Tuesday, July 22nd, 2014

The Brain Death Debate: A Methodological Analysis (Part 3a—Rabbi Moshe Feinstein) by Daniel Reifman

June 9, 2011 by  
Filed under Halakha, New Posts

[Click on these links for Part 1 and Part 2]

Rabbi Moshe Feinstein was one of the very few contemporary poskim with sufficient stature to potentially resolve the contemporary halakhic dispute over brainstem death.  That Rabbi Feinstein’s position on this issue has become the subject of intense debate is particularly unfortunate.  It is also highly uncharacteristic: Rabbi Feinstein’s exhaustively reasoned teshuvot typically leave little room for misunderstanding, so that his legacy has largely avoided the kind of controversy which has marked that of other 20th-centrury gedolim.  Proponents on both sides of the brainstem death debate sometimes give the impression that on this issue, as well, Rabbi Feinstein’s position is perfectly clear, and any confusion stems from the other side’s misinterpretation.  At the same time, others cite the ambiguity of Rabbi Feinstein’s position to undermine the possibility of using his writings to support the halakhic acceptability of brainstem death.  Without impugning these authors’ sincerity or integrity, I would suggest that they place too much emphasis on the most overt passages in which Rabbi Feinstein relates to the means of determining death, and in doing so miss the proverbial forest for trees.  We will endeavor to show that there is good reason to say that Rabbi Feinstein’s position is either ambiguous or non-committal on several points, but that for the most part, his writings on this topic establish a clear and consistent position.

The main reason for the ambiguity of Rabbi Feinstein’s position is simply that he refused to explain himself.  In a June 1968 teshuvah (She’elot Ve’Teshuvot Iggerot Moshe, Yoreh Deah 2:174), written just months after the first successful human heart transplant in Cape Town, South Africa, Rabbi Feinstein denounced the procedure as “truly the murder of two individuals”— the donor whose heart is excised, and the recipient whose functioning (if severely diseased) heart is exchanged with another of dubious value.  Clearly Rabbi Feinstein considered the criteria that doctors were using to establish the donor’s death to be inadequate.  However, rather than present the halakhic reasoning behind his position, Rabbi Feinstein insists that the only response that should be published in his name is a brief statement prohibiting the procedure and excoriating the doctors who were promoting it.  He states that any attempt to explain his position might lead people to question some of his proofs, thus opening the door to permitting a procedure that he considered outright murder.

There is, obviously, much more to discuss regarding Rabbi Feinstein’s position on brain death.  But the effect of Rabbi Feinstein’s uncharacteristically opaque initial response should not be underestimated.  The teshuvah that opens with this brief, forceful statement continues with a lengthy analysis of various issues related to the determination of death and end-of-life treatment.  But at no point in that teshuvah or in any of his other teshuvot relating to end-of-life issues does Rabbi Feinstein explicitly relate his halakhic analysis to his initial assertion prohibiting the removal of the donor’s heart.[1]  (The only place he refers to it again is in a brief 1978 teshuvah [Hoshen Mishpat 2:72] in which he confirms his earlier statement but adds no further elucidation.)  So perhaps the first thing we should say is that about Rabbi Feinstein’s opinion on brainstem death is that we will never have the full picture: whatever we conclude about his position, we should do so with a sense of humility.

Rabbi Feinstein’s general position and interpretation of Hakham Zevi

If there is a passage in Rabbi Feinstein’s later writings that could be understood as clarifying his original response, it is the opening paragraph of a teshuvah penned just over two years later (Yoreh Deah 2:146), where he refers to “what the doctors say—that indications of life and death are found in the brain”.  As in his initial statement, Rabbi Feinstein immediately rejects the doctors’ position:

