Tuesday, January 6, 2015

Rav Moshe Feinstein: Medical screening and Bitachon

 update see Wikipedia - vaccine controversies

In a recent post regarding Dor Yeshorim - the question was raised about Reb Moshe Feinstein's true views on medical screening and its relationship to bitachon and about whether there is a generally agreed upon Torah view of the subject. The Bais HaVaad Institute recently published a series of articles that is relevant to this question. Part I  Part II   Part III

 Part I In Parshas Shoftim after prohibiting sorcery, the Torah instructs, “Tomim tihiyeh im Hashem Elokecha”, “You shall be wholehearted with Hashem your G-d”. The sages in the Sifri interpret the verse not to conjecture about the future. The Shulchan Aruch (YD 179:1) rules, “One should not consult star gazers or cast lots [about the future]”. The Rem’a and Sha’ch explain that while these practices do not fall under the prohibition of sorcery, they are nonetheless not advisable because of the precept of “Tomim tihiyeh”, to be faithful to Hashem. [...]

According to Rabbi Gestetner’s view, “Tomim tihiye” is very limited, and may not apply to health screenings and genetic testing at all. As he explained, only practices similar to fortune telling are prohibited. Arguably, the results of a health screening or genetic test point to facts that are in the present, not the future. This is comparable to leaving a glass at the edge of a table. I cannot say that the glass is destined to fall off and break, but its position certainly puts it at greater risk than the other glasses. Likewise, test results showing hypertension or indicating a genetic mutation do not prophesize a future event, rather it indicates a present level of risk. For this reason, health screenings and genetic testing may not be included in “Tomim tihiyeh” because they are quite different than star gazing or psychic readings. 

 Part II Rashi, in his commentary on Parshas Shoftim explains the mitzvah of “tomim tihiyeh”, “Walk before Hashem with wholeness, hope for Him, and do not speculate about the future. Rather, all that comes upon you accept with wholeness (uncomplicatedness) and then Hashem with be with you”. Based on Rashi’s comments Rabbi Moshe Feinstein understood that “tomim tihiyeh” is a general instruction to place our faith in Hashem when confronting the unknown.

An example of this, is Rabbi Feinstein’s comments in Igros Moshe (1, 90) about a couple dating excessively to make sure it is ‘the right one’. He wrote, “One should not be overly smart {with regards to shidduchim}. Therefore, one could marry the woman that finds favor in his eyes in her appearance and family, and has a good reputation about her mitzvah observance, and assume that she is the one destined to him from heaven. He does not need to excessively tryout if they are compatible because it will not help, as the verse says “tomim tihiyeh im Hashem”, you shall be faithful with Hashem”. Clearly, Rabbi Feinstein is taking tomim tihiyeh beyond fortunetellers and astrologers. 

In 1977, after the Entebbe hijacking and rescue, some Yeshiva students wrote to Rabbi Feinstein asking him how this miracle could happen through Jewish soldiers that do not keep the Torah. Rabbi Feinstein dismissed their question by stating simply that we do not understand the ways of Hashem and we should not involve ourselves in these types of analysis as the verse says “tomim tihiyeh im Hashem”. Here too, Rabbi Feinstein invoked “tomim tihiyeh” as a general instruction to place our faith simply in the hands of Hashem.

Although Rabbi Feinstein extolled faith and simplicity, in his classic work on the Talmud, Dibros Moshe (Bava Metzia, siman 31, he’orah 18), he fully acknowledged a person’s right to be wise and far-sighted about personal matters. The Talmud in Bava Metzia (23b) states that in certain situations a Torah scholar may say a white lie to avoid embarrassment. Rabbi Feinstein observes that in these scenarios the probability of the embarrassment actually happening is very far-fetched according to normal halachic standards. He therefore arrived at a fascinating conclusion, the halachic concepts of majority and chazaka were only intended to make halachic determinations and are not necessarily an instruction in making personal decisions. Therefore, because avoiding embarrassment is not a halachic decision but a personal one, it is acceptable to be concerned even about a minute possibility and therefore it is permitted to tell untruths to avoid this possibility. 

