IN-DEPTH FEATURES
The Man Behind the Patient and the Man Behind the Doctor

An interview with HaRav Yitzchok Silberstein, the rav of the Ramat Elchonon Area in Bnei Brak; Prof. Eren Dolev, head of Internal Medicine 5 at Ichilov Hospital in Tel Aviv, head of the Medical Ethics Committee of the Israel Medical Association, and former IDF Chief Medical Officer; and Dr. R' Menachem Breier, Head of Medical Staff at Givat HaSheloshah Geriatric Center

At this opportunity, we wish to convey our sincere condolences to HaRav Silberstein on the recent passing of his rebbetzin, the daughter of Maran HaRav Yosef Sholom Eliashiv, shlita.

Part II

The first part of this interview discussed the patient's attitude toward life and his or her illness, including the effect of emunah in prolonging life. Also the issues of medical ethics and euthanasia were commented on, as well as the doctor's attitude towards his work, and how much should be told to one who is sick (and also who is well).

Prof. Dolev, as a doctor -- I ask you precisely because you are a doctor -- can medicine benefit from Jewish halocho

Medicine is not a general abstract definition. It is very specific and corresponds to the way a society lives. There is an "Israeli disease" and an "Israeli cure," that are not the same as they are in another place. In that place a different type of people live. Each society has its own exclusive characteristics.

A doctor must listen to his patient. We say that a doctor must treat the sick person, not only the sickness. Can doctors ignore Jewish halocho? No! They are part of our community, the Jewish community.

I have always only gained from this realization. I judge that for many parts of the community at large the fact that I use the laws, regulations, and halochos that obligate large communities is surely beneficial. It is possible, and we must make use of the possibility. If doctors will invest more in this topic we will all extract a blessing from the Jewish Torah.

Can this be the basis?

Yes, but I am afraid that among some doctors there may be opposition.

HaRav Y. Silberstein: In order to illustrate the answer to that question I will use an incident that happened to Prof. Eren Dolev himself. He was then a young military doctor, not yet the IDF Chief Medical Officer. He went out with a force for a military objective and waited under cover. Even before they started their mission one of the force's soldiers was hit in the stomach. Prof. Dolev had two possibilities: One -- to put the soldier on a respirator and request his evacuation by helicopter, with only a paramedic to accompany him. To do so, however, would lessen that soldier's chance of survival. It would be better if a doctor flew out with him. On the other hand, if Prof. Dolev accompanied the wounded soldier, the entire force would then be left without a doctor during its mission.

Prof. Dolev needed to make an immediate decision. He decided to stabilize the wounded man's condition and evacuate him with a paramedic. He chose to remain with the force. Later he asked me what the Jewish halocho was in such a case. I did not know what to answer and presented his question to my father-in-law, Maran HaRav Y. S. Eliashiv. He ruled that in such a case the doctor must remain with the force, since all of the soldiers are considered as "the sick person that is in front of you."

There are extremely difficult questions. I have already proposed to several mayors to prepare a place for a Sanhedrin at the entrance to their cities. That is the way it used to be. A Sanhedrin of twenty-three would sit near each city's gate. They would give rulings about all halochos and would also judge ethical matters. How can we live without this?

I will give you another example: An IDF Air Force plane took off to attack enemy targets. Communication with the plane was lost, making it impossible to let the pilot know that his attacks were -- mistakenly -- aimed at Israeli forces. The only way to prevent Jews from being killed was to shoot him down. Is that permissible? For such decisions a Sanhedrin needs to sit in the city's gate. When I asked Maran HaRav Y. S. Eliashiv he gave me a detailed answer, but it cannot be discussed here.

I will tell you of another incident, something that happened during the Holocaust. This anecdote is recorded by HaRav Aharonson zt'l in Alei Meroros. The Rav was ordered to cover over the communal grave of the kedoshim who were shot, Hy'd. Some of them were still shaking, still living -- covering them with earth would hasten their death. On the other hand, if he refused he would endanger his own life, since it could be assumed that the Nazis would kill him. What should he do? Is it permitted to hasten them to their end? They are still alive! According to halocho it is forbidden to bring someone's death nearer! HaRav Aharonson endangered his life and did not fulfill the order. Halocho is the ethical system of our life. It is halocho leMoshe miSinai.

Prof. Dolev, what in your opinion should be the motto of a doctor towards a sick person?

To listen, to see what he can do to help. I will give you an example: One Friday afternoon some doctors called me up. They had an emergency. There was a sick person who needed an urgent appendectomy but refused adamantly. I asked why he was refusing. The answer was that he was simply not normal. He did not understand his condition or the urgency of the operation. "Did you ask him why he refuses?" I continued to inquire.

