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Non-emergency Tracheal Tube inserted into an
Elderly Person for Future Benefit
1 Question 1
I was on the night-shift in the emergency room when an elderly
woman came in with her daughter. She had dangerously-high fever
and very low blood pressure. After initial treatment to stabilize her
vital signs, I had difficulty persuading the nursing care staff to put
her into a trauma room to continue treatment. Unfortunately, the
attitude towards the incapacitated elderly is lacking. There is far less
eagerness to save their lives than the lives of young people with new,
acute diseases.
The blood-test results of oxygen saturation and acid concentration
reveal that, at this stage, it is not yet necessary to artificially respirate
the patient. The condition requires constant re-evaluation over time
to see how she handles the infection. Her blood pressure has stabi-
lized and she is no longer in any immediate danger.
At this stage, I considered whether to hospitalize her as is, or to
insert a tube in her windpipe (tracheostomy). On the one hand I was
concerned that in case she would require artificial respiration in the
ward, she would not receive it from the physician on duty. In addition,
a patient on an artificial respirator requires more supervision and
more effort than all the others. Hospital protocol dictates that such
a patient receive a lot more personal attention, periodic check-ups,
and dedicated private care in a room near the nurses’ station, with
constant observation. On the other hand, a tracheostomy may cause
abnormalities in cardiac rhythm, vomiting, and infection, and is only
performed under clearly emergency conditions. Therefore, the perfor-
mance of this procedure superfluously does not garner the physician
any respect from his colleagues, if there was a possibility of making
do without it.
Ultimately I decided that since her condition at present is stable,
254 1 Medical-HalacHic Responsa of Rav ZilbeRstein
sicians had differing opinions about whether this man is ill and needs 9
to eat on Yom Kippur, or is healthy and allowed to fast, we would
certainly heed only the advice of the expert, since it is prohibited for
the other doctor to practice medicine in his presence. However, if it
is clear that he is ill and they differ in opinion about whether or not
fasting will cause danger to his life, then they each have the right to
state their opinion. The less experienced physician is also licensed to
practice medicine, and in making this type of decision, the expert has
no advantage over him. As the Rama states (Orach Chaim #618:6): If
a man becomes so weak that it appears to most people that it would
endanger him to fast, we feed him [on Yom Kippur].
The Shulchan Aruch (Yoreh De’ah #336) teaches: “A person should
not practice medicine unless he is an expert and there is no greater
one than he.” Does this imply that a doctor should close his clinic if
there is a greater doctor than he in the city? Likewise, halacha states
that it is forbidden for a Torah scholar to rule on a case if there is a
greater Torah scholar in the city. Should the officers that were ap-
pointed over hundreds, fifties, and tens cease working if there is an
officer appointed over a thousand in town?
A Torah scholar is permitted to issue rulings in cases where the
halacha is clear and obvious. Likewise, a physician can practice medi-
cine in cases where the course of treatment is fairly simple and obvious.
The Gemara in Avodah Zarah and Yevamos refers to a case where one
rules based on a comparative situation, which requires great wisdom.
For this type of case, it is forbidden to rule if there is someone greater
than he in the city. Likewise, in medicine, when a diagnosis is not ob-
vious, it is forbidden for the less experienced physician to get involved
and make a diagnosis with consulting the expert. Consider the case of
the four-year-old boy who was brought to the hospital complaining
of abdominal pain. The physician on duty diagnosed inflammation
of the appendix. Based on this diagnosis, the boy underwent surgery,
at which time it was clarified that the diagnosis was in error and the
correct diagnosis was inflammation of the bowel and severe liver in-
fection, gastroenteritis and hepatitis. As a result of this misdiagnosis
and unnecessary surgery, the boy developed high fever and hemolysis.
The kidneys were damaged to the point that they were lost, and the
Physician Versus an Expert Physician 2 263