The annual gathering of the Puah Institute again tackled the difficult issues in which medicine may clash with Halacha.
By JUDY SIEGEL-ITZKOVICHpuah 311(photo credit: Courtesy)
Orthodox rabbis and secular (and even some observant) physicians are often on opposite sides of the fence when it comes to medical and halachic issues.Regarding halacha as supreme law that must be obeyed, rabbis tend to be on guard when controversial medical solutions are offered for health problems, but they also need and respect doctors because Jewish law regards them as God’s emissaries to heal and save lives.Physicians may be suspicious of the more extreme rabbis’ wanting to intervene in their practice, prohibiting followers from donating brain-dead loved ones’ organs for transplant, refusing treatments that are conventional in the Western world, and stressing technical halachic matters that seem nonsensical. Yet cognizant of the fact that the observant – and especially haredi – camp is growing by leaps and bounds, physicians note their increased influence on Israeli society (as potential private medical patients), while the observant always seek the best specialists when they become ill.THE TWO camps’ coexistence and even respect for each other is always tangible at the annual conference of the Puah Institute for Fertility According to Halacha, which recently convened for the 11th time in Jerusalem’s Ulamei Nof hall, with nearly 2,000 men and women separated by a cloth divider.Intimate subjects and sexual terminology that wouldn’t be used in polite haredi society (its media won’t even use the words “breast cancer”) are openly discussed at the conference.It is always held during the week before the weekly portion in Exodus devoted to the story of the Hebrew midwives Shiphrah and Puah, who saved male Hebrew babies from Pharoah’s death sentence. This year, the lectures continued as usual for 12 hours, but there was a change – the absence of the late former Sephardi chief rabbi Mordechai Eliahu, who was the spiritual and halachic adviser of the institute.Founded 21 years ago and still headed by Rabbi Menachem Burstein, the non-profit organization (www.puahonline.org) originally focused on helping infertile couples. It has a staff of rabbis speaking Hebrew, English, French and Spanish (who get an average of 150 calls a day) and women who carefully supervise in-vitro fertilization to ensure that no mistakes are made. In recent years, it expanded its interests to training counselors for brides and grooms, family purity experts, ritual bath attendants and kashrut supervisors.DESPITE THE respect and cordiality, there are tensions. Rabbi Dov Lior, the chief rabbi of Kiryat Arba who is national religious and not haredi, clearly disappointed some listeners when he ruled in his lecture that young observant single women who can’t find a suitable match may not have their eggs frozen – as permitted recently by the Health Ministry – for later use when they marry, or using sperm donation to produce a baby they will raise alone. The disappointment was especially keen as just before the conference, a secular paper predicted that Lior would endorse such a policy.And Hadassah University Medical Center endocrinologist Dr. David Zangen bemoaned the fact that some haredi rabbis forbid single young men who had hormonal disorders from being tested for fertility because the collection of sperm supposedly violates the prohibition against “spilling seed.” A 17-year-old arrived at his clinic at the end of the day, apparently so he wouldn’t be observed. “He had no secondary sexual characteristics, adolescent-sized testicles or pubic hair. “Nobody in his yeshiva told him that there was something wrong. But he compared himself to the way his peers looked and came for help,” said Zangen, who noted that haredi teachers and parents’ “ignoring such problems in boys as well as girls is not uncommon.”“Tests have to be done,” he continued. If a boy in his early teens does not show grown testicles and pubic hair, a brain tumor may be interfering with his production of testosterone. It can lead to aggressive behavior and even blindness. In this case, we did a scan and found no tumor. The yeshiva student asked if he would ever have children. I told him we would give him hormonal treatment. In some cases, such a patient will look sexually developed but be infertile.
