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...

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.

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".

Dor yeshorim and the Non-disclosure policy

I am so sorry that it took me so long to post again, life is just catching up with me, but I will really try to keep up the pace of at least two posts each week.  We ended last post with a discussion of genetic counselling, and I want to really start getting into the main purpose of this discussion.  I described to you last time the basics of modern genetic counseling, and now I would like to discuss the common and popular approaches of the orthodox community towards this important issue at the current time.

I could summarize the way this issue is dealt with by the orthodox community by dividing it into in three distinct approaches.

1. The first approach is to ignore the topic altogether.  In rare cases, this is a deliberate decision on the part of the parties involved, and sometimes even involves religious justifications, such as the claim that they are "having simple faith" in God.  However, usually it is simply out of sheer ignorance, misplaced fear, or lack of education.  Clearly this approach is extremely dangerous and can lead to unnecessary suffering and terrible consequences.
2. The second approach is the Dor Yesharim approach, which will be described in detail later in today's discussion
3. The third is an educated and thorough discussion with a qualified physician or genetic counselor as we described in the last post.

Since we described the third approach last time, I will paste here a description of the Dor Yesharim approach so that everyone can familiarize themselves with it.  I will freely admit that I cut and pasted this from wikipedia and other online sources, but it is a pretty reasonable and unbiased description of the program, and enough to get the idea of how it works.  The Dor Yesharim approach has had major success in the "Chareidi" world, and has become the primary exposure for most people in that population to genetic testing.  It has received endorsements from major "Gedolim" and has been quite successful.
 
Dor Yesharim is an organization founded to prevent recessive genetic diseases. It is based out of New York and was founded by in the early 1980's by Rabbi Josef Ekstein, who had four of his own children die of Tay-Sachs disease. It is endorsed by many physicians and several major Torah authorities, and is the most commonly used genetic screening program for Jewish diseases in the yeshivish world. (Indeed, it is not uncommon for Orthodox Jewish day schools to sponsor screenings for all their high school students). As of September 2006, over 800 incompatible matches had been prevented.
 
The Dor Yesharim screening program is most effective with those of entirely Ashkenazic descent. Anyone with even a small heritage other than Ashkenanic descent (even one grandparent), may experience reduced reliability. (This may be of special concern to those with Sephardim or Geirim (Converts) in their background). This general background information is noted at the time of testing, to assist interpreting the results.

The program itself is designed to protect the privacy of the individuals involved, and and avoid the risk of stigmatizing a young single or their family members.

An article about Dor Yesharim was published in the June 2006 issue of the Where • What • When magazine, entitled "An Avoidable Tragedy".

Here's how it works, in a nutshell:

Singles have blood taken and their samples labelled with an anonymous identification number, and a control number. These are sent to special labs in New York where they are tested and catalogued. In addition, a contact telephone number is sent along with the sample, and results will only be given via return call to the phone number submitted with the samples, at the time of testing. The singles are normally given a booklet when they are tested, with their identification and control number stickers affixed, as well as, other information about Dor Yeshorim included. The booklet also contains a place to record information, in case the booklet is lost. All results are identified anonymously by number, not by name. The results are kept confidential and will not be released to any individual, not even to the persons themselves. The only information typically released is the response regarding a particular shidduch's genetic compatibility: compatible or incompatible.

However, if a couple is found to be incompatible, and if they request this information, the couple will be informed of the disease for which they are incompatible, the symptoms, and the specific risks they face.
If an individual has a family history of a genetic disease, even a "non-Jewish" one, Dor Yeshorim recommends that they be informed of this, as well (for example, they might run additional tests, if aware of this risk). They can provide confidential counseling, referral, and support services to families afflicted with genetic disease.
Before a shidduch begins (or as early as possible), one or the other parties in the shidduch contacts Dor Yeshorim, and using both each person's anonymous identification number and the birth date of each person, to check if the individuals together are genetically compatible (as noted above). The only information normally revealed is whether the specific couple are incompatible genetically with each other. However, if the couple requests, they will be informed of the disease for which they are incompatible, the symptoms, and the specific risks they face.
There are several rules specific to to Dor Yeshorim:

• Individuals who are engaged, married, already tested, or otherwise aware of their carrier status are not eligible to participate in this program.
• Results will only be left with the phone number registered at the time of testing. If your phone number changes, Dor Yeshorim needs to be notified as soon as possible.
• If you lose your identification number, you will need be re-tested all over again. Since it is entirely anonymous, Dor Yeshorim cannot connect you with your test results, if you lose your identification number.

Currently, the Dor Yeshorim program generally tests for:

• Tay-Sachs Disease
• Cystic Fibrosis
• Canavan Disease (patent-pending)
• Fanconia Anemia
• Familial Dysautonomia (Riley-Day Syndrome)
• Glycogen Storage (Type 1a) / Von Gierke Disease
• Bloom's Syndrome
• Gaucher Disease (on demand only)
• Niemann-Pick Disease
• Mucolipidosis IV

In addition, Dor Yeshorim may also test for other genetic diseases and mutations of existing diseases in a research capacity, unofficially, and proports to be the most thorough program of testing with regards to Jewish genetic diseases.

Those who have already been tested through another screening program, or who are already married or engaged are not eligible for Dor Yeshorim's screening program.The costs and processing times vary by screening venue.For those tested at mass screenings (e.g. Jewish high school-hosted screenings), the cost per person is typically $150 per person, and results may take 3-4 months to process.

For those tested individually, the cost is $200, and results may take 2-3 weeks, from the time the sample is received in New York (so, realistically expect 4-6 weeks, if tested in the Mid-Atlantic area).
If tested in New York, should it be absolutely necessary, there is an emergency, expedited processing available.

In the next post we will talk in more detail about the philosophy of Dor Yesharim, and try to analyze their approach from a rationalist perspective.

Premarital or Preconceptional Genetic Counselling and Testing - a Brief Introduction

In my last post, I summarized the different categories of genetic testing that we will be dealing with in this thread.  As you can imagine, each category has numerous issues of its own and needs to be analyzed through our Rationalist Medical Halachic (RMH) lens separately. Those of you who are new to this blog should review the Five Principles which define the RMH approach. Though many of you might already be very familiar with this subject, it is important to introduce the basics for everyone now. This way, when we start the fun part in our next post, we will all understand the basic issues involved.

Let's start with the second category, which I called premarital or preconceptional testing. The goal of such testing is to determine the risk of a given person or couple for having offspring with a particular genetic disorder.  In theory, if someone can know what he/she is at risk for begetting a child with a particular problem, then he/she will have several choices. (Please try to keep this issue separate from prenatal testing, which refers to testing a fetus that has already been conceived.  We will take on that issue on its own later.)

Those choices will include any of the following:  They could choose not to marry (or if already married - not to get pregnant); they could choose to take the risk; they could choose to do some intervention to either decrease the risk of conceiving such a child or prevent it altogether; or they could choose to take the risk and then to abort the fetus if indeed it is found to have this disorder.

It should be obvious that the moral implications of each of the above choices are incredibly important, difficult, and complicated.  Every single one of the above choices leaves in its wake a potential minefield of ethical and Halachic conundrums.  Our purpose in this post is not to give guidance regarding the choices themselves once a problem is discovered, but rather I will focus on the counseling and testing itself.  How does one decide what type of testing is appropriate for him/herself and what is the rational Halachic way to proceed with this type of genetic testing.

