Rkyhs jewish medical ethics revised

  • 890 views
Uploaded on

rkyhs

rkyhs

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
890
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
6
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Jewish Medical Ethics From Stem Cells to Organ Transplants Aaron H. Chevinsky, MD FACS Chief, Surgical Oncology Morristown Memorial Hospital Co-Director - Carol G. Simon Cancer Center Clinical Professor of Surgery – UMDNJ/NJMS
  • 2.  
  • 3. Jewish Medical Scholars Rav Moshe Feinstein, The Igros Moshe (1895-1986 ) Rav Yosef Kairo, The Bais Yosef , author of the Shulchan Aruch (1488-1575)     Rav Moshe Isserles, The Rama   (1530-1572) The Rambam, Rabeinu Moshe Ben Maimon (1135-1204) R’ Eliezer Waldenberg, The Tzitz Eliezer (1917-2006) R’ Moshe Tendler Yeshiva University Son-In Law of R’ Feinstein Lord R’ Immanuel Jacobovits Chief Rabbi of Great Britain (1921-1999) Dr. Fred Rosner
  • 4. Jewish Medical Ethics
    • The Stem Cell Controversy
    • Genetic Screening and Gene Therapy
    • Organ Donation and Transplantation
    • End of Life Decisions
    • Reproductive Issues
    • Cosmetic Surgery
    • Smoking Cigarettes
  • 5. You’re very selfish Louis. Those Stem Cell Lines were meant for people who have lost their organs
  • 6. Each stored embryo is a stem cell debate Updated 1/30/2007 4:22 PM ET What would you do with excess embryos? Guidelines for stem cell research kindle controversy- CNN 8/24/00                                                   Research avenue adds fuel to stem cell controversy July 18, 2001 Posted: 3:15 p.m. EDT (1915 GMT) -CNN A human embryo in its earliest stages of development is made up of undifferentiated stem cells.   UConn plans to build stem cell institute By Scott Whipple, Herald Press Staff 02/11/2007   Stem-cell researchers look beyond the embryo By Joyce Howard Price THE WASHINGTON TIMES February 11, 2007                     
  • 7. The Stem Cell Controversy
    • What are stem cells?
        • Cells with the potential to differentiate into (become) any cell or tissue in the body
    • Where are stem cells found?
        • Aborted fetuses
        • Umbilical cord blood
        • Amniotic Fluid
        • Adult Bone Marrow
        • Embryos “left over” from In-vitro fertilization
  • 8. The Stem Cell Controversy
    • Why are stem cells important?
        • Understand cellular differentiation (cancer)
        • Organ Transplantation
        • Replace dysfunctional cells that cannot be repaired
            • Brain (Parkinson’s Disease and Alzheimer’s Disease)
            • Spinal Cord (Paralysis and Stroke)
            • Diabetes, Arthritis and Heart Disease
            • Liver and kidney failure
  • 9.  
  • 10. Halachic View on Stem Cell Research
    • Adult and umbilical cord Stem Cells are usable
    • Pre-implantation embryos are not “alive”
        • Cannot be sustained alone
        • IVF generally permissible by most authorities
        • “ mayim b’alma” – mere water. To use a surplus pre-embryo for medical research that will save a life is not halachically prohibited (the Beth Din of America made this point in a ruling on August 21, 2001).
        • “ Pikuach Nefesh” – We are obligated to save lives
    • Abortion for the sole purpose of harvesting stem cells is forbidden
        • Abortion allowed only to “Save” the mother
        • Abortion generally not allowed for genetic abnormalities
        • Some Poskim allow abortion up to 40 days for this
    Stem Cell Research by Rabbi Yitzchok A. Breitowitz (2005) Stem Cell Research in Jewish Law by Daniel Eisenberg, MD (2001) Stem cells and halacha by Rabbi Raymond Apple
  • 11.  
  • 12. Genetic Screening and Gene Therapy
    • Genetics in the Bible and Talmud
        • In Bereishit Ya-akov manipulates the spotted and speckled sheep to his benefit
        • Hemophilia is discussed in Yebamot 64B
            • Bleeding after Circumcision
        • Marriage to a man or woman whose family had epilepsy or leprosy was prohibited (Talmud, Rambam and Shulchan Aruch)
    Biomedical Ethics & Jewish Law – Fred Rosner, MD
  • 13. Genetic Screening and Gene Therapy
    • Issues related to genetic screening
        • Prediction of incurable diseases
            • Huntington’s Chorea and Alzheimer’s
        • Discrimination or shunning of carriers
            • Health and Life Insurance Issues
            • Employment Issues
        • Accuracy and predictability of results
        • Confidentiality
            • Obligation to reveal results to spouse or family
        • Abortions for genetically abnormal fetuses?
