Angelina Jolie and Me: Women's Health and Halachah
The media called it the “Angelina Jolie Effect.” When the superstar actress-director went public three years ago with her decision to undergo a double prophylactic mastectomy, after discovering she carried a genetic mutation that dramatically increased her risk for breast cancer, women flooded physicians’ offices and internet sites seeking information and support.
Women’s health advocates cheered Jolie’s openness about the informed choices she had made. And women like me – Jewish women of Ashkenazic (central and eastern European) descent – finally could speak out, not just about the exponentially greater threat we face from BRCA1 and BRCA2 genetic mutations, but also about bold new approaches to health and life.
But we face another issue: What does Jewish law say? Is it Jewishly permissible to undergo prophylactic surgery for a disease we don’t have and may never get?
Halachah defines the practice of medicine as “a mitzvah that comes under the umbrella of pikuach nefesh (saving a life)” – and, according to the Shulchan Aruch law code, comes from the Torah itself. Under this traditional and objective halachic model, a patient suffering illness or injury is obligated to seek treatment from a trained medical professional, who is similarly obligated to provide medical care.
But what about the threat of illness or injury?
Certainly, immunization against prevalent but preventable diseases is widespread, generally accepted as legitimate medicine, and looked upon favorably by Judaism. This category might include women who have had cancer in one breast and choose to have both removed since the risk of recurrence is higher. But others – like Jolie – who have never had cancer may seek to remove both breasts as a precaution against future illness. Does that qualify as refuah?
Until the 18th century, the answer likely would have been no – not until the crucial work of eminent German posek (Jewish legal scholar) Ya’akov Emden.
Emden concurred with the Shulkhan Aruch’s laws that place saving a patient’s life over even restrictions of the Sabbath. But Emden then refocused the conversation from the objective standard of life and death as the physician sees it, to the subjective standard of the toleration of pain as the patient feels it:
But those who choose to enter into a situation of possible danger (safek nefashot) in order to relieve themselves of great suffering (k’dai l’hatzil atzmam m’isurim kashim)…for example, those who undergo surgery because of a stone in a cyst or vein or the kidney stone that is causing them pain as severe as death (b’tza’ar kashe kamot), may God save us (rahmana leitzlan), we permit them to do it as they desire.
With the new subjective focus on the patient, we may now add to physical pain the alleviation of emotional pain for a patient whose anguish over her at-risk status is “kamot,” like a death sentence to her. And Emden’s ruling would make such surgery halachically acceptable even if disease has not yet (and may never) appear in her body, as long as her fears are reasonable as well as real.
Family history, genetic abnormality, personal cancer history, emotional distress – all of these may factor into a woman’s decision whether or not to undergo prophylactic mastectomy. But we have to remember that each woman’s circumstances are unique. Halachically, she must consider not just her emotional state but her actual risk, as well as available non-surgical alternatives. These criteria parallel those of many medical organizations, as well as insurance carriers’ guidelines for covering such care.
When I was first diagnosed at the age of 40, I did feel emotional pain kamot, like death. At the time, prophylactic surgery was not offered as a choice. I had the normal course of lumpectomy, chemotherapy, radiation, and (because of my type of cancer) five years of Tamoxifen. And, thank God, I have been cancer-free since – though I still fear the threat of recurrence.
As it happens, I discovered through follow-up genetic screening that I do not carry the BRCA1 or BRCA2 genetic mutations, or any other genetic abnormalities known at this time to put me at greater risk than women in the general population. But I have been empowered by the research I have done since then, and by the far more open discussions now taking place. This dialogue allows women like me to make educated, thoughtful – and Jewishly acceptable – decisions for ourselves.