married women cover their hair at all times with headscarves, hats or wigs. Female health workers working closely in the Orthodox Jewish community need to be sensitive to this dress code, especially if their work takes them into people's homes.

There are some groups whose first language is Yiddish, which may cause problems in areas such as speech therapy or dealing with the elderly.

Etiquette

Physical contact between members of the opposite sex is forbidden so many Orthodox Jews will not shake hands with members of the opposite sex.

Orthodox patients may feel more comfortable with health care workers of the same sex. Most Orthodox Jewish women will not mind seeing a male doctor, although if given the option they may prefer a female doctor, particularly when an intimate examination is required. Many Orthodox Jewish men would not be happy to see a female doctor.

Occasionally patients might discuss health-related problems with a rabbi and there may be times when health workers may need to liaise with rabbis, most of whom are very approachable.

Kosher diet

One of the best-known fundamentals of Judaism is the kosher diet ­ strictly adhered to by Orthodox Jews. When possible, medication should contain no non-kosher ingredients. Glycerine, lactose and gelatine are examples of ingredients that may be problematic. The Passover festival, when Jews are forbidden to eat any leavened foods, may cause additional medication problems. Kosher laws only apply to orally ingested substances so parenteral administration presents no problems.

There are no restrictions on blood transfusion or donation. Pharmacies in areas with Orthodox Jewish patients are becoming increasingly aware of the need to keep stocks of Kosher medicines and it is possible to request Kosher medicines on an FP10.

Most infants are breast-fed, but where a formula substitute is required this should be one known to contain only kosher ingredients.

Shabbos (the sabbath)

Shabbos, which lasts from sundown on Friday evening to nightfall on Saturday night, is one of the most cherished fundamentals of Judaism. It is a day of rest and freedom from the outside world, and a time of worship and study. Shabbos is both a spiritual and family day. It starts with candle lighting and there are several synagogue services and family meals. There are restrictions on the types of activities that may be performed on Shabbos and Orthodox Jews observe these meticulously.

They may be reluctant to attend surgeries on Friday evenings or Saturday mornings and may postpone consulting a GP until Shabbos is over.

Yom Kippur (the day of atonement)

On this, the most solemn day in the Jewish calendar, all adults fast for 24 hours. Exemptions may be given to the ill or frail following discussion with a rabbi, who may wish to confer with the patient's GP. Taking of essential medication may be permitted following discussion with the doctor or rabbi.

Contraception

The family is central to Orthodox Jews and families are often large. Marriage is almost universal and having a family and bringing up children is considered to be important. Couples are encouraged to 'be fruitful and multiply', unless there is a good reason not to. Nevertheless, Judaism's attitude to contraception is relatively liberal and a couple might consider using contraception where a woman's physical or mental health might be compromised by pregnancy.

Orthodox Jewish women are unable to have sexual intercourse while menstruating so it may be advisable to avoid contraception that causes irregular bleeding. Many Orthodox Jewish couples will only use contraception if they have received approval from a rabbi, who may occasionally wish to discuss the indications with the doctor.

The end of life

Jews consider all human life to be sacred and of equal value. The elderly, no matter how weak, sick or demented, are afforded great respect both from close family and the wider community and are often cared for lovingly.

Orthodox Jews will go to extreme lengths to preserve and prolong life. Families will lavish care on a severely handicapped child or the victim of a stroke, often at great personal or financial expense. Burial usually takes place within hours of death. GPs may be under pressure from relatives to issue death certificates soon after a death, even at unsocial hours, so as to enable early burial.

Health care values

Judaism considers it a religious obligation to seek medical help when illness presents and Orthodox Jews use medical facilities freely when unwell. Although good health is highly regarded, it is somewhat paradoxical that many Orthodox Jews lead sedentary lives and exercise little.

Obesity is relatively common and morbidity from ischaemic heart disease is high. Health promotional activities are largely ignored.

Care and support in the community

The Orthodox community has a number of care and support organisations. Most are voluntary bodies encompassing a wide range of activities, such as providing support for the sick or housebound, for the mentally ill or for those with physical disability. There are residential homes for the physically and mentally disabled.

There are a number of support groups such as for those who are psychiatrically ill and their carers and for couples with infertility problems.

Orthodox Jews adhere to their ancient teachings and traditions in a way that GPs and primary care team members may find difficult to understand. Jewish law makes it clear that in life-threatening conditions, most restrictions can be set aside but, except in the most critical circumstances, this should only be done with rabbinical guidance. A sensitive, non-judgmental approach will go far when caring for these fascinating and challenging patients.

Attitudes to illness

 · Physical illness In the Orthodox Jewish community, hereditary illnesses or chronic diseases may be concealed and not even disclosed to a health professional unless specifically asked about. It is not unusual for serious illness to be kept secret even from close family and friends. Patients and their families may be reluctant to use words such as cancer and might substitute euphemisms, confounding clear communication. Contrary to current practice, most Orthodox Jews would not want an elderly relative to be told of a terminal diagnosis.

 · Psychiatric illness Psychiatric illness carries a particularly powerful stigma and patients and their families might go to considerable lengths to keep it hidden. Denial is particularly powerful, delaying presentation and diagnosis. Psychiatric or psychological problems, whether as presenting problems or components of other conditions, may not be accepted as such and patients or their relatives may hide behind a pragmatic

medical model of illness, looking for a purely 'medical' cure.

 · Smoking, alcohol and drugs With the increasing awareness of the harmful effects of smoking, and with the religious obligation to avoid activities damaging to health, smoking rates have declined. Alcoholism is rare and drug and substance abuse is still low.

Joseph Spitzer is a GP in London and honorary senior lecturer in general practice and primary care at Barts and The London Queen Mary's School of Medicine and Dentistry

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