People of Japanese Heritage. People of Jewish Heritage. 700 words minimum

oda1113

BookPDF.pdf

Home >Nursing homework help >People of Japanese Heritage. People of Jewish Heritage. 700 words minimum

260

People of Japanese Heritage

Chapter 15

SUSAN TURALE and MISAE ITO

Overview, Inhabited Localities, and Topography OVERVIEW

Nihon, or Nippon, as Japan is called in the Japanese lan- guage, is a 1200-mile chain of islands in the northwestern Pacific Ocean. Japan’s neighbors are Russia, Korea, and China, and its modern history has been shaped by con- flict with these countries.

Japan’s territory extends generally from northeast to southwest, covering an area slightly smaller than California in the United States. The northern and western- most areas have a climate similar to that of northern United States, with some heavy falls of snow in winter- time; the Ryukyu Islands in the south are subtropical. The climate of the Tokyo region, where most of the population is clustered, is similar to that of Washington, DC. Winters are moderate, with snows that seldom accumulate except in the north, whereas summers are hot and steamy.

The population of around 127.4 million resides mainly on the four largest islands (U.S. Department of State, 2006): Honshu, Kyushu, Hokkaido, and Shukoku. Tokyo, on Honshu island, is the capital and largest city with 35.3 mil- lion people residing in its greater metropolitan area and 8.4 million in the city proper. The Japanese, who refer to them- selves as Nihonjin, share a strong sense of nationalism and pride in ethnic purity. Japanese citizenship is not readily obtained, and currently, there are 2 million foreign residents in Japan, required to register as aliens. The inclusion of even third-generation Korean residents in the category of foreign- ers has received considerable adverse international press in recent decades. However, some changes are on the way as Japan has begun acknowledging that a long-revered sense of

ethnic homogeneity may not be sustainable. Globalization, low birth rate, an aging population, and increasing labor shortages are causing the country to rethink its immigration policies. However, this has to be balanced against tensions arising from growing international terriorism; and therefore, stricter controls on immigration have been instigated (Kashiwazaki & Akaha, 2005).

HERITAGE AND RESIDENCE

The original inhabitants of Japan most likely migrated from the Korean peninsula. The marked Chinese cultural influence began in the late 400s and included the Chinese system of writing, the calendar, Confucianism, Buddhism, and East Asian beliefs about health and illness. Following World War II, from 1945 to 1952, Japan was an occupied territory of the United States. As a bitter legacy of that war, the northernmost Kuril Islands are still claimed by Russia, and today, Japan still has U.S. military bases on its soil, in part to counteract perceived threats from neighboring countries.

Japanese citizens residing in North America have tended to locate in large commercial and educational cen- ters. With the establishment or purchase of factories in the Midwestern and Southern states by Japanese compa- nies, communities of Japanese expatriates can now be found in smaller cities as well.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

In the late 1800s, Japanese people began to migrate to the United States and Canada, and from 1891 to 1924, more

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 260 Aptara Inc.

than 250,000 Japanese immigrated, settling primarily in the Territory of Hawaii and along the Pacific coast (Yanagisako, 1985). By 2004, however, an estimated 369,639 Japanese nationals lived in the United States, of whom 240,000 were considered long term and 129,600 permanent (UN Secretariat, 2005). Japanese love overseas travel, and in 2005, more than 3.9 million of them visited the United States and spent 16.5 billion U.S. dollars on goods and services (U.S. Commercial Service, 2006).

EDUCATIONAL STATUS AND OCCUPATIONS

Education is highly valued in Japan, where the illiteracy rate is only about 1 percent (U.S. Department of State, 2006). Completion of the 12th grade by more than 95 percent of young people ensures a highly competent workforce. For instance, calculus is part of the mandatory junior high school curriculum, and high school graduates complete 6 years of English instruction. Many youngsters preparing for high school or college entrance examina- tions attend proprietary juku, or cram, schools, in the evenings or on weekends, which creates enormous pres- sure on youth to succeed in schooling.

About 40 percent of all young people go on to higher education at over 1200 universities, junior colleges, and technical schools. Entrance examinations for high school and college are very competitive. Because the alumni net- work helps to provide job placements, the school one attends determines to a great extent where one is employed after graduation. To gain higher education degrees, Japanese commonly study at the university where they earned their undergraduate degree rather than to go to dif- ferent universities like their American counterparts do.

Whereas the concept of adults returning to college is still new, self-improvement is a huge industry. Hobbies are taken very seriously and often entail formal study to seek “perfection” in a particular hobby: For example, the traditional Japanese arts, such as chadō or sadō (tea cere- mony), ikebana (flower arranging), bonsai, kimono wear- ing, shodo (calligraphy), painting, wood carving, and even doll making, are studied diligently by large numbers of women and by some retired men.

Sales of books, periodicals, and daily newspapers in Japan are among the highest among industrialized nations, and there is an increasing love of manga, comics or print cartoons. In fact, almost half of all periodicals or books are manga (Japan Media Review, 2006). Popular manga are adopted into anime (or animation), and at any time of day, one can witness the very young to middle- aged crowding train stations, bookstores, or convenience stores voraciously reading their favorite comics, some with explicit sexual or violent content. This has a signifi- cant impact on the way in which messages are passed on culturally. Health professionals need to consider the use of manga and anime when promoting health education to Japanese clients. The national broadcasting system, NHK, offers high-quality radio and television news and enter- tainment, and cable TV is increasingly popular.

Although culture reflects Japan’s recent agrarian past, at present, only 2 percent of Japanese are engaged in agricultural occupations because a significant amount of foodstuffs is imported. In the United States, issei (first-

generation immigrants) originally tended to work in agri- culture or as small-business owners. More recent immi- grants work in business, the professions, service industries, and manufacturing. Second- (nisei) and third-generation (sansei) Japanese Americans tend to be highly educated professionals. Most Japanese nationals living in the United States are well-educated executives, visiting schol- ars, individuals with technical expertise, or students.

Communication DOMINANT LANGUAGE AND DIALECTS

Japanese is the language of Japan, with the exception of the indigenous Ainu people. The Japanese spoken in Tokyo is the national standard heard in media broadcasts; how- ever, regional variations to the language do exist. Because high school graduates in Japan complete 6 years of English instruction, even newer Japanese immigrants and sojourn- ers can understand, read, and write the English language to some degree. The biggest problem, however, is conver- sational English; whereas many Japanese may have stud- ied the language for many years, they often lack strong conversational skills and are frequently embarrassed to try their language ability with foreigners.

In the United States, issei vary widely in their English language ability. Nisei and sansei have been educated under the American educational system to the extent that they were permitted; for example, educational access was limited or segregated during the World War II internment of American citizens of Japanese ancestry. Although the language barrier may be an obstacle to understanding ver- bal instructions or explanations in English-speaking health-care settings, Japanese clients are likely to use writ- ten materials effectively. More recent immigrants to the United States are likely to understand English but may need prompting in conversation skills.

CULTURAL COMMUNICATION PATTERNS

Japanese society is both highly structured and traditional. Politeness, personal responsibility, loyalty, and people working collectively for the greater good of the group are very important. One complexity of the Japanese language is the customizing of speech according to relative social status and gender. The Japanese sensitivity to relative sta- tus and the need to constantly gauge one’s behavior accordingly is one reason the circle of intimates with whom one can truly relax is quite limited. In addition, men tend to speak more coarsely and women with more gentility or refinement.

Light social banter and gentle joking are mainstays of group relations, serving to foster group cohesiveness. Polite discussion unrelated to business, often over o-cha (green tea), precedes business negotiations, and sake par- ties are common during the negotiation period. Sake, a fermented beverage with a history of over 2000 years in Japan, is integral to culture and society. Relationship building and respect for personal privacy are important aspects of working relationships in all sectors.

In a densely populated society that values group har- mony above all else, open communication is discouraged,

PEOPLE OF JAPANESE HERITAGE • 261

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 261 Aptara Inc.

making it difficult to learn what people think (Doi, 1971). In particular, among people of Japanese descent, saying no is considered extremely impolite; rather, one should let the matter drop.

A high value is placed on “face” and “saving face.” Asking someone to do something that he or she cannot do induces loss of face or shame. For people to be shown to be wrong may be deeply humiliating. People may feel shame for themselves and their group, but they are expected to bear that shame in stoic silence. In fact, Japan is considered to have a shame-based culture rather than a guilt-based culture (Leonardsen, 2004), unlike many Western cultures. Suicide over shame is a common theme in Japanese literature, lore, and media. Regular reporting of suicides occurs in the daily media, often mentioning the name of the suicidee who has committed the act after embarrassment, shameful deeds, allegations of corrup- tion, or bullying in the workplace or at school. Because of ethnic homogeneity, an ingrained sensitivity to the feel- ings of others, and close contact with one’s family, class- mates, and work group, Japanese believe that vague, intu- itive communication, called hara wo yomu (belly talk), is well understood by fellow group members.

In Japan, presenting a person with choices is regarded as a burden, and it is a kindness to spare people the bur- den of decision-making. For example, a hostess may serve already-poured drinks to spare her guests the burden of deciding what they would like. Professors do not offer a choice of learning activities to their students; a teacher may arrange employment for a former student; a physi- cian will tell the client what to do about a health prob- lem. These actions are motivated by concern for the well- being of the person in one’s care. Japanese society is sometimes described as a web of giri (mutual obligations) that serves to ensure societal integrity and harmony.

Etiquette and harmony are very important, and many Japanese people exhibit considerable control over body lan- guage. Anger or dismay may be quite difficult for Westerners to detect. Smiling and laughter are common shields for embarrassment or distress. However, one need only see tear- ful family partings at train stations to know that, contrary to Western assumptions, Japanese people do show their feel- ings, but often do not hug or kiss one another at such part- ings, as is so common in many other cultures.

Prolonged eye contact is not polite even within fami- lies. Social touching occurs among group members but not among people who are less closely acquainted. In general, body space is respected. Intimate behavior in the presence of others is taboo. When people greet one another, whether for the first time or for the first time on a given day, the traditional bow is performed. The depth of the bow, its duration, and the number of repetitions reflect the relative status of the parties involved and the formality of the occasion. An offer to shake hands by a Westerner is reciprocated graciously. With an introduc- tion, meishi (business cards) are exchanged first, enabling the parties to assess their relative status.

TEMPORAL RELATIONSHIPS

An awareness of Japanese history and legend, a high regard for older people, the value of family honor, and

veneration of dead ancestors suggest a strong connection with the past. However, the overall orientation of the Japanese people, who are known for their postwar eco- nomic miracle, is toward the future. The population made huge sacrifices in the decades after the war for the good of the nation, enabling it to become a world power. Parents encourage their children to study hard so that their futures will be bright. Housewives are diligent savers for future family expenses. Companies plot their growth, and the government anticipates needs decades in advance. Whereas Zen calls its practitioners to attend to the here and now, this tenet actually has few adherents in Japan. Health-care providers may find that Japanese clients are astonishingly motivated in health-related decision- making by considering their children’s needs and the economic future for their family.

Punctuality is highly valued among the Japanese: Commuter trains run to split-second timing; people are expected to be in attendance at the exact start of meet- ings. In an interesting contrast, the clinic system of health care pervades even the private sector in Japan. Clinic services are not expected to be efficient, and hospi- tal stays are still longer than in many Western countries, although the average number of hospitalization bed-days per illness is falling owing to economic problems and some shortages of qualified nurses.

FORMAT FOR NAMES

In Japan, family names are stated first, followed by given names. Seki Noriko would be the name of a woman, Noriko, of the Seki family, and often women’s names end with -ko. The family names of both men and women, married or single, are designated by the suffix, -san, but one does not use that designation when referring to one- self. Women generally assume their husband’s family name upon marriage. School children may use given names when speaking to one another, also designated with -san. Work groups and business associates tend to use family names. Infants and young children are called by their first names followed by -chan. Schoolboys are usually referred to by their first or last names followed by -kun, whereas schoolgirls’ first names are usually followed by -chan or -san. Elders are referred to respectfully. The designation sensei (master) is a term of respect used with the names of physicians, teachers, bosses, or others in positions of authority.

V I G N E T T E 1 5 . 1

With encouragement from their daughter and son-in-law, Mr. and Mrs. Kawamura have agreed to come to day care at your local community center to attend the craft and art classes. They have been feeling isolated, especially because all mem- bers of their family have to go to work each day. They are first- generation Japanese who are both now in their early 80s and very traditional in outlook. The community nurse has been asked by the occupational therapist to help her plan for their introduction to the center.

1. How would you address this older couple in a cultur- ally sensitive fashion?

262 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 262 Aptara Inc.

2. How would you introduce them to others? 3. What elements of communication might be important

to make this couple feel welcome? 4. What kinds of activities might be appropriate for them? 5. What kind of foods and drinks might be appropriate for

them?

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

The predominant family structure among the Japanese is nuclear, accounting for 60 percent of families in 2005, with 28 percent of households composed of one person (Ministry of Internal Affairs and Communications, 2006). This contributes to problems in social isolation, particu- larly among older people, because the number of house- holds in which three generations are present is falling. In feudal Japan, a bride had very limited contact with her own family after marriage, and the mother-in-law domi- nated the household. Now, wives often determine the household budget, their husbands’ pocket money, invest- ments, family insurance, real-estate decisions, and all matters related to child rearing.

Even today, with higher education widely available to women, the role of wife and mother remains dominant. Young women in the workplace may have jobs with little substantive responsibility, even if they are college gradu- ates (Orenstein, 2002), but matters are slowly changing. The Ministry of Internal Affairs and Communications (2006) reported that the ages for first marriages are rising (30 years for men and 28 for women), and now around 45 percent of women under 30 are single. Further, in 2005, the natural increase rate per 1000 population showed !0.2, the first minus recorded since statistics-gathering began in its present form in 1899. With this knowledge, the government is attempting to reduce the strong social pressure confronting women who try to continue work- ing after motherhood, primarily because of Japan’s need for skilled workers.

Longevity Japan (2006) described a new law in 2005 that gave workers the opportunity to take leave to care for sick children and other family members, developed cor- porate strategies to support workers or other family mem- bers who take care of children, permitted shorter working hours for workers who are raising a young child, and allowed more generous family-care provisions. The effects of this law are yet to be seen as it is still difficult to return to work after childbearing. An equal rights amendment has been part of Japan’s constitution since the U.S. occu- pation of Japan. Whereas Japan has protected women’s interests in matters such as property ownership and vot- ing, women are treated far from equally in the workplace. Conversely, increasing numbers of child-care centers assist families in which both parents are working, and a few of the larger corporations have begun to offer child care. Daily newspapers are filled with discussions about how Japan can increase its birth rate, and any reforms to date have failed to stop the trend of increasing numbers of working women, women who choose not to marry, or

couples who choose to have few or no children at all. The difficulty of paid employment or a career after mother- hood and the desire for two incomes to maintain a mid- dle-class lifestyle often cause couples to delay having a family.

Wives in Japan care for their husbands to a degree that many Western women would not tolerate. Japanese men are presumed not to be capable of managing day-to-day matters, and some salarymen (white-collar workers) or office workers may leave for work at 7 a.m. and return after 10 p.m., Monday through Saturday. On Sundays, men may be so exhausted that they sleep a good part of the day, or they may be obligated to socialize with col- leagues. Wives and children often stay behind when hus- bands are transferred by their companies within Japan or overseas, leaving women to raise children singlehandedly. Not surprisingly, one focus of the Ministry of Health, Labour and Welfare in addressing the low birth rate is to convince men to assume more responsibility for child care and housework and for companies to change policies to keep families from being separated.

The paramount family concern is for the children’s education, and it is the mother’s responsibility to oversee the completion and quality of homework. When the chil- dren grow up and leave home, women tend to become involved in volunteer activities, community groups, travel, arts, and the previously mentioned self-improve- ment classes.

V I G N E T T E 1 5 . 2

Mrs. Seike, a 38-year-old mother and housewife, has been liv- ing in the United States for 2 years. Her husband, a busy exec- utive, spends a great deal of his time away from the family home in Chicago. Mrs. Seike, therefore, has the major role caring for the home and their sons, ages 8 and 12. She has become very stressed about her life in general and is home- sick. Her Japanese friend brings her to the community health center where you are the nurse. She reveals that her 12-year- old son is having difficulty adjusting to school and is quiet and withdrawn. Mrs. Seike seems very hesitant to talk about her problems and does not readily make any decisions on her own.

1. What cultural factors need to be considered in this sit- uation?

2. How can the nurse help Mrs. Seike and her son adjust to life in America?

3. What agencies or persons could you call for assis- tance?

Western observers would be wrong to presume that married Japanese couples do not love each other. But in Japan, love has not been valued highly as a prerequisite for a successful marriage, and men and women have tended to be more motivated by duty to fulfill societal expectations than by the desire for spousal companion- ship. Conversely, domestic violence has begun to be openly acknowledged. The Gender Equality Bureau (2006) explained that in 2001, the Law for the Prevention of Spousal Violence and the Protection of Victims was implemented and then amended in 2004. Under this law,

PEOPLE OF JAPANESE HERITAGE • 263

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 263 Aptara Inc.

120 shelters for victims were established and counselling programs offered. Moreover, restraining orders and orders to vacate are now issued at a rate of about 100 a month. With this law, a number of public education programs are in place and a few women’s shelters are opening. In a soci- ety marked by strict norms differentiating the public and the private realms, couples have lacked resources to learn how to deal with tension and conflict.

Health-care providers need to be aware of differences in spousal relationships when assessing the quality of family dynamics and communication, sexual health, and sensitivity to risk for sexually transmitted infections. Health-care providers who work with college-age and young adults may find that Japanese youth are less autonomous than their American counterparts. Conflicts between traditional and American values may arise among these young people and within their families.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES FOR CHILDREN AND ADOLESCENTS

The primary relationship within a Japanese family is the mother-child relationship, particularly that of mothers and sons. It is customary for the mother, and sometimes both parents, to sleep with the youngest child on futons, or mattresses, on the floor or in adult beds (Fukumizu, Kaga, Kohyama, & Hayes, 2005) until a child is age 10 years or older. When a new baby is born, the older sibling may sleep with the father or a grandparent. A special child bed is used for neonates to prevent the parents rolling on the child during sleep. Fukumizu et al. (2005) found that 80 percent of Japanese parents sleep with their young infants and young children. The primacy of the mother-son relationship and the absence of fathers con- tribute to the known problem of mother-son incest. Father-daughter incest occurs, but a stronger taboo pro- hibits public discussion of it (Kanazumi, 1997), and so it is very difficult to find data on it. Despite the occasional occurrence of family dysfunction in this area, health-care providers working with childbearing couples and chil- dren need to be aware of Japanese family sleeping prac- tices and refrain from judgment.

The maternal role is so important for women in Japan that it is not unusual for a young mother to spend hours watching her infant sleep. If she observes the reflexes of urination, she changes the diaper immediately. Babies are not allowed to cry; they are picked up instantly. Women constantly hold their babies in carriers on their chests and sleep with them (Sharts Engel, 1989). “Skinship” or direct contact, is a value to be desired.

Young Japanese children tend to be indulged, espe- cially if they are single children. At the same time, they are socialized to study hard, make their best effort, and be good group members. They are taught to take care of each other, and girls are taught to take care of boys. Self-expres- sion is not highly valued.

