The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew

Introduction

Judaism is an ancient religion that has been practised for over 5,000 years and is based on the belief in one universal God. Jews believe in the Torah (Divine Law), which was revealed to Moses and is viewed as unchanging. They also believe that God is omniscient and will reward the righteous and punish the wicked at the end of time when there will be a resurrection of ail the dead.

Jews must live their lives by certain basic tenets: to carry out the Ten Commandments and to live according to Jewish values based on love of one's neighbour and tolerance of one's fellow human beings.

The religious aspects of Judaism are based on relationships: the relationship of God and man and the relationships between humans based on principles of fairness and equality. Belief in God is a personal acceptance of this close connection between an individual and God, and religious observance is a means of publicly displaying the state of this relationship.

Attitudes to healthcare staff and illness

Most Jewish patients have a positive attitude towards healthcare staff and are willing to seek medical help and advice when sick.

Religious practices

One of the most important Jewish practices is Sabbath observance. The Jewish Sabbath (Shabbat) begins at dusk on Friday and ends with full darkness on Saturday night. It is a day of rest and begins and ends with ceremonies. Before dusk on Friday candles are lit, and a prayer of blessing is said over wine and bread before a festive meal. After dark on Saturday night, a prayer of farewell is said over a candle, wine and spices. If at all possible you should make arrangements to enable Jewish patients to observe these rituals.

On the Sabbath work is prohibited, and this includes things such as writing, travelling and switching on lights or electrical appliances. An Orthodox Jew will not ask a non-Jew directly to do anything they would not do for themselves. If you are arranging travel for a Friday discharge, make sure you leave adequate time for all discharge procedures, such as collecting prescriptions, so that the patient has enough time to get home before dusk. Observant Jews will drive on the Sabbath only if the journey is necessary, such as being discharged from hospital.

Observant Jewish men and women pray three times a day in the morning, afternoon and evening, and would appreciate privacy for this. Any room or area provided for prayer should contain no religious items on display which may offend or distract them in their act of worship. It would be helpful to indicate which way is east.

Diet

The Jewish community has strict guidelines concerning some aspects of their diet, particularly in relation to meat and dairy products. Acceptable food is called kosher. Continuing to eat a kosher diet while in hospital or on a medically restricted diet poses a major problem for Jewish people. Jews will only eat meat which is killed and prepared by their own religiously trained workers and will not take milk and meat in the same meal. A kosher household will also keep meat and milk utensils, crockery and cutlery strictly separate (see the table below for further details on kosher food).

An increasingly common problem for Jews is the availability and use of pre-prepared foods, where it is impossible to know where the meat has come from or whether it may have been contaminated by non-kosher items. This includes most 'ready meals' and things like sausages and burgers. Hospitals may buy the Jewish Food Guide from Beth Din in London (www.kosher.org.uk). Below outlines some of the main requirements for food to be kosher.

Kosher 

• Animals must have cloven hooves and chew the cud e.g. cows, goats and sheep are kosher.
• Fish must haves scales and fins.
• Kosher food must be butchered and prepared in a special way: a single knife blow to the throat killing the animal; the blood drained out of it afterwards; the cut up the meat soaked in water and salted to remove the last traces of blood.
• Animals must be in perfect health to be kosher.
• Fruit is kosher.
• Vegetarian dairy products are kosher.
• Meat and milk utensils, crockery and cutlery should be kept strictly separate. Disposable cutlery and crockery should be used to serve kosher food in the hospital to avoid cross-contamination with non-kosher utensils.

Non-Kosher 

• Examples of non-kosher animals would be horses, pigs and the wild birds.
• Shellfish and eels are examples of non-kosher fish.
• Any meat – even that from kosher animals – that has not been butchered and prepared in a specific way is not kosher.
• Animals that are not healthy, or that have some internal disease discovered after death, are not kosher.
• Fruit damaged by rot or insects is not kosher.
• It is not kosher to mix dairy and meat products together and a three hour wait between eating these kinds of food is preferred.
• Utensils used in the preparation of non-kosher food are non-kosher.

