Jewish Bioethics: Prenatal genetic screening (4 of 4)

Can a Jewish mother undergo during her pregnancy prenatal screening tests. In other words, all those routine tests aimed to detect certain genetic conditions or birth defects in her baby(chas veshalom)?

The answer to this question relates directly with the differences of opinion among the rabbis on the status of abortion (see here) and the timeline when abortion will be authorized or not according to the different opinions (see here).

Based on the opinion of the former Chief rabbi of Israel Abraham Shapira, z'l, rabbi Melamed writes in penine halakha that it is preferable for a pregnant woman to perform all the prenatal screening she is asked by her doctor. Based on the results, if necessary, she would consult with a rabbinical authority how to proceed further. The expert rabbi will base his ruling considering all the pieces of the puzzle: the severity of the detected disease, the month or week during pregnancy when the disease is found, the mother's general heath, etc. Therefore, the more information he is provided, the more well-founded his verdict will be.    Even the mental health of the mother is a point of consideration for the rabbi. Consider this controversy among two contemporary rabbis:  Rabbi Lebushe Mordekhai thinks that the possibility of a mental disorders in the mother of an unhealthy child tantamount being her life in danger. While rabbi Nishmat Abraham disagrees and said that today's psychiatric medication helps the mother to cope with the risks of depression. As the reader can see, this is a very sensitive area and the opinions of the abbis differ, sometimes from one extreme to the other (seehere why). 

  

The information coming from prenatal screening is important even for those whose opinion is against interrupting pregnancy. Because there is a significant psychological value for the parents preparing themselves for the conditions they will find.  

  

  

IN THIS PARTICULAR AND DELICATE SUBJECT, I MUST ASK THE READER TO CONSIDER THE PROVIDED INFORMATION EXCLUSIVELY AS EDUCATIONAL MATERIAL. IF chas veshalom A DECISION NEEDS TO BE MADE, THE COUPLE SHOULD CONSULT WITH THEIR RABBI.  

  

Jewish Bioethics: Abortion and congenital diseases (3 of 4)

Previously (see here) we explained that the modern rabbis have very different opinions on the issue of abortion, when facing a congenital disease. We presented three main schools and we also warned the readers that this information should be used just as educational material. If chas veshsalom a couple faces such a situation, they have to consult with a doctor and a rabbi.  

This consultation should consist of two steps:

First, seeing a specialist physician to examine the results. If he advices interrupting the pregnancy, it is highly recommended to have a second opinion. It might happen than a doctor, because of his philosophical leniency toward abortion, would not see necessary to do more than the standard studies. It is recommended then, unless this is a doctor you know and trust, to have an independent second opinion on such delicate matter. 

Second, if the medical opinion is in favor of interrupting the pregnancy, the couple should consult with a rabbi.  There are many rabbis that are experts in this type of issues who can assess the Halakhic aspects and also the medical and psychological aspects of the situation, each of which will become a factor in his final Halakhic ruling.

Illustration: When the expert rabbi makes the decision of what rabbinical opinion to follow, even if the rabbi would be inclined to follow the stricter opinion which compares abortion to murder, he might consider other extenuating circumstances. For example, the impact on the mental health of the mother, etc. This consideration will affect the rabbi's final ruling.  

Also, and primarily, the expert rabbi knows if the detected disease is a mortal disease, like Tay- Sachs or a different congenital disorder, like Down Syndrome, etc. and he will rule accordingly. 

Most times, an expert rabbi will meet with the couple's doctor to see all the angles before he arrives to his Halakhic ruling. 

  

(Adapted from Penine Halakha liqutim, B, 264-265).

  

Next week, BH, we will deal with the subject of genetic testing.  

  

Shabbat Shalom!

Abortion and congenital diseases (3 of 5)

As we previously explained (see here) the fact that a case is not dealt with in Talmudic and early Rabbinic sources, virtually warrants a lack of consensus among modern rabbis.  

Contemporary Rabbis differ in their views on to the classification of abortion as murder, mutilation, etc.  (see here) and those views will determine their opinion in cases where a congenital disorder was detected and the parents are faced with the decision of interrupting the pregnancy. We are talking about diseases such as Tay-Sachs, Down syndrome and others .   Today, we will see that the opinion of the rabbis will also depend on the stage of the pregnancy.  The more advanced the pregnancy the more the rabbis will be inclined to forbid the interruption of the pregnancy, even if a congenital disorder is found. 

I will present today three main opinions on this subject. 

For the first opinion, during the first forty days we are not dealing with a fetus but with an embryo (no facial features, no capability of motion, etc). Accordingly, abortion will not be prohibited within the first forty days if a congenital disease is detected, (Rabbi M. Feinstein).