Corporal punishment has been more accepted in Japan than in some Western cultures, and the word punishment, for example, is often used in the daily English newspapers to describe actions to counteract the transgressions of government workers. Cases of punishment by school offi- cials or ijime (bullying) by their peers at school have

resulted in the suicide of young children recently—mat- ters debated hotly in the local press. The fears are that bul- lying is reaching epidemic proportions. Children who are bullied by schoolmates typically have different looks, interests, or family structures, and health professionals need to be aware of this among Japanese-American chil- dren.

The Ministry of Education in 2006, under directives of the new Prime Minister, Abe, has begun a review of school education across the country, intending to incorporate content on national values. The government has also begun to address ways for families and schools to more effectively foster the development of Japanese children. One important aspect is that it is now mandatory for teachers and health professionals to report child abuse cases, a matter that has radically increased the reports of child abuse, most of which have involved violence and neglect. As of yet, strategies to identify and intervene or educate the public about child abuse have not been implemented.

Despite strong social pressure to conform, many ado- lescents in Japan have their rebellious streaks and use popular music, pornography, way-out clothing, and illicit drugs and alcohol to escape social restrictions. Increasing numbers of young people are expressing themselves through their clothing, hair, and makeup, but vandalism is a minimal concern in the country. Teenagers and col- lege students in Japan generally do not date to the degree that Western youth do. They typically join clubs, mem- bership in which is taken seriously; most social activities, such as ski trips, are club activities. However, sex educa- tion in school and/or university settings is minimal, despite teenagers having sexual encounters. The use of contraceptives as a preventive measure is not common among teenagers, and about 2 percent of Japanese girls have had abortions by the time they reach their late teens. The rash of abortions in women in their early 20s continues to increase annually (Sato & Iwasawa, 2006). Japan, however, has one of the lowest incidences of births to teenagers in the world. American health-care providers cannot assume that dating holds the degree of concern for Japanese young people as it does for American teenagers; nor can they assume that Japanese youth are well-informed about sexuality and sexual health risks.

Other health concerns among young people include the pressures to conform within a peer group and to per- form well in school, pressures that may lead to depression and suicide risk (Takakura & Sakihara, 2000). Interest in studying eating disorders is increasing, although research indicates lower rates among Japanese youth than among U.S. youth and in college students rather than high school students in Japan (Makino, Hashizume, Yasushi, Tsuboi, & Dennerstein, 2006). One reason for this may be young students’ increasing identification with skinny models from the West, increasingly portrayed in the media.

After graduation from high school or college, young adults are traditionally expected to be employed through their network of school contacts or family friends. Young women now typically live with their parents for many years after school, wheras young men are likely to live in company housing until marriage, and even after.

264 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 264 Aptara Inc.

FAMILY GOALS AND PRIORITIES

Promoting success in school is the mother’s main focus in child rearing. Children compete for their junior and senior high school admission, and high schools vary in the caliber of universities to which their graduates are admitted. The schools from which individuals graduate determine such major issues as career prospects for men and the status of husbands whom young women are likely to marry.

Children are highly valued and motherhood tradition- ally has been revered in Japan. The recent extreme drop in the birth rate has taken the society by surprise, although in prior decades, the expense of rearing and educating children triggered its beginning. Nothing is permitted to interfere with child-rearing responsibilities. Japanese women may be less likely than North American women to engage in activities, including health-care appoint- ments, that require them to leave their children with babysitters.

The ideal of romantic love plays less of a role in mar- riage in Japan than in the United States, and the marriage rate was 5.7 per 1000 population in Japan, lower than in the United States with 7.5 per 1000 population (Ministry of Internal Affairs and Communications, 2006). About 30 percent of marriages are arranged, often by employers or family friends. The o-miai is the ritual of the first arranged meeting between prospective partners.

As mentioned previously, Japanese couples are marry- ing later in life. The groom’s goals for marrying focus on advancement of his career and a desire to be cared for. For the bride, economic security and child rearing are tradi- tional goals. A “honeymoon baby” is becoming less com- mon, and couples are delaying having a family early in the marriage. Few Japanese women bear children outside of marriage, and abortion is one of a number of contra- ceptive practices, with the use of condoms more preva- lent than the use of the contraceptive pill.

Japanese couples place less emphasis on companion- ship and sexual fulfillment than do North American cou- ples and are far less likely to live together without being married. The divorce rate has declined: in 2005, there were 2.08 divorces in Japan per 1000 population com- pared with 3.6 in the United States (Ministry of Internal Affairs and Communications, 2006).

The Japanese family (especially the eldest son, who has a sense of obligation to his parents) has traditionally cared for and respected older people and children. However, with the drift to living in urban areas in small apartments and with more couples working, it is increasingly difficult to care for older parents. Retirement and nursing homes are growing in number across the country, although many of the latter have a poor public image and are poorly regu- lated. With the longevity of its people, Japan is aging more rapidly than any other nation. The government has begun to address how to care for older people, who now account for 20 percent of the total population. North American health-care providers must be sensitive to Japanese clients’ sense of obligation and commitment. Helping families net- work within the Japanese American community both for social support and for resources or good long-term-care facilities is a useful strategy.

Elements of social status include age, gender, educa- tional background, and work group affiliation of oneself or one’s husband. Though there is a peerage system and some old families are known to be descendants of samu- rai, Japan is largely a meritocracy. Exceptions include Korean descendants or descendants of the burakumin, the untouchable caste who cared for the dead and tanned leather in feudal times. In this largely middle-class soci- ety, school children can reasonably expect to study hard and go on for higher education if that is the family goal.

Biases that may be evident among Japanese people who reside in North America are directed at minority groups such as African Americans, Jews, and individuals with limited education, as well as women in high-status positions. This prejudice is seldom overt, but it may threaten the comfort of Japanese people, who are likely to encounter such diversity among health-care providers in North America.

ALTERNATIVE LIFESTYLES

In Japan, a small segment of women have long lived out- side the usual constraints for their gender. Women of “the floating world,” or the entertainment industry, enjoy a fair degree of autonomy. The most traditional of these, the geisha, live in all-female communal arrangements, but they are reducing in number annually. Geisha are not prostitutes, but are considered highly skilled artists, and they are now recognized as a cultural treasure. However, other women in the entertainment industry fulfill men’s need to relax in a society highly constrained by social norms; therefore, the sex trade is flourishing and occa- sional mention is made of the sex slave trade in Japan. Hostesses at bars look after their male customers, pour their drinks, and listen to them. In earlier eras, concu- bines were accepted within families. Today, infidelity by married men is more tolerated than in North America, but much less so for married women.

An increasing number of the Japanese population remains single throughout life, and only a few men and women enter monastic life. The small proportion of het- erosexual couples who live together outside of marriage find greater tolerance in urban settings in Japan. Marriage of a Japanese person to a foreigner is less tolerated than it is in the United States. The existence of a gay and lesbian social network and of cross-dressing clubs is evident in English-language publications in Tokyo.

Workforce Issues CULTURE IN THE WORKPLACE

Japanese employees in North American institutions need to be carefully oriented to the legal and professional requirements of client autonomy and of accountability in reporting, solving, and documenting problems that occur. An overview of dominant American society values may prepare them for the directness of communication they will encounter.

Claims for medical malpractice are growing slowly in Japan but are far less common than in the United States;

PEOPLE OF JAPANESE HERITAGE • 265

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 265 Aptara Inc.

for example, in 2003 in Japan, only 1019 newly accepted lawsuits in the Supreme Court were associated with medical malpractice across the country (Ehara, 2005). American practices designed to avoid liability, such as informed consent, are not routinely implemented in Japanese health-care settings. Client autonomy is rec- ommended in health-care settings; however, the real pri- ority in Japan is meeting dependency and recuperation needs.

Like most Japanese workers, nurses in Japan work long hours, often between 8 and 10 hours per day 5 days per week. Nurses often work extra time after their shift with- out pay. Their pay is low in relation to their cost of living compared with that of other health professionals. With the advance of a university education, nursing is slowly becoming a respected profession. Staffing is complicated by federal restrictions on shift work among women, although change is underway because Japan, like North America, is experiencing a nursing shortage.

The mix of people providing nursing care in Japan rep- resents many levels of educational preparation, and nurses may be prepared for registered nursing practice in a number of different ways. Baccalaureate degrees, repre- senting 4 years of education at university, are growing across the country, with over 130 such programs now in existence. However, registered nurses are still being pre- pared in colleges of nursing and schools attached to hos- pitals offering diploma and associate degree programs. In the face of the nursing shortage and the growing health- care needs of a rapidly aging population, aides are likely to be used more extensively, and Japan is now actively seeking to recruit nurses from selected Asian countries, especially The Philippines.

After registered nurse preparation, an additional year’s course prepares individuals for certification as midwives or as public-health nurses. A recent nursing role is that of clinical specialist in a variety of settings. In addition, the number of masters and doctoral degree programs across the country has experienced a strong growth over the last decade. Like nursing students, medical students enter medical school immediately after high school, and after graduation they complete a clinical residency.

ISSUES RELATED TO AUTONOMY

Japanese workers are quite sensitive to the desires and expectations of colleagues and superiors. Because saying no or delivering bad news is extremely difficult, they may avoid issues or indicate that everything is fine rather than state the negative. Of course, sensitive Japanese workers, who are attuned to nonverbal cues, may understand the true situation. In addition, many Japanese workers tend not to leave work before their boss does nor do they take their full complement of paid vacation time each year, which may contribute to worker stress and tiredness. North American employers should explicitly discuss expectations about starting and quitting times and vaca- tion leave with Japanese employees. Japanese workers do not assert individual rights. Japanese professionals work- ing in North America accept the need to assert themselves if it is presented within the context of legal and profes- sional requirements to protect their clients.

Japanese nurses are less likely than North American nurses to confront or question physicians or to suggest strategies. Workers tend to do what the head of the group tells them to do and make every effort to do it very well. Japanese health-care workers seeking to prac- tice in the United States have studied English from grade 7 throughout professional school, and will have passed an examination certifying minimal competency, but their verbal skills may still be weak. Specific approaches to documentation, such as problem-oriented record- keeping, are now being more widely taught and used in Japan. However, these may still be unfamiliar to some nurses and need to be addressed specifically in employ- ees’ orientation.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Racial features of Japanese people include the epicanthal skin folds that create the distinctive appearance of Asian eyes, a broad and flat nose, and “yellow” skin that varies markedly in tone. Hair is straight and naturally black with differences in shade. Health-care providers who are not accustomed to assessing racially diverse client groups may need to rely on color changes in the mucous membranes and sclerae to assess oxygenation and liver function in Japanese clients. The average stature of Japanese adults is smaller than that of Americans, although the gap has steadily decreased as national wealth has increased and a greater percentage of the population are able to improve their dietary practices.

The Ainu people of northern Japan, who number only about 15,000, are a fair-skinned people whose racial and linguistic origins are unknown. The Okinawan people of the Ryukyu Islands are darker-skinned than “mainlan- ders” and have a stockier build.

DISEASES AND HEALTH CONDITIONS

The three leading causes of death in Japan are malignant neoplasms, heart diseases, and cerebrovascular diseases. These account for over 50 percent of deaths in both sexes. In descending order, other causes are pneumonia, acci- dents, traffic accidents, suicide, renal disease, liver dis- ease, diabetes mellitus, hypertensive diseases, and tuber- culosis (Ministry of Health, Labour and Welfare, 2006). Moreover, men have a life expectancy of 78.5 years, whereas women have a life expectancy of 85.5 years, mak- ing the Japanese the longest living people in the world. An increasing focus is on reducing suicide, particularly among depressed men, because Japan ranks ninth in the world for suicides (Nakao & Takeuchi, 2006). Asthma and other allergic reactions related to dust mites in the tatami (straw mats that cover floors in Japanese homes) are con- sidered some of the few endemic diseases along with ill- nesses related to air pollution in urban areas. In rural areas, allergic reactions to the pollen from numerous sugi (cedar) trees are a seasonal problem.

266 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 266 Aptara Inc.

VARIATIONS IN DRUG METABOLISM

In general, drug dosages may need to be adjusted for the physical stature of Japanese adults, and racially linked genetic differences in drug metabolism can be important. More Asians than whites are poor metabolizers of mephenytoin and related medications, potentially lead- ing to increased intensity and duration of the drugs’ effects (Levy, 1993). Asians tend to be more sensitive to the effects of some beta blockers, many psychotropic drugs, and alcohol. A greater proportion of Japanese peo- ple rapidly metabolize acetylate substances, which has an impact on the metabolism of tranquilizers, tuberculosis drugs, caffeine, and some cardiovascular agents. Asians often require lower doses of some benzodiazepines, such as diazepam, and neuroleptics. Opiates may be less-effec- tive analgesics, but gastrointestinal side effects may be greater than those among whites. Health-care providers need to take all clients’ body mass into consideration in dosing; even with that precaution, clients’ responses to drugs need to be monitored carefully.

The pornography industry thrives, and prostitution is big business. Rape and other sexual abuses are acknowl- edged in Japanese society and are now being more openly discussed. In fact, there have been a number of incidences since 2005 regarding harrassment; rape and murder cases are on the increase. In Tokyo, commuter trains for women now run at night to combat sexual harassment. Health education about avoiding rape and inappropriate touching, when approached in a matter- of-fact way, is very appropriate for Japanese in North America.

High-Risk Behaviors The smoking rate for Japanese men has declined since the mid-1990s to around 57 percent of all men in 2004 aged over 20 years, but it is on the increase in women (13 per- cent). Around 20 percent of women in the 20- to 39-year- old age group now smoke (Ministry of Health, Labour and Welfare, 2006). Many restaurants, aware of the dangers of passive smoking, now offer nonsmoking areas, and plans are to make them smoke-free in the not-too-distant future. Public facilities, hospitals, transport, and many office situations are now smoke-free, and a series of fines can be levied in certain parts of Tokyo for people caught smoking. Cigarettes are easily available in vending machines and shops but are banned for sale to those under 20 years of age.

Alcohol has ritual significance. For example, in the marriage ceremony, the bride and groom drink sake or saki (rice wine), which is also an appropriate offering at Shinto shrines and at the butsudan, or household ances- tral shrine. In addition, alcohol is part of many social rit- uals, such as picnics to celebrate cherry blossoms, autumn leaves, or moon viewing. Adults commonly drink beer and sake in the home, and college students drink beer when they socialize, although the legal age for drinking is 20 years.

The most serious concerns about alcohol use reflect the informal work requirement for men in Japan to socialize

after hours and on Sundays. Considerable alcohol may be consumed, and it is common to see intoxicated salary- men snoozing on the trains or stumbling home late in the evening. In part, this extensive use of alcohol reflects the stress of Japanese corporate life and the rigid protocols that dictate social interactions. Once alcohol is con- sumed, workers can relax and speak freely. This is called bureiko, which means a gathering at which one can speak freely about what is on one’s mind; people are forgiven for what they say because of the alcohol. Although dimin- ished in the recent economic downturn, entertaining is expected in the Japanese business culture, and drinking is tolerated as an obligation to one’s company.

Public acknowledgment of alcoholism is limited, and alcoholism rates are very difficult to determine. According to the Ministry of Health, Labour and Welfare (2006), in the period 1965 to 1999, the average rate of alcohol consumption per head of population rose from 5.86 to 8.30 L. The rate of youth abuse of alcohol is increasing (Tsuchiya & Takei, 2004). Over several decades, the Maryknoll Missionaries established alcohol treatment centers throughout the country and were among the first to publicize the problem of alcoholism among housewives, opening the first treatment center for women in the mid-1980s. Health-care providers need to be aware of the prevalence of smoking and heavy alcohol consumption among Japanese people, particu- larly men. An effective strategy for curtailing these abuses is to give individuals specific medical reasons why they must abstain, thus providing a socially accept- able excuse to do so.

V I G N E T T E 1 5 . 3

Mr. Akutagawa, a 58-year-old business executive, has led a very busy life building up the family business with offices in both the United States and Japan. This has involved a lot of travel, long hours of work, and entertainment of clients. He has recently been diagnosed with gastric ulcers, and it is clear that he needs to modify his diet, change his lifestyle, and reduce his alcohol consumption.

1. What are the culturally sensitive elements to consider when advising Mr. Akutagawa about his alcohol con- sumption and diet?

2. Who needs to be involved in the decision-making about a plan for his lifestyle changes?

Over the last few years, Japan has witnessed a soaring abuse of illicit drugs by young people, particularly in high-density urban districts. The drugs used are mostly narcotics and stimulants, which have caused an increase in mental health problems, school drop-out rates, and drug-related crimes. The most serious is methampheta- mine use, which has been connected to mental illness, and its use has been increasing since the 1990s. Distribution of methamphetamine is believed to be con- trolled by the yakuza, the Japanese mafia (Tsuchiya & Takei, 2004). Also increasing are serious crimes involving guns, which have often been smuggled into the country. In 2003, the Government instituted the New Five Year Drug Abuse Strategy and increased efforts to combat the

PEOPLE OF JAPANESE HERITAGE • 267

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 267 Aptara Inc.

smuggling of drugs and guns into the country by sea (Customs and Tariff Bureau, 2006). Punishment is harsh and swift, and there is no popular sentiment for liberal- ization. Despite such problems, the crime rate is quite low, and in most cities, the streets are safe at all hours.

Students and workers in Japan also make heavy use of over-the-counter stimulants. Students and young salary- men are commonly seen consuming high-dosage caffeine elixirs at train stations in the morning.

Groups of Japanese businessmen may be treated to a sex tour in Bangkok or other Southeast Asian cities. The implications for transmission of HIV to wives and chil- dren back home are clear, but societal acknowledgment of this risk has been slow to develop. In Japan, as in a num- ber of Western countries, the rate of new cases of HIV and AIDS is on the increase, with sex between men identified as being responsible for 60 percent of the transmissions (UNAIDS, 2006), indicating the need for more effort in early discovery and treatment and in education on pre- vention. Every health-care contact with Japanese busi- nessmen or their wives is an opportunity to state the facts about infectious disease risk. The United States is per- ceived as a place high in HIV risk, and concerns among Japanese who come to the United States tend to focus on casual contact as a possible modality.

Other growing concerns are the rise in inactivity and obesity levels of Japanese children. Success in the educa- tional system demands long hours of study each day, thus reducing participation in physical activities, and this is compounded by the growth in the fast food industry and the predeliction for computer and electronic games usage among the young. Another problem is the prevalence of dental caries, which is high owing to unfluoridated water supplies across the country.

HEALTH-CARE PRACTICES

Japanese people are likely to attribute their generally high level of well-being to the centuries-old tradition of the daily bath. The o-furo (Japanese bathtub) is deep enough for an adult to enjoy a leisurely soak in neck-deep water, and the temperature is typically set around 105°F. The purpose of the bath is relaxation. Scrubbing for cleanli- ness and thorough rinsing are done before climbing into the tub. Families share the same water; in fact, they may soak together in the bath. Bath water may be reheated for several days before the tub is drained; depending on the type of bath, the water may be recycled for washing clothes or watering plants. Herbs or bath salts with thera- peutic properties are sometimes added.

