General Anesthesia or Conscious Sedation with Restraint: Treating the Young Child from a Jewish Ethical Perspective
General Anesthesia or Conscious Sedation with Restraint: Treating the Young Child from a Jewish Ethical Perspective
Rabbi Yigal Shafran, Ph.D., and Ari Kupietzky, D.M.D. M.Sc.
Introduction – The Ethical Dilemma
Uncooperative patients present a unique problem for physicians and dentists who treat young children. When confronting a defiant or precooperative young patient with extensive dental decay the pediatric dentist must decide between treatment under conscious sedation or general anesthesia (GA). This dilemma is not limited to the dental profession but is frequently encountered by physicians as well. Sedation is routinely used in pediatric patients undergoing diagnostic procedures including computed tomography, endoscopy, electroencephalography, and bone marrow biopsies.[1],[2] In the last five years, the number of non-operating room procedures performed on the pediatric population requiring sedation has skyrocketed. Some of these procedures, such as bone marrow aspiration or dental restorations, may be painful, whereas others, such as magnetic resonance imaging, are not painful but require a motionless patient. Anesthesia departments are being asked more and more frequently to provide the sedation and monitoring for these procedures.[3] Some practioners prefer to attempt and exhaust sedative techniques in most cases and use GA as a last resort, others do not mandate that alternate approaches first be attempted before treating under general anesthesia. What are the ethical considerations involved in this decision making process?
The following case description will illustrate the problem:
Joey a three–year–old with severely decayed and abscessed teeth caused by prolonged bottle feedings, was in great pain. He was not sleeping, and his upper lip was swollen due to infection. The treatment recommended by the family’s dentist included extractions, root canals and fillings.[4] Should the child be treated under general anesthesia and be exposed to the adherent risks of the invasive anesthetic procedure or perhaps the use of sedation and restraint is the better choice?
Controversy exists as to the benefits and risks, as well as the ethical and legal consequences, of the use of restraint. Medical personnel are ambivalent about using restraints, believing that they affect patients’ freedom, self-respect, and self-reliance.[5] The use of conscious sedation (CS) and restraints has been described by its opponents in very negative terms. One recent article entitled “Strap him down,” described such treatment as perhaps causing lasting psychological damage. An ethicist went as far as commenting that such treatment may be seen as a case of proposed child abuse and that physicians should refuse to treat patients with a restraint device.[6] Critics of pharmacological management of children, especially when it is coupled with restraint, purport that children may learn dysfunctional strategies for coping that result in temporary cooperation at the expense of intensifying fears or anxieties.[7] And yet, other practioners report huge success resulting with future cooperative patients. However little data exists to confirm either position. It is unclear whether sedation techniques with restraint have any long-lasting effect on the young child. When a parent is presented with both modes of treatment many concerns will influence their choice of procedure: Safety of the procedure, completion of treatment, cost, child’s discomfort, and the possibility of the treatment affecting the patient’s future attitude and cooperation in the dental or medical setting.
This paper will attempt to address this issue and provide the physician or dentist with relevant ethical insights from a Jewish perspective to assist the physician and the parent in the decision making process.
The dental condition
The discussion of this paper will focus on the dental condition called Early Childhood Caries (EEC), however the issues discussed are relevant to any similar medical disease or condition. Although many physicians and patients may assume that dental caries is a relatively minor disease, rampant dental caries has been reported to inhibit adequate nutrition, thereby adversely affect the growth of the body, specifically weight and affect a young child’s entire being.[8],[9] Children suffering from ECC may be diagnosed as failure to thrive. Children with EEC receiving comprehensive care achieve improve-ments in their quality of life, as well as overall health including improved abilities to eat and sleep.[10],[11] The prevalence of ECC in 3-5 year olds is high[12] and its persistence is of concern.[13] Treatment of ECC is expensive[14] and if the child is treated in the operating room under general anesthesia, to facilitate the dental treatment, the additional expense for the anesthesia alone may be over double the initial cost.[15]
Definition of terms[16]
Conscious sedation is a controlled, pharmacologically induced, minimally depressed level of consciousness that retains the patient’s ability to maintain a patent airway independently and continuously.
Deep sedation is a controlled, pharmacologically induced state of depressed consciousness from which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes including the ability to maintain a patent airway independently.
