Monday, June 12, 2006

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.

6 Comments:

At 7:42 AM, Blogger Charlie Hall said...

'outside of Israel (where the majority of the patients are not Jewish)'

What difference would the religion of the patients make? Here in the United States it is forbidden for a physician to discriminate on the basis of religion, and my understanding is that the normative halachah now supports this contrary to the Mishnah Berurah.

 
At 3:53 PM, Anonymous David said...

Dr. Avraham explained that those leniencies (and I think we need to realize that they are indeed leniencies) applied to a doctor who is "working" on Shabbos with Jewish patients who also happens to have a couple of non-Jewish patients as well. While taking care of his Jewish patients, according to a large number of poskim, the doctor may "en passant" [Dr. Avraham's language] treat the non-Jewish patients as well.
(This was said specifically in response to the heter given by the Tzitz Eliezer.)

 
At 5:08 PM, Blogger Charlie Hall said...

David,

So what would be the consequences for a Jewish doctor, all (or nearly all) of whose patients are non-Jewish? (Not uncommon in the US.)

 
At 5:31 PM, Blogger Charlie Hall said...

'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]).'

I think that today any person who is a hospital inpatient would need to be considered "seriously ill" at least in the United States. This represents a change from just a few decades ago both in the level of illness required to be admitted and the increased incidence and severity of nosocomial infections.

 
At 10:25 PM, Blogger Avi Oppenheimer said...

While it is true that most patients admitted on the ward are considered chole sheyesh bo sakana or at least Safek sakana. There are many patients in my own experience who are not. I have admitted patients with a simple viral URI or gout exacerbation. (We could discuss who in the ER found it necessary to admit these patients!) But nonetheless they appeared on my service, requiring all the usual work-up, paperwork and orders of any other patient. Certainly these cases pose a halachic challenge on shabbos.

Even for a Chole Sheyesh bo sakana the level of shabbos violation needs to be minimized when possible (shinuy, k'leachar yad, employing the help of a gentile). A physician who fails to do so is also in serious violation of the Shabbos according to many prominent poskim. (More on this last point in a separate post).

 
At 8:11 AM, Blogger E-Man said...

The halachic ruling that most people base Rav Tendler as saying that it is ok to accept non-shomer shabbos residencies comes from the first teshuva in this same book that you are quoting. If you look at the sefer written by Dr. Rosner and Rav Tendler called Practical Medical Halacha 3rd revision he goes through the heter for even a medical student being allowed to work on shabbos. Take a look.

 

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