House Officers in Halacha-Part 2

In this essay, we will explore the varying perspectives of the Tzitz Eliezer and R’ Shlomo Zalman Auerbach zt”l regarding physicians in training administering general anesthesia and injections.

These questions naturally stem from concerns about potential patient harm resulting from errors. However, there are several compelling reasons to allow trainees to carry out these tasks, especially considering that they have received extensive training and that practical experience is essential for physicians to become fully qualified.

Below, we will present verbatim excerpts from both the Tzitz Eliezer, which contains the core discussion, and R’ Shlomo Zalman’s responses.

General Anesthesia

R’ Waldenberg zt”l was asked if it is permissible for a physician in training to perform surgery on a patient under general anesthesia for whom the anesthesia might have adverse effects, considering that the surgery will take longer than if performed by an experienced surgeon? Additionally, is it permissible even for an ordinary patient with no apparent danger, since there is always some risk involved in prolonged general anesthesia?

The Tzitz Eliezer (14:84) responded that it is forbidden:

In my opinion, it is absolutely clear, beyond any doubt, that in both cases, it is prohibited for the trainee to perform the surgery under general anesthesia, since doing so prolongs the anesthesia, which inherently involves Sakana. See the words of the Machane Chaim z”l^[1] in his work Kol Sofer on the Mishna at the end of Kiddushin (4:14), where he offers a remarkable explanation of Chazal’s saying, “The best of doctors goes to Gehinnom”: ‘That is, an expert and proficient physician is one who has investigated and experimented extensively with [the treatment of] various illnesses. He experimented with treatments, and through the fact that many died by his hand, he discovered which remedies are effective and which are ineffective until he ultimately discovered what works. Thus, he spilled much blood until he became the “best of doctors”. A doctor who simply follows in the path of his teachers does not reach the level of the “best of doctors”. If he has become the “best of doctors”, it is certain that he has caused many deaths in the course of experimenting, and is thus deserving of Gehinnom.’  This explanation fits well and can also be applied to trainees who perform surgeries, thereby placing patients at increased risk. (And in general, the more anesthesia is given, the more it affects the patient, and in many cases leaves its mark even after recovery.)”

Rav Shlomo Zalman zt”l disagreed, arguing that it is permissible, under certain conditions (Shulchan Shlomo p134):

In places where non-Jewish physicians are not common, if Jews do not gain practical training, from where will physicians come? Therefore, if the patient does not explicitly demand [that he] only [wants to be treated by] a specialist, we assume that he is generally not particular about it, and it is permitted even by a trainee.

Intravenous Catheters and Medications

This question was posed by Dr. Avraham Sofer to the Tzitz Eliezer, regarding the practice in hospitals allowing trainees to place intravenous catheters and administer intravenous medications, which at times cause injury. He also asked whether patients may consent to this and whether it is permissible on Shabbos.

The Tzitz Eliezer (ibid. 35) responded:

I have observed that it is done quite routinely in hospitals; trainees are allowed to place needles into veins, both to draw blood and to administer medications. And my eyes have seen, and in my own body I have felt, how in performing these injections the trainees – because they are not yet fully skilled and proficient – cause injury to the limbs into which they inject. The area swells and becomes discolored, and the entire limb begins to ache to the point that it becomes necessary to apply a medicated bandage to the swollen and painful area. This lasts for several days or more until it heals.

And so, the question arises: how is it permissible to entrust the performance of these injections to trainees? After all, it is forbidden to inflict injury upon another person. Although this does not reach a level of actual danger, it nevertheless constitutes a violation of the prohibition against causing harm to the body.

Do not answer that this is considered “Chovel l’Tzorech Refua (injury for the sake of healing)”, for this is not the case. The medical treatment itself does not require these injuries, and as I have seen, when a trained individual performs the procedure, these injuries do not occur. Therefore, it should not be permissible to allow a trainee to administer these injections except in a situation where no trained person (i.e., someone who knows how to perform the procedure without causing injury) is available at that moment, and the procedure must be carried out immediately.

What is even more serious is that they do not even ask the patient’s permission in this matter – to inform him and request his consent to allow a trainee to perform the procedure and waive any [claims of] injury that may result. Instead, the trainee approaches the patient’s bed with the syringe and, without a word or explanation, performs the procedure, causing bruising and pain.

Even if the patient were to grant permission, this would still be ineffective. The Rivash (494) explains clearly that the entire discussion in the Gemara (Bava Kama 93a) regarding “Strike me and wound me on condition that you be exempt” applies only to monetary liability – whether the one who struck or wounded must pay damages. But to say that one may initially strike or wound another person, thereby violating the prohibition of hitting one’s fellow (derived from the Pasuk “Lo Yosif”), merely because the other granted permission – this is indeed impossible.

The words of the Rivash are unambiguous: granting permission for injury is effective only to exempt someone from compensating the injured party for the damage he caused. But in no way does such permission prevent him from transgressing the Torah’s prohibition. Instead, the one who inflicts injury certainly commits a transgression even if the injured party granted permission. Thus, it is clear that it is forbidden to injure another person, even if that person gives consent.

This is also the conclusion of the Shulchan Aruch haRav (Hilchos Nizkei Guf v’Nefesh 4): It is forbidden for a person to strike his fellow even if the latter permits him to do so. He explains the reason: A person has no authority over his body whatsoever to allow it to be struck. The meaning is that a person is not the owner of his body to the extent that he may grant permission for someone to injure it, for the body is the possession of Hashem. This principle is well-established.

Therefore, it is clear that there is no permission to cause injury to a person’s body so that a trainee may learn this skill. The only exception is when there is no one more qualified available, and immediate injection is medically necessary as described above. In such a case, it may be permitted, and one may regard everything the trainee does in performing the medical task as being for the sake of Refua, since at that moment there is no more expert person on site to perform it. This also applies if the more expert physician is occupied at that time with more urgent cases; then it is considered as if no expert is present.

It must be emphasized that this is a grave issue when this is allowed for a trainee on Shabbos, at a time when a qualified physician is available to perform it. In such a case, it practically amounts to Chovel baChavero b’Shabbos.

I will not refrain from adding that there may be room to permit it when it is very questionable whether the trainee will actually cause injury, as it is very possible that he will not. In that case, it may be regarded as Davar she’Eino Mischaven, rather than a Psik Resha. However, even in that situation, obtaining the patient’s permission is undoubtedly required.

[1] R’ Chaim b. Mordechai Ephraim Fishel Sofer zt”l, 1821-1886.