Rabbi Feinstein seems to be balancing these opposing concepts in his discussion about genetic testing for tay-sachs before marriage (Igros Moshe EH 4:10). First he writes, since the probability of both spouses being carriers is minute it may be included in the precept of “tomim tihiyeh” according to Rashi, which instructs us not to delve into the future. However, he then writes, since the test is easily available and if an inflicted child is born it is devastating, the public should be educated about their options. 

Part III  How do halachic sources view preventative measures like health screenings or genetic testing? Are they included in our obligation to heal, or are they a form of speculation that the Torah instructs us not to concern ourselves with?

In the previous post we highlighted factors like probability of occurrence, severity, and the reliability of the treatment or testing as important variables in balancing faith and responsibility. In this post we will continue to develop these concepts, and their application to health screenings and genetic testing. 

The famed Rabbi Shlomo Luria (1500’s) wrote, despite the sages’ general disfavor with unreliable practices, an ill person is not expected to rely on faith alone. Therefore, he may seek a sorcerer or astrologer to heal. Rabbi Luria, However, does strongly discourage a well person from such behavior based on the Mitzvah of “tomim tihiyeh”. 

This assertion can be embellished with the comments of the Maharal of Prague (Nesivos Olam, Nesiv Hatemimus). The Maharal explains that faith in Hashem is referred to as temimus, or wholeness, because it is a straight and sensible path. For this reason, seeking astrologers or sorcerers is discouraged because it deviates from a straight and logical approach to life. With this in mind we can gain a better appreciation for Rabbi Luria’s position. The Mitzvah of “tomim tihiyeh” is instructing us to be sensible. Logic dictates that a well person should not be concerned with far-fetched or whimsical possibilities, rather he should place his faith in the Master of the World. Therefore, because sorcery and astrology are far-fetched and whimsical, they should be avoided. That said, if a person is ill and desperate, it is reasonable to seek all possible options, even if they are not reliable (see Maharal Be’er Sheva p.30 in standard edition).

In this light we can understand a conversation of Rabbi Moshe Feinstein about cancer screening from the late 1970s (Mesores Moshe p.293). Apparently, a doctor was urging an ostensibly well person to undergo excessive (lit. strange) and possibly dangerous tests. The patient asked Rabbi Feinstein his opinion on the matter. Based on “tomim tihiyeh”, Rabbi Feinstein asserted that if there are no symptoms present, there is no reason to seek medical attention because it is not part of our normal responsibility to follow “derech hateva”, or the natural ways of the world.

It seems that Rabbi Feinstein had halachic concerns with the testing because it was far more excessive than the normative standards of the time. Additionally, the tests carried health risks, and were possibly inconclusive. In a similar vein, Rabbi Dovid Feinstein permits pregnant women to go for routine ultrasounds, because it is the common standard of care. Therefore, there is no concern of “tomim tihiyeh”. Apparently, the issue of “tomim tihiyeh” is only when the testing is considered excessive compared to the standard medical practice of the times.[...]

19 comments :

  1. what is a white lie (halachically), and what assurances does give that this isnt a blank cheque for rabbis to tell lies with eery breath of air they take?

    ReplyDelete
  2. so why are vaccinations allowed (mandatory?) no one can see a microbe.

    ReplyDelete
  3. For those who despise and distrust rabbis, nothing can give any assurance.

    ReplyDelete
  4. I challenge someone to prove that the overall illness and mortality
    rates have improved at all because of Dor Yeshorim's costly and
    intrusive efforts.


    The same challenge can be extended to you when you say:

    Dor Yesharim's work may have indeed emptied Tay Sachs wards, but is
    seems that cancer (and other) wards have quickly taken their place.

    ReplyDelete
  5. if a rabbi lies to me, or someone else, then why should I trust him?

    ReplyDelete
  6. a) Who said anything about you? b) Your question did not reference rabbis who are known to have lied, but rabbis in general. And so my answer remains the same.

    ReplyDelete
  7. It is in Dor Yesharim's court -- since they are trying to convince people to buy into their program both by participating and through financial assistance -- to prove the overall efficacy of their program in face of stark realities.


