CCAR RESPONSA COMMITTEE

5759.10

Compulsory Immunization

She’elah.

Our congregation has a policy that children who have not received the standard immunizations will not be admitted into our religious school. Recently, this policy has been challenged by several member families, who object to some of these immunizations as excessively risky and who have therefore not immunized their children. Attempts to reach a compromise have failed, and these families have now left the congregation. Is our immunization policy correct and justifiable according to Jewish tradition? (Professor Marc Bernstein, Ann Arbor, MI)

Teshuvah.

1. The Mitzvah of Medicine. Any discussion of our she’elah must begin with this fundamental fact: Jewish tradition regards the practice of medicine as a mitzvah, a religious obligation.^[1] It is an aspect of pikuach nefesh, the preservation of human life,^[2] a mitzvah that takes precedence over virtually every other requirement of the Torah.^[3] Even the rules of Shabbat and Yom Kippur are superseded in order to save life, and medicine falls under this instruction. Should an “expert” or “competent physician” (rofe uman or rofe baki) prescribe a remedy for a patient with a serious illness, the patient must accept the remedy even if its preparation and application would normally violate the prohibitions of those holy days.^[4] One who refuses this treatment on the grounds that he or she prefers to observe the laws of Shabbat “is a pious fool (chasid shoteh). This is not an act of piety but of suicide. He is compelled to do what the physicians prescribe.”^[5] Although our tradition speaks of a variety of acts that might be undertaken by and on behalf of the sick, such as t’shuvah (repentance), t’filah (prayer), and tz’dakah (giving to the poor),^[6] we are nonetheless required to follow the law of nature and to call the physician when we fall ill.^[7] Whoever refuses medical treatment in favor of the other, non-natural responses, is guilty of the sin of arrogance, of assuming that one deserves to be healed by way of a miracle.^[8]It follows from all this that we are obliged to accept appropriate medical treatment and to provide it to our children, for their health and well-being is our responsibility. The key word here is “appropriate”: we are not required to accept medical treatment that serves no legitimate therapeutic purpose. If a course of medical treatment is not therapeutic–that is, if it does not contribute to the successful treatment of disease–it does not qualify as “healing” (r’fuah) as Jewish tradition understands that term. It ceases to partake of the mitzvah of pikuach nefesh, and hence it ceases to be obligatory. The precise definition of terms such as “therapeutic” and “successful treatment,” as we have written elsewhere,^[9] is difficult to establish with precision. Still, our tradition does distinguish between therapies regarded as “proven” (r’fuah vada’it or r’fuah b’dukah), which offer a reasonably certain prospect of successful treatment, and those that are experimental or untested, which offer but an uncertain therapeutic benefit. We are required, the authorities tell us, to accept “proven” remedies; they are pikuach nefesh, and we have no right to refuse them. On the other hand, we are not required to accept medical treatments that are “unproven,” of dubious therapeutic value.^[10]This distinction is of critical importance to the case before us. The parents in question claim that the immunizations required by their congregation pose excessive risks to the health and safety of the children who receive them. If this claim is correct, then Jewish tradition may well support the refusal of these parents to immunize their children, for “excessively risky” treatments might not be regarded as legitimate medicine. Indeed, a therapy that poses an unacceptable danger to life can hardly be said to fulfill the mitzvah of pikuach nefesh.^[11]

   The questions we must answer are these. Do immunizations qualify as r’fuah bedukah, as proven remedies? Do they offer a reasonably certain prospect of successful treatment, in this case, the prevention of dangerous diseases, or are their therapeutic benefits dubious at best? Granted that no medical therapy can be entirely free of risk, do vaccines pose a level of danger that outweighs their benefits? And even if we regard vaccines as a clear and positive good, is it the proper concern of a synagogue (or any public body for that matter) to require that children be immunized?