The first question, to which I will not devote much time to at all, is the question of whether such testing should be done at all.  The argument against it would come from a religious perspective and sound something like: "Tamim Te'Hyeh Im Hashem Elokachah" that one should have simple faith in God and not try to mess with God's plans.  This perspective was already treated by R' Moshe Feinstein in Iggerot Moshe Even Ha'ezer 4:10 in a landmark teshuva regarding Tay Sachs testing.  The bottom line is that virtually every Halachic authority agrees with R' Moshe that a simple risk free test that can prevent suffering would be Halachically required of any person as part of his/her responsibility to protect his/her health and that of his/her offspring.  R' Moshe compares this is closing one's eyes from seeing the obvious, which is certainly not indicative of simple faith in God, but rather it is indicative of willful stupidity.

So now that we let that issue rest, let's discuss what genetic testing is like today, and then we will analyze how it is (or isn't!) done by Halachic Jews today. Then we can apply our rationalist lens to determine what the Halachic approach should be.

The field of genetic counseling has grown in the last few decades into a significant player among the various medical specialties.  As our knowledge has grown, available tests has grown, and available treatment choices have grown, this specialty has of course grown more and more important. The knowledge base today is so extensive, that ordinary family doctors can no longer possibly have all the knowledge necessary to appropriately counsel their patients in this area.  So we turn more and more often to trained genetic counselors, or physicians who concentrate specifically on this area.

The meeting with a genetic counselor is typically a long one, like 30-45 minutes, and by its nature it will include filling out a long questionnaire beforehand, and discussions about relevant topics.  The topics first investigated include (but are not limited to): an extensive family history of the potential father and potential mother; extensive personal medical histories; a review of any genetic tests that may have already been done on the potential parents; and a review of ethnic and racial backgrounds of the potential parents.  All of this information is processed by the counselor to determine the specific level of risk this couple may have to transmit various genetic disorders to their potential offspring.

It is extremely important to remember that EVERY person has around a 3% risk of transmitting genetic disorders to his/her children.  The problem is that there are thousands upon thousands of potential disorders, and the risk for transmitting any particular one of them in any given couple is so minuscule that testing for every one would be extremely inefficient, ineffective, and and just a really bad idea.  The trick is to identify the problems that each couple is at a significantly increased risk of transmitting, and then to discuss whether or not testing for that particular problem might be warranted.

Any given Jewish couple will have baseline risks for certain problems, simply because they are Jewish.  The fact that we are aware of genetic diseases common to Jews is a blessing of modern medicine and of our unique heritage.  The average non-Jew (at least in the US) doesn't know very well what he/she is at risk for, because the population is so heterogeneous and therefore impossible to track the risk factors unless they have a specific family history. But being a Jew generally means that you come from a specific genetic population that (at least until recently) has had relatively minimal mixing with the society around it.  This is a blessing because it allows us to target specific disease that are known to occur in our population.

The couple in question may then also identify family specific problems, and then they will be presented with some complicated decisions to make.  Primarily they will have to decide two things.  What should we test for?  What would we do with the results of these tests should they uncover something?

The answers to these questions will vary tremendously according to the circumstances and the personal preferences of the people involved.  They will take into account numerous factors including, but not limited to:

1. How high is our risk for carrying this disorder?
2. How high is the risk of transmission?
3. What are the risks and/or costs of the test?
4. What would be the consequences of transmitting this disorder to our child (how severe is the problem, are there treatments for it etc...)?
5. What options would be available to prevent having a baby with this problem (i.e. prenatal testing, abortion, Preimplantation diagnosis, and so on)
6. What options would Halachically be available to us?

As you can see, this process is very complicated and potentially very stressful, but also very very important.  Closing one's eyes to this information is similar to closing one's eyes when crossing the street.  In today's world, it is imperative for potential parents to go through this process.  Of course the decisions made will vary for every couple and every individual. But to ignore it completely is nothing less than willful stupidity.

Now that I gave you a summary of what genetic testing should be, in my next post I am going to discuss some of the programs that are in place today in the Halachic community, and use our rationalist lens to decide the merits and/or critical problems with some of these programs.

Genetic Testing - What is it and Let's get Started Again!

