Tuesday, September 23, 2014

Clashing Values - Rosh Hashanah and Rationalist Medical Ethics

Shana Tova and Ketiva V"Chatima Tova to all Rationalist Medical Halachists.  I wish everyone a wonderful Chag with their families and a healthy and beautiful New Year. May all of our discussions about medical issues remain purely theoretical for all of you, and may you enjoy a year of only health and happiness.  A few words about the upcoming holiday before I start my new topic, one which is sure to challenge you and stimulate some serious thought.

One of the primary themes of Rosh Hashanah is the acceptance of God upon ourselves as our King. This has always been quite a challenge for me, as most of us don't really believe in kings anymore these days.  When I think of a king, I think of an institution that is brutal, dictatorial, and based on hereditary luck.  I'd like to think that this institution will remain in the dustbins of history where it truly belongs. I like democracy. 

It is very difficult for me to imagine God as a king.  Imagine even the most kind, and the most just King.  A King who is as perfect a ruler as a human can possibly be.  He metes punishments only after careful consideration to those who deserve it, and rewards those who are good.  This is the King of the Disney movies, the kind of King we would supposedly love and cherish. But is this God? Is this who I want to make my "King" on Rosh Hashanah? 

The method I use to answer this Rosh Hashanah dilemma is the same method I use to tackle the most difficult Medical Halachic topics when they seem to clash with my Rationalist viewpoint.  I did this when I couldn't understand why some Orthodox Jews wouldn't donate their organs to save the lives of others, and when my soul understood that the right thing to do on Shabbat is to save lives no matter what the religious and ethnic background of my patient happened to be. I will explain.

To answer the question of the type of King we are supposed to accept this Rosh Hashanah,  allow me to quote from the Rambam in Moreh Nevuchim 3:23 (Friedlander Translation):
" ... The description of all these things (the description of Elihu in Job where he describes the wondrous creatures of God's creation - RMH)  serves to impress on our minds that we are unable to comprehend how these transient creatures come into existence, or to imagine how their natural properties commenced to exist, and that these are not like the things which we are able to produce. Much less can we compare the manner in which God rules and manages His creatures with the manner in which we rule and manage certain beings. We must content ourselves with this, and believe that nothing is hidden from God, as Elihu says: "For his eyes are upon the ways of man, and he seeth all his goings. There is no darkness nor shadow of death, where the workers of iniquity may hide themselves" (xxxiv. 21, 22). But the term management, when applied to God, has not the same meaning which it has when applied to us; and when we say that He rules His creatures we do not mean that He does the same as we do when we rule over other beings. The term "rule" has not the same definition in both cases: it signifies two different notions, which have nothing in common but the name. In the same manner, as there is a difference between works of nature and productions of human handicraft, so there is a difference between God's rule, providence, and intention in reference to all natural forces, and our rule, providence, and intention in reference to things which are the objects of our rule, providence, and intention. This lesson is the principal object of the whole Book of Job; it lays down this principle of faith, and recommends us to derive a proof from nature, that we should not fall into the error of imagining His knowledge to be similar to ours, or His intention, providence, and rule similar to ours. When we know this we shall find everything that may befall us easy to bear; mishap will create no doubts in our hearts concerning God, whether He knows our affairs or not, whether He provides for us or abandons us. On the contrary, our fate will increase our love of God; as is said in the end of this prophecy: "Therefore I abhor myself and repent concerning the dust and ashes" (xlii. 6); and as our Sages say: "The pious do everything out of love, and rejoice in their own afflictions." (B. T. Shabb. 88b.) ..."

This is the only type of King we should be accepting upon ourselves this Rosh Hashanah. Forget your silly, human, and mundane conceptions of justice, and certainly get rid of the Disney king image, and take the God that the Rambam is describing and make Him your King.  I can accept that.

So what does this have to do with Rationalist Medical Halacha!?!

That's easy to explain.  In the past 7 or 8 years of my life, I have concentrated my Torah study in areas that the traditional yeshivos I studied in during my youth purposefully ignored.  The study of Nach, and the study of the Moreh Nevuchim have changed my spiritual life in such dramatic ways, that I often feel as if I have discovered a new religion.

Focusing for a moment on the Moreh, the primary lesson that sums up the entire sefer is that one should never take for granted his simple and surface understanding for granted as the truth.  When one takes the simple understanding of almost any concept presented in the Written and/or Oral Torah, one is led to inconsistencies and contradictions that will almost inevitably lead to doubts and and rejection.  The way to come to the truth is to study and investigate to find out what is really the meaning of the Torah, the ma'mar chazal, or the pasuk, that seems to present a difficulty.  If you work at it, and you study it honestly and openly, you will understand, and your search will lead to the truth instead of leading to despair.

The Rambam did this for us with our concept of what we accept upon ourselves when we realize that God is our King.

We need to do this as well when we encounter difficulties in our study of the Torah.

Let us start the new year with a study of one of the most difficult and impossible to understand passages in Chazal (at least for me, and I suspect that many other rationalist medical halachic blog followers will agree).

The Mishna in Horayot, 3:7-8 says as follows:
3:7 - A man comes before a woman to (save) his life, and to return his lost object, and a woman comes before a man to clothe her and to save her from captivity, and if they both are at equal risk of abuse (in captivity) then a man comes before a woman
3:8 - a Kohen comes before a Levy, a Levy before a Yisrael, a Yisrael before a mamzer, a mamzer before a Netin, a Netin before a convert, a convert before a freed slave. when is this true? Only if they are equal, but if the mamzer is a talmid chacham, then a mamzer talmid chacham comes before a Kohen gadol who is an am ha'aretz
This mishna raises so many obvious questions, that it is almost unnecessary to list them, but I will anyway:

  1. Why should I save the life of a man before a woman just because he was born with a "Y" chromosome?
  2. If the risk of abuse is equal, why does gender give the man precedence over the woman?
  3. Do these rules apply nowadays?
  4. Where do these rules come from?
  5. Why should simple genealogy give a Kohen precedence over a Levy and a Levy over a Yisrael and so on?
  6. Why should a convert be one of the last on the list, shouldn't he/she be higher on the list? After all, didn't he/she accept Judaism voluntarily, while the others were just born into it?
  7. What about other circumstances that might make one person more "valuable" than another, other than prowess in Torah study?
  8. Most importantly: Can one conclude from this mishna that one person's life is more valuable than another simply because of the family he was born into? 
I will not answer these questions today. Indeed, many of you probably have given some thought to this mishna and have done some research yourselves. I am going to take the approach of the Moreh, and begin a lengthy and detailed analysis of this Mishna from many different perspectives.  I ask you to be patient and help me as I wade through this. Please comment as you wish, especially if you have something intelligent to say, but please, don't jump to conclusions until you have done the work and have intellectually honest things to say.

I hope to demonstrate that we can still remain faithful and intellectually honest Orthodox Jews, despite the fact that the Mishna seems to contradict so many of the modern values that we have come to accept and hold dear.  It will take me a while, so please be patient with me.  I also have a day job ;-)

Friday, September 19, 2014

Whose Life is More Important? When Modern Ideals and Ethics Conflict with Chazal

Orthodox Jewish Rationalists, and I include myself among that group, consider it appropriate to reconcile conflicts between the statements of Chazal and modern science by understanding that not all statements of Chazal were derived from Torah and Divine inspiration.  Thus, a rationalist doesn't have to perform mental gymnastics to understand why the Talmud makes many statements that conflict with our current scientific understanding.  As far as I am concerned, this remains the only intellectually honest way to remain faithful to our religious heritage, while still embracing the truth that we are presented with through honest scientific observation and study.

However, this is easy when it comes to facts of science, but much more difficult when it comes to the analysis of the moral and ethical observations that we find in Chazal.

For example.  It is easy to say that when Chazal stated that it is permissible to kill lice on Shabbat because they do not sexually reproduce, that this was based on their best understanding at the time, but we now know that lice actually do sexually reproduce.  It is easy to say that when Chazal prohibited eating fish and meat together, that they indeed believed that it was dangerous to one's health, though we now know that this is not the case. 

However, it is much more theologically difficult to say this when Chazal teach us about moral, ethical, behavioral or social observations.  While we innately know that their statements were clearly affected by the prevalent social attitudes, it is much more theologically challenging to say that these types of statements are no longer consistent with our current, and supposedly more advanced, attitudes.

Examples of this abound throughout the multitude of clashes between "modern" ideals that don't seem to be consistent with what Chazal teaches.  It seems to me that this area of conflict is often swept under the rug because it is just too controversial and too difficult to maneuver through the many potential pitfalls without seriously risking our adherence to Orthodoxy.  However, I also believe that for precisely this reason, if we are going to maintain our faith in both the written Torah and the Oral tradition, it is absolutely essential for us to tackle these problems.

The Chareidi approach is to claim that we have to ignore modern values and learn our values exclusively from Chazal and the traditional sources.  I believe that this approach is intellectually very dishonest, as it is abundantly clear to any honest observer that many modern values have become completely acceptable in Chareidi society despite the fact that they conflict with "traditional" values as expressed by Chazal and other traditional sources.  The guest in R Slifkin's latest blog post makes this point very eloquently.

I decided, when I began this blog 4 and 1/2 years ago, that I was not going to shy away from these types of conflicts.  More than anything else, I want to remain faithful to the Torah while finding  intellectually honest answers to these types of conflicts.  Naturally, I will focus on medical topics, because that is where I am most competent.

My previous posts on the subject of treating gentiles on Shabbat represents my most comprehensive foray so far into the morass of trying to sort out the halachic imperatives of keeping Shabbat while understanding the different social environments and ethical mores that existed in the time of Chazal.  I hope that my approach to that issue has helped my fellow rationalists on the path toward finding a way out of these types of conundrums.  Let us continue together on this path as we tackle more issues like this on this blog.

The next topic I will address, bli neder and B'ezrat Hashem, is even more challenging, and even more fraught with potential pitfalls.  It will take us some time, and serious research, and I hope you can stay with me as I develop my thoughts.