Young people in Japan do not drive until age 18, and an expensive and lengthy course of instruction is manda- tory. Driving under the influence of alcohol or reckless operation of a vehicle carries stiff penalties. Rigorous inspection standards mean that people drive recent mod- els of vehicles that are fully equipped with standard safety features. One major problem, however, is the rise in injury by rear seat passengers not using seat beats, a com- mon feature in busy traffic, even though Japanese gener- ally exhibit a high degree of public-safety consciousness.

Traditional housing materials and the close proximity of buildings have made fire a common and large-scale

hazard. Each neighborhood has modern fire stations. Japanese readily use public services. Explicit instructions for accessing the local police, fire station, paramedics, and an emergency medical facility in a given North American community may be necessary, as well as the circum- stances under which access is appropriate.

Nutrition MEANING OF FOOD

Many Japanese social and business interactions begin or end (or both) with the serving of o-cha (coffee and snacks), or an o-bento (boxed lunch) (Fig. 15–1). Business entertaining can be lavish. Part of the atmosphere of con- geniality depends on the artistic presentation of the food.

COMMON FOODS AND FOOD RITUALS

In Japan, all food groups are well represented, even in small shops, and the national diet is steadily becoming more Western, particularly among young people. In a wealthy, cosmopolitan society in the big cities, one can find just about any food or drink in common use in North America and Europe.

Large-scale agricultural production within Japan pro- vides rice, beef, poultry, pork, seafood, root vegetables, cabbage, persimmons, apples, and mikan (tangerines). Rice, or gohan, the mainstay of the traditional diet, is included in all three meals as well as snacks. The electric rice cooker is a household necessity.

A traditional breakfast includes fish, pickles, nori (vari- ous seaweeds used to flavor or garnish meals), a raw egg stirred into the hot rice, miso (soybean-based) soup, and tea. Some people prefer a Western breakfast of toast or cold cereal and coffee.

School children lunch on their o-bento, packed with rice, pickles, vegetables, and meat or fish. Elementary schools generally provide a school lunch for pupils. A popular lunch among working people is o-bento, which can be ordered to be delivered quite cheaply to

268 • CHAPTER 15

FIGURE 15–1 Misuko jizu are implored to protect the souls of aborted fetuses in the Japanese Buddhist tradition.

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 268 Aptara Inc.

workplaces, or cold noodles on a hot summer day. Instant broth, or instant noodles, though high in sodium, is another popular quick lunch.

An example of a traditional dinner would be a pot of boiled potatoes, carrots, and pork seasoned with mirin (sweet sake), garlic, and soy sauce; or a stir-fried meat and vegetable dish. In major cities, Japanese housewives and working people have easy access to an enormous range of take-out food or home-delivery service, including Japanese, Chinese, and Western selections. American or Japanese fast food hamburger chains can be found in all cities. The daily intake of sweets can be high and often includes European-style desserts, sweet breads and cook- ies, sweet bean cakes, soft drinks, and heavily sweetened coffee, which may contribute to the high incidence of tooth decay.

For people in Japan, rice has a symbolic meaning related to the Shinto religion, analogous to the concept of the “bread of life” among Christians. One of the Emperor’s duties is to ceremonially plant the first rice in the spring and harvest the first rice in the late summer. A staple of school children’s o-bento is a bed of white rice garnished with a red plum pickle, reminiscent of the Japanese flag. Meals combine elements of land and sea. Office workers commonly have an o-bento box delivered to their workplace by one of the many bento companies in existence.

Holidays and family celebrations are times for ritual use of food. O-bon, in the summer, is a holiday for remem- bering family members who have died and a time when many travel to their family home, causing transport con- gestion across the country. Vegetables, especially daikon (large white radishes), are carved into animals, which are said to carry dead ancestors back to the afterlife after the holiday. Likewise, the new year’s festival, O-shogatsu, is a 3-day celebration with food that has been prepared in advance. Japanese may ring in the new year by literally standing in line at a Shinto shrine to ring a gong, and then drinking a cup of warm sake. Another traditional new year’s food is mochi, a ball of sticky rice dough that celebrants take turns pounding out with a heavy mallet. Red rice, or rice with red beans, is a celebratory food, as are various sweet bean desserts. A meal customarily begins with the simple grace, Itadakimasu, with the palms of hands facing together, and ends with the compliment, Gochisosama deshita. Western food rituals, including birthday cakes, wedding cakes, Christmas cakes, Valentine’s chocolates, and Halloween trick or treats, have been incorporated into Japanese life, no doubt spurred on by a consumer-driven market economy.

DIETARY PRACTICES FOR HEALTH PROMOTION

Increasingly Westernized food tastes, resulting in higher fat and carbohydrate intake, have contributed to the rise in obesity, particularly in young children, in modern Japan as it has in many Western countries (Wang & Lobstein, 2006). These dietary changes and other lifestyle factors are causing great concern about an increase in conditions such as diabetes and heart disease. A huge Japanese diet industry has arisen that includes weight-loss clinics and programs and an amazing array of diet foods

and medications in supermarkets and pharmacies. Public education programs continue to warn the public about the high sodium content of soups and the overuse of food additives, soy sauce, and table salt. General principles of nutrition are the same in America as in Japan, although the food preferences may differ significantly.

Green tea, although high in caffeine, is a good source of vitamin C. Garlic and various herbs are widely used for their medicinal properties. In larger cities, health-food stores offering organically grown produce are available, and 10 percent of the population now use dietary supple- ments (Ishihara, Sobue, Yamamoto, Sasaki, Akabane, & Tsugane, 2001).

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

Although some Asian people, including the Japanese, may have difficulty digesting milk products owing to lac- tose intolerance, increasing amounts of dairy products, including milk, cream, cheese, butter, ice cream, and yogurt, are on sale throughout the country, although these are not used to the same extent as in Western diets. Reduced-lactose milk is now available, as are low-fat milks and cheeses. Calcium is supplied in other foods such as tofu (soybean curd) and small, unboned fish. Water sup- plies are not fluoridated, and dental caries continue to be widespread. Fluoridated dental products can be recom- mended to Japanese clients, with the rationale for their use provided. Iron deficiency anemia is a concern among young women and can be alleviated with dietary counsel- ing or dietary supplements. Nori (seaweed) is a traditional food source for iron.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

After a national debate that lasted nearly 40 years, oral contraceptives became legal in Japan in 1999, shortly afterwards sildenafil citrate (Viagra) was quickly approved. The use of oral contraceptives, however, still remains fairly limited, and they are still not often used to treat menstrual cycle problems. In fact, Japan has man- aged to achieve a low birth rate without the major use of contraceptive pills. Condoms remain the most common contraceptive method used in Japan. Many women, both married and unmarried, have several abortions during their fertile lives. Although the number of reported abor- tions has steadily declined each year in Japan (just over 250,000 in 2003), the incidence is rising in the 15- to 24- year-old age group (Sato & Iwasawa, 2006). Some temples have jizo shrines where women give offerings of gifts and money to attendants who watch over aborted or miscar- ried fetuses (Orenstein, 2002), and often, a woman or a couple will place a gizo at a temple or shrine in memory of their aborted or miscarried fetus (Fig. 15–2).

The decline in the Japanese birth rate is regarded as a national crisis, and the economic implications are

PEOPLE OF JAPANESE HERITAGE • 269

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 269 Aptara Inc.

devastating as the country ages. An educated female pop- ulation, in a society in which women are oppressed, has asserted itself in a way that has certainly caught the nation’s attention. As a result, many social structures and policies regarding female labor laws and child-care and social support systems are under scrutiny. Japan’s status as a “low-birth-rate country” has created great interest in assistive reproductive technology within the last few years, and the Ministry of Health, Labour and Welfare has targeted infertility treatment as a priority. In the past, male infertility was too shameful to address.

Within traditional Japanese culture, pregnancy is highly valued as a woman’s fulfillment of her destiny. Women may enjoy attention and pampering that they get at no other time, and our observations are that they take their role as mother-to-be very seriously, including health and diet. When a pregnancy is first detected in Japan, it is registered with the local government office, which distributes a special mother/child handbook that becomes a comprehensive longitudinal health record for the child right up until kindergarten. Some Japanese nationals living in the United States might want to receive and complete this handbook.

Maternity clothes are now often very fashionable. Some believe that keeping one’s feet warm will promote uterine health. Pregnant women may undergo a cere- mony involving the wrapping of an hara obi (a bleached cotton abdomen sash) obtained and purified at a Shinto shrine. The sash is wrapped around the abdomen for pro- tection as part of a small ceremony performed on the Day of the Dog in the 5th month of pregnancy (Ito &

Sharts-Hopko, 2002). Because dogs give birth easily, the Chinese word for “dog” may be drawn on the obi by the obstetrician or midwife before they wrap it on the woman. Some women wear this sash throughout the rest of the pregnancy, but others may use a maternity girdle, a stomach band, or a special amulet to ensure a safe delivery.

Continuity of care throughout pregnancy is generally different in the United States and Japan. In Japan, a woman usually receives medical care and birthing sup- port, including ultrasonography and physical examina- tions, from the same medical staff. In the United States, these may occur in different locations. Japanese women often return to their mother’s home for the last 2 months of their pregnancy (called satogaeri bunben) and through the first 2 months’ postpartum. Alternatively, mothers may come to stay with their daughter during this period, even traveling abroad to be with her. Although this trend may be lessening, it is still impor- tant for health providers to consider. American health- care providers should explore a Japanese woman’s expec- tations during pregnancy and the possibility that she might return to Japan. Finding another Japanese woman who has experienced childbearing in the United States and who can share her experiences can provide support for the pregnant client.

V I G N E T T E 1 5 . 4

Keiko Okuni is a 29-year-old Japanese woman living in a high-rise apartment in your city and is 4 months’ pregnant, having moved to the United States 6 months ago. She is not working and has no social or family supports here apart from her husband. You meet her at the antenatal clinic and are responsible for helping her to plan for the delivery of her baby.

1. What specific factors would you need to take into con- sideration when trying to ensure that her prenatal care is culturally and socially appropriate?

2. How could you help her find appropriate ways to learn about the American health system, particularly in rela- tion to prenatal and postnatal care?

3. What are some of her health beliefs that need to be taken into consideration during her pregnancy, labor, and the postpartum period?

4. What kinds of information do you think needs to be supplied to her husband in relation to pregnancy and childbirth?

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

Health teaching for pregnant women in Japan empha- sizes rest and restraint from stressful activities. Women who are found working until late in their pregnancy are given special considerations in the workplace. Loud noises, such as trains or very loud music, are believed to be bad for the baby. Shinto shrines sell amulets for con- ception and easy delivery, and women may pray for their

270 • CHAPTER 15

FIGURE 15–2 Torii are the gates that mark the entrance of all Shinto shrines.

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 270 Aptara Inc.

safe delivery at these shrines. Some women now attend exercise classes for pregnant women but are rarely accom- panied by their husbands.

In the past, it was not so common for husbands to attend the births of their children; however, this is chang- ing and varies considerably across Japan. Some hospitals still do not allow husbands to be present. Most Japanese women choose private obstetric care and give birth in 1 of the 2500 maternity hospitals in which most births occur with a physician delivering the baby. Certified nurse-mid- wives often give perineal massages during childbirth. They may deliver the baby, sometimes observed by a physician who assists if complications occur. However, the strong tradition of local community-based midwifery, with independent midwives offering services at their own birth houses, is regaining popularity. Currently, about 350 of these across the country cater to about 2 percent of the births. Birthing houses are quite separate from hospi- tals and are supported by the community. Birthing at home is quite rare in Japan.

Episiotomies may still be performed for first deliveries, but shaving and the use of enemas predelivery are not common in Japan. In addition, Japanese midwives often use perineal massage. Oxytocics are common in the sec- ond stage of delivery if contractions are weak, and antibi- otics are often prescribed after delivery even though there may be no sign of infection. Pregnant women are edu- cated about balanced natural foods, and easily digested foods are preferred during the first stage of labor.

The differences in birthing procedures need to be explained to women giving birth in the United States, especially when they may have knowledge only of proce- dures in their home country. It is important for midwives and obstetricians in the United States to remember that Japanese families want to keep the dried umbilical cord that falls from the newborn’s abdomen. This is very spe- cial, and it is stored by the family for many years in boxes made of kiri (paulownia) wood; sometimes, it may be given to the bridegroom on marriage.

Physicians are skilled at mid- and high-forceps deliver- ies because cesarean delivery is viewed as hard on the mother; such surgery is reserved for emergency cases. Vaginal deliveries are usually performed with minimal medication, and the mother tries to be very stoic, using the breathing exercises taught during pregnancy. Ito and Sharts-Hopko (2002) explained that Japanese women pre- fer nonpharmacological interventions such as the Lamaze method whenever possible. To give in to pain dishonors the husband’s family, and mothers are said to appreciate their babies more if they suffer in childbirth.

Japan enjoys one of the lowest rates of infant and maternal mortality in the world. Maternal mortality, at 7.3 per 100,000 births in 2003, is most commonly caused by hemorrhage, and is associated with delivery in small, single-physician birthing hospitals (Ministry of Health, Labour and Welfare, 2006).

Japanese women in the United States are not likely to have a birth plan when they are admitted to a health- care facility. They prefer natural methods of child deliv- ery as they would in Japan and to avoid cesarean deliv- ery and pain relief whenever possible. Their husbands may choose not to attend the actual delivery, in which

case, women will need additional supportive nursing care.

In the postpartum period, time to recover from child- birth is taken seriously. In Japan, a woman may stay in the hospital 5 days to 1 week while learning to breastfeed and attending daily mother-care classes. Japanese hospi- tals vary about allowing rooming-in of babies. Culturally, postpartal women often do not wash their hair for a few days postpartum. Because the new mother often stays with her mother, the new father may not see his baby for a few months until he comes to take the mother and baby home from the grandmother’s house. Because of the per- ceived risk of infections, it is unusual to see infants in public before the age of 3 months.

Mothers will often be asked about the feeding method they used for their baby, for example, on kindergarten admission forms. Maternal rest and relaxation are deemed essential for success. Lactation nurses are widely available, and breast massage is one of their strategies for promoting milk production and flow. A number of pro- motional campaigns have been held recently to encour- age women to breastfeed, and concerns do exist about its decline when women choose to re-enter the workforce.

Japanese women who give birth in the United States may resent the American expectation that they will resume self-care and child-care activities quickly, which they believe is harmful to them and their relationship with the baby. Although American health-care providers cannot provide the length of hospital stay the women would have experienced in Japan, they can explain the expectations for postpartal care, exercise sensitivity, and help plan for assistance upon discharge.

Death Rituals DEATH RITUALS AND EXPECTATIONS

In Japan, open discussions about death, serious illness, and mental illness are usually not common subjects for discussion, but recently, the daily media include more awareness and discussion about depression, HIV/AIDS, and dementia. Most Japanese people still hesitate to reveal serious mental illness in their family. However, physicians are more commonly revealing diagnoses of cancer or other life-threatening illnesses to patients, whereas in the past, patients were rarely told of the pos- sibility of their impending death. This paternalistic approach was meant to relieve the patient of emotional suffering. In recent years, the biomedical literature has begun to reflect open discourse on pain management in terminal illness, the need for greater national invest- ment in intensive-care services, the need to increase organ transplantation, and the need for end-of-life deci- sion-making.

Under the Organ Transplant Law of 1997, organ trans- plantation is not permitted in children under the age of 15 nor are children permitted to donate organs. Brain death is not considered a legal means by which ventila- tors can be turned off by medical staff. Recently, contro- versial decisions have been made to charge medical staff who have done so.

PEOPLE OF JAPANESE HERITAGE • 271

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 271 Aptara Inc.

RESPONSES TO DEATH, GRIEF, AND SUFFERING

When considering the death and grief reactions of Japanese, one must not neglect the close intertwining of Buddist and Shinto beliefs at large in the population. In Shinto, death is believed to be impure and one should not spend time dwelling on it. According to the first Noble Truth of Buddhism, all human beings suffer. When a Japanese person is dying, the family should be notified of the impending death so they can be at the dying person’s bedside. Traditionally, the eldest son has particular responsibility during this time.

Many homes have a Buddhist altar, butsudan, where deceased family members are honored and remembered. Photographs of the deceased are displayed, floral arrange- ments are placed within and outside of the home, and a special altar may be constructed when a person dies. A bag of money is hung around the neck of the deceased to pay the toll to cross the river to the hereafter (Shinto Online Network Association, 2006). An alternate version of this custom dictates that if the dead is satisfied with the amount of money, then the inheritance is freed for the survivors. Visitors bring gifts of money and food for the bereaved fam- ily. White flowers are the symbol of death in Japan and are used at funerals; therefore, these should not be sent to someone who is ill.

Modern corporate life in Japan does not allow for tak- ing more than a few days off from work for official mourning. However, in terms of religious practice, the mourning period is 49 days, the end of which is marked by a family prayer service and the serving of special rice dishes. At this time, the departed has joined those already in the hereafter. Perpetual prayers may be donated through a gift to the temple. In addition, special prayer services can be conducted for the 1st, 3rd, 7th, and 13th anniversaries of the death. The common belief is that the dead need to be remembered and failure to do so can lead the dead to rob the living of rest. Proper funeral rites and reassurance that they are remembered during temple and family prayers alleviate the agitation of the dead.

V I G N E T T E 1 5 . 5

Mrs. Kobayashi, aged 78 years, was admitted to the local hos- pital with a myocardial infaction. She lapsed into a comatose state and died. The community nurse has been visiting Mrs. Kobayashi’s frail husband in their apartment over the last 3 months. She was his main caregiver, and they were both very traditional in their beliefs and outlook on life, even though they had lived in the United States for 25 years. The nurse and the social worker from the local health center are very concerned for Mr. Kobayashi. He wants to remain in his apartment until his son arrives from Tokyo.

1. In order to help Mr. Kobayashi to deal with his wife’s death, what culturally appropriate rituals could the nurse and the social worker suggest to assist him?

2. Who could be called to help Mr. Kobayashi? 3. What are some challenges the nurse might encounter

while working with Mr. Kobayashi?

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Japan does not have a clearly articulated theology or reli- gious belief system. Tradition holds that the Japanese peo- ple are descendants of the Sun goddess and that the emperor is a God (Keene, 1983), although the Occupation forces required Hirohito to publicly renounce this status after World War II ended. Some say that the demotion of the emperor from God to mortal has left the Japanese with a spiritual vacuum. Reischauer and Jansen (1995) believed this secularization of Japanese society began when Confucianism, imported during the 9th century, grew in influence during the 17th century. Confucian val- ues, including faith in education, hard work, and the emphasis on interpersonal relationships and loyalty, con- tinue to be important today.

Shinto, the indigenous religion, is the focus of joyful events such as marriage and birth. Many matsuri (festi- vals) are marked by offerings, parades through the streets, and a carnival on the grounds of the shrine. Buddhism, brought to Japan in the 6th century, has permeated Japanese artistic and intellectual life. Very few Japanese people regularly attend services, but most are registered temple members, if only to ensure a family burial plot. One percent of Japanese people are Catholic or Protestant in nearly equal numbers, and Christianity has been known, although at times not well tolerated, in Japan since the 16th century. Most Japanese do not identify themselves solely with one religion; even a baptized Christian might have a Shinto wedding and a Buddhist funeral. These days, some young people get married in a commerical-style chapel that looks like a Christian chapel but has nothing to do with religion.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

This crossover of Shinto and Buddhist beliefs and customs may be a surprise to visitors from overseas. Many Japanese believe in reincarnation, a Buddhist belief, and also accept the Shinto recognition of the eternal life of the soul, which needs purification in the earthly life. Ancestor worship is widespread, and many Japanese believe that their ancestors can be called back to earth. Such beliefs play a large part in mourning the dead. Other valid interpretations include honoring one’s family and country, working hard, being a good group member, and joining one’s deceased ancestors (Woss, 1992).

