Medical Ethics

From Halachipedia

Abortion

Abortion

Donating Blood

  1. It is permissible and a mitzvah to donate blood, as it is used to save lives.[1]

Organ Donation

  1. One may donate an organ if the donor's health not suffer as a result of the donation. [2]
  2. It is permissible and a big mitzvah to donate a kidney.[3]

Heart Transplant

  1. A heart transplant isn't allowed since it is a major dispute if taking a live heart is considered killing the donor.[4]


End of life care

Allocation of medical supplies

Triage

  1. Regarding the larger issue of halachic triage see Rav Schachter (Piskei Corona #15 Updated). Here is a relevant sourcesheet on Halachic Triage. Rav Asher Weiss (Teleconference April 6 2020, min 5-15) discusses triage in halacha and what doctors should do.[5]
  2. A doctor may and is encouraged to perform a life saving procedure if he is wearing the correct protective gear.[6]

Precedence Based on Horiyot

  1. The Mishna Horiyot 3:7 delineates a certain protocol of precedence when several people are in mortal danger and not all of their needs can be met. Most poskim accept that this Mishna is binding today.[7]
  2. However, once the doctor starts he shouldn’t stop to help someone with a higher level of priority according to Horiyot 13a.[8]
  3. The same ordering applies to those in danger of spiritual assimilation.[9]

Chayey Olam vs Chayey Shaah

Both in Front of the Doctor

  1. If there is a shortage of ventilators and there is two patients in front of you, one who according to the assessment of the doctor is not going to live more than a year and another who is going to live more than a year, the ventilator should be used for the one who can live more than a year.[10]

Already Started Treatment

  1. If the patient who can't live more than a year is already hooked up to the ventilator the doctor can not remove him in order to treat the patient who potentially could live longer than a year.[11]
  2. A doctor who started treating a patient who is assessed not to be able to live another year (chayei shaah) may not stop in order to treat a patient who can live for longer than a year (chayei olam).[12]

One Here Currently

  1. If there's only the patient who is assessed to not be able to live a year before the doctor, and the doctor thinks that another patient who could live longer might come in shortly, the doctor has the obligation to immediately help the one who is before him even though afterwards someone who can live longer might come in.[13]

Emergency Worker Responding When Called for Two Cases

  1. If a doctor is called to work on a patient first he should deal with him first even if afterwards he’s called for another patient with a higher precedence level (as in Horiyot 13a).[14]
  2. However, if the doctor knows that the second patient is in more serious danger he should go there first. This is up to the doctor’s call.[15]
  3. Alternatively, if the doctor doesn’t know how to heal the first patient but does know how to heal the second one he should go to the second one. Yet, sometimes he should go to the first one even though he doesn’t know how to heal him in order to help him calm down and not think that the doctors gave up on him.[16]
  4. All of these criteria are for when the doctor got several calls but didn’t start to treat one of them, otherwise he shouldn’t stop the one he started to work on.[17]

Endangering Yourself

Endangering Yourself for a Mitzvah

  1. It is forbidden to endanger yourself to fulfill a mitzvah.
    • Endangering Oneself to Learn Torah: Ketubot 77b records and praises the practice of Reish Lakish to teach Torah to those ill with tzarat, some translate as leprosy, even though it is contagious. The gemara explained that he did so out of his love for Torah. Daf Al Hadaf cites Mishnat Pikuach Nefesh 69:7 who asks how Reish Lakish could endanger himself and rely on a miracle. He answers that the disease he was concerned with was only dangerous to health but not life threatening.

