Alan Jotkowitz
Introduction
…For many centuries rabbis and physicians, often merging their professions into one, were intimate partners in a common effort for the betterment of life. The perplexities of our age challenge them to renew their association in the service of human life, health, and dignity. Indeed, they challenge Judaism itself to reassert its place as a potent force in the moral advancement of humanity.[1]
With these words, Rabbi Lord Immanuel Jakobovits not only began his magnum opus Jewish Medical Ethics (JME); he pioneered the new academic discipline of Jewish Medical Ethics. JME was published at an auspicious time in 1959 right before the scientific and technological explosion of the second half of the twentieth century. Issues such as determining the time of death, the ethics of transplantation and artificial reproduction, and the allocation of scarce resources such as dialysis and intensive care came to the forefront of the medical and ethics community in the 1960s. Many of these dilemmas were not addressed in Rabbi Jakobovits’s classic work as they had not yet become relevant (or, in some cases, had not even been imagined as possible.
Rabbi Tendler and Rav Moshe
Rising to the challenge of bringing a halakhic perspective to the complex issues raised by these almost miraculous advances in modern medicine were the great Poskim of the last century: Rabbi Moshe Feinstein, Rabbi Ovadia Yosef, Rabbi Shlomo Zalman Auerbach, and Rabbi Eliezer Waldenberg. But as their landmark halakhic opinions were written in technical rabbinic language, there was a need for experts who were fluent not only in Halakhah, but they also spoke the language of modern science and medical ethics. Rabbi Moshe Dovid Tendler was one of these experts.
Not only was Rabbi Tendler the interpreter of Rabbi Feinstein’s positions; he also was a main source for the immense scientific knowledge and understanding needed to make a halakhic ruling in these complex cases with life-and-death implications. I remember a visit with him where he told me how he took Rabbi Feinstein to the hospital to see both comatose and brain-dead patients in order to learn how to make the crucial distinction between the two. This work laid the groundwork for Rabbi Feinstein’s position defining death as the cessation of spontaneous respiration (which is controlled by the brain stem) and essentially allowed for organ transplantation from a halakhic perspective.[2]
In addition to interpreting R. Feinstein’s positions, R. Tendler became a recognized halakhic authority in his own right. He was uniquely positioned for this role. Not only was he a Rosh Yeshiva at RIETS for more than fifty years; he was also a distinguished scientist. He received a Ph.D. in microbiology from Columbia University, authored scientific articles in the most prestigious medical journals, and served as the longtime chairman of the department of biology at Yeshiva College. In R. Tendler’s classroom, a Gemara shiur in Hullin could become a lecture in biology, and a lecture on embryology in biology class could become a shiur on kashrut. In his worldview, the Torah and scientific worlds were in perfect harmony with each other.
The language of halakhic compromise or taking shortcuts with Halakhah had no place in R. Tendler’s lexicon. He did not take his sometimes controversial approach for societal or populist reasons; rather, he did so because he felt it was the absolute halakhic truth. He was brave enough to fight for this truth even when it was unpopular. Sometimes it led to halakhic leniencies―as in the case of brain death (even though he would not consider it a leniency) and organ transplantation―and other times it led to strict rulings, as in his position regarding abortion. But in both examples, it was born out of total commitment to the halakhic process and tradition.
Over the course of his whole life, he supported and modeled the belief that Torah and science were both expressions of the wisdom of ha-Kadosh Barukh Hu. He showed no patience for anyone who denied the validity of either of these. In this regard, he was a true disciple of Rambam. This was not only on a theoretical level; he was a firm believer that new technologies could be used to solve difficult halakhic problems because the discovery of them is, in reality, just revealing another aspect of the wisdom of ha-Kadosh Barukh Hu and the beautiful world He created. For example, as I wrote above, he was restrictive in his approach to abortion. Nevertheless, he was well aware of the tragedy of giving birth to a child who was doomed to suffer and die and therefore advocated for the universal genetic screening of young adults before marriage, which is a perfect example of how scientific progress can be used in the service of Halakhah.
He continued to be engaged in these issues into his nineties and co-authored seminal articles on the ethical issues in synthetic biology, Crisper technology, and stem cell biology. These articles indirectly address the issue of how to develop a halakhic ethic to questions that our ancient sources and traditions could never even imagine (much less write about). But true to his lifelong mission, R. Tendler believed that halakhic Judaism has answers to these questions as well: answers not only for Jews, but for the world at large as well. He was a firm believer of the sentiments expressed above by R. Jakobovits that Jewish values and ethics have relevance for all the world’s peoples.