2. Immunization as R’fuah. “Immunization” is the process of artificially inducing immunity or providing protection from disease. There are two forms of immunization: “active immunization,” by which the body is stimulated to produce antibody and other immune responses through the administration of a vaccine or toxoid; and “passive immunization,” the provision of temporary immunity through the administration of preformed antibodies derived from humans or animals.^[12]Not so long ago, infectious disease was counted as the most serious threat to human life. Its effect upon children was devastating: of every 1000 children born in 1900, 160 died of an infectious disease before the age of five.^[13] Today, by contrast, “parents in the developing world no longer fear these diseases.”^[14] This welcome change, surely one of the great success stories of the twentieth century, is largely due to vaccines, which “are among the most effective means of preventing disease, disability, and death.”^[15] The ultimate goal of immunization is the eradication of disease, and the model for this eradication is the experience with smallpox. This once deadly killer was eliminated from the world in 1980 through a combination of a worldwide campaign of immunization, surveillance, and adequate public health control measures.^[16] This experience has been repeated time and again. Prior to the development of the Salk vaccine in 1955, paralytic poliomyelitis claimed up to 18,000 victims in the United States during epidemic years; today, this number is down to five to fifteen cases per year, primarily among those who for some reason have not been immunized. Diphtheria was once a common respiratory illness, with a 5% to 10% fatality rate; today, fewer than 100 cases are reported in the United States each year. Before the 1960s, well over 500,000 cases of measles occurred each year in the United States, and one out of every fifteen children who contracted the disease during the large epidemics died from it. Today, the incidence of measles has been reduced by 99%.^[17] Worldwide, it is estimated that at current levels of immunization, 3.2 million deaths from measles and 450,000 cases of paralytic polio are prevented each year and that another 1.2 million measles deaths and 12,000 cases of paralytic polio might be prevented if full immunization is achieved.^[18] During a rubella epidemic in 1964-1965, 20,000 infants born to mothers infected during pregnancy suffered from blindness, heart disease, and mental retardation. “Today, thanks to nearly universal use of an effective vaccine, the rubella virus poses virtually no threat to the children of expectant mothers.”^[19] In addition, immunization has brought with it an enormous economic benefit, for it is far more efficient to prevent a disease than to treat it. Recent studies in the United States suggest that each of the traditional vaccines is cost saving in terms of direct medical costs alone and that an integrated immunization program saves $7 to $9 for each $1 spent.^[20] It is true, of course, that immunization is not the only factor to be credited in the successful battle against these diseases. Other measures, such as improved nutrition and sanitation, play an important role as well. Yet in the absence of effective vaccines these other measures would not have produced the impressive life-saving results that we have witnessed in our time. Thus, in addition to all other disease-fighting tools, “every health authority with responsibility for child health must have a well-organized program of immunization as locally appropriate.”^[21] These programs are often made compulsory for the residents of the particular community. In the United States, the schedule of immunization for children is determined by the Advisory Committee on Immunization Practices of the U.S. Public Health Service and the Committee on Infectious Diseases of the American Academy of Pediatrics.^[22] All states require immunization of children at the time of entry into licensed child care and entry into school. In addition, many states have regulations requiring immunization of older children in upper grades as well as those entering college.^[23]

   The parents of whom our she’elah speaks fear that some or all of the vaccines administered on the required immunization schedule pose unacceptable risks to their children. These risks are not imaginary ones. The Committee on Infectious Diseases of the American Academy of Pediatrics states openly that “although modern immunizing agents are generally considered safe and effective, they are neither completely safe nor completely effective. Some vaccines may have an untoward reaction, and some will not be protected.”^[24] It is hardly a surprise that vaccines may cause “untoward reactions.” Medical therapies, many of which carry the potential for harmful side-effects, are inherently risky; as our own tradition so starkly puts it, “that which heals one patient may kill another.”^[25] Yet this unhappy reality does not mean that we should refuse to go to the doctor or that the practice of medicine is not a mitzvah. Rather, we measure the risks against the benefits offered by the therapy in question. When we do this with respect to vaccines, we find that the risks they pose are far outweighed by the prospect of infection, morbidity and mortality from the diseases they are intended to prevent.^[26] For example, each year in the United States, eight to ten people will develop paralytic polio as a result of immunization with the oral polio vaccine (OPV) or through contact with a person who has received that vaccine.^[27] This number is tiny compared to the many thousands of cases of polio which occurred each year prior to the development of the first successful vaccine. Another instructive case is that of the whole-cell pertussis vaccine, the subject of great controversy during the late 1970s and early 1980s. Due to claims that some children had been injured by the vaccine,^[28] many parents in Japan, Sweden, and the United Kingdom chose not to immunize their children against the disease. The result was a return of pertussis in those countries to epidemic proportions.^[29] The risks of the pertussis vaccine are real enough: grave complications (encephalopathy and permanent neurological damage) occur in 1 out of 100,000 and 1 out of 300,000 cases, respectively. Still, the risk of death or encephalopathy from pertussis infection in an unimmunized child is much higher. Projections from the recent epidemics indicate that the risk of pertussis-related death is 10 times greater in an unimmunized population than in an immunized population of children.^[30]