I sincerely apologize to everyone who has followed this blog in the past for my prolonged absence from the "blogosphere".  I attribute my absence to my busy life as a father, physician, and simply being an active participant in the community that I live in. So blogging had to take a back seat for a while. However, after much soul searching, i realized that this blog afforded me the opportunity to express my ideas to the people who could most benefit from them, but more importantly, the opportunity to get feedback from those very same people.

So here I am, ready to pick up where I left off a while back, the topic of genetic testing from a rationalist medical Halachic perspective.

Before I begin, let me say with a measure of both pride and humility, that the three topics (Time of death, treating gentiles on Shabbat, and abortion) I covered so far and my treatment of those subjects, has made significant waves in the Jewish community.  This blog has positively influenced the thinking of many leaders in the field, and I am proud of that achievement.  But there is so so much more work to do, and the list of issues we need to tackle grows daily.  

Please feel free to suggest topics, and as always, please feel free to speak your mind in the comments section, I really enjoy and learn from the feedback you give me.

Several weeks ago, a pamphlet published by YU landed in front of my seat in shul called, "To-Go" and the topic of this pamphlet was strengthening marriage and relationship-building.  Naturally I picked it up and perused through it, with my mind settling on an article by Dr Eddie Reichman about the Halachic "Mandate of Genetic Testing".  Naturally, any article by Dr. Reichman deserves my attention, so I read it carefully and enjoyed it, and will be referring to it as we progress through this blog topic.

But most importantly for me, this article gave me the "kick in the pants" that I needed to get back to blogging!

So here we go!

The term genetic testing conjures up all sorts of images in the popular imagination. It seems to me that any discussion of genetics stimulates more fear and trepidation than other types of medical testing, especially among Jews.  There are obvious historical reasons for this, but the purpose of this blog is not to delve into the history of the relationship between anti-semitism and genetics.  However, it is imperative for any Jew who believes that being informed about his/her health is part of the biblical mandate of "VeNishmartem Me'od L'Nafshoteikhem" to get him/herself educated about this incredibly important topic.

Just for a "heads up", I am going to be discussing various programs for genetic testing that are currently being used in the Orthodox Jewish community.  I hope to analyze through our "Rationalist" lens  some of the advantages and disadvantages of several of these approaches.

What does the term "genetic testing" mean?

The term genetic testing refers to any medical test that is meant to determine any part of the genetic makeup of any individual or future individual (such as an embryo).  It is thus a very broad term, and I first need to describe the basic areas in modern medicine in which genetic tests are used.  There are many different types of genetic testing that are used by physicians today.

1) Prenatal testing - This refers to testing of a fetus during the various stages of development during pregnancy.  The purpose is to diagnose any possible medical conditions that the fetus may be afflicted with, specifically medical conditions that are known to be genetically caused.

2) Premarital or preconception testing - This refers to testing that prospective parents might get in order to determine what types of genetic disorders they may be at risk of transmitting to their potential offspring, should they decide to have children together in the future.

3) Individual Testing - This refers to testing a person who is not currently afflicted with any known genetically caused disorder in order to determine his/her risk for developing a particular disease that is at least partially caused by a known genetic defect. The most common example of this is the BRCA gene which is known to significantly increase the risk of breast cancer in those people who carry the gene.  The purpose of such testing is to determine if interventions might be able to be done in select individuals that would reduce the risk of them ever contracting the disease.

4) Diagnositic testing - This is done in a person who is afflicted with an illness, and it is suspected that it may be due to a certain genetic disorder.  By checking off specific genes, this may help determine exactly what is causing the problem, which may help to properly treat the afflicted person.

5) Testing embryos, ova or sperm for eventual fertilization or  implantation - Such testing is usually done during the process of infertility treatment.  In such cases, embryos are tested before implanting them into the mother's uterus.  The purpose is to diagnose which embryos nay have certain desirable or undesirable characteristics which will help determine which embryos to implant and which to discard.