General anesthesia is a induced state of unconsciousness accompanied by partial or complete loss of protective reflexes, minimally depressed level of consciousness including the ability to maintain a patent airway independently.
An emphasis should be made that the discussion of this paper is conscious sedation, not deep sedation. Deep sedation is a dangerous procedure because it includes the suppression of protective reflexes (as occurs in GA) without the safeguards routinely employed in GA. GA is not an extension of CS and CS should not be equated with yhe first stage of GA.[17]
Risks of GA and CS
One of the most frequent questions asked of a pediatric anesthesiologist is “What are the risks of general anesthesia for my child?” Although it is generally accepted that GA is relatively safe when administered in a hospital setting, it is not without risk of complications.[18] Unfortunately, few studies have examined the consequences of general anesthesia in children. Of the 26 patients who died during the course of GA for dental procedures in Great Britain between 1984-1993 more than 50% were children.[19] In one study when all events were considered (both major and minor), there was a risk of an adverse event in 35% of the pediatric cases. This contrasts with 17% for adults.[20] This difference may be attributed to the supposition that when mishaps occur during general anesthesia in children there is a small window of opportunity to correct the situation. The risk of death in all children undergoing hospital GA is high and ranges between 2 and 6 per 100,000 anesthetics.[21] GA administered for dental treatment is safer, and the risks involved are lower than can be claimed by any other general anesthetic procedure. However, even one death is too many if it can be avoided.
The risks of GA are not limited to the anesthesia period alone but also may occur during the induction and postoperative periods. Complications are observed almost equally during induction, maintenance and on recovery.[22],[23] Events occurring during the post anesthesia period in the post anesthesia care unit continue to be a source of patient morbidity, the incidence of major complications that occurred during or within 24 hours of the anesthesia being 0.7 per 1000 anesthetics. The incidence was higher when a previous history of anesthesia was present which may be another reason to avoid GA when other treatment methods are available.
The risk of death is lower in CS. Mortality studies suggest approximately 1 death in 300,000 during the preoperative period of parenteral (intravenous, intramuscular) conscious sedation in the dental office.[24] Oral CS is even safer. A recent study[25] showed that minimal minor adverse events occurred with an oral sedation regimen with 100 percent oxygen, or O2, supplementation. The study concluded that oral sedation offers reasonable outcomes with minimal adverse events under a strict protocol and use of O2 supplementation.
Another aspect of GA to be considered is not only the increased risk but rather the increase in medical procedures involved in the administration of GA. As mentioned although the administration of GA is relatively safe, major life threatening complications such as allergic reactions and bronchospasms may occur during induction, however they are not expected and are not common. Nonetheless, non-life threatening complications may routinely occur and may be expected. Sore throat and pharyngitis are common occurrences and are due to several factors: traumatic intubation, with the blade of the laryngoscope cutting or irritating the pharyngeal wall; prolonged coughing on an endotracheal tube or airway, or using a tube which is too large or over inflating the cuff, all causing damage to the pharyngeal wall. Nasotracheal intubation is the method of choice for dental procedures since it does not restrict the operating field during dental surgery. However it’s major disadvantage is that it can cause trauma and dislodgment of adenoidal tissue. The dislodged tissue could be carried into the tracheas. Damage to adenoidal tissue can increase the risk of postoperative infection, bleeding and sore throat.[26]
Effects of CS on future patient behavior
When parents are presented with both modes of treatment, GA or CS, a major concern, which will influence their choice of procedure, is the possibility of the treatment affecting the patient’s future attitude and cooperation in the dental setting. Despite widespread use of both techniques, there has been little clinical study of the influence of either method of treatment on the child’s future dental behavior. Advocates of general anesthesia report its success with minimum psychological trauma that the child might experience during treatment. Frequent users of conscious sedation report that their sedations are usually very successful and that although a child under conscious sedation may cry during treatment they experience no pain and only minimal discomfort.
