Full Interview (Part 2)
[9 minutes 42 seconds]
Until development of life support systems, the definition of death was clear and you started cardiopulmonary resuscitation when the person stopped breathing and there was heartbeat, definitely you start resuscitation. Even when there was no heartbeat, you started resuscitation.
The problem was with life support systems, that when a person was on what was later called the ventilator, then it was called the respirator, you cannot deduce from the breathing action that it was not a life function. Because even a football or a balloon can breathe when you pump air into it and it doesn’t make it alive. So when air is pumped into the lungs and the lungs expand and contract, this is not sign of life. Now as you know, the heart is an autonomous organ that can pump blood into the body without the brain. The heart can pump in an icebox when it’s totally detached from the rest of the body as long as it’s supplied with nutrients. And that’s why when someone is on the life support system, we see that he is breathing and he has cardiac function, he still may be, he can still be considered dead. Because actually the only thing alive in him is just the heart and the living heart doesn’t mean that a person is alive. This was the question that was raised when the life support system was developed.
Now, here we had to change or deviate on the classical definition of death. And then they had the idea of death in halacha had to be reviewed. What is considered to be a dead person according to halacha?
In response to that Rav Moshe, zecher tzaddik lebracha, wrote in ’76 to my father-in-law, this was at the time when the life support system problem was raging, and the question was when you can you stop the life support in intensive care and have the person buried because you’re not allowed to keep a dead person unburied, you have to bury him when he dies – so you have to know when he dies. So the answer was very simple, stop the life support system and see if he’s dying. If he’s dead, he’s dead, if he’s alive continue with the life support system. But the problem was that if you stop the life support, you may kill him. So the very cessation of the life support may be considered murder. So this was the dilemma. It was a dilemma in halacha and it was a medical dilemma.
Moshe wrote in the responsa from 1976, which was published in the sixth part of Iggrot Moshe, in Yoreh Deah chelek gimmel, siman kuf lamed bet, he writes there that the machine, the breathing through a machine, does not signify life. Because of course machine respiration is not a sign of life. Now, the interesting thing is that Rav Moshe, in this responsum, predicts that actual determination of death that was accepted fifteen years later by the medical profession. But then it was what he wrote that seemed totally outlandish. He says that we have to stop the respirator and check whether the person has some breathing or not but we cannot do that. But this is actually what we’re supposed to do. He offered a technical solution to the people that opposed organ transplant said that what I published or what was published after Rav Moshe’s ptira was not authentic. But this tshuva cannot be disputed because it was published and was printed in thousands, tens of thousands of copies when Rav Moshe was still alive and fully functioning and he, as I said, he saw every letter of the book. In this sefer, in the sixth volume, there is not one letter that did not come out of Rav Moshe’s pen.
Anyway, so he writes there that respiration, it’s not autonomous, but it’s respirator, it comes from a ventilator, is not considered to be a sign of life. Why we discuss the sign of life in respiration, we’ll come to it in a second.
So he said that you should make what was later known in the medical profession, Apnea test. And he said that to stop the respirator and see whether the person regains his breathing. But, what’s the problem, the problem is that you kill him. So Rav Moshe proposed a solution. He said that don’t use a respirator that’s connected to an infinite or close to infinite supply of oxygen and air. Use small tanks that could last, let’s say, half hour. Now when the tank is finished, you did not stop the respirator but you have to do an active, you have to something active in order to replace the tank. You don’t have to replace the tank unless you know that the person is alive. So what was his proposal? Use tanks, connect the ventilators to half-hour tanks and between tanks, check whether the person regains his own breathing or not. This was his idea.
At that time, in 1976, this idea was not applicable because physicians would refuse to accept such an idea because you risk the person’s life. Maybe he could regain breathing after 45 minutes and after half an hour if you don’t replace the tank, you kill the patient.
Anyway, Rav Moshe then writes, so but since we don’t have the system, what is the alternative system? Then Rav Moshe wrote something, and I think here was a tremendous error on the part of the proponents of death – of brain death. Bichlal, I think that the term brain death is a bad term and I told that to my father-in-law and he agreed with me. If you say brain death, you imply that the brain is dead but the person is alive.
I think that this concept was developed by Christian Bernard, where he meant brain death meant the death of the thinking part of the brain, of the cortex. But Rav Moshe was maneuvered in this tshuva, to say what if we cannot do a good Apnea test, then we have another definition of death in halacha. And this definition is the cutting of the head, severing the head. If the head of a living creature, either a person or an animal was severed off the body, then the person is considered to be dead. Rav Moshe writes in a different responsum that this is true even though the medical profession will find a way to reconnect the head to the person, it will be reversible. Severing the head will be reversible, it’s still considered to be dead. Because it is death according to halacha, is legal death – legal death is when you have severed the head from the body.
Rav Moshe wrote that once blood does not reach the brain, and we know that it was so for a long enough period that the brain itself is denatured, it became liquid actually, the cells are destroyed, this is equivalent to the severing of the head. So Rav Moshe said that even without a good Apnea test, when we have the cold dead and the angiogram test, the test that shows that no blood comes to the brain. Then this is also a good definition of death that you can act upon.
This was all, I must say again, about seven or eight years before anyone dreamed about organ transplants. This was relevant to removing someone from a life support system, for pulling the plug.
However, this, the idea of what was later called the Apnea test, I heard myself from Rav Moshe, that once we know that the person’s spontaneous breath stopped, this is considered to be death, this I heard from Moshe himself. The idea of the brain death, this I saw when Rav Moshe wrote it and I called Rav Moshe twice to understand exactly what he wrote and he verified, he explained to me what he wrote in this tshuva, that when the brain is destroyed it is equivalent to the severing of the head. Because the head does not mean the skull, if we’re talking about the living function of the head, we are talking about the brain. This was the thing of the brain death, Rav Moshe’s agreement to brain death. What was the form in the issue, how can we determine that the brain is dying, is dead. Most of the tests that were needed demanded or required the moving of the patient to the x-ray room or moving him and doing tests that were impossible to do without moving the person who we think that he is dead and we cannot move a dying person because the moving can kill him. So technically, it was still a problem.
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