Parashas Shmos – Trading Call With Another Jew On Shabbos

Parashas Shmos – Trading call with Another Jew on Shabbos

 וירא אלקים את בני ישראל וידע אלקים (שמות ב:כה)

“And G-d saw the children of Israel and He knew.”

The Beis Halevi asks what is the meaning of the concluding phrase of this pasuk “and

G-d knew”.  What did He know?

To answer, he refers to a Midrash Yalkut.  “The angel of Egypt protests to Hashem, why do the Jews who worship Avodah Zara merit redemption.  They are no different than the Mitzrim?  הללו עובדי עבודה זרה והללו עובדי עבודה זרה

Hashem answers that the Jews only worshiped because they were oppressed and disorientated.  How can I equate אונס--the unwillful actions of Israel to רצון--the willful transgressions of Egypt?  The Jews have no time to think and are too weary to contemplate their actions.  However “I know”, Hashem says, “that if they had not been subjected to such punishing circumstances they would never be idolatrous.”

The Beis HaLevi elaborates that a claim of involuntary transgression (אונס) is only valid if the circumstances are such that had the coercive condition not been present he would not have done the action.  However, if not withstanding the אונס one would still sin, then no reprieve is granted for even an involuntary transgression. 

Similarly, a couple in chutz la’aretz who are married for ten years without children are not forced to divorce since we may attribute the failure to merit progeny to the sin of not living in Israel (yishuv eretz yisroel), rather than to the unsuitability of the union.  The Hafla’ah explains that one might question this ruling based on the accepted opinion of Rav Chaim Cohen (cited by Tosofos Ketubos 110b) that one is not obligated to settle in Israel at his time given its difficult and taxing living conditions, creating a situation of אונס.  Nonetheless, the claim of involuntary residence in exile is rejected since it is possible that even without the challenges of Aliyah, he might have still chosen to remain living in galus and thereby deserves some degree of culpability.  Therefore, the ruling stands and they need not divorce.

The Beis HaLevi concludes that any Jew who regularly and willfully violates a particular mitzvah, such as shmiras shabbos, even when he involuntarily transgresses (such as to save a sick person) is liable and not accorded the leniency of אונס.  Therefore, the Torah relates “וידע אלקים” – G-d knew us.  What did he know?  He looked at Bnei Yisroel’s oppression and knew that the circumstances alone were responsible for their idolatry.

This concept of the Beis Halevi forms the basis for a very important and well known debate between Rav Moshe Feinstein and Rav Shlomo Zalman Auerbach--zichronam livracha.  The question was raised whether it is appropriate for a frum, shomer shabbos doctor to switch a Saturday call with an irreligious Jewish doctor.  Rav Feinstein (Igros Moshe, O.C. 4:79) contends that it is preferable to have the non-frum doctor work on shabbos since he would have been mechalel shabbos at home anyway.  At least, at the hospital the majority of one’s actions would be required for pikuach nefesh.  However, Rav Auerbach argues, based on the aforementioned Beis Halevi that if the doctor was going to violate the shabbos at home anyway, then even if at the hospital he will be forced to be mechalel shabbos for the infirmed he does not get the credit of אונס and his actions are still classified as chillul shabbos.  Instead Rav Auerbach concludes, in this particular case, it is preferable for a frum Jew to keep the call so that while performing melachos in the hospital his actions are intended le’shem mitzvah (cited in Shmiras Shabbos Kehilchasa, chapter 32, note 125).

I would like to append the following comments from my father Dr. Steven Oppenheimer that lend additional insight into Rav Moshe’s position:

Rav Hershel Schachter, however, is quoted as questioning whether this Beit HaLevi would apply to the non-observant Jewish doctor. Rav Schachter observes that the Beit HaLevi's concern would only apply if the person would have done this specific act anyway. The example given is when a non-observant person was going to drive to a specific place on Shabbat and then he is forced, at gunpoint, to drive to the same place. According to the Beit HaLevi, he is considered a deliberate sinner. This is because he intended to drive to the same place even before he was threatened. On the other hand, argues Rav Schachter, the non-observant Jewish doctor is driving to a particular emergency for the purpose of saving a life, pikuach nefesh. Therefore, even if the doctor may have driven elsewhere on Shabbat, the halachic infractions that he now commits are for the purpose of pikuach nefesh.

This explanation of Rav Schachter (See Gray Matter, Vol. 2, Saving Lives on Shabbat, page 6, footnote 7) lends support to Rav Moshe's position and helps answer Rav Auerbach's proof from the Beit HaLvi.

It seems, in this country, that many people rely on Rav Moshe's position that it is permissible to switch call with a non-observant Jewish doctor in order for the observant Jewish doctor to avoid issues of Shabbat observance.

Paranthetically, it is interesting to note that Rav Neuwirth quotes Rav Auerbach that it is preferable to call an observant Jewish doctor on Shabbat rather than a non-observant Jewish doctor since summoning a non-observant Jewish doctor would be a violation of lifnei iver (Shemirat Shabbat Kehilchata, chap. 32, note 125).