A study was performed to test the hypothesis that conscious sedation used with physical restraint would negatively affect the dental behavior of children experiencing sedation in comparison with children who underwent treatment under general anesthesia.[27] The results of the study supported the view that conscious sedation with physical restraint does not affect the future dental behavior in a negative manner. The results of this study suggested that children undergoing CS with restraint and separation will remember their treatment, but the majority will not view it as being difficult or bad. These children can develop into cooperative and even enthusiastic patients. The results of this study are in agreement with a similar study conducted in Sweden.[28] Children who had been treated five years previously with GA had a poorer level of cooperation and acceptance than those who had conscious sedation. The authors stated that children who had conventional treatment more often show a lasting positive acceptance than do children who had received GA. The authors postulated that children undergoing GA probably did not experience the positive feeling of having coped with a difficult situation by their own efforts and thus were not given the possibility of changing their negative attitude towards the dental situation. Delaying treatment to a later time and thus avoiding GA or CS is not an option. Children who had started dental treatment younger showed a significantly better lasting acceptance and had become better patients than did the older ones. Another recent study[29] has shown that young children who experienced sedation with restraint for their dental treatment exhibited good behavior when subsequent dental treatment was provided and was not statistically different than a control group of children who were matched by age and gender but who had never received sedation. The data suggests that sedation regardless of its effectiveness or the time elapsed between the sedation and future dental treatment, does not lead to negative behavior or dysfunctional strategies for coping with fears or anxieties in the dental setting.
Based on the conclusions of these studies, parents may be reassured that there is no difference between GA and CS in regard to a child’s future behavior. If their child visits a dentist who will employ the wide spectrum of management techniques including: tell-show-do, positive reinforcement and desensitization in a gentle manner with patience and skillful confidence their child will evolve into a cooperative and enthusiastic dental patient regardless of either method previously employed.
The parent’s choice and approval
The decision to use a general anesthetic or CS is often subject to parent bias regarding its safety, costs and practicality.[30] The acceptability of pediatric dental behavior management techniques has become a serious concern for many dentists.[31] Increasingly, the acceptability of behavior management techniques is being held to the reasonable parent’s standard and not to adherence to the professional community standard for determining acceptable behavior management practices.[32] The past decade has seen a revolution in public and professional attitudes toward the management of children, which may not necessarily be for the benefit of the child. Pediatric dentists overwhelmingly report changes in parenting have occurred during their practice careers and these changes were regarded as negative.[33] Parenting changes have affected child behavior and thus the practice of pediatric dentistry. Divorce, parental fatigue, and a hurried lifestyle prevent parents from setting limits and providing consistent discipline. Children do not have consequences for their behaviors in today’s child rearing paradigm.[34] Dentists have shifted their behavioral management techniques to less assertive ones as a result of perceived parenting changes. This may be the result of a protective response to counter more involved and difficult parenthood and not be for the benefit of the child. The use of GA in managing difficult children has increased.[35] Rather have their child face a difficult situation and teach their child to cope and overcome their fears, today’s parent may prefer to avoid the stressful situation and opt for GA. The role of parenting in heath care and health behaviors is now well established and has been noted by the medical community. With the emphasis on children’s rights and the increasing participation of parents in the decision process, the attitude of parents toward behavior management constitutes an important factor when a method of treatment is selected and parents need guidance in the decision making process.
Another concern of parents with regard to the use of CS and restraint is due to their perception that a child’s crying is indicative of pain. Many parents may object to the use of restraint and sedation if hysterical, interfering child behaviors including crying, and body and extremity movements may be expected and perhaps cause their child psychological trauma. However, parents should be reassured that crying is not necessarily related to a child’s pain. Crying is a form of communication. While infants cry from need, toddlers and preschoolers generally cry out of frustration. Toddlers seek independence and may scream in protest at losing the power he or she has enjoyed sine birth. Power struggles that include crying are not limited to the dental office and may occur over toilet training, eating sleeping and separating.
Studies on the acceptability of behavior management techniques showed that passive restraint and sedation are viewed by parents with equal disapproval. More parents accept and consent for GA then for CS with passive restraint.[36] However, the dentist may play a role in the decision-making process and increase the parent acceptability of a proposed technique. For example, parental attitudes can be influenced by the way that proposed dental behavior management procedures are presented.[37] Personal oral delivery of information is most likely to result in parents who feel well informed and who are likely to provide written consent. Also, parents should be informed that when treating a child under GA, dental surgeon will prescribe a more radical and aggressive approach of treatment to avoid future treatment failure and the need to return to the OR. Thus, parents should be made aware that children under GA would be treated with more extractions and crowns than if they were treated under CS. And finally, parents need to be told that successful sedations do not mandate complete and absolute patient immobility or somnolence.[38]
Treatment outcome: Are the results of treatment under GA better than CS?