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

Japanese religions play a significant role in health-care practices. People or objects such as cars are taken to spe- cial shrines for purification from evil by priests. People often buy protective omamori (amulets) at shrines or tem- ples for a wide variety of reasons. Some shrines and tem- ples specialize in specific illnesses. Kampo (pharmacists or traditional healers) often set up shop in the vicinity. At

272 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 272 Aptara Inc.

the temple or shrine, a person might be seen scooping incense smoke onto an ailing body part or praying for good health. Prayer boards might bear requests for special healing. Gifts of toys or devices used in child care may be left with Buddha statues. Newborns are taken to a shrine for a blessing. Children are taken for blessings on November 15, when they are 3, 5, or 7 years old (the shichi-go-san). Visits to shrines and temples in Japan are social, recreational, and spiritual outings. Souvenirs and refreshments are usually available, and the hike into the prayer area provides exercise, with access to many tem- ples or shrines involving a climb up steps.

Various types of diviners, soothsayers, and prophets may be present at shrines, temples, and even along the most fashionable streets in Tokyo. Statues depicting folk- tale heroes, often animals, are believed to bring luck. Americans may have difficulty understanding and accept- ing the reliance of sophisticated and well-educated people on what may be viewed as superstitions. But these mea- sures appear to be more sources of comfort than deciding factors in health-care decision-making. They should be accepted as a very important part of what it means to be Japanese.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

The general health of the populations of Japan and the United States are similar, with a shift in leading causes of morbidity and mortality from infections to chronic ill- nesses and diseases. However, behaviors and underlying belief systems differ markedly between Japan and the United States. The Japanese are more tolerant of self- indulgence, even during minor illnesses. Because Japanese are less likely to express feelings verbally, this indulgence may be a way for people to affirm caring for one another nonverbally. Hypochondriasis among the Japanese has been described in the medical literature and is more toler- ated. Bodily flaws, for example, birthmarks, are a source of concern; and body piercing is now becoming more fashionable in the young.

In Japan, people seem less inclined to seek correction of minor orthopedic and dental variations than those in middle-class American society, although immigrant fami- lies make full use of services offered in the United States. Health-care providers engaged in health promotion and screening need to be aware of this difference. Function, rather than appearance, may be a more appropriate emphasis.

Humankind is a part of nature, subject to its forces, and a person is an integrated whole. Whereas Chinese tra- dition calls for a restoration of balance when one is ill, Shinto calls for purging and purification. Both influences operate in modern Japan. In the past, Shinto was the source of principles of prevention, whereas Buddhist priests healed the sick. Centuries before the germ theory was known, Shinto effectively distinguished between spaces and body parts that were dirty versus those that were clean and pure. For example, taking off one’s shoes at the doorway keeps one’s home clean, and people wear

slippers inside. However, only stockinged feet or bare feet are used on grass matting or tatami. Family members will also change their slippers when entering bathroom or toi- let areas. Mothers carefully teach young children to fear dirt. People with colds in Japan customarily wear dispos- able surgical masks in public to shield others from their infection.

Preoccupation with germs and dirt is not likely to interfere with daily life. It may account for prejudices among some Japanese against certain categories of work- ers, including nurses. Americans who visit Japanese homes should usually assume that outside shoes are taken off before entering the home, and the hostess will usually offer guests slippers to wear. The same thing may occur in special types of businesses, in some restaurants, or in areas in aged-care homes or special clinics.

RESPONSIBILITY FOR HEALTH CARE

Newsstands and vending machines, particularly in com- muter rail stations in Japan, provide large quantities of flavored caffeine elixirs, high-potency vitamin elixirs, and electrolyte replacement drinks. These products are pro- moted to give workers and students an edge in their daily work. Health-care providers need to ask specifically what remedies are being used and why. Japanese clients in North America find general principles of nutrition to be the same as those taught in Japan, although their food preferences may differ.

The health of pregnant and nursing mothers and of children has the highest priority in the Japanese health- care system, and all school children and workers have comprehensive annual check-ups at the expense of their school system or employer. National insurance is avail- able to all Japanese, including foreigners, for a sliding- scale fee, and covers both medical and dental care. Treatment by osteopaths, chiropractors, and traditional practitioners is covered if clients have been referred by a physician; in fact, acupuncture, moxibustion (heat applied to acupuncture sites), and other traditional modalities of care are still part of the national university curriculum for physical therapists. Older people and peo- ple with certain chronic conditions receive free treat- ment, whereas low-income people may be eligible for sub- sidized services. The municipal government handles enrollments.

Japanese residents in the United States frequently carry Japanese health insurance. Japanese nationals working for American institutions or companies may be eligible for the same coverage as other employees, but they often need assistance in understanding how their benefits work. Students and others can continue their Japanese national health insurance while in America, but they may need assistance in seeking care and understanding the American billing and payment process.

Many American over-the-counter medications, or their Japanese equivalents, are widely available in Japanese pharmacies. In addition, many pharmacies stock tradi- tional herbal kampo preparations, as well as a large amount of stomach preparations for gastric upset.

Japanese people make liberal use of both modern med- ical and traditional providers of health care. Influenced

PEOPLE OF JAPANESE HERITAGE • 273

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 273 Aptara Inc.

by German and American medical science, the Japanese health-care system incorporates local primary care, neigh- borhood hospitals, specialty clinics, academic medical centers, and national research institutes. Most hospital beds are found in tiny, unregulated, physician-owned neighborhood clinics, and it is not common for patients to have their own room, even if they have private insur- ance. A sophisticated public health system offers prenatal and well-child care, school health initiatives, visiting nursing services, home health services, senior centers, and health education at little or no cost to the public.

Japanese residents in the United States have Internet and mail order access to traditional medications, if they are not available locally. As with any client population, a complete health assessment includes inquiry about home therapies. From the second generation of immigrants onward, the tendancy is to rely fully on the American health-care system.

FOLK AND TRADITIONAL PRACTICES

Morita therapy, one of the most popular indigenous models of psychotherapy in Japan, is used to address shinkei shitsu, excess sensitivity to the social and nat- ural environment. Morita therapy focuses on constructive physical activities that help clients adjust to and accept the reality in their lives and the interconnectedness to others (Tamura & Lau, 1992). This form of psychotherapy is very different from Western psychotherapy in that it tries to avoid introspection and deep analysis of self in an individualistic sense. Naikan therapy is another indigenous psychotherapy of reflection on how much goodness and love is received from others and is very much focused on well-being in Japanese culture. A third indigenous therapy, Shinryo Naika, focuses on bodily illnesses that are emotionally induced.

Within the last several decades, Western-style psychia- try has been fully incorporated into Japanese health-care services. Indeed, psychiatric care in Japan in the early 1990s was predominantly given in overcrowded institu- tions. Today, it is moving toward a community-based emphasis. However, according to Tsuchiya and Takei (2004), substantial changes are needed in forensic psychi- atry, child and adolescent psychiatry, substance misuse, and the naming of psychiatric disorders. One major prob- lem is inadequate provision of mental health care for chil- dren and adolescents. Japan today has 348,966 psychi- atric beds for a population of nearly 27 million people, approximately three times higher than the 10 psychiatric beds per 10,000 population in the United Kingdom in 1998 (Ministry of Health, Labour and Welfare, 2002). Despite the greater availability of psychiatric inpatient care, increased stress and violent attacks in the commu- nity continue to fill the daily newspapers without any sign of improvement. This is of great concern to Japanese people at large, especially when Tsuchiya and Takei (2004) pointed out that there is no special provision for violent mentally ill offenders other than in regular psy- chiatric hospitals.

Health-care providers need to be sensitive to workplace or family issues that may underlie illnesses among Japanese clients, as among all clients. If a provider

believes that psychotherapy is indicated, the therapist must be someone familiar with the Japanese culture. Guidance in locating resources may be obtained through large academic medical centers or universities in coastal (particularly the Pacific Coast) cities, as well as through professional associations, Japanese churches, or other reli- gious organizations.

Health care is easily obtained in Japan. However, the system of referrals is unique. When a physician leaves medical school, she or he becomes part of that school’s “family.” She or he is unlikely to refer patients to special- ists or hospitals outside the “family” of her or his fellow alumni or former professors. Personal acquaintance is essential for doing business in Japan, and it is also reflected in health-care practice.

Japanese people may be unlikely to assert themselves in American settings, and their efforts to do so may seem inappropriate to American health-care providers. Their high regard for the status of physicians decreases the like- lihood of asking questions or making suggestions about their care. The idea that clients should be given care options may be alien. Health-care providers need to pro- vide ample opportunity for dialogue and explain the choices that are offered. Japanese and Japanese American health-care providers may be an important resource in bridging gaps in understanding.

V I G N E T T E 1 5 . 6

Mayuko is a 19-year-old Japanese student studying at the local university in your city. She has been referred to the men- tal health clinic by one of her tutors because she has been missing classes, appears not to be taking care of herself, and is withdrawn and uncommunicative. She would not visit the health center at the university or visit her local doctor. When the nurse meets her, it is clear that she seems depressed and unhappy and says she is missing her family in Japan.

1. What specific cultural factors could be contributing to Mayuko’s present state?

2. Why has she been reluctant to seek help? 3. How could the nurse provide education about depres-

sion to her in a culturally sensitive fashion?

CULTURAL RESPONSES TO HEALTH AND ILLNESS

Pain, itami, may not be expressed, and bearing pain is considered a virtue and a matter of family honor. Medications that specifically relieve pain are used less fre- quently in Japan than in the United States; narcotic use in particular is restricted. Addiction is a strong taboo in Japanese society. Biomedical researchers are beginning to study the comfort needs of dying patients (Morita, Tsunoda, Inoue, & Chihara, 2000), but the use of hos- pices, as they are known in the Western sense, is not com- mon in Japan. Those that do exist often combine the comfort of the dying with intrusive medical care. Davis, Konishi, and Mitoh (2002) pointed out that terminal care of the dying in Japan is much different. Some hospices may be attached to acute-care hospitals, and most patients are not told of their diagnosis or prognosis

274 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 274 Aptara Inc.

because the ethical notion of health professionals is that protecting the patient from distressing news is the moral thing to do.

American health-care providers may use a schedule of analgesic administration rather than an as-requested or a patient-controlled approach to ensure adequate pain management. Japanese clients may respond positively to the information that physiological status and healing are actually enhanced by pain control.

Physically and intellectually handicapped children and adults are not commonly seen in public in Japan. In fact, most handicapped children, if they attend school, go to special schools rather than being integrated in the pub- lic school system. In addition, many public areas in Japan are not designed to cope with people with disabilities, making it very difficult for people who use wheelchairs or other assistive mobility devices. However, recently, the number of public toilets with facilities for handicapped people has increased. Many Japanese families hide knowl- edge of deformity or disability in family members because of shame, and there are still instances of people with physical handicaps—for example, cerebral palsy—being admitted to psychiatric hospitals owing to a lack of suit- able facilities elsewhere. Japanese families residing in the United States need encouragement to avail themselves of community resources and to understand that shame asso- ciated with disability is not as prevalent in American society.

Assumption of the sick role is highly tolerated by fam- ilies and colleagues, and a long recuperation period is encouraged by Japanese health-care providers. For exam- ple, in Japan, a client with a myocardial infarction may be hospitalized for a month, with outcomes comparable with those found in the United States (Kinjo et al., 2004). However, changes to the national insurance system to extend care for rehabilitation, to shorten hospital stays, and to provide for more rehabilitation are now starting to have an effect, particularly in rehabilitation after stroke (Miyoshi, Teraoka, Date, Kim, Nguyen, & Miyoshi, 2005). Rehabilitation to achieve the full level of activities of daily living after serious illness or injury is less aggressive than in the United States. However, the number of higher education programs to train occupational and rehabilita- tion specialists is slowly growing across the country, and the importance of rehabilitation is becoming more recog- nized and implemented.

BLOOD TRANSFUSIONS AND ORGAN DONATIONS

Giving blood is encouraged in the Japanese culture. The Japanese Red Cross is a very active and highly respected organization that runs 92 Red Cross hospitals in the country and collects blood in 77 centers, using over 340 blood mobiles, which travel around the country (Japan Red Cross, 2006). Donees are not paid for their contribu- tions. Blood usage is accounted for by 100 percent of domestic usage; however, blood products for hemophilia have to be imported. People with negative blood types account for less than 1 percent of the population; there- fore, RhoGam, used to protect an Rh-positive fetus from

antibodies from an Rh-negative mother, is not commonly stocked in Japanese hospitals.

Critical-care technology has not received the empha- sis in Japan that it has in the United States. Moreover, Ohaki, Yano, Shirouzu, Kobayashi, Nakagomi, and Tamura (2006) explained that in Japan, organ donation following diagnosed brain death was legalized in 1997, except for children under 15 years of age. Japan now has the strictest laws on organ donation in the world. Very few organ transplants have been from brain-dead donors; the number of transplants needed is vastly more than the organs available. Japanese people, including health pro- fessionals, may be distrustful of the diagnosis of brain death, which may be thought of as a persistent vegetative state. Critical care and organ transplantation and dona- tion issues need to be approached sensitively with Japanese residents in the United States. Health-care providers must be cautious in initiating extraordinary measures with Japanese family members. Japanese peo- ple rely more heavily on the physician’s opinion, and the family may have difficulty negotiating for cessation of treatment. The concept of advance directives has not been implemented in Japan, and upon admission to an American hospital, families need to understand what this means.

V I G N E T T E 1 5 . 7

Kyoko Moromoto, aged 10 years, was admitted to intensive care following a serious car accident in which she sustained ruptured kidneys as well as other injuries. She is currently on renal dialysis, and her attending and other physicians believe she requires a kidney transplant. Kyoko was on holiday with her Japanese parents when the accident happened in New York.

1. Given that Kyoko and her parents are Japanese, what are some cultural issues that may be involved in this case?

2. What specific information should be given to the par- ents about organ donation in the United States, partic- ularly in relation to organs donated from people who were diagnosed with brain death?

3. What may cause Kyoko’s parents to hesitate about approving a kidney transplant for their daughter?

Health-Care Practitioners TRADITIONAL VERSUS BIOMEDICAL PRACTITIONERS

In modern Japan, physicians are clearly in charge of the health-care team. Some physicians may have a high degree of understanding of kampo, or Japanese herbal medicine, and may offer patients a choice between Western medicine and kampo. However, Teramoto (2000) noted that only about 10 percent of the population uses herbal medicines today and that Japanese medical stu- dents may now receive poor training in its use. Kampo may be used in psychiatric care and care of older people;

PEOPLE OF JAPANESE HERITAGE • 275

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 275 Aptara Inc.

traditional practitioners may refer clients to the medical establishment and vice versa. Japanese health practition- ers who come to the United States face a different type of health-care system, with greater diversity and autonomy for many professionals. The authority of insurers to dic- tate care is novel for them, as is the extent of concern for malpractice liability.

STATUS OF HEALTH-CARE PROVIDERS

Physicians, referred to as sensei, are highly esteemed. Self- care as a philosophy is not evident in Japan. Being told what to do by the physician or kampo practitioner is expected, and his or her authority is not questioned. Physicians control most health-care delivery in Japan, running public and private hospitals and owning most private hospitals. Hospital administration is not an estab- lished field, and administrators in public hospitals are generally physicians elected to their post.

In Japan, females account for only about 15 percent of physicians, and male nurses account for about 6 percent. However, the professions and their interrelationships generally tend to reflect traditional gender roles. In the past, nurses were titled according to gender, kango-shi if a male, and kango-fu if female. The former means approxi- mately “Mr. Nurse,” whereas the latter means “Ms. Nurse.” However, the title of nurse is pronounced the same as the former one, but it is literally different in meaning in Kanji. The unified Kango-shi literally means “person to be a nurse by profession” and has the same written Kanji character as doctor and pharmacist.

Nurses in Japan today believe that nursing is still not highly regarded in Japanese society, but the raising of educational levels to a baccalaureate will undoubtedly change this, as has been the case in the United States. However, as noted previously, Japanese women do not hold high status in society, so this reflects strongly on the status of a largely feminine occupation. The prolif- eration of various types of health-care providers and technicians is less in Japan than in the United States (Anders, 1994; Tierney & Tierney, 1994). Japanese resi- dents in the United States need considerable assistance in understanding how the health-care delivery systems work and the functions of the different health-care providers they encounter. In particular, they need to understand the autonomy of a diverse group of health professionals. Home care, and the orchestration of many community-based providers, may be overwhelm- ing for Japanese residents who expect longer recupera- tions in the hospital.

Japanese health professionals working in the United States need careful orientation to laws and institutional regulations about appropriate male-female interactions and professional requirements for accountability in com- municating problems. Japanese residents seeking health care in America may be surprised by the assertiveness and autonomy of nonphysician professionals. An overview of the details of their care and who will be doing various aspects of that care can be helpful. Japanese residents in the United States may need assistance in seeking care. Their verbal English skills may be an impediment to mak- ing their needs known and to understanding the care

they are offered, although their ability to understand written information is very good. Japanese people tend to believe that they are physiologically different from non- Japanese people, and they may be skeptical of recommen- dations. They may also be very unwilling to discuss fam- ily members with mental health problems for fear of stigma. Calling on the local Japanese community for sup- port and encouragement may be a useful strategy with these clients.

REFERENCES

Anders, R. L. (1994). An American’s view of nursing education in Japan. Image: Journal of Nursing Scholarship, 26, 227–230.

Customs and Tariff Bureau. (2006). Trends in illicit drugs and firearm smug- gling in Japan: 2005 report. Toyko: Ministry of Finance.

Davis, A., Konishi, E., & Mitoh, T. (2002). The telling and knowing of dying: Philosophical bases for hospice care in Japan. International Nursing Review, 49(4), 226–233.

Doi, T. (1971). The anatomy of dependence (J. Bester, Trans.) Tokyo: Kodansha International Ltd.

Ehara, A. (2005). Lawsuits associated with medical malpractice in Japan [Letter to the editor]. Pediatrics, 115(6), 1792–1793.

Fukumizu, M., Kaga, M., Kohyama, J., & Hayes, M. J. (2005). Sleep-related nighttime crying (yonaki) in Japan. A community based study. Pediatrics, 115, 217–224.

Gender Equality Bureau, Cabinet Office. (2006). Steps toward gender equality in Japan. Retrieved November 4, 2006, from http://www.gender.go.jp/ english_contents/Pamphlet2006.pdf

Ishihara, J., Sobue, T., Yamamoto, S., Sasaki, S., Akabane, M., & Tsugane, S. (2001). Validity and reproducibility of a self-administered question- naire to determine dietary supplement users among Japanese. European Journal of Clinical Nutrition, 55(5), 360–365.

