Collecting Halakhic Case Studies

From David Shabtai:

I am trying to collect "Patient Cases" that raise important halakhic questions. I am hoping that they will be useful in preparing and organizing various shiurim. I have looked around and could not find such a database and decided that perhaps it would be wise to start one.
If anybody has any such cases already written down and is willing to share or if anybody (or hopefully everybody!) is willing to write up some cases (actual, made up, or a combination of both) - I would be happy to collect them and start such a database. Perhaps the best way, is to write up actual cases and then add elements that make them more halakhically meaningful or challenging.
I am currently working on "end of life issues" (as per my last posts) but would like to collect cases dealing with any and all possible issues. I will hopefully organize such a list by topic and make it available on the web.

Please send cases to david.shabtai@gmail.com

Thanks!

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

When is "dead" really "dead"? Part III

I was curious to know why Dr. Avraham did not give the same answer we offered previously – a distinction between hutaz rosho and other signs of halakhic death (as per Shevut Ya'akov 1:13). I spoke with R. J. David Bleich who defended R. Moshe Feinstein's position. He claims that death means "cessation of vital motion." Motion refers to any movement that is useful for life; the heart is considered a muscle just like any other. He therefore requires cessation of all movement, including the heart muscle to declare death. The purpose of this definition (as per Hatam Sofer YD 338) is to approximate the case of Ohalot 1:6 – hutaz rosho; that is the prototypical definition of death and it is absolute. Any movement that occurs after that moment, the Mishnah defines as pirkus (death rattle) and is not considered vital motion (this is R. Bleich's source for a distinction amongst different types of motion). Therefore, once hutaz rosho a person is dead by definition. R. Bleich accepts the possibility of tehiyat ha-meitim (at
least in theory, it is not practical today) and believes that this is what R. Moshe Feinstein refers to in Iggerot Moshe YD 2:174:2.
One could argue therefore, that those who do not believe that "ordinary people" can engage in tehiyyat ha-meitim (as opposed to prophets who may do so) – the definition of death focuses on irreversibility. If a person were to return to natural life by any medical means – by definition, he could not have previously been dead. Therefore, hillul Shabbat is warranted and even obligated in any situation where a person will 'regain his life' regardless of his current condition or required treatment. Perhaps this is how one could
explain the challenge to R. Feinstein's position.
R. Bleich proceed to explain how he understood the concept of hashash illuf. A person who experiences the halakhic signs of death and then "comes back to life" has done so spontaneously. The doctors have only helped or assisted his inherent abilities of vital function. Performing cardiac massage, applying electric shock or administering pressers 'merely' help the body do what it is normally supposed to be doing – living. He argued that there is no difference between any of these procedures and opening up a patients mouth who is unable to do so and allowing oxygen to flow in.

Therefore, hashash illuf refers to a period where a person has within his own bodily function, the ability to live – he may just need some help. Hutaz rosho is definitionally different – it is the definition of cessation of vital force. Therefore, reconnecting the head (if it were possible) is different than any other procedure – it is not allowing a person's inherent functions to return, but rather giving the patient function that he was missing in his death.

Smoking in Halacha

The RCA Halacha Committee has published a ruling prohibiting smoking (ruling - PDF; RCA press release). Although this Teshuva was published last week and has been discussed elsewhere, I wanted to bring it to the attention to the members/readers of the NMHS Blog. Much of the discussion has focused on why this topic and why now? (Ironically, the RCA ruling just preceded the Florida Supreme Court decision to throw out a $145 billion liability suit against Big Tobacco.) But there is another aspect to the issue that relates to the phycisian directly.
Every H & P form asks whether the patient smokes/ed and the hospials I have worked at have a policy that these patients should receive smoking cessasion counselled (albeit usually mere lip service). Usually we view smoking cessasion as "risk factor modification" just as we counsel patients to eat less fat and cholesterol or encourage diabetics to attain better glycemic control.
However, if there is a halachic prohibition to smoke, perhaps, there is a halachic obligation for Jewish phycisians to seriously encourage smoking cessasion for their patients--le'hafrisho me'issur. Beyond the patient's family, one's phycisian is best positioned to affect this change in prohibitted practice. But remember hocheyach to'chiach and le'hafrisho me'issur requires the proper approach, time and place.

My father, Dr. Steven Oppenheimer wrote an excellent article (I can't help but be biased) on the the topic of preventative health in which he quotes the Chafetz Chaim:

It is amazing that even before the strong medical evidence against smoking that exists today, the saintly Chafetz Chaim wrote the following regarding smoking (this would also apply to any activity that might endanger a person){:

"I said to the smokers, who gave you permission to get into the habit (of smoking)? While it is true that our sages said, One who harms himself, even though it is not allowed, he is exempt, they still said that it is not allowed to harm oneself. First, because (the torah commands us) ve'nishmartem le'nafshoteichem. Moreover, the world and its inhabitants belong to the Almighty, who created us for His glory and in His mercy gives each and everyone the proper amount of energy to devote to Torah and this world. How can the servant permit himself to do whatever he wants when he belongs to his Master? If smoking saps a persons vigor, in the end he will be made to answer for this, for he did this on his own and not because of coercion. Therefore, when one reflects upon the harm one brings upon onself, one will find the strength to avoid the habit." (Likutei Amorim, chapter 13. See also Rambam, Hilchot Sanhedrin, 18:6 and the commentary of Radvaz.)