Fasting

Yom Kippur is probably the most important holy day of the Jewish year. Many Jews who do not observe any other Jewish custom will fast during Yom Kippur, which is viewed as a major time for fasting. It is a complete, 25-hour fast beginning before sunset on the evening before Yom Kippur and ending after nightfall on the day of Yom Kippur. These restrictions can be lifted where a threat to life or health is involved. Children under the age of nine and women in childbirth (from the time labour begins until three days after birth) are not permitted to fast, even if they want to. Older children and women from the third to the seventh day after childbirth are permitted to fast, but are permitted to break the fast if they feel the need to do so. People with other illnesses would consult a physician and rabbi for advice.

There are also five minor fasts in the Jewish calendar. The minor fasts last from dawn to nightfall, and a person is permitted to eat breakfast if arising before sunrise to do so. There is a great deal of leniency in the minor fasts for people who have medical conditions or other difficulties with fasting.

Washing and toilet

On waking, Jews must wash their hands and may not eat or drink before doing so. A brief blessing is recited before eating any food, and Orthodox Jews will want to wash before eating bread. Some Orthodox Jews do not bathe or shower during major festivals or Shabbat and some men prefer to be bearded or will only use an electric razor (a modern circumvention of a ruling against shaving).

Ideas of modesty and dress

Both sexes may wish to keep their hair covered (Orthodox Jewish women may wear a wig and Orthodox Jewish men a skull cap called a yalmulke). If the examination is to include the head, then discuss the removal of head coverings sensitively, and where appropriate offer an alternative (a theatre cap, for example).

Death customs

There are specific Jewish laws and customs for dealing with the dead. It is important to contact the family and the Hebrew Burial Society as soon as possible. No mutilation of the body is allowed unless there is a legal requirement for a post mortem. When a Jewish person dies, the following guidelines apply:

• Do not touch the body until 20 minutes after death.
• Do not wash the body — this will be done ritually before burial.
• Do not remove false teeth or other prostheses.
• Close the eyes.
• Straighten the body out, laying it flat with the feet together and arms by the side.
• Cover the body with a plain white sheet without emblems.

Jewish law forbids Jews to do anything to hasten a person's death and at the same time requires everything possible to be done to comfort the dying. So the range of what you can or cannot do for a dying person may vary and you should consult a trusted rabbi. Some Jews would not touch a dying person for fear that the slightest touch might hasten their death.

From the moment a Jewish patient dies an appointed person (preferably not a relative of the deceased) keeps a watch over the body. This person should be reciting psalms constantly until the burial service. People are paid or appointed by the funeral home to carry out this service. Jews are buried and not cremated.

Immediately after death, mourners sometimes tear their clothes and sit on the floor.

Birth customs

A healthy male boy must be circumcised on the eighth day after birth, although this could be delayed for a premature or unhealthy baby. The ritual is performed by a trained and medically certified religious functionary. If the mother and child are still at the hospital a small room may be requested and others of the family will attend the ritual and name the child.

If a child dies, the body should be treated in the same way as an adult. Jewish law requires the burial of miscarried foetuses, which should be delivered to the family or burial society.

Family planning

Traditionally Jewish law has discouraged contraception; however, contraception has recently become more acceptable as long as it is part of a couple's scheme for planned pregnancies and not a total avoidance of them.

The method of contraception permitted may depend on the type of Judaism practised Orthodox Jews prefer to rely on the rhythm method or the oral contraceptive pill, whereas Reform Jews may be more likely to consider other methods. Condoms are generally not allowed as there is a commandment against `killing the seed'. However, some liberal Jews may use this method. Discussion about contraception should involve both husband and wife, who may wish to consult their rabbi.

The issue of abortion within the Jewish community is complex. Jews believe that until the head of a baby has left the womb of its mother, it does not gain full status as a living person. This means that where the mother may die if the pregnancy continues, Jewish law permits a therapeutic abortion to save the life of the mother at the expense of the child. In cases of rape or where the mental health of the mother may be at risk if the pregnancy continues, opinion is split as to whether abortion is permissible. As with many issues, the mother may wish to consult her family and rabbi before making a decision.

Blood transfusions, transplants and organ donation

Jewish law approves blood transfusion in order to achieve the desired medical outcomes.

Jewish law permits organ donation from dead bodies where there is a high chance of success for the specific recipient. Relatives of a potential donor will wish to consult an appropriate rabbi before making a decision, and this should obviously be facilitated.

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