Some events are too large to be evaluated while being experienced in real time. Maybe because the way the individual experiences the event is insular. Perhaps only time and the addition of the experiences of others, combined with greater communal and societal data, can give insight into the true nature and repercussions of the event. The Coronavirus pandemic, arguably the single most impactful event of the last century, is one of those occurrences. Covid upended both the world at large and the individual lives of people worldwide.
Covid has been approached and dissected from many angles, most of them secular. Medical Halachah Annual, Volume 1: The Pandemic and Its Implications, published by Touro University and New York Medical College, is a concise work that presents a halachic approach to some of the ethical pandemic-related questions dealt with by the secular world. The book is divided into two main sections: “Issues in the Clinic and Hospital” and “Issues in the Community.” With a few exceptions, the first section does not discuss the pandemic itself, but rather the fundamental issues it raised and how halachah approaches them. Each chapter was written by an expert on that particular topic. The book is a mix of many styles, some rigorously mathematical, some explanatory/procedural, and some descriptive of the social context in which Covid arose and how it was dealt with.
The first chapter, by Rabbi Mayer Twersky, a rosh yeshivah at Yeshiva University, addresses risk assessment in halachah. The chapter includes an esoteric analysis of why a risk of precisely 1 in 1,000 (0.1%) represents a risk to life “and completely supersedes Shabbos,” while a risk of 1 in 1,001 does not—an intellectual exercise in attempting to translate what appears to be a somewhat random cutoff point into a distinct and logical inflection point. After establishing this methodology, he analyzes the theoretical underpinnings of how major posekim have applied these concepts to determining halachic risk and how the concepts of vadai sakanah (a definite risk) and safek sakanah (a questionable risk) are applied to individual risk. He then examines the repercussions of these concepts on communal risk.
The book then presents three chapters explaining how halachic concepts were used to inform the management of several specific pandemic-related medical conditions. In “The Management of Profound Multi-Organ Failure,” Rabbi Professor Avraham Steinberg, MD, a world expert on Jewish medical ethics, briefly discusses a halachic approach to medical futility by explaining how Jewish law approaches this subject. He first defines several halachic terms, such as gosses (“the dying patient”), chayei sha’ah (“temporary life”), and tereifah (“non-viable”), and then explains the difficulty of applying them to specific medical conditions. Nevertheless, he presents a concise, practical guide to applying these halachic concepts to the realities of modern medicine. Rabbi Dr. Akiva Tatz, the author of Dangerous Disease and Dangerous Therapy in Jewish Medical Ethics, brings his expertise to bear in a succinct and carefully organized presentation of the application of Jewish law to allocating scarce resources.
This section is rounded out by a lengthier, more medically technical essay, “Adult ECMO and Mechanical Circulatory Support,” by Dr. Jonah (Yona) Rubin and Rabbi Dr. Jason Wiener, on one of the more esoteric areas of medical therapy used during the pandemic. ECMO is a risky but at times lifesaving treatment for patients who cannot breathe and sometimes cannot maintain adequate blood circulation. Having written an essay on the halachic issues related to ECMO for an international ECMO conference in 2013, I found this subject particularly fascinating. The chapter deals with the ethical and medical difficulties of applying halachah to an area of medical uncertainty that is available to only a small number of patients, has a questionable benefit-to-risk ratio and may place the physician in an untenable ethical position regarding the continuation of the treatment if the patient does not respond and improve.
Most interesting is the section of the book dealing with decision-making on the part of the patient or potential patient, and the realities of evaluating medical information gleaned from multiple sources. Must one listen to his doctor? Must one follow established medical care? There is a standard of care in medicine that is both legally recognized and generally considered to be the prudent course. But there are always dissenting opinions, sometimes by conventional healthcare providers and sometimes by “alternative” medicine advocates. Does halachah circumscribe the permitted healthcare decisions of a patient based on the obligation to guard one’s health?
One of the book’s lengthiest chapters, “Halacha’s View of the Requirement to Follow the Established Standard of Care,” written by Rabbi Moshe Rotberg, a leading expert on halachot concerning end-of-life and medical emergencies, begins by discussing the level of trust that halachah grants the medical community to determine proper practice, and when doctors should be trusted. The author then explores questions that were hotly debated during the pandemic, such as whether all suggestions and opinions are “created equal” and whether one must follow the CDC (Centers for Disease Control and Prevention) and WHO (World Health Organization) recommendations. He addresses topics such as the layman’s requirement to adhere to medical and safety guidelines; whether the halachic concept of shomer peta’im Hashem (Hashem’s promise to watch over those who live their lives normally, not worrying about the small dangers that lurk in activities of daily living) mitigates the need to follow certain health guidelines; and what the proper course is when medicine and science contradict the Gemara’s statements of reality. He ends with a short description of how great rabbis dealt with cholera pandemics in earlier times.
Rabbi Mordechai Willig . . . offers a “memoir” of his role in the Jewish communal pandemic timeline, including the hard choices that motivated the closing of Jewish communal institutions and the real-time process of balancing medical, rabbinic and public opinion.
