Thursday, February 17, 2011

Class: Medical Halachah - Prostate surgery, endometrial ablation and more

I'm out of time these days to write anything new and substantive; my apologies. Here, instead, for those who are interested, are the vignettes I have prepared for my "Medical Halachah with CME credit" class coming up this Sunday morning. Please comment.

1. Jason, 50, a Type II diabetic, has been experiencing painful difficulty in urination due to growth of his prostate. His urologist offers the option of surgery, which risks causing retrograde ejaculation, or tamulosin, which risks hyperglycemia as well as a less likely possibility of retrograde ejaculation. Which option is halachically better?

2. Tim, 30, is experiencing bouts of moderate-to-severe depression, and his physician wishes to prescribe antidepressants. Tim is concerned that the side effects include impotence. Need Tim be concerned about the halachic ramifications of medication-induced impotence?

3. Jane, 33, has already birthed three sons and three daughters, with difficult side effects during her pregancies, and her physician has warned that her health would be at risk in a further pregnancy. He recommends Ovabloc, a silicon plug to be inserted in her fallopian tubes. Would such a procedure be halachically permitted? Are there better options?

4. Tanya, 35, has already birthed three sons and three daughters, and she is now experiencing heavy, prolonged vaginal bleeding, causing pain as well as rendering her a niddah on an on-going basis. The bleeding is resistant to treatment. Her physician recommends endometrial ablation - which would destroy the endometrial lining, at least temporarily. Would such a procedure be permitted?


  1. A broader question - is there any situation which halacha/HKB"H is indifferent to the alternatives (i.e. there is no halachic preference and you can roll your own without worry that you didn't make the best choice)
    Joel Rich

  2. By coincidence, I listened to (and learned from and enjoyed) your class on "double effect" last night.

    I thought you might have done more to contrast the approach of side effects vs intended effect with the halachic contrast between active and passive effects ("kum v'asei" vs "shev v'al ta'aseh") (cf the 1st Rav Chaim) or the difference between direct and indirect damage in hilchot nezikin.

  3. I was in Tanya's situation. The problems described can be debilitating. Endometrial ablation saved my sanity and my marriage, and possibly my life.(My blood pressure was being affected by the constant bleeding)I sure hope the halacha would have allowed it.

  4. I am neither a doctor nor a rabbi, so maybe I'm missing something in these cases. There are no sources, so these issues seem simple. The sources below aren't just show that the simple answer (of course it's allowed, it's pikuach nefesh) is correct.

    It is clear (Tzvi Pesach Frank, quoted by Sheilat Moshe EH 22) that we don't have to worry about patzua daka, all the more so to safek infertility, with regard to surgery (even if not life-threatening). The Chazon Ish (Nashim 12:7) agrees, and says there may be no problem of patzua daka on internal operations, and none if there is even a safek of danger. The Tzitz Eliezer says that in any case of medical need, there is no worry. The first two cases seem to be medical needs, and probably safek sakana.

    For the third case, I may not know of better options as I don't have the background, but what would be the halachic problem if this is the best option.

    For the fourth case (and this would apply to the third case), I also hope this is muttar. Everything that I saw in otzar haposkim simanim 1-2 seem to imply that there is no chiyuv of priah urviah on the woman, and therefore when she has a real need

  5. (continued) there would be no problem with causing infertility (this was mefurash in a few places there I thought, and i don't remember any dissenting opinions)

  6. Interesting. Russell, I'd like you to know that the Shulchan Aruch at the end of Even Ha'ezer Siman 5 discusses sterilization. Most relevant to case 2 is se'if 12 - "if one offers a potion to a person or animal to make it a saris is forbidden, but there is no [Biblical] Lashes. And a woman is permitted to drink this to maker her like saris so she cannot give birth." For case 2, when impotence is a side effect, is that included as a "potion" when the purpose of the antidepressant is not to sterilize?

    For 1 & 2 the risks of these side effects occurring could affect their permissibility.