Although GA theoretically allows for optimal conditions under which dental treatment can be performed restorative failures are not uncommon.[39] The successful outcome of full mouth rehabilitation for the pediatric dental patient under GA is dependent on the ability of the parents to comply with preventive dental care for their children following GA.[40] Studies report that between 9%[41] and as high as 39%[42] of children who had been treated under GA needed to be retreated within less than a year and a half of initial treatment. Over 10% needed to be retreated under general anesthesia because of severe management problems. A recent study reported a failure rate of 51% of tooth colored restorations of anterior teeth.[43] These teeth are those the most affected by EEC.
To summarize this section:
1) The use of GA should be reserved for use when sedation attempts are inadequate or believed to be high risk or inappropriate.
2) Sedation is are usually successful and although a child under conscious sedation may cry during treatment they experience no pain and only minimal discomfort
3) Conscious sedation with physical restraint does not affect the future dental behavior in a negative manner.
The Jewish medical ethics perspective
The question of whether a child should be placed under general anesthesia for the purpose of performing dental treatment or whether restraint (combined with the use of conscious sedation) is preferable is a multi-faceted halachic issue.
In principle, it is clear that the use of general anesthesia where not completely necessary is altogether forbidden. This is because any invasive medical procedure that is carried out without vital need for it is to be considered as harmful and injurious and constitutes an assault upon the body and is forbidden as an act of “wounding” (havalah[44]), even if it is carried out by a doctor with intent to help the patient.[45],[46],[47],[48] Since no medical authority would disagree that general anesthesia involves a certain element of risk, general anesthesia that is not vitally necessary should clearly be considered harmful and injurious.[49] In this sense it is of no significance that the doctor receives the patient’s permission to carry out the procedure (or, in the case of a minor, the permission of the parent or guardian), for a person has no right to injure himself or to place himself in danger.[50],[51]
On the other hand, however, we must take into account the fact that restraining a child, when not carried out by a skilled and sensitive doctor with a very good level of communication with children, may cause the child fear and panic, which are also forms of injury and harm. Although the harm caused by panic is considered only gerama[52] (i.e., harm that is caused indirectly, since the actual mechanism of fear is created by the patient himself[53]), it is nevertheless forbidden (a secondary or indirect cause in the case of damages (nezikin) is forbidden but carries no liability; patur aval assur), and a person who frightens another is subject to Divine punishment.[54] Therefore in the event that the technique of restraint is applied in such a way as to cause panic, the doctor is considered as having caused harm directly, since he frightened the child unnecessarily while there existed a possibility of avoiding this, and he is therefore even liable to pay damages by Jewish law since he frightened the child through physical contact as stated in the Rambam:[55] “He who frightens his fellow, although he became ill from fear, is exempt from the judgments of man but liable according to the judgments of Heaven. However, if he made physical contact with the individual while he was frightening him, or even if he just held onto his victims clothing or similar forms of contact, he is legally liable for damages” and also in the Shulchan Aruch.[56]
Therefore we must establish which is the “lesser of two evils” – to restrain the child and take the chance that he will panic if the procedure is not carried out gently and with cooperation, or to place him under general anesthesia? In principle, general anesthesia is considered a more severe action than restraint, even if the restraint causes panic, because causing panic is forbidden but is punishable only by Divine justice, while general anesthesia is a form of harm that is punishable by human law, like any other type of harm that a person causes directly. Nevertheless, there is room to claim that restraint, with its attendant intimidation of the child, should also be considered a form of injury subject to human law, since in order to carry out the procedure the doctor touches the child, and panic that involves physical contact is punishable by human law.
Attention should be paid here to the fact that the general anesthetia procedure also contains an element of fear, at the stage of induction. Therefore the issue must be weighed carefully and with great caution.
The following eight questions should be considered:
1. To what extent is the dentist obligated by the halachic requirement that the child suffer as little pain as possible during the treatment or following it?
2. Are there existing halachic rulings that address the use of general anesthesia?
3. May a patient be restrained so that he will not move during treatment?
4. Should we not be concerned that psychological trauma may be caused?
5. Are parents obligated to provide the best possible dental treatment for their children?
6. Is the question, “Restraint or general anesthesia?” one that should be decided by the doctor, or is the decision in the parents’ hands?
