In a powerful essay, Angelina Jolie recently informed the world of her decision to prophylactically reduce her risk of developing breast cancer. Given her mother’s death from breast cancer at age 56, coupled with harboring the genetic variant BRCA1, she is estimated to have an 87 percent risk of developing breast cancer and a 50 percent risk of ovarian cancer. Undergoing a multi-stage double mastectomy, Jolie reduced her risk of breast cancer to less than five percent. She has chosen to push off an oopherectomy (removing her ovaries), at this time.
The issues raised by Jolie are very real for many women, particularly Ashkenazi Jewish women, who are often at a higher risk of developing breast cancer than others.
From the perspective of halakha, Jewish law, the issues are both straightforward as well as quite complex. All surgical procedures involve the Biblical prohibition against wounding (havalah), while an oopherectomy also raises a question violating the Biblical prohibition against causing sterility (sirus). Both are serious infractions that cannot be taken lightly or easily dismissed.
Nonetheless, most halakhic authorities permit both procedures because of the well-known Talmudic dictum, that saving lives (pikuah nefesh) temporarily sets aside all other prohibitions. As prophylactic measures, both the mastectomy and oopherectomy reduce the risk of cancer – seemingly falling within the ambit of pikuah nefesh as well as adhering to the Torah’s dictum that we take our health and well being seriously.
In most other pikuah nefesh circumstances however, the danger is clear and present. In terminology of the Chatam Sofer, the nineteenth century rabbinic authority, violating a prohibition requires a “holeh be-faneinu” (a sick person ‘in front of us’), not the mere possibility of a dangerous future. How then could we permit prophylactic procedures?
A careful reading of Chatam Sofer indicates that he only meant to exclude cases of a remote, speculative, chance that at some point in the future, there may or may not be some danger. Careful statistical analysis can alleviate Chatam Sofer’s concern, and in Jolie’s case revealed a very real risk of greater than 85% chance of getting cancer. While it is definitionally uncertain, it is definitely not speculative.
Effectively, the pikuah nefesh principle that saving a life permits violating prohibitions applies not only to prevent immediate potential death, but even future potential death, when predicated on reasonable statistical probabilities. It is part and parcel of what pikuah nefesh means. Indeed, generally speaking prophylactic measures that are designed to significantly reduce risk are halakhically obligatory. However, in this case, Halakhah does not mandate these procedures, only sanctions them, and therein lies the complication.
The surgery itself entails very real (although not so frequent) risks. While we are commanded to proactively take steps to ensure our well-being, this mandate does not require taking risks, be they physical or psychological. As permissible activities, Halakhah allows a person leeway in making these decisions, leaving it up to the individual to make a risk-benefit calculation (albeit within reason). Critically, surgery is not necessarily the only prudent prophylactic measure available and depending on an individual woman’s particular risk, other options may be more suitable and appropriate.
Aside from physical morbidity from the surgery, there are also important psychological ramifications. These procedures often entail significant personal hardship, both in terms of body image as well as the resulting inability to have children. Some women are understandably concerned that such dramatic surgery will make them feel less of a woman. Jolie’s comment on this point is particularly inspiring. “On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.” There is little that doctors (especially men) can do to help a woman reach this realization. When spoken by a woman in “the thick of it” however, it is not only more inspiring, but having been spoken from the heart they have a complementary greater impact on the listener’s heart.
While the permissive ruling seems clear-cut, Halakhah realizes that the ultimate decision depends on many variables. Even though BRCA testing may be inappropriate for most women, since French Canadians (such as Mrs. Jolie) and Ashkenazi Jews are at significantly increased risk of carrying the BRCA gene, the calculation is vastly different. The incidence of BRCA1 in Ashkenazi Jewish women is about five times greater than in the general population and those with BRCA1 are about five times more likely to develop breast cancer than those without the genetic mutation. The risk of cancer increases with a positive family history for breast cancer, with the precise calculus depending on many factors.
Additionally, the risk of ovarian cancer is also significantly increased in women carrying BRCA1 by at least 10 fold. While oopherectomy seriously mitigates that risk (although not absolutely), it renders a woman unable to have children. Given the ramifications of this decision and in light of Judaism’s focus, promotion, and support of procreation, fertility is an important factor to consider. Thankfully, for most women the risk does not become significant until their mid to late thirties, leaving time for childbearing in their earlier years.
Since each woman’s situation is unique and there are no guarantees – it practically means that there is no simple solution and each woman brings a different perspective to the mix. Perhaps because of this, Halakhah views the ultimate decision as a deeply personal one, requiring taking all of these factors into consideration. The only requirement is that we invest intellectually and emotionally in doing so