Abstract: Tattooing is prohibited in Jewish Law (halacha). A real medical need supercedes this prohibition. Marking a location for radiation therapy may be such a need. However, halacha-observant women may prefer the use of other techniques such as markers.
Discussion: In many cancer centers, proper alignment of the radiation field is achieved by tattooing the outline of the area to be irradiated with tiny dots [1]. Tattooing poses a halachic problem stemming from Leviticus 19:28. According to most halachic authorities, this biblical prohibition applies to any mark that is caused by the use of both an instrument and color. There is a minority opinion that unless letters are formed there is only a rabbinic prohibition.
The halachic imperative to save lives permits tattooing if there is no other option, and there is no need for a patient to look for another, possibly less satisfactory, facility just to avoid tattooing. If tattooing is required, however, it is preferable for the procedure to be done by a non-Jew. If this is not feasible and a Jew performs the tattooing, at the least the patient should not assist in the procedure but should remain passive.
Another option is to use markers. Most facilities find this less preferable because the markings tend to fade. However, since radiation therapy is generally performed daily, new marking can be reintroduced over the existing color. Problems may arise when there is a hiatus of a few days, or the color may fade when the woman showers. Even in this case, however, there is usually enough color remaining for the technician to reintroduce the markings.
There continue to be new innovations to allow for marking the area without the use of visible tattoo ink.[2] [3]
As the ink is under the skin, a tattoo is not considered a barrier to ritual immersion. Marking is also not considered a barrier to immersion since it must be in place for an extended period, the patient wants (and needs) it to be there, and the ink is absorbed into the skin rather than adhering to its surface.
Implications for Patient Care: Due to halachic issues with tattooing, halacha-observant women may prefer to use non-tattooing options. In cases where the physician considers tattooing to be critical, the reasons should be conveyed to the patient’s halachic advisor.
Medical References
[1] Rathod S, Munshi A, Agarwal J. Skin markings methods and guidelines: A reality in image guidance radiotherapy era. South Asian J Cancer. 2012 Jul;1(1):27-9.
[2] Moser T, Creed M, Walker R, Meier G. Radiotherapy tattoos: Women’s skin as a carrier of personal memory-What do we cause by tattooing our patients? Breast J. 2020 Feb;26(2):316-318
[3] Lim LH, Pang EPP, Sultana R, Kusumawidjaja G, Wong RX, Yeo RMC, Ho BS, Ng WL, Lim FLWT, Chua ET, Sim AYF, Wong FY. A Prospective Randomized Controlled Trial to Compare the Use of Conventional Dark-Ink Tattoo and Ultraviolet-Ink Tattoo for Patients Undergoing Breast Radiation Therapy. Pract Radiat Oncol. 2021 Nov-Dec;11(6):463-469.