Wednesday, March 30, 2005

life, brain function, death and in between- a brief guide

The cells in the body require energy not only to function, but to stay alive. If they do not have a source of energy(oxygen and other stuff) they first stop working, and then die. It is like the ice cream in your freezer. If you shut off the electricity for a short time, it will soften, but will still be ice cream if you get the electricity back on in time. If you wait too long, it will be melted goo, and even if you freeze it again, it will never be ice cream again.

The oxygen comes by breathing air through the lungs, and it gets pumped around by the heart. So, the cells can die if either the breathing stops, or the heart stops. The electrical system of the heart is kind of on automatic. It will pump as long as there is a supply of oxygen. It doesn't need any outside signals to tell it to pump. You can take a frog heart out(a common experiment in biology classes) and watch it keep on beating. It is pretty much self triggering. The lungs are different. There is an area in the brain(brainstem to be exact) where the signal to breath starts. It gets sent down the spinal cord, then to nerves(phrenic) that go to the diaphram, that moves up and down. If the signal is interrupted anywhere along that path, from brainstem to diaphram, then there is no breathing. Therefore, breathing can stop becuase of brain injury, or spinal cord injury(think Christopher Reeve). And, unless the person is put on a respirator(breathing machine) death will follow pretty quickly.

Consciousness is a bit more complicated. There is an area in the brainstem called the reticular activating system that is kind of an on/off switch for consciousness. If you damage it enough, you will be unconscious. You can also lose consciousness from extensive damage to both sides of the front part of the brain(cerebrum- the part that makes our foreheads stick out and distinguishes us from apes).

Brain death is a situation where the brain has been totally and irreversably damaged. There are criteria(known as the Harvard criteria, for the place where they were first promulgated) for brain death. Unfortunately, not eveyone always goes by the criteria, the criteria themselves are vague in places, and actually the definition is different in other countries. There is a bottom line however: there can be absolutely no brain function, no breathing, no brain reflexes(a bunch of things your face does that you have no conscious control over, like your pupils getting smaller in light, etc), studies that show overwhelming brain damage(like a CT or MRI), no blood flow to the brain (you inject dye into the arteries and take pictures that show that the blood doesn't enter the arteries of the brain). You can have spinal reflexes(there is a cool one that is rarely seen, called the reflex of Ivan, where all the muscles contract at once, makes it look like the person is sitting up, but it is just a reflex). Measuring brain waves(EEG) doesn't help a whole lot, although if one is done it needs to be flat(no activity). Then you have to repeat the exam at least 12 hours later to make sure that there is no brain function, especially no breathing(have to disconnect the ventillator and watch the patient for a while to see if they breath or not).

(For those interested, the skull can be thought of as a box, filled with the brain, blood vessels, etc. When the brain is injured, it swells, taking up more space. IF there is a blood clot, or a tumor, that also takes up space. As the volume of brain, swelling, blood clot, etc increases, the pressure in the skull increases, because the skull does not expand. If the process is bad enough, the pressure in the skull gets very high. Remember blood pressure? that is the force that the heart is exerting to push the blood around the body. If the pressure in the skull gets to be equal(or higher) than the blood pressure, then no blood gets into the skull(or the brain). This makes more brain die, and adds to the swelling, which increases the pressure, and it is this cascade of events that lets one establish that a person is truly brain dead- the pressure in the skull is too high for blood to get in, and the brain cannot last for much longer than 5 minutes without blood supply.)

What happens with a brain injury? this can be from car accidents, gunshot wounds, episodes where the heart stops or the blood pressure drops and no blood gets to the brain for a while(called a stroke), bleeding in the brain(also called a stroke, sometimes hemorrhagic stroke) and other reasons. Sometimes a lot of brain is injured, sometimes just a little. Sometimes the pictures(CT or MRI scans) show a lot of damage, sometimes they dont. Sometimes parts of the brain are only temporarily not working, and take a while to get better. Sometimes there is permanent damage. Many times it is hard to tell how much better a person will get. Frequently with severe brain damage, the patient isn't breathing enough, and needs to be on a breathing machine. Over time, unless there is severe damage(or brain death), most start to breath on their own. Most patients who are going to get better will start to do so in the first few weeks. Most improvment happens in the first 6 months. It is very rare to have significant improvement past 1-2 years after the injury. The scans of the brain also will change with time, but after a week or two will usually show the extent of the injury, and unless there is an additional problem, will not change significantly after 6 months.

Coma, or persistant vegetative state(pvs) is a description of someone who does not respond to their surroundings. It is a description of the patient, therefore established by observation and examination, not by scans, EEG's or anything else. Obviously, the CT and MRI scans can show why, and define the anatomic extent of the brain damage, but you can have people in pvs with not a whole lot wrong on their scans(maybe damage in the on/off reticular activating system), or people with almost no brain left whatsoever, but enough that their breathing centers are telling the diaphram to move.