Endangering Yourself for a Profession

  1. It is permitted to endanger yourself for a profession. Most poskim only permit this for a very small risk of danger but not a very dangerous profession.[18]
  2. For example, Rav Moshe permitted someone to be a professional ball player, even though there were certain health risks.[19]
  3. For example, poskim permit a person to go hunting as a profession, even though it involves some danger.[20]
  4. Some poskim permit joining the army for a pay, even though it involves danger.[21]
  5. Some poskim use this principle that it is permitted to endanger oneself for a profession to justify why doctors may treat contagious patients.[22]

Endangering Yourself in Minimal Danger (Shomer Petayim)

  1. A person is allowed to engage in normal activities in society that people aren't concerned that they are dangerous.[23]
  2. This principle is known as "shomer petayim Hashem," (lit. "Hashem protects the fools"; heb. שומר פתאים ה') which permits a person to act simple and rely on Hashem to be protected.
  3. This principle is the reason that women may become pregnant and give birth, even though that inevitably involves some risk (especially earlier in history).[24]
  4. Some poskim hold that this concept only permits activities that objectively don't have a risk factor of more than 1/1000. Otherwise, it is considered objectively too risky and forbidden, even if other people do it without concern.[25]
  5. Some say that shomer petayim Hashem is only relevant if it is a risk or danger that applies equally to everyone. However, if there's a risk that only applies to a specific person or group, such as if they're sick, shomer petayim is inapplicable.[26]
  6. Some poskim use the concept of shomer petayim Hashem to explain why it is permissible to travel through the desert or take a boat.[27]

Endangering Yourself to Save Someone Else

  1. Most poskim hold that it is permissible but not obligatory to endanger oneself in a possibility of danger (safek sakana) to save someone else from certain danger.[28]
    1. Some poskim hold that it is an obligation to endanger oneself to save someone else.[29]
    2. A minority opinion holds that it is forbidden to endanger oneself to save someone else.[30]

Defining the amount of risk

  1. Some say that if the risk is less than 50% to the one saving it is an obligation to save someone in danger.[31] Others argue that even if the danger is far less than that there's no obligation.[32]
    1. Others define the threshold at 1 in 1000. If the danger is less than that, it is permissible to save someone in danger.[33]
    2. Others define the threshold at the amount that people would be worried about. If he would do this activity for a specific reason, such as if he was going for a job or another purpose, and wouldn't be worried about the danger, he should do so to save someone else. If he wouldn't enter that situation for any purpose then he is not obligated to save someone in that situation.[34]

Saving unique individuals or groups

  1. Some say that it is permissible to endanger yourself to save someone who is a talmid chacham and tzaddik.[35] Some forbid this.[36]
  2. Some say that it is permissible to endanger yourself to save your only son if you're too old to fulfill pru urevu again.[37]
  3. A pregnant doctor who is concerned that if she treats a patient with German measles it may place their fetus at risk is not obligated to treat the patient. However, if the doctor wishes to do so, they may and they should be blessed from heaven.[38]
  4. It is permissible to endanger yourself to save many Jews.[39]

Doctors endangering themselves to save patients

  1. A doctor may take care of a patient with a contagious disease even without proper protection (when it is impossible to get proper protection) to help save the patient.[40]
  2. A medic in the army must save wounded soldiers on the battlefield in times of war, even though it means exposing themselves to risk. However, he is not obligated to enter the war zone to save a non-military patient.[41]

Giving up one's life to save others

  1. If a terrorist threatens you "either kill another Jew or I'll kill you," you may not kill another Jew and must give up your life.[42] You must also give up your life and not even murder the other Jew indirectly such as by causing a dog to bite someone to showing a non-Jew where the Jew is hiding in order to kill him.[43]
  2. If a terrorist threatens you "either let me cut off one limb of your body that won't kill you or I'll kill another Jew," some say that you must allow him to cut off your limb, but most poskim hold that you don't have to, but it is a middat chasidut to do so.[44]
  3. If a terrorist threatens you "either give me your sword so that I can kill another Jew or I'll kill you," some say that you may not give up your sword in that case, while most hold that should give up your sword.[45]
  4. A minority position holds that it isn't necessary to endure difficult pain in order to save someone else's life, but most poskim disagree and hold that is necessary.[46]