The topic is the subject of triage in life-threatening situations. In particular, what should the priorities of society be when there are limited resources and those resources must be dedicated to one person or one group of people to the detriment of others.  Hang in there for my next post, where I will begin the analysis of this issue in depth.

Friday, September 12, 2014

Vaccinations: Some Comments

Over at Rationalist Judaism, the discussion has come up regarding vaccination and R' Shmuel Kaminetsky's support for parents who choose not to vaccinate their children.  There is much to be said about this topic, but I don't have much to add that hasn't already been said.  The most comprehensive and rational treatment I've seen yet is R' Asher Bush's article in the Hakirah Journal here.  Another nice article, which gives a little bit of a historical perspective as well, is by Dr Eddie Reichman in Jewish Action here.

Frankly, I am not sure what to make of this trend or how to approach it.  It is clear that the objection to vaccination among the "non-vaccinators" comes from a deep-seated mistrust of modern medicine. This can be prevalent among Chareidim, which is probably mostly a result of the overall mistrust of science that is so ingrained in that society.  However, it is also common among many other groups, such as the growing number of liberal minded people who are mistrustful of the medical establishment, which they consider part of the corporate, profit-oriented elite.

When these two forces are allied, it is impossible to overcome the prejudices that are inevitably the key factor in forming opinions on this matter.  It is hard enough to convince a non-religious oponent of vaccination by presenting the medical evidence that contradicts his/her views.  They will always claim that it was cooked up by the pharmaceutical companies in order to make a profit selling vaccines.  However, it is exponentially more difficult when the belief in that conspiracy theory is compounded by a belief that all science is only relevant if it is approved by "Da'as Torah."

I honestly have no idea how to overcome this problem, and I am very afraid that it will be getting worse and worse in the coming years.  At least the readers of this blog should inform themselves about vaccinations, and a great start would be to read the articles I linked to in the beginning of this post.  I don't think I have much more to add. Shabbat Shalom.

Thursday, September 11, 2014

MBP Again! A Scientific Perspective?

Well, just as I was preparing my next topic for discussion, MBP has resurfaced as the big subject of conversation in the rationalist blogosphere.  So I just HAD to say something, so here it is.  First, please read this article here.  A well known group of MBP defenders authored this article, and it is important to read before you continue with this post.  Second, please read R Natan Slifkin's response to this article here.  Now you are prepared for what I have to say.

The article is full of very tricky language and misleading use of medical literature, so one has to be careful not to fall into the trap being laid out by the authors.

They begin with a statement designed to make one think that New York City is outlawing a religious practice:
"In  September 2012, New York City passed a regulation declaring metzitza be peh (MBP), a part of many ritual circumcisions, illegal, unless the circumciser or mohel obtains a signed form from the parents, including: “I understand that direct oral suction will be performed... and that [the New York City Department of Health and Mental Hygiene] advises parents that direct oral suction should not be performed because it exposes an infant to the risk of... herpes (HSV)... infection, which may result in brain damage or death.”
The language chosen by the authors, that MBP is "illegal", is a deliberate misrepresentation of the actual regulation.  The NYC government website here describes the regulation in a very clear manner.  It is clear that the city deliberately avoided making the practice illegal, and simply required a consent form prior to its performance.  While one can argue that this is simply an argument over semantics, sometimes a choice of language can be highly misleading even if it is technically true.  Especially when the pattern repeats itself throughout the article as I am about to demonstrate.

Why would they choose to misrepresent the true nature of the city regulation?  Of course they do so in order to frame the city health department as the enemy of religion, instead of simply as acting in their proper capacity in their mandate to protect the health of the citizens of New York City.

I will take a pass on the legal comments that follow in the next two paragraphs of the article, simply because I am not a legal scholar and don't know enough to comment on the nuances of the court decisions.  However, they then continue as follows:
"In response to the ruling, Sam Sokol wrote, on these pages, an article entitled: “Analysis: New York circumcision controversy emblematic of longtime Orthodox ideological split,” advancing two positions: (a) “Contemporary medical knowledge” supports the assertion of a causal link between MBP and HSV infections, as stated by the Centers for Disease Control and Prevention and “several prominent contemporary decisors of Jewish law (poskim)” – specifically Rabbi Tendler, described as a son-in-law of Rabbi Feinstein, and Rabbi Slifkin, otherwise known as the Zoo Rabbi; (b) MBP is practiced by a fringe segment of the ultra-Orthodox."
In item "a", the authors claim that Rabbi's Tendler and Slifkin are the rabbinic advocates of the idea that there is a causal link between MBP and HSV infections.  This is both highly confusing and grossly inaccurate, as neither of these Rabbis ever claimed to be the source of the assertion that there is a causal link between MBP and HSV.  The causal link was reported in the medical literature, and each Rabbi reacted to the information appropriately: Rabbi Tendler, in his role as a posek, by proposing that other forms of metzitzah are halachically acceptable; and Rabbi Slifkin, in his role as a popular proponent of the Rationalistic approach to Jewish tradition, by explaining how different streams of Judaism would react to this scientific information.  Neither Rabbi ever "advanced" the "position" that MBP causes HSV, as the authors claimed.

The authors also identify these two rabbis (WADR to these two individuals), as if they are the only rabbis who have supported halakhic alternatives to MBP! When Sokol wrote about "several prominent decisors of Jewish law" he was referring to none other than the Chasam Sofer, Rav SR Hirsch, Rav Azriel Hildesheimer, and numerous other poskim throughout the generations!

But then in item "b" they fall right back into their pattern of using misleading and deliberately incendiary language.  They claim that Sokol "advanced the position" that "MBP is practiced by a fringe segment of the ultra-Orthodox".  Once again they choose language that portrays their detractors as the enemy, as if Sokol was demeaning the practitioners of MBP by calling them a "fringe segment."  In fact, Sokol uses no such demeaning language, as he tried in his article to be balanced and open to the fact that there are different streams and approaches to this issue.  They are trying to pick a fight, while Sokol was simply being open and honest.

However, the real problems begin when they start quoting the medical evidence. 

Allow me to explain some basic facts that most people who are not familiar with reading medical articles are not necessarily aware of.

First fact. To prove a true causal link between two variables "a" and "b" is extremely rare and extremely difficult in modern medicine.  Even when data strongly suggest an association between the two variables, one can often claim that a hasn't actually been proven to cause b.  See this article in Wikipedia which explains this concept.  Therefore, the authors are actually correct when they claim that no causal link has ever been proven.

However, if a correlation between MBP and HSV infections in the newborn has been identified (which has been identified), and there is a clear mechanism by which MBP can cause HSV (which there is), and this implied causation fits with everything else we know about both variables (which it does) then assuming a causation between a and b is extremely reasonable even if technically one can claim that it hasn't been "proven".  Especially when the danger and risk of assuming that no causation exists is so significant. So the authors are playing the semantics game again by claiming that there is no "causal link".  While it is a true statement, it is also a very dangerous statement.

Another fact.  Every single study published in scholarly medical journals ends with a section describing the limitations and flaws of the study.  This is important for any honest researcher to recognize openly the particular shortcomings of their work.  Even the most widely accepted and influential studies have flaws, and it is  always important for physicians who use these studies to care for their patients to understand the limitations of the evidence presented. However, recognizing the limitations does not invalidate the findings of the study, it simply helps us understand the limits of the practical application of its findings.

So now let's look at the following paragraphs:
"A 2013 University of Pennsylvania study, moreover, analyzed the relevant evidence and all the prevailing literature and concluded that: “This evidence base is significantly limited by a very small number of reported infections, most of which were not identified or documented systematically. Other important limitations include incomplete data about relevant elements of the cases, the presence of confounding factors, and indirect data sources.”
"As to the single study claiming statistical evidence for an elevated risk among babies who underwent MBP, the Penn report noted that the study lacked scientific foundation: “this finding is limited by methodological challenges in determining the total population at risk, limited information about some of the cases, and the small number of infected infants.”
These paragraphs are so grossly misleading that it is obscene. The actual conclusion of this Pennsylvania study reads as follows:
"...Standard principles of infectious disease suggest that exposing a neonatal circumcision wound to human saliva, even briefly, creates a risk of HSV transmission... Neonatal HSV infection can cause severe morbidity and death, so mitigating potential risks for infection is critical. Current evidence suggests that direct orogenital suction during ritual circumcision was the likely source of infection in recent cases that resulted in significant illness and death (emphasis added)..."
The authors simply ignored the findings and conclusions of the entire University of Pennsylvania article, and they blatantly contradict the opinions and assertions of the researchers.  Instead they chose to quote those few sentences in which the researchers honestly discuss the understandable limitations of their study.  In fact, the Pennsylvania researchers recommended that the only way to prove causality would be to design a randomized trial with two groups of ultra orthodox Jews, in two cohorts, and to perform a proper prospective trial.  We all know that this would be completely impossible to do, as the ultra-Orthodox would never cooperate with a trial that asks half of them to randomly decline MBP.

We therefore have to rely upon the best science available, and on common sense.

Although this concludes my analysis of what was written in the article,  I cannot leave the topic without mentioning what was not written in the article. No mention of the following scientific articles that support the relationship between MBP and HSV infection:

Gesundheit B - Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. Pediatrics - 01-AUG-2004; 114(2): e259-63

Centers for Disease Control and Prevention (CDC) - Neonatal herpes simplex virus infection following Jewish ritual circumcisions that included direct orogenital suction - New York City, 2000-2011 MMWR Morb Mortal Wkly Rep - 8-JUN-2012; 61(22): 405-9

Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Isr Med Assoc J 2003;5:893–4

Rubin L, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatr Infect Dis 2000;19:266–8

Koren A - Neonatal herpes simplex virus infections in Israel Pediatr Infect Dis J - 01-FEB-2013; 32(2): 120-3

Yossepowitch O1, Gottesman T, Schwartz O, Stein M, Serour F, Dan M. Penile herpes simplex virus type 1 infection presenting two and a half years after Jewish ritual circumcision of an infant.  Sex Transm Dis. 2013 Jun;40(6):516-7

These are just some of the articles that have been published and have been ignored by the authors.

