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Is Living on a Heart-and-Lung Machine Considered a Life?
By Rabbi Micha Cohn
Q: Is a person whose heart is not beating and is living on a heart-and-lung machine Halachically considered alive?
A: When heart transplantation was in its early stages with very low success rates, there was much Halachic discussion about the permissibility of these procedures not only from the perspective of the donor, but from the perspective of the recipient as well. These discussions raised a fundamental modern Halachic problem: If a stopped or missing heart is Halachically viewed as death, how could a recipient allow his heart to be removed? Is it permitted to ‘die’ in order to live? The discussion begins with a classic dispute between two great 17th century authorities in the laws of Terefot (mortal physical conditions that render an animal Halachically unfit for consumption).
Maran in Shulhan Aruch[1] rules that an animal missing its heart has the status of a Terefa and is not kosher. In the Kesef Mishne, Maran’s commentary on the Rambam[2], he explains that the Rambam does not mention a missing heart as one of the conditions that render the animal a Terefa, because the Rambam only mentions maladies of organs that if missing or damaged the animal could still live for a short amount of time. However, organs that if missing or removed the animal could not survive even for a short amount of time are not mentioned as the animal is considered to be already dead (Nevela). Likewise, organs that an animal could not be born without, like a brain, heart, esophagus or trachea, are not mention because they do not occur.
The Heartless Chicken
The Hacham Tzvi (Amsterdam, 17th century)[3] was asked about a slaughtered chicken which was found to have no heart. Curiously, although the Shulhan Aruch writes that an animal missing a heart is a Terefa, the Hacham Tzvi ruled otherwise.
He argued that since, as Maran himself writes in Kesef Mishne, it is impossible for a chicken to live without a heart, the heart must have fallen out and was eaten by an eager house cat. Even though the Hacham Tzvi was challenged about his ruling, he maintained that even if witnesses testify that there was no heart we should consider them to be lying rather than accept the impossibility of a heartless living chicken. The Hacham Tzvi[4] cites additional proof from the Zohar, More Nevochim, and Rav Sa’adia Ga’on, that the source of life is in the heart and therefore it is preposterous to maintain that the chicken could have been living without a heart.
The Kereti U’Fleti, written by Rav Yehonatan Eibshitz, took issue with the Hacham Tzvi‘s position. While Rav Eibshitz agreed that in the original case of the heartless chicken it is most probable that there was a heart and it was snatched by the hungry house cat. However, to uphold this position and render the chicken kosher even against the words of two competent witnesses is taking this argument too far.
Rav Eibshitz points out that the Rambam only omitted a case of a heartless animal, but did not write explicitly that it is a considered to be a Nevela – a dead carcass, because he did not want to completely rely on his own logical assumption that it is an impossibility. Therefore, the safer approach would be to consider the chicken not kosher. Interestingly, the Kereti U’Fleti cited a report from physicians of his time that perhaps other organs could compensate for the heart. [It is also possible that the chicken had a heart but was malformed.] The classic 19th century compendiums on Yore De’a – the Darke Teshuva and Da’at Torah – discuss these differing points of view at length.
Modern Times
In contemporary times the divergent views of the Hacham Tzvi and Kereti U’Fleti became a focal point in the discussion about the permissibility of receiving a heart transplant. According to the Hacham Tzvi, immediately upon the removal of the recipient’s heart the patient should be considered to be Halachically dead; the subsequent ‘revival’ after the new heart is implanted may be viewed as a ‘resurrection’!
If this is correct, it would be highly questionable if a patient is permitted to ‘die’ in order to live a longer life. While the objection of the Igrot Moshe[5] in letters from 1968 and 1978 considering heart transplantation as “murder of two souls” was because of the very poor outcomes, the Minhat Yitzhak[6] and Tzitz Eliezer[7] raise this issue in more recent times, with significantly higher success rates.
Rabbi Menachem Kasher in Dirve Menahem[8] pointed out that the implications of applying the logic of the Hacham Tzvi to heart transplantation are very far reaching. If a husband undergoing the surgery is considered Halachically dead during the surgery, his wife would then be a widow, and after he becomes ‘resurrected’ with his new heart he will have to remarry his own wife!
While there may be various solutions to this Halachic problem based on the comments of the Hida in Birke Yosef[9], and a broader definition of Pikuah Nefesh and Haye Sha’a (see Divrei Menahem ibid.), I would like to propose a solution of my own.