Saving Yourself by Endangering Someone Else

  1. See Violating_Torah_to_Save_Your_Life.

Sources

  1. ↑ Rav Yitzchak Yosef (Motzei Shabbat Kedoshim 5779 min 1)
  2. ↑ See Yachava Daat 3:84, Tzitz Eliezer 9:45, Minchat Yitzchak 5:7. Similarly, Rav Asher Weiss (Aguda Teleconference, April 6, 2020, min 20-22) stated that donating a kidney isn’t risk free but it is minimally dangerous and it is life saving and therefore it is a middat chasidut to do it.
  3. ↑ * The Steipler (Kehilat Yakov, Igrot Vreshimot v. 4 siman 10) wrote to Rav Moshe Neislish in 1966 that if the danger from surgery of a kidney transplant is less than 1 in 1000 and the danger afterwards is almost nothing, it is permissible to donate a kidney.
    • Rav Shlomo Zalman Auerbach (Shulchan Shlomo Refuah v. 2 p. 44) writes that if the sakana is rechoka (lit. far away; transl. remote) for the donor, as the doctors say, it is permissible to donate a kidney and it is a big mitzvah. Rav Avraham Avraham (Hamayan v. 28:3 p. 25) also quotes Rav Shlomo Zalman as permitting kidney donations in the 1970s.
  4. ↑ Rav Yitzchak Yosef (Motzei Shabbat Kedoshim 5779 min 10)
  5. ↑ Rav Asher feels that there are only two factors that we consider for halachic triage: give precedence to someone who is in immediate danger, and give treatment to whoever has a better chance for survival. Age or spiritual need for the community are not factors for precedence.
    • Rav Asher says that for choleh shebifanenu the knowledge that another choleh is going to come in soon is considered pikuach nefesh if will with certainty be helpful. Therefore, if an older patient comes into the hospital but they know a younger patient is going to come in, they can consider them as though they came in together and treat according to who is in immediate danger and who has the better chance to live. Rav Schachter felt the same way in his teshuva.
    • If a hospital has a certain regulation, does he need to disregard the hospital protocols? Rav Asher Weiss felt that the doctors should not disregard hospital protocol, for multiple reasons but partly because if he doesn't he'll lose his license and having more able doctors at this time is pikuach nefesh.
    • Pulling a patient off a ventilator because someone entered the hospital who has a better chance of living, Rav Asher (min 27) felt is forbidden. Rather the doctor should say that he feels uncomfortable to do this and should let another doctor do it. Rav Schachter felt that one should try to convince the older patient to sign a DNR at that point in order to save the younger patient.
  6. ↑ Rav Asher Weiss (Aguda Teleconference, April 6, 2020, min 18-22) explains that you can’t put yourself in danger. However, you can if you’re saving someone from an immediate danger and you’re putting yourself in minimal danger then it is a middat chasidut to do so. Therefore, a doctor should do mechanical ventilation CPR on a COVID19 patient if he has the correct protective gear.
    • Rav Asher (min 33) allowed sharing ventilators when the doctors see fit in order to save another life because moving a patient from a single ventilator to a shared ventilator isn't considered doche nefesh mipnei nefesh since it isn't proven to be dangerous to use a shared ventilator. He also cited the Chazon Ish regarding turning the arrow to the side killing fewer people to save more people.
    • Rav Asher (min 38) said that a doctor who isn't in that particular field or is retired or has vacation doesn't have to volunteer but his doing so would be a middat chasidut. However, if he is endangering himself such as if he's over 70, he is immune compromised, or has a family member who is, then he shouldn't volunteer.
  7. ↑