The answer was: "No!"

I went over to the hospital and talked with the patient. It seems that his brother had died when he was once given anesthesia. Since he did not recall the name of the substance that was used, he was afraid to undergo an operation. He wanted to consult with a rav. What do you think? An hour later he was already being operated on.

Is it necessary to listen to the family too? They have their own demands . . .

Prof. Dolev: Surely we must listen. Families sometimes ask extremely difficult questions. Sometimes a family also has difficult requests. It once happened that a son of a man's first marriage argued with the patient's third wife over whether the medical apparatus should be disconnected. I told them: "If you want to help the patient, please go outside and pray . . . that is the only thing you can now do to help!"

I will tell you another interesting incident. An elderly woman was lying in my ward. After I looked into her file I saw that she was a mother of six children. The surprising thing was that she was alone all the time; no one came to visit her. On Wednesday I saw that one son came, alone at night, to visit her. He did not want to see any doctor, and did not ask questions or show any interest in her condition. I decided to find out what was going on. I waited for him next Wednesday and when he came I called him into my room. I asked him why the family did not come to visit.

What happened was the strangest thing that I have ever seen in my career as a doctor. The son turned around and closed the door. He took off his shirt, and on his back were terrifying scars. This man told me that when he and his siblings were children their mother beat them with gruesome violence. These were now the results: no one wanted to come to visit her. "Leave us alone," he asked.

For me this was not an answer. Halocho deals with all areas of life, and therefore I am certain that HaRav Silberstein has an answer. I can only give general rules of conduct for doctors, no more . .

HaRav Y. Silberstein: The mother surely acted foolishly, but the children are still obligated to honor her. There was a person who tried to kill his son, and handed him over to be killed. That person was Terach, the father of Avrohom. HaKodosh Boruch Hu then told him: "You are exempt from kibbud av." That ruling is only in such a case, but in all other cases a person must honor his parents.

This is the mitzvah of paying back a debt for what the parents have done for us. Such a case as the one mentioned is the same.

The mother is considered a shotah. There are different levels of a shotah. There are some people who act in a certain way because of life's hardships and pressures. They collapse and become shotim for that moment. Nonetheless, according to din Torah the children are not exempt from honoring their mother.

A person is exempt only if his mother goes so far as to hand him over to be killed. At that moment she loses the zechus for what she has given her son. However, when a mother hits a son, even in a cruel way, the son is not freed from honoring her. He still needs to show his gratitude for bringing him into the world.

Thirty percent of Israel's health budget goes for the first year of life and the last. The financial means available to the health system are not sufficient. How do they manage? In the past the acclaimed scientific newspaper Nature printed an article written by Francis Crick, a Nobel Prize winner. His article suggested to consider a newborn as living only after 48 hours. Until then all medical tests should be done and they will decide whether to let him live or not. Also, a person at the age of 85 will be considered dead and according to the law they will be able to end his life. The one who proposed this is at the summit of scientific acclaim. Why, in your opinion, is it really necessary to finance people "who cannot contribute to society"? What is your opinion about this dreadful approach?

Prof. Dolev: Let us start one point at a time. It is true that 30% of the health budget goes for these two periods of life. This is without a doubt. In the middle of life people are usually healthy and do not need any help. This is true. This is just saying that the last years come at the end. Of course! If they did not arrive at the end they would not be the last years. If a person did not die that year it would not have been his last year. These people therefore also need help.

As concerns the question we are discussing, I am forced to say that even should there be a ruling from a court allowing such acts it will be very difficult to find a doctor who will agree to detach a person from life-saving apparatus . . . More does not need to be said.

HaRav Y. Silberstein: The moral level of society is measured by the treatment of the weak and the needy. On Rosh Hashanah we read in the novi, "Behold I will bring them from the land of the north and gather them from the ends of the earth. Among them will be the blind and the lame . . ." (Yirmiyohu 31:7).

We take pride in our blind and lame people. We will take care of all those who are broken and need help. They are important to society! We need them! By their zechus we live! It is written that it is preferable to be mechalel one Shabbos so that a person can go on to observe many days of Shabbos. This has an additional meaning. Who will observe many days of Shabbos? The doctors! The nurses! It is preferable that they profane one Shabbos to save a sick person and treat him, so that they will be zoche for a length of days to observe many days of Shabbos!

The Greeks were proud of their culture. The Romans were proud of their power. We are proud of taking care of broken people. We take pride in doctors who have high moral levels and Jewish hearts.

People may be unfortunate, but as long as they breathe they are human beings, with all that means.

