Praying for a Miracle

Rav Hershel Schachter writes regarding the prohibition of asking G-d for a miracle: (http://www.torahweb.org/)
"The Shaarei Teshuvah quotes the three exceptions to the rule as stated by the Acharonim, as to when one is permitted to ask for a nes: 1) One may ask for a nes nistar. For this is what hashgacha is all about- God controls the world from behind the scenes, without openly violating any of the rules of nature. 2)Since we believe that, "ein mazal le-yisrael," that the Jewish people are, "lemala min hateva," there is nothing at all improper about requesting a nes nigleh on their behalf. 3) Even if the nes is not for Klal Yisrael, but only on behalf of an unusual tzadik, this too is allowed, as is evidenced from the various stories related in the Gemara Taanit regarding several tzadikim who prayed for miracles. The great tzadik is also "lemala min hateva."

In Parshat Korach we find Moshe Rabbeinu requesting of God that even if the opening of Gehenom not be here, that He make a nes and "yivra Hashem" - let it move to here. Because the miracle was needed- either for klal yisrael or the unusual tzadik- Moshe was allowed to pray for it. A similar situation appears in the Haftorah. Shmuel Ha-navi calls upon God to bring about a miracle on Shmuel's personal behalf, to indicate his righteousness. This appears to be the thematic similarity between the sedra and the Haftorah: the exceptions to the rule i.e. when one is permitted to pray for a miracle.

To illustrate this point, I remember many years ago, when I visited the Ponovez Yeshina in Benai Brak, the tzibbur was reciting tehillim on behalf of a cancer patient on whom the doctors had given up hope. The Mashgiach, Rav Yecheskel Levenstein - refused to participate in the prayers because in effect they were praying for a miracle."

There is much discussion in the medical halacha literature regarding the permissibility of praying for the DEATH of a terminally-ill patient. However, it appears from Rav Shachter's analysis above that the reverse question must also be addressed. Is one allowed to pray for the continued LIFE of a terminal patient? The answer, I suspect, is not absolute. In many cases praying for the cure of a terminal patient may only require a nes nistar, which is permissible. Apparently, Rav Levenstein ZT"L felt that an even more open miracle would have been required in the case of the cancer patient.

Avi Oppenheimer

When is "dead" really "dead?" Part II -by David Shabtai

(please see the original "When is 'dead' really 'dead'" post for more on this). The question was: Dr. Avraham therefore asks (Nishmat Avraham 5, 99 [my translation]): "Nowadays we attempt to revive clinically dead patients [no spontaneous respiration, heartbeat or movement] through cardiac massage, electric shock, artificial respiration, etc., even on Shabbat and I have never heard that this is not considered to be a great mitzvah nor not to do so on Shabbat!" (He continues to equate this ruling with that of treating a ben shemonah that was considered by Hazal to be considered dead – ve'akmal.) He leaves his question unanswered.

Before attempting to answer this question, it is important to understand how the moment of death is understood in Halakhah. The Shulhan Arukh (OH 330:5) writes: "If a woman dies in labor [on Shabbat] – we bring a scalpel, even through a reshut ha-rabim to attempt to remove the child, since there is a chance that he may be alive." The Rama comments however, that we do not follow this practice even during the week since "de-ein beki'in be-mitat ha-eim kol kakh she-efshar la-velad li-heyot – we are no sufficiently proficient in determining the time of death ..." Magen Avraham (330:11) explains that we are concerned "shema nitalfah – perhaps she has fainted" and we must wait a certain amount of time after we think she has died to ensure that she has not indeed fainted; once a sufficient amount of time has passed, we can be certain that she is dead. However, once that time has passed, there is no chance that the fetus is still alive and as such, we are not permitted to violate Shabbat in attempting to remove it. This same idea of hashash iluf (concern with the possibility of fainting) is also found in the Rambam (Hilkhot Avel 4:5) where he writes that one is forbidden from closing the eyes of someone who has just died since even touching such a person may hasten his death. Rather, a person should wait a while, shema nit'alef and only then close the eyes and prepare for burial. This view is codified by Shulhan Arukh YD (339:1).