  

For the second opinion the boundary is the end of the third month, when pregnancy begins to be visible. Before that the fetus is still viewed as an integral part of its mother's body. According to this opinion, if a congenital disease is detected during the first three months, it will be permitted to interrupt pregnancy (Rabbi O. Yosef). 

  

For a third opinion the deadline is the seventh month. For this view, the determining factor is not the process of the embryo becoming a fetus or its visible presence. Rather, the determining factor is the fetus vital dependence on its mother.  Since normally only after seven months of pregnancy the fetus might live outside its mother body, before the seventh month, it is still considered as  part of its mother. In these extreme circumstances therefore, interrupting the pregnancy will be permitted  (Rabbi E. Waldenberg). After the seventh month, abortion will be authorized only if giving birth will endanger the life of the mother. 

  

(See  Penine Halakha  liqutim B, 258-259)   

  

IN THIS PARTICULAR AND DELICATE SUBJECT, I MUST ASK THE READER TO CONSIDER THIS INFORMATION EXCLUSIVELY AS EDUCATIONAL MATERIAL. IF chas veshalom A DECISION NEEDS TO BE MADE, THE COUPLE SHOULD CONSULT WITH THEIR RABBI.  

Shabbat Shalom!

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TWO VERSIONS OF LEKHA DODI

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Abortion and congenital disorders (Part 2/5)

The issue of abortion in case of a congenital disorder could not have been directly addressed in older rabbinic sources. Only today we have the means for such diagnosis. As we explained last week (see here) the fact that there are no Talmudic precedents makes this issue open to radical differences among modern rabbis. 

1. The stricter opinion considers abortion within the category of murder, but of a lesser degree. Despite the fact that Talmudic Law did not sanction abortion with  capital punishment (to this particular effect-the punishment- it is similar, but not identical, to the differentiation between homicide and manslaughter). According to this opinion, even if the child suffers from a congenital disease, it will be forbidden to interrupt the pregnancy. The only circumstance in which abortion will be allowed is when the life of the mother is at risk as a matter of self defense (Rab M. Feinstein IGM , CHM 2:9 and other rabbis).  

  

2. A second opinion holds that the unborn baby is not considered an independent life, and abortion cannot be compared to murder, in any degree. It is rather compared with hashchatat zera i.e., destroying the 'seeds' of life. Accordingly, this opinion  will be more lenient and authorize abortion in extreme circumstances, for example, if a congenital disorder is detected (Tzitz Eliezer 9:51 and others). 

  

3. A third opinion says that the unborn child is not considered an independent life but as a living organ of his mother. This opinion follows a Talmudic statement ('ubar yerekh immo). Accordingly, abortion will be classified under the category of 'mutilation' (Torat Chesed Milublin, EHE 42:32)  As such, abortion will be authorized for the sake of saving a life (when the mother's life is at risk) or if the organ or limb is irremediably sick , i.e., a congenital disorder. (Mishpete Uziel, CHM 3:46). 

  

Next week, BH, we will explain that these opinions would vary according to the diseases, the time of detection, etc.  (Adapted from  Penine Halakha, by R. Eliezer Melamed. Liqutim 2, pp 254-258). 

IN THIS PARTICULAR AND DELICATE SUBJECT, I MUST ASK THE READER TO CONSIDER THIS INFORMATION EXCLUSIVELY AS EDUCATIONAL MATERIAL. IF chas veshalom A DECISION NEEDS TO BE MADE, THE FAMILY SHOULD CONSULT WITH THEIR RABBI FIRST.  

  

  

SHABBAT SHALOM

  

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BIOETHICS: Abortion and congenital disorders in Jewish law (2 of 4)

Other than for medical reasons (see for example, here) abortion is forbidden by Jewish Law.  However, Jewish Law does not considered abortion as murder, i.e., a crime which deserved a capital punishment at the times when Jewish courts applied execution.  Similarly, a case in which a person accidentally caused a pregnant woman to miscarry her baby (such a case is explicit in the Tora, Shemot 21:22) was not classified as manslaughter (unintentional murder) and the penalty was monetary compensation. In this respect Judaism is different from other religions, for example, Christianity.   For the Catholic church, life begins at conception and for the most part abortion is equated with murder.