7. How is the decision to be made in the event of a difference of opinion between doctors concerning the most preferred procedure?
8. May a doctor use a more dangerous procedure if a less dangerous procedure exists but the doctor prefers the former because it makes his work easier?
Question 1:
Clearly, the aim of medicine is first and foremost to minimize the pain or discomfort of the patient, even if this does not cure him. Were this not the case, it would not be permissible to extinguish a candle on Shabbat to ease the discomfort of a person who is dangerously ill, for such an act does not cure him.[57] It is certainly true, then, that a doctor who treats a patient but does not do his utmost to minimize his pain, is not fulfilling his mission properly.
The doctor must do whatever he can to ensure that the treatment does not involve pain, and if a treatment involves pain that may be avoided by the use of medications then the treatment is considered more praiseworthy and justifies greater payment according to halacha.[58],[59],[60]
Not only is the doctor obligated to ensure that the patient will not suffer unnecessary pain related to the treatment, but in fact several medical issues are addressed in halacha not from the point of view of their objective medical aspect but rather from the point of view of the pain that they involve.[61]
In general, in our generation it is vital that we raise awareness among doctors that their obligation to calm patients is no less binding than their obligation to treat the actual illness. After all, the crux of the doctor’s mission, and for which he is deserving of Divine reward, is that he calms the patient and eases his suffering as can be seen in the Zohar in which the mandate of the physician is discussed.[62]
Question 2:
Anesthesia has been recognized since the days of Adam in the Garden of Eden as a method of preventing pain during surgery.[63] Our Sages were aware of methods by means of which a person could be made to sleep in order that he would not suffer, as detailed in the Talmud. For example, in Sanhedrin:[64] “When one is led out to execution, he is given a goblet of wine containing frankincense, in order to benumb his senses” and in Baba Metzia:[65] “Thereupon he was given a sleeping draught, taken into a marble chamber and had his abdomen opened, and basketsful of fat removed from him.” At the same time it is clear that because general anesthesia contains an element of danger it should be avoided where possible, just as one should avoid placing himself in any other type of danger as can be seen in the Rambam:[66] “Since when the body is healthy and sound one treads in the ways of Hashem, it being impossible to understand or know
anything of the knowledge of the Creator when one is sick, it is obligatory upon man to avoid things which are detrimenta[1]l to the body and acclimate himself to things which heal and fortify it.” Similar prohibitions against placing one’s health or life at risk are found in the Shulchan Aruch[67] in a chapter devoted to “the positive commandment of removing any object or obstacle which constitutes a danger to life.”
But although general anesthesia is a dangerous procedure, halachic authorities have ruled that it is permissible for medical needs, just as blood may be taken from a person for the purposes of healing[68]. However, it is forbidden to perform an anesthetic if the same medical result may be obtained without it. For this reason it is forbidden to prolong the patient’s general anesthesia for the sole purpose of training an intern to perform the procedure – even if a specialist is supervising him. The presence of the specialist makes it permissible for the intern to carry out the treatment, but does not justify prolonging the anesthetic.[69]
In defining the permissible bounds of anesthetic that may be undertaken for elective surgery, halachic authorities[70] (R’ Yosef Shalom Eliyashiv as quoted by R’ Ovadiah Yosef) specified a period of one hour as a reasonable period for an anesthetic and as not giving reason for concern. In other words, general anesthesia for longer than an hour is considered dangerous and may not be undertaken unless there is really no other option.
Question 3:
The Tosefta[71] brings a parable to of a patient with a problem in his leg, who is restrained by a doctor in order that the necessary surgery may be performed. There are those that learn from this parable that the use of restraint during medical treatment was so widely accepted that it could be brought as a clear and simple example of any situation in which force is used against a person for his own sake, and the person thereafter ultimately recognizes that all was done for his benefit. But the formulation as we have it suggests that the discussion really concerns the question of how to bring about a situation whereby the patient will not move during surgery. The technique discussed here is restraint, apparently arising not out of any desire to force the treatment upon the patient but rather out of the patient’s own free choice that it be performed, in order that his body will not budge under the doctor’s knife. In other words, it is a sort of request by the patient that the doctor help him not to flinch as a natural result of the pain, and therefore he places himself in the doctor’s hands and asks to be restrained. If this analysis is correct then it is of particular interest that although the technique of general anesthesia was known to the Sages of that period and they made use of it, nevertheless, the above parable demonstrates that they preferred restraint over general anesthesia.
