Jewish Perspectives on End-of-Life Care
The following article was originally published by 70 Faces Media and appeared as part of a series supported by MJHS Health System, 70/Faces Media and UJA-Federation of New York to raise awareness and facilitate conversations about end of life care in a Jewish context.
Jewish approaches to medical decision-making for the terminally ill.
BY MY JEWISH LIFE
Decisions concerning medical care in the final stages of life present a range of Jewish ethical and legal conundrums. They are often messy and complicated, and they have vexed ethicists, medical professionals and religious leaders alike.
While Jewish tradition maintains that human life is of infinite value and that its preservation and extension overrides virtually every other religious imperative, relieving pain and allowing for the soul’s peaceful departure are also values well-established in Jewish tradition. Of course there is a moral distinction between hastening death and removing obstacles to its natural progression, but in practice the difference isn’t always easy to discern.
Below is a general overview of a number of issues that commonly arise at life’s end — and how Jewish authorities have weighed in on them. Jewish thinkers often emphasize that specific cases vary substantially and must be considered individually. And while weight is always given to a patient’s wishes, those who are concerned about complying with Jewish law are always urged to consult with trusted advisers.
For patients unable to eat or drink, doctors can provide food and water intravenously or through a feeding tube. This is a common situation faced by those with advanced-stage dementia. Most Orthodox authorities generally consider nutrition, hydration and oxygen — even if artificially provided by a feeding tube or ventilator — to constitute essential human needs that should never be discontinued as long as they are effective. This position is was also reflected in the 1990 paper on endof- life care authored by Conservative Rabbi Avram Reisner. However, the Conservative movement’s religious law authorities also endorsed a paper by Rabbi Elliot Dorff, who advanced several possible justifications for removing artificial nutrition and hydration for the terminally ill, among them the contention that a medically administered treatment that conveys food and water to the patient by tube is more properly regarded as medicine than as simple food and water.
Hospice is a form of medical care for people suffering from terminal illnesses with a life expectancy of six months or less. Patients are typically referred to hospice care when further medical treatment is not expected to reverse the course of their disease and they elect instead to focus on therapies geared toward reducing pain and sustaining the highest quality of life for as long as possible. Jewish hospice programs are typically equipped to provide hospice services while abiding by Jewish traditions. Because hospice focuses on a patient’s quality of life rather than aggressive medical treatment, some Orthodox rabbis do not believe hospice conforms with Jewish tradition. However, not all Jewish authorities agree. Many contemporary Jewish authorities argue that Jewish tradition allows a focus on comfort and pain reduction and the eschewing of aggressive medical interventions in certain circumstances.
Do Not Resuscitate Orders
Known as DNRs, these are legally binding directives signed by doctors ordering medical professionals to withhold CPR or advanced life support in the event a patient’s heart stops functioning. DNRs are typically requested by patients who are elderly or are suffering from an advanced terminal illness that makes it unlikely they would survive CPR without a severely diminished condition. Some Jewish authorities consider these orders extremely problematic, as a patient needing CPR is in acute distress and could be saved, even for a brief period, with proper treatment. But given the often low success rate of resuscitation and the high likelihood of adverse effects for the elderly or those weakened by terminal illness, some authorities permit DNRs under certain conditions. Reisner, in his 1990 paper on treatment for the terminally ill, writes that it is proper to respect a patient’s DNR request in cases where it is not possible to restore “a full measure of life.”
These are documents specifying a person’s wishes concerning medical care in the event they are unable to make such decisions for themselves and/or appointing a health care proxy to make decisions on their behalf. The laws concerning advance directives vary considerably from state to state. A number of state-specific forms are available here. In addition, both Conservative and Orthodox Jewish versions of advanced directives are available, some of which explicitly state a person’s desire to have Jewish law and custom respected in their health care choices. There is typically also space to name a specific rabbi to be consulted when making such choices.
While most Jewish authorities would require a patient to submit to a therapy if it is known to be effective at curing their condition, this is not the case with respect to experimental treatments whose success rate and potentially adverse side effects are not known. These can include treatments whose effectiveness has yet to be demonstrated in clinical trials, or new drugs whose safety and effectiveness have not yet been established. Jewish authorities from across the denominational spectrum support the right of a patient to refuse treatment that is risky or of unproven value. Equally, a patient who desires to undertake an experimental therapy in the hope of being cured is permitted to do so even if there are risks involved. According to some authorities, this is even the case with a hazardous treatment that may itself result in death. Dorff writes that it is permissible to undertake a hazardous therapy if it presents a “reasonable chance” of cure, even if it simultaneously poses a risk of hastening death if it fails.