   The risks associated with immunization are of vital concern to the medical profession and the scientific community, which have developed various means to monitor the safety of vaccines. The American Academy of Pediatrics issues recommendations that attempt to minimize risk by providing specific advice on dose, route, and timing of the vaccine and by delineating circumstances that warrant precaution in, and abstaining from, administering the vaccine.^[31] In the United States, the Food and Drug Administration and the Centers for Disease Control and Prevention manage a program called the Vaccine Adverse Event Reporting System (VAERS), which like similar programs in other countries maintains surveillance over vaccine safety.^[32] Improved and safer versions of the vaccines are constantly tested and made available. These surveillance and testing measures are not perfect; they do not reduce the risk factor of the vaccines to zero. Yet with all that, “the overwhelming view of the medical/public health community is that the risks of vaccine reactions, both the common mild reactions and the rare, more serious reactions, are very much outweighed by the public health benefit conferred by current vaccination practices and policies.”^[33]

   All of this leads to the conclusion that immunization qualifies as r’fuah b’dukah or vada’it, a medical therapy of proven effect. As such, Jewish tradition would define immunization as part of the mitzvah of healing and recognize it as a required measure, since we are not entitled to endanger ourselves or the children for whom we are responsible by refusing proven medical treatment. Immunization, moreover, is a matter of social ethics and responsibility as well. Scientists recognize that protection of individuals from serious diseases depends not only on their own immunization but on the immunization of others in the community. Vaccines are not one-hundred percent effective; even in a fully immunized population, the vaccine will not succeed in conferring immunity upon every single person. Our chance of contracting disease is lower, therefore, if those around us remain healthy–that is, if they are immunized–than if they carry the disease. The concept here is “community immunity” or “herd immunity,” the level of immunity achieved when there is a sufficient level of vaccine protection in the population to prevent the spread of the disease to those who remain biologically susceptible. “With herd immunity, the likelihood of two susceptible individuals being within the range for transmission is very, very small.”^[34] Immunization, therefore, is not a purely private matter but one of social ethics: our decision to vaccinate or not to vaccinate directly affects the lives and health of our neighbors.^[35

   For these reasons, we would endorse programs of compulsory immunization in our communities, with exemptions granted to those individuals whose medical conditions place them at particular risk of injury or untoward side effects.^[36] Aside from those individual cases, there are no valid Jewish religious grounds to support the refusal to immunize as a general principle.

3. A Note on Scientific Evidence. The preceding section draws heavily upon expressions of scientific opinion, particularly those of researchers associated with the universities, professional societies, governmental agencies and other institutions that comprise the mainstream of the scientific community. As noted above, it is “the overwhelming view” of this community that immunizations are both safe and effective. This view has been challenged, however, by critics whose arguments have provoked a controversy that rages in print, on Internet sites, and before government bodies.^[37] The critics charge that many of the vaccines currently in use are ineffective or dangerous to the lives and health of children. These criticisms, in turn, are rebutted by the representatives of “the overwhelming view” who insist that vaccines prevent disease and that the risks they pose are either non-existent or minimal.^[38]
   