While the above questions are engaging and the topics interesting, they have been explored before. One chapter, written by Rabbi Baruch Fogel, campus rabbi at Touro Law School, asks a provocative question that is rarely discussed and which I find fresh and new, despite my having decades of experience learning and teaching Jewish medical halachah and ethics: What is the proper approach to medical uncertainty in halachah? While the previous chapter posits a known standard of care, the pandemic presented a different reality. In normal circumstances, once an accurate diagnosis is made, a physician determines which known and proven treatments will work best for a given patient and provides that treatment. But what if there is no standard of care? Such was the case at the beginning of the Covid pandemic, as the book correctly states:
In the earliest stages of the Covid-19 pandemic, uncertainty reigned. With the number of infected patients increasing daily and the mortality rate rising, there was a desperate search for effective therapies. Researchers and physicians suggested experimenting with various approaches in the hope that something—anything—would help stem the upward mortality rate.
Rabbi Fogel then asks several fundamental questions that had been dealt with in halachic medical ethics discussions but had to be applied in the new reality of Covid. For instance, is it appropriate to experiment with a therapy without the benefit of a properly designed trial? He argues:
Without a properly designed clinical trial, it is nearly impossible to conclude whether a particular therapy was the true cause of a patient’s recovery. Stated differently, from a halachic standpoint, is it correct to experiment on the limited number of sick patients in the present, or should an experimental treatment only be offered in the context of an established clinical trial that will (potentially) produce conclusive results for the future?
As Rabbi Fogel puts it, “Does my obligation to the patients that are currently in front of me outweigh my obligation to the eventual higher number of patients that will present in the future?” He then deals with the question of when to accept the results of trials that do not show efficacy of the proposed treatment despite some anecdotal reports of success. He ends with a discussion on who, according to halachah, is deemed reliable to offer an opinion in times of medical uncertainty. As he states, “Not every opinion is equal when it comes to medical decisions.”
As stated above, the second section of the book focuses on communal and social issues. An excellent chapter by Rabbi Ahron Lopiansky, rosh yeshivah of the Yeshiva of Greater Washington, evaluates “the roles of medical expertise and rabbanim in the pandemic.” The essay lays down the axiom that halachah takes precedence over any other considerations, and then evaluates the appropriate role of scientific and rabbinic input in medical questions. The beauty of the essay is Rabbi Lopiansky’s ability to delineate the various levels of certainty in science and pesak halachah and how each category is given a different weight. He then delves into expert opinion versus outlier opinions, reliability, and the role of both the doctor and posek in medical decision-making.
Rabbi Mordechai Willig a rosh yeshivah and rosh kollel at Yeshiva University, offers a “memoir” of his role in the Jewish communal pandemic timeline, including the hard choices that motivated the closing of Jewish communal institutions and the real-time process of balancing medical, rabbinic and public opinion. I found it fascinating to read about decisions that were made contrary to the better judgment of the rabbis to appease the public and avoid worse outcomes.
A short halachic interlude follows, written by Rabbi Yossi Sprung and medical student Judah Eisenman, entitled “Dishonest Acquisition of Potentially Lifesaving Care,” which discusses issues of obtaining medical care at the expense of others. Rabbi Zvi Ryzman then offers an extensive and stimulating essay on vaccination against Covid, which discusses multiple philosophical, halachic and practical issues that lead to a vigorously presented case for the obligation to vaccinate both adults and children. Some of the most thought-provoking and controversial questions raised involve the vaccination of children: May a child demand to be vaccinated against his parents’ wishes? May institutions, such as schools and shuls, require children to be vaccinated even over the parents’ objections? May doctors vaccinate children without parental consent or against parental wishes? And lastly, may one parent insist on vaccinating his child if the other parent objects?
The second-to-last chapter is a fitting follow-up to Rabbi Ryzman’s article. Dr. Sarah Becker offers an enlightening essay on vaccine hesitancy in the Orthodox Jewish community, despite the evidence of vaccine safety and nearly universal medical advocacy of vaccination, and efforts to increase vaccination acceptance in segments of the Orthodox community that were reticent to vaccinate. She demonstrates the importance of dealing with the true motivations of those hesitant to vaccinate (particularly their children) and understanding where people are coming from, not where we presume they are coming from. She explains how educating certain segments of the community with material relatable to its members led to increased vaccination rates.
The last chapter, labeled a “Special Jewish Historical Feature,” discusses the horrendous results of the Jews being blamed for the Black Death outbreak that decimated Europe in the fourteenth century. In their chapter “Othering the Jews during the Calamitous Black Death of the 14th century and the COVID-19 Pandemic of the 21st Century,” while mostly laying out the history of terrible persecution of the Jews, Margot Lurie and Dr. Edward C. Halperin discuss the twenty-first-century parallels of “othering” minority groups during the recent Covid-19 pandemic.
Overall, Medical Halachah Annual: The Pandemic and Its Implications is a stimulating mix of academic medical information for physicians and other healthcare workers, along with halachic insights into medical ethics issues and their effect on individuals and communities. The book raises thought-provoking questions for healthcare professionals and the people they treat. It will be interesting to see the topics dealt with in what I presume will be volume 2.
Dr. Daniel Eisenberg is a practicing radiologist in Philadelphia and has been writing and lecturing internationally on Jewish medical ethics topics for over thirty years. He is the author of the soon-to-be-published three-volume set: Judaism and Ethics: Exploring the Traditional Jewish Perspective on Contemporary Medical Issues.