Jewish tradition generally requires that every effort be made to sustain and extend life, but that position is not absolute. In cases where diseases are incurable, and medical interventions would be risky, painful, of uncertain efficacy or serve merely to prolong a life of unbearable physical or psychic pain, there is support in Jewish tradition for an individual’s right to reject such treatment. This was the reasoning behind the Reform Rabbinate 2008 ruling that a lung cancer patient did not have to submit to chemotherapy that could extend her life by three months, but only at a cost of significant pain and suffering. Within the liberal denominations, there is broad respect for individual autonomy in making decisions concerning health care, including the right to refuse care if the patient feels it would not be effective or would be too painful. Among Orthodox authorities, there is also support for refusing treatment in situations where it would not cure the patient but would only prolong individual suffering.
Praying to Die
Taking active steps to hasten death are prohibited in Jewish law, but praying for death is another matter. The 14th-century Catalonian Talmud scholar Rabbenu Nissim, commenting on the talmudic story in which the maidservant of Rabbi Yehuda Hanasi prays for his death, observes: “There are times when one should pray for the sick to die, such as when the sick one is suffering greatly from his malady and his condition is terminal.” (Nedarim 40a:2) The Jewish bioethicist J. David Bleich has formulated it this way: “Although man must persist in his efforts to prolong life, he may, nevertheless, express human needs and concerns through the medium of prayer. There is no contradiction whatsoever between acting upon an existing obligation and pleading to be relieved of further responsibility.”
Withdrawing Life Support
Many Jewish legal experts believe it is permissible to withhold advanced life-support measures from terminally ill patients. However, once such measures have been provided, withdrawing them to let natural death occur becomes more problematic. While there are grounds in Jewish law for withholding advanced life-support measures from terminally ill patients, once such measures have been provided, withdrawing them to let natural death occur becomes more problematic. As a general rule, withdrawing life support is not permitted in traditional readings of Jewish law. However, there are many contemporary Jewish authorities who consider a person to be dead if activity in their brain stem stops. If such a patient were kept “alive” only by means of medical machinery, these authorities would permit those machines to be disconnected. For those seeking to adhere to more traditional interpretations of Jewish law, there have been some interpretations used by rabbinical medical experts, that have been applied to withdraw treatment in cases where a patient is entirely dependent on machines for breathing and blood circulation and has little hope for recovery. However, it must be considered on a case by case basis, informed by accurate information between the physician, rabbi and family.
Jewish authorities from across the spectrum of religious observance, from Reform to ultra- Orthodox, support the lifesaving potential of organ donation, with some authorities going so far as to suggest that Jewish tradition mandates organ donation. Traditional requirements — such as burying the dead quickly, avoiding defilement or benefit from a dead body — that would seem to preclude organ donation are superseded by its lifesaving potential. The Halachic Organ Donor Society (an organization for Jews who want to strictly comply with Jewish law) offers an organ donor card that specifically states that any transplant procedures be conducted in consultation with the deceased’s rabbi. The Conservative movement has a similar card.
Most Jewish authorities adamantly reject euthanasia or assisted suicide of any kind. Taking active steps to hasten one’s death is considered tantamount to suicide, while assisting another to do so may be considered murder. A number of Reform rabbis have challenged this view, questioning the validity of the commonly drawn distinction between active measures to hasten death and merely withholding treatment or removing impediments to death. Peter Knobel, a prominent Reform rabbi and past president of the movement’s rabbinical association, has argued that in certain cases, active euthanasia may even be a praiseworthy act, however this remains a decidedly minority view. Over the years, the Reform rabbinate has repeatedly reiterated its opposition to euthanasia and assisted suicide.
While honesty is a well-established imperative in Jewish tradition, there is ample precedent for the idea that full disclosure of a terminal diagnosis ought to be withheld from a patient since it may sap their will to live. Various biblical sources are cited in support of this idea, including the prophet Elisha’s response to the query of Ben Haddad, in which the prophet told the king he would recover from his illness though he knew the opposite was true. The Shulchan Aruch rules that, while a person near death is instructed to confess their sins, they must also be reassured that many have confessed their sins and not died. (Yoreh Deah: 338) Bleich has gone so far as to suggest that a doctor not only refrain from conveying information that might cause a patient to despair and thereby hasten their death, but he must continue to “feign medical aid even though there is no medical purpose in his ministrations.” End-of-life decisions can be challenging, particularly for those who wish to ensure that the decisions comply with traditional Jewish law. And, while there are areas of consensus, there are also differences in how Jewish leaders interpret relevant Jewish teachings and texts. While the article provides an overview, we encourage families concerned with abiding by Jewish practices and beliefs when facing these difficult decisions to consult with trusted spiritual leaders for advice.
At MJHS, we value both personal and professional caregivers and recognize the critical work you do. That is why we have created these online caregiving resources to help you through this crucial time in your life.
If you need additional help and support caring for your loved one, please feel free to contact MJHS. We can recommend other care options available to you through one of our programs.