    • The Mishna Horiyot 3:7 states that a man is given precedence before a woman for sustenance. It also gives precedence to a Kohen before a Levi, then to a Yisrael. There is a dispute whether this is applicable to a case of life and death or only food where there's no mortal danger. Bet Yosef 251:8 explains that it is referring to giving precedence even in cases of mortal danger. Beer Sheva (Horiyot 13a s.v. ha'ish) quotes Tosfot Nazir 47b s.v. vhatanya as a proof to the Bet Yosef. Shevet Halevi 10:167:1 agrees. Rama 252:8, Taz 252:6, Shach 251:11, Yavetz 1:68, Pitchei Teshuva 252:7, Birkei Yosef 252:1, and Aruch Hashulchan 252:13 codify and agree with the Bet Yosef. However, the Rashba Ketubot 67a, Meiri Horiyot 12b, and Levush 252 understand the mishna to be dealing with sustenance and not cases of mortal danger. Mareh Panim Horiyot 3:4 shows that the Yerushalmi explains the mishna in terms of food and not mortal danger, however, Meromei Sadeh 13a answers his question.
    • Shevet Halevi 10:167:1 writes that everyone agrees that in a case of mortal danger we follow the order of precedence in the Mishna Horiyot before for man before woman as well as kohen, levi, and then yisrael. Erech Chaim Bhalacha v. 6 pp. 284-287 quotes most poskim as holding of the Mishna Horiyot 13a as binding for giving precedence when dealing with triage: Chazon Ish (B"m 62a, Likutim 20), Igrot Moshe CM 2:75:2, Minchat Shlomo 2-3:86:1, Rav Kook in Mishpat Kohen 143 and Rav Elyashiv.
    • However, Tzitz Eliezer 18:11:1-8 writes that we don't give precedence of a man before a woman today. This is on the basis of the Meiri and Rashba above and explains this as the opinion of the Rambam and Shulchan Aruch. He says that it all depends on how many mitzvot they accomplish and since it is a fixed standard policy it is left up to the decision of those involved in saving.
    • See also the Yavetz in Migdal Oz (Otzar Hatov, Even Habochen, Pina 1, n. 92) writes he didn’t see that people gave precedence to the kohen, levi, and then yisrael because today we don’t have certain kohanim. Furthermore, the Yavetz in Migdal Oz (Otzar Hatov, Even Habochen, Pina 1, n. 92) writes that there is precedence given to an old healthy person over someone old and sick. He seems to place this precedence only within each category of kohen, levi, and yisrael.
    • Chashukei Chemed Ketubot 49a isn’t sure if the precedence of a boy before a girl is only after they have reached chinuch or even beforehand.
  8. ↑ Shevet Halevi 10:167, Igrot Moshe 2:74:1
  9. ↑ Yavetz 1:68 holds that if a boy and girl are both in spiritual danger of being assimilated because of being taken in captivity, precedence is given to the boy as we find by saving the life of a boy before a girl. Pitchei Teshuva 252:7 and Chashukei Chemed Ketubot 49a cite this.
  10. ↑ Shevet Halevi 6:242 regarding a defibrillator writes that if there's someone who the doctor assessed cannot live a year and another who will live more than a year the defibrillator should be given to the one who can live more than a year. Since halacha values chayey olam more than chayey shaah it has precedence similar to the other priority in the Mishna Horiyot 13a. He notes that this is a contradiction between the Chazon Ish b"m 62a and Chazon Ish on Grach Yesodei Hatorah, whether to give it to the one who can live more than a year or it should be split even though both will die. Igrot Moshe CM 2:73:2 agrees with the Shevet Halevi.
  11. ↑ Shevet Halevi 6:242 writes that once the person who cannot live a year is already hooked up he cannot be removed in order to save someone else who could live more than a year.
  12. ↑ Igrot Moshe CM 2:73:2 agreed that a patient who is chayey shaah can’t be removed from his bed in the emergency room for a chayey olam patient since the chayey shaah patient has the right to be treated and doesn’t need to sacrifice his life for the other patient. Rav Elyashiv in Kovetz Teshuvot 3:160 seems to agree that once a doctor is treating a patient in mortal danger he shouldn’t stop to attend to a patient who is more seriously in danger. See also Minchat Shlomo 2-3:86:1 in this vein. See, however, Rabbi J David Bleich (Tradition Winter 2021 p. 16) who argues that chayey olam is given greater weight than chayey shaah even if one already started to treat the chayey shaah patient. He considers the rule of osek bmitzvah to be outweighed by the pikuach nefesh of the chayey olam patient. He cites that this is also the opinion of Rav Elyashiv (Shiurim Lrofim v. 2 p. 109) that osek bmitzvah doesn’t apply to pikuach nefesh.
