Mishpatim: Applied Torah

Much of Mishpatim deals with the problem of the practical application of the Law engraved in stone.  Real situations require subtle interpretations. 

I like to think that the eternal Truth of the Torah  is applicable in all situations, including my medical practice.

I saw a patient yesterday who had been treated for a life threatening blood clot to the lung.  Analysis showed that she had an immune problem, the Lupus Anticoagulant.  This diagnosis has a very bad reputation for causing all kinds of clotting problems, including strokes.  

I saw this patient  in the context of her desire to become pregnant.  The Lupus Anticoagulant that she had could become more dangerous because pregnancy alone increases the risk of blood clots.  In addition, the Lupus Anticoagulant increases the risk of miscarriage by generating blood clots in the placenta. 

Most clots do not have a clearly identifiable cause. The usual, basic treatment for people who have blood clots is to give them anticoagulants, medicines that make it somewhat harder to  generate a clot.  The anticoagulant medicine is given for some time,  often  6 months.  The duration of treatment represents a time in which the unknown cause, hopefully, goes away.  A few years ago, the New England Journal of Medicine published an article implying that the physician should check a blood test, d-dimer, a test for ongoing clotting, before stopping treatment .  That article makes sense to me, and I routinely do that. The d-dimer test is somewhat ( possibly) overly sensitive.  Sometimes it is positive, and no clot is found. 

We had treated the patient in the usual manner.  We then rechecked the Lupus Anticoagulant  test and d-dimer test and they were negative.  I then applied the parsha: 

לֹא-תִהְיֶה אַחֲרֵי-רַבִּים, לְרָעֹת; וְלֹא-תַעֲנֶה עַל-רִב, לִנְטֹת אַחֲרֵי רַבִּים--לְהַטֹּת.

2 Thou shalt not follow a multitude to do evil; neither shalt thou bear witness in a cause to turn aside after a multitude to pervert justice;

Rashi interprets this to mean

From here they [the Sages] expounded that we may not decide unfavorably [for the defendant] by a majority created by one judge. They interpreted the end of the verse: אַחִרֵי רַבִּים לְהַטֹת, “after the majority to decide,” [to mean] that if those [judges] voting [that the defendant is] guilty outnumber those voting [that the defendant is] innocent by two, the verdict is to be decided unfavorably according to their [the majority’s] opinion. The text speaks of capital cases [i.e., in regard to the death penalty] (Sanh. 2a).

I understand this to mean that one should not make a life or decision based upon a single determination. 

So, before stopping anticoagulant we repeated the tests.  This time the Lupus anticoagulant was again negative, but the d-dimer was positive. 

The patient told me that she had gone to and ER for leg swelling and asked that the d-dimer test be done. 

The ER doc told her that he would not do the test because if  this overly sensitive test  came back positive, he would have to treat her!

מִדְּבַר-שֶׁקֶר, תִּרְחָק; וְנָקִי וְצַדִּיק אַל-תַּהֲרֹג, כִּי לֹא-אַצְדִּיק רָשָׁע.

7 Keep thee far from a false matter; and the innocent and righteous slay thou not; for I will not justify the wicked.