Ito, M., & Sharts-Hopko, N. (2002). Japanese women’s experience of child- birth in the United States. Health Care for Women International, 23(6–7), 666–677.

Japan Media Review. (2006). Publishers push the return of the E-book. Retrieved November 19, 2006, from http://ojr.org/japan/media/ 1082135229.php

Japan Red Cross. (2006). About us. Retrieved December 11, 2006, from http://www.jrc.or.jp/english/index.html

Kanazumi, F. (1997). Interview. In S. Buckley (Ed.), Broken silence: Voices of Japanese feminism (pp. 70–81). Berkeley: University of California Press.

Kashiwazaki, C., & Akaha, T. (2005). Japanese immigration policy: Responding to conflicting pressures. Retrieved November 19, 2006 from http://www. migrationinformation.org/Profiles/display.cfm?ID"487

Keene, D. (1983). Ise. In D. Richie (Ed.), Discover Japan: Vol. 2. Words, cus- toms and concepts (pp. 196–197). Tokyo: Kodansha International, Ltd.

Kinjo, K., Sato, H., Nakatani, D., Mizuno, H., Shimizu, M., Hishida, E., Ezumi, A., Hoshida, S., Koretsune, Y., & Hori, M. (2004). Predictors of length of hospital stay after myocardial infarction in Japan. Circulation Journal, 68(9), 809–815.

Leonardsen, D. (2004). Japan as a low-crime nation. New York: Palgrave Macmillan.

Levy, R. A. (1993). Ethnic and racial differences in response to medicines: Preserving individualized therapy in managed pharmaceutical pro- grammes. Pharmaceutical Medicine, 7, 139–165.

Longevity Japan. (2006). The spread of corporate measures to support child care and family care. One dimension of action in response to the declining birth rate in Japan. Retrieved December 1, 2006, from http://longevity.ilc- japan.org/f_issues/060706.html

Makino, M., Hashizume, M., Yasushi, M., Tsuboi, K., & Dennerstein, L. (2006). Factors associated with abnormal eating attitudes among female college students in Japan. Archives of Women’s Mental Health, 9(4), 203–208.

Ministry of Health, Labour and Welfare. (2006). Vital statistics tables 2005. Retreived January 26, 2007, from Ministry of Health, Labour and Welfare Homepage http://www.mhlw.go.jp/

Ministry of Internal Affairs and Communications. (2006). Statistical hand- book of Japan. Retrieved November 30, 2006, from http://www.stat.go.jp/ English/data/handbook/c02cont.htm#cha2_4

Miyoshi, Y., Teraoka, J. K., Date, E. S., Kim, M. J., Nguyen, R. T., & Miyoshi, S. (2005). Changes in stroke rehabilitation outcomes after the

276 • CHAPTER 15

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 276 Aptara Inc.

implementation of Japan’s long term care insurance system: A hospi- tal based study. American Journal of Physical Medical Rehabilitation, 84(8), 613–619.

Morita, T., Tsunoda, J., Inoue, S., & Chihara, D. (2000). Pain and symptom management. Terminal sedation for existential distress. American Journal of Hospice and Palliative Care, 17(3), 189–195.

Nakao, M., & Takeuchi, T. (2006). The suicide epidemic in Japan and strategies of depression screening for its prevention. Bulletin of the World Health Organization, 84(6), 492–493.

Ohwaki, K., Yano, E., Shirouzu, M., Kobayashi, A., Nakagomi, T., & Tamura, A. (2006). Factors associated with attitude and hypothetical behaviour regarding brain death and organ transplantation: Comparison between medical and other university students. Clinical Transplantation, 20(4), 416–422.

Orenstein, P. (2002, April 21). Mourning my miscarriage. New York Times. Retrieved from http://www.NYTimes.com

Reischauer, E. O., & Jansen, M. (1995). The Japanese today. New York. Longitude Books.

Sato, R., & Iwasawa, M. (2006). Contraceptive use and induced abortion in Japan: How is it so unique among developed countries? The Japanese Journal of Population, 4(1), 33–54.

Sharts Engel, N. (1989). An American experience of pregnancy and child- birth in Japan. Birth, 16(2), 81–86.

Shinto Online Network Association. (2006). Retrieved December 11, 2006, from http://www.jinja.or.jp/english

Takakura, M., & Sakihara, S. (2000). Gender differences in the association between psychosocial factors and depressive symptoms in Japanese junior high school students. Journal of Epidemiology, 10(6), 383–391.

Tamura, T., & Lau, A. (1992). Connectedness versus separateness: Applicability of familty therapy to Japanese families. Family Process, (4), 319.

Teramoto, S. (2000). Doctors’ attitudes to complementary medicine. The Lancet, 355, 501–502.

Tierney, M. J., & Tierney, L. M. (1994). Nursing in Japan. Nursing Outlook, 42(5), 210–213.

Tsuchiya, K. J., & Takei, N. (2004). Mental health care in Japan: An overview. The British Journal of Psychiatry, (184), 88–92.

UNAIDS. (2006). Country progress report: Japan 2005/2006. Retrieved December 8, 2006, from http://data.unaids.org/pub/Report/2006/ 2006_country_progress_report_japan_en.pdf

UN Secretariat. (2005). Possibilities and limitations of Japanese migration policy in the context of economic partnership in Asia. New York: UN Department of Economic and Social Information Affairs.

U.S. Commercial Service. (2006). Japanese tourism marketing opportunities. Retrieved November 20, 2006, from http://www.buyusa.gov/japan/ en/tourism06.html

U.S. Department of State. (2006). Background note—Japan. Updated June 2006. Retrieved November 30, 2006, from http://www.state.gov/r/pa/ bgn/4142.htm

Wang, Y., & Lobstein, T. (2006). Worldwide trends in childhood over- weight and obesity. International Journal of Pediatric Obesity, 1(1), 11–25.

Woss, F. (1992). When blossoms fall: Japanese attitudes towards death and the other world: Opinion polls 1953–1987. In R. Goodman & K. Refsing (Eds.), Ideology and practice in modern Japan (pp. 72–100). New York: Routledge.

Yanagisako, S. J. (1985). Transforming the past: Tradition and kinship among Japanese Americans. Stanford, CA: Stanford University Press.

For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

PEOPLE OF JAPANESE HERITAGE • 277

FABK017-C15[260-277].qxd 12/12/2007 10:43am Page 277 Aptara Inc.

278

People of Jewish Heritage

Chapter 16

LARRY D. PURNELL and JANICE SELEKMAN

Overview, Inhabited Localities, and Topography OVERVIEW

Being Jewish refers to both a people and a religion, not a race. Throughout history, the terms Hebrew, Israelite, and Jew have been used interchangeably. In the Bible, Abraham’s grandson, Jacob, was renamed Israel. His 12 sons and their descendants became known as the chil- dren of Israel. The term Jew is derived from Judah, one of Jacob’s sons. Hebrew is the official language of the state of Israel and is used for religious prayers by all Jews wherever they live. “Thus today, the people are called Jewish, their faith Judaism, their language Hebrew, and their land Israel” (Donin, 1972, p. 7).

Judaism is both a religion and a culture. The religion is practiced along a wide continuum that ranges from lib- eral Reform, 31 percent; to Conservative, 33 percent; to strict Orthodox; 8 percent; to Reconstructionism, 2 percent. Only 53 percent belong to a synogague (American Jewish Committee, 2006). Although Reform Jews might not engage in any special daily practices, they still observe holidays, religious rites, and selected dietary or cultural customs. The traditional Orthodox Jew attempts to adhere to most of the religious laws. Ultra- Orthodox groups also exist. No caste system or social hierarchy exists within the Jewish community. However, instances occur within the ultra-Orthodox communities when individuals cannot make decisions without con- sulting their rabbis.

A significant issue within Orthodox communities in Israel, frequently debated in America is, “Who is a Jew?” A child born to a Jewish mother is Jewish. As mixed mar-

riages have increased, the debate over patrilineal descent has ensued. A child born from the union of a Jewish father and a non-Jewish mother is recognized as Jewish by those in the Reform movement but not by those in the Orthodox movement. Although Judaism does not actively proselytize, the vast majority welcome converts as full members of their community. Clergy offer precon- version classes for adults and perform conversions.

Whereas the goal of this chapter is to provide an understanding of all Jewish Americans, the focus is on the needs of the more-traditional religious individuals and their families. These descriptions may vary somewhat for Jewish people according to the primary and secondary characteristics of culture (see Chapter 1) and the other parts of the world in which they inhabit.

HERITAGE AND RESIDENCE

The initial group of 23 Jews in North America arrrived in 1624, having fled the Office of the Inquisition in Brazil. Their numbers grew as a result of European immigrations to between 1000 and 2500 individuals by the time of the American Revolution, when many fought for the colonial army (Haim Solomon, a banker, raised significant funds in Europe and the colonies and dedicated all his personal resources and finances to George Washington’s army). Their numbers reached aproximately 250,000 by the 1880s, close to 6 million a century later, and finally stabi- lized by 2002. Greater than half currently live in the Northeast, primarily in New York and New Jersey, and the Southeast, mainly in Florida (Wertheimer, 2002). Although many prefer to live in or within reach of large Jewish communities in order to have access to specific ser- vices, Jews make their homes in rural as well as urban cen- ters in the United States.

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 278 Aptara Inc.

REASONS FOR MIGRATION AND ASSOCIATED ECONOMIC FACTORS

Migration of Jews from Europe began to increase in the mid-1800s, often because of the fear of religious persecu- tion. However, the greatest influx of immigrants occurred between 1880 and 1920. Many of these immigrants came from Russia and Eastern Europe after a wave of pogroms, anti-Jewish riots and murders (Jewish American Committee, 2006). Once in America, acculturation became their motivation to live safely and practice their religion.

Most Jewish families in America today are descendants of these Eastern European and Russian immigrants. They are referred to as Ashkenazi Jews. Ashkenazi Jews make up 82 percent of the world’s Jewish population (Haumann, 2002). Many American Jews of Ashkenazi descent have sto- ries of how some members of their families escaped to America, whereas others had relatives who were part of more than the six million Jews killed in the pogroms and the Holocaust. Sephardic Jews, conversely, are originally from Spain, Portugal, the Mediterranean area, and North Africa. They represent a more diverse group. A Sabra is a Jew who was born in Israel.

In the 1980s and 1990s, a significant increase occurred in the number of Jewish immigrants from Russia. Because the practice of religion was illegal there for over half a century, these Jews often have a relatively relaxed con- nection to religious and cultural practices. The same was true of the Falasha Jewish community in 1984. These black Jews from Ethiopia participated in a mass exodus to Israel, and subsequently, a small number continued on to America.

EDUCATIONAL STATUS AND OCCUPATIONS

Despite bias against Jews in every century, they have made major contributions to society, across the arts and professions, including the fine arts, sciences, and health care. Throughout their history, they have placed a major emphasis on education and social justice through social action.

Continued learning is one of the most respected values of the Jewish people, who are often called the People of the Book (Robinson, 2000). Whereas this usually refers to the study of Torah, it includes both Jewish and secular learn- ing. Formal education is highly valued, and advanced degrees are respected. Overall, this population is well edu- cated. Jews have won 39 percent of the Nobel Prizes in the life sciences, 11 percent in chemistry, and 41 percent in physics (Haumann, 2002). Well-known composers of Jewish ancestry include George Gershwin and Aaron Copland; the American theater counts Arthur Miller as one of its most celebrated of playwrights. The 20th cen- tury finally saw the first Jewish Supreme Court Justices in Louis Brandeis and, most recently, Ruth Ginzberg.

Because of their emphasis on education, a high per- centage of Jewish Americans have succeeded in science, medicine, law, and dentistry. Thirty-nine percent of Jewish men and over 36 percent of Jewish women list their occupation as professional, compared with only 15 percent of the American white population. With respect to higher education, over 10 percent of professors in

American colleges and universities are Jewish (Jewish American Committee, 2006). Their traditional values of study and preserving life have contributed to directing many into the life sciences, medicine, and research.

Throughout their history, Jews were repeatedly forbid- den to own land, and the Christian Church barred its members from moneylending. As a result, since the early Middle Ages, Jews frequently became moneylenders, ped- dlers, and tailors because these were the only options available to them. The early Jews in America were busi- nessmen and craftsmen (Center for Jewish History, 2007). They became well respected for their expertise in trade and commerce. Today, one-quarter of Jewish men are in retail sales.

Their emphasis on social action, volunteerism, and involvement in helping others are common vocations or avocations. The term tzedakah (justice) is used to indicate charity, a central concept to Judaism. Jewish children are raised with the concept of giving tzedakah by sharing with others who have less than they do.

Communication DOMINANT LANGUAGE AND DIALECTS

English is the primary language of Jewish Americans. Although Hebrew is the official language of Israel and is used for prayers, it is generally not used for conversation in the United States.

Many older Ashkenazi Jews who immigrated early in the 20th century or who are first-generation Americans speak Yiddish, a Judeo-German dialect. Many Yiddish terms have worked their way into the English language, including kvetch (to complain); chutzpah (clever audacity); bagel (a boiled roll with a hole in the middle); challah (a rich, braided white bread); knish (a dumpling with filling); nosh (a [or to] snack); zaftig (plump); tush, tushie, or tuchus (buttocks); ghetto (a restricted area in which certain groups live); klutz (a clumsy person); mentsch or mensh (a respected person with dignity); shlep (to drag or carry); kosher (legal or okay); and oy or oy vey (oh my), and oy veys mier (woe is me).

Common Hebrew expressions include l’chaim (to life), which is said after blessing wine; shalom alechem (peace be with you) a traditional salutation; mazel tov (congratula- tions) and shabbat shalom (a good and peaceful Sabbath) which are said from Friday evening at sunset until Saturday at sunset.

CULTURAL COMMUNICATION PATTERNS

No religious ban or ethnic characteristics prevent Jews from openly expressing their feelings. Communication practices are more related to their American upbringing than to their religious practices.

Humor is frequently used as a coping mechanism and as a way to communicate with others. However, jokes are considered to be insensitive when they reinforce main- stream stereotypes about Jews, such as implying that Jews are cheap or pampered (e.g., Jewish American Princess). Any jokes that refer to the Holocaust or

PEOPLE OF JEWISH HERITAGE • 279

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 279 Aptara Inc.

concentration camps are also inappropriate. Jewish self- criticism through humor is acceptable, but is usually expressed “in-house.”

Modesty is a primary value in Orthodox Judaism. It is seen in the style of dress and in all behavior. Modesty involves humility. Jews are encouraged not to “show off” or try to impress others.

Hasidic Jewish men are not permitted to touch a woman other than their wives. They often keep their hands in their pockets to avoid touch. They do not shake hands with women, and their failure to do so when one’s hand is extended should not be interpreted as a sign of rudeness. Because women are considered seductive, Hasidic men may not engage in idle talk with them nor look directly at their faces. Non-Hasidic Jews may be much more informal and may use touch and short spatial distance when communi- cating. Health-care providers should touch Hasidic men only when providing direct care. “Therapeutic touch” is not appropriate with these clients.

TEMPORAL RELATIONSHIPS

Jews live with regard for and in the present, conscious of being a part of a long historical tradition, and with both hope and a wary eye to the future. The last 2 millenia have seen a sucession of struggles to survive external pres- sures, yet the tradition affirms their belief in survival and a better time to come. They are raised with stories of their past, including the relatively recent Holocaust. They are warned to “never forget,” lest history be repeated. Therefore, their time orientation is simultaneously to the past, the present, and the future.

The Jewish calendar is based on both a lunar and a solar year, with each month beginning with the appear- ance of the new moon. The festivals and holidays are based on lunar phases, whereas the seasons are based on the solar year, which is 11 days longer than the lunar year. Therefore, an extra month is periodically added.

FORMAT FOR NAMES

For secular use, the Jewish format for names follows the Western tradition. The given name comes first, followed by the family surname. Only the given name is used with friends and in informal situations. In more formal situa- tions, the surname is preceded by the appropriate title of Mr., Miss, Ms., Mrs., and the like.

Babies may be named after someone who has died, to keep their memory alive, or after a living person, to honor them. The format chosen largely depends on whether the family is of Ashkenazi or Sephardic heritage. In ultra- Orthodox circles, children are not referred to by their names until after the bris or brit milah (circumcision). The biblical traditions are preserved for religious occasions. Infants are given a Hebrew name that is used when they are older and are called to read from the Torah. An exam- ple would be Josef ben Ezra (Joseph, son of Ezra). Although one’s Hebrew name may be the same as one’s birth certificate “official” name, parents may choose a non-Hebrew, main-culture name for the birth certificate that is entirely different or one that preserves the initial letter (i.e., Ezra could become Edward).

Family Roles and Organization HEAD OF HOUSEHOLD AND GENDER ROLES

The family is the core of Jewish society, and whereas the man is traditionally considered the breadwinner for the household, and the woman is recognized for running the home and being responsible for the children, in recent times, there is more flexibility for gender roles, even in very observant homes. According to Jewish law, the father has the legal obligation to educate his children in Judaism, to teach them right from wrong, to teach them to swim, and to teach his sons a trade (Robinson, 2000). He must provide his daughters with the means to make them marriageable. With acculturation, little difference is seen today between Jewish and non-Jewish white families with regard to gender roles. In most Jewish families, both par- ents share the responsibilities for supporting the home and raising the children.

According to the Talmud, Jewish husbands are required to provide their wives with food, clothing, medical care, and conjugal relations, in addition to meeting other needs. They are prohibited from “beating their wives, forc- ing them to have sex, or restricting their free movement” (Robinson, 2000, p. 161).

Although traditional Jewish law is clearly male-ori- ented, Jewish women have been at the forefront of activ- ities to demand and protect all human rights, especially those of women. They were prominent in movements to gain women’s suffrage, reproductive health-care rights, and equal rights for all segments of society. Women are now expected to achieve an optimal level of education and to seek gainful employment if they so desire. Both sexes are expected to give service to their community.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO BEHAVIORS FOR CHILDREN AND ADOLESCENTS

Children are the most valued treasure of the Jewish peo- ple. They are considered a blessing and are to be treated with respect and provided with love. Jewish children are to be afforded an education, not only in studies that help them progress in society but also in studies that transmit their Jewish heritage and the laws. Jewish school-age chil- dren typically attend Hebrew school as least two after- noons a week after public school throughout the school year. Children are welcomed and incorporated into most holiday celebrations and services.

Respecting and honoring one’s parents is the fifth of the Ten Commandments. Children should be forever grateful to their parents for giving them the gift of life. Jewish parents are expected to be consistent and fair to all their children, avoiding favoritism. In addition, parents should not promise something to their children that they cannot deliver. They must be flexible and yet caring and attentive to discipline. The individuality of each child’s special traits should be recognized (Amsel, 1994).

In Judaism, the age of religious majority is 13 years for a boy and 12 years for a girl. At this age, children are deemed capable of differentiating right from wrong and capable of committing themselves to performing the

280 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 280 Aptara Inc.

commandments (Amsel, 1994). Recognition of religious adulthood and assumption of its responsibilities occurs during a religious ceremony called a bar or bat mitzvah (son or daughter of the commandment). In America, this rite of passage is usually accompanied by a family cele- bration. However, because sons and daughters are still teenagers living at home, it is recognized that they are still the responsibility of their parents.