מה שאומרים הרופאים שסימני חיות ומיתה הוא בהמוח שאם לפי השערותיהם אין המוח פועל פעולתו הוא כבר נחשב למת אף שעדיין הוא נושם… אבל האמת ודאי שלא זה שפסק המוח לפעול הוא מיתה דכל זמן שהוא נושם הוא חי, רק זה שפסק המוח לפעול פעולתו הוא דבר שיביא למיתה שיפסוק לנשום, ואפשר כיון שעדיין הוא חי שאיכא מיני סמים בעולם מהידועים לאינשי או שעדיין אינם ידועים שיעשו שהמוח יחזור לפעול פעולתו… שלכן פשוט שההורגו הוא רוצח וחייב מיתה… דהא לא הוזכר בגמ’ ובפוסקים שיהיה סימן חיות במוח, ולא שייך לומר נשתנו הטבעים בזה, דגם בימי חז”ל היה המוח פועל הפעולות כמו בזמננו וכל חיות האדם היה בא ממנו ומ”מ לא היה נחשב מת בפסיקת פעולת המוח, וכמו כן הוא ברור שגם בזמננו הוא כן.

Regarding what the doctors say that indications of life and death are found in the brain, that if according to their assessment the brain isn’t functioning [the patient] is considered dead even if he’s still breathing…   The truth is that cessation of brain function isn’t death, since as long as one is breathing he’s considered alive; rather the cessation of brain function is what causes death since [the patient] will stop breathing, and it’s possible that since he’s still alive that there are types of drugs—either of those that are known to man or that are as-of-yet unknown—that would cause the brain to function again…  Therefore it’s clear that one who kills such an individual is a murderer and liable for capital punishment… for neither the Talmud nor the poskim mention that indications of life are found in the brain, and it’s not possible to say that nature has changed, for even in the time of the Sages the brain worked as it does now and all human life depended on it and even so one wasn’t considered dead upon cessation of brain function, and so it’s clear that the same is true in our time.

The central point that emerges from this passage is that Rabbi Feinstein’s objection to the doctors’ use of loss of brain function to determine death is that the patient is still breathing.  On a purely technical level, then, if the doctors’ position that Rabbi Feinstein presents here is the same one he was referring to in his 1968 statement, it’s clear that he was objecting to the diagnosis of death based on partial loss of brain function (e.g., cerebral function), since full loss of brain function—specifically loss of brain stem function—is inconsistent with continued spontaneous respiration.[2]

On a more conceptual level, Rabbi Feinstein rejects the notion of “brain death” in the sense that he does not regard brain function as the definitive indicator of life and death; that is to say, he rejects the notion espoused by the secular medical community that death is defined as the cessation of neurological functions.  This is a vital point, one that Rabbi Feinstein returns to repeatedly in this teshuvah: Halakhah regards spontaneous respiration—over and above all other physiological functions—as the definitive indicator of life and death.  In support of this position, Rabbi Feinstein cites the sugya in Yoma 85a, which establishes that regardless of how a victim located in the rubble of a fallen building is uncovered, it is both necessary and sufficient to examine his nose.  Cessation of neurological functions cannot serve as the basis for determining death simply because it does not feature in halakhic literature.

If this passage seems dismissive of modern medicine, Rabbi Feinstein corrects that impression in subsequent passages, where he offers a more complex description of the relationship between respiration and other bodily functions:

אבל ברור ופשוט שאין החוטם האבר שהוא נותן החיות בהאדם, וגם אינו מאברים שהנשמה תלויה בו כלל, אלא דהמוח והלב הם אלו הנותנים חיות להאדם וגם שיהיה לו שייך לנשום ע”י פוטמו [חוטמו], ורק הוא האבר שדרך שם נעשה מעשה הנשימה שבאין ע”י המוח והלב, ואית לנו הסימן חיות רק ע”י החוטם אף שלא הוא הנותן ענין הנשימה, משום שאין אנו מכירים היטב בלב ובטבור וכ”ש שאין מכירין במוח, וכוונת הקרא דנשמת רוח חיים באפיו לא על עצם רוח החיים שזה ודאי ליכא בחוטם, אלא הרוח חיים שאנו רואין איכא באפיו אף שלא נראה באברים הגדולים אברי התנועה, וגם אחר שלא ניכר גם בדפיקת הלב ולא ניכר בטבור, שלכן נמצא שלענין פקוח הגל בשבת תלוי רק בחוטם.