In summary, the authors of this article chose to:
  1. .... mischaracterize the New York City government as if they were somehow trying to outlaw a religious practice, while in fact the City was only trying to protect the health of its' citizens, while preserving their religious rights
  2. .... misrepresent Rabbis Slifkin and Tendler as if they were the ones who asserted that there was a causal link between MBP and HSV, while they simply were using the available medical information to discuss areas that they are fully competent and qualified to discuss.
  3. .... identify the above two rabbis as if they are the only Orthodox Rabbis who support alternatives to MBP, while numerous rabbis including the Chassam Sofer are the actual sources for the halakhic alternatives!
  4. .... misquote Sam Sokol by claiming that he referred to "fringe segments" in order to make him sound like he was demeaning to the practitioners of MBP
  5. .... state that no "causal link" has been identified between MBP and HSV, which although in the strictest sense it may be true, it completely misrepresents what contemporary medical science believes to be true based on the overwhelming available evidence
  6. .... completely and utterly ignore the findings and conclusions of the most important and most complete study of the relationship between MBP and HSV, and instead to quote the researchers discussion of the limitations of their study
  7. .... completely and utterly ignore the scientific studies that contradict their contention that MBP does not cause HSV


Friday, August 29, 2014

Organ Donation after Cardiac death

Just a quick post before Shabbat begins.  I noticed an article in the Jerusalem Post that may have an effect on the way the Chareidi community views becoming an organ donor. Apparently, doctors in Israel were successful in transplanting a kidney from a donor that had been without a heartbeat for several hours.

This is an exceptional accomplishment, because it opens the possibility for those who believe in Cardiac death to donate their organs after what they consider to be halachic death.  (See my extensive posts from October 2010 for more on this topic). Whether or not it actually changes the practice of the Chareidi world remains to be seen of course.

Just FYI, there still is a long way to go before it can become regular practice to harvest donor organs after cardiac death.  The new techniques will need to be tested and attempted on other organs as well as the kidneys.  Furthermore,  harvesting the organ prior to cardiac death is still much more likely to be successful.  However, maybe it can open the path for a Chareidi living will that explicitly states that the individual is willing to donate his/her organs if cardiac death is established first.

This may turn out to be a real opportunity for the Chareidi world, once organs can be donated even after cardiac death, they can join the ranks of the potential organ donors! I certainly hope we see that happen!

Monday, August 25, 2014

MBP - Does a rinse with Schnapps help?

I must admit that I was somewhat caught by surprise by the overwhelming responses to my previous post about MBP.  In addition to the comments that are published, I received many emails as well, and tried my best to respond to all of them. Sitting up late at night in the hospital can sometimes be a useful time for emails!  I used to use that time for Nach Yomi, and catching up on medical articles, but now it seems to be email and blog time! BTW, Nach Yomi is an OU program that has changed my life, and I highly recommend it to the many Nach deficient people out there.  If even one of you takes up Nach Yomi as a result of my encouragement, then this blog may turn out to be something useful after all! But let's get back to MBP.

If at all possible, I beg you to comment publicly on the blog rather than send me an email.  I want everyone to benefit from your thoughts, whether you agree with me, or not.  If you want to remain anonymous, I have no problem with that at all.  The discussions generated by the comments can be very interesting and beneficial for everyone, and it allows me to respond publicly.  I will still read and respond to emails, but please let everyone benefit from your ideas, not just me.

One of the issues that has come up over and over again is the question of whether or not rinsing the mouth with wine or whiskey helps mitigate the risk of transmission of the HSV virus.  One person even wrote to me in an email, that apparently in Yemen, the custom was to perform the MBP with a mouthful of Arak, and even to rinse several times.  His source was Rav Kapach's Sefer Halichot Teiman.  Since there has been so much interest in this topic, I am dedicating this post to the question of alcohol rinses and HSV transmission.

There are many reasons why the alcohol rinse does not mitigate the concern for HSV transmission.  For starters, alcohol as a disinfectant loses most of its potency when it is less than 60-90% concentration.  Even the strongest whiskey's are rarely more than 40-45% alcohol.  See the CDC here for details on the concentration of alcohol necessary for it to have any useful potency for germicidal use. Furthermore, bear in mind, that the alcohol is further diluted as soon as it is placed in the mouth by natural saliva.  So the alcohol used is simply not strong enough to kill bacteria or viruses.

In addition, even if one were to use pure ethyl alcohol to rinse the mouth, it would still be impossible to kill all the viruses and bacteria present in the mouth.  The mouth is full of areas to which the alcohol will never reach, such as the gums, between the teeth, all the folds between the cheeks and lips and the teeth and so on. It is well known that it is impossible to actually disinfect the mouth.  So even if you could reduce the amount of virus present in the mouth, there is no way anyone can eliminate the possibility of transmission.  To make matters worse, the skin on the outside of the lips can transmit virus as well, and this area is never rinsed.

We also need to bear in mind, that the germicidal activity of alcohol, even when it is potent enough to kill bacteria, is measured when it is used on smooth surfaces, together with scrubbing the surface.  In order to effectively replicate this, one would have to scrub every surface within and around the mouth (which is absolutely impossible like I described before) with alcohol with at least a 70% concentration!

The bottom line is that the alcohol  in wine and schnapps is simply too weak to be effective, and even if it were an adequately strong germicide, the mouth cannot be disinfected.

I think it is worthwhile to bring another example that will hopefully drive home the point that the only way to eliminate the risk of HSV transmission is to eliminate the direct contact between the one who has the virus and the baby.

We all know that surgeons sterilize their hands and arms, or "scrub", before performing surgery and coming into contact with open wounds.  However, would anyone ever even think of allowing surgeons to operate bare-handed just because they washed their hands really well and scrubbed them with germicidal solutions?  Of course not! We mandate gloves and gowns and etc. because it is common sense to eliminate contact between the surface of the surgeon's hands and the open wounds.  That is the only way to guarantee that germs do not get passed back and forth.

In the same way it makes no sense to allow contact between someone's open mouth and the open circumcision wound, no matter how much schnapps one may rinse his mouth with.

Thursday, August 21, 2014

MBP - Dispelling Some Common Misconceptions

The mere sight of the term MBP (Metzitza B'Peh - direct oral/genital suction of the circumcision wound) may set off fireworks in the minds of many of the medical halachic rationalist readers of this blog.  Some of you might have been waiting for me to say something about this subject. MBP has been in the news lately due to some high profile court rulings in New York, so it is once again a hot topic.  However, I must disappoint you by admitting that I don't have that much to add that hasn't already been said.  In fact, a close friend of mine, Shlomo Sprecher, has already written what I consider to be the most definitive rationalist medical halachic (even if he didn't use the term "RMH" to describe it!) article on this topic, and you can read it here.  I highly recommend that you read it if you haven't already done so.

However, I have come across an extreme amount of ignorance when it comes to understanding exactly what the medical concerns are regarding the transmission of HSV (Herpes simplex virus) and circumcisions.  The ignorance in the Orthodox Jewish world seems to reflect the ignorance of the general population about this virus, which I encounter on a regular basis in my medical practice. As such I feel like I need to counsel everyone regarding how this virus works, and then you can understand what the issues really are.

For starters, HSV is a virus.  That means that it cannot be treated with antibiotics.  This particular virus has the nasty habit of being incurable, which means that once you become exposed to it, it will be in your system forever.  It has figured out a way to hide deep inside your nerve roots ("ganglia") and hang out there for the rest of your life.  Every once in a while it may decide to leave its hiding place, travel up the nerves to your skin, and cause a lesion to pop out on your skin and annoy you.

When this happens, the sore is likely to shed more virus, so if someone else becomes exposed to it, he/she can catch it from you.  However, the virus is even sneakier than that.  Sometimes it travels out to your skin and sheds virus, but doesn't show any sores at all.  This is called asymptomatic shedding.  This means that you can be shedding and transmitting the virus and have no idea at all that it is going on. While an active lesion is much more likely to shed virus than when there are no symptoms, it is well known that asymptomatic shedding can and does occur.

So that's the bad news, what is the good news?  The most important good news is that HSV is generally not a very dangerous virus at all, in the overwhelming majority of cases.  The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while.  Most people don't even know that those annoying sores are HSV, they just think it is a pimple that came and went after a few days.  They usually don't even know that they have HSV, and they certainly don't know that they can transmit it to someone else!

But that good news can also be bad news. Why is that? Because if you don't know that you can transmit it, and it can be transmitted even if you have no symptoms at all, how are you supposed to prevent the transmission of HSV throughout the general population? Well, guess what! You now understand why close to 90% of the adult population of the US has been exposed to HSV 1 at some point in their lives.

When two moist surfaces of the body, such as the oral region, and/or the genital region come into contact, and one surface is shedding HSV, this is the most effective way to transmit the virus.  If one person has a cold sore (which is caused by HSV), or is shedding asymptomatically, and people share a cup, a kiss, share a food utensil, wipe their mouth or cough and then pass the kugel, or any other moist contact, the virus can be transmitted.  Of course the chances are very small each time this type of contact occurs, but if it happens over and over again, it only takes once ...

The vast majority of people will have been exposed to HSV in this manner.  By now you should understand that a person with HSV 1 is usually not infected because he/she is guilty of some type of sexual contact. Most of the time it was completely innocent, and most of the time the person him/herself is never even aware of having been exposed.

You probably noticed that I mentioned HSV 1, which means that there is another type called HSV 2.  This is a very closely related virus that tends to hang out more in the genital region.  This type is usually transmitted through genital or oral/genital contact.  However, there is much crossover between the two types, as HSV 1 is often found in the genitals, and HSV 2 is often found orally as well.