What is concsiousness? How do we measure it? These are tough questions. Usually we consider consciousness to be evidence of non-reflex behavior, or, a little more stringent, purposeful behavior. Moving a hand away in response to pain(or more accurately, a stimulus, because feeling pain implies that one is conscioius enough to have a response to a stimulus that we recognize as pain) does not imply consciousness, it can be a reflex. Slapping the hand that is pinching the person implies consciousness. As you can see, there is a significant grey area where a person could be considered conscious or not, depending on the interpretation of the movements and responses. We have a not of reflexes- movements that are not dependent on thinking, that happen automatically, and these sometimes are confused with purposeful behavior as well.

In view of recent events and discussions, I hope this has been helpful. The amount of ignorance, especially on the part of some of our elected officials has been astounding. To quote R. Gil, this has been only for purposes of education , not l'halacha. for specific problems, please consult a competent authority.

Comments-[ comments.]

music review- The Moshe Skier Band(well, not exactly)

This past motzei Shabbat I talked my wife into going to see the Moshe Skier Band. But first a little background. My wife, quite a skilled musician herself, and someone who appreciates alternative rock and all sorts of pop music that inhabits the radio, does not appreciate shiny shoe music, to say the least. She had assumed that we were going to sit for a few hours and be serenaded by the shiny shoe brigade, and, to her credit(and against her best judgement), agreed to accompany me. I, of course, had heard some cuts of the band, and had seen the ads from Adam Davis, and had some idea of the experience ahead. Also, the concert was at a club.

I will dispense with the following complaints quickly: My clothes smelled of smoke, my ears rang for a few days, and it took about 45 minutes for my liver and other solid abdominal organs to stop vibrating. In addition, I was one of the few males who not only brought a female with me, but left with same said female.

That being said, it was a very nice crowd, not rowdy, a mix of many singles, a few middle-aged couples that were there for the music(guess I fall into that catagory, middle aged), a sprinkling of kippot, and a few in costume in honor of purim.

The first act was heedoosh, which featured Yaniv. He was accompanied by the always excellent Matt Kantor(drummer for Even Shesiyah, and drummer for what seems like 99% of the Jewish gigs in the city-even I have had the zichut of playing a gig with him, but that is anothe story), a very earnest and quite good Zev Goldberg on rhythm guitar, and unknown(to me) bass and lead guitar players. Yaniv has a very good voice, good range, and is usually seen with his band, dressed in shiny shoe uniform, velvet kippah, dark pants, and the occassional suit jacket, singing with an ashkenazic accent. It was different to see him with a kippa serugah at a jaunty angle, shirt unbuttoned a little, and what looked like jeans, singing in his native sephardic accent. They rocked. They played a few original songs, the best version of Yo-Ya I have ever heard(kind of a surf rock attack), and even covered a rock song(deemed to be excellent by the in-house rock afficianado)

The second act was Ari ben David, or Moshe, or somebody. He looks a bit like Pauly Shore, and tossed his hair more often than a group of flirty 8th grade girls. He also had an affection for David Copperfield like hand movements. When he wasn't using his hands to demenstrate choreic movements, he did play a pretty good piano/organ, and was accompanied by his band. The music was reggae, with shouted platitudes that seemed to be related to Judaism in some fashion. I did not appreciate it, but the in house rock critic thought it was ok.

The concert was supposed to start at 9, but actually started at 10. Unfortunately, the baby sitter had to be home by midnight, so we left while Pauly Shore was still banging on his Kurzweil, waving to the crowd, and yelling something about being good. We never did get to hear the Moshe Skier band. However, I did get a chance to talk toMoshe, and he is going to send me some cd's. And, my wife actually had an excellent time and enjoyed the music. Kudos to Adam Davis, kfar, and the kehilla and all the sponsors. I think most everyone had a good time once the blood stopped running from the ears. For those who were there and are wondering if you saw me in the dim light, you may have. Clues: kippah, with his wife, by the stairs.

Comments-[ comments.]

An oversight

My list of blogs of thinking and educated people was not meant to be exhaustive, and I did not include the chief rabbi of the blogosphere, R. Gil Student over at Hirhurim, because I assumed pretty much all of my readers were familiar with him and his blog. If not, his blog is an excellent source of Torah and opinion. For penance, I will post the links he has sent, as his publishing house has placed an entire book online. The book is Rabbi Israel Salanter, Religious-ethical thinker. I have seen a number of good reviews(well, one was from R. Gil).

