Thursday, September 15, 2016

Rules Governing a Doctor in an ICU

Professor Avraham Steinberg published a guide on how to treat patients in an ICU; the protocol was reviewed and approved by Rabbi Shlomo Zalman Auerbach and Rabbi Shmuel Vosner:

The following protocols pertain to patients in the ICU that fulfill the following conditions:
(a) Patients who were accepted into the ICU on the assumption that there was hope to save their life.
(b) Patients who received intensive care, including mechanical ventilation, treatment for infections, treatment to sustain blood pressure, treatment to prevent clots and bleeding, blood transfusion, parental feeding and permanent monitoring of blood pressure, pulse, breathing, and oxygen saturation.
(c) Patients who after all that was done above experienced irreversible failure of at least three vital organ systems, and when all the doctors who are caring for them, which includes all the doctors of the ICU, and all the specialist consults for the various medical problems of the patients, have decided that there is no chance to save their lives, and their death from their disease is expected in a short time, and specifically on condition that the patients are suffering, therefore we can assume that they [the patients] would not want to continue with unending suffering. These rules are true for all patients in an ICU, whether they are adults, children, or newborns.

The central halachic principle in relationship to these patients is based on the balance between the requirement to save a life and the prohibition of shortening life actively (with one’s own hands), and the need to reduce further unending suffering on the other hand.

Therefore one should act accordingly:

(a) One should not start any new treatment that will lengthen the life of suffering of these patients.
(b) One should stop ordering new tests, such as blood tests that are supposed to asses the status of the patient, since the patient suffers because of them, and there is no purpose in performing these tests.
(c) There is no purpose in checking and guarding the patient in this condition, including checking the blood pressure, pulse, oxygen saturation (even though these are done automatically with machines that are attached to the patient beforehand), and there is no need to treat the state of the patient based on the values that are shown on the screen, since the patient is suffering, and there is no purpose in these tests.
(d) One should continue treating the patient with pain-killers in order to reduce the amount of pain and suffering the patient experiences.
(e) It is prohibited to do any action that will lead to the immediate death of the patient. If it is questionable whether the given action will lead to the immediate death of the patient, it may not be performed.
(f) Therefore it is prohibited to disconnect a patient from a respirator, if the opinion of the doctors is that it is possible that his breathing is completely dependent on the machine. It is prohibited to immediately and completely stop medications such as dopamine, which are intended to maintain the blood pressure of the patient, if it is the opinion of the doctors that it is possible the blood pressure will fall immediately and the patient will die immediately.
(g) It is permitted to change or end therapy, if the opinion of the doctors is that the patient will not die immediately (even if because of the action the patient will die in a number of hours), as long as the doctors deduce that the patient is suffering, under the condition the changes will be done over a set of stages, with an analysis of the state of the patient after the changes have been made.
(h) Therefore, it is allowed to lower the rate of breathing of the respirator until the rate that the patient still breathes with his own force; it is allowed to lower the oxygen concentration that is flowing to the patient via the machine until it reaches 20 percent, which is the normal room oxygen concentration; one may lower the level of dopamine, as long as there is no serious change in the blood pressure of the patient, or even if there is a change but it will not lead to the immediate death of the patient; one may stop the total parental nutrition of the patient and change it to nasogastric tube or even to give only IV water and glucose; one may stop giving medications that are meant to prevent clots from forming or bleeding, such as heparin and H2 blockers; one may stop the giving of insulin to lower the level of glucose in the blood. All of this is on condition the patient is suffering. Therefore, it is permitted to refrain from refilling medications or restarting treatments that are given in a discrete basis and not on a continuous basis, for example: to stop treatment with dialysis; to stop treatment with dopamine after the bag is done; to refrain from replacing the IV bag of antibiotics after the bag is completed. All of this is if the patient is suffering. These protocols are only applicable on patients who fall into the category of all of the above-mentioned requirements. In any other case a competent rabbinic authority should be asked.

-Steinberg, Avraham, “Rules Governing a Doctor in an ICU,” Assia, 1998, nos.63–64, pp.18 ff.

