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