Halakhic Opinions
Rabbi Tendler’s opinions on brain death and organ transplantation are well known, but thankfully, those situations are rare. In another much more common area of medical Halakhah, he was also a trailblazer. Basing himself on the opinions and work of his father-in-law, R. Moshe Feinstein, R. Tendler was instrumental in developing a halakhic end-of-life ethic. He wrote:
A Physician is only obligated to heal when he has some medical treatment to offer the patient. If the patient is dying from an incurable illness and all therapy has failed or is not available, the physician’s role changes from that of a curer to that of a carer. Only supportive care is required at that stage, such as food and water, good nursing care and maximal psychosocial support. If a patient near death is in severe pain and no therapeutic protocol holds any hope for recovery, it may be proper to withhold any additional pharmacological or technological interventions so as to permit the natural ebbing of the life forces.[3]
Basing himself on Talmudic and Midrashic sources, R. Tendler maintained that suffering is not limited to the physical:
Judaism is not only concerned with physical pain but also with psychological or emotional pain. Mental anguish is just as significant as intractable physical pain. Mental and physical suffering are recognized as being of equal importance in Jewish legal thought.[4]
These landmark opinions have become the standard of care for Orthodox Jews. They have also been a great comfort, not only for the dying patients and their families but also for Orthodox physicians who struggle daily with delivering end-of-life care in a compassionate manner while remaining true to Halakhah. In these sensitive and very common areas, R. Tendler was the final authority for decades and was a phone call away for both patients and physicians.
The Role of the Community
R. Tendler was one of the first poskim to look more broadly at the ethical questions raised by modern medicine and to address the question of whether a community or society is required to act differently when allocating scarce resources and developing priorities. R. Tendler refers to two Talmudic sources in his discussion:[5]
- Nedarim 80b discusses whether a community is required to share its limited water resources with another community even if it only needs the water for laundry while the other community needs the water to drink. Rabbi Yosi held that the community’s own laundry needs have priority even over the drinking needs of the neighboring community. This is because if the community does not do laundry, it might at a future time lead to illness and possible danger to life. Rabbi Tendler was disturbed by this conclusion. Why should the community not be required to share its water in order to save the neighboring community at immediate risk? He explains that a community is different from an individual because it is required to consider future risks. An individual is required to do whatever is in his or her power to save a person at immediate risk. A community, however, is required to think in broader terms either because the future needs of its own citizens take precedence over the immediate needs of another community’s citizens, or because when dealing with a community, risk should be interpreted more broadly. Jewish law requires the leaders of society to take into account future needs when allocating resources.
- Gittin 45a teaches that one is not allowed to redeem captives for an exorbitant sum for one of two reasons:
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- Doing so might encourage future hostage-taking.
- A community does not have to impoverish itself for the sake of one individual.
The first answer takes a long-term consequentialist approach to the question. Life is an ultimate value, but by saving the hostage’s life, other lives will be put in danger. One can infer from this answer that a community must take into account future considerations even when dealing with immediate life-and-death questions.
The second answer has obvious relevance to our question, and again, R. Tendler was disturbed by its implications. Even if paying the ransom will not lead to future hostage-taking, the community does not always have the obligation to pay the ransom. However, isn’t saving a life an ultimate and priceless value in Judaism? Again, the answer is that the perspectives of an individual and the community are different. He explains that a community does not have to exhaust its resources to save an individual. This case is therefore relevant to our question of how to distribute a fixed healthcare budget among different healthcare priorities and suggests that, for a community, there are limitations to the “law of rescue” (which mandates that we prioritize the life of a person at immediate risk instead of taking a long-term perspective).
Rabbi Tendler and the Rav
R. Tendler was the son-in-law of R. Feinstein and also one of his closest students, but what is less well known is his relationship with Rabbi Joseph B. Soloveitchik (the Rav). Concerning the Rav, R. Tendler wrote the following:
My shver, zts”l, is often called “the Rosh Yeshivah.” Rav Soloveitchik, zts”l, on the other hand, is known as “the Rav.” Nothing could be further from the truth, though. Rav Yosher Ber [the Rav] did not know what kind of a berachah you make on rabbanus, but he was a great rosh yeshivah. My shver did not know what it means to be a rosh yeshivah, but he was the great rav. Of course, crazy America switched the titles for them.[6]
The Rav also held R. Tendler in high esteem. In discussing the issue of brain death, Rabbi Binyamin Walfish recounts a conversation he had with the Rav:
I then went to the Rav and told him what Rabbi Tendler had advised us to do. The Rav asked me: “Is Rabbi Tendler sure this test is foolproof?” I answered in the affirmative and offered to have Rabbi Tendler call him directly. The Rav said this would not be necessary. He said that if Rabbi Tendler was certain, this was sufficient for him since he [Tendler] was the expert in such matters.[7]
The Rav was also a major philosophical influence on R. Tendler. The Rav enthusiastically championed the religious imperative for man to master and control the natural world and had much appreciation and respect for the achievements of modern science and technology:
Only when man rises to the heights of freedom of action and creativity of mind does he begin to implement the mandate of dignified responsibility entrusted to him by his Maker. Dignity of man expressing itself in the awareness of being responsible and of being capable of discharging his responsibility cannot be realized as long as he has not gained mastery over his environment.[8]
Perhaps no student of the Rav has taken this message more to heart than R. Tendler, who has similarly written:
We are obligated to teach the truths of Hashem’s interaction with the natural world… To refuse to master the science of astronomy is to refuse to see Hashem as He interacts with the natural world. Rav Yochanan added it is a mitzvah to do so because it fulfills the commandment of Hashem to study and apply Torah knowledge (Shabbat 75a). This is the wisdom and the understanding that the other nations appreciate.[9]
The Rav ends the Lonely Man of Faith with a beautiful and inspiring homily on the first meeting of Elisha and Elijah. The Navi relates (I Kings, Chapter 19, Old JPS Translation):
19 So Elijah went from there and found Elisha son of Shaphat. He was plowing with twelve yoke of oxen, and he himself was driving the twelfth pair. Elijah went up to him and threw his cloak around him. 20 Elisha then left his oxen and ran after Elijah. “Let me kiss my father and mother goodbye,” he said, “and then I will come with you.”