I will tell you a story that happened in a camp in the Holocaust: In one tent of many people, there were two who were both named Kahane. One of them was insane and feeble. The Germans entered the tent and demanded "Kahane." They wanted to kill him. Everyone knew that they meant the normal one.

One of the people decided to exchange one Kahane for the other. Instead of the Kahane the Germans demanded, he gave them the insane Kahane, who went to his death singing ani ma'amin. (Actually, he used to sing that song all the time.) After the war, he was bothered by what he did, and the one who had exchanged the Kahanes asked rabbonim if he had acted correctly. The answer he received was unambiguous: What he did bordered on murder! A person is a person as long as he lives. His right to live is not less than another's right. Look in the Shut Ish Mazliach.

Prof. Dolev: Ethics deals with the principle of the "slow and steady decline." Today we are talking about improper treatment of Alzheimer's patients, tomorrow we will be talking about elderly above 90, and eventually we will reach people belonging to certain groups or faiths. If we allow not treating one person we are decreeing the fate of all.

The Ethics Office drafted a document about the approach to a mortally ill person, in what conditions is it possible to obey him and not connect him to life-sustaining apparatus. First of all, there must be a definite diagnosis that he is incurable, that he is suffering terribly, and that death is coming soon. The second condition: If he himself is requesting the non-connection. When that happens we must ascertain that his request stems from his free will and is not influenced by medicine, pressure or environment.

Why do we only consider the request of those who are sane? Why not also a request from an Alzheimer's patient? Because then we will be able to bring the next victim. . . . We also need extremely strict classifications. The assumption is that not every one is a tzaddik and a doctor is liable to judge one case on the basis of another. This is likely to cause an ethical snowball.

HaRav Y. Silberstein: It is surely liable to cause a snowball. I will give you an example: In the time of the Holocaust there was a halachic question: Is it permissible to eat the flesh of a dead person? The answer was No! since if we will announce that it is permitted to eat the flesh of a dead person, people will also eat flesh of live people. One can cause the other.

Prof. Dolev, what if a person leaves a will stating that when he, cholila, arrives at a certain condition he wants to die?

Prof. Dolev: Why is he involving me in this affair? He does not want to take his own life, but he wants me to do it for him? Why is he dragging me into this business? Let him go to Dr. Kervorkian! [A doctor who is being tried in the USA for killing someone at his request -- YN.] I will not do it!

Prof. Dolev, perhaps let us end on an optimistic note.

I am definitely optimistic, since conditions are constantly improving. Awareness among doctors is increasing and also more people are demanding their rights. I do not believe in revolutions but in trends. Listen, I heard that people who were at the pyramids in Cairo were amazed how people could carry such large stones, weighing several tons, especially considering the technology of those days.

I myself was more excited about what I saw in China. I saw the colossal wall of China. I was not excited about its endless length. I was excited about the wall being made of small stones. Every Chinese person carried one small stone. Millions of Chinese contributed the same small contribution: a small step until the wall became what it should be. We have gone a long way. Sometimes I feel as if I am holding my finger in a dam to stop a flood. Today things are improving.

HaRav Silberstein: The gaon HaRav Yaakov Kamenetsky zt'l refused to say a hesped for a certain person. Although he had been a yirei Shomayim and talmid chochom R' Yaakov refused to say any eulogy. He answered his amazed acquaintances, "I once told him not to fast on Yom Kippur because the doctor forbade him to fast. He did not do what I told him. I will not be maspid him, so that everyone will learn a lesson. A doctor's decision is important and therefore also his responsibility is great."

R' Elazar the son of R' Shimon bar Yochai brought Asya Katringa (a doctor) to his father. R' Shimon was extremely impressed by him and his incomparable wisdom, and said that in him was fulfilled, "He discovered him in a desert land, in desolation, a howling wilderness" (Devorim 32:10).

A poor Jew is lying in a house alone and the doctor comes to him in "a desert land." What does he do? "He encircled him, He granted him discernment, He preserved him like the pupil of His eye" (ibid.). A doctor who is so devoted will be zoche to Divine aid that no other doctor could be zoche to.

The first midwife was Shifrah. Why was she called Shifrah? She had a shefoferes (a tube) with which she would respirate the children who were born. Today such an apparatus is used in medicine, but what Shifrah did happened not 40 years ago, but thousands of years ago. Because of this devotion, she was zoche to botei malchus and botei kehuna. This is the reward that a doctor deserves for his devotion and love.

With Hashem's help, "The diseases that I placed upon Egypt, I will not bring upon you, for I am Hashem, your doctor" (Shemos 15:26).

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