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S C I E N T I F I C A RT I C L E

Treating Very Young Patients with Conscious

Sedation and Medical Immobilization:
A Jewish Perspective
Ari Kupietzky, D.M.D., M.Sc.
oey, a 3-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 owing to infection. The treatment recommended by the familys dentist included
extractions, root canal treatments and fillings.1 The
patient was referred to a pediatric dentist. The specialist examined a screaming, kicking Joey and confirmed
that he needed to receive extensive dental care. He
recommended two methods for patient management
and delivery of treatment: treatment given under general anesthesia in a hospital operating room with
nasal intubation or treatment under conscious sedation in a private dental setting. When the patient is
treated with the latter method, the child is premedicated with an oral sedative, placed in a passiverestraint device (medical immobilization) and treated
with supplemental nitrous oxide/oxygen inhalation
analgesia. Local anesthesia would also be used. During treatment, the child might be expected to react
with a wide spectrum of behaviors, ranging from
sleep to hysteria, and interfering child behaviors, such
as crying, and body or extremity movements. The
parents now face a dilemma: Should their child be
treated under general anesthesia and be exposed to

the adherent risks of the invasive anesthetic procedure

or would the use of sedation and medical immobilization be the better choice?
Some parents may prefer to avoid any potentially
stressful situation and opt for treatment under general
anesthesia. However, the decision may become more
troublesome and complicated when multiple treatments are needed and the child might repeatedly be
exposed to general anesthesia and consequently all of
its risks. Whereas some practitioners prefer to attempt
and exhaust sedative techniques where indicated and
use general anesthesia as a last resort, many others do
not. They routinely recommend general anesthetic as
their first choice, thus avoiding any stressful situation
in their private practice.
As a pediatric dentist and ordained rabbi, I am
approached by many parents, and, indeed, even colleagues, seeking advice on this issue. Differing opinions
and controversy between various medical centers, dental professionals, staff and family regarding the dental
care of precooperative or preschool young children
have dominated my own involvement in these clinical
ethics consultations. These conflicts include the cost of
treatment, considerations of financial expense covered
by insurance companies and psychological stress on

Ari Kupietzky, D.M.D., M.Sc.

Ari Kupietzky received his D.M.D. at the

Hebrew University-Hadassah School of
Dental Medicine Founded by the Alpha
Omega Fraternity in Jerusalem in 1990. He
continued his studies at the medical school
and earned a master of science degree in
pharmacology. Dr. Kupietzky completed
his pediatric dentistry training at the University of Medicine and DentistryNew Jersey Dental School in
Newark. During his postgraduate studies, he conducted fluoride
research at Colgate Palmolive Research Laboratories and was
awarded an Alpha Omega Foundation Postdoctoral Research

Fellowship twice during his studies abroad. Currently, Dr. Kupietzky is performing research on the sedation of the very young
child and practices pediatric dentistry in his private office. He is
a fellow of the American Academy of Pediatric Dentistry and a
diplomate of the American Board of Pediatric Dentistry. Dr.
Kupietzky is currently serving as a Board member on the editorial board of Pediatric Dentistry and is a member of the Advisory
Council of the American Board of Pediatric Dentistry, Sedation
and Hospital Section. Dr. Kupietzky teaches part time at the
Department of Pediatric Dentistry of the Hebrew UniversityHadassah School of Dental Medicine. He resides in Israel with
his wife and seven children.

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parents. Biases often exist among parents and dentists

regarding the safety, costs and practicality of the various methods and affect the decision-making process.
For example, children treated under general anesthesia
will achieve their treatment during a single session.
Parents may opt for such treatment in comparison with
prolonged and numerous treatment sessions and
ignore concerns about the safety of each mode of treatment. Dental-phobic parents may be so influenced by
their own dental anxiety that they are unable to fully
comprehend the advantages of conscious sedation. The
purpose of this article is to present to the reader
another point of view on this very emotional dilemma
and to illustrate how this problem can be analyzed
using Jewish rabbinical sources.