Hence we see a preference for restraint rather than general anesthesia – at least in the conditions prevalent at that time.
Question 4:
Essentially, by Jewish law a patient has no right to withhold treatment from himself,[72] but this applies principally where there is danger to life. Coercion for treatment that is not related to saving a life rests on an earlier debate concerning the extent to which a person may be forced to fulfill a positive mitzvah which he is obligated to perform and which does not affect anyone else. According to the Kezot,[73] only a Rabbinical court, a Bet Din has the authority to force an individual to perform a positive commandment, e.g. to build a Succa or give charity. The Netivot[74] disagrees and states that an individual may act in this manner in the same manner as a Bet Din and force a person to perform the commandment. At the same time it seems that there are many situations in which all opinions would agree that a patient may be forced to accept treatment against his will, despite the fact that there is no danger to his life. There are two reasons for this:
· We may assume that the patient fails to understand the damage that he may suffer if the problem is left untreated. Hence no attention should be paid to his protests, since it is not the patient himself who opposes treatment but rather a spirit of foolishness and intellectual weakness that has attached itself to him as a result of his illness as the Talmud[75] states: “If the physician says: He needs it, whilst the patient says that he does not need it, we listen to the physician, Why? Stupor (tunba) seized him.”
· It is possible that a doctor must treat a patient even against his will – even if there is no life-threatening danger – because this is the biblically-ordained obligation of the doctor (“and thou shalt restore it to him,”[76] meaning to heal his body), who must ensure that he does what he can to heal others. The patient is not entitled to nullify this obligation pertaining to the doctor even though it involves his own body.[77]
Despite all of the above, a doctor must avoid forced treatment if there is a risk of causing the patient fear or shock, for if the patient suffers shock as a result of his fear the doctor will be considered as having harmed the patient directly. The fact that he performed the procedure for the patient’s benefit will not stand in his defense. If the patient should die, heaven forefend, as a result of his fear, the doctor is considered as having caused his death directly.[78] Special care should be taken in this regard not to break the will of an adolescent patient, since this represents the breaking of the central element in the consolidation of his future personality and the development of his independence.[79]
Therefore one should certainly select a medical procedure that minimizes conflict and the breaking of the patient’s will. If, for example, the child is likely to remember very clearly the first few moments of general anesthesia induction, where pressure is applied with a view to exposing him quickly to the anesthetic, then there is room for concern that this trauma may give rise to more profound anxieties in his subconscious than would result from restraint in conjunction with nitrous oxide, where no such force is involved although the child is passively restrained.
Question 5:
Although no source explicitly addressing a father’s obligation concerning his children’s medical needs may be found in the halachic literature, modern halachic authorities have ruled that he is indeed obliged to heal his children, and this obligation is derived from the husband’s responsibility to heal his wife.[80] Dental treatment is considered a medical need just like treatment of any other bodily organ or illness.[81] Our sages were especially cognizant of the fact that any infection in the mouth is potentially dangerous because of the direct circulatory connections between the oral cavity and the brain.[82]
Question 6:
The responsibility for selecting the nature of the treatment rests with the doctor, and parents have no status in the decision as to what is preferable if the question is a medical one and pertains only to issues of danger or lack thereof. Therefore if parents request a procedure that is dangerous, against the opinion of the doctor, the doctor must not accede to their request since they have no right to endanger their child.[83] Some authorities have ruled that a father may place his child in slight danger if this is vital for the purposes of a mitzvah,[84] but no license for a greater danger that may be avoided may be found in the halachic literature. It is only in the event that there exist a number of possibilities, each medically sound with its own advantages and disadvantages such that the decision is given over to the family, that their wish must be fulfilled.[85] If, on the other hand, the doctor believes that a certain procedure is medically preferable, he is obligated to treat the child in accordance with his better medical judgment and not in accordance with the wishes of the parents. This is because the doctor’s obligation pertains to the child – he must treat him in accordance with the halacha. The doctor is not merely a service-provider for the parents, who want him to treat the child in accordance with their instructions. Therefore the doctor is not entitled to desist from providing the best possible treatment for the child as he sees it[86] and he may not decline to treat him, unless there exists a medical opinion that such treatment may harm the child.[87] As written in the Shulchan Aruch: “The Torah gave permission to the physician to heal; moreover, it is a religious precept and is included in the category of saving life; and if he withholds his services, it is considered as shedding blood” this may be derived from the combination of the two biblical sources for permission to heal: “Do not stand idly by the blood of your neighbor”[88] and “and thou shall restore it to him.”[89],[90] In addition, the Rambam[91] explains: “It is obligatory from the Torah for the physician to heal the sick and this is included in the explanation of the scriptural phrase “and thou shalt restore it to him” meaning to heal his body. If he sees him in danger and is able to save him, he should save him with his body or his money or his wisdom.”