However, it is abundantly clear that the nose isn’t the organ that gives life to a person, nor is it the organ on which life depends.  Rather the brain and the heart are the organs that give life to a person and enable him to breathe via the nose, and the nose is only the organ through which occurs the respiration that comes from the brain and the heart, and we have no indication of life other than nasal [activity]—even though the nose isn’t what generates respiration—since we cannot easily detect activity in the heart or abdomen and all the more so in the brain.  And the verse, “All that has the breath of life in its nostrils” [Gen. 7:22], isn’t referring to the [source] of the breath of life—for that’s definitely not in the nose, but rather [it’s saying that] the breath of life that’s visible to us is located in the nostrils, even if it’s not visible in the larger, moving organs or in the heartbeat or abdomen; and therefore the matter of clearing the heap on Shabbat depends only on nasal [activity].

Later in the teshuvah, Rabbi Feinstein twice reiterates this position:

…דהא ודאי לכו”ע הרי עיקר חיותא שאנו רואין הוא בחוטמו, ועיקר חיותא ליתן החיות והכח בהאברים הוא הלב והמוח.

…for surely everyone agrees that the primary manifestation of life that we see is nasal [activity], and the primary manifestation of life that gives life and strength to all the limbs is the heart and the brain.

…שודאי הלב הוא עיקר נותן החיות, וכן ודאי המוח נמי הוא עיקר נותן החיות שבכלל זה הוא גם הנשימה דרך החוטם כדלעיל.

…for it is certain that the heart is the main provider of life, and so, too, it’s certain that the brain is also the main provider of life—which includes breathing via the nose.

Notwithstanding his point that the gemara and later poskim make no mention of brain function as an indication of life, Rabbi Feinstein clearly has no problem accepting it as part of a broader definition of life within Halakhah.  That he does so without citing any sources suggests that he is fully willing to incorporate contemporary scientific perspectives into the halakhic process as long as they do not contradict established psak.  This, too, is a vital point, because it forces us to qualify what we mean when we say that Rabbi Feinstein rejects the notion of “brain death”: it does not mean that he considers neurological criteria irrelevant to the determination of death.  It’s clear from these passages that he considers all three factors—heart function, brain function, and respiration—germane to Halakhah’s understanding of life and death.

It is Rabbi Feinstein’s manner of integrating these three factors that constitutes the central difficulty in determining where he comes down on the issue of brainstem death.  First of all, he systematically refuses to single out either the heart or the brain as the primary source of life,[3] undermining the simple dichotomy that has framed the contemporary debate.  More problematic is way his description of the relationship between breathing and heart/brain function seems deeply counterintuitive: if the brain and heart are the sources of life, why is breathing the definitive indicator of life? 

One possible explanation is that respiration is not inherently significant, but merely serves as a reliable external indicator: because we lack the necessary tools to detect heart and brain activity, we use respiration as a litmus test.  This interpretation is not only suggested by Rabbi Feinstein’s language in the above passage (“…we have no indication of life other than nasal [activity]… since we cannot easily detect activity in the heart or abdomen and all the more so in the brain”), but also is explicitly endorsed by Hakham Zevi, in the teshuvah that we referred to in the previous two posts. (She’elot Ve’Teshuvot Hakham Zevi #77)  Recall that Hakham Zevi argues that a slaughtered chicken whose heart was not found should not be considered a tereifah, since the heart must have gone missing after it was killed.  His reasoning is simply that the heart is essential for life, so that had the heart gone missing beforehand, the chicken could not have been alive at the time of slaughter.  In explaining why the gemara in Yoma rules that death is determined by the absence of breathing rather than heartbeat, Hakham Zevi explains that breathing is always perceptible, whereas a weak heartbeat may not be.  Based on this approach, would we possess more advanced means of detecting brain and heart activity, respiratory activity would be irrelevant.

However, Rabbi Feinstein himself specifically rejects this understanding of the relationship between heart activity and respiration:

ואין צורך להסבר החכ”צ שפעמים א”א לשמוע דפיקת הלב מפני שהלב תחת החזה ומרוב חולשה א”א להכיר אם עודנו בחיים, וכוונתו מפני שהדפיקה היא נמוכה ביותר, דאף אם נימא שנפסק הדפיקה ממש עדיין הוא נותן כח חיות מעט להגוף דלכן הוא נושם בחוטמו עדיין. ומש”כ הרמב”ם דאם ינוח הלב כהרף עין ימות ויבטלו כל תנועותיו, אין כוונת הרמב”ם על הפסק דפיקה אלא על הפסק עבודתו ליתן חיות להאברים, שהדפיקה הוא רק סימן לעבודת הלב ואירע שעובד הלב עבודתו ולא ניכר סימן זה דדפיקה כשהלב הוא בחולשה, והפסק עבודתו לגמרי ניכר בפסיקת הנשימה מהחוטם.