“Go back,” Elijah replied. “What have I done to you?”
21 So Elisha left him and went back. He took his yoke of oxen and slaughtered them. He burned the plowing equipment to cook the meat and gave it to the people, and they ate. Then he set out to follow Elijah and became his servant.
The Rav explains, “Elisha was a typical representative of the majestic community.” He was representative of a successful businessman whose main concern was the accumulation of wealth and power. “What did this man of majesty have in common with Elijah, the solitary covenantal prophet” who lived a lonely life detached from society, periodically resurfacing to chastise the people for straying from God? Yet suddenly, with the appearance of Elijah, “A new Elisha emerged. Majestic man was replaced by covenantal man.” Elisha was no longer concerned with the accumulation of wealth or familial relationships; he was willing to burn his plows, leave his oxen and family, and become homeless and detached from society like his mentor, Elijah, in order to serve God. However, his exile was not final. After reaching the pinnacle of faith under Elijah’s tutelage, “He came back to society as a participant in state affairs, as an adviser of kings and a teacher of the majestic community. God ordered him to return to the people, to offer them a share in the covenantal drama.”[10]
R. Tendler, like the Elisha of old―through his decades of teaching Talmud, Halakhah, and biology at Yeshiva University and serving as a communal Rav―has taught us by example that majestic man and covenantal man do not have to live in dialectical confrontation with each other. Instead, they can complement each other to create a beautiful synthesis of majesty and faith.
[1] Immanuel Jakobovits, Jewish Medical Ethics: A Comparative and Historical Study of the Jewish Religious Attitude to Medicine and Its Practice (New York: Bloch, 1975), vii–viii.
[2] Igrot Moshe Yoreh Deah 3:132. In an earlier teshuvah (Igrot Moshe Yoreh Deah 2:174) he came out in opposition to heart transplants. According to R. Tendler, this teshuvah was referring to patients who were comatose or in a chronic vegetative state but did not meet the criteria for brain death.
[3] Responsa of Rav Moshe Feinstein Vol 1 Care of the Critically Ill, trans. Moshe Dovid Tendler (Hoboken, NJ: Ktav Publishing House, 1996), 145-146.
[4] Idem., 143.
[5] Moshe David Tendler, “Problems in Triage: Public Expenditures and Saving One Life versus Another” [Hebrew] in Sefer Ha-Yovel Likhvod Moreinu HaRav Y.D. Soloveitchik (New York: Student Organization of Yeshiva, S.O.Y., 1984).
[6] Available at: http://www.kolhamevaser.com/2010/08/an-interview-with-rabbi-dr-moshe-d-tendler/
[7] Binyamin Walfish, “Rabbi Joseph B. Soloveitchik on Brain Death and Organ Donation: A Testimony,” in Halakhic Realities: Collected Essays on Brain Death, ed. Zev Farber (Jerusalem: Maggid Books, 2015), 225.
[8] Joseph B. Soloveitchik, The Lonely Man of Faith (Jerusalem: Maggid Books, 2012), 11. Notwithstanding the above sentiments, it is interesting to note that the Rav was less than enthusiastic on the opening of Yeshiva University’s Albert Einstein College of Medicine and writes that if he was consulted before the decision was made, “I do not know what my opinion would have been.” See the letter in Rabbi Joseph B. Soloveitchik’s Community, Covenant and Commitment: Selected Letters and Communications, ed. Nathaniel Helfgot (Jersey City, NJ: Ktav Publishing House, 2005).
[9] Available at: http://www.lookstein.org/resource/articles/evolutionary_theory.htm
[10] Joseph B. Soloveitchik, The Lonely Man of Faith, rev. ed. (Jerusalem: Maggid Books, 2012), 58.
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