Question 7:
When there is a difference of opinion between two schools of medical thought, one asserting that a certain procedure (such as general anesthesia) is dangerous, while the other maintains that while a danger does exist, that is the proper procedure to follow, the proper advice would seem to be to act in accordance with the five rules that are set down for decision-making in situations of doubt where there is possible danger to life. (Although situations presenting a threat to life require special care, the principles seem worthy of applying even in situations involving some degree of risk, where there is a difference of opinion as to how to proceed.) The rules are as follows:
i. The decision should be made only after the facts are clarified and the matter weighed up in a composed and calm state of mind.
ii. It is obligatory that the matter be investigated in the professional literature, in order to access the opinion of the leading doctors in the field.
iii. The opinion of a single specialist should not be relied upon; a number of specialists should be consulted and the decision made according to the majority.
iv. A procedure involving risk should be undertaken only if it is recommended by double the number of doctors who oppose it.
v. The halachic authority of the city – a Rabbi well versed in such matters – must also approve the procedure.[92]
Question 8:
The fact that anesthetic makes the doctor’s work easier neither adds to nor detracts from the permissibility of the procedure, if it does not involve either a better quality of procedure or significantly better results. The primary principle that should guide the doctor is that he is forbidden to endanger the patient to a greater degree than is required for the purposes of treatment. Moreover, even if a procedure was carried out that included general anesthesia when it could have been performed using restraint and conscious sedation, and the child awakened with no problem, and even if it becomes clear that no harm was caused to him as a result of the general anesthesia, the doctor is still guilty of having endangered the child unnecessarily.[93],[94]
Even a simple injection may not be given if it is possible to manage without it[95] – how much more so, then, a general anesthetic.
Summary:
A comparison of the two techniques – restraint with conscious sedation vs. general anesthesia – shows that from an halachic perspective, restraint is preferable, with positive communication and maximal cooperation between doctor and patient, and with safe, professional administration of conscious sedation. An emphasis should be made to differentiate between CS and deep sedation. Only in situations requiring treatment where, according to medical opinion, restraint would not be effective is it permissible to place a child under general anesthesia in order to treat his teeth.
General anesthesia, where avoidable, is considered injurious and may not be undertaken, based on the prohibition against unnecessary risk. A doctor who performs general anesthesia unnecessarily is guilty of this even if in fact nothing happened to the child as a result of the general anesthesia.
The responsibility for the best possible treatment lies with the doctor and not with the parents, and therefore the selection of restraint rather than anesthetic is likewise his responsibility. In the event of differences of opinion, an organized mechanism exists to determine the proper procedure according to halacha.
Conclusions and practical suggestions
Children over two years old with EEC should be treated as soon as possible.
Delaying treatment to a later time and thus avoiding GA or CS should not be considered an option.
The goals of CS should be understood and parents should not have false expectations.
It is suggested that the Papoose Board, which is defined as passive restraint, only be used if it is coupled together with conscious sedation in addition to local anesthesia and administered by a qualified specialist.
If a dentist cannot perform dentistry under CS the patient should be referred to another dentist who is trained to treat under CS.
If GA is preferred by the parents, they should be told to consider:
The increased risks involved with GA.
The treatments prescribed will be more aggressive and radical (extractions, crowns).
Children who have conventional treatment more often will show a lasting positive acceptance than do children who receive GA.
Returning to the dental clinic for preventive treatments is essential since the child treated for EEC is highly susceptible for the disease.
