High-Risk Medical Procedures - Part Three by Rabbi Chaim Jachter
In the past two issues, we have outlined some of the basic issues regarding risky medical procedures. The Gemara specifically permits one who is expected to live only a very short while (Chayei Shaah) to undergo a medical procedure that involves a great risk. Last week we discussed how much risk is tolerated and what is considered Chayei Shaah. This week we shall continue our discussion of this topic with a discussion of two more facets of this issue. We will discuss whether one is ever obligated to undergo a hazardous medical procedure, and whether one may risk very brief Chayei Shaah for an extended period of Chayei Shaah.
Risky Surgery to Eliminate Pain
Rav Moshe Feinstein (Teshuvot Igrot Moshe Yoreh Deah 3:36) argues that one may not undergo very risky surgery merely to eliminate pain. He addresses a case where the patient would be able to live a number of years even without a surgery if he would remain in bed and would not walk. Rav Moshe rules that we may undergo very hazardous surgery only in order to save one’s life, but not to eliminate pain or enhance one’s quality of life. Perhaps Rav Moshe reasons that since our bodies belong to Hashem, we have no right to endanger our bodies merely for our convenience.
On the other hand, Rav J.David Bleich (Tradition Spring 2003) presents a possible alternative opinion. He notes that Rav Yaakov Emden (Mor UKetzia 328) writes (in the eighteenth century) that a high-risk surgical procedure that is intended to alleviate the excruciating pain of kidney stones or gallstones is “Karov LeIsser” (close to being forbidden). Rav Bleich notes that Rav Emden regards it as “Karov LeIsser” and not actually forbidden, unlike Rav Moshe who specifically writes that such a risky procedure is technically forbidden. Rav Bleich writes that an analogous contemporary situation would be surgery to sever a nerve in order to eliminate pain (though I am unsure if the modern surgery is as risky as the surgery described by Rav Yaakov Emden).
In addition, Rav Eliezer Waldenberg (Teshuvot Tzitz Eliezer 13:87) specifically permits administering morphine to a very sick patient despite the risk involved (morphine depresses the respiratory system). Among the reasons offered by Rav Waldenberg for his leniency is that for a very ill patient, extreme pain may hasten death. Rav Shlomo Zalman Auerbach (cited in Shmirat Shabbat KeHilchata 32: footnote 150) suggests that it is permitted to administer morphine on Shabbat because great pain may endanger the patient (recall that we are permitted to violate Torah prohibitions on Shabbat only to save a life, but not merely to eliminate pain).
Moreover, Rav Bleich writes that it seems that the Rama (Y.D. 241:13) permits assuming a considerable risk in order to alleviate pain. The Rama permits one to amputate a limb in order to eliminate pain. Rav Bleich observes that in the time of the Rama (sixteenth century) amputation of a limb was accompanied by significant risk to the patient. To this Rav Moshe might respond that he forbids only surgery that involves considerably more risk than the surgery described by the Rama.
We may add that it is also possible that circumstances have changed since Rav Moshe issued his ruling in 1972. The current generation that has grown up with central heating and air conditioning along with other comforts unavailable to earlier generations probably has a dramatically lower tolerance for pain than previous generations. Thus, extreme pain constitutes a much greater danger for the current generation than in earlier times. It is also possible that Rav Moshe forbids very risky surgery only in the case he described where the surgery was to be done to eliminate psychological pain of the patient being confined to his house. However, it is possible that Rav Moshe would permit even a very risky medical procedure to eliminate true physical pain.
Risky Surgery: Obligatory or Discretionary
Ordinarily, one is obligated to undergo medical treatments. Indeed, the Halacha believes that a duly constituted and recognized Beit Din is authorized to coerce an unwilling patient to undergo medical treatment (Mishna Berura 328:6 and the soon to be published Gray Matter volume two). The reason for this appears to be that since our bodies belong to Hashem, we have no right to neglect our health. Just as a guardian of an object must properly guard the item under his watch, so too we must guard our health, for we are only guardians of the body that Hashem has given us.
However, Rav Moshe Feinstein (ad. loc.) and Tiferet Yisrael rule that even in cases where Halacha permits one to risk Chayei Shaah and undergo very risky surgery in the hope of achieving a cure, one is not obligated to risk his Chayei Shaah. I have not found a single authority that disagrees with this ruling.
Rav Bleich offers a very cogent explanation of this ruling. He explains (as we have cited in the past two weeks) that the Halacha obligates us to guard our bodies in the manner that prudent people normally guard their bodies. Rav Bleich also notes that Hashem has created people with different temperaments (Berachot 58a states that just as our faces differ, so too our temperaments differ.) Some people tolerate more risk than others.
Both the risk-averse and the risk-tolerant individual might be acting prudently, as there is a range and variation for what is regarded as reasonable behavior (Rav Bleich offers the example of investment strategy; some will invest very conservatively, others will invest aggressively, and yet others will seek to balance conservative and aggressive investments.) Thus, just as the person who is willing to risk his Chayei Shaah is guarding his body appropriately, so too the individual who does not wish to risk his Chayei Shaah is guarding his body properly, as some people are by nature more conservative than others.
Next week we shall, IY”H and B”N, complete our discussion of hazardous medical procedures with a discussion of the role of the Rav in the decision making process in this context.