  

The Jewish criteria has implications for the examination of abortion when a malformation or a congenital disorder is detected in an unborn baby.   This type of cases represent a new challenge in Jewish Law. Obviously, the Rabbis of the Talmud or of the Middle Ages (Rishonim = Rambam, Shulchan Arukh, etc.) could not have possibly addressed such cases, because only in our days we have the capability to examine the health of an unborn baby.  Similar to cases like 'organ transplantation' or many 'end of life' issues, there is no Talmudic legislation to relay upon.  And it is important to know that whenever a direct precedent cannot be found in Talmudic Law, we should expect a number of different Rabbinic opinions, which based on Talmudic analogies (not direct precedents!) will arrive to various and dissimilar conclusions, sometimes, completely opposed to each other.  Additionally, with no precedents in Talmudic legislation, one is not able to say thatJudaism --as a whole-- unequivocally opposes or supports this or that position. The matter at hand, then, is open to particular ideas which have been formulated by modern Rabbinic legislators (=posqim) based on their particular analyzes and interpretations. 

As a rule, in these cases, every individual Jew is instructed to follow his or her own community's Rabbis and community's traditions. 

  

Next week we will present the main opinions in the matter of abortion and congenital disorders. We will based our discussion on the book: Penine Halakha, by R. Eliezer Melamed. Liqutim 2, pp 254-258. 

  

Shabbat Shalom!

  

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Bioethics: Abortion and Jewish Law (1 of 4).

The case of abortion primarily discussed by the Talmud refers to what we call today "therapeutic abortion", i.e., when the life of the pregnant mother is in danger, and the doctors estimate that the only way to save her life is by taking out/killing the unborn baby.  Independently of how Jewish Law considers the status of an unborn baby--we will analyze that later on--in this case, the early Talmudic sources (Mishna Aholot, 7:6, written ca.200 CE) already established unequivocally that if necessary, the unborn baby should be sacrificed in order to save the mother's life.  The Mishna understand that this is a case of rodef ("chaser", a potential killer) and therefore the principle of "self defense" is applied: If  A is attacked by B, if necessary, A can kill B to save his life (habba lehorgekha, hashkem lehorgo, Sanhedrin 72a). The baby, ironically, is viewed as an "involuntary" rodef. 

The Talmud analyzes the Mishna's statement and asks what happens when the baby is actually at the very process of birth. Should we still apply the same criteria of self defense and allow to sacrifice the life of the baby to save the life of the mother? After all, in this extremely difficult situation, the mother is also a rodef toward the unborn baby! The answer of the rabbis, in very simple terms, is that before the baby is born, the life of the mother has priority, because the life of the baby is still a 'potential life'. But once the baby is born, i.e. when at least the head and /or the majority of the body is already outside, his life could not be sacrificed, and both mother and baby are in an equal situation. The doctors should try their best to save both lives.

(Adapted from penine halakha, Rabbi E. Melamed, liqutim B, page 241-242).   

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Jacob meets Esav... and a surprising alternative ending  

Organ donation cards

In the previous weeks (see here), I explained the opinions of the Rabbis regarding living organ donation, and the differences on opinion over the determination of the moment of death, which affects the Rabbis' ruling on cadaveric organ donation.

In our days, the willingness to donate one's organs is stated in the driver license or in a card that one carries in his or her wallet.  The practical question we will address today is, what is the best way to declare that one wishes to donate his or her organs.

In my opinion, the best recommendation (and what I have personally done) for a Jewish person who wishes to donate his organs, is to register in the Halachic Organ Donor Society, and to carry their card in his wallet. 

The advantages of this card, compared to the general statement written in the driver license, is that the HODS card specifies the following points:

1. Organs should be removed only if they are to be transplanted, not for research or experimentation.  Due to the importance Judaism gives to the integrity of the body at the time of burial, only the possibility to save a life outweighs those concerns. 

2. To insure that medical care is not compromised in most sensitive moments, the HODS card specifies that:"Transplants may commence only after a medical team, that is independent of the attending physicians and that is unaware that I am a potential organ donor, determines death ...."

3. It also indicates that the body damage should be minimized: "All medical procedures must be done with proper respect, and minimum damage, to the cadaver." To this effect, consultations will be made with a family-appointed rabbi.

4. Finally, it gives the carrier the option to choose between one of the two major Halakhic opinions prevalent on determination of death:  a. Irreversible termination of  breathing activity, for those who follow the more stringent rabbinic opinion, or b. Irreversible brain stem death, for those who follow the Chief Rabbinate of Israel's opinion.  

Each person should consult with his or her Rabbi to make a final decision on this delicate issue. 

  

For those who wish to register as potential Halakhic organ donors, see here . 

For Israel, see here. 

May Hashem bless all of us with good health and a long life!

*Read more on organ donation from a Jewish Orthodox perspective, by rabbi Moshe Tendler 

*For Israel see here 

Organ donation: the heart or the brain?