   As rabbis, we are not competent to render judgments in scientific controversies. Still, we do not hesitate to adopt “the overwhelming view” as our standard of guidance in this and all other issues where science is the determining factor.^[39] True, the scientific consensus is not infallible; history teaches us that the “predominant viewpoint” among scientists has often been wrong. The conclusions we reach in this responsum would therefore change were we to be convinced that the scientific information on which they are based is faulty. Yet we rely upon “the overwhelming view” of scientists, not because scientists are immune to error, but because today’s science is a discipline defined by a rigorous methodology that leads to the recognition and correction of mistakes. The findings of any researcher are tested and retested carefully; they are subject to close scrutiny and peer review. Questions concerning the safety of any vaccine are vigorously examined by the medical community, and these examinations can and do lead to changes in the recommended schedules of vaccines.^[40] It is precisely because scientists acknowledge that they can be wrong and precisely because the medical community trains such a watchful eye upon the issue of vaccine safety that “the overwhelming viewpoint,” the consensus opinion among practitioners, is worthy of our confidence.
4. May a Congregation Require Immunization as a Requirement for Religious School Admission? Jewish tradition recognizes the right of the community to make legislative enactments made by a community for the maintenance of its vital institutions and the governance of its public affairs. These enactments are called takanot hakahal (“communal ordinances”), a concept we have cited as the basis for our own community’s power to determine its destiny and to adopt rules that bind its members.^[41] In terms of substance, moreover, the community may adopt any rule it sees fit, even if the rule is not supported by formal Talmudic halakhah, so long as it does not constitute an egregious violation of conscience or a clear religious prohibition.^[42] This congregation is therefore entitled to require that its students be immunized against disease prior to their admission to religious school. Such a rule violates no prohibition of Jewish law or tradition. On the contrary: inasmuch as this rule would reinforce a policy of immunization that medical opinion accepts as a vital measure in the battle against life-threatening disease, it reflects our understanding of medicine as a mitzvah and our ethical responsibility to those who live alongside us.

Conclusions.

1. Immunization is in the category of r’fuah b’dukah or r’fuah vada’it, “proven” medicine, and as such is part and parcel of the traditional obligation to practice and to avail ourselves of medical treatment.
2. Because it can create the conditions that lead to “herd immunity” or “community immunity,” compulsory immunization is a vital aspect of the medical policy of society. So long as exemptions to vaccination requirements are granted to those individuals to whom the vaccines pose a particular medical risk, neither Jewish tradition nor our own Reform understanding of that tradition would object to compulsory immunization against disease.
3. A congregation is entitled, should it so choose, to adopt a rule that requires immunization of students before their admission to religious school.