If treatment is delayed, fertility is less likely.”Zangen said he could see that the boy was upset.“It turns out he cried all night and said he didn’t want to live. Fortunately, a few weeks ago, somebody had given me the phone number of Rabbi Ovadia Yosef. I called him, and he asked to meet the boy with me present. He asked relevant questions, and when the student left, he was smiling. I gave him hormone treatment, and he developed normally.When he began to meet young women for marriage, he asked me what he should say about his fertility.Some rabbis refused to let him undergo a fertility test. Rav Ovadia approved it. He married, and just recently he and his wife had their third child.”ZANGEN ADDED that the pituitary gland behind the eyes is responsible for producing hormones. If there is a deficiency of estrogen in girls and testosterone in boys, the child will not reach normal height or be fertile. The process of biological adolescence must begin no earlier than eight years for girls and nine for boys, and they should begin to show secondary sexual characteristics in girls (breast buds and pubic hair) by 13.5 and 14.5 in boys (enlarged testicles and pubic hair). The onset is different in each family, with premature or late appearance running in families. If there is a problem, take the child to an endocrinologist, he concluded.Lior, speaking about fertility treatments, said the majority opinion on artificial insemination in couples with fertility problems holds that it is permitted, even though some rabbinical arbiters prohibit it. The child who is conceived is, in the eyes of the majority, the biological and halachic child of the husband if he was the source of the semen.“But a test-tube baby [produced by in-vitro fertilization (IVF)] is much more complicated and a difficult question, because there is no physical contact between the father and the fetus. It is important in Jewish life to know who one’s father is.There are problems with this technique,” he said, countering the view of many leading rabbis. As for single girls who want to freeze their eggs, the Kiryat Arba rabbi said women are not – unlike men – halachically obliged to have children. “If a child is born without a father figure, there can be negative characteristics; this is not the solution.” He objected to the modern view that women have to have advanced college degrees and good jobs before they marry. If they don’t find a proper match, they can always adopt an existing child, Lior suggested, without addressing the problem that the supply of decent religious men for religious girls in their 20s and 30s seems to be dwindling.Rabbi Shlomo Daichovsky, who heads the Supreme Rabbinical Court, tackled the problem of medical negligence and lawsuits, whose awards are rising and which cause the cost of healthcare to spiral. He noted that it was unnecessary to go to a “leading specialist” for ordinary conditions, such as colds or flu. “But if there’s a serious disease, it is desirable to consult leading specialists with good reputations. They have an angel accompanying them at all times. According to Jewish law, such a physician has immunity from being used. If he unintentionally made a mistake, it’s a matter for Heaven to punish him, not a court.” Daichovsky continued that if the specialist believes a fetus is defective, the problem “is not simple. Even imaging is not 100 percent accurate,” he said, noting there have been scans showing a “defective” fetus that was later born completely healthy.More liberal was Holon Chief Rabbi Avraham Yosef (son of Ovadia Yosef), who approved the use on Shabbat of the handheld TENS electrical device that neutralizes pain from contractions before delivery if a woman is unable to stand by herself. Women suffering from such pain may be weakened during delivery. “They need a lot of strength; with the device, they will be more relaxed during the early states and have more strength to give birth successfully.” It can be used on Shabbat and holidays, he says, even if the woman’s life is not in danger. A husband can take his wife to hospital (by car or taxi) on Shabbat when she’s having regular contractions.The problem of obesity in reducing the fertility of both men and women was raised by Prof. Eyal Sheiner of the obstetrics/gynecology department at Beersheba’s Soroka University Medical Center.Morbid obesity is increasing the world over, and in Israel as well, causing fertility problems, said Sheiner, who is writing an English-language book on the subject. When body-mass index is over 29, “it is difficult to get pregnant.If a woman loses even five kilos, she is likely to find it easier to conceive.” After conception, obesity can cause gestational diabetes, riskier anesthesia and too-heavy newborns. Obese women with fertility problems will find IVF less likely to succeed, while very overweight men tend to have fewer sperm. “We conducted a prospective study of 300 women, 80 of whom were obese, who needed many more treatments than those of normal weight. They were more likely to have hypertension and need a cesarean section.The need to treat depression in time and well is vital, said Prof. Eliezer Witztum, a leading psychiatrist at Beersheba’s Mental Health Center and Jerusalem’s Herzog Hospital. Depression has been known for 2,500 years and for a long time was known as melancholy (from the word for “black liquids,” whose excess were thought to cause it). The great medieval rabbi and physician, Maimonides, wrote about depression and was an expert in his time on psychosomatic disease. Today, many sufferers go untreated, and half of those who do get treatment don’t react positively to the first drug. Then 30% fail to improve with a second drug. Other medications can help, along with psychotherapy, exercise, nutrition, employment and cognitive behavioral treatment, he said. A pill based on a natural herb, St.John’s wort (hypiricum) can improve the conditions of the lightly and moderately depressed, said Witztum, with almost no side effects. Prescription drugs have to be taken for a relatively long period, he concluded, noting that haredim often stop taking medications on their own.“We have learned how to deal with the doctors; they’ve learned how to deal with us. We’ve learned how to accept each other,” summed up Rabbi Gideon Weizman of the Puah staff. “We’ve also learned how to work together because really it’s about creating relationships. The doctors understand that we’re on the same side. We’re rabbis, not doctors. We don’t give medical advice per se, but we give medical direction about new treatments. Sometimes a doctor doesn’t know how to speak to a religious couple. That’s where we come in.”