HSV 1 outbreaks are generally more mild than HSV 2 outbreaks, and especially with HSV 2 in the genitalia, the first outbreak can be quite severe.  But both types of the HSV virus have a very similar clinical course, and they are transmitted in basically the same way.  The reported cases of HSV transmission through MBP in New York were HSV 1 cases, not HSV 2. This is important because HSV 1 is much more common, and is still more associated with Oral infection than with genital infection.

So what's the big deal? If it is true that HSV is only a nuisance and rarely causes health problems, why is it such a concern? What is all the hoopla regarding MBP?

The big deal is that in certain very rare cases, if HSV gets into certain body fluids it can cause very serious problems.  Those two places are the blood, where it can cause viremia (a viral blood infection) or in the brain where it can cause encephalitis or meningitis.  Viral infections such as these can be extremely dangerous, and are notoriously difficult to treat, especially because antibiotics do not work against viruses.  Furthermore, as you recall, there are no cures for HSV.

When would someone be at highest risk for such a horrible infection of the blood or the brain with this virus?  For starters, if it is introduced directly into the blood. That would be really bad.  Now if you take a person who does not have a very strong and mature immune system, that would be worse.  Then if it enters the brain of someone who is still developing neurologically, that would be tragic beyond words.

Now let's make it scarier.  Let us find a well meaning person.  This person seems perfectly healthy.  He himself has no idea that he has any infections of any type. Everyone around him knows that he is "very clean" and scrubs his hands really well.  He has lived a virtuous lifestyle and has never exposed himself to any situation which would make one concerned that he may have gotten any transmittable diseases.  Maybe when he was a child in cheder he shared a cup of juice and got a little cold sore, which went away after a few days because his Mom shmeared on some Vaseline.  He was a little "tzaddik'l" and went on to become a popular Mohel.  But he has this HSV 1 virus for life.  In his mouth.

Let us go further. This mohel never sees any lesions that he thinks could represent a major health risk, except occasionally he may get a cold sore which he thinks is just chapped lips.  The mohel is such a tzaddik and so well loved and well respected that he does a Bris Milah just about every day in his community.  Asymptomatic shedding is very rare, so it only happens a few days a year, but he does a bris milah every day ....

And one fine day, a happy young couple brings their beautiful little child to shul for his bris milah.  The well meaning, wonderful Mohel performs the ceremony.  He does MBP. This young child, with an immature immune system, and a developing nervous system, now has an open wound, giving the virus direct access to his bloodstream, and to his newly forming brain.  The Mohel happens to be shedding virus that day, and has no symptoms whatsoever. And the virus gets into the baby's bloodstream, and it replicates, and may God save us, a horrible, totally preventable, unspeakable tragedy occurs.

This is the problem.  Like I said before, the cases reported in New York were HSV 1, simple Oral HSV that 90% of the adult population has.  The only way to prevent it from happening is by avoiding the exposure in the first place and protecting our children from tragedy.  May common sense prevail.


In this post, I have tried to dispel the following extremely prevalent and extremely dangerous notions (I have heard ALL of these in murmurings at shul kiddushes, Shabbos tables, during leyning - bein gavra l'gavra only of course etc...)
  1. If the Mohel is a genuine tzaddik and ben Torah there is no risk of herpes transmission
  2. the Modern Orthodox are just trying to find ways to show that the Chareidim have Herpes infested Mohelim and they are all hypocrites
  3. If the Mohel has no history of disease and has no herpes sores there can't be a risk
  4. This Mohel has done thousands of Bris Milah ceremonies and "no one" has ever had a problem (this would be extremely difficult to prove, and even if it was true, it still doesn't protect you)
If any of you have heard other such comments, I would be interested to hear them.

Thursday, August 14, 2014

Home Births and Halacha

The authors conclude their article with a discussion of the issue of planned homebirth vs. hospital birth. In their words:

"Similarly it is commonly believed that the twentieth-century transfer of births from the home to the hospital has aided the cause of piqquaḥ nefesh by lowering infant mortality. Statistics, however, do not support such a belief. Western countries with more home births than in the United States have lower maternal mortality rates and lower infant mortality rates than ours.26 Australia, New Zealand, Japan, and all Western and Central European countries all have lower mortality rates than the U.S.’s, yet more than one-third of all of their births are planned home births attended by a midwife. ...
Within the United States, studies also show that for normal pregnancies, home births are at least as safe as hospital births and that births attended by midwives are safer than births attended by physicians. Certain procedures such as multiple vaginal examinations and routine premature rupture of membranes are commonly performed by obstetricians, but not by midwives. Rather than promoting piqquaḥ nefesh, these interventive procedures, which naturally necessitate viewing of and contact with female genitalia, have actually been shown to be dangerous to the birthing woman and to her child.  There is also growing concern—even among some obstetricians—that other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs to hasten labor all have few health benefits and may indeed harm the baby."
The issue of planned homebirth has been the subject of significant discussion in recent decades, and there is no way that I can do it justice on this blog.  However, I will respond to the authors contentions with a few simple points that I believe are very important.  I will first refer the readers to the statement of ACOG on this topic here.  It is worthwhile reading, but as is often the case with medical literature, some important points still seem to be misunderstood by the public.

Before I explain anything, I need to remind the readers of this blog, that it is a blog for medical halacha and not meant to be a discussion of medicine.  So we need to establish the halachic issue here before we move on.  The halachic issue that the authors of the article are raising is that they contend that having a baby in a hospital may potentially be more risky then a home birth.  This would be a halachic problem, suggesting that a home birth may actually be safer and thus halachically preferable.  In their words, having a baby in a hospital exposes one to " ... interventive procedures ... [which] have actually been shown to be dangerous to the birthing woman and to her child..." Furthermore, according to the authors, " ... other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs ... may indeed harm the baby."

Could it be that having a baby in a hospital is riskier than a home birth, and thus halachically prohibited?

The best and most comprehensive study evaluating this issue, is the one quoted in the ACOG statement that I linked to above.  This was a meta analysis evaluating all known scientific studies of home birth vs. hospital birth.  The bottom line is that even under the best of circumstances (and I will describe briefly those circumstances in just a moment) a home birth has a rate of neonatal death that is 2-3 times higher than hospital births.  Now it is extremely important to understand that the actual rates are so low, (1.5-2/1,000 vs. .4-.9/1,000) that the studies certainly confirm that a planned home birth can be considered safe if done properly.  But to claim that it is less dangerous than, and thus halachically preferable to a hospital birth is simply wrong.

Now here are the points that need to be understood.

  1. No studies can actually be ever done that will truly answer the question of which birth is safer.  That is because in order to do this study, we would need to randomize women to planned hospital vs. planned home borth.  This is impossible in today's society.
  2. In every study that did try to retrospectively compare (or prospectively without randomization)  the two birth locations; only women that were healthy, had uncomplicated pregnancies, and with normal and healthy babies were allowed as participants in the studies.  So the studies only established that in these types of cases (of course this represents the significant majority of pregnancies) that it is safe to have a home birth. No one disputes that this is true.
  3. In all of the countries mentioned by the authors, those countries have in place highly integrated health care systems that address which women are candidates for home delivery, which personnel are certified and qualified to attend and supervise home deliveries, and transportation systems and communications for emergent transfer to a hospital are in place.
So we can all agree, that if proper systems and safeguards are in place; that a home birth can be a viable, safe, and halachically sound option for people who want to choose that type of delivery.  However, to suggest that a home birth is somehow halachically more preferable than a hospital birth is misleading and wrong.

In the United States, (I am not intimately familiar with the system in Israel) our health care system is set up to take care of women in labor in hospitals.  The poskim have thus overwhelmingly permitted (and encouraged) women to travel to the hospital, even on Shabbat, when they are in labor.  Whether or not it is preferable to have a baby at home (assuming that all of the conditions we mentioned above are in place), is a decision a woman needs to make with her qualified health care provider, and depends on many factors which are well beyond the scope of this blog.

I think that should conclude my discussion of this topic, but if you have any questions, comments, criticisms, etc... please let me know as I would love to hear what you have to say.

Tuesday, August 12, 2014

Obstetric Drugs

In the final section of the article the authors decry the use of drugs during labor to treat pain.

They refer us to the early debate regarding whether or not it is appropriate to use pain relieving medications to treat women in labor.  It is well known, that many early religious (mostly Christian, but some Jewish as well) authorities felt that pain was a natural part of labor, and that women were supposed to have pain due to the curse associated with Eve's sin when she took a bite of the forbidden fruit.  They felt that it was therefore inappropriate to provide women with pain relief.

This philosophy would strike most modern readers as incredibly cruel, and indeed the overwhelming response of the Rabbinic authorities has been to support, and even encourage, the use of anesthetic and analgesic medications to relieve the pain of childbirth.  The authors quoted R' Moshe Feinstein in YD:2 p140 where he recommended that women be put to sleep for delivery so as not to feel pain.  This responsa was written in 1972, when it was common practice to give women heavy doses of sedatives during the final stages of labor to treat pain.  This usually required the physician to intervene and deliver the baby with forceps as the woman was not awake enough to push the baby out herself.

This practice fell out of favor well over 35 years ago when doctors realized the risks of forceps deliveries when done routinely, and the risks of the medications involved in heavy sedation.  I am not aware of any doctors or institutions that have practiced this way in almost two full generations.

So the authors agree that Judaism does support pain relief during labor and does not subscribe to the "curse of Eve" philosophy which would prohibit pain relief.  However, they then introduce us to another concern, which they feel should be a halachic basis for avoiding the use of drugs during childbirth:
"... Nevertheless, not all objections to obstetric analgesia and anesthesia can be dismissed as mistaken religious obscurantism based on the Genesis narrative.
As Rabbi Immanuel Jakobovits outlines, Christian objection to the use of drugs during childbirth was two-pronged. While some cited the curse of Eve as their source, others objected for medical reasons. Rabbi Jakobovits writes that, “towards the end of the last century, a Catholic medical moralist still forbade the use of chloroform at normal births because it might endanger the mother and the child…” Jakobovits then praises Judaism for being above any such considerations."
The authors are suggesting, that halachically speaking, we need to reconsider our use of drugs in labor because they may be dangerous.  They make this suggestion as if it can be assumed that drugs in labor are inherently dangerous, but they do not have evidence to back up this claim.  In fact, every treatment used in labor is subjected to controlled clinical trials and years of experience that have attested to their safety and efficacy.  It is far far beyond the scope of this blog to review every pain treatment and its' specific risk/benefit profile. However, we have established that in Judaism, treating pain in labor is an honorable and appropriate goal. Every woman is not religiously obligated to suffer to atone for Eve's sin.