Sunday, September 06, 2015

Global Warming

Let's just discuss global warming for a bit. The science itself is pretty well settled at this point. The earth is indeed warming and human activities are the culprit. CO2 levels in the atmosphere are higher today than they have been in likely millions of years and do act in a greenhouse fashion. The recent increase is strongly correlated with the onset of the industrial revolution and the explosion of the human population. None of this is realistically in doubt.

Although this has been generally known for decades, the global will to do anything to counteract the trend of global warming has been, basically, a dismal failure. The Kyoto protocol, so celebrated in its time (back in the 1990s), was, with all its faults, a wonder of international diplomacy. Yet there were major national polluters who never adopted it at all and others who never acted within its principles in a serious fashion. And the reason for this is obvious. In a competitive world, to ask the nations of the world to voluntarily gear down on their economic engines, is wasted breath at best. Indeed, knowing a little bit about human behavior, it should be obvious that just asking the world to try to cut down on its energy use, is a strategy of minimal efficacy.

To my mind, it kind of like asking a severe diabetic to, y'know, try to cut down on the sweets. That strategy might work on a minority of well-motivated patients, but will far and large be an abject failure. Global warming is just like many modern human diseases - they are problems stemming from human behavior. Granted, they could be fixed by simply changing people's behavior, but that just ain't going to happen. I think that continuing to harp on trying to reduce carbon emissions are well intentioned, but just are not going to cut it. The world's appetite will not slake and the CO2 will continue to rise.

So, why aren't we trying other things? There are plenty of drugs that exist which treat and control diabetes, heck there are even surgeries which may even offer a cure. Sure, most type-2 diabetes is caused by human behavior, but so what? We can treat it by intervening in other ways. Can the same be said about global warming?

Yes! The issue is not that humans are releasing too much CO2 into the atmosphere. The issue is that it stays there and causing too much warming. But there are things we can actively do which can pull CO2 out of the atmosphere and put it in safe places. This is little different from pulling sugar out of the bloodstream and putting it back into cells where it's safe. For one, a major carbon sink are the world's forests. When trees grow they grab carbon from the air and use it to grow. Granted, stopping active deforestation is the simplest and cheapest way to maintain this carbon sink, but the world could also be actively reforesting millions of acres of unused flatlands. It's so simple, but adding millions of trees to our world would be awesome for our ecology, biodiversity and would suck in billions of tons of CO2 from our atmosphere. Why is this not already being done?

Iron is an excellent fertilizer for ocean algae. With carefully selected ocean sites, we could be dropping tons of cheap iron particles which would create huge algae blooms with loads of carbon dioxide stuck within it. The algae would eventually die and then sink to the ocean floor, taking all of that carbon down with it. This literal carbon sink could keep the carbon safely out of the atmosphere for millennia. There are numerous other hypothesized mechanisms to trap carbon out of our atmosphere. Some are higher tech and may cost more, but are still worth considering. I don't need to list all of them here. If you are truly interested, the internet is available to all for perusal.

Now, managing the carbon is just one side of the equation. The other major variable is simply the heat itself. Even if atmospheric carbon levels remained unchanged, is there something we can do that would cool the Earth? Of course! What killed the dinosaurs? Global climate change set off by a meteorite which on impact released huge amounts of dust into the atmosphere which blocked the Sun's rays and cooled the Earth. It's also been shown that the release of sulfate compounds from volcanic eruptions cause climatic cooling effects. Could this be done artificially? Sure. There have even been more imaginative proposals to modify sunlight by placing mirrors or lenses in orbit.

The bottom line is that global warming is happening. The best solution would be to cut down on our emissions, but that just ain't gonna happen - and even if it did, it's probably too late. The next best thing is to make some alternative interventions. Like in medicine, there may be side effects, but I'd rather brave those than to just allowing global warming to happen.

[Plus, keep an eye on this venture. It's the most reasonable engineered mechanism for fusion power that I have yet to see.]