6) Forensic and paternity testing - This refers to testing of blood or materials for DNA with the purpose of determining the identity of the origin of the DNA. In the case of paternity testing it is to determine the father of a particular individual, in the case of forensic testing it is to determine the person from whom the material originated, usually for the purpose of criminal investigation.

With that behind us, let's move on to my next post, in which I will discuss some of the reasons why from a religious perspective, genetic testing is such an important part of taking care of our health.

Genetic Testing

This is the start of a new series in this blog, one which has been on my mind for quite some time, and one which has been on my mind for quite some time.  It seems to me that each topic I have chosen so far has something unique and special about it that makes it stand out as a paradigm for what i believe is a fresh "rationalist" approach to medical Halacha. 

The first topic we discussed, brain death, represents the difficulty one has when contemporary Halacha has to consider the medical knowledge that led to the Halachic precedents that are recorded in Chazal and earlier poskim.  We described how important it is to understand why the gemara said what it did regarding the determination of death, and what chazal's understanding of physiology was.

Our second topic, treating goyim on shabbos, represents the problems one encounters when Halacha seems to conflict with our basic moral sense of right and wrong.

The third topic, abortion, was a rationalist approach to a subject which had no clear Halachic consensus, and the decision making process that should be involved in dealing with something this unclear and complex.

This new thread, will deal with a Halachic topic that is unique for several reasons, which I plan on demonstrating during the writing of the series.

1)  This topic is unique, because the scientific knowledge in this area increases so quickly and so dramatically, that a Halachic treatment of the subject that may have been valid two years ago may be no longer valid.  I am going to argue, that not only is the knowledge that we accumulate quantitatively increased, but qualitatively as well.  Thus, not only do we know more "stuff", but the accumulated knowledge needs to fundamentally change the way the religious community deals with this subject responsibly and consistent with Halacha.

2) This topic is also unique because it forces us to consider fundamental Jewish concepts in ways that our great leaders of the past could not possibly have foreseen.  Concepts and ideas such as fate, predestination, divine guidance of wordly events ("hashgachah pratis"), hishtadlut, bitachon, and many other most fundamental concepts have to be reconsidered in light of the challenges of this wonderful new area of knowledge that science has given us.  It is my contention, that the approach one takes to genetic testing is highly dependent upon how one approaches the above mentioned concepts and their relative value in Judaism. The intersection of "Hashkafah" and "Halacha" is especially relevant when considering this topic.

The question then becomes, how much should scientific knowledge change the level of importance that we give to certain Torah values.  I know this sounds a bit heretical at first, but please give me a chance to explain exactly what I mean before you make any judgements.

3) This topic is also unique, in that a primary issue involved is the value of knowledge itself. Most Halacha revolves around actions.  Halacha usually forces one to consider such questions like, "what am I allowed to do?" or, "What am I obligated to do?"  However, when it comes to genetic testing, the question is very different. This is because one is asking, "what knowledge should I seek to find out?" or "Is it better to know some piece of information or not to know it?"  This is not the usual Halachic quandary, and it forces us to inquire into the fundamentals of the Jewish values of seeking knowledge and learning vs. faith and trust in God.

I must beg your patience as we work through this subject, as it will take me some time to develop my ideas.  Please forgive me, because I also have a "day job" ;-). So if I miss a few days, please be aware that it is not because I have given up on this enterprise.

My general plan will be as follows, though I may change it here and there as we progress through the subject.

First I plan on giving some background.  I will review the state of genetic testing in practical medicine today, and review the options, treatments available, and enough science that you will hopefully understand the basics.  I will then review the sources that the poskim bring from chazal and rishonim acharonim etc. that are used when discussing the subject.  Then we will discuss the various major contemporary poskim and how they dealt with (or deal with) these issues.  Then we will embark on our rationalist analysis, using the five principles of Rationalist Medical Halacha.