NOTES

[1].         SA Yore De`ah 336:1, drawn from Tur, Yore De`ah 336. The wording of that passage indicates how this concept developed over the centuries. The Torah itself never states explicitly that medicine (r’fuah) is a mitzvah. The Sages, for their part, were decidedly ambivalent as to the value of medical practice, with some even condemning it as evidence of lack of faith in the power of God to heal the sick; see the discussion in Teshuvot for the Nineties (TFN), no. 5754.18 (373-375). Rabbinic halakhah did recognize that the physician was permitted to practice medicine (BT Bava Kama 85a, based upon a midrash of Ex. 21:19); thus, the Shulchan Arukh begins by declaring that “the Torah grants the physician the permit (reshut) to practice medicine.” The passage adds immediately, however, that this permit is in fact “a mitzvah, in the category of pikuach nefesh.” See note 2.
[2].         It was Nachmanides (Ramban) who developed this connection in his Torat Ha’adam, Chavel ed. (Jerusalem, 1964), 41-42. He notes that the prohibitions connected with Shabbat and Yom Kippur are set aside when their observance would endanger human life and that we rely upon the diagnosis of a physician to determine that a situation of danger exists. The Tur and the Shulchan Arukh (see note 1) adopt this theory to justify the assertion that medicine is an integral element of the mitzvah of pikuach nefesh.
[3].         On pikuach nefesh see BT Yoma 85b and Sanhedrin 74a (and parallels); BT Yoma 82a (“nothing stands in the way of pikuach nefesh except for [the prohibitions of] idolatry, adultery and incest, and murder [which may not be violated even in order to save one’s life]”); Yad, Yesodei Hatorah 5:1ff.; SA Yore De`ah 157.
[4].         For the details of the halakhah, see Yad, Shabbat 2 and SA Orach Chayim 328 and 618
[5].         Resp. R. David ibn Zimra 1:1139.
[6].         See especially BT Shabbat 32a and Bava Batra 116a (on Proverbs 16:14).
[7].         See Nachmanides to Lev. 26:11. Although Ramban seems to give only a grudging assent to medical practice in that passage (one that is very much at odds with the halakhic formulation in Torat Ha’adam; see note 2), he does conclude that while in an ideal world we might be able to rely upon prayer and repentance as remedies to disease, in this world we are forbidden to rely upon miracles. See Turei Zahav, YD 336, no. 1.
[8].         R. Chaim Yosef David Azulai, Birkei Yosef, YD 336, no. 2, cited by R. Shelomo Ganzfried, Kitzur Shulchan Arukh, 192:3.
[9].         For a more complete discussion, see our responsum TFN, no. 5754.14, “On the Treatment of the Terminally Ill,” part III, at 346ff.
[10].       The classic statement of this distinction is R. Ya`akov Emden, Mor Uketzi`ah 328.
[11].       Much here depends upon the medical condition of the patient. A treatment that is “excessively risky” for one patient might well be in order–that is, therapeutically appropriate–for another patient who would likely or surely die without it. See Moshe Raziel, “Kefi’at choleh lekabel tipul r’fu’i,” Techumin 2 (1981), at 335-336.
[12].       Stephen C. Hadler (Director, National Immunization Program, Epidemiology and Surveillance Division, Centers for Disease Control and Prevention) and Walter A. Orenstein (Director, National Immunization Program, Centers for Disease Control and Prevention), “Active Immunization,” in S. Lang, L. Pickering, and C. Prober, eds., Principles and Practice of Pediatric Infectious Diseases (New York: Churchill Livingstone, 1997), 49.
[13].       R.H. Waldman and R.M. Kluge, eds., Textbook of Infectious Diseases (New York: Medical Examination Publishing Co., 1984), 4.
[14].       Susan S. Ellenberg, Ph. D. (Director, Division of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration) and Robert T. Chen, MD (Chief, Vaccine Safety and Development Activity, Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention), “The Complicated Task of Monitoring Vaccine Safety,” Public Health Reports 112:1 (1997), 11.
[15].       Hadler and Orenstein, 49.
[16].       Committee on Infectious Diseases, American Academy of Pediatrics. 1994 Red Book: Report of the Committee on Infectious Diseases (Elk Grove Village, IL: American Academy of Pediatrics, 1994), 7. The smallpox vaccine, developed in England by Edward Jenner in 1796, was the first successful immunization measure.
[17].       The figures for polio, diphtheria and measles are taken from John H. Dorsett (Professor of Pediatrics, The Pennsylvania State University College of Medicine), “Immunizations,” in R.A. Hoekelman et al., eds., Primary Pediatric Care, Third Edition (St. Louis: Mosby, 1997), 182-194.
[18].       R. Kim-Farley and the World Health Organization Expanded Program on Immunization Team, “Global Immunization,” Annual Review of Public Health 13 (1992), 223-238.
[19].       David Satcher, M.D., Ph.D., Surgeon General of the United States, Statement Before the U.S. House of Representatives Committee on Government Reform, August 3, 1999.
[20].       Hadler and Orenstein, 49. And see Satcher: every $1 spent on measles-mumps-rubella vaccine (MMR) results in $13 total savings.