    Case 3 would at first blush be related to the famous sugya "shalosh nashim meshamshos bimoch." An interesting derivative in this case would be is having a non-Jewish doctor insert this plug better than the woman using a moch which she would insert herself.

  7. Russell, a good resource is Nishmat Avraham on Even Ha'ezer by Avraham S. Avraham. In English the link is here:

  8. Joel-
    Interesting question. I believe there are.

    Mike S.-
    Yes, a lot more could be done. Time is restrictive, though.

    Anonymous 10:47 AM-
    Thanks for writing, glad you are better now.

    Thanks for writing.
    1) The fact that one is not a ptzua daka does not remove the issur sirus. Cf R' Mordechai Halperin in Assia 10, pg. 253. Also note that the contention that ptzua daka is limited to external parts is not 100% מוסכם. Much more to say on that, in the shiur.
    3) Indeed, you might enjoy R' Mordechai Halperin's footnote 54 in the aforementioned article, where he tries to resolve an apparent contradiction between sources on a woman's issur sirus (as they are understood by the GRA) based on the machlokes re: women's obligation in pru urvu. But not all poskim see the issues as linked; see, for example, SA Even haEzer 5:11, Taz Even haEzer 5:6 and Yabia Omer 8:EH 14:6.

    The Talmid-
    Much to say here, but to settle for two points:
    1) The ben noach issue is an interesting wrinkle in its own right, because of the machlokes regarding a ben noach and sirus.
    2) I'm actually re-doing Case 3 to eliminate the moch issue. It's a distraction from my main point, which is the question of sirus for women, as well as a further question (to be presented in the new version of the vignette) of whether she may then get married, or whether there is a ptzua dakah law for women.

  9. Hi Talmid (and ba'al hablog),
    As I mentioned, it seems the Chazon Ish, R' Tzvi Pesach Frank, and R' Waldenberg all permit it even if the side effects are guaranteed -- if the procedure itself causes infertility. They all state that not only is this person not a patzua daka (it seems they turn it into bidei shamayim), but there is no issur sirus. The Chazon Ish says that theoretically, there may be an issur d'rabanan, but in cases of medical need, there is no problem whatsoever.

    Regarding EH 2:12, that is discussing sterilization for its own sake, whereas this is only as a side effect. This is discussed in the sources quoted earlier, and if I'm not mistaken in the pitchei teshuva ad loc.

    I do not have access to Assia, as I none of the libraries or batei midrash to which I have access have it, so I unfortunately will not be able to look it up. Perhaps I can ask around to see if anyone has it. I have seen the Yabia Omer on this, but I didn't look up any of the sources he quoted at the time.

  10. Hi Russell,

    You might want to take another look at those poskim. While poskim do mention heterim for sirus, their discussions that you cite are limited to ptzua daka, and it is possible for an action of sirus to be prohibited even if it does not generate ptzua daka.

  11. Shavua tov- I am new to this wonderfully open and scholarly,yet clear discussion of relevant topics to a religious Jew.

    I will just respond tonight to number two ,since I also deal with these issues professionally.Someone with that level of depression would be considered at least ,a choleh she'en bo sakana if not even safek pikuach nefesh,with posible suicidal thoughts.
    The possible side effect of impotence is reversible with lowering of medication or after full treatment.

  12. Hello daat y,

    Thanks for commenting. I wholeheartedly agree; you might enjoy a shiur I gave on the topic not long ago, available here.

  13. Note: The audio for the shiur, with the source sheet, is now on-line here. Please make sure to read the "Please Note" I included with it. Comments welcome.

  14. Re the Gra - probably the best pshat is that sirus of a zachar is the ikur lav and sirus nikeivah is the tafel lav, so there's no malkos for it. Similar to bal tashchis - ikur lav is fruit trees, but not destroying anything else is nichlal in the lav, but there is only malkos for the ikur lav.

  15. The Talmid-
    A good thought, but subsequent to the shiur I checked in Igros Moshe, and he explains the GRA as saying it's an issur aseh, from משחתם בהם.