Jewish Ethics in Medicine

By David Podwall, MD
The board has asked me to speak upon the very topical issue of medical ethics, through the guideposts of both a Jewish perspective and my own as a neurologist. As you may know and if you have spoken to my mother, you definitely know that I am a neurologist in private practice in Great Neck. More so than other medical specialties, neurologists are called to deliver judgments in cases that have strong ethical component to them.
Being the day, which a decisions of life and death are decided, it is these precise issues that consume much of the literature on medical ethics. In my research on these issues, it is no surprise that there is a diversity of opinion. The joke about a desert island with two Jews and three temples holds a grain of truth. Yet there are certain posek, authorities on Jewish law and practice that appear to greater sway than others. One issue that got much attention in the late 70 and 80s was the issue of brain death. In the late 80s, a symposium on this topic was held at my medical school alma mater, Albert Einstein College of Medicine. There one of the most respected posek held sway; his name is Moshe Dave Tendler. He discussed how he would review records and patients for years at Jacobi and then presented this to his father in law, one of the premier poseks of the day, rabbi Moshe Feinstein. After much discussion and learning, Rabbi Feinstein wrote a tesuvah acknowledging the halakhic status of brain death, which had not been accepted earlier. What this shows is that it is possible for halakhic thinking to adapt and respond to the fact that medical practice is constantly in flux. For only in the last thirty years was it possible to keep a brain dead person in such as state in which organ donation was possible.
This brings me to the first major point I want to get across today. There can be books of Jewish thoughts and well-attended symposiums, but that is not what makes what they say or write important. It is the fact that it can be relevant, the medical world is changing in lightening speed. Half a century ago, the idea of keeping someones heart beating so it could be transplanted into another person was in the realm of science fiction. Today, it is accepted medical practice. But if Jewish law and thinking cannot adapt to the changing reality, then it loses its relevance. The issue of brain death is an excellent example of how Jewish ethics can maintain its relevance and yet be true to itself. When no less than Rambam himself said that all factors concerned death are determined by what the doctors will tell you (Rambam, Hilkhot Tetzicha 2:8). In my mind, he must have realized that what doctors will tell patients in his day and the future will be different and this needs to be taken into account. Often people discuss the idea of interpretations as either strict, which is known has humrah or lighter which is called koolah. But this is really an artificial divide. To paraphrase Rambam in his commentary in Sanhedrin where he berates those who misunderstand the abstruse