As we explained last week, the issue of cadaveric organ donation in Jewish Law depends directly on the criteria applied to define death. First of all, as we said, there is a practical issue. Vital organs like the heart cannot be removed for transplant unless the heart is beating. And according to certain Rabbinical criteria, while the heart is beating, the patient is still alive, even if he is brain dead (see for example here).  The Biblical source for this opinion is that when man was created the Torah describes that God insufflated in Adam's innert earthly body a "breathing of life" (nishmat chayim), which indicates that life is determined by breathing.

Because of the complexity of this issue and its repercussions in Israeli society (hospitals, army, etc.), the Chief rabbinate of Israel issued a ruling a few years ago, indicating that in their opinion irreversible brain-death should be considered death, even if the patient is still attached to a ventilator, and his heart is still active.  They explained that although there seem to us that the patient is still breathing, once the brain-stem death is determined, the control-center of autonomous breathing is irreversibly deactivated and it has lost forever its control over the heart. They based their opinion on the same source in Bereshit: life is "breathing", meaning: autonomous breathing, i.e. the capacity to breathe. A patient with a dead brain who still breathes is not really 'breathing'. It is as if a decapitated body would be, somehow, connected to a ventilator: the heart would still beat because the hearth is an autonomous muscle and it could be kept functioning "mechanically" even when it is not controlled anymore by the brain-stem.  But, since there is no possibility for an autonomous breathing anymore, the patient is considered dead and under certain conditions, his organs might be removed for transplant. 

  

(to be continued...)

  

Organ Donation: the definition of death.

Last week we explained organ donation. We started from the situation in which the donor is alive. This type of organ donation includes bone marrow, blood transfusion and kidney transplant (see here ).

The most common form of organ donation, however, and the most controversial one is the cadaveric organ donation, i.e. donating the organs after one's death. This is the organ donation which is alluded to in the driver licenses where one authorizes or not to remove his organs for donation.

As we previously explained there is a wide consensus among rabbis about the permission to donate an organ or a segment of an organ while the donor is alive, especially since in our days the risks for the donors have diminished dramatically.

But with cadaveric donation there is a crucial point, which needs to be defined. That is: the definition of "death". Let me explain: some organs, like the heart for example, cannot be transplanted after they stops functioning. The heart must be removed from the body of the donor while it is still beating.

Up to the 1970s, this operation was impossible because irreversible cardiopulmonary failure was the only standard for determining death. But, later on, scientists developed ventilators and respirators which would maintain the breathing, avoiding the heart from stoping. In a situation known as 'irreversible stem brain death', the brain might completely stop its activity, while the patient is still breathing and his heart still beating. The question is: is this patient considered dead because his brain is dead, or is he considered to be still alive, because his heart is still functioning?

The answer to this question would determine the Halakhic status of after life organ donation.

(to be continued...)

Shabbat Shalom!

Understanding brain death, an educational video by HODS

For a comprehensive analysis of all the Rabbinical opinions on this matter and for one of the best available resources about organ donation in Jewish Law, visit: www.hods.org

Organ Donation in Jewish Law

In today's Halakha we will focus exclusively on living donors. The cases under this category are, for example, kidney donation; bone marrow and blood donation.

It is a consensus among modern orthodox rabbis that one should be willing to undergo a minor risk in order to save someone else's life.

In the past, many rabbis, among them Rabbi Yitzchak Weiss and Rabbi Eliezer Yehuda Waldenberg z'"l, had certain reservations about the permission to donate a kidney, because they thought that although a person can have a normal life with one kidney, the risks involved for the living donor, during and after surgery, were too high and would endanger his life.

In our days, however, donors are carefully screened physically and psychologically, and the surgical and post-surgical risks of complications for the donor have diminished dramatically, thanks to the advances of modern medicine. Today it is consented by most (if not all!) Modern Orthodox rabbis thatdonating a kidney is at least permitted, if not mandatory. Nevertheless, one may never obligate or coerce someone else to donate an organ, even to save the life of another person.

In his rabbinical response Rabbi Obadia Yosef evaluates the objections of Rabbi Weiss and Rabbi Waldenberg, and asserts that since today the risks involved in kidney donation are so low, it is considered a great Mitzvah to donate a kidney, fulfilling the commandment of saving a life, (piquach nefesh). Donating a kidney to save a life, he suggests, might be also required by the Tora's commandment "lo ta'amod al dam re'ekha", "You shall not stand still while your fellowman bleeds to death (i.e. is dying)" .

To understand the impact of this great Mitzva, let us keep in mind that a typical patient who receives a kidney, will live 10 to 15 years longer with a kidney transplant than if kept on dialysis.

(to be continued...)

For a comprehensive and reliable source of information about Jewish Law and organ transplant see Halachic Organ Donors Society