R. Moshe Feinstein (Iggerot Moshe YD 2:174:2) writes that the halakhic signs of death (loss of respiration, cardiac function and movement) are seen due to death itself, or alternatively, in a patient whose disease has taken over so much that he can no longer perform these vital functions independently. Such a person cannot live much longer, but is nonetheless still considered fully alive. R. Shelomoh Zalman Auerbach (Shulhan Shelomoh 2, 35) writes that nowadays we can treat many conditions that were thought to be fatal in the times of Hazal. Even once the halakhic signs of death have been observed, there are [perhaps many] instances where it is possible to heal the patient and allow him to live a full life afterwards. R. Auerbach therefore explained that the time allotted to hashash iluf should be longer today that it was during the times of Hazal – and should correlate with the medical chances of effectively treating such a patient. The time of hashash iluf should extend until such time where there is absolutely no hope of returning the patient to life.

Therefore, when a patient immediately experiences cardiac arrest – we are concerned with hashash iluf and therefore treat the patient as potentially alive. One is obligated to treat even questionable cases of pikuah nefesh on Shabbat and this is no different. There is therefore a "great mitzvah" indeed in treating such a patient and attempting to bring him back to life, despite the halakhic signs of death having set in.

In the case of hutaz rosho (the case R. Feinstein described) however, there is no concern of hashash iluf – since it is absolutely clear that the patient has not fainted – their head has been removed! Since there is no hashash iluf, we can be absolutely sure that the patient is dead and as such there is no permission granted to violate Shabbat in attempting to resuscitate this patient. The Shevut Ya'akov (1:13) even writes that if a woman in labor is beheaded – we do violate Shabbat in an attempt to save and remove the child. The Rama (above) was concerned with determining the moment of death – in this case it is certain and therefore the ruling reverts to that of the Shulhan Arukh.

Shomer Shabbos Residency II

There is a lively and candid discussion of this issue is going on on a different blog, http://hirhurim.blogspot.com/2006/06/shomer-shabbos-residency.html

When is "dead" really "dead?" - by David Shabtai

R. Moshe Feinstein (Shu"t Iggerot Moshe YD 2:174:) describes the [as of yet] theoretical situation where a person who has been completely beheaded still has the chance of living a normal life if his head were properly reconnected. R. Feinstein writes that once the head has been completely severed, the person is declared halakhically "dead." Therefore, reconnecting the head is considered 'reviving the dead,' and not 'healing / medicine.' Since there is no obligation to engage in resurrection, performing such actions on Shabbat (which one may have thought to be pikuah nefesh) is absolutely forbidden. (R. Feinstein then proceeds to explain how to understand the Gemara and Tosafot in Bava Batra 114 in light of this position – hopefully a discussion for a later post.)

The case of beheading (hutaz rosho) is often used as the prototypical sign (or maybe cause) of death agreed to by all posekim, based on the Mishnah Ohalot (1:6). The conclusions should apply equally however, to other definitions of death as well, for each posek according to his opinion.

Dr. Avraham therefore asks (Nishmat Avraham 5, 99 [my translation]): "Nowadays we attempt to revive clinically dead patients [no spontaneous respiration, heartbeat or movement] through cardiac massage, electric shock, artificial respiration, etc., even on Shabbat and I have never heard that this is not considered to be a great mitzvah nor not to do so on Shabbat!" (He continues to equate this ruling with that of treating a ben shemonah that was considered by Hazal to be considered dead – ve'akmal.) He leaves his question unanswered.

Any thoughts?

Moderator Note: This is the first of what will (hopefully) be a weekly posting. Please feel free to submit any posts (weekly or otherwise) for this blog to nmhsblog@gmail.com

Naming Poll Results

And the Winner is ... National Medical Halacha Society (NMHS)!
Thank you to all those who voted. Furthermore, thank you to all who are participating and reading this Blog. We have great hope for this society and for the tremendous potential it possesses.

Ovulation Watch

Dr. Reichman writes:
Dear Colleagues,
The latest in ovulation testing is the Ovulation watch, which can predict 4-5 days prior to ovulation and significantly increase "fertile" days beyond existing testing. It works by sensing chloride ions from the sweat of the body. There is no color change, but a chemical analysis occurs. Rabbis will likely be asked about the permissibility of wearing such a watch on Shabbos. For more info, see http://www.ovwatch.com/ We will have to clarify the nature of the mechanism of action in order to answer the shabbos question.
ER
Any thoughts/suggestions?

