[Avodah] Fasting on Yom Kippur

[Chana Luntz]

RMS writes: 

>There are several separate issues that this raises. 

>1) What is the level of risk, and nature of risk, that is halachically 
>acceptable in this context?  Is it merely risk to the mother, or also 
>risk to the fetus? How machmir are we on pikuach nefesh? 

I think this is one of the key factors here.  My sense is that in
general the doctors are worried about miscarriage and/or prematurity (ie
risk to the fetus) and not so much about the risk to the mother. 

My sense is also that this is not just (or particularly) related to fear
of a malpractice suit.  The medical stance taken here in the UK
regarding fasting is similar to the US despite it also being a
jurisdiction (along with Israel) in which medical malpractice suits are
far rarer, and unlikely to be occasioned by this sort of thing (it is
too indirect, after all the patient is the one doing the fasting, not
the doctor).  

However, a lot of what is driving my sense about this is my experience
when I was nearly 34 weeks pregnant with my youngest.  At that time I
needed a very minor medical procedure, that normally could have been
carried out by a local doctor, if not at home.  However, because I was
34 weeks pregnant, my local NHS hospital insisted on hospitalising me
for the night.  As the consultant explained to me, at nearly 34 weeks
*anything* can set off labor, but that at that stage it is likely that a
baby cannot yet breath in air.  In order to make it more likely that the
baby could breathe in air if I did go into labor, they gave me an
injection of a steriod that, if I did not go into labor, would pass
harmlessly through my body, but if I did go into labor, would somehow
strengthen the baby's lungs and give it a fighting chance of being able
to breath in air.  Everything seemed fine, but the next morning the
machine detected contractions (so minor that I could barely feel them,
and if I had not been lying in bed doing nothing but watch out for them
I am sure I would never have noticed them), so then of course there was
no way they were letting me out (even though that evening was Shavuos,
and I was desperate to get home).  In any event,  I stayed another two
nights, the contractions completely disappeared, and they let me out -
and in the end the baby wasn't born until Shiva Aser B'Tamuz, well and
truly at term.

And yet a busy NHS hospital was prepared to block a bed for several
nights because something really minor *might* set off labor.  Note also
that they were clear that if I *had* been at term, they would not have
hospitalised me, because if it had set off labor, so what?  They don't
hospitalise all pregnant women at term in case they go into labor.  And
the whole tenor of the discussion was that they were not worried about
me, but about the fact that the lungs at not quite 34 weeks were
probably not sufficiently developed for the baby to survive without neo
natal care, and they therefore wanted all of that close by if I went
into labor.  That also seems to suggest (although I never asked this at
the time) that a labor at that time would be much faster than could be
expected at term, because at term they do not hospitalise you, they ask
you to wait until you are in established labor and then come in.  Here,
they wanted me there so all the equipment would be there, not to rush in
if there were any contractions (which again would have saved them money
and not have blocked a bed).

The other reason I suspect we are talking about risk to the fetus here
is because (and I may be propagating medical myths here), it was once
explained to me that women are programmed to miscarry in times of famine
and other risky situations - because if there is a famine, then there
will not be enough food for the baby when it comes out, and yet by
draining the mother, it may put the mother's survival at risk.  The
balance between baby and mother is thus tilted in favour of the mother,
so that she will live to get pregnant another day (and/or look after her
existing offspring) rather than have a "perish with the Plishtim" type
situation.  If this is indeed true, and not mythology (and it does sound
logical), then again the risks of fasting would seem to be borne by the
fetus.  I would also indicate the nature of the risk, and that it is a
real risk - it is just presumably that 25 hours is not, in most women,
enough to trigger a "famine" response (especially if they take it easy
etc), but in some whose threshold to trigger miscarriage is lower than
others, it might be.

The only risk I have really heard about to the mother (assuming no
specific complications) is that she may be too tired and worn out by
fasting for labor, and that may be dangerous. For some reason though I
have only ever heard that in regard to women who are at term (which
again suggests that my supposition above regarding labor being much
quicker and hence less dangerous before term might be correct - it does
make sense that is it more dangerous for the woman to give birth at term
than to miscarry earlier, because the baby is so much smaller - and
hence presumably causes much less disruption).  I would also note that
most women fast during labor (it's the nature of the beast), and for
those with a long labor - and 40 hours for a first child is not unheard
of, (I gather that is the time limit in my local NHS hospital (ie the
cautious one referred to above) before they will do an emergency
cesarian, if no other risk factors are showing that necessitates it
earlier), that will mean 40 hours of fasting prior to the actual birth.
But on the other hand, if you are possibly facing a 40 hour labor, then
it might be problematic if you had a 24 hour fast on top of that.  I am
sure there is data on length of labor for premature births and
miscarriages versus term births which might add to this part of the
discussion, and might explain why the heterim I have generally heard in
relation to Yom Kippur/Tisha B'Av, absent specific concerns, have all
been for women who are already at term.

>1) Our current medical knowledge is such that we disagree with the 
>position that fasting is safe for most healthy pregnant women 
>(essentially a nishtanu hatevaim position - even if we mean by 
>nishtanu hatevaim that our knowledge is different (rabbenu avraham ben 
>harambam) (In some ways, this is similar to the metziza debate - that
current 
>medical knowledge would suggest the halacha is based on a medical 
>position that is no longer considered valid - but here there is the 
>problem of an issur karet, which makes it more difficult) 

Well I am not sure.   It could also be said to be more like the case of
mila.  We know that some babies indeed die machmas mila.  In fact, we
have a halacha that states that mila is not required if a boy has two
brothers who have previously died from mila.  But for everybody else,
including boy number 2, you do indeed perform mila, despite the halacha
recognising that there is some level of risk for everybody, albeit that
it may be low.  If doctors came out today and said don't do it because
of the risk, we wouldn't listen to them.

If anything, the risk in relation to pregnancy seems much more accepted
within our sources as meaning that women often shouldn't fast, as
witnessed by the discussion regarding the minor fasts.

>2)  While there may be a substantial population, or even the majority, 
>  of women for whom fasting in pregnancy may be safe, our current 
>status of medical knowledge does not allow us to determine who those 
>women are - we have learned enough to know that there is increased 
>risk for some, but not enough to identify more precisely the at risk  
>population - and safek pikuach nefesh lehakel... 

But if I am right and the risks are fundamentally to the fetus, then you
have to make the judgement that not putting the fetus at risk is an
issue of pikuach nefesh, and I am not sure that is necessarily agreed -
unless you are talking close to term. You have to hold that a fetus
constitutes a nefesh to which pikuach nefesh applies, which means you
end up on one side of the abortion debate that we have rehashed a number
of times here.  

>3) While still recognizing that some women may still be safe fasting, 
>to dramatically limit the number of women who would be allowed to 
>fast (for example, healthy women who are already at term - and  
>therefore delivering right after YK would not be problematic). 

Well as mentioned, out there in the real world, my sense is that the
heterim are more generally given when the woman is at term than when
they are not.  Which would make sense if a) the risk to the woman and
not just the fetus was greater at term and/or b) the fetus was regarded
as a nefesh to whom pikuach nefesh applied at term, but not before.

>Meir Shinnar 

Regards

Chana