Friday, June 19, 2015

Matir Issurim

"Using mail-order DNA, they’re tricking yeast cells into producing a substance that’s molecularly identical to milk. And if successful, they’ll turn this milk into cheese. Real cheese. But vegan cheese. Real vegan cheese. That’s the name of the project: Real Vegan Cheese. These hackers want cheese that tastes like the real thing, but they don’t want it coming from an animal."

Interesting project and so clearly to be the food of the future. Making meat and animal byproducts like milk in the lab has clear benefits in the long run in simple terms like financial costs and environmental preservation. It'll just be quicker and easier with better quality control to make this stuff in vitro than with actual animals. With advances in food science what they produce may be indistinguishable from the natural version. It also has the added benefit of limiting the cruelty to animals, which is an endemic problem in modern factory farming. In the future it will be bizarre and backwards to eat something that comes from actual, unsanitary animals.

But besides all the above benefits, what will it do to the kosher food industry? Is it meaningful to talk about the kashrut of single cells or the byproducts of micro-organisms? If the whole world will be eating foods made from GMO bacteria or yeast - what exactly would ever not be kosher?

Perhaps it is in this way that the midrash about pigs one day becoming kosher will actually come true.

Sunday, June 14, 2015

Shabbos in a Pepper Shaker

Found this product recently. Interesting idea, but it also emphasizes one of the greatest incidental benefits from shabbos observance in modern times.

Sunday, June 07, 2015


So it's been 5 years and I'm finally finishing my residency in general surgery. Been a tough road and by far the most difficult and challenging thing I've done in my life. Here's a gem I made awhile back. Seems like a fitting way to commemorate.

Exodus 40:

You shall bring the Table and prepare its setting; bring the Menorah and kindle its lamps...

You shall place the gold altar for incense before the Ark of the Testimony...

and emplace the Curtain of the entrance to the Tabernacle.

You shall place the Laver between the Tent of Meeting and the Altar, and you shall put water there...

You shall take the anointment oil and anoint the Tabernacle and everything that is in it...

sanctify it and all its utensils...

You shall bring Aaron and his sons near to the entrance of the Tent of Meeting, and wash them with water...

You shall dress Aaron in the sacred vestments...and his sons you shall bring near and dress them in tunics...

...and they shall minister to eternal priesthood for their generations.

Friday, June 05, 2015

Is Belief a Jewish Notion?

Gary Gutting: You say you’re a naturalist and deny that there are any supernatural beings, yet you’re a practicing Jew and deny that you’re an atheist. What’s going on here? What’s a God that’s not a supernatural being?

Howard Wettstein: Let’s begin with a distinction between participation in a practice and the activity of theorizing, philosophically and otherwise, about the practice. Even an advanced and creative mathematician need not have views about, say, the metaphysical status of numbers. Richard Feynman, the great physicist, is rumored to have said that he lived among the numbers, that he was intimate with them. However, he had no views about their metaphysical status; he was highly skeptical about philosophers’ inquiries into such things. He had trouble, or so I imagine, understanding what was at stake in the question of whether the concept of existence had application to such abstractions. Feynman had no worries about whether he was really thinking about numbers. But “existence” was another thing.

It is this distinction between participation and theorizing that seems to me relevant to religious life.

Sunday, May 31, 2015

Philosopher of the Week

This is my favorite modern Jewish philosopher this week: Samuel Lebens. I came across his work actually by accident just recently, but what I've seen so far appears intriguing. [It doesn't hurt that he kind of looks like Ted Mosby and has a great English accent.] I thought it was worth sharing, especially given the paucity of jblog material lately.

