Halachic Talking Part V

D. Other Applications

Another issue that has significant ramifications is the therapeutic options available to patients who undergo total laryngectomy. As reported by the CDC, in the United States, 12,500 cases of laryngeal cancer are diagnosed annually and 3,800 people die from the disease. Risk factors for developing laryngeal cancer include an extensive smoking history and development of human papillomavirus. When the tumor is situated in the glottic larynx, patients frequently present with hoarseness in the early stages of the disease. However, supraglottic and subglottic laryngeal and hypopharyngeal cancers tend to present in the advanced stages due to lack of early symptoms. Total laryngectomy is indicated in patients with extensive lesions, poor pretreatment laryngeal function or with recurrent disease after chemoradiation. There are many complications of this life saving surgical intervention, the one specifically relevant to our discussion is the loss of oral communication due to excision of the vocal cords[1].

There are three mainstream therapeutic interventions for voice restoration are artificial larynx (electrolarynx), tracheoesophageal voice restoration and esophageal speech; utilized by 55%, 31% and 6% respectively (8% remain non vocal). Selection of which therapy is used depends on the patient’s individual needs, personality, physical capabilities, independent function, caregiver support and motivation[2].

The electrolarynx is an electric device that produces vibrations that are transmitted through the external tissues or delivered intraorally via a plastic tube into the oral cavity. As such, it replaces the function of the vocal cords and lungs in the lower portion of the oral cavity. The user then retains the physiological function of the upper oral cavity in producing sounds by manipulating the tongue, jaw, lips and pharynx as if the patient was speaking physiologically. The recommendation is that all patients receive training in utilizing an electrolarynx as they can learn how to use them most easily after surgery and they are a good backup if one of the other methods of communicating fail. Disadvantages of the electrolarynx is that older models require use of the hand to hold them up to the throat, the mechanical sound of the speech and they draw attention that may not be warranted.

Tracheoesophageal (TE) puncture is most similar to normal laryngeal speech in quality, fluency and ease of production. Patients that utilize this method are more satisfied with their speech. A small surgically controlled fistula is created in the TE wall either during the initial laryngectomy or in a subsequent surgery. A unidirectional valved prosthesis protects the airway during swallowing and opens to divert pulmonary air across pharyngoesophageal mucosa for phonation with closed. The patient inhales and covers the stoma forcing the air to be exhaled through the esophagus. That sound can then be shaped into words by movement of the upper oral cavity as in with the electrolarynx.

The oldest method of regaining some speech capability is with esophageal speech. Patients are taught to rapidly force air into the esophagus and then control the expelled air as it passes through the oral cavity to produce speech. Vibration here is achieved in the pharyngoesophageal segment. The sound produced is most similar to physiological speech, however the pitch and intensity are considerably lower. The main advantage of this therapy is that no further surgical intervention or external devices are required to achieve oral communication. However, it takes a long time (up to six months of daily practice and regular speech pathology sessions) to learn these techniques and quality of speech is lower than with tracheoesophageal speech[3].

We are not aware of any halachic sources that discusses whether these methods of regaining oral communication are considering halachic talking. Intuitively, it would seem that all authorities should maintain that esophageal speech and TE puncture should be considered halachic talking. To assume the negative would require one of two positions. Either proving that halacha mandates that speech be produced in a very specific physiological manner and any deviation therein would not be considered halachic talking. Or, since the resultant voice does not sound like physiologic speech it cannot be considered halachic talking. Both positions are weak, at best. One would be hard pressed to find halachic sources that define the exact nature of speech and how it must be replicated in order to be considered halachic talking for the simple reason that throughout the centuries people did not know how physiological speaking was accomplished. It would then be difficult to argues that halacha has a specific formula that must be followed. The second argument is also difficult to maintain as to do so would require defining what talking must sound like. The general population has people whose speech varies greatly; some speak with a high pitch, others with low frequency, some whisper and other yell. To demand a specific sound be produced would inadvertently reject perfectly healthy individuals who utilize physiologic speech from halachic talking.

The electrolarynx, an artificial larynx, leaves more room for debate. It is more plausible to make the argument that since the resultant sound is mechanical and does not resemble physiological speaking, a halachic decider might argue it would not be considered halachic speaking.   A possible argument would be to assume that kol haavara would include sound that does not sound natural. Rabbis Shapiro, Frank and Waldenberg might indeed argue that since the sound produced with an electrolarynx does not sound natural it cannot be used to fulfill the obligation of blowing shofer[4]. However, as they do allow migglah to be heard over the “mixed” sound over a speaker, they may allow the use of the electrolarynx.

The above analysis assumes that we consider the authenticity of sound based on the result, not how that sound was produced. The other authorities described above all consider the process through which the sound was produced. The electrolarynx merely provides the vibrations that would otherwise be produced in the larynx. Rabbis Feinstein, Karelitz and Halpern may then all agree that even though the manipulation of the sound was conducted by a person, since its initiation was caused by the vibrations of the electrolarynx, it is not considered halachic talking.

It may however be plausible that Rabbi Auerbach would assume that an electrolarynx is considered halachic talking as his primary concern was the use of devices that convert the sound once it is emitted from the person’s body. Halacha may place no significance on sound before then. Case in point, the basic issue of kol haavara is that the sound produced by a person is echoed in a pit. However, sound undergoes a similar process within the upper and lower larynx and, yet halacha is not concerned by those changes. The finale sound is produced naturally, only the vibrations is accomplished by use of the electrolarynx.

Finally, speech generating devices (SGD) are a type of augmentative and alternative communication (AAC) device that allow paralyzed patients to communicate verbally. Depending on the degree or type or paralysis, patients are able to interact with SGDs by eye-gaze, head tracking or joysticks. The patient selects words that appear on the screen in front of him and the device’s speaker produces the chosen words verbally[5]. As the halachic sources above did not discuss anything remotely similar to an SGD assuming their position is complicated and possibly futile. However, there are principles that can be considered that we will apply to analyze the use of SGD to fulfill halachic obligations. It is palatable to assume that the positions that consider a speaker to be halachic talking would have a similar position with SGD. However, it is important to note the difference. The sound a speaker produces is the result of the sound waves emitted by the person, with an SGD no such sound waves are every produced. Their position may be limited to that which produces biological sound waves. Nevertheless, Rabbi Orienstein’s position might be in favor of SGD as halachic sound. Rabbi Orienstein, discussed above, described halachic sound as vibrating air produced by a person. It may stand to reason that vibrating air is not limited to that which is produced by the vocal cords and therefore eye movement that results in speech may qualify for halachic talking.

[1] https://www.uptodate.com/contents/management-of-late-complications-of-head-and-neck-cancer-and-its-treatment?search=total%20laryngectomy&topicRef=3402&source=see_link#H23196635

[2] Christopher G. Tang, Catherine F. Sinclair, Voice Restoration After Total Laryngectomy, Otolaryngologic Clinics of North America, Volume 48, Issue 4, 2015, Pages 687-702,ISSN 0030-6665, ISBN 9780323389006, https://doi.org/10.1016/j.otc.2015.04.013. (https://www.sciencedirect.com/science/article/pii/S0030666515000596)

[3] https://www.uptodate.com/contents/alaryngeal-speech-rehabilitation?search=total%20laryngectomy&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4#H8

[4] That is, assuming the electrolarynx is needed for a patient with a total laryngectomy to blow shofar.

[5] https://www.prentrom.com/caregivers/what-is-augmentative-and-alternative-communication-aac, https://www.wired.com/2015/01/intel-gave-stephen-hawking-voice/