Information about the book can be found at : http://www.YasharBooks.com/Salanter.html


The book can be downloaded from the Open Access webpage: http://www.yasharBooks.com/Open/


The Open access site is a very nice one for reading and discussing issues. I encourage all who are interested to visit and participate.

Gadol Hador also has good Torah when he isn't off outing the Gedolim, not to mention aspaklaria, Orthodox caucus, and many others.

Comments-[ comments.]

Tuesday, March 29, 2005

Jewish values and public policy

Rabbi/Lord Immanuel Jakobovits, in Medicine and Jewish Law(edited by Fred Rosner, a compilation of talks at the `AOJS physicians' conference in 1989) addresses the topic of The Role of Jewish Medical ethics in shaping legislation:

There is a basic difference between secular medical ethics and Jewish medical ethics. Secular medical ethics seeks to turn ethical guidelines ..into law... the law is a product of moral intuition or consensus.

Jewish medical ethics operates in reverse. Out of legal verdicts..we distill the ethical guidelines and principles responsible for the legal judgements. Jewish medical ethics derives from legislation, it does not lead to legislation... the legislative rulings have been given as Halachah, and we then have to extrapolate the rules and principles from them....

As Jewish citizens, we clearly have certain moral obligations, perhpas even halachic duties, at least to contribute to the public debate on moral issues in medicine, but perhpas also to apply our influence in the formulation of legislation.

(discussing autopsies and abortion vis a vis israeli law)

In principle, I have always opposed the idea of seeking to enforce halachic discipline in Israel by way of Knesset legislation, thus subjecting the majority..secularists, to "religious coercion.". As a rule this can only further alienate the secular majority from the religious minority and their beliefs. But there are bound to be certain exceptions.

(regarding abortion, which is an exception to the above rule)..I believe that precise legislation was vital, but its presentationi was all-important. In light of the fact that the majority of Knesset members do not share our respect for Halacha, it was imperative that legislation..be presented in a manner that would be persuasive to them and lead them to consider our concerns.
It seems strange that for a long time ther was absolutely no agitation on abaortion in religious circles. Even the Agudah did not raise the matter until the mid-1970's. It had evidently been of no major concern to them or to the otherreligious parties. Why?.... (it) did not affect the religouis community. No one forced anyone to have an abortion, so the religious community felt no need to seek legislation on the subject. (he goes on to say that the thrust of his arguement against abortion was framed in the context of national survival-abortion lessens the number of Jews, rather than simply a religious basis)
I use this illustration to show that in terms of legislation what is at stake is not merely the strit demands of Halacha. Of critical importance is the effect that the discipline of Halachah has on the Jewish public.

(on non-Jewish legislation)

To what extent must (I) bring (my) Jewish moral convictions to bear on society in general and the laws governing it?

...the major areas of medical ethics ..come under the heading of the Seven Noahite Commandments...We should endeavor to ensure, as best we can, that non-Jews fulfill the Seven Commandments incumbent on all humans, and for that legislative enactments are required.

(he then goes on to bring examples from his speeches in the House of Lords of his opposition to abortion on demand and his bringing a tradional Halachic viewpoint to other topics.)

We have a duty as custodians of what we believe to be the universal moral order as enshrined in the Seven Noahite Commandments, and more extensively in the divinely ordained laws of the Torah, to do our utmost to advance the appreciation oand the rule of these moral values.

Notice all of his efforts are within the legal system, not street protests. Also his aim is a general societal acceptance of moral values, not a case by case intervention.

Comments-[ comments.]

An opinion on " mercy killing" of non-Jews

NOTE: I DO NOT AGREE WITH THIS OPINION. IT IS BROUGHT FOR EDUCATIONAL INTEREST ONLY.

HaRav Moshe Sternbuch, Rosh Yeshiva of Rosh Ha'ayin, in Pathways in Medicine, 1984 discusses the following case:

A critically ill non-Jew has only a short time to live and was in intense pain. He and the family requested the doctors give him drugs to cause a speedy death. They agreed, but needed approval of the director of the hospital, a frum Jew, who asked if it was permitted to allow it. He was concerned if he did not allow it, his career would be harmed.

Rav Sternbuch starts with the assumption that shedding blood is prohibited and that this also applies to a Jew killing a non-Jew. He then states that "The Rabbis in our generation have considred the question of whether in our day non-Jews should be considred to be in the same category as the idol-worshippers of Biblical days. They generally come to the conclusion that the non-Jew in our day could be considered an idol-worshipper. Now, according to the Torah, an idol-worshipper is deserving of death. One could suggest taht, in this case, since the Jewish doctor is not actually administering the drugs himself, and since the patient could perhaps be classified as an idol-worshipper who is deserving of death, a Rabbi may give the Jewish doctor permission to sign the authority. One could also say that the strict prohibition against killing a non-Jew refers to an actual killing in a cruel manner, and may well not apply to a case of "mercy-killing" done out of love for the patient, where the Jewish doctor himself would not carry out any physical action in a cruel manner.