FAMILY GOALS AND PRIORITIES

The goal of the Orthodox family is to live their lives as prescribed by halakhah, which emphasizes maintaining health, promoting education, and helping others. In addition, “each person must find those qualities and characteristics that make him or her unique and then he or she must attempt to maximize potential by fully devel- oping those qualities” (Amsel, 1994, p. 234). The family is central to Jewish life and essential to the continuation of Judaism from one generation to the next.

Marriage is considered the ideal human state for adults. The Bible states that man should not be alone. The two goals of this union are to procreate and provide com- panionship (Kolatch, 2000), allowing an individual to focus on another person. Marriages are monogamous, and limitations on whom one may marry exclude close blood relatives.

Sexuality is a right of both men and women. In addi- tion to procreation requirements, conjugal rights for women exist. Nonprocreative intercourse is required for married women who may be pregnant or are unable to conceive, and this is not considered as “wasting seed” (Kolatch, 2000). Sexual intercourse is viewed as a pure and holy act when performed mutually within the relation- ship of marriage. With some exceptions, a husband’s refusal to have sex with his wife is grounds for a divorce (Robinson, 2000). However, the act of sex, if performed in the wrong context, is considered disgusting and against Jewish values (Amsel, 1994). Premarital sex is not con- doned.

Among the ultra-observant, women must physically separate themselves from all men during their menstrual periods and for 7 days after (Robinson, 2000). No man may touch a woman nor sit where she sat until she has been to the mikveh, a ritual bath, after her period is over. Sexual contact for this group may, therefore, occur only during 2 weeks of each month.

Judaism supports the need for sex education. The Jewish community sees this as its responsibility. This belief has been re-emphasized during the AIDS epidemic, with the goals of protecting the next generation and pro- viding them with accurate information so they can make informed choices.

Whereas it is recognized that the later years are a time of physical decline, older people receive respect, espe- cially for the wisdom they have to share. The Talmud defines older people as those who have reached their 61st birthday (Robinson, 2000). Old age is a state of mind rather than a chronological age; one may continue to “give” to society in a variety of ways other than employ- ment. In addition, one may never “retire” from practicing the commandments.

Honoring one’s parents is a lifelong endeavor and includes maintaining their dignity by feeding, clothing, and sheltering them, even if they suffer from senility. Respect for older people is essential even when their actions are irrational. The care of an older family member is the responsibility of the family; when the family is unable to provide care owing to physical, psychological, or financial reasons, the responsibility falls to the com- munity. This role has always been a hallmark of Jewish communal life (Robinson, 2000). A number of older Jewish people move to Florida or other warm states after retirement because the weather there is more conducive to maintaining their health and safety. Of noninstitution- alized older adults, one-third live alone.

Few Jewish American families now have three genera- tions living together. Older immigrants who experienced imprisonment in concentration camps during the Holocaust in the 1940s, or those more recently incarcer- ated in Russia, may refuse to enter long-term-care facili- ties for fear of returning to an institutional environment that robs them of their freedom (Martha Braverman, per- sonal communication, February 4, 2007).

ALTERNATIVE LIFESTYLES

The Jewish view on homosexuality varies with the branch of Judaism. As might be expected, the Orthodox are largely unaminous in scripture-based (Lev. 18:22) nonacceptance of same-sex unions. The Bible, especially as interpreted by the Orthodox, prohibits homosexual intercourse (Kolatch, 2000); it says nothing specifically about sex between les- bians (Dorff, 1998). Some of the objections to gay and les- bian lifestyles include the inability of these unions to fulfill the commandment of procreation and the possibility that acting on the recognition of one’s homosexuality could ruin a marriage. The official position of the Conservative movement had sided with the Orthodox until as recently as 2006, when it revised its position to increase inclusivity of views within Jewish philosophy. This implies allowing ordination of gay and lesbian clergy, although not recog- nizing same-sex marriage. The liberal movement within Judaism, however, supports “full legal and social equality for homosexuals” (Washofsky, 2000, p. 320).

Workforce Issues

V I G N E T T E 1 6 . 1

Lisa H., a registered nurse, has worked triage in the Emergency Department in a regional midwestern hospital for 12 years. Originally from New Jersey, she was a nonpracticing Jew until her late 20s. Now, approaching 40, she has become increas- ingly committed to religious observance. She keeps kosher at home, bringing her own food to staff lunch meetings. She has been able to use vacation time for the major High Holy Days, but would like to be shomer shabbos (follow strict sabbath observance) and has requested a permanent schedule change from her supervisor, with a written explanation attached, to reflect her need to not work any Friday afternoon through

PEOPLE OF JEWISH HERITAGE • 281

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 281 Aptara Inc.

Saturday evening. The supervisor refused her, saying it would not be fair to the other nurses, that Lisa should also try to “fit in more—be part of the team,” as the others perceived her as “standoffish.” When Lisa said it was a religious requirement for her, the supervisor said maybe she should “. . . consider going back to New York where she’d be more comfortable.”

1. How do you feel about Lisa’s request? 2. How might this request be honored? 3. Was the supervisor culturally competent in this situation? 4. If Lisa were to discuss the issue at a team meeting, how

could she present her concerns?

CULTURE IN THE WORKPLACE

Specific workforce issues may occur, especially with Sabbath observance. Jews who observe the Sabbath must have Friday evening and Saturday off. They may work on Sundays. Supervisors must be sensitive to the needs of Jewish staff and recognize the holiness of the Sabbath. Jewish staff should be allowed to request time off for the major Jewish holidays. Remembering that all holidays begin the evening before, they must have off the evening shift before and the following day. Staff should not be penalized by having to use this time off as unpaid holidays or vacation time, but they should have the option to exchange for the Christmas and Easter holidays, time usually afforded to Christian staff.

Jewish health-care providers are fully acculturated into the American workforce. Judaism’s beliefs are congruent with the values American society places on the individual and family. As English is the primary language for Jewish Americans, no language barriers to communicating in the workplace exist. For some newer Jewish immigrants (e.g., those from Russia), English may pose a challenge.

ISSUES RELATED TO AUTONOMY

Jewish nurses have begun to speak out on their needs in the workplace. With the recent emphasis on cultural compe- tence, including cultural sensitivity, many are now address- ing this long-ignored area. In 1990, a National Nurses Council was established through Hadassah, the Zionist women’s organization (Benson, 1994). This group pro- motes solidarity and empowerment to enhance sensitivity within the health-care community. Still proportionally under-represented among American nurses, Jewish nurses have a disproportionate percentage of advanced degrees and positions in management, education, and research (Benson, 2001). Ways in which the professional nursing community demonstrates its insensitivity to Jewish nurses are by scheduling major nursing conferences during the High Holy Days in the fall or during Passover in the spring or by serving pork products during catered affairs.

Biocultural Ecology SKIN COLOR AND OTHER BIOLOGICAL VARIATIONS

Ashkenazi Jews have the same skin coloring as white Americans. They may range from fair skin and blonde

hair to darker skin and brunette hair. Sephardic Jews have slightly darker skin tones and hair coloring, similar to those from the Mediterranean area and those who lived for centuries in nearby regions such as Yemen. There are also Jewish groups throughout Africa who are black, most notably, the Jews originally from Ethiopia, known as Falasha.

DISEASES AND HEALTH CONDITIONS

Because Jews are integrated throughout the United States, no specific risk factors are based on topography. Genetic risk factors vary based on whether the family immigrated from Ashkenazi or Sephardic areas. There is a greater inci- dence of some genetic disorders among individuals of Jewish descent, especially those who are Ashkenazi. Most of these disorders are autosomal recessive, meaning that both parents carry the affected gene. Although the best known is Tay-Sachs disease, Gaucher’s disease is more prevalent. Others include Canavan’s disease, familial dysautonomia, torsion dystonia, Niemann-Pick disease, Bloom syndrome, Fanconi’s anemia, and mucolipidosis IV (Center for Jewish Genetic Diseases, 2007).

Gaucher’s disease is the most common genetic disease affecting Ashkenazi Jews, with 1 in 10 carrying the gene (Center for Jewish Genetic Diseases, 2007). Gaucher’s dis- ease is a lipid-storage disorder. This inborn error of metabolism results in a defective enzyme that normally breaks down glucocerebroside, a lipid by-product of ery- throcytes. The glucocerebroside accumulates in the body, resulting in weakening and fracturing of the bones owing to infarctions, anemia, and platelet deficiencies. There are 34 different genetic mutations of the disease; 4 of them account for 95 percent of cases in Ashkenazi Jews. The disorder can be detected by a blood test for both those affected and carriers. Gene therapy treatments are now being tested (National Gaucher Foundation, 2001).

The gene for Tay-Sachs disease (also called infantile cere- bromacular degeneration) is carried by 1 in 27 Ashkenazi Jews and 1 in 250 Jews of Sephardic origin. This autoso- mal recessive condition is a lysosomal sphingolipid stor- age disorder caused by an absence of hexosaminidase A, resulting in an accumulation of a lipid called GM2 gan- glioside in the neural cells. The onset of mental and devel- opmental retardation begins in the middle of the first year of life, with progressive deterioration, increasing seizure activity, and death by approximately age 5 (Center for Jewish Genetic Diseases, 2007). Because of the ease of testing for carriers as well as testing the fetus during preg- nancy, and because of a concerted effort among the Jewish American community to provide testing, the inci- dence of Tay-Sachs disease has decreased significantly since the early 1980s. Because the ultra-Orthodox are opposed to abortion, this group recommends the testing only before marriage (Washofsky, 2000). It should be noted that because there are 50 different mutations, test- ing can identify 95 percent of carriers with a Jewish back- ground and 60 percent of non-Jewish individuals (Center for Jewish Genetic Diseases, 2007).

Canavan’s disease is a rare, fatal, degenerative brain disease caused by a defective gene that impairs the forma- tion of myelin. Approximately 1 in 40 Ashkenazi Jews

282 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 282 Aptara Inc.

carry the gene. The resulting symptoms begin in midin- fancy and include developmental delay, loss of vision, and a loss of reflexes resulting in death by the age of 10 years (Center for Jewish Genetic Diseases, 2007).

Familial dysautonomia, or Riley-Day syndrome, is also an autosomal recessive genetic disease, with the gene located on chromosome 9q31. It causes dysfunction of the autonomic and peripheral sensory nervous systems. Affected children have decreased myelinated fibers on nerves that lead to afferent impulses but maintain a nor- mal intelligence. Symptoms include a decrease in the number of taste buds; altered pain sensation; increased salivation and sweating; abnormal sucking or swallowing difficulties and vomiting, resulting in failure to thrive; decreased tears, resulting in increased risk of corneal ulceration; and temperature and blood pressure fluctua- tions. Fifty percent live to the age of 30. One in 30 Ashkenazi Jews is a carrier (Center for Jewish Genetic Diseases, 2007).

Other autosomal recessive conditions also have a higher incidence among Ashkenazi Jews. The gene for tor- sion dystonia is carried by 1 in 70 Ashkenazi Jews in the United States. The disease leads to rapid progression in loss of motor control and twisting spasms of the limbs. Affected individuals lead a full life and have a normal intelligence. Niemann-Pick disease type A is a severe neu- rodegenerative disorder that starts at 6 months of age. It involves an abnormal storage of sphingomyelin and cho- lesterol in organs caused by an enzyme deficiency and leads to central nervous system degeneration. Whereas those with type A usually die by age 3, those with type B survive into their 50s and have a milder presentation, with the sphingomyelin building up in their liver, spleen, lymph nodes, and brain.

Bloom syndrome, a rare genetic condition, involves increased risk of respiratory and gastrointestinal infec- tions, erythema, telangiectasia, photosensitivity, and dwarfism. Whereas the intelligence of those affected is usually normal, they face an increased risk of infertility, malignancy, and diabetes. Fanconi’s anemia results in pancytopenia and an increased risk of cancer. Many die before early adulthood. Type C is found more frequently among Ashkenazi Jews; 1 in 89 are carriers. Mucolipidosis IV is found in 1 of 100 Ashkenazi Jews. This lipid-storage disease results in central nervous system deterioration during the first year with motor and mental retardation as well as various eye disorders. The prognosis varies (Center for Jewish Genetic Diseases, 2007).

Orthodox rabbis usually do not support genetic testing because it might cause couples to “refrain from marrying or having children, thus preventing them from fulfilling the mitzvah of procreation” (Washofsky, 2000, p. 266). The Reform movement supports a couple’s right to make the decision as to whether or not to have the testing done. “If we have the means by which to discover this information, so vital to the emotional and psychological well-being of a couple, then we must use them; failure to do so cannot be morally justified” (Washofsky, 2000, p. 267).

Other conditions occur with increased incidence in the Jewish population. Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) is seen four to five times more often in white Jews than in other white

groups. Colorectal cancer appears to be seen with increased frequency in Ashkenazi Jews (6 percent) (American Cancer Society, 2001). Although the incidence of breast cancer among Jews is similar to that in other Caucasians, “three distinct mutations in the BRCA1 and BRCA2 genes, found in one out of every 40 Jewish women of Ashkenazic background, increase a woman’s odds of getting breast and ovarian cancers” (Wyce, 2001, p. 20).

VARIATIONS IN DRUG METABOLISM

One of the few drugs found to have a higher rate of side effects in people of Ashkenazic ancestry is clozapine, used to treat schizophrenia. Twenty percent of Jewish clients taking this drug developed agranulocytosis, compared with about 1 percent of non-Jewish clients. A specific genetic haplotype has been identified to account for this finding (Levy, 1993). Thus, health-care providers must order testing for agranulocytosis when Jewish clients are prescribed clozapine.

High-Risk Behaviors According to Jewish law, individuals may not intention- ally damage their bodies or place themselves in danger. The basic philosophy is that the body must be protected from harm. To the religious, the body is viewed as belong- ing to God; therefore, it must be returned to Him intact when death occurs. Consequently, any substance or act that harms the body is not allowed. This includes smok- ing, suicide, taking nonprescription or illegal medica- tions, and permanent tattooing (Washofsky, 2000).

Alcohol, especially wine, is an essential part of reli- gious holidays and festive occasions and is a traditional symbol of joy. The Jewish attitude toward wine is ambiva- lent. The Bible speaks of the undesirable effects of wine on the person, as well as its positive use as a medicine. Consequently, wine is appropriate and acceptable as long as it is used in moderation.

HEALTH-CARE PRACTICES

Because of the respect afforded physicians and the emphasis on keeping the body and mind healthy, Jewish Americans are health conscious. In general, they practice preventive health care, with routine physical, dental, and vision screening. This is also a well-immunized popula- tion. Although the older generation is still more likely to defer to medical authority, Jewish adults tend to want to participate in health-care decision-making.

Nutrition MEANING OF FOOD

Eating is important to Jews on many levels. Besides satis- fying hunger and sustaining life, it also teaches discipline and reverence for life. For those who follow the dietary laws, a tremendous amount of attention is given to the slaughter, preparation, and consumption of food. In

PEOPLE OF JEWISH HERITAGE • 283

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 283 Aptara Inc.

addition, the family dinner table is often the site for reli- gious holiday celebrations and services, especially the Sabbath, Passover, Rosh Hashanah (Jewish New Year), and breaking the fast for Yom Kippur (Day of Atonement). Jewish dietary practices serve as a spiritually refining act of self-discipline and are a unifying factor in ethnic identity.

COMMON FOODS AND FOOD RITUALS

V I G N E T T E 1 6 . 2

Anna Novack, a 90-year-old widow and Holocaust survivor from Poland, came to New York City after WW II; she worked in the garment district, marrying another survivor and raising a family in a strictly kosher household. Her diagnosis of “dementia” has progressed such that her youngest son, who lives nearby, has had to place her in the Alzheimer’s unit of a long-term-care facility. She does not recognize him or anyone else during his weekly visits. Her son was shocked and angry today when he looked for her in the dining hall and found her eating breakfast sausage and drinking a carton of milk. Although the nursing home did not have a kosher kitchen, Mr. Novack had been assured by the staff that his mother’s tradi- tions would be respected. Deeply upset, he demanded an explanation. The health-care technician and nurse explained that, although her cultural preferences were known to the staff and they were aware of what she was eating, there were sev- eral factors that lead them to look the other way, especially in the last 6 months as her condition deteriorated. They reminded him that she seemed unable to distinguish kosher from nonkosher anymore. In addition, she had been slowly losing weight, so they were glad she was willing to eat.

1. What does it mean to be kosher? 2. What in Mrs. Kovack’s meal violated kosher dietary

laws? 3. Why was Mr. Novack so upset? 4. Did the staff act in the best interest of the patient? 5. Short of relocating Anna, what could be done by her

son and the staff to remedy the situation? 6. Where might the long-term-care facility get kosher

meals?

Perhaps the food identified as “Jewish” that receives the most attention is chicken soup. This has frequently been referred to as Jewish penicillin, and is often served with knaidle balls (dumplings made of matzoh meal). Although it has no intrinsic meaning or religious value, it is a staple in religious homes, especially on Friday evenings to usher in the Sabbath and during times of illness. It is frequently associated with a mother’s warmth and love.

Other common foods include gefilte fish (ground freshwater fish molded into oblong balls, steamed, then served cold with horseradish), challah (a rich, braided white bread), kugel (noodle pudding), blintzes (crepes filled with a sweet cottage cheese), chopped liver (served cold), hamentashen (a triangular pastry with different types of filling), and lox or nova (cold smoked salmon) served with cream cheese and salad vegetables, on a bagel.

The laws regarding food are found in Leviticus and Deuteronomy. They are commonly referred to as the laws of kashrut, or the laws that dictate which foods

are permissible under religious law. The term kosher means “fit to eat”; it is not a brand or form of cooking. Whereas some believe that the mandatory statutes were developed and implemented for health reasons, reli- gious scholars dispute this view, claiming that the only reason for following the laws is that they are mandatory commandments of God. Therefore, the laws are fol- lowed as a personal attachment to the religion and as a belief that God has mandated them (Kolatch, 2000). The laws’ promotion of health is only a secondary gain. Kashruth issues may be a significant part of an in-patient stay, making it helpful to know what is and is not acceptable.

Foods are divided into those considered kosher (per- mitted or clean) and those considered treyf (forbidden or unclean). A permitted animal may become treyf, or for- bidden, if it is not slaughtered, cooked, or served properly. Because life is sacred and animal cruelty is forbidden, kosher slaughter of animals must be done in a way that prevents undue cruelty to the animal and ensures the ani- mal’s health for the consumer. The jugular vein, carotid arteries, and vagus nerve must be severed in a single quick stroke with a sharp, smooth knife, causing the animal to die instantly. No sawing motion and no second stroke are permitted (Robinson, 2000). This also allows the maximal amount of blood to leave the body. Care must be taken that all blood is drained from the animal before it is eaten. Drinking of blood is prohibited. An animal that dies from old age or disease may not be eaten, nor may it be eaten if it meets a violent death or is killed by another animal. In addition, flesh cut from a live creature may not be eaten.

