Throwing Digital Stones at Doctors Using Tech on Shabbat

I truly admire the logical thinking that is pervasive throughout the Talmud. Time and time again during my own learning, I came across the foundations for modern Halacha related to the use of technology on Shabbat. Interestingly, it is only because of modern technology that I managed to learn one complete cycle of the Daf Yomi project. By copying prerecorded lectures to my smart phone, I was able to learn portions of the “daf” during the course of a day, until I would complete the whole 1/2 hour to 45 minute session by nighttime.

This experience by no means formally qualified me to render a halachic opinion. I appreciate how much more concentrated and formal study would be required by me to even hope to sit for rabbinical exams. But the reason for my perusal, over 7 1/2 years, of the entire Talmud was to try and understand the way of thinking of the ancient Rabbis. And I will say again, that I was repeatedly and truly impressed by their scope of thought.

It is totally reasonable to question how a religious system of law, written over 3000 years ago, could in any way be applicable to a world in which experimental computers are already reading human thought. I have faced people who have dismissed Jewish law out right, on the principle that it could not put forth any worthwhile opinion concerning issues that did not exist so long ago [such as electricity and experimentation on human embryos]. Interestingly, I personally have never heard anyone deny the applicability of American law to modern ethical dilemmas, based on the principle that the founding fathers did not have electric lights in their homes. I would say that for any system of law to remain pertinent, it must present ground rules, ethics, a way of analyzing an issue and precedent. And the Talmud definitely does all these things.

I remember one fascinating Talmudic discussion related to the treatment of a woman who had just given birth. For three days after the birth, the woman was considered to be in a dire state of health, due to which all of her needs required immediate attention. Such a woman was not even allowed to fast on Yom Kippur. And if this woman requested something that even involved transgressing the laws of Shabbat, the attendant was required to do so.

The Talmud discusses health issues in great detail at multiple points throughout its thousands of pages. One of the basic issues is the classification of a patient as being simply ill versus being in a very high risk situation. This classification very much applies to a woman who has just delivered a child. Very late pregnancy and the actual delivery, especially before modern medicine, were very high risk medical states. Whereas today, a mother Gd forbid dying during childbirth makes the front page news, such an event was sadly commonplace even a century ago.

If a doctor is caring for a patient who is in a dire state of health, can that doctor use technology on Shabbat? Can the doctor use his or her phone to call for a second opinion? Can the doctor digitally record the events that are transpiring, on Shabbat, despite the fact that such recording has no direct affect on the patient? Once again, what I present here is not a formal halachic opinion, and each physician should consult  his or her own Rabbi when faced with such issues. But I will share with you my perspective on this whole matter.

What is fascinating about pregnancy is that in most cases, the woman is perfectly healthy at the time of delivery. Nevertheless, during labor and then during delivery of the child, the mother is at significant risk for a whole range of complications. Most people have read newspaper articles about new mothers who were feeling perfectly fine but then “crashed” and died two days after delivering without warning. So it is clear that an apparently healthy woman, even days after delivery, is still at significant risk.

When the Rabbis discussed this case, were they speaking only of a pregnant woman, or were they thinking more broadly? Pregnancy can be thought of as a paradigm for a patient who is perfectly healthy until he or she is affected by a medical condition, which if treated correctly, returns the patient to a perfect state of health after a few days. This description applies to many situations in medicine. For example, a 16-year-old young woman who is suddenly complaining of right lower abdominal pain may end up being diagnosed with appendicitis. Despite the fact that we speak of this disease very casually these days, it is nevertheless a significant intra-abdominal infection. If an appendicitis is not appropriately treated, it can definitely lead to an infection of the abdomen [called peritonitis] and death.

So we now also have a case where a perfectly healthy young person suddenly becomes ill with a potentially life-threatening condition, which if treated properly returns the patient to perfect health. There are other medical conditions, such as a heart attack or stroke or major bone fracture, that can be described in the same way.