However, in Minchat Shlomo 2:34:41, Rav Auerbach opines that just as one may violate Shabbat, if necessary, to call a non-observant Jewish doctor in order to save a life, so too, he may violate lifnei iver.

Anatomy of an Esrog

The above radiology image demonstrates the four characteristic features that distinguish a proper esrog from an esrog murkav (grafted). [Magen Avraham, Orach Chaim 648:23]

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   Bumpy rather than a smooth surface
  
  
  
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  An embedded or inward oketz.  The oketz of an esrog murkav protrudes outward.
  
  
  
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  A thick peel with a narrow center.  An esrog murkav has a thin peel and a thick juicy pulp.
  
  
  
• 
  
  Orientation of the seeds along the longitudinal axis of the esrog--except where it is "constrained by its neighbors".  In the above esrog notice how the seeds at the top and bottom of the pulp lay vertically.  The seeds toward the center are packed more tightly together and maintain a more oblique orientation.  The seeds of an esrog murkav are positioned horizontally even when there is sufficient space.
  
  
  

For extra credit:

Can you guess what radiology technique was used to produce this image?

(esrog image courtesy of Judah Burns, MD)

Giving of Oneself

Rabbi Shemuel Eliyahu, chief rabbi of Tzefat and son of former Rishon le-Tziyyon (Chief Sephardic Rabbi of Israel) R. Mordechai Eliyahu, gave a rather interesting shiur at the HODS conference last week (November 16, 2006). I would like to share a brief summary of what he spoke about.

R. Eliyahu discussed the issue of whether one person may place himself into a potentially dangerous situation (safek sakkanah) to save his fellow from an absolute danger / risk to life (vadai sakkanah). This question has been discussed extensively by the posekim (a modern example was the question of the permissibility of kidney donation) and the general consensus is that while a person is certainly not obligated to enter such a safek sakkanah situation, one may nonetheless choose to do so.

This week in particular, it is appropriate to note that the Tzitz Eliezer thought that a person is forbidden to undertake a safek sakkanah to save his fellow (9:45, 10:25:7, 13:100-101 [regarding war]). R. Eliyahu assumed the majority position and did not refer to R. Waldenburg's opinion. Hopefully, the Tzitz Eliezer's position will be the subject of a future post.
In all of the cases discussed by the posekim, the person in question wanted to know if he must / should / should not undertake a safek sakkanah to save his fellow. The danger to the questioner is uncertain. R. Eliyahu posited that we could expand this idea to cases where a person could voluntarily undertake a vadai sakkanah – meaning death – to save his fellow from death.
R. Eliyahu cited the story of Pappus and Lulyanus (Taanit 18b) who gave themselves up to the Roman government – vadai sakkanah (death) – to save the citizens of Lod from certain death. R. Eliyahu argued that all of the sources that seem to say that one may not sacrifice one life to save another – all refer to cases where an outside force is compelling the taking of the life – meaning that no third party can choose one life over another – ein dohin nefesh mipnei nefesh (Sanhedrin 72b). However, if a person would voluntarily offer his own life, like Pappus and Lulyanus – such an act is worthy and such a person is considered holy. [R. Eliyahu limited this position to allow a person to voluntarily forgo hayyei sha'ah only and not more. This was a sub topic of the shiur and will not be addressed here.]

The practical ramifications of this involve a gossess (moribund patient) who previously agreed that were he to become a gossess, he willingly forgoes the small amount of time left in his life so that his organs may be used to save another person (removing the organs results in certain and immediate death). R. Eliyahu argued that since such a patient is a volunteer, he may risk a vadai sakkanah (death) to save another person. He argued this position regardless of how one views brain death – even the position that assumes that a brain dead patient is fully alive, he argued, would agree that such volunteerism is permitted (and possibly praiseworthy).

This is a novel and dare I say, radical position, that I do not believe has received much attention by the medical halakhic community.

Tzitz Eliezer passes away at age of 89

Rav Eliezer Yehuda Waldenberg best known as the Tzitz Eliezer after his monumental halachic treatise Tzitz Eliezer passed away in Jerusalem on Tuesday Novermber 21, at the age of 89.

He was a leading rabbi and a dayan on the Supreme Rabbinical Court in Jerusalem and was considered an eminent authority on medical halacha. He was the rabbi of the Shaare Zedek Medical Center in Jerusalem.

Rav Waldenberg's involvment in medical ethics began during the period that he served as rabbi of a synagogue adjacent to the old location of Sha'arei Tzedek Hospital in downtown Jerusalem.
Professor Avraham Steinberg, a pediatric neurologist and head of the Medical Ethics Center at Sha'arei Tzedek Hospital recalled that "Doctors who prayed at the synagogue, myself included, started asking him questions. Eventually, he began teaching a weekly medical ethics class for doctors and nurses."