He also has separate paper which I found rather interesting about  the epistemology of religious experience, which I quote below:

"My intention in belittling the role of belief isn't to adopt the fashionable desire to replace Orthodox Judaism with orthopraxy. [...]I claim that that epistemology places very little emphasis on classical propositional belief and is generally much more interested in attitudes, postures, make-belief, and non-propositional knowledge. Orthodox Judaism, indeed religion, so conceived is at once more demanding – because it asks for much more than mere belief and practice – and more human –in that it embraces attitudes and emotions that more autistic conceptions of religion ignore."
The paper is worth reading in full and I linked to it above. It gives a rather different perspective on traditional Jewish belief and behaviors and how propositional beliefs, though he surely considers them critical, are hardly the focus and are in fact among the weakest points of contact for those invested in religious life. He argues that "make-believing" that certain ideas are true is important than merely holding certain propositions to be factual. Worth a read, check it out.
I'm going to read more of his material when I have some time.

Wednesday, May 27, 2015

Where is Everybody?

Where is everybody? I know I've been out of the loop for awhile, but I was just checking out how things were going recently in the old jblogosphere and it seems like all of the old skeptic blogs have gone silent or have closed. Basically all my links to other blogs from this site go to places where the blog no longer exists or hasn't had a recent post in years. Why?

Did all the angst, confusion and cognitive dissonance that had been brewing from the crash of modernity and orthodoxy just dry up? Are all the issues resolved and have those old bloggers simply lost interest? Was the community held together by a couple of heavy bloggers like Mis-nagid or Godol Hador and once they moved on the other people left as well? Or did the party move elsewhere and nobody left directions?

I get it that hashing and rehashing issues is unfulfilling and ultimately boring, but was there no curious young people around to keep the conversation fresh? Or not enough of those who were willing to delve deeper into these issues to come out with something more productive on the other end? Maybe those deeper delvers went and became the founders of sites like (a very good site by the way, which I recommend), with a much more professional appearance compared to the casual coffee shop-like venue of a personal blog.

I thought that a few years ago the "Orthoprax" were getting all this attention from rabbinic articles and published papers. Not good attention, mind you, but attention nonetheless. Presumably, the goals of those articles were to quash orthoprax sentiments among the ranks - and if so, perhaps the quiet out there is evidence of their apparent success.

As for me, my time of relative blog silence coincided with much novel busyness in my personal life. This did not leave much time for metaphysical introspection, much less for an involved blogging hobby. But that's just me - where did everybody else go?

Come back.

Friday, February 21, 2014

The Moral Landscape

I've just finished reading The Moral Landscape by Sam Harris. I had been hoping to read it much earlier, like in 2010 when it was published, and when I was actively involved in the Jblogosphere discussing critical topics including the legitimacy of objective morality. But real life has a way of interrupting these extracurricular activities.

Since my last post, I've gotten married, I now have a year and a half year old son and have been working hard in my surgical residency - which I am just now starting to see the light at the end of the tunnel. Suffice it to say that my recent life has seriously curtailed my elective reading.

Anyway, back to the topic at hand. I liked the book for the most part. Besides for one odd chapter where he seem to tangentially go off on Francis Collins, Sam Harris does a good job defending the concept of a secular objective basis for morality. He does this by identifying the common values of humanity being human flourishing and wellbeing and that there are acts and social policies, etc, that objectively either progress or regress on those goals. Morality is then that which moves us towards greater human wellbeing; immorality that which moves us further from it.

Here's Harris giving the general argument in a TED talk:

It also helps that before my hiatus I had made some very similar arguments on my own. Much of my discussions were found on the now defunct blog of XGH, but as I wrote in the comments of this blogger post from 2009:

"Morals are made in response to human nature and the human condition - objective facts. People may disagree on methods and mechanisms but the goals are always to do what is in the best interests of man. And unless you believe all interests are equally rational and valid, i.e. to eat an apple is as valid a choice as is swallowing a gallon on bleach, then you must recognize a hierarchy of objectively correct decisions: that some acts, some moral codes, make more sense than others. The value of human life makes sense whereas it's non-value is self-defeating.

With that recognition and the assumed goal that rules be made to lead to the best interests of man then it becomes potentially able to be studied scientifically - objectively. Does a given moral in a given society lead to the wellbeing of man in that society? By the mere process of evolution of human civilization, we have already learned how a great deal of once-idealized moral behavior is in fact counterproductive."

Of course different people can converge on similar ideas, but it makes you wonder if Harris was a Jblog fan himself...