    The incontrovertible fact is that a great many more children in our communities suffer from illness today than did years ago. I think a visit to any shul or large hospital, or a look at the many organizations dealing with these issues, will confirm that the rate of these illnesses appears to be far higher than previously. Some of the maladies were virtually unheard of, certainly few were nearly as prevalent as they are today.

    When my friend (who lost a child r"l) pointed out this fact in his discussion with the principal of his daughters' high school -- a leading and vocal advocate of Dor Yesharim (who, I believe, lost a child to the diease, r"l), the man conceded that reality. He also agreed that – in principle – a study should be done to see if anything was objectively gained. On the other hand, his emotional pain regarding the horror of Tay Sachs would not allow him to stop advocating for Dor Yesharim testing.

    ReplyDelete
  8. a) worthless point
    b) known by whom? I refer to those known by me to have lied. You probably have not come across them. However, if this is a general psak, then it may be relied upon by many rabbis.

    ReplyDelete
  9. Not a worthless point at all. You asked a general question, and then objected to the answer b/c of specific rabbis you know. Same problem with your response to B. Your original insinuation is that this halachah allows rabbis in general to tell lies with every breath. Suddenly you're discussing specific rabbis. My point stands: for those who despise and distrust rabbis wholesale, no assurance would ever suffice.

    ReplyDelete
  10. You too are arguing for a position. In your case, it's an anti-DY positiion.You support your position with a claim of more disease since DY opened for business. I don't see why the need for proof of their claim is greater than the need for proof of yours.

    ReplyDelete
  11. I myself do not believe they carry equal weight. The near disappearance of Tay-Sachs families is not a claim; it is a fact. The counterclaim -- that Tay-Sachs has been replaced with new diseases -- needs evidence. My point to Ari B. was that at the very least he must admit that his claim also requires evidence.

    ReplyDelete
  12. Don't drink and drive. And He also says tamim tihiyeh, don't try to
    control the stuff behind the scenes. That's "kavshi drachmanah."


    i read it.

    ReplyDelete
  13. <1>The incontrovertible fact is that a great many more children in our
    communities suffer from illness today than did years ago.

    prove it.


    I think a
    visit to any shul or large hospital, or a look at the many organizations
    dealing with these issues, will confirm that the rate of these
    illnesses appears to be far higher than previously.



    the plural of anecdote is not data. and i don't know what shul you go to, but i see no such things at my shuls.

    ReplyDelete
  14. I did jut suggest that eradicating disease is futile. Please reread what I wrote.

    What I tried to explain that genetics and chance are different than direct cause-and-effect. And that trying to play G-d doesn't help in the greater picture.

    ReplyDelete
  15. I don't see why eradicating disease through genetic testing is different than doing it through vaccination. If you believe the latter is futile, you should believe the same for the former. What's the difference?

    ReplyDelete
  16. I meant to say (as you correctly understood) that I DIDN'T suggest eradicating diease if futile. Nor I do believe that one shoudl cross teh street without looking.


    One is directly "causual," one is trying to control something that is still completely a guessing game, and where having all-healthy children would not be remarkable, miraculous, or noteworthy (especially since a person wouldn't know if he or she is a carrier).

    ReplyDelete
  17. if someone knew that going for a drive entailed a 25% chance that he would be seriously injured or killed, there no way he would get into the car. it would probably be forbidden al pi halacha.



    so why in the world would anyone like a tay sachs carrier, marry someone if it meant there was a 25% chance that his kid would die of that disease. this isn't guessing, this is simply not taking what is clearly an entirely unreasonable risk.

    ReplyDelete
  18. Entering marriage without ascertaining a fact that can be discovered by a simple blood test is a wilfull not knowing, akin in my eyes to closing one's eyes when crossing the street. Hey, there's a 90% chance that no car will be coming at that exact moment, and even if one is coming, the driver will probably notice you (unless he's got his eyes shut too), so why bother looking?

    ReplyDelete
  19. If the Torah had not stated "v'rapoh yerapei," would one be allowed to go to a doctor for medical care [let's say for something that was not life-threatening]?

    ReplyDelete

ANONYMOUS COMMENTS WILL NOT BE POSTED!
please use either your real name or a pseudonym.