After learning this portion of the Talmud, it was clear to me that the Rabbis intended, for the described case of the pregnant woman, to be a paradigm. The Rabbis were speaking of the ONLY medical condition at their time that could suddenly create such a high risk to the patient, yet pass uneventfully most of the time. Today, with modern medicine and technologies, physicians and surgeons can sometimes perform magic on a person who was healthy but then suddenly became severely ill. In my mind, there is no question that a physician should transgress the laws of Shabbat for a patient post appendicitis or heart attack or stroke or other similarly dangerous conditions. If the specific transgression involves using an electrical device, then it is less of an issue than lighting a lamp, so technology is a better solution. In my mind, this is a perfect example of how a 2000 year old discussion amongst Rabbis can still be applicable today.

When I was younger and living in Montréal, there was a house that had a sensor that turned on a light  as you passed near its front door. I was told quite clearly by my Rabbi at the time, that I should try to avoid triggering this light on Shabbat. All I had to do was to partially cross the street to be out of the range of the sensor. So problem solved.

But what happens today when more and more of our environment is laden with all types of sensors? What happens when a doctor can only get into the staff room using an electric key? What happens when all of the hospital doors open automatically based on a movement sensor? I have heard of some physicians trying to manage a workaround for these situations.

One of the biggest issues that religious doctors face on Shabbat is unrelated to electricity. It involves physically writing on the paper chart. This is far more problematic from a Halachic point of view. Let me share with you my take on all of this.

I will speak first to the issue of writing on a paper chart. If a computer is available and it is possible to type the chart directly into the EMR, this is actually preferable from a Halachic point of view. My problem is that I’m old school. Despite my extensive use of technology in my everyday life, the process of taking notes while questioning a patient about their medical condition, is critical for my clinical thinking process. As I would write what the patient was saying, I would be processing this information and already be deciding on a next question or testing or perhaps even coming to a diagnosis. On the occasions that I tried to remember the patients’  descriptions, I found that I often had quite simply forgotten key points by the time I exited the room and opened the computerized chart.

The charting process is not a nicety,a courtesy or a task solely related to billing later on. In my case, and the same goes for a number of my colleagues, the writing process was as important as placing the stethoscope over the lungs or placing hands on the patient’s abdomen. To be denied this task because of Shabbat was to provide substandard care, which could have been life-threatening in some cases.

In the near future, there will be various interfaces that are available in the examining room. Whether by typing, writing on a digital pad, speaking into a microphone or even thinking a series of medical thoughts, the medical chart will be filled out. Once again let me say that having the chart is not just a convenience.  Without a chart, some computer systems would not even allow you to order tests and discharge the patient with a formal diagnosis.

The medical chart is critical for follow-up. When the patient presents to the family doctor on the following day, it is the patient’s chart that passes along all of the necessary medical information for continued work up and/or care of the patient. 2000 years ago, charts were not filled out. But today, they are a critical part of the patient assessment. In my mind, there is no question that the completion of a medical chart is critical to the welfare of the patient and thus should be permitted on Shabbat.

When the time comes that computers can accurately read our minds such that we are not performing any evident action  to record a chart or order a test, I am sure that there will be a major Halachic discussion  about this option for completing the medical record. Is it better than writing? I’m pretty sure it is. Is it better than directly typing into the computer? Once again, I’m pretty sure it is.

In Israel, there is an organization that has devoted itself to the development of technological options for minimizing Sabbath transgressions for physicians, paramedics, nurses, police, firemen and anyone else who provides a critical service 24/7. This organization [with which I have no connection] has embraced modern technology and welcomes it as a way in which to increase the observance of the Sabbath.

I suspect that the original engineers who worked on the first computers never thought that such technologies would be used in such a way. Gd seems to like watching us complete the puzzle of how to live a Halachic life in this very complex and technologically advanced world.

I must say that I can’t think of a justification for writing my blog on Shabbat. So considering that it is already Friday, I will hurry and end my typing now. Please accept my Shabbat wishes as well as my standard sendoff,

Thanks for listening