  13. ↑ Shevet Halevi 6:242. Igrot Moshe CM 2:73:2 writes that if a chayey shaah patient comes in first he should be brought in first, even though a chayey olam patient can come shortly. He adds that even though they didn’t start to work on the chayey shaah patient they can’t remove him for the chayey olam because doing so might cause the chayey shaah patient to think that the doctors gave up on him.
  14. ↑ Igrot Moshe CM 2:74:1, Shevet Halevi 10:167. Igrot Moshe 2:75:2 writes should respond to the patient he was called to first, even if he gets another call before he starts treatment of the first. Rabbi J David Bleich (Tradition Winter 2021 p. 15-16) argues that ein maavirin al hamitzvot or osek bmitzvah does not apply by merely determining to go do a mitzvah.
    • Tzitz Eliezer 18:69:3 in regards to ordering patients (where there is no mortal danger) writes that we follow whoever came first in line and not the ordering system of Horiyot so as not to come to fights. He distinguishes between if patients come before the doctor arrives and after; before there's no concept of a line in halacha but since it is the practice it is binding, whereas afterwards there is a basis for a line in halacha.
  15. ↑ Igrot Moshe CM 2:74:1, Shevet Halevi 10:167
  16. ↑ Igrot Moshe CM 2:74:1
  17. ↑ Erech Hachaim Bhalacha v. 6 p. 188. See also Igrot Moshe CM 2:73:2.
  18. ↑ Igros Moshe 1:63:1, Mishpat Kohen 134
  19. ↑ Igros Moshe CM 1:104
  20. ↑ Nodeh Beyhuda YD 10, Tzitz Eliezer 9:17:5
  21. ↑ Imrei Esh cited by Tzitz Eliezer 9:17:5 and Chashukei Chemed Bava Metsia 112a
  22. ↑ Tzitz Eliezer 9:17:5
  23. ↑ Rav Elchanan (Ketubot n. 136)
  24. ↑ Igros Moshe EH 1:63:1. Binyan Tzion 137 agrees that this is the reason for allowing childbirth but he applies it even if the danger to the mother is greater than a regular birth.
  25. ↑ Rabbi Mayer Twersky infers from Maggid Mishna that if the danger is 1/1000 or greater it is considered too dangerous even to rely upon shomer petayim Hashem. Igrot Moshe CM 2:76 permits smoking because of shomer petayim Hashem but just writes that it is a danger for only a miyuta d'miyuta of people.
  26. ↑ Igros Moshe EH 1:63:1-2, 4:73:1
  27. ↑ Binyan Tzion 137. Rabbi Twersky quotes Shem Aryeh 27 who holds that shomer petayim allows traveling through the desert or in a boat only if there's a parnasa need or another real need.
  28. ↑ Mishna Brurah 329:19, Aruch Hashulchan CM 426:4, Igrot Moshe YD 2:174:2, Rav Elyashiv (Va’vaey Haamudim V’chashukeyhem 13:22), Rav Asher Weiss (Minchat Asher 1:115)
  29. ↑ Hagahot Maimoniyot cited by Bet Yosef CM 426:2
  30. ↑ Shulchan Aruch Harav 329:8
  31. ↑ This is the literal reading of Radvaz. This is how Tzitz Eliezer 10:25:28, Shevet Halevi 5:137:2, Yabia Omer 9:12, Dr. Avraham Steinberg (Encyclopedia of Jewish Medical Ethics v. 3 p. 907), and Rav Gavriel Siner (Or Yisrael v. 78 p. 33) understand Radvaz, that he's discussing if there's more or less than 50% survival rate for the one coming to save. These poskim hold that there's no contradiction between the teshuvot of Radvaz. In 5:1082 he is simply defining the level of sakana he was discussing in 3:627. See Rav Shlomo Amar (Shma Shlomo CM 5:7:8) who addresses this approach and explains it.
  32. ↑ Rabbi Yitzchak Zilberstein (Shiurei Torah Lrofim v. 2 siman 110) and Minchat Asher 3:123 take Radvaz non-literally. He doesn't mean if there's 50% of survival. He means putting yourself in a situation of sakana, which is a much lower threshold of risk, is forbidden. It is only obligatory to save someone else is the risk is below that threshold. Alternatively, Rabbi J. D. Bleich (Tradition, Spring 1993, Vol. 27, No. 3, pp. 59-89) and Asher Chanan CM 3-4:100 explain that Radvaz's teshuvot contradict each other. According to their approach the halacha follows the teshuva that does not require endangering oneself to save someone else.