Medical Halacha Not a College Subject

I feel that I am forced to make a point regarding a problem that I have struggled with for years and despite my wishing otherwise, does not seem to be disappearing. These comments as well as an accompanying article may be met with shock and indignation and may even be labeled a diatribe, but are vital for the ultimate success of this society with all its tremendous potential. "Medical halacha" is not a subject to be taken in college, to serve as intellectual stimulation for doctors, or to be discussed as a matter of opinion. Like all halacha, it is the will of G-d, which is not to be determined by untrained individuals or to be taken lightly. Questions of halacha, certainly those that involve severe prohibitions such as shabbos are not to be classified as "thought provoking" or to be based on what someone "thinks is reasonable" or even to be based on hearsay without a personal response from recognized poskim. There is only one way to deal with such question of halacha on a practical level --to ask and be prepared to accept the answer from a recognized posek. Of course there is room for learning and discussion of the underlying basis of a psak, but only after the psak is delivered by a posek. For this society to realize its potential, the members and postings on the blog must reflect this- it is one thing to discuss a sugya or request source material and another to request comments and thoughts regarding a psak. If R. Willig or R. Schachter were to respond to all queries on the blog, that would be acceptable, but until that happens we must recognize our place and be prepared to submit ourselcves to the ramifications of a psak from our posek.
-Akiva Bergman

See linked documents Medicinethoughts.doc

Halachic Essays for Medical Students and Residents

Dr. Akiva Bergman writes:

I have been a casual observer of the evolution of the NMHS- it is a wonderful opportunity to pool resources and join efforts for the sake of enhancing adherence to halacha and committment to G-d in a field that poses many challenges to these ideals. I was not planning on posting any 'blogs" but I was encouraged by Dr. Reichman to respond to a recent posting concerning shabbos observance. I will not respond directly to the questions raised in that post but will share some general comments.

One, for the benefit of members of the society I have decided to make available a brief compilation of halachos that are pertinent to medical school and residency that I wrote while training in Internal Medicine. This has been reviewed extensively by Dr. A.S. Abraham, Dr. Reichman, Dr. Rosner and many others (it should be noted that none of the above take responsibilty for what is written nor necessarily agree with all the points contained therein). I view it as a work in progress and am not ready to publish it yet. I would greatly encourage all members of the society to at least skim through it- comments, corrections, and additions will be greatly appreciated. Medical students and residents from around the country have already benefited and contributed.

See linked documents:
Shomer Shabbos Residency & Footnotes
Med School and Residency Halachos

Shomer Shabbos Residency

Corrected (See below)
From Practical Medical Halacha by Dr. Fred Rosner and Rabbi Dr. Moshe Tendler p.8
Question: Is a physician obligated to seek training, employment or attending physician status at a hospital where there is a minimum or no conflict between hospital policy and Sabbath observance? Should a house officer seek training at an inferior quality hospital where he is “guaranteed” not to have to work on the Sabbath or should he seek training at a hospital where training and overall patient care is far superior, but where there may be interference with the Sabbath spirit but not with the observance of halachic restrictions? Must one compromise ones medical education in order to simplify Sabbath and Kashruth observances?

Answer: A physician must seek association with the most reputable and prestigious hospital possible to ensure excellent training and continuing education.

Comment: Jewish law requires that the physician acquire maximum skill and competence to practice his chosen profession. Therefore, he should forgo the personal comfort and convenience of training in a hospital that is sympathetic to his religious needs in favor of the hospital that will provide him with the best possible training, provided that he is certain of his fortitude in maintaining all halachic requirements, despite the less favorable environment.

If the superior training is to be acquired at the price of Sabbath desecration, even of Rabbinic ordinances only, the student-physician must forgo the educational advantages of the prestige hospital.

Their source for the Torah requirement to achieve maximal medical training I believe appears in the previous topic on p.7. There they write:
A physician is required by Jewish Law to acquire the maximum skill and knowledge possible to practice the highest quality of Medicine. The Code of Jewish Law (Shulchan Aruch, Yoreh Deah #336) specifically states that "no man should occupy himself with medicine unless he is well trained and there is no one better fitted than he in the place; otherwise he is shedding blood." It is not obligatory for anyone to become a physician but once an individual undertakes to heal the sick, then he accepts the responsibilities that are entailed by the profession ... Therefore, within the framework of halachic permissibilty (emphasis by author, not mine), the medical student or house officer must sacrifice some of the "spirit" of the Sabbath in order to obtain the maximum training in his chosen profession.