    Rosner, Fred – “Judaism, Genetic Screening and Genetic Therapy” 2006
  • 14. Diseases for which Genetic Screening Exists
    • Ashkenazi Jews – Carrier Risk
      • Tay-Sachs – 1:25
      • Cystic Fibrosis – 1:25
      • Bloom Syndrome- 1:100
      • Canavan Disease – 1:40
      • Factor XI Deficiency
      • Familial Dysautonomia – 1:30
      • Fanconi Anemia – 1:89
      • Gaucher Disease – 1:14
      • Mucolipidosis IV- 1:120
      • Niemann-Pick Disease – 1:90
      • Torsion Dystonia
  • 15. Diseases for which Genetic Screening Exists
    • Sephardic Jews
      • Beta Thalassemia
      • Familial Mediterranean Fever
      • GSPD Deficiency
      • Type III Glycogen Storage Disease – 1:70
  • 16. Diseases for which Genetic Screening Exists
    • Breast Cancer
        • BRCA 1 & 2
        • 2.3% of Ashkenazi Women
        • 5x higher than the population
        • Risks of ovarian, uterine and prostate cancer
        • No JEWISH obligation to screen or reveal results to other potential carriers (family)
    • Pancreatic Cancer
        • BRCA 2
        • Also associated with male breast cancer
    • Colon Cancer
    • FAP & HNPCC
    • Huntington’s Chorea
  • 17. Daniel Eisenberg, MD
  • 18. Daniel Eisenberg, MD
  • 19. Daniel Eisenberg, MD
  • 20.                                                                                                  Genetic Screening Causes Controversy by Aaron Klein Dor Yeshorim, an international genetic testing program operating within the Jewish community, was brought to Yeshiva University by YCSC on Tuesday March 10, giving students an opportunity to utilize its services. The program is aimed at couples who wish to get married, and determines their genetic compatibility by screening the blood of each individual and testing for evidence of unexpressed (recessive) genetic diseases.
  • 21. Genetic Screening and Gene Therapy
    • Tay-Sachs Disease
        • Screening prior to marriage is encouraged
        • Abortion is not permitted for this per R’ Feinstein
            • Only permitted to prevent injury to the mother
            • Physical or Psychological Risk
        • Abortion up to 3 mos is permitted per R’ Waldenberg
            • Up to 6 months for a fetus with a terminal condition
            • Tzitz Eliezer - Allowable if deformity causes suffering
        • Dor Yeshorim
            • Provides confidential screening for orthodox couples
        • Pre-Implantation screening a controversial option
            • In Vitro Fertilization
    Biomedical Ethics & Jewish Law – Fred Rosner, MD Jewish Medical Law – Avraham Steinberg, MD
  • 22. Daniel Eisenberg, MD
  • 23.  
  • 24. Gene Therapy
    • The modification of an existing cell by injecting new or corrected DNA
        • Would be permissible to restore health
        • Modifying sperm, ovum, or fertilized egg permitted since it is “not a person yet”
        • R’ Moshe Hershler warns of potential problems
            • Prohibition of mating diverse animals, sowing different seeds, wearing mixed garments
            • Does changing the genes change the individual
        • Genetically modified foods are of great debate
    Rosner, Fred – “Judaism, Genetic Screening and Genetic Therapy” 2006
  • 25. Organ Transplantation
  • 26. Organ Donation & Transplantation
    • Autograft – Transplant from the person
    • Allograft – Transplant from human donor
    • Xenograft – Transplant from an animal
    • Living or Cadaveric (dead person)
    • Whole organ or part
    • Transplantable Organs
        • Blood and Blood Products, Bone Marrow, Bone
        • Cornea, Heart, Kidney, Liver, Lung, Pancreas, Skin
  • 27. Organ Donation & Transplantation
    • What is the Biblical source for organ donation?
        • "And you shall surely heal" (Exodus 21:19)
        • "And you shall restore (a lost object, which surely includes health)" (Exodus 23:4)
        • "You shall not stand on the blood of your fellow" (Leviticus 19:16)
    • Organs may be given to or used from Non-Jews
    • Living Donor
        • Obligation to donate – Cannot be Coerced
        • Risk to the donor must be minimal
        • Kidneys, bone marrow, blood and split liver donations
    • Cadaveric Donor
        • “ Pikuach Nefesh” – Overrides issues of desecration of the dead
        • Brain Death – Brain Stem Death
        • You may ventilate a “Brain Dead” individual to keep the organs alive
    Rabbi Dr. Moshe Tendler
  • 28. Organ Donation & Transplantation
    • Xenotransplantation (Animals)
        • Man is not permitted to cause needless pain to animals, but man is given dominion over them
        • This is allowable (Rabbi Dr. Moshe Tendler)
        • Even from nonkosher animals (Pig Heart Valves)
    • Artificial or Synthetic Organs
        • Generally allowable
        • Heart valves, artificial joints, synthetic skin
        • Dialysis and cardioplumonary bypass
        • Artificial Heart?