The image of a screaming terrified child, pinned to

a board for several hours of work on his mouth and
She [the dentist] mustnt follow a plan [of restraining the child for dental treatment] that is inhumane
and risky.1 What is the basis of such biased and negative opinions of the technique? Why do many suppose that general anesthesia is less harmful to the
childs well-being than treatment with conscious
sedation and medical immobilization? Perhaps
todays ethicists are products of a society in which
parenting styles have drastically changed and these
new styles have affected their view on such matters.
It would be informative to introduce to the reader
the ethics found in Jewish sources pertaining to the
use of restraint for the benefit of a patient.

Medical Ethicists View

Jewish Perspective

In both the professional and the lay media, medical

immobilization is often referred to as strapping
down or tying up a child. Controversy exists as to
the benefits and risks, as well as the ethical and legal
consequences, of the use of medical immobilization.
Medical personnel are ambivalent about using
restraints, believing that they affect the patients
freedom, self-respect and self-reliance.2 The use of
conscious sedation and restraints has been described
by its opponents in very negative terms. One recent
article, entitled Case Study: Strap Him Down,
described such treatment for a young dental patient
as perhaps causing lasting psychological damage.1
An ethicist went as far as commenting that such
treatment may be seen as a case of child abuse and
that physicians should refuse to treat patients with a
restraint device. Some ethicists were axiomatic that
the use of medical immobilization is ethically wrong
and focused on only one ethical issue, namely, if the
physician may perform treatment (using restraint)
on a child that is dictated by insurance companies
and yet is in conflict with the physicians own ethical
and moral standards (who preferred treatment
under general anesthesia). The misconception and
misinterpretation of the use of medical immobilization with conscious sedation is clearly evidenced in
the extreme and harsh statements published in the
aforementioned article: To strap a child to a board
for the time required to complete treatment or

Rabbi Lord Dr. Immanuel Jakobovits (the late

knighted Chief Rabbi of Great Britain), who was the
first to introduce the term Jewish medical ethics,
explains that there is a basic difference between secular medical ethics and Jewish medical ethics.3 The former seeks to turn ethical guidelines or rules of conscience into law, legislation or codes of conduct. The
law is the product of moral intuition or consensus.
Jewish medical ethics, however, operates in reverse.
Jewish medical ethics derives from legislation; it does
not lead to legislation. The Jewish ethicist extrapolates
or enucleates the ethical rules and moral principles
from the Jewish law or halacha. As Glick summarized:
The guidelines of Jewish medical ethics are a product
of traditional source texts, clearly defined methodology, recognized scholars and rigorous principles of
charity, justice and mercy, which shape these standards.4 Each individual who accepts the Jewish tradition is governed in all aspects of life by this Jewish
value system as represented by halacha, patient and
physician alike. However, it is important to clarify and
clearly state that physicians are required by halacha to
obey the law of the land as adjudicated in the courts.
Keeping this in mind, let us proceed and analyze the
medical ethical problem from a Jewish point of view.
Obligation to Heal

A physician is considered to be Gods emissary to

heal the sick.5 The physician is permitted and even

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required to treat patients according to currently

acceptable medical standards and need not fear that
he or she will err. Maimonides (leading Torah
scholar, philosopher and physician of the Middle
Ages, 11351204) asserted: It is obligatory from the
Torah [the five Books of Moses] for the physician to
heal the sick and this is included in the explanation of
the scriptural phrase (Deuteronomy 22:2) and thou
shalt restore it to him meaning to heal his body.6
It is evident that the source of the obligation to
treat a patient is not based on the patients request to
have treatment but rather is placed on the physician
directly. However, just as the physician is obligated to
heal, the patient is commanded to seek medical
attention and is not allowed to refuse standard medical treatment. The patient who refuses reasonable
and appropriate medical treatment through ignorance or irrational fear is in violation of a positive
commandment. The physician, acting in what is
known to be the interest of the patients health,
would thus not be subject to Jewish ethical sanctions
for not obtaining consent.7 In such a case, the physician must do all he or she can to bring about the
treatment of the patient. In the extreme case, the
patient may be forced to receive the treatment.8
Restrictions on the Physician