ואולי מה שהוצרך החכ”צ לסברתו הוא מחמת שסובר דאם אך הלב לא הפסיק עבודתו היה ודאי נשמע הדפיקה, לכן כתב שכל זמן שנושם בחוטמו איכא ודאי דפיקה בלב אבל מאחר שעובד בחולשה הוי קול הדפיקה נמוך מאד עד שלא נשמע כלל מאחר שהוא תחת החזה, ואף שאין הכרח לזה אפשר שהוא כן.  וזהו כוונת החכ”צ…

And there’s no need to invoke Hakham Zevi’s explanation that sometimes it’s not possible to hear the heartbeat since the heart is beneath the chest and due to its weakness it’s not possible to tell if it is still alive—meaning that the heartbeat is very faint; for even if we assume that the heart had actually stopped beating, it would still be providing minimal life force to the body which is why the individual is still breathing.  And regarding that which Rambam wrote, that if the heart stops the individual will die instantly and all his movements will cease, he’s not referring to the cessation of the heartbeat but rather to the cessation of [the heart’s] function in providing life to the limbs, for the heartbeat is only an indication of the heart’s functioning, and when the heart is weak it may happen that it is performing its function without this indication being discernible, but the complete cessation of heart function is discernible in the cessation of breathing through the nose.

And perhaps what drove Hakham Zevi to his explanation is his assumption that unless the heart stopped functioning, the heartbeat would still be audible; therefore he wrote that as long as the individual breathes through his nose the heart is certainly still beating, but since the heart is weak, the sound of the heartbeat would be very faint to the point where it’s imperceptible since it’s beneath the chest; and even if this isn’t necessarily the case [that the heart would still be beating imperceptibly], it’s a possible that it is so.  That’s what Hakham Zevi meant…[4]

There is no denying that Rabbi Feinstein’s assumptions in this passage are a bit unsettling: he seems to say that the heart’s physiological function—providing life force to the body—is not dependent on its beating, an idea that modern medicine utterly rejects.  That having been said, we should note that this assumption is not integral to Rabbi Feinstein’s approach; he freely concedes that Hakham Zevi may be correct in assuming that the heart continues to beat as long as it functions.  Whether or not there is ever an actual (i.e., biological) divergence between heartbeat and heart function, Rabbi Feinstein insists on making a conceptual distinction between the two when it comes to determining death.  The aspect of cardiac function that is relevant to the determination of death is not the heartbeat per se but rather the heart’s ability to provide life force to the rest of the body, and respiration is the final manifestation of that life force.  Thus when we conclude from the gemara that absence of breathing is the definitive indicator of death, what we mean is that the heart’s inability to provide life force to the body is determined—not merely indicated—by its failure to support spontaneous respiration.

Rabbi Feinstein’s understanding of Hakham Zevi’s teshuvah stands in stark contrast with the approach taken by numerous opponents of brainstem death, who equate Hakham Zevi’s insistence that life depends on the heart with the notion that the heartbeat is a dispositive sign of life, even in the absence of spontaneous respiration.[5]  Indeed, Rabbi Feinstein explicitly rejects just such an interpretation, proposed to him by Rabbi Chaim Dov Ber Gulevsky (the questioner to whom this teshuvah is addressed):

ולא מובן לי היכן ראה כתר”ה מה שמסיק, נמצא שלהחכ”צ ישנו סימן אחד של חיות וזה הלב ולפ”ז אדם שהלב פועם דינו כחי ואדם שהלב נפסק דינו כמת אולם בלי נשימה הלב אינו פועל והוא מת תיכף, דאין זה כוונת החכ”צ אלא כדכתבתי שהחיות לכל האברים נותן הלב כדהביא מזוהר ומרמב”ם במו”נ, וגם זה שאיכא ענין הנשימה ע”י החוטם הוא מהלב, וכשפוסק הלב מלעבוד לגמרי נפסק תנועת כל האברים וגם הנשימה מהחוטם נפסק, אבל כל זמן שעובד הלב אף בחולשה גדולה באופן ששאר אברים לא מתנוענעים איכא עדיין חיות בנשימה דהחוטם שהוא אבר האחרון מלהפסיק…