[21].       Eva Alberman (Emeritus Professor of Clinical Epidemiology, University of London) and Peter O.D. Pharoah (Professor of Public Health, Department of Public Health, University of Liverpool), “Children,”in R. Detels, W.W. Holland, J. McEwen, and G.S. Omenn, eds., Oxford Textbook of Public Health (New York: Oxford U. Press, 1997), 1379-1396. See also Roger Detels (Professor of Epidemiology, School of Public Health, University of California at Los Angeles) and Lester Breslow (Professor of Public Health, School of Public Health, University of California at Los Angeles), “Current Scope and Concerns in Public Health,” in Detels et al., 3ff: before 1981, with the spread of AIDS, it appeared that pandemics of infectious disease other than influenza had been eliminated as a major problem in developing countries. This was due to provision of safe drinking water, better handling of sewage, effective vaccine campaigns, improved personal hygiene, and improved nutrition, especially among children.
[22].       Hadler and Orenstein, 52.
[23].       1994 Red Book, 623.
[24].       Ibid., 29. See also Dorsett, 184: “no vaccine is perfectly safe and always effective” (italics in original).
[25].       Nachmanides, Torah Ha’adam, inyan hasakanah (Chavel ed., 43).
[26].       Dorsett, 187.
[27].       D.R. Prevots, R.W. Sutter, P.M. Stickel et al., “Completeness for Reporting Paralytic Poliomyelitis, United States, 1980-1991,” Archives of Pediatric Adolescent Medicine 148 (1994), 479-485.
[28].       See H. Coulter and B. Fisher, DPT: A Shot in the Dark (New York: Warner Books, 1985).
[29].       M. Kimura and H. Kuno-Sakai, “Developments in Pertussis Immunization in Japan,” Lancet 336 (1990), 30-32; D. Miller et al., “Pertussis Immunization and Serious Acute Neurological Illnesses in Children,” British Medical Journal 307 (1993), 1171-1176; I. Krantz, J. Taranger, and B. Trollfors, “Estimating Incidence of Whooping Cough Over Time: A Cross-Sectional Recall Study of Four Swedish Birth Cohorts,” International Journal of Epidemiology 18 (1989), 959-963.
[30].       Dorsett, 187.
[31].       The protocols are summarized in 1994 Red Book, 35-39.
[32].       The system is described in Ellenberg and Chen (note 14).
[33].       Ellenberg and Chen, 19.
[34].       Phyllis Freeman, JD (Professor and Chair of the Law Center, MacCormick Institute, University of Massachusetts), “The Biology of Vaccines and Community Decisions to Vaccinate,” Public Health Reports 112:1 (1997), 21.
[35].       In its publication, Six Common Misconceptions about Vaccination (Atlanta, 1999), the Centers for Disease Control and Prevention expresses the concept as follows: “A successful vaccination program, like a successful society, depends on the cooperation of every individual to ensure the good of all. We would think it irresponsible of a driver to ignore all traffic regulations on the presumption that other drivers will watch out for him or her. In the same way we shouldn’t rely on people around us to stop the spread of disease; we, too, must do what we can.”
[36].       See 1994 Red Book at note 30.
[37].       See, e.g., Coulter and Fisher at note 25. For a sharp critique of the “anti-immunization” movement see A. Allen, “Injection Rejection,” The New Republic, March 23, 1998, 20-23. The proliferation of anti-immunization Internet sites has spawned a number of other sites in response; these are simply too numerous to detail. See the “Informed Parents’ Vaccination Webpage” (www.unc.edu/~aphillip/www/vaccine/informed.html), administered by Alan Phillips of the Citizens for Health Care, Durham, NC. Mr. Phillips describes himself as an “informed parent; a technical writer; a freelance writer on alternative health issues; an internationally known singer-songwriter/composer; and founding director of a small international nonprofit corporation.” A representative “pro-vaccination” page is www.vaccinesafety.edu, the Institute for Vaccine Safety at The Johns Hopkins University. For “government bodies,” see the testimony of Dr. David Satcher (note 19.
[38].       Thus, Dr. Neal Halsey, Director of the Institute for Vaccine Safety at The Johns Hopkins University, speaks of “misperceptions” regarding causality: that is, many in the public believe that a number of vaccines are causally related to specific diseases, even though no evidence exists to prove such an association (N. Halsey, “Ensuring the Safety of immunizations,” Programs and Abstracts from the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. (San Francisco: September 26‑29, 1999; Abstract 486). See, in general, the text at notes 12-23.
[39].       Reform Judaism, in particular, has taken a positive stance towards modern science as a guide to making religious decisions in matters that can legitimately be defined as “scientific.”See our responsum no. 5757.2: “given our positive attitude as liberal Jews toward modernity in general, it is surely appropriate to rely upon the findings of modern science, rather than upon tenuous analogies from traditional sources, in order to render what we must consider to be scientific judgments.”
[40].       See the text at notes 31 and 32, and Satcher (note 18). See also Morbidity and Mortality Weekly Report (published by the Centers for Disease Control and Prevention) 48:27 (July 16, 1999), 590: the Advisory Committee on Immunization Practices (ACIP) now recommends that the oral polio vaccine (OPV) be replaced by inactivated poliovirus vaccine (IPV). OPV has tended to cause “vaccine-associated paralytic polio” (VAPP) in one case out of every 2.4 million distributed doses of the vaccine. While this level of risk was regarded as justified, given the life-saving effects of OPV, it has been decided that given the success of worldwide polio eradication efforts, the safer vaccine ought to be administered.
[41].       See our responsum 5758.2, “A Reform Rabbi’s Obligations Toward the UAHC,” section 2, for sources and discussion.
[42].       R. Chaim Yair Bachrach, Resp. Chavat Yair, no. 57. For analysis, see Jacob Katz, Halakhah vekabalah (Jerusalem: Magnes, 1984), 244-246.