IY"H I'll post the full article later to the website.
Avi Oppenheimer

Triage

In Igros Moshe (Choshen Mishpat 2, siman 73, part 2) Rav Moshe Feinstein ZT"L speaks of prioritizing two critically ill patients with differing prognoses, one who will only live a "chayai sha'a" (temporary relief) even with medical intervention and one who is projected to live a "chayai olam" (normal healthy life) with it. He says that were they to arrive simultaneously under your care, then one would be permitted (and in fact required?) to treat the patient who's has a better chance at survival rather than work with the patient who's prognosis is for "chayai sha'a" at best. However, if the "chayai sha'a" patient would come under your care first and you would begin his treatment it would be totally prohibited to leave him and treat the patient with the more promising prognosis. It seems to me that Rav Feinstein gives two reasons for this prohibition: The second reason given is because leaving his care would indicate to this ill patient that he has a worse or no chance of survival. This psychological fact and it's effect on the patients mental health would contribute to hastening his death and is threfore prohibited.
My question is regarding the first reason given. R' Feinstein seems to assume as a very basic and fundamental idea that being there first entitles this ill person to the continuation of his care. He says that in effect this "chayai sha'a" person has already acquired his place and as such cannot be removed from it even to save this more promising outcome. I do not see a source for this assumption anywhere. I have also seen this very same logic quoted from R' Shlomo Zalman Aurbach in the footnotes of the Nishmat Avraham (Y"D p.156) . What is the source for this halacha? Shouldn't the logic which dictates the p'sak when they arrive simultaneously, namely that with a chance to save one life choose the more promising outcome) still apply here?
Please post any suggestions.

Judah Goldschmiedt

Egg Donation

Thank you to E. Rosman for forwarding this to NMHS.

From the NY Times Religion Journal: When Science Aids Reproduction, Some Parents Wonder What It Takes to Be Jewish

When Medicine and Religion Clash

Below is an article of possible interest to the group.
On the famous pigeon remedy, see
Fred Rosner, “Pigeons as a remedy for jaundice,” NY State Medical Journal 92:5(May, 1992), 189-192.
There have long been debates about the cause of death of the pigeons. One study attributed it to ruptured spleens. The concept of disease transference is an old one. I do not know how old the Jewish tradition of the pigeon treatment is, but I found an early historical record of the use of pigeons to treat disease:
Dr. Thomas Lodge popularized the concept of disease transfer in 1603. He plucked the tail feathers from live pullets and placed them on the sores of plague victims. The unlucky fowl became infected and died whereupon the good doctor would place another tailless fowl upon the sores. When at last, a pullet survived, he proclaimed the human patient on the road to recovery. News spread fast of this new cure and by the time the Black Death hit London in 1665, the common treatment for its victims was to have pigeons which had been cut in two, placed upon their sores to draw out the infection.
The pigeon/hepatitis treatment may possibly trace its origins back to this.
Kol tuv,
Dr. Eddie Reichman

Israeli doctors are told what to do when medicine and religion clash Jerusalem Judy Siegel-Itzkovich BMJ 2006;333:14 (1 July)

The ethics bureau of the Israel Medical Association has released a position paper to guide its members on how to act when their medical training clashes with their patients’ faith and beliefs.

Avinoam Reches, chairman of the ethics bureau and a senior neurologist at Hadassah University Medical Centre in Jerusalem, said he hopes the guidelines published in the latest issue of the association’s Hebrew language magazine, Zman Harefuah would help colleagues in a country where religion and faith in general often have a powerful influence.

“This is especially true when medicine has no solution, and patients and their families are desperate,” said Professor Reches. “Doctors may then find themselves facing advice and ‘treatment’ from the clergy, ‘healers,' or charlatans that run counter to their professional knowhow or world view.”

Israel’s Patients Rights Law, passed about a decade ago, gave patients the freedom to choose among the various possibilities within conventional medicine and outside it. Professor Reches said, “This choice may frequently conflict with the doctor’s autonomy, but the doctor can forgo some of his power in such cases.”

The rule of thumb is that doctors should allow the use of services that are based on beliefs or religion but cannot be forced to supply them themselves. Where treatments go against their professional knowledge doctors may, Professor Reches noted, refuse to be involved but can acquiesce as long as the patient, medical staff, and other patients are not harmed and the treatments do not come at the expense of medical resources needed to treat others.

He gave as an example the practice, rather common among ultra-Orthodox Jews, of healers using pigeons to treat jaundiced patients. Seven pigeons are used in sequence, with the healer pressing the bird’s anus on the patient’s navel, “releasing the poison” into the bird. The birds inevitably die, either as a result of the “poison” or of the pigeon handler breaking its neck in the process.

Professor Reches noted that some members of the clergy try to interfere with doctors’ work, advising patients to undergo tests or treatments that doctors do not recommend. “But if they come to pray or place amulets near the patient we should not interfere. We have to set boundaries between medicine and faith, which can have psychological, moral, and even placebo value. We mustn’t chase faith out of the hospital, but it must remain in the proper dimensions.”