A fascinating exchange about this topic took place in Montreal Canada in 1849, shortly after the discovery of anesthesia.  An article about this debate was published in the Journal of the American College of Obstetrics and Gynecology, also known as ACOG.  The Journal is called "Obstetrics and Gynecology", and in volume 88 No. 5, November 1996, pages 895-898, Dr Jack Cohen writes of the debate that took place in Montreal between Dr James Simpson and Rabbi Avraham De Sola.  Rabbi De Sola was the first rabbi in Canada, and he was the new young Rabbi of Montreal's oldest congregation, the Spanish Portugese synagogue - Shearith Israel.

Dr Simpson had argued against the use of anesthesia for women in labor based on Genesis 3:16, the verse declaring that "B'etsev Tayldi Banim".  By using his knowledge of Hebrew, and the Jewish commentators (primarily the Radak), Rabbi De Sola boldly took on the Christian interpretation of the verse and shows how the word "B'Etsev" refers to the uterine contractions of labor and not the pain experienced by the woman in labor.  Interestingly, Rabbi De Sola went on to become a Professor of Hebrew Language at McGill University in Montreal.

The poskim in the almost 175 years that have passed since Rabbi De Sola's debate have almost universally understood and acknowledged the importance of treating the pain of labor.  It is accepted that we must treat a woman's labor pain the same way we would treat all pain and suffering for every person.

This is true even though every treatment has some level of risk. When risk is balanced against benefit, halachah has determined that since these treatments are overwhelmingly safe and effective when administered by trained professionals, they are halachically desirable, not just permitted. Furthermore, every patient has the opportunity to choose whether or not to avail themselves of these treatments, and each person can evaluate the risks of benefits of each medication before deciding whether or not she desires to use it.

In their conclusion, the authors clarify their case, and they cite some "evidence" to back their claims:
"To begin with the third example, the dangers of drugs during pregnancy, including obstetric analgesia and anesthesia, are well documented today. In fact, they have been well documented since at least the 1980s. Both the mother and child can suffer side effects ranging from sluggishness to brain damage and death. The fact that no Jewish authority has restricted or discouraged the use of drugs during labor may not be an occasion for self-congratulation; it may call for some serious halakhic soul-searching."
As sources for their assertion that obstetric analgesia and anesthesia drugs are dangerous, they quote two articles from 1981 (see their footnote #24).  If one carefully examines the sources used to support this article's assertions, and the general tone of the article itself, one is struck by impression that the authors are reflecting a worldview that views modern medicine, and especially obstetric medicine, with an extreme amount of suspicion. I suspect that arguments like these will go on forever, as they are not amenable to resolution by providing evidence to support one point of view over the other. For example, one of the sources cited was titled "Malepractice: How Doctors Manipulate Women".  If someone believes that doctors are guilty of intentionally manipulating their patients, then it will be very difficult, in fact almost impossible, to convince him/her by quoting evidence from the medical literature.

I hope that I at least provided some information for those people who are open minded enough to look upon their physicians, midwives, nurses and other appropriate caregivers as their allies instead of their enemies.  I totally agree with the authors of the article that we should never engage in self congratulation.  However, the fact that "no Jewish authority has restricted or discouraged the use of drugs during labor..." does not reflect a lack of "serious halakhic soul-searching", as the authors declare.  Rather, it reflects centuries of serious halachic concern for the comfort and well-being of women in labor.

I do owe you one more brief post on this topic regarding the safety of home births, and then we can move on to our next topic.

Thursday, July 17, 2014

My oh my, How Times Have Changed

We have now described the fundamental assumption upon which the article "Obstetrics and the Curse of Eve" is based.  According to the authors, a birthing woman is in a category not exactly equal in halachic status to the critically ill patient. Thus, in what they consider to be the classical halacha; on Shabbat one must use a shinuy whenever possible, prior to the final stage of labor one may do nothing other than to call the midwife, and generally speaking only the midwife is called upon to violate Shabbat restrictions.

From here they go on to describe how much things have "changed".  Here are the next few paragraphs:
"Such halakhot could be easily implemented in a society where midwife attended home births were the rule. The only person who, under normal circumstances, had to transgress the Sabbath was the midwife. From a global perspective, home birth is still the norm and hospital birth the alternative. In middle- and high-income countries the opposite is true: the home birth rate in these countries is very low, for example, less than 1 percent in the United States. Where hospital births are the norm, the traditional halakhot about Sabbath observance have quickly become inoperative. 
Even a brief examination of a respected 1979 halakhic compendium will show how much these laws have changed. According to Rabbi Joshua Neuwirth, a woman should travel to the hospital at the onset of the slightest sign of labor. She may carry her possessions with her to the hospital, even through an area without a permitting enclosure (‘eruv) and can be accompanied by an “escort” (presumably her husband), who may also transgress the Sabbath. She may even, under certain circumstances, travel home from the hospital on the Sabbath if in fact she had been mistaken about being in labor.
What sources does Rabbi Neuwirth quote when allowing wholesale transgression of the Sabbath before the final stages of labor? Almost invariably he says, “So I have heard from rabbinic authorities” or refers his readers to the general rule of life-threatening situations (piqquaḥ nefesh). There is no attempt to justify these radical changes; piqquaḥ nefesh apparently speaks for itself."
We have already demonstrated that the fundamental assumption made by the athors is deeply flawed.  That is because the majority of the poskim follow the simple meaning of the words of the Shulhan Arukh and the rambam and the Gemara that state unequivocally that a birthing woman is "B'sakanat nefashot", and that the same laws that apply to any critical patient apply to her as well.  The Maggid Mishna that was quoted by the authors which differentiated between a birthing woman and a critically ill patient was either not accepted by many poskim, or interpreted by the poskim to be refering only to things being done l'yashev da'atah - to calm her fears.

R' Neuwirth, in Shemirat Shabbat K'Hilchatah (SSKH), paskens exactly NOT like the authors of the article would have you assume is the accepted halacha.  In fact, he paskens exactly like many of the poskim we quoted before, and that there is no halachic difference whatsoever between a birthing woman and a critically ill patient.  See SSKH Vol 1, 34:4 note 6 where he states, and I quote:
"see earlier in 32:28 (where R' Neuwirth paskens that one must use a shinuy for every critically ill patient whenever possible), therefore, the law of a birthing woman is the same as the laws of a critically ill patient, in that whenever it is possible, a shinuy must be used."
It is unclear why in the text of the SSKH R' Neuwirth quotes the Maggid Mishna when he states that the pain of birthing is a natural process. However, he provides the source in his note and refers us to the Arukh Hashulkhan and the Mishna Berura.  It is well known that the normal style of the SSKH is to leave this type of detailed analysis to the reader, and simply to provide the sources for someone interested in further investigation.  Regardless, the SSKH is crystal clear, both in 32:28 when he discusses the laws of the critically ill patient, and in 36:4 when he discusses the laws of the birthing woman, that he considers them exactly the same.  He thus follows, not surprisingly at all, the pattern of most poskim throughout the centuries, who did not differentiate between the two.  Unlike the authors who would have you believe that "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient".

Thus it should be no surprise at all when he allows what the authors consider "wholesale transgression of the Sabbath".  He doesn't need any more sources, as the poskim, especially the Arukh HaShulkhan who WAS quoted by the SSKH, made abundantly clear that even things that are only needed to calm her down, but aren't medically necessary, are permitted on the Shabbat.

The next issue that the authors discuss is the use of male birth attendants.  In summary, they contend that Halakhah in general "severely limited the access of male physicians to women". Traditionally, births were attended by women only, and midwives were the attendents at births.  However, "today most Orthodox women standardly have their babies delivered by male physicians...", and this has been supported by the halachic authorities.  Consistent with the theme of their article, the assumption is made that the reason for this leniency of the modern poskim is that when life is in danger, we can allow transgressions of halachah, including the use of male birth attendants.  In their words, "The male physician is exempted from this rule (the rule prohibiting males from being present at the birth), presumably for reasons of piqquaḥ nefesh."

I will discuss this issue in detail in my next post.

Wednesday, July 16, 2014

Stages of Labor

We now continue with our analysis of the article of interest, "Obstetrics and the Curse of Eve."  The paragraph we took apart in the first post ends with the following statement:
"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
Those readers who have followed this blog from its inception, should be familiar with the Five Principles of Rationalist Medical Halacha.  It should be immediately obvious that the quote above is a gross violation of principle # 2, the "historical corruption principle."  To quote myself, it is of utmost importance when one analyzes a topic in medical halacha, that they "understand how the medical understanding of their predecessors affected the decisions that they made."

They use the term "final stage of labor" which is a modern medical term with a very specific meaning, and they use this term to describe the words of the Shulkhan Arukh.  Their intent in doing this is to emphasize that for most of the process of labor, most transgressions of shabbat were not permitted, other than to summon the midwife.  Only in the "final stage" are we allowed to do anything else if it violates Shabbat.  This further illustrates their contention that the process of childbirth should not warrant as much chillul shabbat as is commonly assumed today.

This is based on a serious misinterpretation of the term used in the sifrei halacha "K'shekora'at leyaled" "when she bends over to give birth".  It is true that one may not violate Shabbat until that time, but when is that time exactly?  Doesn't that sound like the "final stage" of labor?  This seems to support the contention of the authors that only during the "final stage" of labor are we allowed to violate Shabbat.

