Medical Procedures on a Parent

The beginning of Parshas Tazria includes references to parent-child relationships…

Question #1: My Daughter, the Surgeon

“I specifically want my daughter to perform my upcoming operation. Is this permitted?”

Question #2: My Son, the Medic

“May my son, a trained medic, give me my daily shot?”

Foreword

One of the many mitzvos mentioned in parshas Mishpatim is capital punishment for someone, male or female, who strikes his or her parent. As we all know, the aseres hadibros include a mitzvah of kibud av ve’eim, honoring parents, and the Torah also has another mitzvah of yiras av ve’eim, treating parents with awe (Vayikra 19:3). Obviously, the opposite extreme is someone who curses or strikes his parent. Yet, there are situations in which the parent wants the child to “wound” him because of the resultant benefit. For example, if the parent needs open heart surgery, and the child is the most qualified thoracic surgeon available, he would probably want him or her to perform the operation. (We are assuming, of course, that the “child surgeon” in this instance feels that he can make objective medical decisions.) Another situation is that the parent requires an injection and it is more convenient or less expensive to have the child, who is a nurse, physician or medic, administer the injection. Yet a third, common situation is when the child is a dentist and will provide free dental care to the parent, but this involves either a painkilling shot or causing the gums to bleed.

Introduction

Although the Torah states that someone who strikes his parent shall be put to death, we know that capital punishment is meted out only when:

(a) a beis din of 23,specially-ordained dayanim rule this way,

(b) the crime is witnessed by two halachically valid witnesses,

(c)  the defendant receives a clear warning prior to performing his criminal act,

(d) he acknowledges to have understood the warning, including the ramifications of its punishment, and

(e) he commits the crime immediately (Rambam, Hilchos Mamrim 5:5).

The potential capital punishment meted out by the Torah for striking a parent establishes this as a major sin, a significant factor relating to our opening questions (see Sanhedrin 84b).

Our first discussion will be about the passages in the Mishnah and in the Gemara, located in Sanhedrin 84-85, that discuss the halachic details of this prohibition. The Mishnah (Sanhedrin 85b) states that someone who strikes his father or mother is deemed punishable by the death penalty only when he draws blood. The poskim provide three instances to explain what this means:

(1) We see blood from the injury (Bava Kama 86a). Bear in mind that bleeding can be tiny, painless and insignificant; yet, that would be included in the Torah’s prohibition. Examples of causing bleeding would include injecting something directly into a vein or pressing against sensitive gums.

(2) An injury in which it is noticeable that there is bleeding under the skin, called colloquially a “black and blue mark.”

(3) An ear injury that causes deafness, which is an indication that the blow caused internal bleeding (Bava Kama 86a, 98a).

The Gemara (84b) states that the punishment for striking a parent does not exist if the wound was for a medical purpose, such as using a needle to remove a thorn, lancing a boil, or bloodletting.

Having ruled that it is permitted to cause therapeutic bleeding on a parent, the Gemara tells us that Rav did not allow his son to remove a thorn from him, nor did Mar berei de Ravina allow his son to drain a boil. The Gemara questions: why should a son performing this procedure on his father be any different from anyone else performing this procedure on his fellowman? There is a lo sa’aseh min haTorah to injure another Jew, but this action is permitted when it is beneficial. Upon this basis, we have blood tests, perform surgery and donate blood. What difference does it make whether the practitioner performs this service for his parent or for anyone else?

The Gemara answers that the concern is that if the person performing the procedure cuts more than is necessary, this is a negligent (shogeig) violation of the prohibition. We are more concerned about a child performing this act on his parent, since this involves a more serious violation than injuring a fellow Jew. Thus, we view with greater concern something for which the Torah prescribes a high level of punishment – and there is a difference in practical halacha that results from the greater degree of culpability.

Prohibited or suggested?

The rishonim note that Rav and Mar brei deRavina seem to disagree with the previous passage of the Gemara, which permits a child to perform a medical treatment on a parent, even when it causes bleeding. Are these amora’im, Rav and Mar berei deRavina, disputing the previous conclusion of the Gemara, or, perhaps, is there another way to explain the differences between the rulings? In fact, there are numerous approaches to answer this question, two of which figure prominently among the (see Beis Yosef and Bach, Yoreh Deah 241):

(A) Rav and Mar berei deRavina conclude that, although a child may carry out these medical acts when no alternative exists, he may not do so when someone else is available to perform them (Rambam, Hilchos Mamrim 5:7). However, when no one who can perform the treatment is available, the child may do so, and we are not concerned about a potential mishap. This approach is followed as definitive halacha by the Rema and others (Bach, Gra).