Wednesday, June 09, 2010

Paul Davies' God

"[A] deistic god, a sort of god of the physicist, a god of somebody like Paul Davies, who devised the laws of physics, god the mathematician, god who put together the cosmos in the first place and then sat back and watched everything happen…one could make a reasonably respectable case for that." - Richard Dawkins (@3:25)

What Happened Before the Big Bang?

By Paul Davies

It is often said that science cannot prove the existence of God. Yet science does have value in theological debate because it gives us new concepts that sometimes make popular notions of God untenable. One of these concerns the nature of time.

Many people envisage God as a sort of cosmic magician who existed for all eternity and then, at some moment in the past, created the universe in a gigantic supernatural act. Unfortunately, this scenario raises some awkward questions. What was God doing before he created the universe? If God is a perfect, unchanging being, what prompted him to act then rather than sooner?

The fifth-century theologian St. Augustine neatly solved the problem by proclaiming that the world was made with time and not in time. In other words, time itself is part of God's creation.

To make sense of Augustine's concept, it is necessary to place God outside of time altogether, and the notion of a timeless Deity became official church doctrine. However, it is not without its own difficulties. How can a timeless God be involved with temporal events in the universe, such as entering into human history through the Incarnation?

Today, religious people like to identify the creation with the Big Bang of scientific cosmology. So what can we say about the nature of time in the scientific picture?

Albert Einstein showed us that time and space are part of the physical world, just as much as matter and energy. Indeed, time can be manipulated in the laboratory. Dramatic time warps occur, for example, when subatomic particles are accelerated to near the speed of light. Black holes stretch time by an infinite amount. It is therefore wrong to think of time as simply "there," as a universal, eternal backdrop to existence. So a complete theory of the universe needs to explain not only how matter and energy came to exist, it must also explain the origin of time.

Happily, Einstein's theory of relativity is up to the job. It predicts a so-called "singularity" at which time abruptly starts. In the standard Big Bang scenario, time and space come into being spontaneously at such a singularity, along with matter.

People often ask, What happened before the Big Bang? The answer is, Nothing.

By this, I do not mean that there was a state of nothingness, pregnant with creative power. There was nothing before the Big Bang because there was no such epoch as "before." As Stephen Hawking has remarked, asking what happened before the Big Bang is rather like asking what lies north of the North Pole. The answer, once again, is nothing, not because there exists a mysterious Land of Nothing there but because there is no such place as north of the North Pole. Similarly, there is no such time as "before the Big Bang."

Of course, one can still ask why a universe popped into existence this way. Cosmologists believe the answer lies with the weird properties of quantum mechanics, a topic beyond the scope of this essay.

We can now see that Augustine was right, and popular religion wrong, to envisage God as a superbeing dwelling within the stream of time prior to the creation. Professional theologians acknowledge this. The doctrine of creation ex nihilo (out of nothing) does not mean God pushing a metaphysical button and making a Big Bang, then sitting back to watch the action. It means God sustaining the existence of the universe, and its laws, at all times, from a location outside of space and time.

Can science give any credibility to such a notion? Mostly, scientists either are atheists or keep God in a separate mental compartment. However, there is a strong parallel in the scientific concept of the laws of nature. Like the theologians' God, these laws enjoy an abstract, timeless existence and are capable of bringing the universe into being from nothing. But where do they come from? And why do these laws exist rather than some different set?

Science is based on the assumption that the universe is thoroughly rational and logical at all levels. Miracles are not allowed. This implies that there should be reasons for the particular laws of nature that regulate the physical universe. Atheists claim that the laws exist reasonlessly and that the universe is ultimately absurd. As a scientist, I find this hard to accept. There must be an unchanging rational ground in which the logical, orderly nature of the universe is rooted. Is this rational ground like the timeless God of Augustine? Perhaps it is. But in any case, the law-like basis of the universe seems a more fruitful place for a dialogue between science and theology than focusing on the origin of the universe and the discredited notion of what happened before the Big Bang.