And I don’t understand on what basis you concluded: “It emerges that for Hakham Zvi there is but one indication of life and that is the heart, so according to this an individual whose heart is beating is considered alive and an individual whose heart has stopped is considered dead, though without respiration the heart cannot function causing [the individual] to die immanently.”  For this isn’t the intention of Hakham Zvi, but rather as I wrote above that the heart provides life force to all the organs, as he cited from the Zohar and Rambam in Guide to the PerplexedAnd even nasal respiration is [enabled by] the heart, and when heart stops functioning completely all limbs stop moving, and breathing through the nose stops as well.  But as long as the heart is functioning—even with great weakness such that the rest of the limbs aren’t moving—life is still present in respiration, since the nose is the last organ to cease

 

Based on Rabbi Gulevsky’s understanding of Hakham Zevi, absence of respiration functions as an indicator of death only because heart function will quickly cease without it.  Rabbi Feinstein counters by reversing the direction of causation: what’s important is not that absence of breathing causes the heart to stop beating, but rather that the absence of heart function invariably causes cessation of spontaneous respiration (along with all external bodily movement).  The difference between these two formulations is crucial.  If spontaneous respiration is significant only in as far as it sustains the heartbeat, then any alternate means of sustaining heart function—such as mechanical ventilation—would be just as effective at keeping the patient “alive”.  But according to Rabbi Feinstein’s explanation, spontaneous respiration is that which defines heart function: because respiration is necessarily the last physiological function to cease, it determines what it means for the heart to provide life force to the rest of the body.  Based on this, we might conclude that the absence of observable spontaneous respiration is a definitive indication that meaningful heart function has ceased. 

We will revisit this conclusion in our next post, as we analyze the significance of residual heart and brain activity in more detail.


[1] There are reports that, in later years, Rabbi Feinstein gave oral approval to individuals seeking various cadaveric organ transplants. (Rabbi Moshe Dovid Tendler, “Rabbi Moshe Feinstein and Brain Stem Death”, Le’ela [March, 1996], p. 31)  However, these reports do not relay a clear explanation of what changed in Rabbi Feinstein’s thinking and thus don’t help us understand precisely what he was objecting to in his initial rejection of the procedure.

[2] See Rabbi Moshe Dovid Tendler, “קביעת רגע המוות והשתלת אברים: ‘התזת ראש’ פיסיולוגית”, עמק הלכה (Jerusalem: Dr. Falk Schlesinger Institute of Medical-Halachic Research, 1989), p. 215; “Halakhic Death Means Brain Death”, Jewish Review (Jan.-Feb. 1990), p. 20. 

Dr. Abraham Steinberg (“קביעת רגע המוות והשתלת הלב”, אור המזרח 36:1 [1987], p. 61) suggests that Rabbi Feinstein’s objection to the use of neurological criteria to determine death while the patient is still breathing shows that he did not fully understand the nature of brainstem death, since one of the diagnostic requirements for brainstem death is the absence of spontaneous respiration.  But Rabbi Steinberg’s assessment is somewhat anachronistic, based on standards of establishing brainstem death that were not universally accepted in 1970, when this responsum was written.  Although the criteria issued by the ad hoc committee at Harvard Medical School in Aug. 1968 did include a stipulation of no spontaneous respiration, first-hand accounts of the first successful heart transplant at Groote Schuur hospital in Cape Town suggest that doctors there were concerned solely with lack of neurological responsiveness.  To wit, a 2006 account of the surgery based on the testimony of Marius Barnard (the brother of head surgeon Christiaan Barnard and one of only three witnesses to the excision of donor Denise Darvall’s heart) reveals that the surgical team debated whether or not to wait for the Darvall’s heart to stop beating of its own accord (they did not), but suggests that they were not similarly concerned by Darvall’s continued “labored breathing”; see Donald McRae, Every Second Counts: The Race to Transplant the First Human Heart (New York: G. P. Putnam’s Sons, 2006), pp. 191-2.  See also the account of Olivia Rose-Innes, daughter of Dr. Peter Rose-Innes, the neurosurgeon charged with diagnosing Darvall’s condition, who does not mention cessation of respiration as a necessary criterion for establishing brain death. (http://www.health24.com/medical/Condition_centres/777-792-812-1735,43227.asp)