Nothing could possibly be further from the truth however.  The truth is that the poskim say clearly that we are allowed to violate the shabbat from the time of "Kora'at leyaled", and they describe clearly exactly when that is.  Three examples are given by the gemara in Shabbat 128b-130a, and these examples are repeated in all the sifrei halacha:
  1. When the blood starts to drip
  2. When she sits upon the birthing chair
  3. When her friends are carrying her
I will digress a little to teach you some modern obstetrics, and a little bit about the signs of labor. Every woman experiences labor differently, and there is no one exact way that every labor progresses.  However, there are still some general concepts that can help us understand how labor progresses, and modern medicine is great at dividing things into categories and stages.  

The first stage of labor starts with a closed cervix and ends when the cervix is fully dilated, generally around 10 centimeters.  This is divided for conceptual purposes into two phases, the latent phase and the active phase.  The latent phase is slower, usually less painful, and consists of contractions that are usually farther apart. This phase can last anywhere from two days to just a few hours, and usually is much shorter in women who have had babies before.  This phase usually ends around 4 centimeters when the woman enters into the active phase.  During the active phase of labor, the contractions are much stronger, closer together, and much more uncomfortable.  The cervix dilates quicker, and this phase is usually over in a few hours when the cervix is fully dilated.

The second stage of labor starts when the cervix is fully dilated, and ends when the baby is delivered.  this is often called the pushing stage, as the woman's natural urge to push is very strong, and she will have to work extremely hard to push the baby out.  This can last anywhere from a few minutes to a few hours, depending on all sorts of factors.

It is very important to differentiate between "stages" and "signs" of labor.  Signs of labor include things such as bloody show, the passing of the mucous plug, the "dropping" of the baby, pelvic or low back pressure, and other such symptoms. Stages are what we just described in the previous two paragraphs. The important difference between stages and signs is that not every woman experiences all the signs of labor, and sometimes the presence of those signs doesn't necessarily mean that someone is in labor.  However, every woman does go through the stages of labor, although it could happen at way different speeds, and way different levels of intensity, but the stages always happen.

During the time of chazal, they needed to define the signs of labor that meant the woman is in sakanah.  This was important in order to provide guidance as to when chillul shabbat was permitted. In those days labor was not described in stages like we do today in modern medicine.  Chazal knew very well that there were soft signs that meant labor was imminent, but that the woman was not yet in danger when they happened. They also knew that at some point in time, she transitioned into a stage of sakanah.

When I was a resident, the nurses and residents came up with what we called was the "visual labor check".  We used to joke about how one could usually tell when a couple walked off the elevator towards the front desk whether or not she passed the "visual" test to be admitted.  If her partner (be it a friend, mother, doula, or husband) was holding her as she breathed through her contractions, that was a positive visual test. If she was wet with blood and water, that was a positive visual test.  If she was in such discomfort that the security guard had to wheel her in, that was a positive visual test.  No exam was really necessary to confirm that she was in labor.

The "positive visual test" usually correlates well with the active phase of the first stage of labor, also known as "active labor".  This was of course confirmed when we examined the woman and found out how far dilated her cervix was.  If she was in latent labor, we may send her home, or may send her for a nice walk around the hospital for a few hours, but she did not require admission.  Why? because in the early stages of labor it is commonly understood that there is no serious risk to the health of the Mom or the baby.  However in the active phase, there is risk.  What risks are more common in the active phase? Some examples (but there are certainly many more) include:

  1. Hemorrhage due to abruption (separation of the placenta) or vasa previa (a condition where the umbilical cord can tear)
  2. infection (especially in cases where the labor lasts a long time and the membranes have been broken)
  3. fetal intolerance of labor (the baby may not tolerate the contractions well - which is why we monitor the baby during active labor)
  4. seizures due to blood pressure abnormalities
Now remember that all of these problems are rare, but also recall what we said in the first post on this topic. We explained that although the overwhelming majority of women make it through labor just fine without any medical interventions, the Halacha still paskens that they are all considered pikuach nefesh, so that we can intervene in order to prevent the few deaths that would occur if we didn't intervene.

For example.  We monitor the heart rates of every baby on Shabbat, even though the vast majority of babies would do just fine without a monitor.  Why? because we want to save the one in a thousand that we can find abnormalities in the heart rate.  Another example: We check every woman's blood pressure and temperature, why? because we need to find the one in a hundred that have problems that we can treat! and so on.

Let's go back to the "visual test" from my residency days.  Even though they didn't use the same terminology to describe the stages and phases of labor, Chazal absolutely knew about all the signs of the latent phase of the first stage of labor.  They knew it because it was common knowledge, and everyone knew that it wasn't yet a dangerous time.  But they also knew that when she transitioned into active labor, she was in danger? They knew this as well because it is something that has been observed for as long as human beings have been having babies! What were the signs that she had entered this phase, the signs that any observant person can see? When the blood is flowing, when her friends need to help her walk, and when she lies or sits down in the birthing bed (see Arukh Hashulchan OC 330:4 who explains that sitting on the "Mishbar" does not mean sitting in the bed to push the baby out, but it means when she lies down due to the pain of the contractions).  This fact is so obvious to anyone that has ever seen a woman in labor that one need not even bother explaining it further.

The authors of our article wrote that "before the final stage of labor" violations of shabbat were not permitted.  They assumed that one may not violate the shabbat until the second stage, when the woman is pushing the baby out.  But this is patently wrong.  One may clearly violate Shabbat at the onset of active labor, during the first stage of labor.  Chazal were extremely clear about this, as they observed in nature the same phenomena that we observe today, that the really risky time is the active phase of the first stage of labor.  Just like modern hospitals usually won't admit a patient in the latent phase of labor, chazal also knew that chillul shabbat was inappropriate as well.  It is not necessary to be a modern scientist to know these obvious facts.

"except for summoning the midwife" - of course one may summon the midwife before the onset of active labor.  Because we don't want to wait until the woman is in potential danger before we summon her! She needs to be there before that stage begins!

In short, our authors used a modern medical term, the "final stage" of labor, and assumed that this is what Chazal meant when they said K'shekora'at leyaled".  They therefore concluded that the poskim only permitted chillul shabbat during the final stage of labor, except for summoning the midwife.  This is a mistake. Chazal were referring to the active phase of the first stage of labor.  This is exactly the time when everyone agrees the time of potential danger has begun, and this agreement spans the entire history of humanity, up to and including in modern hospitals.  The modern poskim all agree with what I just wrote, and correctly so. But the authors of our article, not surprisingly, proceed to criticize the modern poskim for this, but that will be coming up soon in an upcoming post...

Monday, July 14, 2014

Why am I so Interested in "Obstetrics and the Curse of Eve?"

This probably should have been the first post in my series on the article "Obstetrics and the Curse of Eve", but I originally thought it would be obvious to my readers why I felt this subject was so important.  However, based on some comments from friends of mine, it seems that many of them didn't understand why I chose to spend so much time on a short article "Obstetrics and the Curse of Eve" in the Hakirah journal.  So let me explain.

I suspect that your rationalist antennae will perk up as much as mine did after you read this explanation.

The modern literature discussing the relationship between Torah and medicine can be divided into several categories.  This may not be an exhaustive list, so I am open to suggestions if you feel I have left something out.  But I would divide it as follows:

  1. The "Laws of  ... " category - This refers to the many handbooks that describe halachot very dryly and in a clear style.  This is permitted, this is not permitted and so on... These books read like instructive handbooks, and generally don't give much instruction regarding the historical, philosophic, or even the halachic developments behind the laws being written.  I am sure many of you have seen these handbooks, and I will not be commenting on these right now, though we probably will at some point in the future of this blog.
  2. The "Medicine of the Torah ..." category - These are the various books describing the medical treatments, cures, and sometimes theories of the Torah, Talmud, Rambam etc.  There are many different angles from which these books approach this topic, some more rationalistic than others, some more mystical than others, and some may be more or less willing to compare the knowledge of the rabbis with the contemporary scientific knowledge. I won't be commenting on this category either during this thread.
  3. The "Ethical guidance of the Torah" category - This includes the vast amount of essays, articles, op-eds, journal entries, and books that have used the Torah sources to develop some sort of ethical or moral idea that the writer believes is "the Torah view" or "the Torah way".  This body of literature assumes that we can learn ethical teachings from the laws of the Torah, and that indeed these teachings can be applied to other areas of life.  We often read about the value the Torah places on things such as the "sanctity of life" or the "responsibility to the other" and so on.  This is the body of literature I am referring to.
  4. The "Torah is a TEA Party Mission Statement" category - This is what you are reading every time an uber-conservative writer uses a verse in the Torah or passage in the Talmud to support his/her ultra conservative views.  This can be about women's role in religion, the Torah's attitude toward homosexuals, or various other topics.  I am NOT taking a position here on these topics, though I will eventually hope to deal with them and others.  All I am saying is that we sometimes find uber-conservatives using what they claim is the Torah to support what are essentially simply just plain old uber-conservative views. This category also includes medical topics, such as abortion, end-of-life issues, organ donation and more. I am not dealing with this category in this particular thread, but I have dealt with some of this in previous threads.
  5. The "Torah is the Huffington Post of the Ancient Times" category - This is the exact opposite of category # 4.  Whenever an uber-liberal expresses his/her uber-liberal views and then uses the Torah sources to back up the idea, he/she is writing literature of this type.  This happens often with environmental issues, social justice issues, and more.  But it also happens often with medical issues, and THIS is what the current thread is about.  I have seen this happen with the scary proliferation of people who don't vaccinate their children, as they may often claim some Torah source for their neglect.  I hope to deal with vaccinations specifically in the future, but I would refer you to the excellent article by Dr. Eddie Reichman about this topic. This brings us to the topic of our current thread, "Obstetrics and the Curse of Eve."
(I hope I have not offended anyone when I used the terms "uber-conservative" or "uber-liberal",  I used them for dramatic effect only. I do not mean to demean anyone who holds these views, in fact, in some cases I may even hold such views myself! I also beg you to not make assumptions about my personal beliefs on a particular topic. I hope that you have learned by now, if you have read anything on this blog, that I freely share my opinions about any topic I am discussing.  However, I will never give in to the temptation of giving out sound bytes of what I think about this or that topic.  If I write about something, it will take me time to develop the sources and reasoning behind my thoughts.  You can then agree or disagree as you see fit.  I am sorry that some may find it boring if they can't get a juicy sound byte from me, but if that's what you want, find another blog.)