In conclusion, increasing awareness of the potential risks of general anesthesia led researchers to develop alternative methods[96] and should lead parents to accept perhaps controversial but safer methods to treat their child. Safe and effective use of sedation in combination with local anesthesia is a realistic alternative to general anesthesia for many outpatient procedures.[97] The use of GA should be reserved for use when sedation attempts are inadequate or believed to be high risk or inappropriate.
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44. Devarim 25; 3, Rashi comments: From here we derive that one is forbidden to strike one’s fellow.
45. Tosefta, Baba Kamma 9:11.
46. R’ Shimon Ben Tzemach Duran, Responsa, Tashbetz, III, 82.
47. Turei Even, Megillah ?7, a.
48. Minchat Chinuch, Mitzvah 48.
49. Responsa Tzitz Eliezer, R’ Eliezer Yehuda Waldenberg 14:85.
50. Rambam, Hilchot Chovel u’Mazik 5, 1.
51. Shulchan Aruch, Choshen Mishpat 420, 31.
52. Baba Kamma 60a.
53. Kiddushin 24b.
54. Baba Kamma, 56a.
55. Rambam Hilchot Chovel u’Mazik 2:7.
56. Shulchan Aruch, Choshen Mishpat 420, 32.
57. R’ Nissim Chaim Moshe Mizrachi, Responsa Admat Kodesh: part I, Orach Chaim 6. Chief Rabbi – Rishon LeZion – of Jerusalem, circa 1740.
58. Baba Kamma 85a.
59. Rambam Hilchot Chovel u’Mazik 2; 10.
60. Shulchan Aruch, Choshen Mishpat 420, 16.
61. R’ Eliezer Yehuda Waldenberg, Responsa Tzitz Eliezer part 8, 15, Meshivat Nefesh 10.
62. Zohar, Haazinu, page 299, “He found him in a desert land, and in the waste, howling wilderness.”
63. R’ Yitzchack Arama, Akedat Yitzchack (Berashit 8), fifteen century philosopher.
64. Sanhedrin 43a.
65. Baba Metzia 83b.
66. Rambam, Mishne Torah, Hilchot De’ot 4:1.
67. Shulchan Aruch, Choshen Mishpat 427.
68. R’ Shlomo Zalman Auerbach, Responsa Minchat Shlomo, 2-3, 35.
69. R’ Eliezer Yehuda Waldenberg, Responsa Tzitz Eliezer part 14, 84.
70. R’ Ovadia Yoseph, Responsa Yabia Omer, part 8, Choshen Mishpat, 12.
71. Tosefta, Shekalim, 1, halacha 2.
72. R’ Yaacov Emden, Mor U’Ketziah, Orach Chaim, 328.
73. Kezot, Shulchan Aruch, Choshen Mishpat, 3,a.
74. Meshovev Netivot, Choshen Mishpat, 3,a.
75. Yoma 83a.
76. Devarim 24:2.
77. Responsa Tzitz Eliezer, R’ Eliezer Yehuda Waldenberg 15:40.
78. R’ Moshe Feinstein, Responsa Igrot Moshe, Choshen Mishpat, 2:73.
79. R’ Avraham Yitzchack Hacohen Kook, Orot Hakodesh, part III, page 76.
80. R’ Yitzchack Weiss, Responsa Minchat Yitzchack 6:150.
81. Shulchan Aruch,, Orach Chaim 328.
82. Rosner, F Modern Medicine and Jewish Ethics, 2nd edition, Katv Publishing House inc, Hoboken, NJ, – Yeshiva University, NY 1991, pp. 407-408.
83. R’ David Tzvi Hoffman, Responsa Melamed Lehoel part II, 104.
84. R’ Moshe Sofer, Chidushei Chatam Sofer al HaShas, Shabbat 134.
85. R’ Moshe Feinstein, Responsa Igrot Moshe, Choshen Mishpat, 2:74.
86. Shulchan Aruch,, Yoreh De’ah 336.
87. R’ Yaacov Emden, Mor U’Ketziah, Orach Chaim, 328.
88. Vayikrah, 19:16.
89. Devarim 22,2.
90. Sanhedrin 73a.
91. Rambam, Mishna Commentary on Nedarim 4:4.
92. R’ Yaacov Risher, Responsa Shevut Yaacov part III, 75.
93. Taanit 20b.
94. Kiddushin 29b.
95. R’ Moshe Feinstein in the introduction to Shabbat Shabbaton by Rabbi Y. Ziberstein.
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