Although Rabbi Tendler is widely quoted as permitting one to accept a "non-shomer shabbat" residency, I believe that part of this heter is misrepresented. Indeed, Rabbi Tendler and Dr. Rosner would allow a resident to accept a position that will require clinical responsibilities on Shabbat. However, they only permit him to "forgo the personal comfort and convenience of training in a hospital that is sympathetic to his religious needs", but he/she may NEVER violate the Shabbat "even of Rabbinic ordinances only". This means that only those melachot that are halachically permissible to perform for a given patient and scenario (eg. ONLY Rabbinically prohibited actions for a non-seriously ill patient [chole she'ein bo sakana] and Biblically prohibitted actions for ONLY a seriously ill patient [chole she'yesh bo sakana]). If the medical student or resident will be required to perform melacha on Shabbat that is not permitted by Jewish Law for that type of patient then Rabbi Tendler's heter does not apply and " the student-physician must forgo the educational advantages of the prestige hospital." (The classic example is the need to sign a death certificate.) In other words, a resident in training may sacrifice the "spirit" of Shabbat, but may NEVER desecrate the law of Shabbat. Whether the same ruling would be true for a medical student needs to be clarified.

Other Poskim (notably, Rabbi H. Schachter) have publicly taken a more stringent stand against accepting a "non-shomer shabbos residency". Dr. Avraham S. Avraham, author of the Nishmat Avraham, spoke on this topic at a recent AJOS conference in Woodmere, NY. He argued that given the complexity of Hilchot Shabbat and the often inflexible demands clinical practice on the wards, it would be extremely difficult NOT to violate Shabbat. He tells a story of an intern who comes to his home erev shabbat prior to his first call. Dr. Avraham quickly went to his study and handed the anxious intern his copy of Shmirat Shabbat Kehilchatah. "Read and remember this book cover to cover, but go quickly because you only have a few hours left until Shabbat begins!", he advised the intern. Since there is no obligation to become a physician and accepting clinical responsibilities on Shabbat will inevitably lead to violation of the Shabbat, therefore Dr. Avraham concludes that outside of Israel (where the majority of the patients are not Jewish) one is obligated to seek a shomer-Shabbat residency or arrangements that will circumvent the need to work in the hospital on shabbos. Indeed, Dr. Avraham related that during his training as a chief resident (in the days before "shomer-shabbos programs" existed) he traded every Sunday for an entire year just to be off for three Shabbatot!

Poskim clearly have multiple opinions on this topic (only two were presented above) and each individual must ask their own posek to address his/her personal situation. Personally, I believe that the story of Dr. Avraham and the intern also highlights that the crucial time to study Hilchot Shabbat is well before these issues arise.

Avi Oppenheimer

P.S. I appologize for incorrectly relating the story of Dr. Avraham and the intern. The correct episode occurred as follows: The intern came to Dr. Avraham's office on the floor. Dr. Avraham would have liked to have told him "read the 9 chapters on Med Hal. in SSK" but he didn't. Instead, Dr. Avraham spent an hour going through some basic Halachot with the intern.

Kavod HaMeis for the Healthcare Professional

Elly Gamss writes:
As halachically interested health care professionals, many of us are or will become well versed on the issues that we face in regards to patient care in hospitals. Many seforim and shiurim are available on these subjects.

The issues that arise in the care of a Jewish corpse with and just after passing away in the hospital are not as well known. In fact, as a house officer over the last 2 years I have been in the position on numerous occasions where questions have been posed to me regarding the cleaning up and preparing of a Jewish body before being picked up by a chevra kaddisha. Only some did I know what to answer.