The writers of the article of interest are expressing views that are mostly compatible with an entire popular movement in our culture, namely, the "home birth" movement.  It is far beyond the scope of my blog to describe the various controversies relevant to the home birth movement.  However, I can tell you that there are many outspoken critic, including many celebrities, who have criticised various aspects of modern obstetric medicine, especially in the US.  You can follow this link to one of the most influential films called "The Business of Being Born" if you want to find out more about this topic.  This movement has criticised, often rightly, aspects of modern childbirth including using too many drugs, too many surgical interventions, too little personal control over the process, and too much greed.

As an obstetrician myself, I obviously have a lot to say about the topic, and some of it may surprise you. Most importantly, I believe in listening to anyone and everyone that has a reasonable, well researched, and helpful comment or suggestion.  The home birth movement has accomplished a lot regarding the way women in labor are treated, but there are still many differences of opinion, especially between the extremes.  I would be happy to discuss these issues specifically, but for now I want to continue this thread.

The writers of the article are presenting what they believe is a Torah based justification for their belief in home births and the other issues that are related such as drugs in labor and so on.  They may or may not be right, and after you read my blog series I hope you will form your opinion on this matter.

In my first post, I quoted their claim that the Halachic authorities recognized that although a pregnant woman is in a life threatening situation, it is not quite as life threatening as an ordinary critically ill patient.  They made that claim in order to set up their argument that the Torah sources recognize that a birthing woman is undergoing a natural process that is not as dangerous as someone who has an actual critical illness.  They brought some sources that supported this idea, and I brought sources that demonstrated that many, if not most, authorities did not make this distinction at all, and in fact they held that a birthing woman is in exactly the same category as any critically ill patient.

I hope that you now understand why this issue is so important to me, and why it should be so important to anyone interested in rationalist medical halacha.  The way I approach this topic, I believe, should be the way any halachic rationalist should approach anyone who writes an article or book that fits into the "Torah is the Huffington Post of the Ancient Times" category.

We can now move on with our analysis.  I hope you stay along for the ride.

Friday, July 11, 2014

Obstetrics and the Curse of Eve

I sincerely apologize to all of my readers for my prolonged absence from posting on this blog.  The difficulty of posting on a regular basis was something I never realized when I started, but I really will try to make this something more regular.  So please forgive me, and feel free to make suggestions if there are topics that you would like me to cover.  I am going to stop the genetic screening thread for now (with the intention of coming back to it sometime in the future), to deal with an article that was published in the Hakirah Journal in their Winter 2013 issue, Volume 16.  The title of the article is "Obstetrics and the Curse of Eve".

It would benefit the reader to click on the link to the article above, and read it for yourself in order to appreciate what I have to say.  You may also find it worthwhile to refer to the article as I develop my overall theme in my upcoming blog posts.  So let's begin.

The overall theme of the article is to argue that modern obstetrical practices have influenced modern halakhic practice in ways that need to be reconsidered.  The primary four areas that the article attacks are modern halakhic attitudes toward:
  1. Use of drugs in pregnancy and in labor and delivery
  2. The practice of having male attendants during delivery
  3. The ease with which Shabbat restrictions are violated
  4. The practice of hospital birth vs. home birth 
All four of these areas need to be addressed, as they are all extremely important, and I will attempt in this blog series to address them all.

The first topic discussed starts on page 145 of the Journal, and it is called "Birth on the Sabbath". According to the authors:
"Halakhic literature has always recognized that the rules of Sabbath can be transgressed to aid a birthing woman. Nevertheless, medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient (ḥoleh she-yesh bo sakkanah), since “the birthing woman’s pains and strain are natural and less than one in a thousand die in childbirth.” Whenever possible an act of transgressing the Sabbath for the sake of a laboring woman was to be done beshinnui, in a different manner than it would have been done on a weekday. In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
The authors quote three sources for these statements.  The Rambam Hilchot Shabbat 2:11, the Maggid Mishna on site, and the Shulchan Arukh OC 330:1. It is of course worthwhile for the reader to check these sources for themselves.  It is clear that the intent of the authors is to give the impression that a woman in childbirth is not quite as much in danger as is the standard critically ill patient.  This sets up their argument advocating home birth as an alternative to hospital birth, and that the use of drugs should be minimized, and so on.  So according to the authors, a birthing woman is halakhic category that is not quite as severe as an ordinary critically ill patient. 

This assertion however, is extremely misleading, and the halachic sources do not at all reflect what the authors claim that they reflect.  It will take me some time to make my point, as this requires a thorough review of the halakhic literature.  I will begin this thread by analyzing the assertion made by the authors of the article in this paragraph, and then I will move on and continue with the rest of the article in a series of posts. Eventually we will be able to summarize our findings and decide what our final approach to this issue will be.  I will also try to remain true to the rationalist approach to medical halacha, and draw from both Torah sources and the relevant scientific and historical sources when appropriate.

Let's start with the Rambam:
"A woman giving birth, her life is considered in danger and one may transgress the Shabbat for her, we can call the midwife from one place to another, and one may cut the cord and tie it, if she needs a light when she is crying out in pain from labor one may light it for her, even if she is blind (one may light for her) because she becomes more calm when there is light even though she herself cannot see.  If she needs oil or any similar thing one may bring it to her.  In any way that one can change (the way it is usually done during the week) then one should change (do it with a "shinuy") at the time one brings it such as her friend can carry a vessel hanging in her hair, but if this is not possible one may bring it the usual way."
And now the Maggid Mishna:
"From the language of our teacher (the Rambam) it seems that a critcally ill person is not included in the need for attempting to do things differently (a "shinuy") but only a midwife must.  This is why he writes that she is "like" she is in danger of death but he did not mention the need for a shinuy when he discussed a person with a critical illness ... And it seems that the reason for this is because the pain of a woman in labor is like a natural thing for her, and not even one in a thousand die from childbirth and therefore they were stringent that one should change the usual way whenever possible but they weren't stringent by a critically ill person ..."
The Shulchan Arukh brings this halachah as well, however the language he uses is a little different, in that he uses the same language as the Tur.  The Tur specifically says that "a Yoledet has the same laws as a critically ill patient" and the Shulkhan Arukh follows suit.  It seems that they are purposefully choosing a language even stronger than the Rambam, as the Rambam only stated that she is considered in danger, while they equate the woman in labor to the critically ill patient.  We will return to this point later.

The Magen Avraham on site brings the Maggid Mishna to explain why the Shulkhan Arukh only requires a shinuy by a woman in labor, but not by an ordinary critically ill patient.  Since the woman in labor is a natural process therefore the Rabbis were more stringent and they required, whenever possible, a shinuy.  The Shulchan Arukh HaRav OC 330:1, and the Mishna Berurah also understood the Maggid Mishna and the Rambam in this way.  They follow the path of the Magen Avraham, and understand that Chazal were more stringent with a birthing woman than a critically ill patient because labor is a natural process and only a small minority of women die in childbirth. 

So all of this so far would seem to support the claim of the authors, that the "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient."

However, a complete analysis of the poskim actually does not support this contention at all. Allow me to explain.

The primary difficulty that the Maggid Mishna is trying to explain, is why the Rambam mentions by a woman in labor the need for a shinuy, but not by a critically ill patient.  His answer, as described above, was that a woman in labor is a natural process.  Let's think about that for a minute.  The Rambam just stated, following the Mishna and the Gemara in Shabbat 128b, that a laboring woman is considered to be in life threatening danger, and that one is permitted to transgress the Shabbat for her.  If this is true, why then does it matter if it is a natural process or an illness? Even if death is rare, as the Maggid Mishna said, the Gemara already told us that this is sufficient to allow us to transgress the Shabbat!  So why is this any different than an ordinary ill patient?  What if you told me that a particular illness had a 1/1000 chance of death, wouldn't you be allowed to transgress the Shabbat to save such a person?

There must be something deeper here, something that we are missing, and indeed the poskim are bothered by the same questions that we are asking.  So let's see how they deal with it.

Prior to explaining our difficulties with the Maggid Mishna's explanation of the Rambam, we need to mention that this entire discussion is of course only relevant according to the Rambam who seems to differentiate between the woman on childbirth and an ordinary critically ill patient.  The opinion of the Ramban however, is very different.  The Ramban actually brings proof from the gemara that discusses using a shinuy by a birthing woman that one must use a shinuy by all critically ill patients.  The Ramban obviously does not agree with the assertion of the authors that there is "a clear distinction between the birthing woman and the standard critically ill patient".  According to the Ramban, no such distinction exists at all, despite the fact that birthing is a natural process.

Let us return though to our analysis of the opinion of the Rambam and the explanation of the Maggid Mishna.

The Arukh HaShulkhan in OC 330:2 is bothered by our difficulties with the differentiation between the two cases.  He also brings the idea of the Maggid Mishna that labor is a natural process, but he explains it a bit further.  He notes that the gemara only applies this rule of using a shinuy to the lighting of a candle and bringing oil to the woman in labor in order to calm her down ("leyashev da'atah").  That is, since labor is a natural process, most women are calm and able to bear the pain.  However, if the woman requires something just to calm down, though it isn't medically necessary, we can still violate the Shabbat for her, because fear itself can harm her.  However, since it isn't really medically necessary, one should try to use a shinuy.  For things that are medically necessary though, one need not use a shinuy.

Interestingly, the Arukh HaShulkhan can find support for his assertion in the words of the Meiri.  The Meiri in Shabbat 128b describes the need for a shinuy for a birthing woman only in reference to things that are being done LeYashev da'atah.  He describes how things can be done LeYashev Da'atah for a birthing woman even if they require transgressing an Issur De'Oraytah, but then says that a shinuy should be done when possible.  He explains the reason for  requiring a shinuy to calm the birthing woman as opposed to calming a critically ill patient because, "a birthing woman is different because for most of them the danger isn't as great."