  33. ↑ Kehilat Yakov (Igrot Vreshimot v. 4 siman 10)
  34. ↑ Rabbi Yitzchak Zilberstein (Shiurei Torah Lrofim v. 2 simanim 110 and 114)
  35. ↑ Sefer Chasidim, Yabia Omer CM 9:12, Yavetz (Migdal Oz Otzer Hatov pina 1 n. 85)
  36. ↑ Igros Moshe YD 2:174:4
  37. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 85). Rav Zilberstein (Shabbat Shabbaton p. 172-3) quotes Yavetz that a person may not endanger himself to save someone else unless the other person is a bigger talmid chacham and a tzaddik than you, your father, or your rebbe. Even to save your only son it is forbidden to endanger your life for him, unless the father is too old to fulfill pru urevu anymore. Rabbi Zilberstein asks why this is permitted and suggests that since the child could have more children it is like endangering yourself to save many people which is allowed. He also quotes a story about the Shaar Efraim that when his son was deathly sick he davened to Hashem to take him instead and so it happened that his son was healed and he died. However, it isn't a clear proof, says Rav Zilberstein, since davening isn't the same as doing an action.
  38. ↑ Rabbi Zilberstein (Bshilvei Harefuah v. 10 p. 58, Asya v. 7 p. 3, cited by Encyclopedia of Jewish Medical Ethics v. 3 p. 907) holds that a doctor who will endanger her fetus by treating her patient is not obligated to do so, but may do so.
  39. ↑ Gemara Tanit 18b, Rav Zilberstein (Shabbat Shabbaton p. 173), Igros Moshe 2:174:4, Mishpat Kohen 143
  40. ↑ Tzitz Eliezer 8:15:10:13 based on Sma 426:1 writes that a doctor does not have to place themselves at risk in order to save a sick patient. However, Tzitz Eliezer 9:17:5 presents several arguments why doctors may and should treat contagious patients. 1) He quotes Sht Harama 19 who writes that people shouldn’t be worried about any contagious disease since it isn’t the contagious disease mentioned by the gemara, namely Raatan. Tzitz Eliezer quotes Zera Emet who distinguishes between a general contagious disease and an epidemic, which a person should be worried about. However, he also cites the Knesset Hagedola (Shaarei Knesset Hagedola, Hagahot Hatur YD 335:2) who doesn’t distinguish and holds that a person should be bikur cholim even for someone who is sick with a contagious disease. Tzitz Eliezer concludes that doctors may and should treat patients, even if they have contagious diseases, and fulfill the mitzvah of bikur cholim and rapo yirapeh. 2) He suggests that it is permitted since this is the way of the world for doctors to treat sick patients. 3)  Furthermore, for a paid doctor there’s another reason to permit it. Gemara Bava Metsia 112a is clear that a worker can endanger himself for his job. Nodeh Beyhuda YD 10 is a good precedent for this concept. 4) Hagahot Maimoni holds that it is an obligation to enter into risk to save someone else.
  41. ↑ Tzitz Eliezer 12:57, Harefuah Leor Hahalacha v. 4 1:7, Rabbi Zilerbstein
  42. ↑ Sanhedrin 74b
  43. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 82)
  44. ↑ Maharam Ricanti holds that in this case it is an obligation to give up your life. However, Radvaz holds that it is only a middat chasidut. Yavetz (Migdal Oz Otzer Hatov pina 1 n. 83) agrees that it isn't obligation but it is a voluntarily mitzvah if he chooses.
  45. ↑ Radvaz holds that you may not give your sword in that case. However, Yavetz (Migdal Oz Otzer Hatov pina 1 n. 82) argues because you only need to give up your life not to actively kill someone, but you don't need to give up your life not to passively watch another Jew die.
  46. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 83) holds that it isn't an obligation to go through pain in order to save someone's life. However, Magen Avraham and Yabia Omer 9:12 disagree.
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