[3] Contra. Rabbi J. David Bleich (“Of Cerebral, Respiratory and Cardiac Death”, Tradition 24:3 [1989], p. 60), who cites the first passage in which Rabbi Feinstein identifies both the heart and the brain as life-giving organs and then incongruously concludes that “[t]hose comments certainly reflect a clear recognition that the primary vital force in the human organism is the beating of the heart.”

[4] Incredibly, numerous authors ascribe to Rabbi Feinstein the first explanation we articulated above (that respiration is significant only as an indicator of an extant heartbeat), even though he explicitly rejects it in this passage.  See Dr. Abraham Sofer Abraham, ” קביעת זמן המוות: על הערות העורך להחלטת מועצת הרבנות הראשית לישראל”, אסיא 42-43 (1997), pp. 82-83; R. Bleich (ibid.); Joshua Kunin, “Brain Death: Revisiting the Rabbinic Opinions in Light of Current Medical Knowledge”, Tradition 38:4 (2004), p. 49; 2010 paper of the RCA Vaad Halacha (pp. 27, 29).  These authors draw their conclusions about Rabbi Feinstein’s position from the earlier portion of this teshuvah, ignoring this later passage in which Rabbi Feinstein’s critiques Hakham Zevi’s explanation.  (Dr. Abraham takes note of this critique of Hakham Zevi, but admits that he doesn’t understand Rabbi Feinstein’s point.)

[5] For instance, see Rabbi Eliezer Waldenberg, She’elot Ve’Teshuvot Tzitz Eliezer, vol. 9 #46; Rabbi Shmuel Wozner, אסיא 42-43 (1997), pp. 92-94.  Cf. Bleich, op. cit., p. 57; “Establishing Criteria of Death” Tradition 13:3 (1973), p. 96; “Survey of Recent Halakhic Periodical Literature,” Tradition 16:4 (1977), pp. 133, 137; “סימני מיתה”, הפרדס 51:4 (Jan. 1977), p. 16. 

This interpretation of Hakham Zevi’s position is so pervasive that even proponents of brain death don’t think to challenge it.  Rather, they question whether we should rely on Hakham Zevi’s psak given that he clearly relies on a medieval conception of heart function.  (For instance, see Steinberg,”קביעת רגע המוות והשתלת הלב [תשובות להשגות]“, אור המזרח 36:3-4 [1988], p. 285; Edward Reichman, “The Halakhic Definition of Death in Light of Medical History”, Torah U-Madda Journal 4 [1993], pp. 160-162.)  Yet there is a much more basic problem with applying Hakham Zevi’s ruling to the issue of determining the moment of death.  While Hakham Zevi insists that heart activity is necessary for life, he says almost nothing about whether it is sufficient for life.  In other words, the notion that heart activity is in-and-of itself a dispositive sign of life is irrelevant to his ruling on the kashrut of the chicken.

The only portion of the Hakham Zevi’s teshuvah that could be understood as taking a definitive stance on this issue is his reference to the idea that the heart “expires last, after all the other organs, close and distant from it, have expired.”  Admittedly this is not the portion of the teshuvah that is typically cited (it is, after all, a single line in an utterly voluminous teshuvah), nor does Rabbi Feinstein cite that reference.  Nonetheless, several other authors (e.g., Rabbi Aharon Soloveichik, “Death According to the Halacha”, Journal of Halacha and Contemporary Society 17 (1989), p. 43-44; Rabbi Bleich, Time of Death in Jewish Law [New York: Z. Berman Publishing Co., 1991], p. 174-175) do cite this reference, along with a similar reference in Rabbenu Bahya in his commentary on the phrase בכל לבבך in Deut. 6:5.

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