Jewish law, however, places some restrictions on the

manner in which the physician is licensed to carry
out his duty. For example, the doctor must do whatever he or she can to ensure that his treatment does
not involve pain. A doctor who treats a patient but
does not do his or her utmost to minimize pain is
not fulfilling his mission properly.9 Another restriction involves the prohibition of assault. Judaism recognizes divine proprietorship over the human body.
The individual has no proprietary rights with regard
to his or her own body.10 Any form of assault on the
body is against Jewish law. The source for this prohibition is Deuteronomy 25:3, as stated by Maimonides: A person is forbidden to wound himself
or his fellow being. As is written, lest he additionally
flog him. 11 Rashi (acronym for Rabbi Shlomo
Yitzchzki, 10401105; fundamental commentary on
the Torah) commented: From here we derive that
one is forbidden to strike ones fellow.11 This pro-

hibition, which is called havala, includes selfinflicted wounds and those caused by others. The
terminology of a wound includes any type of physical damage done to the human body. For example,
injections, sutures, incisions, irradiation and even
the taking of blood for diagnostic purposes are all
considered forms of havala and are forbidden in
principle by Jewish law. However, surgical operations or any other medical procedures for therapeutic or diagnostic purposes are excluded from
the prohibition of wounding of the body through
the biblical commandment and he shall cause him
to be healed (Exodus 21:19). To clarify this point, a
physician, when performing any medical treatment,
should attempt to do so in the least invasive manner
and minimize the amount of havala or danger to his
or her patient. Although surgical procedures performed for the benefit of the patient are excluded
from the prohibition of havala (wounding), an
effort should still be made to inflict the least
amount of havala on a patient.
A rabbinical ruling by Rabbi Y. Ziberstein in
response to a question asked of him is found in the
Hebrew edition of ASSIA12 and is very much relevant
to our discussion. The question posed to him was
whether a dentist can prolong treatment and extend
it to two sessions of treatment for reasons other than
medical if the same treatment could be accomplished in one session. In his reply, he stated that
administering even one injection of local anesthesia
that is unnecessary is considered a violation of the
prohibition of any form of wound or assault on the
human body, whether it is self-inflicted or done to
another person. Rabbi Zilberstein emphasized that
this law is discussed in the Tractate Sanhedrin of the
Talmud. Therefore, a dentist or physician may not
prolong any procedure that may necessitate additional injections of local anesthesia for any purpose
other than the medical benefit of the patient.
Application of the Principles to the
Issue of General Anesthesia versus
Conscious Sedation

With regard to our dilemma of general anesthesia or

conscious sedation with medical immobilization,
although the administration of general anesthesia is

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relatively safe, major complications could occur. Lifethreatening complications, such as allergic reactions
and bronchospasms, could occur during induction,
although this is not highly expected. Nonetheless,
nonlife-threatening complications could routinely
occur and could 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 that is too large or overinflating
the cuff. All these may cause damage to the pharyngeal
wall. Nasotracheal intubation can cause trauma and
dislodgment of adenoidal tissue, increasing the risk of
postoperative infection, bleeding and sore throat.13 It
would seem that if general anesthesia, which routinely
includes the above-mentioned havala, can be avoided,
that it would be preferable, and as such, conscious
sedation would be the first choice.
On the other hand, we must take into account the
fact that restraining a child, when not carried out by a
skilled and sensitive doctor with a high level of ability
in communication with children, may cause the child
fear and panic, which may also be seen as a form of
injury and harm. Although the harm caused by panic
is not considered a havala (and is not legally punishable by Jewish law), it is nevertheless forbidden, and a
person who frightens another is subject to divine
punishment. Therefore, in the event that the technique of restraint is applied in such a way as to cause
trauma or fright, the doctor is considered as having
caused harm, as stated by Maimonides: He who
frightens his fellow, even though he became ill from