Milk and meat may not be mixed together in cooking, serving, or eating in order to respect the sensitivity of liv- ing creatures (You must not boil a calf in its mother’s milk [Deut. 14:20]). To avoid mixing foods, utensils and plates used to serve them are separated. Religious Jews who fol- low the dietary laws have two sets of dishes, pots, and utensils: one set for milk products (milchig in Yiddish) and the other for meat (fleishig). Because glass is not absorbent, it can be used for either meat or milk products, although religious households still usually have two sets (Kolatch, 2000). Therefore, cheeseburgers, lasagna made with meat, and grated cheese on meatballs and spaghetti are unacceptable. Milk cannot be used in coffee if it is served with a meat meal. Nondairy creamers can be used instead, as long as they do not contain sodium caseinate, which is derived from milk.

A number of foods are considered parve (neutral) and may be used with either dairy or meat dishes. These include fish, eggs, anything grown in the soil (vegetables, fruits, coffee, sugar, and spices), and chemically produced goods (Robinson, 2000). A “U” with a circle around it is the seal of the Union of Orthodox Jewish Congregations of America and is used on food products to indicate that they are kosher. A circled “K” and other symbols may also be found on packaging to indicate that a product is kosher.

When working in a Jewish person’s home, the health- care provider should not bring food into the house with- out knowing whether or not the client adheres to kosher standards. If the client keeps a kosher home, do not use

284 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 284 Aptara Inc.

any cooking items, dishes, or silverware without knowing which are used for meat and which for dairy products. Health-care providers must fully understand the dietary laws so they do not offend the client, can advocate for kosher meals if they are requested, and can plan medica- tion times accordingly.

Mammals are considered clean if they meet the other requirements for their slaughter and consumption and have split (cloven) hooves and chew their cud. These ani- mals include buffalo, cattle, goat, deer, and sheep. The pig is an example of an animal that does not meet these cri- teria. Although liberal Jews decide for themselves which dietary laws they will follow, many still avoid pork and pork products out of a sense of tradition and symbolism. Serving pork products to a Jewish client, unless specifi- cally requested, is insensitive.

Birds of prey are considered “unclean” and unaccept- able because they grab their food with their claws. Acceptable poultry includes chicken, one of the most fre- quently consumed forms of protein, turkey, goose, and duck. Fish can be eaten if it has both fins and scales. Nothing that crawls on its belly is allowed, including clams, lobsters and other shellfish, tortoises, and frogs (Robinson, 2000).

In religious homes, meat is prepared for cooking by soaking and salting to drain all the blood from the flesh. As increased residual salt may result, clients with sodium restrictions may need counseling to assist them in making dietary adjustments. Broiling is acceptable, especially for liver, because it drains the blood (Robinson, 2000). Care must be taken in serving cheese to ensure that no animal substances are served at the same time. Breads and cakes made with lard are treyf, and breads made with milk or milk by-products (e.g., casein) cannot be served with meat meals. Eggs from nonkosher birds, milk from nonkosher animals, and oil from nonkosher fish are not permitted. Butter substitutes are used with meat meals. Honey is allowed.

Kosher meals are available in most hospitals. They arrive on paper plates and with sealed plastic utensils. Health-care providers should not unwrap the utensils or change the foodstuffs to another serving dish. Frozen kosher meals are available on a commercial basis. Help may be needed for a patient to choose from a facility’s menu options. Neither a carton of milk nor one of yogurt should be included on a tray with meat, nor may butter accompany the bread. Even salad dressing needs to be made without dairy ingredients. If health-care providers have difficulty locating a supplier, they should contact a local rabbi. Determining a client’s dietary preferences and practices regarding dietary laws should be done during the admission assessment.

DIETARY PRACTICES FOR HEALTH PROMOTION

As mentioned previously, although many Jewish dietary practices afford the secondary gain of preventing disease, their intention is not for health promotion, but rather for observance of a commandment. Many Jews understand the dietary laws as a guide to raising the act of eating to a spiritual level, which is also true of the practice of wash- ing one’s hands and praying before and after eating.

NUTRITIONAL DEFICIENCIES AND FOOD LIMITATIONS

No nutritional deficiencies are common to individuals of Jewish descent. As with any ethnic group, nutritional deficiencies may occur in individuals in lower socioeco- nomic groups because of the expense of certain foods.

In addition to the dietary laws discussed previously, other dietary laws are followed at specified times. For example, during the week of Passover, no bread or prod- uct with yeast may be eaten. Matzoh (unleavened bread) is eaten instead. Any product that is fermented or can cause fermentation may not be eaten (Kolatch, 2000). Rather than attend synagogue, the family conducts the service (seder) around the dinner table during the first 2 nights and incorporates dinner into a service that includes all participants in study, singing, and retelling the story of Moses and the Exodus from Egypt.

The Jewish calendar has a number of fast days. The most observed is the holiest day of the year, Yom Kippur. On this Day of Atonement, Jews abstain from food and drink as they pray to God for forgiveness for the sins they have committed during the past year. They eat an early dinner on the evening before the holiday begins, then fast until after sunset the following day. Ill people, older people, the young, pregnant or lactating mothers, and the physically incapacitated are absolved from fasting and may need to be reminded of this exception to Jewish law. Maintaining an ill person’s health supersedes the act of fasting. If concerns arise, a consultation with the client’s rabbi may be necessary.

Pregnancy and Childbearing Practices FERTILITY PRACTICES AND VIEWS TOWARD PREGNANCY

God’s first commandment to humanity is, “Be fruitful and multiply.” Children are considered a gift and a duty, with men considered more important by the ultra- Orthodox because they can say kaddish (the prayer for the dead) for their parents. In other branches of Judaism, both sexes may recite the kaddish. Families are encour- aged to have at least two children (Kolatch, 2000).

Couples who are unable to conceive should try all pos- sible means to have children. This includes infertility counseling and interventions, comprising egg and sperm donation. “Orthodox opinion is virtually unanimous in prohibiting . . . artificial insemination when the semen donor is a man other than the woman’s husband” (Washofsky, 2000, p. 234). Some Orthodox Jews view this as adultery, whereas others argue that it cannot be con- sidered adultery if no sexual intercourse has occurred. When all natural attempts have been made, adoption may be pursued. Having children allows religious parents to fulfill many of the commandments.

The lower number of pregnancies occurring among Jewish Americans and the high intermarriage rate have resulted in a decreased Jewish population. By age 45, Jewish women averaged 1.6 children compared with 2.1

PEOPLE OF JEWISH HERITAGE • 285

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 285 Aptara Inc.

children born to non-Jewish white women in the same age range. Because one-third of all Jews were killed during the Holocaust, some believe that today’s Jews “have a special moral obligation to bring one more child into the world than they would have normally” (Amsel, 1994, p. 314).

Prevention of pregnancy in the more Orthodox view implies deferring the commandment to be fruitful and mul- tiply. Unless pregnancy jeopardizes the life or health of the mother, contraception is not looked on favorably among the ultra-Orthodox. Liberal Judaism recognizes that chil- dren have the right to be wanted and that they should be born into homes in which their needs can be met. Therefore, the use of temporary birth control may be acceptable. Condom use is supported, especially if unprotected sexual intercourse would pose a medical risk to either spouse.

To the Orthodox, it is important to know the mecha- nism of action of the birth control. Coitus interruptus and masturbation are not acceptable because they result in the needless expenditure of semen, although most Jews con- sider the former practice a normal, healthy activity (Kolatch, 2000). Barrier techniques are not acceptable because they interfere with the full mobility of the sperm in its natural course. The birth control pill does not result in any permanent sterilization, nor does it prevent semen from traveling its normal route. Therefore, use of this method is the least objectionable to most branches of Judaism. “Today, almost all rabbinic authorities permit the use of contraceptive devices . . . in cases where pregnancy may imperil the life of the mother or where it is certain that the newborn might be afflicted with a serious con- genital disease or abnormality” (Kolatch, 2000, p. 153). Sterilization implies permanence, and Orthodox Jews gen- erally oppose this practice, unless the life of the mother is in danger. Reform Judaism leaves the choice of what to use and whether to use contraceptives up to the parents.

Recognizing that Judaism’s primary focus is the sanctity of life, it is important to identify when life begins. The fetus is not considered a living soul or person until it has been born. Birth is determined when the head or “greater part” is born (Robinson, 2000). Until that time, it is merely part of the mother’s body and has no independent identity.

The mother and her health are paramount. If her phys- ical or mental health is endangered by the fetus, all branches of Judaism see the fetus as an aggressor and require an abortion (Kolatch, 2000). Whereas saving the mother’s life is certainly grounds for abortion, random abortion is not permitted by the Orthodox branch because the fetus is part of the mother’s body and one must not do harm to one’s body.

Reform Judaism believes that a woman maintains con- trol over her own body and it is up to her whether to abort a fetus. Although no connotation of sin is attached to abortion, the decision is not to be made without seri- ous deliberation. Most Jews favor a woman’s right to choose regarding abortion.

PRESCRIPTIVE, RESTRICTIVE, AND TABOO PRACTICES IN THE CHILDBEARING FAMILY

A Hasidic husband may not touch his wife during labor and may choose not to attend the delivery, because by Jewish law he is not permitted to view his wife’s genitals.

These behaviors should never be interpreted as insensitiv- ity on the part of the husband. During the delivery of a child to an ultra-Orthodox family, these interventions should be initiated: The mother should be given hospital gowns that cover her in the front and back to the greatest extent possible. She may prefer to wear a surgical cap so that her hair remains covered. The father should be given the opportunity to leave during procedures and during the birth, or if he chooses to stay, the mother can be draped so that the husband may sit by his wife without viewing her perineum, including by way of mirrors, in order to protect her dignity. Because he is not permitted to touch his wife, he may offer only verbal support. The female nurse may need to provide all of the physical care. Pain medication during delivery is acceptable.

For male infants, circumcision, which is both a med- ical procedure and a religious rite, is performed. The ori- gin of this ritual dates back to Abraham and Isaac in the Book of Genesis. A brit milah (sometimes referred to as a bris) symbolizes the covenant made between the Jewish people and God (Lau, 1997). The procedure itself and the accompanying ceremony are performed on the 8th day of life by person called a mohel, an individual trained in the circumcision procedure, asepsis, and the religious cere- mony. Although a rabbi is not necessary, it is also possible to have the procedure done by a physician with a rabbi present to say the blessings. Jewish parents who are not very observant and/or are unaffiliated may still opt for medical circumcision, illustrating how the power of this ritual endures over thousands of years.

Attending a brit milah is the only mitzvah for which religious Jews must violate the Sabbath, so that the brit can be completed at the proper time (Robinson, 2000). The brit milah is a family festivity, and many relatives are invited. In most cases today, the ceremony is performed in the home; however, if the child is still in the hospital, it is important for the hospital to provide a room for a small private party to celebrate. Whereas the medical commu- nity sometimes debates the practice of circumcision, to even suggest to Jewish parents that the practice is “bar- baric” is insensitive.

A circumcision may be delayed for medical reasons, including unstable condition owing to prematurity, life- threatening concerns during the early weeks after birth, bleeding problems, or a defect of the penis, which may require later surgery. At birth, a child is free of all sin; fail- ure to circumcise carries no eternal consequences should the child die.

Although there is no rule against designating godpar- ents for a newborn, it is considered local, not traditional, custom.

Death Rituals

V I G N E T T E 1 6 . 3

Mercedes Colon, RN, came from a small city in Colombia. Two months into her new career at a large pediatric hospital, she continues adjusting to life and work in the United States.

286 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 286 Aptara Inc.

Although her English comprehension is good, she still has trouble expressing herself. Mercedes has felt very close to the Kaplans, whose only child, 3-year-old David, is being treated for acute lymphocytic leukemia. The staff was optimistic, based on his excellent response so far. David’s mother said just yesterday that she “. . . used to hope he’d become a doc- tor or university professor, but now I’m just happy for him to grow into a happy, healthy adult.” Unfortunately, just as Mercedes came on shift this morning, the child coded and died. Mercedes’ manager told her to stay with the Kaplans until the pastoral care department could send someone, and to “prepare them” as they might be asked to sign for an autopsy. Mercedes looks in to see the Kaplans sitting on oppo- site sides of David’s bed, staring without expression. Mercedes doesn’t know what to do.

1. What could Mercedes do and say to help the parents? 2. When should she begin asking them questions? 3. Mercedes was recently oriented on autopsy protocol

for Jews. How might she relay this information to the Kaplans?

4. What resources might this nurse use to help the family?

DEATH RITUALS AND EXPECTATIONS

Death is an expected part of the life cycle. Yet, each day is to be appreciated and lived as fully as possible. Religious Jews start each day with a prayer of appreciation for having lived another day. The goal is to appreciate things and peo- ple while one still has them. Brain death as a criteria for organ donation remains controversial, with some sects agreeing to this criteria while others do not (Beitowitz, 2006). Many also accept a flat electroencephalogram (EEG) as determining death. Traditional Judaism believes in an afterlife in which the soul continues to flourish, although many dispute this interpretation because it is not men- tioned in the Torah (Beitowitz, 2006). Most Jews do not dwell much on life after death and are unconcerned about it; their focus is on how to conduct one’s present life.

Active euthanasia, in which something is given or done to result in death, is forbidden for religious Jews. One of the Ten Commandments is “Thou shalt not kill,” and euthanasia is considered murder. A dying person is con- sidered a living person in all respects. Sufficient pain con- trol should be provided, even if it decreases the person’s level of consciousness (Beitowitz, 2006). Withholding food from a deformed child to speed its death is consid- ered active euthanasia and is forbidden.

Passive euthanasia may be allowed, depending on its interpretation. Nothing may be used or initiated that pre- vents a person from dying naturally or that prolongs the dying process. Therefore, anything that artificially prevents death (e.g., cardiopulmonary resuscitation, use of ventila- tors) may possibly be withheld, depending on the wishes of the patient and his or her religious views. Regardless of the decisions made, pain control must be maintained.

Taking one’s own life is prohibited and is viewed as a criminal act and morally wrong because it is forbidden to harm any human being, including oneself. To the ultra- religious, suicide removes all possibility of repentance.

Adult Jews who commit suicide, who are not insane or depressed, and who belong to ultra-religious factions of Judaism are not afforded full burial honors. They are buried on the periphery of the Jewish cemetery and mourning rites are not observed, unless the individual was not mentally competent. However, the more-liberal view is to emphasize the needs of the survivors, and all burial and mourning activities proceed according to the usual traditional rites and wishes of the family. Children are never considered to have intentionally killed them- selves and are afforded all burial rights.

The dying person should not be left alone. It is consid- ered respectful to stay with a dying person, unless the visi- tor is physically ill or their emotions are out of control (Lamm, 2000). Judaism does not have any ceremony simi- lar to the Catholic sacrament of the sick. Any Jew may ask God’s forgiveness for her or his sins; no confessor is needed. However, it is not commonly known that Jews have a per- sonal confession called Viddui, which is recited when death is imminent. It may be said by the dying person or by somebody for her or him. Some Jews feel solace in saying the Shema in Hebrew or English. This prayer confirms one’s belief in one God. At the time of death, the nearest relative can gently close the eyes and mouth; the face is covered with a sheet. The body is treated with respect and revered for the function it once filled. Health-care providers may need to ask the closest relative of the deceased specifically about the practices to follow after death. Health-care providers who have acquired some familiarity with Jewish attitudes and practices associated with death go a long way toward helping their patients and families. They are per- forming mitzvot (good deeds) with their informed presence that will continue to benefit all involved as the long process of integrating loss into their lives continues.

Ultra-Orthodox Jews follow a ritual that is not con- ducive to hospital protocols and is more commonly observed for those who die at home. After the body is wrapped, it is briefly placed on the floor with the feet pointing toward the door. A candle may be placed near the head. However, this does not occur on the Sabbath or holy days. The dead body is not left alone before the funeral, so as not to leave it defenseless.

Autopsy is usually not permitted among religious Jews because it results in desecration of the body, and it is important that the body be interred whole. Allowing an autopsy might also delay the burial, something that is not recommended. Conversely, autopsy is allowed if its results would save the life of another patient. Many branches of Judaism currently allow an autopsy if (1) it is required by law; (2) the deceased person has willed it; or (3) it saves the life of another, especially an offspring (Dorff, 1998). The body must be treated with respect during the autopsy.

Any attempt to hasten or retard decomposition of the body is discouraged. Cremation is prohibited because it unnaturally speeds the disposal of the dead body. Embalming is prohibited because it preserves the dead (Lamm, 2000). However, in circumstances in which the funeral must be delayed, some embalming may be approved. Cosmetic restoration for the funeral is discour- aged.

Jewish funerals and burials follow certain practices; they usually occur within 24 to 48 hours after the death.

PEOPLE OF JEWISH HERITAGE • 287

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 287 Aptara Inc.

The funeral service is directed at honoring the departed by speaking only well of him or her. Flowers either at the funeral or at the cemetery are not the usual; this was a Christian custom used to offset the odor of decaying bod- ies. The casket should be made of wood with no orna- mentation. The body may be wrapped only in a shroud to ensure that the body and casket decay at the same rate. A wake or viewing is not part of a Jewish funeral. The prayer said for the dead, kaddish, is usually not said alone, but is recited in and with the company of others. The prayer says nothing about death, but rather, it praises God and reaffirms one’s own faith. A funeral according to halachah (Jewish law) emphasizes that death is death. Realism and simplicity are the characteristics of the Jewish burial.

After the funeral, mourners are welcomed at the home of the closest relative. Water to wash one’s hands before enter- ing is outside the front door, symbolic of cleansing the impurities associated with contact with the dead. The water is not passed from person to person, just as it is hoped that the tragedy is not passed. At the home, a meal is served to all the guests. This “meal of condolence” or “meal of con- solation” is traditionally provided by the neighbors and friends; it frequently includes hard-boiled eggs.

Shiva (Hebrew for “seven”) is the 7-day period that begins with the burial. Shiva helps the surviving individuals face the actuality of the death of the loved one. During this period when the mourners are “sitting shiva,” they do not work. When health-care providers are the ones experienc- ing the loss, it is important for supervisors to understand the mourning customs. In some homes, mirrors are covered to decrease the focus on one’s appearance; no activity is per- mitted to divert attention from thinking about the deceased; and evening and morning services may be con- ducted in the closest relative’s home. Condolence calls and the giving of consolation are appropriate during this time.

After shiva, the mourning period varies based on who has died. Mourning for a relative lasts 30 days, and for a parent, 1 year. Judaism does not support prolonged mourn- ing. A tombstone is erected within 1 year of the death, at which time, a graveside service is held. This is called an unveiling. According to the Jewish calendar, the anniversary of the death is called yahrzeit, and at this time, candles are lit and the kaddish is said.

Understanding some specific practices related to death and dying may have an impact on other aspects of health care, including the death of premature infants and the care of amputated limbs. Mourning is not required for a fetus that is miscarried or stillborn. This is also true of any premature infant who dies within 30 days of birth. However, parents are required to mourn for full-term infants who die at birth or shortly thereafter (Washofsky, 2000). Although the baby should be named, not all of the traditional burial customs are followed.

Within Orthodoxy, when a limb is amputated before death, the amputated limb and blood-soaked clothing are buried in the person’s future gravesite. This custom might not be practiced by recent Russian immigrant Jews because they were not allowed to practice their faith under Communism and, therefore, lost many of the tra- ditional practices. Because the blood and limb were part of the person, they are buried with the person. No mourn- ing rites are required. In the case of an amputation, the

health-care provider may need to assist with arrangement for burial of the body part.