Rav Sternbuch in fact did give permission for the doctor to sign the order, considering that the patient was fatally ill, with only a short time to live in any case, noting that "some Rabbis are of the opinion that killing a non-Jew who is on the point of dying need not always be classified as murder."

He then goes on to make it clear that if the hospital treated both Jews and non-Jews, he would certainly not give permission, for fear that mercy-killing would be done on Jews as well. "It should be made clear to all in a Jewish hospital that such an act is out of the question."

Note that he uses a lot of "could", and "some" and "opinion", leaving the impression that l'katchila he is opposed, but is trying to find a way to allow it so(I assume) the director/doctor's career will not be harmed. I may be over reading, but that is how it appears to me. He is certainly not being definitive.

At the end of the chapter he emphasizes that "permission for a Jewish doctor to violate the Sabbath to treat a non-Jew is only to be given in exceptional cases" and discusses those issues.

Unfortunately, there are no footnotes or sources, so I do not have any further information on the basis for the opinions.

Comments-[ comments.]

Risk/benefit analysis in Halacha

the discussion of metzitza b'feh involved the issue of balancing the risk of harm with the benefit of performing a mitzvah. I found the following opinion on a similar issue:

In 1772 the Duke of Mecklenburg ordered that burials could not be done until 3 days after death, in order to be absolutely sure that the person was really in fact dead. R. CHaim Yosef David Azulai wrote: "If one in several tens of thousands of buried persons turns out later to be alive, we should not see this as a basis for a prohibition(against prompt burial), for that was decreed upon him.. if they erred... this is Divine Will...." from Responsa Chayim Sh'al part 2, no. 25. Quoted by Rabbi/Dr. Abraham Steinberg in Medicine and Jewish Law, edited by Fred Rosner. I wonder if he would apply the same numbers to getting disease from metziza b'feh(ignoring the possibility that the halachic imperative for prompt burial may not be the same as for doing metziza b'feh). Also, are there any other t'shuvot that put a number out like this one does?

Also, note the acceptance of Divine Will as a rationale for accepting the error that may occur.

Comments-[ comments.]

Monday, March 28, 2005

clarity of thought

Its been an interesting few weeks. I have had to examine what I do when Halacha(or medical ethics derived from Halacha) conflicts with accepted western ethical/moral/legal standards. I have also been beset with some accusations. The accusations, when they have come, have mostly been of standing passively by, and/or condoning murder. I must ask those accusers, and even those who dont believe it was murder(or who dont think we have an obligation to intervene) the following questions:

1. why have you not been this agitated with other cases of withdrawal of care?

2. If Ms. Shiavo had a living will that specifically expressed her desire not to remain in a persistant vegetative state, would you still call it murder?

3. Is it the uncertainty over her condition and/or her wishes that provokes this reaction?

4. Is Halacha supposed to be the law in the United States with regard to medical care?

5. Would it make a difference if Ms. Schiavo was Jewish?

6. How would you treat a person who had a spinal cord injury, could not breath without a breathing machine, who asked to be withdrawn from the machine?

7. If Ms. Schiavo had a life threatening infection, would you insist she be given antibiotics?

8. What are the factors that determine how loud we raise our voices to ensure that the laws of the land are in consonance with Halacha? if at all?

9. Assuming that we will never have a society in the us governed by halacha, is it better to err on the side of too much freedom? or too much restriction? In other words, too much freedom allows Jews to practice as they want, without any restriction, but also allows looser societal values. Whereas restriction may limit our ability to practice, but societal values and practices would be more in keeping with the moral values of the Torah. You can err at the extremes like the French, who do not allow kippot in school, or with the inquisition at the other side. More moral values in society at the expense of the occassional mention of Jesus in school? Which is more preferable?

I came across some articles that I will try to abstract in the next few days that address the role that Judaism should play in the public sphere in general, and a little specifically dealing with cases like Ms. Schiavo.

Comments-[ comments.]

Great blogs from knowledgable and thinking Jews

(many of us are thinking, but not so knowledgable, some of us are neither)

if you haven't already, go visit these people:

Rabbi Doctor Jeffrey Woolf at My Obiter Dicta

The ADDeRabbi

Naomi Chana at Baraita(mazel tov on the upcoming nuptials)-

Ben Chorin

Also see R. Adlerstein quoting and giving respect(although disagreeing vehemently) to R. Broyde

Comments-[ comments.]