midrashic comments in the Talmud and interpret them literally If only they would admit that they do not understand. This allows Jewish thought to change with time and now the issue of brain death is very much accepted in Jewish law. Interestingly to note, that New York state law defines brain death but does make an exception in the family does not believe in the concept. So obviously, not everyone accepts it.
But the disagreements on the issue of brain death are minor compared to the charged feelings of the next two topics I will present
On Feb 25, 1990, a 26 yr old woman suffered from cardiac arrest at home, likely secondary to low potassium. After a month of being comatose, she entered what is known as a persistent vegetative state. She is awake and has sleep wake cycle, but no ability to interact with the environment or communicate with anyone. Over the next decade, several neurologists examined her and all agreed with this diagnosis. Brain CTs and EEGs were consistent. After years of advocating aggressive treatment for her, her husband decided that she was not going to improve, which lead to a schism between him and her parents that explode and eventually involve the governor, the Supreme court, the Congress, the President and capture the attention of the American people. A Florida court ruled that the husband as her guardian was authorized to order the removal of the feeding tube, a decision confirmed by an appellate court and the Florida Supreme court. Then the governor Jeb Bush signed emergency legislation requiring the reinsertion of the feeding tube, an act later struck down as unconstitutional. Then the US Congress enacted legislation requiring review of the matter in federal courts. The federal courts found she received proper due process and asserted no justification to reverse the state court. The US Supreme court refused to hear her case on a total of six appeals including the day before Terri Schiavo died. There was a strong religious overtone to the discussions about her situation, and of course, Judaism has an opinion or opinions
The opinion centers on how one view a feeding tube, if it is a way to provide basic nutrition or a medical device. Much of the opposition to the removal of the feeding tube follows from the line of reasoning the considers breathing, eating, and drinking to be normal activities of daily living and therefore it is an extension of normal physiologic process. But again, how we do that is much different today than in years past. A well-written article on this says this is premise on two assumptions. The first is that that the mode of treatment is beneficial or essential and no harm is done. So in this case, that food and water must be beneficial, or at least not harmful, and the delivery system, in this case a PEG tube must be basically risk free. Thus the aforementioned rabbi Feinstein position that this is assumption is the overwhelming issue to be addressed as to opposed to an objective obligation to feed per se.
It is in this capacity that as a neurologist that I can provide insight. This is a common situation we deal with terminal patients or those with advanced dementia. My observations are in agreement with generally accepted medical literature that such patients do not suffer from hunger or thirst like you or I would. In fact, studies have shown that patients do not necessarily get better nutrition and are at risk of aspirating (choking) from the food in the PEG. Additionally, there is no proof that these interventions in the advanced demented individual prolong their life. Now, in Ms. Schiavos case, it is clear that without this intervention she will die. But I will make the argument that her death was not from starvation or dehydration, but from the cardiac event that deprived her brain of oxygen 16 yrs ago. Therefore, the feeding tube may be stopped as it only removes an unnatural impediment to her death. This segways into the other major take home point of my talk is that none of this would have happened if she had a clear living will and health care proxy. Todays liturgy reminds us that only God knows who shall live, who shall die, who shall perish by fire, by water or by illness. We may die like Moses, of old age, 120 years, quickly and quietly, with the accomplishment of our lifes goal in sight in the presence of the Lord. More than likely, that not what will happen. We need to have the discussion however unpleasant today, so others will know how to make difficult decisions if they need so tomorrow. If you are not sure how, there are more than a few attorneys here who will be happy to help you in this process.
Medical ethics often involves the bookends of life. Therefore, one needs to discuss briefly the issues of stem cells. These stem cells have potential to develop into any tissue in the body, but over time, they mature and differentiate, decreasing their overall flexibility. The status of these early clumps of dividing cells was not an issue decades ago, but as medical science has advanced, we now have lots of these and the potential for them to be used for the common good. Why do we have so many? Well, look around the room; they are the byproduct of intro fertilization, as many more embryos are created than are implanted. These are considered of much interest in medical researchers for multiple conditions including those I see on a daily basis such as Alzheimers or Parkinsons. As someone who sees the huge toll these conditions take on the patients and these families, I find it hard to imagine passing over potential breakthroughs on the premise that one of these embryos could potentially become a person and therefore are more important than those already living. How is this interpreted by Jewish poseks scholars. First of all, in contrast with other religions, Judaism has no problem with playing god as long as we do so according to his rules. In fact, it is a religious imperative, to heal wherever possible. Jewish law encourages medical intervention to correct congenital and acquired defects and makes no distinction between stem and somatic (body) cell tissues. An example, one of the most influential posek in

Israel Rabbi Eliyashuv allows the preimplantation diagnosis to avoid a Tay Sachs baby. Rabbi Moshe Tendler, who I mentioned earlier, in testimony for the National Bioethics Advisory Commission, argued strongly in favor of the use of pre-embryos for stem cell research.
Most of you, like most Americans, likely felt that stem cell research should not be hindered as it is currently under federal law. Now, you can take comfort that your beliefs concur with the greater consensus of modern Jewish scholarly thought. So, my last point to you today is that it is not only important that you feel comfort in your beliefs, but that you advocate for them. Let me tell you, there is a distinct minority of Americans who feel otherwise and have no problem imposing their thoughts and beliefs on you. Judaism requires us to transgress all of the laws in the Torah with the exception of murder, adultery and idol worship, to save a life. If someone were gravely ill today on Yom Kippur, even the most orthodox rabbi would allow using a car to take him for care. This issue of stem cells is not going away and I hope that this talk today will allow you to be more comfortable for advocating for those who are and those who one day shall be in need. Who those people will be, we do not know, but that is why we are all here today.

David Podwall, MD
Neurological Associates of Long Island
1000 Northern Blvd. Suite 150
Great neck, NY 11021