(B) Others conclude that, indeed, Rav and Mar brei deRavina disagree with the position of the Gemara, cited earlier, and rule that a child may not perform therapeutic activity that will cause bleeding on a parent. Since this is the last opinion mentioned in the passage of Gemara, it is accepted by these rishonim (Beis Yosef,in his understanding of the position of the Rif and Rosh). The Shulchan Aruch (Yoreh Deah 241:3) rules that this is the halachic conclusion.

So, at this point, we see that the Shulchan Aruch, usually followed by Sefardim, rules that a therapeutic treatment that causes bleeding cannot be performed by a child, even when no one else is available. The Rema and other early Ashkenazic authorities permit a child to perform these treatments when no one else is available.

When is it considered that someone else is available? What is the halacha if the procedure can be performed by someone else, but the parent prefers that the child does it. For example, the child is a well-known heart surgeon, but the surgery is considered routine and any competent thoracic surgeon should be able to perform it successfully.

Similarly, if the child will charge his parent less than someone else will, is this permitted? Notwithstanding that cost is not usually a factor when we deal with violating Torah prohibitions, here, it may be a factor, because the parent, who wants the child to perform the activity, is not violating any prohibition of the Torah. Thus, if the parent wants the child to perform the procedure because it will now be gratis, many authorities consider this as if there is no one available other than the child (Aruch Hashulchan, Yoreh Deah 241:6; Gesher Hachayim 2:1; Minchas Shelomoh 1:32)

My daughter, the surgeon

At this point, we can answer the first of our opening questions: “I specifically want my daughter to perform my upcoming operation. Is this permitted?”

The answer is that if your daughter is Ashkenazi, it is permitted, but if she is a Sefardiyah, it probably is not.

Mechilah

Does it make any halachic difference if the parent is mocheil the child in advance for any unintended injury? The Minchas Chinuch contends that had Rav and Mar berei deRavina stated that they were completely mocheil their sons, even if the result was an unintended injury, there would be no problem for the sons to perform the procedure. In the opinion of the Minchas Chinuch, the case of the Gemara is when Rav and Mar berei deRavina never declared that they were completely mocheil their sons, regardless of the result. Rav Shelomoh Zalman Auerbach rules that this approach of the Minchas Chinuch should be given credence, at least as a tziruf, which means that we may use this as a heter, combined with other reasons to be lenient.

The Minchas Chinuch proposes a further novel suggestion germane to this prohibition. He contends that if a father asks a son to injure him, there is no prohibition on the son to do so. He understands this to be included in the rule that a parent is permitted to be mocheil on his honor. However, as is noted in Minchas Shelomoh (page 184 note 2), this last opinion of the Minchas Chinuch runs contrary to a ruling of the She’iltos of Rav Achai Gaon (She’ilta #60) wherein it states that, whereas a parent may be mocheil on kavod, as is done whenever a mother prepares meals for adult children, this does not permit striking, cursing or treating a parent with disdain, which is prohibited even if the parents grant permission.

Injection

At this point, let us discuss the second of our opening questions: “May my son, a trained medic, give me my daily shot?”

Most people would not be that concerned whom they entrust with giving them a shot, provided the individual is a medical professional with proper training. According to what we have explained until this point, it would seem that, according to all poskim, this should not be performed by a child for a parent.

However, there are some differences between this case and the situations discussed by the Gemara. Inoculations and most other shots are injected into a muscle, and should not cause any bleeding. Does this permit this action, even when another professional is available, or is it no different from therapeutic bloodletting or boil lancing that is permitted, even according to the Rema, only when no one else is available? Furthermoroe, if a medical professional will charge to give the shot, but the child will do it gratis, does this permit the child to perform it?

These two questions were discussed by Rav Yechiel Michel Tukachinsky, a highly respected posek of old yishuv Yerushalayim, in his magnum opus, Gesher Hachayim (Volume II, Chapter 1). There, he mentions that he was asked a shaylah by an emergency medical technician whose mother required regular injections whether he could do them for her, something which would save both of them an appreciable amount of money. Since the Rema paskins that a physician should not perform bloodletting on his parent whenever there is another physician available who can, does that preclude a son from injecting his mother?

The Gesher Hachayim presents three reasons why he believes that it might be permitted:

(1) All the situations we have so far described involve causing bleeding for a therapeutic reason. The concern is the child might cause more bleeding than necessary. However, intramuscular shots do not usually cause any bleeding at all. Although they could cause bleeding, since, in most instances no bleeding occurs, we do not need to be concerned.