What a Miracle
The son of the Hacham Tzvi, Rav Yaakov Emden, sought to alleviate some of the criticism of his father’s position on the chicken missing a heart. He explains[10] that his father asserted that the witnesses are not believed not because it is a total impossibility, but because it would be considered Ma’ase Nissim – a miraculous occurrence. As we find in other areas of Halacha, while we believe miracles can happen, the remoteness of the possibility would just make it more probable that the witnesses are lying.
According to Rabbi Emden’s understanding of his father’s position, he is conceding that a heartless chicken is not fundamentally dead, just a rare and miraculous occurrence. Accordingly, a missing heart is different than other forms of certain death, like decapitation. From a Halachic standpoint, even if a headless-body could miraculously walk and function, it is still not considered alive.
Based on this new understanding of the Hacham Tzvi, a person attached to a heart-and-lung machine could still be considered living, just it may be considered an outright miracle. It would also seem that according to Rav Emden, his father’s reference to the Zohar and other sources that life is in the heart is a general idea but subject to exception.
A New Phenomenon
Going further, we can assert that a person living on a heart-and-lung machine does not need to be viewed as Ma’ase Nissim – a miraculous occurrence – but rather as a new reality. There is an interesting discussion among contemporary Poskim about whether an infant conceived via artificial insemination can be circumcised on Shabbat. The basic discussion revolves around the comments of Rabbenu Hananel who wrote that if a woman conceives artificially, then the circumcision cannot be performed on Shabbat as it is a miraculous occurrence.
Rav Shlomo Zalman Auerbach deliberated over the possible application to today’s artificial reproductive technologies. However, Rav Shmuel Wosner[11], strongly dismissed the notion of considering these commonplace procedures miraculous and maintained that the Brit Mila could be performed on Shabbat. Rav Wosner explained that we cannot compare artificial reproductive technologies to an artificial conception taking place many centuries ago. Whereas Rabbenu Hananel‘s case was a rare and miraculous occurrence, the highly developed reproductive technologies of today and are not miraculous but rather a new reality based on advanced medical knowledge.
In a similar vein, Rav Moshe Feinstein[12] maintains that the definition of Terefot pertaining the laws of Kashrut is fixed on the mortality of these maladies at the time of the giving of the Torah on Sinai. However, the definition of Terefot as it pertains to criminal punishment depends on the mortality rate in contemporary times.
To arrive at the conclusion that the definition of Terefa as it pertains to Kashrut cannot follow contemporary conditions, he asserts that Hachamim recognized that nature changes and these occurrences of survival cannot be dismissed as Ma’ase Nissim, miraculous. Therefore, the definition of Terefa for Kashrut must be fixed, based on the conditions at the time of the giving of the Torah.
In his discussion he writes[13]: “Today this surgery has been done to millions [of people and animals and they lived] and certainly it cannot be considered a miracle or a minority”. Rav Feinstein’s comments about considering something to be miraculous in respect to Terefot fit very well with Rav Wosner’s assertion that artificial reproductive technologies cannot be considered miraculous.
In Conclusion
Based on these sources we could arrive at the following conclusion: Despite the fact that the Kesef Mishne and Hacham Tzvi viewed a heartless chicken as dead, they were referring to a chicken living without a heart at all. However, as qualified by Rav Emden, the Hacham Tzvi never considered an animal or person without a heart who is seemingly alive to be fundamentally dead, rather highly improbable and miraculous.
The new phenomena of a human being living on a heart-and-lung machine during an open-heart surgery or transplantation (and the heart subsequently being successfully restarted) is yet different than Rav Emden’s discussion of the heartless chicken. The very fact that these procedures are commonplace with high success rates forces us to recognize these situations as a new reality. Therefore, although many sources point to the heart as the home of the soul, that is only as a general rule – when the heart is removed and there is no heart-and-lung machine. However, under these unique conditions we can consider the patient to be living, albeit without a heart.
Additionally, it could be argued that the machine can be viewed as part of the patient’s body and therefore they are not completely without a heart. As such, we can consider a patient without a heartbeat on a heart and lung machine to be very much alive and married!
Sources:
[1] Y.D. 40:5 [2] Hilchot Shehita 10:9 [3] Siman 74 [4] Siman 77 [5] Y.D. 2:174, H.M. 2:72 [6] 5:7 [7] 10:25.5-6, 17:66.1-2 [8] Shu”t 1:27 [9] Even Ha’Ezer 1 [10] She’elat Ya’avetz 1:121 [11] Shevet HaLevi 9:209 [12] Igrot Moshe E.H. 2:3.2, Y.D. 3:33, H.M. 73.4 [13] Ibid. E.H. 2:3.2, the Hazon Ish arrives at the same conclusion