Rabbi Zohn, the head of the Queens Chevrei Kadisha as well as the one at LIJ (where I am in residency) has graciously agreed to give a lecture on the subject of Kavod HaMeis for the healthcare professional.
We have scheduled the shiur for Monday evening June 19th at 7:30 PM at Long Island Jewish Medical Center in New Hyde Park, NY. The shiur will take place in the Boardroom in the Gurwin Teaching Center. Please feel free to pass this info on to any others who'd be interested. (ie residents, fellows, med students, etc.)
We plan on digitally recording the shiur so that we can make it available to those who can't make it. It should prove to be a useful and informative shiur.

Yeshiva University Medical Ethics Society's Conference

From Yonah Bardos:
Is anyone interested in helping out with planning the Yeshiva University Medical Ethics Society's conference on organ donation in Jewish law? We are looking for creative people to help with the advertising and graphics as well as some people who are able to help with logistical planning and spreading the word in their respective communities.

Shabbat observance during the clinical portion of medical school

I was wondering what the NMHS membership thought about shabbat observance during the clinical portion of medical school.

The only explicit responsa that I have read on this matter is Dr. Rosner's short piece in Practical Medical Halacha, where he writes that a medical student is obligated to work in the clinics on Shabbat provided that he does not transgress any melacha, be it biblical or rabbinic. He bases this on the concept that once a Jew decides to pursue medicine, he must educate himself to the best of his ability.

Based on this essay, it seems that a medical student should not be allowed to do any melocho while doing his primary required 3rd year clerkships because his responsibilities are purely educational. Is everyone in aggreement then that a medical student should be allowed to do melocho while doing his sub-internships, when he has patient care responsibilities?

Additionally, I would like to raise the possible distinction between 3rd year experiences where the student has patient care responsibilities versus those experiences that are purely educational. For example, at my medical school, the medical student has no primary responsibilites while on the Internal Medicine clerkship. The intern and Sub-I on the team are collecting all of the same information that the medical student collects.

On the Surgery rotation, the medical student is solely responsible to record the vital signs and i/o's every morning. I think that it is reasonable that a medical should be allowed to do at least melocho d'rabbanan while on Surgery, but not while on Medicine.

I would love to hear comments on this matter.

David Wise

NMHS blog is LIVE!!!

We would like to introduce the National Medical Halacha Society's official blog. The blog will serve to educate and initiate discussions on medical halacha topics. It will also serve as our temporary website for general announcements, info, networking and content until a full and separate website is developed.

#1 This is NOT a personal blog where only ONE person posts. We need EVERYONE to submit posts and comments to the blog. Relevant posts include short medical halacha essays, interesting news articles/links, presentation of medical/halachic dilemmas and questions, personal experiences and "networking" posts. Please send posts to NMHSBlog@gmail.com The email should include the text of your post and your name (anonymous authors for sensitive posts will be accepted at the discretion of the blog administrators).

#2 I wrote a few posts that should serve as examples of different types of posts (and which I hope you will also enjoy reading).

#3 Please comment

#4 There is a poll in the side bar for naming the society please vote ONCE.

#5 Enjoy, post, comment, spread the word, and visit the website often.

Surrogacy and the Halachic Definition of Maternity

As a follow-up to the previous post re: religion and medicine, I decided to offer a short summary of just one of the numerous brilliantly crafted arguments and creative proof-texts that are quoted relating to the definition of maternity (birth mother vs. genetic mother). The well-known story of Yosef and Dina's in-utero transfer is widely suggested as a definative source establishing the birth-mother as the halachic mother. However, as illustrated below this is far from the case.

Targum Yonatan comments that Leah’s prayers to Hashem that Rachel bear a male child where answered. Miraculously, the male and female fetuses in Leah and Rachel’s wombs respectively switched locations. Yosef, whose conception occurred within Leah, was born to Rachel; and Dina, who was conceived from Rachel, was born to Leah. This episode also appears in the commentary of Da’at Zekanim and in the litergical poems of Rosh Hashanah. In addition, it is also reported by the Maharsha (Masechet Niddah 31a) in the name of Sefer Panach Raza.

The miraculous fetal exchange of Yosef and Dina would appear to be a direct parallel to our modern dilemma of maternal identity in surrogacy. Since the Torah refers to Dina as the daughter of Leah, it could be argued that this proves that birth, and birth alone, determines maternity. Indeed, the Torah is replete with references to Yosef as Rachel’s son and never as a child to Leah. This proof is further significant in that it establishes the birth mother as the halachic mother even when conception and partial gestation occurred in another host.

