By Avraham Steinberg
Translated from Hebrew by Tzvi Hersh Weinreb
Rabbi Yosef Shalom Elyashiv, zt”l, the supreme halachic authority in our generation, rendered halachic decisions on the use of some of the latest medical technologies as well as on other medical matters. I was privileged to raise various weighty questions with him on such topics. Below, I briefly discuss some of these questions and his halachic decisions, all of which I heard directly from him.
Preventing Genetic Defects
If both a husband and wife are carriers of the Tay-Sachs gene, even though they are perfectly healthy themselves, there is a 25 percent chance that they will have a child who will suffer from Tay-Sachs, a life-threatening disease. Due to recent advances in medical technology, it is possible to assist such a couple in preventing them from having a child with Tay-Sachs. This process—known as pre-implantation genetic diagnosis (PGD)—is achieved via in vitro fertilization (extracting a number of eggs from a woman and fertilizing them with her husband’s sperm outside the womb). A single cell is then extracted from each fertilized egg and analyzed to determine whether or not the gene for Tay-Sachs is present. Those eggs in which the gene is not present are then implanted in the mother’s womb to develop into a healthy fetus. Those eggs in which the Tay-Sachs gene is present are destroyed, thus preventing the birth of a child afflicted with this devastating illness. PGD can be employed for any disease for which the gene or faulty chromosome is known. Hundreds of disease genes have been identified to date.
Is PGD halachically permissible? According to Rav Elyashiv, it is permissible, and the destruction of the eggs in which the gene for the disease is present is permitted. What are possible rationales for this ruling? 1. An egg fertilized in vitro is not considered a human being, and indeed has no potential to develop into a full-fledged human being unless the egg is implanted in the woman’s womb; 2. A fertilized egg is at the stage of development that is halachically considered “within the first forty days of gestation.” According to our Sages, at such an early stage of development, the fetus is defined as mere fluid and is not considered a person with a soul.
Rav Elyashiv’s ruling would also permit stem cell experimentation using cells of fertilized eggs for the purpose of curing severe diseases. The fundamental principles justifying such experimentation are identical to those identified above: an egg fertilized outside the womb, and especially within the first forty days of development, is not considered a full-fledged human being; therefore, its destruction constitutes neither abortion nor murder.
Anesthesia at a Brit
Medical evidence indicates that infants experience the pain of circumcision. Therefore, some physicians recommend performing circumcisions using localized numbing or anesthesia. One could either numb the localized genital area with an ointment, or use a local anesthetic by injecting an anesthetizing substance. The first approach would allow for the procedure to be performed even by non-medical personnel, including the mohel himself, whereas the second approach could only be done by a credentialed physician. As both methods entail changing the traditional procedure for performing a brit milah, some halachic authorities forbid both approaches. Rav Elyashiv ruled that it is clearly preferable not to change the procedure from the way in which it has been performed through the generations, nevertheless, in situations where the parents insist upon anesthesia, it is permissible for the mohel to apply the aforementioned ointment. However, he maintained that the procedure involving an injection should not be performed.
Recently, the practice of metzitzah b’peh, oral suction, has been making headlines. The question at the heart of the debate surrounding this issue is whether the practice can possibly infect the baby with the disease of herpes. In the past, many different objections to the performance of oral suction have been asserted. Among halachic authorities there is a consensus that suction must be performed, but they disagree as to whether the suction can be performed via a tube (thereby avoiding direct contact with the mouth) or via oral contact. Rav Elyashiv ruled that it is obligatory to continue the tradition of oral suction, for there is no conclusive scientific proof that a herpes infection would result from this procedure, unless the mohel had some sore or bruise in his mouth. In such a case, it would be forbidden for him to perform oral suction and another person should be assigned to perform it in his stead.
On the Brink of Death
Among halachic authorities, there is a widely held opinion that one who is suffering from an incurable malady and who, in the opinion of physicians, cannot survive more than a year is regarded as “a person on the brink of death.” According to Rav Elyashiv, one is classified as “on the brink of death” only if his anticipated life expectancy is no more than several months. Most halachic authorities agree that there is no obligation to extend the life of such a person, and if he is suffering, it is permissible to refrain from attempting to extend his life through various medical means (use of respirators or dialysis, surgery, et cetera). A number of authorities regard the very fact that a person is on the brink of death as “suffering,” and therefore maintain that even if the person is in a state of deep unconsciousness, it can be assumed that such a condition constitutes a sufficient degree of suffering to justify refraining from extending his life through the means described above (although in every instance it is prohibited to cease the provision of nutrition and hydration, or to actively hasten death by removing a respirator). According to Rav Elyashiv, only for someone who appears with absolute certainty to be suffering can we permit suspension of life-extending procedures. However, we would be obligated to extend the life of someone in a deep state of unconsciousness by every possible means, because we cannot clearly ascertain that he is indeed suffering. Similarly, in opposition to other authorities, Rav Elyashiv was of the opinion that there is a distinction between a minor and an adult. For an adult who is suffering in a manner which is visually apparent, it would be permissible to refrain from continued life-prolonging treatment. On the other hand, this would not be true in the case of a young child, for whom it would be necessary to attempt to extend his life by every possible means, even if he appeared to us to be suffering.
Halachic authorities do not agree on whether a person who has no brain and breathing functions but whose heart and other organs are functioning is considered dead or alive. Halachic consequences of this debate are numerous, among them implications for organ donation. According to Rav Elyashiv, as long as the heart is beating, a person is considered alive, even if it can be demonstrated that his brain function, including the brainstem as well as respiratory functions, has totally and irreversibly ceased. Personally, I did not hear from Rav Elyashiv his halachic justification for this ruling and I do not know his rationale for this decision.
Rabbi Dr. Avraham Steinberg is the director of the Medical Ethics Unit and senior pediatric neurologist at Shaare Zedek Medical Center and head of the editorial board of the Talmudic Encyclopedia.
Rabbi Dr. Tzvi Hersh Weinreb is executive vice president, emeritus of the Orthodox Union.