    • It is a mitzvah to donate organs either when alive or after death ( Midat Chasidut )
  • 29. Harvard Ad Hoc Committee on Brain Death In 1968, this committee of the Harvard Medical School published a report describing the following characteristics of a permanently nonfunctioning brain, a condition it referred to as "irreversible coma," now known as brain death : Unreceptivity and unresponsitivity- -patient shows total unawareness to external stimuli and unresponsiveness to painful stimuli; No movements or breathing- -all spontaneous muscular movement, spontaneous respiration and response to stimuli are absent; No reflexes--fixed, dilated pupils; lack of eye movement even when hit or turned, or ice water is placed in the ear; lack of response to noxious stimuli; unelicitable tendon reflexes. In addition to these criteria, a flat (EEG) was recommended. The committee also noted that drug intoxication and hypothermia which can both cause reversible loss of brain functions should be excluded as causes. The report was used in determining patient care issues and organ transplants. The condition of irreversible coma, i.e., brain death, needs to be distinguished from the persistent vegetative state , in which clinical presentations are similar but in which patients manifest cycles of sleep and wakefulness. [See President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death (Washington, DC: U.S. Government Printing Office, 1981)].
  • 30. Organ Donation & Transplantation
    • Jewish Definitions of Death stem from discussions on the Sabbath
        • Babylonian Talmud – Yoma 8:6-7
            • It is permissible to clear debris from a fallen building to ascertain if someone is alive.
            • If he is found alive, the debris can be cleared – otherwise leave him until after Shabbat
            • You must clear off the nostrils to check for breathing.
            • “ In whose nostrils was the breath of the spirit of life” – Genesis 7:22
        • Rashi – No air emanates from the nose
        • Rambam – No sign of breathing detected at the nose
        • R’ Joseph Karo - Shulchan Aruch - Orach Chayim 329:4
            • “ If one cannot detect signs of respiration at the nose, then he is certainly dead .”
            • If a woman dies giving birth on Shabbat, it is permissible to incise the womb and remove the baby (330:5)
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 31. Organ Donation & Transplantation
    • Modern Jewish Commentary on death
        • R’ Moses Schreiber (Chatam Sofer – Yoreh Deah 338)
            • If the person is motionless and without pulse in neck or wrist and no spontaneous breathing
        • R’ Isaac Yehudah Unterman (1968)
            • One is dead when one has stopped breathing
        • R’ Eliezer Yehuda Waldenberg (Tzitz Eliezer 9:46, 10:25)
            • Cessation of both respiration and cardiac activity
        • R’ Immanuel Jacobovits (1968)
            • “ The classic definition of death as given in the Talmud and Codes is acceptable today and correct. However, this would be set aside in cases where competent medical opinion deems any prospect of resuscitation, however remote, at all feasible.”
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 32. Organ Donation & Transplantation
    • R’ Moshe Feinstein (Iggrot Moshe Yoreh Deah 2:174, 2:146, 2:132, Chosen Mishpat 2:72)
        • 1968 - Heart transplantation is double murder
            • The donor is killed
            • The recipient’s life is shortened
        • It is a mitzvah for the family to donate organs to save the lives of others ( Midat Chasidut )
        • 1970 - One cannot declare death if “The brain is not functioning….even if the person is still breathing [spontaneously].”
            • Removing an organ from someone in a deep coma or persistent vegetative state is against halacha
            • Yachol Linshom (capable of breathing)
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 33. Organ Donation & Transplantation
    • R’ Moshe Feinstein (Iggrot Moshe Yoreh Deah 2:174, 2:146, 2:132, Chosen Mishpat 2:72)
        • 1976 – One is dead if there is no connection between the brain and body and there is no spontaneous breathing
            • Absence of a heartbeat is not essential for “death”
            • Absence of cerebral blood flow and lack of respiration
            • Halachically equivalent to decapitation
        • 1980 – Heart, liver and lung transplants permissible
            • Donor must be completely brain dead (No respirations)
    • Israeli Chief Rabbinical Council – 1987
        • Brainstem death is an acceptable surrogate
    • Not all agree that heart and lung transplants are allowable (R’ Waldenberg -Tzitz Eliezer)
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 34.  