However, not all commentators understood the implications of this episode uniformly. The Tur, in his commentary to the Torah (Breishit 46:10), asks how Shimon was permitted to marry Dina, since even Noahide law prohibits marriage to a sister of the same mother. (Shaul ben ha'kenaanit is listed among Shimon’s children who decended to Egypt with Yaakov. The midrash identifies the Canaanite as a euphamism for Dina who was violated by Sh’chem.) He answers that since Dina was conceived in Rachel’s womb, she was in actuality Rachel’s daughter. Therefore, Shimon and Dina were only paternal siblings and did not share a common mother. According to the Tur, birth is not the determinant of maternity. Rather some earlier event, shared by Dina and Rachel, creates that maternal bond.

Rabbi Moshe Sternbach (Teshuvot Ve'hanhagot) rejects adducing any proof from the story of Yosef and Dina on the grounds that "Ein Lemaidim Mima'ase nisim". He suggests the possibility that Dina not only physically transferred to Leah’s womb, but miraculously acquired her genotype as well. Therefore, Leah is both the genetic and birth mother of Dina and no comparison to surrogacy can be made.

An additional approach to understanding this episode is based on the plain meaning of the Gemara Berachot 60a. The gemara discusses whether it is appropriate to beseach G-d for a male or female child once his wife is already pregnant. Alternatively, such a request constitues a prayer in vain--tefilat shav, since what is done is already done. In support of such requests, the gemara states that after Leah’s prayers on behalf of Rachel the male fetus within her womb transformed into a female, while the female fetus in Rachel became a male. Apparently, this refers to a metamophasis, rather than an actual fetal exchange. (This source corroborates the Kabbalistic notion that Yosef’s vanity stems from his initial conception as a female.) Taking this approach neutralizes any inference from the circustances surrounding Yosef and Dina’s births regarding the determinant of maternal identity.

Avi Oppenheimer

Shomer Shabbos Residency Positions

For those seeking shomer shabbos or shabbos friendly residency positions--wouldn't it be nice to have an up-to-date list of programs with a few details about what they offer??? The immediate solution is simple: organize recent graduates experiences. If you are a recent graduate and would like to help in this effort, please send a list (word.doc) to TOBICHKA@aol.com. Include program name, shabbos status (friendly/unfriendly) and any relevant details. All submitted lists will be ANONYMOUS (names, email addresses, identifiers will be removed).
Also see Dr. Eisenberg's website devoted to this issue www.daneisenberg.com

"Anatomy of Halacha" Follow-up

Dr. Reichman writes:
Dear Colleagues,

A major Yasher Koach to all involved in this past week's event. The morning after our lecture discussing the black market trade of bodies for dissection, I noticed the following article in USA today. I hope you will find it of interest. I guess some things never change.

Illegal trade in bodies shakes loved ones
http://www.usatoday.com/money/2006-04-26-body-parts-cover-usat_x.htm?POE=click-refer

Religion and Medicine Mix, Survey Indicates

http://www.livescience.com/othernews/060501_doctor_faith.html
More than 90 percent of the doctors said it is appropriate to discuss religious or spiritual issues with a patient. I assume that at one point or another, Jewish doctors will have to discuss a medical-halacha/ethics issue with a Jewish patient. During my OB/GYN rotation, I was present when a Jewish couple experiencing fertility problems (ovarian failure) inquired about egg donation. The Jewish attending physician referred them to some medical literature and options without any mention of the halachic implications. (who is the halachic mother? Jew vs. Gentile egg donor?) At the time, I was only vaguely familiar with the halachic literature on surrogacy and egg donation. Are Jewish patients responsive to halachic issues raised by their doctors? I imagine some view it as out of the physician's realm or as mussar? Has a similar episode happened to anyone as a medical student/resident?

WELCOME!

Welcome to the National Medical Halacha Society Blog. This website will serve as the temporary site for all postings and NMHS info. So far, the NMHS has started off with a bang! @100 medical and undergrad students and residents attended the inaugural meeting held at Albert Einstein College of Medicine. Thank you to Dr. Reichman for delivering a fascinating shuir on the "Anatomy of Halacha".
If you would like to be included in the NMHS email list use the link to the NMHS google group on the top right of the page.