Random Megillah thoughts

From a literary point of view, Megillat Esther is rather cumbersome. There is a lot more detail, a lot more repetition, and much longer sentences than most other books of Tanach. I paged through my artscroll megillah book, and in Esther there is about 7-10 Pesukim(sentences) per page. In the other four megillot, there were 10-14 pesukim per page. From a trop point of view, since there can be only one etnachta per pasuk, this means that there are a lot more zarka-segol, kadma-v'azla, revi'e, darga-t'vir and pazer trops than other books. Some of the pesukim reach 30-40 words in length.

The extra words consist not only of additional descriptors(medina oo'medina kechitava, v'am v'am kelishona, or shisha chodashim b'besamim....) but also a lot of repetition in the form of "tell someone to do this... I told him to do it... he did it... what did he do...."

Why? I have no idea. I really don't. ADDeRabbi has an excellent post on yeridat hadorot, how over time as we get further from the word of God we compensate by codifying more of the details. Perhaps the megillah, being the first without a specific reference to Hashem, spells everything out in great detail to compensate for the distance from HKBH. As if the author wanted to be absolutely sure we got everything exactly as they wanted it said, not depending on Inspiration to fill in the blanks. Please comment if you have an answer.

2. Haman goes home, tells Zaresh and the friends(the name of my next rock group) that life isn't good as long as Mordechai HaYehudi(the Jew) is in the gate. They tell Haman to hang Mordy. The next day, after Haman comes home with garbage on his head, Zaresh and the friends, quite unsolicited tell Haman " Im m'zera ha'Yehudim, Mordechai, asher hachilota linpol l'fanav lo toochal lo.." If from the offspring of the Jews, Mordechai, that you have started to fall in front of, you will not succeed, for you shall surely fall in front of him(translated literally). Z and friends are tell Haman that he is not going to succeed, and it seems that he isn't going to succeed because Mordy is a Jew. But Haman made that pretty clear the day before, saying that he wasn't happy as long as Mordy the Jew was in the gate. All of a sudden Z and friends realize he is Jewish? I found two answers, both peshat based, and it hinges on what is different in the phrasing.

1. they say "from the offspring (zera) of the Jews". One commentator says that zera refers to the tribe of Binyamin, but the plain sense is that if Mordy is acting as a Jew, following in the traditions of his forefathers and mothers, and because of his actions and the protection of his ancestors, haman will fail.

2. The key is actually in the words "asher hachilota linfol.." that you have started to fall. The scary thought is that there may have been a window of opportunity for Haman to succeed. However, now that he has started to slip, for whatever reason, that window is closed. When Haman first decided to kill the Jews, he rushed the messengers out to all the lands, announcing the news, although the event wasn't to take place for about a year. One explaination is that he wanted the Jews to worry about it, and have their death hanging over their heads for a year, knowing that they would be annihilated. However, this time allowed Mordechai and Esther to mobilize the repentance movement. Perhaps if Haman had satisfied himself with just killing the Jews, and not adding the psychological torture of knowing their demise for a year, the outcome may have been different.

Comments-[ comments.]

Wednesday, March 23, 2005

Post-Nuptual Agreements

Someone recently brought to me attention that noone has been pushing the BDA, post-nuptual agreement, which is basically the "agunah" pre-nup for couples that are already married.

Although Rabbis & others have been encouraged to not marry couples without a pre-nuptual agreement, the way to really effect change would be to have entire Synagogues and Communities sign them en masse. Just as synagogues have a "Shabbos Tilamdeni" or a Shabbos for Jewish Hospices", they should have a post-nup Shabbos.

I will not get into why the major Orthodox Jewish Org's have dropped the ball on this one, at that would serve no purpose, but rather I will just post the post-nup herehoping for this to bubble up through the blog-o-sphere.

THE BETH DIN OF AMERICA BINDING ARBITRATION AGREEMENT

THIS AGREEMENT MADE ON THE ________________ DAY OF THE MONTH OF _____________________________ IN THE YEAR 20 ___, IN THE CITY/TOWN/VILLAGE OF ______________________________STATE OF______________________
between:
HUSBAND: _________________________________________________________
RESIDING AT:_______________________________________________________
and:
WIFE:______________________________________________________________
RESIDING AT: ___________________________________________________________
The parties, who were married on , hereby agree as follows:

I. Should a dispute arise between the parties, so that they do not live together as husband and wife, they agree to refer their marital dispute to an arbitration panel, namely, The Beth Din of the United States of America, Inc. (currently located at 305 Seventh Ave., New York, NY 10001, tel. 212 807-9042, www.bethdin.org) for a binding decision.