RESPONSES TO DEATH AND GRIEF

The period following a death has discrete segments to assist mourners in their adjustment to the loss. The period of time between the death and the burial is short, and is the time for the emotional reaction to the death. The burial may be delayed only if required by law, if rela- tives must travel great distances, or if it is the Sabbath or a holy day. Mourners are absolved from praying during this time. Crying, anger, and talking about the deceased person’s life are acceptable. A common sign of grief is the tearing of the garment that one is wearing before the funeral service. In liberal congregations, a black ribbon with a tear in it is a symbolic representation of mourn- ing. During shiva, the mourner sets the tone and initiates the conversation. Because there are such discrete periods of mourning, Judaism tells the mourner that it is wrong to mourn more than 30 days for a relative and 1 year for parents.

Spirituality DOMINANT RELIGION AND USE OF PRAYER

Judaism is over 3000 years old. Its early history and laws are chronicled in the Torah, called the Old Testament by Christians. Jews consider only the Torah as their Bible. They have a history of being singled out as a people and have often been persecuted; expelled from countries; for- bidden to practice their religion; “black-balled” from jobs, housing, and admission to college; rounded up and killed; and mass-exterminated.

Judaism is a monotheistic faith that believes in one God as the Creator of the universe. The watchword of the faith is found in Deuteronomy (6:4), “Hear O Israel, the Lord is our God, the Lord is One.” No physical qualities are attributed to God, and making and praying to statues or graven images are forbidden by the second command- ment.

Many Jews in America have immediate family mem- bers who were killed in the pogroms in Russia in the early 1900s and in the Holocaust in Eastern Europe. Yet, throughout this persecution, Judaism has lived and flour- ished. The spiritual leader is the rabbi (teacher). He (or she, in liberal branches) is the interpreter of Jewish law. Rabbis are not considered to be any closer to God than common people are. All Jews pray directly to God. They do not need the rabbi to intercede, to hear confession, or to grant atonement. Some of the major principles that guide Judaic bioethics are

• Man’s purpose on earth is to live according to cer- tain God-given guidelines.

• Life possesses enormous intrinsic value, and its preservation is of great moral significance.

• All human lives are equal. • Our lives are not our own exclusive private pos-

sessions (Perlin, 2006).

288 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 288 Aptara Inc.

The first five books of the Bible, also known as the five books of Moses, are handwritten in Hebrew on parchment scrolls called Torah. These scrolls are kept in the “Holy Ark” within each synagogue under an “eternal light.” The Torah directs Jews on how they should live their lives; it provides guidance on every aspect of human life. The rest of the Bible includes sacred writings and teachings of the prophets.

The 613 commandments within the Torah (also called Mitzvot) and the oral law derived from the biblical statutes determine Jewish law, or halakhah. These commandments ask for a commitment in behavior and also address ethi- cal concerns. Thus, the commandments reflect the will of God, and religious Jews feel it is their duty to carry them out to fulfill their covenant with God. This makes Judaism not only a religion but also a way of life.

The current practice of Judaism in America spans a wide spectrum. Whereas there is only one religion, there are three main branches or denominations of Judaism. The Orthodox are the most traditional. They adhere most strictly to the halakhah (Code of Jewish Law) of tradi- tional Judaism and try to follow as many of the laws as possible while fitting into American society. They observe the Sabbath by attending the synagogue on Friday evening and Saturday morning and by abstaining from work, spending money, and driving on the Sabbath. Orthodox Jews observe the Jewish dietary laws; men wear a yarmulke or kippah (head covering) at all times in rever- ence to God, whereas women usually wear long sleeves and modest dress. In many Orthodox synagogues, the ser- vices are primarily in Hebrew, and men and women sit separately.

Orthodox Jews and some Conservative men and women use the tefillin, or phylacteries, during morning prayer services. These are two small black boxes, with parchment containing biblical passages, that are con- nected to long leather straps. These are wrapped around the arms and forehead as reminders of the laws of the Torah. The tallis (or tallit) is a rectangular prayer shawl with fringes. This is also used only during prayer but is frequently used by both Conservative and Orthodox Jews. Ultra-Orthodox men wear a special garment under their shirts year-round; the tzitzit has long fringes as a reminder of the laws of the Torah.

A mezuzah is a small container with scripture inside. Its origin was a sign ensuring God’s protection; it serves as a reminder of the presence of God, His commandments, and a Jew’s duties to Him. Jewish homes have a mezuzah on the doorframe of the house. A number of individuals also wear a mezuzah as a necklace. Other religious symbols include the Star of David, a six-pointed star that has been a symbol of the Jewish community since the 1350s, and the menorah (candelabrum).

The Conservative branch is not quite as strict in its tra- dition. Whereas Conservative Jews observe most of the halakhah, they do make concessions to modern society. Many drive to the synagogue on the Sabbath, and men and women sit together. Many keep a kosher home, but they may or may not follow all of the dietary laws outside the home. Women are ordained as rabbis and are counted in a minyan, the minimum number of 10 required for communal prayer. (These practices are unacceptable to

the Orthodox.) Whereas a yarmulke is required in the synagogue, it is optional outside of that environment.

The liberal or progressive movement is called Reform. Reform Jews claim that postbiblical law was only for the people of that time, and only the moral laws of the Torah are binding. They practice fewer rituals, although they frequently have a mezuzah for their homes, celebrate the holidays, and have a strong ethnic identity. They consider education and ethics of paramount importance in one’s personal life and try to link Jewish religious values with American political liberalism. They may or may not fol- low the Jewish dietary laws, but they may have specific unacceptable foods (e.g., pork), which they abstain from eating. Men and women share full equality, and they engage in many social-action activities.

Of the many small groups of ultra-Orthodox funda- mentalists; the Hasidic (or Chasidic) Jews are perhaps the most recognizable. They usually live, work, and study within a segregated area. They are visually identifiable by their full beards, uncut hair around the ears (pais), black hats or fur streimels, dark clothing, and no exposed extremities. Women, especially those who are married, also keep their extremities covered and may have shaved heads covered by a wig and often a hat as well.

A relatively new denomination, Reconstructionism is a mosaic of the three main branches. It views Judaism as an evolving religion of the Jewish people and seeks to adapt Jewish beliefs and practices to the needs of the contempo- rary world. Many Jews do not indicate any affiliation.

The Jewish house of prayer is called a synagogue, temple, or shul. It is never referred to as a church. However, Jews may pray alone or as a group anywhere that 10 Jews over the age of 13 who have had their bar mitzvah are gathered together for prayer. This group is called a minyan. Orthodox Jews pray three times a day: morning, late afternoon, and evening. They wash their hands and say a prayer on awakening in the morning and before meals.

Religious clients in hospitals may want their prayer items (yarmulke or kippah, tallit, tzitzit, tefillin) and may request a minyan. Hospital policies regarding the number of visitors in the sick person’s room may have to be ignored in such instances.

One of the most common religious practices related to patients involves “visiting the sick” (bikkur cholim). This commandment is one of the social obligations of Judaism and ensures that Jews look after the physical, emotional, psychological, and social well-being of others and pro- vides hope as well as companionship. Moreover, one must consider the patient’s welfare and not stay too long, tire the patient, or come only to satisfy one’s own needs.

MEANING OF LIFE AND INDIVIDUAL SOURCES OF STRENGTH

The preservation of life is one of Judaism’s greatest priori- ties. Even the laws that govern the Sabbath may be bro- ken if one can help save a life. Each individual is consid- ered special, and the individuality of the human experience is one of the precepts of the faith. Good health is considered an asset. In this regard, individuals who are ill must not fast during Yom Kippur (Robinson, 2000).

PEOPLE OF JEWISH HERITAGE • 289

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 289 Aptara Inc.

SPIRITUAL BELIEFS AND HEALTH-CARE PRACTICES

The second of the Ten Commandments is to remember the Sabbath day and keep it holy. The Sabbath begins 18 minutes before sunset on Friday. Lighting candles, saying prayers over challah and wine, and participating in a fes- tive Sabbath meal usher in this weekly holy day. It ends 42 minutes after sunset (or when three stars can be seen) on Saturday, with a service called Havdalah. The Sabbath serves as a release from weekday concerns and pressures. During this time, religious Jews engage in congregational study and do no manner of work, including answering the telephone, operating any electrical appliance, driving, or operating a call bell from a hospital bed.

If an Orthodox client’s condition is not life-threatening, medical and surgical procedures should not be performed on the Sabbath or holy days. However, extenuating circum- stances such as illness or foul weather are legitimate reasons for not attending the services. Although the Sabbath is holy, matters involving human life take precedence over it (Robinson, 2000). Therefore, a gravely ill person and the work of those who need to save her or him are exempted from following the commandments regarding the Sabbath.

In addition to the Sabbath, a number of Jewish holidays are celebrated with special traditions. Rosh Hashanah (Jewish New Year) and Yom Kippur (Day of Atonement) are called the High Holy Days, and usually occur in September or early October. They mark a 10-day period of self- examination and repentance. Rosh Hashanah is started by eating apples and honey to wish for a sweet year, and on Yom Kippur, one fasts for a day to cleanse and purify one- self. Fasting for Yom Kippur may be broken for reasons of critical illness or labor and delivery or for children under the age of 12. The holiday includes the blowing of the sho- far (a ram’s horn) and the greeting, “May you be inscribed in the book of life for a good year.”

Other major holidays include Passover, the Feast of the Unleavened Bread, which lasts 8 days and celebrates the Exodus from Egypt and freedom from slavery; Sukkot, a festival of the harvest in which individuals may live in temporary huts built outside their homes or synagogues for a week; and Shavuot, which celebrates the giving of the Ten Commandments. Minor holidays include Chanukah, an 8-day holiday, and Purim, both of which celebrate reli- gious freedom. Table 16–1 provides a list of Jewish holi- days for the years 2006 through 2010.

Health-Care Practices HEALTH-SEEKING BELIEFS AND BEHAVIORS

According to those who interpret Jewish law, all people have a duty to keep themselves in good health. This encompasses physical and mental well-being and includes not only early treatment for illness but also pre- vention of illness. Judaism teaches its members to “choose life.” “To refuse lifesaving medical treatment is to commit suicide, to choose death over life” (Washofsky, 2000, p. 223). All denominations recognize that religious requirements may be laid aside if a life is at stake or if an individual has a life-threatening illness. However, once it is clear that an individual is dying and that medical treat- ment is no longer working, individuals may choose not to interfere with death. Hospice care is fully consonant with Jewish beliefs.

In ultra-Orthodox denominations of Judaism, taking medication that is not necessary to preserve life on the Sabbath may be viewed as “work” (i.e., an action per- formed with the intention of bringing about a change in existing conditions) and is unacceptable. This belief may result in some people with conditions such as asthma not recognizing the severity of their condition; they may also be unaware of the laws that allow them to take their nec- essary medications. These patients need to be taught about the potential life-threatening sequelae of their con- dition as well as the exceptions to Jewish law that permit them to take their medications.

In the Jewish faith, all individuals have value regard- less of their condition. This includes individuals with developmental disabilities and AIDS. The Jewish AIDS Network (2006) has been established with a mission of opposing discrimination against people with physical, mental, and developmental conditions.

RESPONSIBILITY FOR HEALTH CARE

Although it is the responsibility of health-care providers to heal, individuals must seek the services of the physi- cian to ensure a healthy body. Once individuals have the knowledge necessary to effect their healing, it is their obligation to do so. To abstain from healing would be equivalent to murder. Jews believe that God provides human beings with wisdom, and it is up to them to use

290 • CHAPTER 16

T A B L E 16.1 Jewish Holidays: 2006–2010*

Holiday 2006–2007 (5767)† 2007–2008 (5768)† 2008–2009 (5769)† 2009–2010 (5770)†

Rosh Hashanah 9/23–24 9/13–14 9/30–10/1 9/19–20 Yom Kippur 10/2 9/22 10/9 9/28 Sukkot 10/7–12 9/27–10/2 10/14–19 10/3–8 Chanukah 12/16–23 12/5–12 12/22–29 12/12–19 Purim 3/4 3/21 3/10 2/28 Passover 4/3–10 4/20–27 4/9–16 3/30–4/6 Shavuot 5/23–24 6/9–10 5/29–30 5/19–20

*Jewish holidays always begin at sundown the evening before the date recorded on this type of calendar; holidays end at sundown on the date shown. †Dates on the Jewish calendar.

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 290 Aptara Inc.

that wisdom to create a better world. This includes the discovery of new medications and treatments to elimi- nate or modify disease and suffering. Jews also believe that God gives humans freedom of choice.

Because the preservation of life is paramount, all ritual commandments are waived when danger to life exists. Physical and mental illnesses are legitimate reasons for not fulfilling some of the commandments. Because adult Jews are often well read, they may be interested in trying the newest available treatments. This could have both positive and negative consequences. The literature reveals no studies regarding Jews’ self-medicating practices.

FOLK AND TRADITIONAL PRACTICES

Jewish folk practices are historically and biblically based. Jews have adopted and adapted to customs from the cul- tures and countries they have lived in during the cen- turies of diaspora. Specific practices are explained in the sections of this chapter on Nutrition and Spiritual Beliefs and Health-Care Practices.

BARRIERS TO HEALTH CARE

Aside from the unavailability of health insurance for some people, or being underinsured secondary to eco- nomic situations, no major barriers to health care for Jews in contemporary America exist. The Jewish community helps those in need, including new immigrants, and assists fellow Jews in becoming self-sufficient. Community organizations that include programs to help the needy are ubiquitous today wherever Jews live in the United States.

CULTURAL RESPONSES TO HEALTH AND ILLNESS

The verbalization of pain is acceptable and common. Individuals want to know the reason for the pain, which they consider just as important as obtaining relief from it. The sick role for Jews is highly individualized and may vary among individuals according to the severity of symptoms. As prescribed in the halakhah, the family is central to Jewish life; therefore, family members share the emphasis on maintaining health and assisting with indi- vidual responsibilities during times of illness.

Many Jews have become physicians, psychoanalysts, psychiatrists, and psychologists. In addition, many of their clients are Jewish. The maintenance of one’s mental health is considered just as important as the maintenance of one’s physical health. This designation includes psy- chiatric conditions. However, requirements for those who are rational but have cognitive deficiencies are decided on an individual basis.

According to Jewish law, individuals must be taught the Torah regardless of their age or level of disability. This speaks to the unique value of each individual.

BLOOD TRANSFUSIONS AND ORGAN DONATION

Jewish law views organ transplants from four perspec- tives: the recipient, the living donor, the cadaver donor,

and the dying donor. Because life is sacred, if the recipi- ent’s life can be prolonged without considerable risk, then transplant is favorably viewed. For a living donor to be approved, the risk to the life of the donor must be con- sidered. One is not obligated to donate a body part unless the risk is small. Examples include kidney and bone mar- row donations (Lamm, 2000). The action of donating an organ to save another is considered a great mitzvah.

Conservative and Reform Judaism approve using the flat EEG as the determination of death so that organs, such as the heart, can be viable for transplant. Burial may be delayed if organ harvesting is the cause of the delay. However, among other groups, this definition of death remains controversial (Beitowitz, 2006). Health-care providers may need to assist Jewish clients to obtain a rabbi when they are making a decision regarding organ donation or transplant.

The use of a cadaver for transplant is generally approved if it is to save a life. No one may derive economic benefit from the corpse. Although desecration of the dead body is considered purposeless mutilation, this does not apply to the removal of organs for transplant. Use of skin for burns is also acceptable.

Health-Care Practitioners The ancient Hebrews are credited with promoting hygiene and sanitation practices and basic principles for public health care. From the practice of visiting the sick and the desire to initiate measures to prevent the spread of disease, Lillian Wald, a well-known Jewish nurse, devel- oped the Henry Street Settlement as a prototype of public health nursing for those in need.

STATUS OF HEALTH-CARE PROVIDERS

Physicians are held in high regard. Whereas physicians must do everything in their power to preserve life, they are prohibited from initiating measures that prolong the act of dying (Rosner, 1993). Once standard therapy has failed, or if additional treatments are unavailable, “the physician’s role changes from that of curer to that of carer. Only supportive care is required for that state and includes care such as food and water, good nursing care, and optimal psychosocial support” (Rosner, 1993, p. 10).

REFERENCES American Cancer Society. (2001). Retrieved September 16, 2007, from

http://www.Cancer.org/eprise/main/ docroot/cri/cri_2_3x American Jewish Committee. (2006). Retrieved February 4, 2007, from

www.ujc.org Amsel, N. (1994). The Jewish encyclopedia of moral and ethical issues.

Northvale, NJ: Jason Aronson. Beitowitz, Y. A. (2006). Brain death controversy in Jewish Law. Retrieved

February 4, 2007, from http://www.jlaw.com/Articles/brain.html Benson, E. (1994). Jewish nurses: A multicultural perspective. Journal of the

New York State Nurses Association, 25(2), 8–10. Benson, E. (2001). As we see ourselves: Jewish women in nursing. Indianapolis,

IN: Center Nursing Publishing. Center for Jewish Genetic Diseases. (2007). Retrieved February 4, 2007,

from http://www.mssm.edu/jewish_genetics/genetic_diseases.shtml Center for Jewish History. (2007). Retrieved February 4, 2007, from http://

www.cjh.org/

PEOPLE OF JEWISH HERITAGE • 291

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 291 Aptara Inc.

Donin, H. (1972). To be a Jew: A guide to Jewish observance in contemporary life. New York: Basic Books.

Dorff, E. (1998). Matters of life and death: A Jewish approach to modern med- ical ethics. Philadelphia: The Jewish Publication Society.

Haumann, H. (2002): A history of East European Jews. Central European University Press.

The Jewish AIDS Network. (2006). Retrieved February 4, 2007, from http:// www.jewishaidsnetwork.org/

Kolatch, A. (2000). The second Jewish book of why. Middle Village, NY: Jonathan David.

Lamm, M. (2000). The Jewish way in death and in mourning. Middle Village, NY: Jonathan David.

Lau, I. (1997). Practical Judaism. Jerusalem: Feldheim. Levy, R. (1993). Ethnic and racial differences in response to medicines:

Preserving individualized therapy in managed pharmaceutical pro- grammes. Pharmaceutical Medicine, 7, 139–165.

National Gaucher Foundation. (2001). Retrieved September 16, 2007, from http://www.gaucherdisease.org

Perlin, E. (2006). Jewish bioethics and medical genetics. Journal of Religion and Health, 33(4), 333–340.

Robinson, G. (2000). Essential Judaism: A complete guide to beliefs, customs, and rituals. New York: Pocket Books.

Rosner, F. (1993, July/August). Hospice, medical ethics, and Jewish cus- toms. American Journal of Hospice and Palliative Care, 6–10.

Washofsky, M. (2000). Jewish living: A guide to contemporary reform prac- tice. New York: UAHC (Union of American Hebrew Congregations) Press.

Wertheimer, J. (2002). American Jewish yearbook. New York: The American Jewish Committee.

Wyce, M. (2001, Summer). Genetic profiling: Who will be seen as damaged goods? Inside, 18–22.

For case studies, review questions, and additional information, go to http://davisplus.fadavis.com

292 • CHAPTER 16

FABK017-C16[278-292].qxd 12/12/2007 10:44am Page 292 Aptara Inc.