The questions Waldenberg answered were compiled in his Tzitz Eliezer. Though he wrote numerous books and articles in all fields of halacha, he was best known for his decisions on medical issues such as fertility, abortion, organ transplantation, euthanasia, autopsies, smoking, cosmetic surgery, and medical experimentation.

Rav Waldenberg forbade performing elective surgery on someone who is neither sick nor in pain, such as cosmetic surgery, arguing that such activities are outside the boundaries of the physician's mandate to heal. (Responsa Tzitz Eliezer, 11:41; 12:43.) Notably, Rav Moshe Feinstein disagreed with this opinion.

Unlike most halachic authorities, Rav Waldenberg held that abortion performed by a Jew was not considered murder. He allowed first trimester abortion of a fetus which would be born with a deformity that would cause it to suffer. He futher permitted the termination of a fetus with a lethal fetal defect such as Tay-Sachs disease up to the end of the second trimester of gestation. (Ibid. 9:51:3.)

Another unique ruling was Rav Waldenberg's complete opposition to in-vitro fertilization (IVF). He ruled that a child conceived outside the womb, through IVF bears no halachic relationship either to the biological parents or the "surrogate mother," the woman who carries the child to term. According to Rav Waldenberg, the baby produced from IVF is not related to the biological mother and father and, therefore, does not fulfill the Torah injunction to "be fruitful and multiply." As a result, the removal of sperm for the purpose of IVF was prohibited. (Ibid. 15:45.)

He was also one of a small but growing number of rabbis to forbid smoking. (“Should Jewish law forbid smoking?” B’Or ha’Torah 8)

In addition to his magnum opus, a 21-volume set of responsa entitled Tzitz Eliezer, Rav Waldenberg also authored a book on the laws of sea travel on Shabbat called Shvita b'Yam, a book on mourning laws called Ein Ya'akov and a book on legal issues in the modern state called Hilchot Medina.

Shomer Shabbos Residency Positions

I am reposting re: shomer shabbos residency positions. Many seniors will begin interviews soon and I would like to solicit your feedback. Information from residents would be extremely helpful regarding their own hospital/program.

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. Please include:
1. Your name and contact information. (Anonymity will be granted if requested)
2. Specialty (ie. radiology, medicine, orthopedics, etc.).
3. Name of hospital.
4. Contact person in the program (usually the program director) with contact information.
5. Any other information that you think is pertinent.
6. How you know about the program (interviewed there, on staff there, etc.).
7. Contact information for someone (or several people) who are currently training in the program or did train in the program.
Yasher Koach to Dr. Dan Eisenberg for his efforts regarding this issue. www.daneisenberg.com

MEDICINE ON TRIAL conference on Medical Errors and Medical Liability Reform

From Andrea Wershof Schwartz

MEDICINE ON TRIAL:

Medical Errors and Medical Liability Reform

The Jewish Theological Seminary

3080 Broadway at 122nd, New York, New York 10027

Sunday, October 22, 2006

The Louis Finkelstein Institute for Religious and Social Studies of The Jewish Theological Seminary is sponsoring a conference titled "Medicine on Trial," which deals with issues surrounding medical errors and medical liability reform. This will be a day-long conference held at The Jewish Theological Seminary, 3080 Broadway at 122nd, New York, New York, on Sunday, October 22, 2006. It is co-sponsored by the Medical Society of the State of New York and the Stein Center for Law and Ethics Fordham University School of Law.

Often in public discourse, these issues are discussed from a political or economic standpoint, frequently with those on opposing sides talking past each other. This conference aims to look at these issues from a perspective of ethics and moral responsibility and foster a dialogue among interested individuals.

The morning session will tackle medical errors and untoward events. It will focus on identifying and correcting systemic problems in healthcare settings that contribute to medical errors, as well as with the responses to errors once they have occurred, including apology legislation, mediation, and alternatives to litigation. The afternoon session will center on questions surrounding the litigation process, including testimony by paid experts, jury of one's peers, medical courts, the victim of malpractice whose damages are not great enough for a lawyer to be willing to take the case, and the problems associated with the cost of liability insurance.

Each of the main sessions will include brief formal presentations followed by a roundtable panel discussion involving experts from the fields of law, medicine, religion, and bioethics. The conference will then break into smaller groups for more intimate discussions between members of the audience and faculty.

Continuing Medical Education Credit: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Medical Society of the State of New York (MSSNY) through the joint sponsorship of MSSNY and JTS. MSSNY is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The Medical Society of the State of New York designates this educational activity for a maximum of 6.5 AMA PRA Category 1 Credits ä. Physician should claim commensurate with the extent of their participation in the activity.

Continuing Legal Education Credit: This program is accredited for 7 non-transitional New York State continuing legal education credits in the areas of ethics (4 credits) and professional practice (3 credits). A financial hardship application for this Conference can be found at http://law.fordham.edu/cle.htm

For further information on fees and other matters, to register, or to receive registration forms by mail, contact 212-280-6093 or publicevents@jtsa.edu.

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.”

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