fear, is exempt from the judgments of man but liable

according to the judgments of Heaven.11 It follows
that, in principle, general anesthesia is considered a
more severe action than medical immobilization, even
if the restraint may cause fear, because causing panic
is forbidden but is punishable only by divine justice,
although general anesthesia, when not performed
properly, is a form of harm that is punishable by a
legal system (judgments of man), as any other type
of bodily harm that a person causes directly. Another
point to consider is the fact that even the general
anesthesia procedure may contain an element of fear,
for example, at the stage of induction.
It is with this reasoning that the preferred treatment of a young child would be medical immobilization, but to avoid possible trauma, it should always
be coupled with conscious sedation and local anesthesia. This conclusion holds true only in instances in
which there are no medical contraindications to the
treatment. An assumption is being made that there
are no significant differences in the risks involved
with either procedure. However, a medically compromised patient who might be at increased risk should
be treated only in the safest method available. The
guiding principle is to do what is best and safest for
the patient. If dental treatment under general anesthesia will be proven to be significantly better than
treatment rendered under conscious sedation (this
has not yet been proved), then general anesthesia
should be the treatment of choice (Tables 1 and 2). If
the risks of in-office sedation surpass the risks of general anesthesia, then, once again, general anesthesia
will take preference.

Table 1 General Anesthesia

Disadvantages

Advantages

Premedication
With/without separation
Masking (at times child briefly restrained during mask application)
Intravenous insertion
Anesthesia agents
Risk of hospital infection
Intubation and subsequent irritation of nose/throat
Fear immediately after extubation and recovery
Mortality/morbidity risks
Aggressive dental treatment owing to mode of management

All treatment performed in one session

Child unaware of treatment
Ease of delivery of treatment by dentist
Safety of hospital setting

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Table 2 Conscious Sedation with Medical Immobilization

Disadvantages

Advantages

Premedication
With/without separation
Restraining device throughout treatment
Crying during treatment may be expected
Child aware of treatment
Lack of effectiveness
Multiple treatment sessions
May be difficult for dentist and parent

Familiar surroundings
Less threatening environment
Recovery less traumatic
Child aware of treatment and may use experience positively
Conventional dental treatmentnonaggressive

Conclusion

A comparison of the two techniquesconscious

sedation with passive medical immobilization versus
general anesthesiashows that from a Jewish perspective, if all conditions are the same (risks, safety,
quality of dental treatment), restraint with positive
communication and maximal cooperation between
doctor and patient and with safe, professional
administration of conscious sedation is preferable
(Table 3). Only in situations requiring treatment in
which, according to medical opinion, medical immobilization would not be effective is it not only permissible but also obligatory to place a child under general anesthesia for medical treatment.
General anesthesia, where avoidable, is considered injurious and may not be undertaken based on
the prohibition against unnecessary risk. A doctor
may not refer a child for general anesthesia based on
any considerations other than the medical needs of
the patient. Concerns of malpractice, high insurance,
ease and personal preference are not acceptable as a
basis for performing general anesthesia.
Patients (or their parents) requests that would
compromise the physicians professional or moral
standards need not be carried out by the physician
from a Jewish ethics point of view.14 The message of
Table 3 Principles of Jewish Medical Ethics
The act of healing and seeking or rendering medical treatment is an
obligation of both the patient and the physician.
The least invasive method is preferable on the condition that it is also
the safest method and does not lower the standard of the medical
procedure.
Causing unnecessary physical injury to a patient is of more severity
than psychological damage.

this article and the Jewish medical ethics discussed

may have relevance beyond the specific faith community and be appreciated by all. As Glick stated: Jewish medical ethics has not only a message for the Jewish world, but a universal message that has stood the
test of time throughout the millennia.4
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3. Jakobovits I. The role of Jewish medical ethics in shaping
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12. Ziberstein Y. [Dentistry: Responsa to treatment planning
and non-dental considerations]. ASSIA 1988; 44:4653.
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general anesthesia cases. ASDC J Dent Child 1985; 52:3641.
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