II. The decision of the Beth Din of America shall be fully enforceable
in any court of competent jurisdiction.

III. The parties agree that the Beth Din of America is authorized to
decide all issues relating to a get (Jewish divorce) as well as any issues arising from this Agreement or the ketubah and tena'im (Jewish premarital agreements) entered into by the Husband and the Wife. Each of the parties agrees to appear in person before the Beth Din of America at the demand of the other party.

IV:A. The parties agree that the Beth Din of America is authorized to decide any monetary disputes (including division of property and maintenance) that may arise between them in accordance with the general principles of arbitration and equity customarily employed by the Beth Din of America.

IV:B. The Beth Din of America may consider the respective
responsibilities of either or both of the parties for the end of the marriage, as an additional, but not exclusive, factor in determining the distribution of marital property and maintenance.

V. Failure of either party to perform his or her obligations under
this Agreement shall make that party liable for all costs awarded by either the Beth Din of America or a court of competent jurisdiction, including reasonable attorney's fees, incurred by one side in order to obtain the other party's performance of the terms of this Agreement.

VI. The decision of the Beth Din of America shall be made in
accordance with Jewish law (halakha) or Beth Din ordered settlement in accordance with the principles of Jewish law (peshara krova la-din), except as specifically provided otherwise in this Agreement. The parties waive their right to contest the jurisdiction or procedures of the Beth Din of America or the validity of this Agreement in any other rabbinical court or arbitration forum other than the Beth Din of America. The parties agree to abide by the published Rules and Procedures of the Beth Din of America (which are available at www.bethdin.org, or by calling the Beth Din of America) which are in effect at the time of the arbitration. The Beth Din of America shall follow its rules and procedures, which shall govern this arbitration to the fullest extent permitted by law. Both parties obligate themselves to pay for the services of the Beth Din of America as directed by the Beth Din of America.

VII/A. The parties agree to appear in person before the Beth Din of
America at the demand of the other party, and to cooperate with the adjudication of the Beth Din of America in every way and manner. In the event of the failure of either party to appear before the Beth Din of America upon reasonable notice, the Beth Din of America may issue its decision despite the defaulting party's failure to appear, and may impose costs and other penalties as legally permitted.

VII/B. Husband acknowledges that he recites and accepts the following: I hereby now (me'achshav), obligate myself to support my Wife from the date that our domestic residence together shall cease for whatever reasons, at the rate of $150 per day (calculated as of the date of our marriage, adjusted annually by the Consumer Price Index-All Urban Consumers, as published by the US Department of Labor, Bureau of Labor Statistics) in lieu of my Jewish law obligation of support so long as the two of us remain married according to Jewish law, even if she has another source of income or earnings. Furthermore, I waive my halakhic rights to my wife's earnings for the period that she is entitled to the above stipulated sum, and I acknowledge, that I shall be deemed to have repeated this waiver at the time of our wedding. I acknowledge that I have effected the above obligation by means of a kinyan (formal Jewish transaction) in an esteemed (chashuv) Beth Din as prescribed by Jewish law. However, this support obligation shall terminate if Wife refuses to appear upon due notice before the Beth Din of America or in the event that Wife fails to abide by the decision or recommendation of the Beth Din of America.

VIII. Husband and Wife execute this document to further enhance the continued harmonious marital relationship between themselves as husband-and-wife. Furthermore, the mutual promises of the parties are consideration each for the other, and this agreement shall be fully enforceable in a court of competent jurisdiction.

IX. This Agreement may be signed in one or more duplicates, each one of which shall be considered an original.

X. This Agreement constitutes a fully enforceable arbitration
agreement. Should any provision of this Agreement be deemed unenforceable, all other surviving provisions shall still be deemed fully enforceable; each and every provision of this Agreement shall be severable from the other. As a matter of Jewish law, the parties agree that to effectuate this agreement in full form and purpose, they accept now (through the Jewish law mechanism of kim li) whatever minority views determined by the Beth Din of America are needed to effectuate the obligations contained in Section VII and the procedures and jurisdictional mandates found in Sections I, II, III, IV and VI of this Agreement.

XI. Each of the parties acknowledges that he or she has been given the opportunity prior to signing this Agreement to consult with his or her own rabbinic advisor and legal advisor. The obligations and conditions contained herein are executed according to all legal and halachic requirements.

In witness of all the above, Husband and Wife have entered into this Agreement.

SIGNATURE OF HUSBAND: ____________________
WITNESS: ____________________________________
WITNESS: _________________________________

SIGNATURE OF WIFE:________________________
WITNESS: ____________________________________
WITNESS: _________________________________
END OF DOCUMENT

[THIS DOCUMENT SHOULD BE PROPERLY NOTARIZED IN ACCORDANCE WITH RELEVANT LOCAL REQUIREMENTS]

Comments-[ comments.]