At least according to the Arukh Hashulkhan, the author's claim has just fallen apart.  The Shulkhan Arukh and the Tur specifically compare the laboring woman to the critically ill patient, because their laws are exactly the same. Not only can we violate the Shabbat for both of them, we can do it without a shinuy.  Only when we are doing something Leyashev da'atah, only then are we required to try a shinuy first.

These words seem clear from the language of the Rambam himself. As he states:
In any way that one can change (the way it is usually done during the week) then one should change (do it with a "shinuy") at the time one brings it ("Besha'at hava'ah")
This makes it clear that the need for a shinuy only applies at the time of bringing these items, but not when one needs to intervene medically to save her life.

But we are far from finished.  Other poskim as well have dealt with these questions, and it is worth looking at some other approaches.

The sefer Yitzchak Yeranen (R' Elyakim Guttenov d. 1795), is also bothered by the same questions.  He explains the difference based on the well known halachah (see Rambam earlier this perek se'if 3) that when it comes to treating the ill on Shabbat, one should not do it through a gentile or a child, but rather the "Gedolay Torah", the Rabbis themselves should violate the Shabbat, in order to teach the public not to hesitate in similar future situations.  According to R' Guttenov, the same rule applies to a shinuy.  That is to say that in truth, even for any critically ill patient a shinuy should be used.  However, we specifically prohibit the use of a shinuy in order to teach the public not to hesitate in future situations.  By a laboring woman though, there is no need to prohibit the shinuy. That is because despite the fact that the risk to life is there, the chance of death is small, and coupled with only a suspicion that maybe in the future someone might hesitate for a woman in childbirth, that is not enough of a concern to prohibit using a shinuy.

This approach of R' Guttenov also specifically equates the laboring woman to the critically ill patient, only that the Rabbis went out of their way in more critical situations to prohibit the use of a shinuy for the reasons we just described.  Although using R' Guttenov's approach the author's claim that there is a difference between the two cases remains true; it is not because the Rabbi's were more lenient for the birthing woman.  Rather it is because the Rabbis added an extra stringency by more severe illnesses.

The Beit Yehuda (R' Yehuda Ayash d. 1759) in OC 59, is also bothered by our questions, and he strongly disagrees with the entire premise of the Maggid Mishna that there is any difference at all between a birthing woman and a critically ill patient.  According to R' Ayash, the Rambam is of the opinion that one must always do something with a shinuy if possible, and that the Rambam completely agrees with the Ramban in this matter.  It is worthwhile to review his response in its entirety, but for our purposes, our summary should suffice.  Once again, the premise of the authors has fallen short.

The Divrei Yirmiyahu (R' Yirmiyahu Lau d. 1874) also offered an explanation of the Maggid Mishna.  R' Lau explained that the difference between a woman in childbirth and a critically ill patient has to do with the actual presence of illness at the time of the required intervention.  When a person is actually critically ill, one need not use a shinuy when intervening on his/her behalf. However, a woman during the natural process of labor is not ill at this moment, rather she is at risk of becoming ill if we don't intervene.  Thus, says Rav Lau, our interventions are only preventative, not curative, and therefore require a shinuy.  Thus the difference has nothing to do with labor versus illness, as to do an intervention that is only preventative one would always be required to use a shinuy, not just for a birthing woman.

R' Yehuda Navon (d. 1760) , in his sefer Kiryat Melekh Rav, disagrees with the Maggid Mishna in his interpretation of the Rambam, because of the problems we pointed out.  He feels that despite the fact that most women survive childbirth, it is still considered a life threatening situation, just the same as any critically ill patient. Therefore, even for a critically ill patient we would require a shinuy, just like we do for a birthing woman.  However, since in most cases a shinuy for a critically ill patient would cause a delay in care, we therefore never allow a shinuy because we are afraid that one may inadvertantly cause a delay in care. However, by the birthing woman, a delay in how one carries an item to her won't usually cause a delay, so we require a shinuy whereever possible. 

In more modern times, R Yosef Kaddish Bransdorfer, in his sefer "Orah VeSimchah", asks our questions on the Maggid Mishna as well.  He also proposes, like the other poskim we just mentioned, that the Rambam does not differentiate at all between a birthing woman and a critically ill patient. He also mentions the proof from the language of the Rambam when he says, " then one should change (do it with a "shinuy") at the time one brings it ("Besha'at hava'ah")".  He claims, that the only reason why we require a shinuy by a birthing woman, is because labor is something that should be anticipated, so we should be prepared before Shabbat as the end of the pregnancy is approaching. However her status as a person in a life threatening situation is no different at all from the status of any critically ill patient.

R' Bransdorfer points out another interesting observation.  It seems (see the Frankel Rambam for more on these different versions of the Rambam) that the Maggid Mishna, in his version of the Rambam, the "bet" in the word "B'sakanat nefashot" was replaced with a "kaf".  Therefore his Rambam text read as follows:
"A woman giving birth, her life is considered as if she is in danger and one may transgress the Shabbat for her ..."
This is possibly what led the Maggid Mishna to state that:
"From the language of our teacher (the Rambam) it seems ..." 
The "kaf" sounds like it is merely a comparison, but not an exact equation with a critically ill patient, as though there are some inherent differences. However, if he had the wording with a "kaf", like we have in most printed versions of the Rambam today, it would not have led him to believe that there is any difference between the two, as it would have been a clear and unambiguous statement:
"A woman giving birth, her life is considered in danger and one may transgress the Shabbat for her ..."
A much earlier authority, R' Chaim Abulafia (d. 1743) in his sefer Mikra'ey Kodesh, also noted that it seems that the Maggid Mishna had a "kaf" instead of a "bet" in his version of the Rambam.  R' Abulafia goes on to say as well that there is no reason at all to assume that the Rambam disagrees with the Ramban, rather he feels that the Rambam also does not distinguish at all between a birthing woman and a critically ill patient. 

We have thus demonstrated clearly, that the contention of the authors of the article that there is a clear halakhic distinction between a birthing woman and a critically ill patient is not so clear at all. It is true that according to the Magen Avraham, who was quoted by the Mishna Berurah and the Rav Shulkhan Arukh as well, and his interpretation of the Maggid Mishna, that the Halakhah treats a birthing woman as if she is in less of a danger than a standard critically ill patient. However, many other authorities did not understand the Rambam, or the Shulkhan Arukh, in this way.  Certainly the Ramban did not make such a distinction.

This concludes the halakhic discussion for today and my analysis of the first half of the paragraph we started with. The paragraph ends:
"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
I will deal with that statement in the next post.  However, before I sign out, allow me to discuss some non-halachic but very relevant thoughts.

The Maggid Mishna asserts, that "not even one in a thousand die from childbirth".  I find this statement troubling for numerous reasons.

For starters, we are not only concerned about the health of the mother, as we are concerned about the health of the newborn as well.  The halacha states clearly that one can transgress Shabbat even to save the life of an unborn fetus.  Many of the interventions of modern medicine are designed to prevent infant mortality, not just maternal mortality.  To claim that in the time of the Maggid Mishna that the infant mortality rate was less than one in a thousand defies common sense and defies our knowledge of historical reality.

However, this question may not have been relevant to the Maggid Mishna, because in his time there was very little anyone could do if an infant was not born full term and healthy.  However, in our time, when there is a lot that modern medicine can offer, one cannot simply say that “the birthing woman’s pains and strain are natural and less than one in a thousand die in childbirth.”  One must also remember that everything needs to be done to ensure a healthy baby, and the baby is also in a state of life-threatening danger.

Furthermore, I am somewhat baffled by this idea of "less than one in a thousand".  While this have been comforting to the Maggid Mishna, that could be because of the limited interventions they had available in his time.  Don't forget, in the time of the Maggid Mishna, most critically ill patients succumbed to their illness.  Today though, with modern medicine our attitude is usually to fight with everything modern medicine has to offer.  We aren't so ready to accept defeat to "natural processes."

Let me illustrate my point with some real numbers. According to the Israel Central Bureau of Statistics, there were 171, 207 births in Israel in 2013.  If, God Forbid, one in a thousand women died in childbirth, that would mean that 171 women would die every year during childbirth in Israel alone! What a horrible horrible thought.  One in a thousand may sound like a small number, but in a large population, that's a lot of people.  I think most of would argue that everything should be done, even on Shabbat, to save those 171 women's lives, just as one would do for any critically ill patient.

For your reference, according to the US Department of Health and Human Services:
"Maternal mortality in the United States has declined dramatically over the past century. The rate declined from 607.9 maternal deaths per 100,000 live births in 1915 to 12.7 in 2007." 
it is interesting that the 1915 numbers in the US are almost exactly the same as the assessment of the Maggid Mishna.  1,000 per 100,000 births would be "one in a thousand", and the Maggid Mishna said "not even one in a thousand" which is roughly the same as 607.9 per 100,000.  Cool.  But even more cool is the fact that modern medicine has improved upon those numbers significantly, and we haven't even discussed infant mortality statistics yet.

If we assume that 1/7 of all births occur on Shabbat, that's 608 (maternal deaths in 1915) - 13 (maternal deaths in 2007) = 595 women saved every year/ 7 (days of the week) = 85 women per year whose lives we've saved by treating them on Shabbat!  I think that speaks for itself, especially if one of those lives saved was you or your wife.

I will deal with the issue of the safety of home births later, I promise. I am fully aware that much of the decline in maternal mortality in the US is not necessarily because of doctors, drugs, and hospitals etc.  At this point I am just demonstrating (I still do adhere to the famous "five principles" that I set down in my first post) that according to the "common sense principle" of Rationalist Medical Halacha, childbirth is a life threatening situation, even though, in the days before modern medicine, "not even one in a thousand" women died from childbirth.

Hope to see you next time, as we continue our analysis of "Obstetrics and the Curse of Eve".