  • 35. End of Life Decisions
    • Withholding care and euthanasia
        • Talmud – One who is dying ( Goses ) is regarded as a living person in all respects (Semachot 1:1)
            • Goses – One whose death is imminent (3 days)
        • Maimonides – One may not move a dying person or in any way hasten death (Mishne Torah – Hilchot Avel 4:5)
            • One may not chop wood or disturb him
        • R’ Jacobovits – Any form of euthanasia is prohibited and condemned as murder
            • Care may be withdrawn which artificially delays the demise
        • R’ Waldenberg – Physicians must do everything possible to save a dying patient, even if temporary (Tzitz Eliezer)
            • Pain killers may be given even if the slow breathing
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 36. End of Life Decisions
    • Resuscitation and withdrawing support
        • R’ Waldenberg – An artificial ventilator is permissible
            • One is not permitted to place an incurably or irreversibly ill patient on life support
            • Life support may be disconnected when a patient is halachically dead
        • Nutrition, Hydration and routine life-saving medications must be given even to dying patients
            • Medications and painful treatment may be refused
            • Experimental therapies may (but are not required) be tried of under the care of an “Expert” physicians
    Rosner, Fred – Biomedical Ethics and Jewish Law - 2001
  • 37. Reproductive Issues
    • In-Vitro Fertilization
        • Fertilization occurs outside the body
        • The fertilized zygote is re-implanted in the mother
            • Approved by Chief Rabbi Ovadiah Yosef
        • What is the status of un-implanted fertilized zygotes?
            • May be used for research or discarded
            • Committee on Medical Ethics – Federation of Jewish Philanthropies
    In Vitro Fertilization: Legal and Ethical Considerations by Fred Rosner, MD
  • 38. Reproductive Issues
    • Artificial Insemination
        • Not allowed with a donor
        • Some consider it adultery
            • Issues of inheritance, legitimacy and incest remain
        • From the husband it is permitted (IVF)
    • Surrogate Mother
        • Permitted only as a last resort
        • Forbidden by R’ Jacobovits
    • Embryo Transfer
        • Conflicting opinions given
        • Who is the “real” mother –biological or gestational
    N. Shulman – Jewish Answers to Medical Ethic Questions A. Steinberg, MD – Jewish Medical Law
  • 39. Is Plastic Surgery Permissible Under Jewish Law
    • Reconstructive Procedures
        • Congenital (from birth) Malformations
        • Acquired Malformations
    • Cosmetic Surgery
    • Halachic Issues
        • Improving G-ds work
        • Risks of surgery
        • Prohibition on mutilation of the body - Chavala
        • Ethical censure of human vanity - particularly men
    R’ Immanuel Jacobovits in Jewish Medical Ethics
  • 40. Is Plastic Surgery Permissible Under Jewish Law
    • R’ Immanuel Jacobovits’ recommendations
        • Surgical risk must be minimal
        • The operation is medically indicated
            • Following an accident
            • To prevent grave psychological harm
        • Correction of the deformity will facilitate or maintain a happy marriage
        • Correction of the deformity will allow the individual to earn a living or play a constructive role in society
  • 41. Is Plastic Surgery Permissible Under Jewish Law
    • Rabbi Mordechai Yaacov Breish ( Chelkas Yaakov )
        • There is an acceptable amount of risk
            • Childbirth
            • Bloodletting (Talmudic)
        • “ Shomer Pasaim Hashem”
            • G-d protects the simple (not medically sophisticated)
        • To prevent psychological pain (Tosofos)
    • Rabbi Moshe Feinstein
        • Chavala (self-mutilation) implies only with malice
        • Therefore it is permissible
    • R’ Eliezer Waldenberg ( Tzitz Eliezer ) forbids all “elective” surgery that is “cosmetic”
    Jewish Medical Law – Avraham Steinberg, MD
  • 42.  
  • 43. Smoking Cigarettes
    • Medical Conditions Associated with Smoking
        • Cardiovascular Diseases
            • Emphysema
            • Coronary Artery Disease (Heart Attacks)
            • Peripheral Vascular Disease
            • Strokes
        • Cancers
            • Lung
            • Bladder
            • Mouth, Tongue and Larynx
            • Esophagus
            • Pancreas
  • 44. Smoking Cigarettes
    • Chafetz Chaim
        • “ Smoking is harmful to the body and Soul”
    • R’ Feinstein (1973)
        • It is not proper to start smoking
        • Not prohibited because, “The Lord preserves the simpletons (Shabbat 129b & Niddah 31a)
    • R’ Eliezer Waldenberg (Tzitz Eliezer) – Smoking is Prohibited
    • R’ Aberbach (1969)
        • Should be prohibited due to the danger
    • R’ Chaim David Halevy (1976)
        • Chief Sephardic Rabbi of Tel-Aviv
        • Smoking is a violation of Jewish Law
    • R’ Bleich (1977)
        • Many actions are dangerous (crossing the street)
    • Dr. A. Abraham citing R’ Ovadiah Yosef (1980)
        • “ One should do one’s utmost to avoid smoking”
        • Smoking is not halachically prohibited (General Consensus)
    F. Rosner – Biomedical Ethics and Jewish Law Schussheim, Eli and Eliezer Waldenberg . (“Should Jewish law forbid smoking?” B’Or ha’Torah 8 (1993))
  • 45. Any Questions?