Monday, March 21, 2005

Putting your nose where it doesn't belong

Hard to believe, I know, but I am chairman of my hospital ethics committee. A few weeks ago, as part of a presentation on ethics to the hospital staff, I used the Terry Shaivo case as a source of discussion on the principles of ethics and how they are applied. But first, a few facts, from the public articles and discussions that I could find: 1. There isn't a lot of money involved. There was a 1 million dollar settlement, but most of that has been eaten through with medical bills.

2. 5 independent neurologists have decided that Ms. Schaivo is in a persistant vegetative state.

3. A court trustee observed her for a long time and did not feel that she responded to her environment, not even to the parents when they were there.

A quick discussion of persistant vegetative state(pvs): this is where enough of the brain(or small specific parts) have been damaged so that the patient does not seem to be aware of his/her surroundings, does not respond to stimulation, and does not interact with the environment(no purposeful movement). This is very different than brain death, where the brain is totally not working so that absolutely nothing works(no breathing, no reflexes, no nothing). People in a persistant vegetative state breath, can swallow sometimes, can blink, can have non-purposeful movements, can spontaneously grasp(makes you feel like they are holding your hand when it is really a reflex) and have other signs of life.

Here in the US, a person is allowed to chose treatment, or no treatment. One is allowed to refuse feeding/water. We are also allowed to designate a surrogate, someone to make decisions for us when we are incapable of making one. If there hasn't been a person designated, then the spouse is the person to make the decisions, unless there is a specific reason that the spouse shouldn't be the decision maker.

According to Halacha, the issue is very simple. Halacha is paternalistic in this case, and one is not allowed to refuse food/water. End of story.

However, in the US, it is allowed to refuse food and water, and it is allowed for a surrogate to request no food/water. In this case, the spouse has not been found to be a lacking surrogate, and the request is reasonable by US legal/ethical standards. The parents have no standing. There is absolutely no reason for any court to listen to the parents, unless they are making a claim that withholding food/water is not whata Terry wanted and that there is a good reason that they would know better than the husband. The arguements about how conscious she is are legally immaterial.

There is absolutely no reason for the governer of Florida, the Congress, and the President to be involved. It is a horrible legal precedent. If they dont like the legality of witholding food/water to people in PVS(a position I would agree with) then they should addresss that issue. But getting involved in a proceeding that has proceded legally and fairly just because they dont like the outcome, but dont have the guts to tackle the underlying issue, that is an abuse of power. They should all be ashamed.

Obviously this is a complex issue, and one could argue that the end of saving the life of Ms. Schaivo outweighs the horrific injustice of meddling in settled legal affairs. But they are not trying to change the underlying law. They are just trying to score political points and brownie points with their constituencies at the expense of poor Ms. Schaivo's feeding tube.

interestingly, at my overwhelmingly Catholic institution, on one had a problem with withholding food/water from Ms. Schaivo. There was some uncertainty as to who had her best interests at heart, but the large majority sided with the husband.

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Friday, March 18, 2005

Yes, I am still (sometimes) here

I apologize to those who asked questions in the comments and I have not had time to answer. Also, you may have noted the dearth of significant posting. Unfortunately, there has been a significant increase in demands on my time, and so blogging seemed to the best place to make a cut in time committment(as opposed to work, time with my family, study time, etc.) I will try to post as possible, but it seems frequency will be way down. If Nisht wants to have another guest blogger, I would welcome him/her.

Shabbat Shalom to all

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Friday, March 11, 2005

Money and medicine

I consulted on a patient in the hospital and my physician's assistant(PA) called to tell me the neurologist on the case had ordered an electroenecephalogram(EEG- measures brain waves, good for determining if a patient has a seizure/epilepsy problem). There wasn't any doubt in my mind that the patient did NOT even have a question of seizures. My PA asked why the EEG was ordered. The only answer I could give her was that it was a procedure, and the neurologist can bill not only for doing it, but for reading it, and procedures are a good source of revenue(better than just doing consults or office visits).

I referred a patient for a procedure that was recently approved by the FDA(food and drug administration). It has been in use in Europe for a long time, and is a significant improvement on what was available previously. The insurance company declined to pay for it, saying there was insufficient evidence for effectiveness. This despite FDA approval, and many scientific studies from other countries. Are they really trying to protect people from unproven procedures? Of course not. They dont want to pay for another procedure. They said they would revisit the issue in 3-5 years.

Doctors get paid for doing more procedures and having more office visits. Insurance companies make more by limiting what they will pay for. No one has the patient's interest solely at heart, except for those who specifically and narrowmindedly put aside any financial motive and focus exclusively on what is good for the patient. I try my best to be one of those, and in all honesty I think I am successful in keeping away any thoughts about reimbursment when I am deciding about patient care. There are many doctors who do. Unfortunately, there is a significant number who let greed infuence their decision making.