(2) To understand his second approach, I note the following: In the case of surgery, a surgeon decides where and how to make the incision. If the child surgeon uses a technique that causes more bleeding than is necessary, this might be considered a negligent violation of the Torah law.

Similarly, in the instances of bloodletting, the practitioner decides how much blood he needs to remove and, in the case of boil lancing, how he will lance the boil. There is ample room for a judgment error that will cause a greater amount of bleeding than the situation requires. On the other hand, the medic in our case of an injection is not deciding how much bleeding or cutting is necessary. Therefore, there are grounds to allow the son to provide this injection for his mother.

(3) The son’s willingness to work without charge is considered as if no one else is available. The logic is that Mom is not required to hire someone to give her the injection, when her son is willing to do so for free. After all, it is not her prohibition. Once she decides that she does not want to hire someone, no one is providing her with the necessary service, and the son is not required to hire someone to take his place.

Rav Tukachinsky then reports that after he thought of these three reasons to permit the son to inject his mom, he sent the shaylah to many rabbonim of Yerushalayim to see if they agreed with his conclusion. The three rabbonim who, indeed, answered him and agreed with him all dated their responsa, from which we see that this shaylah came up in the spring of 1944. The three rabbonim were:

(1)  Rav Yitzchak Halevi Herzog, a close, personal friend of Rav Tukachinsky, who was the Ashkenazi Chief Rabbi of Eretz Yisroel at the time.

(2) Rav Tzvi Pesach Frank, who was the rav of Yerushalayim.

(3) Rav Shelomoh Zalman Auerbach, at the time a very young, up-and-coming superstar in psak halacha. In addition to his reply published in Gesher Hachayim, a longer form of his reply is supplied in Minchas Shelomoh (#32).

Applying leaches

Rav Tukachinsky then discusses a similar, related question whether a child may apply leaches to a parent’s wound. Is this considered that the child is injuring the parent in a way that causes bleeding? Rav Tukachinsky was not convinced that this is permitted, but

Rav Shelomoh Zalman Auerbach permitted it for two reasons: When applying leaches, the leaches do not begin to draw blood immediately, and therefore this is not equivalent to striking and drawing blood from a parent. Instead, it is an indirect action that would be exonerated from capital punishment. Once this action is no longer included under the Torah’s punishment, the prohibition to perform it on one’s parent is the same as on anyone else, and is permitted when done for therapeutic reasons.

Secondly, since the parent has the ability to pull off the leaches before they begin to suck blood, the child has not inflicted any injury (Minchas Shelomoh #32:4).

Conclusion

In conclusion to this article on the concepts of kibud horim, I would like to share a comment that I once responded to in an advice column: “My mother-in-law and I have an excellent, warm relationship. However, one area of conflict causes her anxiety and me irritation. The issue is attending the weddings of extended family members, which is very large (sic.) and there are many weddings. She claims that not attending the weddings of these family members, whom I hardly know, rebels against the family norm. I attend about two or three of these weddings every year, when it works out for my schedule, and I forgo the others so that I have more time for professional work, housework, family time and much-needed sleep. On the rare occasions that I attend, I don’t know most of the people there, and I don’t feel my presence appreciated enough for me to have killed a night. My mother-in-law agreed that I present this issue to the rav. Please advise.”

I answered her: You seem to be asking whether you are obligated to acquiesce to your mother-in-law’s request. In response, I’d like to start by briefly reviewing the halachos of kibud av va’em. You do have an obligation of kibud av va’em towards your husband’s parents, although not on the same level as your obligation towards your own parents or your husband. However, the mitzvah includes only two components – kibud and morahKibud encompasses ensuring that your in-laws have their physical needs met. This involves providing them with food if needed, bringing them a drink if requested, taking care of their medical needs if relevant, and so on. Morah requires you to show them respect by not contradicting them, not sitting in their set places etc.

In the situation you describe, I do not see how either kibud or morah come into play.   One can claim that, since your mother-in-law is insisting so strongly on this, there is an element of morah. However, that is only a result of her insisting so strongly that your refusal is rude.

If you are like most frum women today, between caring for a large household, supplementing the family income, and taking care of all your other responsibilities, you are juggling the equivalent of at least two full-time jobs.  It seems unfair for your mother-in-law to pile even more on your already overburdened shoulders. Women today are already far too stressed and need to spend more, not less, time with their nuclear families. Encroaching on that time for the sake of fairly distant relatives is not a wise move.