GREED. That is the problem with our society in general and the practice of medicine in particular. Greedy doctors, greedy health insurance companies who want to look good for wall street and pay their CEO's millions and millions of dollars, greedy malpractice insurance companies who want to recoup what they lost on natural and other disasters and also pay their CEO's millions of dollars and look good for wall street, greedy patients who want excellent care but dont want to pay a lot for it, greedy lawyers who are willing to file lawsuits they know are not justified but have a chance of winning large sums of money.

There are no specific checks on any of this greed activity. It is hard for a patient to know if the doctor is making a recommendation based on what is good for the patient or what is remunerative for the phsycian. It may be hard to tell even by someone looking at it from the outside. Sometimes it is little things like an extra EEG. Sometimes it might be surgery. But as long as something looks reasonable, there is no check on what is reccomended, and because medicine is frequently subjective, there usually is some justification for the test, or procedure, even if it wasn't totally neccessary.

There is little recourse if your insurance wont pay for a procedure. Well, you can argue with them, and you and your doctor can paper them with letters, phone calls, etc. You can call your congressman, call your human resources person and try to threaten them with transferring your company insurance coverage, but it takes a lot of effort and time to get anything done, with no guarantee of success. Ultimately, sometimes it takes a law suit to get coverage.

There is also little recourse for physicians who get charged exorbident rates for malpractice insurance. There is a market, but very few companies offer insurance, and the rates are always pretty similar. Going without coverage is against the law in most states, and also not allowed by a lot of hospitals. The option is to move to a state with lower rates, limit your practice, or stop practicing.

Any lawyer can file a malpractice lawsuit as long as he can find a doctor to certify that there is a cause for the case. Unfortuantely, there are a lot of doctors needing money, or wanting more, who, for a fee, are willing to say almost anything with a bad outcome is malpractice. Even if the suit is thrown out, it is very difficult for the doctor to go back and sue the lawyer for filing a frivolous lawsuit. Most of those get thrown out. So, there is very little repercussion for filing lawsuits. There is no penalty for losing, and the client pays your expenses anyway.

In order for there to be a fair system of health care, all these problems need to be addressed. taking care of one or two, and neglecting the others will just skew the system, not fix it.

carefully putting away my soap box for use at another time.

Shabbat Shalom

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Tuesday, March 08, 2005

medicine and business, like oil and water

One of the business people associated with my practice gave a presentation recently. She emphasized that we had to be committed to achieving certain business goals. I raised my hand and told her I that while I was certainly willing to take part in pr, community outreach, education programs and other similar activities to promote the business aspect, as far as patient care, there really no way I was going to change, I was committed to practicing the best I could, no matter what the business down side was. It was just incredible to see the look on her face. Business people have the approach that you set financial or production goals, then do what is neccessary to achieve them, and sometimes with little regard for the consequences, as long as the goal is reached. Health care cant be approached like that without risk to the care that is extended. It never was so clear to me in such stark terms. I am sure that if I told her that I could off all my patients and her goals would be reached, she would have said "ok" with out batting an eyelash. Good thing she is not the voice at the top(luckily it is a physician run practice, and she only gives advice)

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Wednesday, March 02, 2005

Papal Medicine

A bit off my usual topics, but I thought it might be interesting to talk a bit about the Pope and his medical condition. It is well known that he has Parkinson's disease, and you can see his tremor, masked facies(not a lot of facial expression), slow movement, and other manifestations. In late stages(I am not making a claim that this is going on, merely that it is possible) you can see dementia, trouble with swallowing and the gag reflex, and other things. Obviously he had pneumonia once or twice, and recently had a tracheostomy(making an incision in the front of the neck and inserting a tube that goes into the trachea, thus for the purpose of breathing the mouth and upper airway is bypassed). A tracheostomy is usually indicated if a patient has been on a ventillator(breathing machine) for a long time(more than a week or so), if long term breathing machine usage is going to be neccessary, or if the patient cannot clear their secretions(cough out the inevitable junk that winds up in the trachea)(it is easier to pass a suction tube into the lungs through a tracheostomy than down through the mouth, which is nearly impossible while awake). It is NOT the usual treatment for pneumonia, unless one of the above conditions is present as well. Conclusion: The Pope's Parkinson's has worsened to the point he cannot keep his lungs clear, and the tracheostomy is probably a permanent neccessity. The sad part is that it is difficult to talk with a tracheostomy, unless it has a special attachment that lets the air flow up and out the mouth in the usual fashion(called, of course, a talking trach). If it weren't for that device, we might never hear the Pope speak again. It may be time to start stocking up on wood for the Cardinal's convention.

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