4 Core Jewish Values at the End of Life
Guiding our health care decisions according to Jewish law.
Health care decisions have grown increasingly complex with the advancement of medicine, and are influenced by the values of those involved. Halacha (Jewish law) has much to say about these issues, and it serves as the single source for Jewish Medical Ethics. As is always the case, significant debate exists amongst Torah scholars about what exactly the Halacha prescribes. Nevertheless, there exists a mainstream consensus amongst widely respected Halachic authorities who have addressed these issues in the context of modern medicine.
What follows is an attempt to formulate in a simple, non-technical manner four basic Jewish values that should guide our health care decisions. In our complex world, these values are often in tension with one another, and we need to apply much work and thought situationally to resolve the tension by determining which values control the specific case at hand. While there is no simple formula that can plot a clear path forward in all situations, identifying the core values can help us recognize that path.
Value 1: Pursue Life
A significant number of Orthodox Jewish communities have a Hatzalah ambulance corps as an important part of the communal infrastructure. Hatzalah is comprised of dozens of heroic volunteers who have trained as Emergency Medical Service providers and who make themselves available 7 days a week, 24 hours a day to respond to calls. Behind the paramedics are volunteer teams of dispatchers and support staff, as well as significant funding to provide the needed life-saving equipment, including a fleet of fully-equipped ambulances.
This huge investment of human and financial resources is arguably superfluous, as every community has its Emergency Medical Service providers via the local fire department. Yet, Orthodox Jewish communities recognize that if they do it themselves they can cut down on response time in situations where seconds make a difference. Their efforts are a natural expression of the value that our faith and tradition places on the pursuit of life, giving it priority over virtually all other values, and thus sending these ambulances speeding around town in response to calls even on Shabbos and Yom Kippur.
It is this same attitude that has spawned a growing number of Orthodox Jewish medical referral resources. Individuals – with and without formal medical training – have emerged as reliable and expert sources of guidance to those facing medical challenges of all kinds. These people identify those providers – locally and nationally – most capable of handling the presenting condition, as well as emerging or promising experimental protocols. They often forge personal relationships with providers that allow them to arrange for the patients to be seen sooner than they would with a cold call to the doctor’s office.
In the early 80’s, a fellow student at the Ner Israel Rabbinical College suffered from advanced liver disease. After a waiting period, he travelled to Pittsburgh where he was given a liver transplant, at the time a rare procedure. The surgeon, the pioneering Dr. Thomas Starzl, commented to a friend of the patient that he had once been puzzled by what appeared to be an extremely high number of Orthodox Jewish people with serious liver disease. Eventually he came to realize that the numbers affected by the disease were not exceptional. What was exceptional was the numbers of the Orthodox who came running to Pittsburgh upon hearing through their communal networks that there was a crazy doctor there who offered hope through transplantation.
The pursuit of life is a core Jewish value.
Value 2: Cherish Life of Any Quality or Duration
One of the primary sources discussing the preeminence of our mandate to pursue life is a Mishnaic teaching regarding a building collapse on Yom Kippur that requires making every effort to rescue possible survivors. The Talmud (Yoma 85a) affirms that even if a victim is found barely alive with no hope of long-term survival, we must continue to work to rescue him for the sake of whatever life he has left, despite its limitations in both quantity and quality (see Biur Halacha 329:3). Apparently for the sake of continuing the poor quality of life of a dying patient we are required to put aside the observance of our most holy day.
Human life is of infinite value and any fraction of the infinite is equally infinite.
The value underlying this mandate was articulated beautifully by one of the fathers of the field of modern Jewish Medical Ethics, the British Chief Rabbi, Lord Immanuel Jakobovits z”l. As he saw it, human life is of infinite value, and elementary mathematics teach us that any fraction of the infinite is equally infinite. We can therefore never turn away from our mandate to pursue and preserve life because we view it as unworthy.
In discussions of quality of life, some suggest that in certain situations it would be appropriate to apply the Biblical phrase, “My death would be better than my continuing to live.” This seems a rather ironic citation. Its source is the prophet Yonah (Chapter 4), who finds himself sitting in the blazing heat outside the city of Nineveh. After the gourd that had shielded him withered and died, Yonah declared his disgust with continued life in such heat. This statement leads to a strong rebuke from God, who places this attitude in the context of Yonah’s apparent general disregard for the value of human life, as expressed in his objection to God’s saving the city of Nineveh. God clearly corrects Yonah and makes him understand that the value of life is so great that it compels us to pursue life even if it offends our sense of justice or our personal comfort. My continuing to live is far better than dying.
The value placed on life of any quality is something to which many of us are very sensitive, as we recall that the same evil Nazi machinery that destroyed millions of Jews as ostensibly inferior beings also set out to destroy hundreds of thousands of the mentally and physically handicapped. Yet in the span of a few decades we have seen a dizzying evolution in society’s attitudes in this area. In the 1990’s Dr. Jack Kevorkian was widely seen as a monster – “Dr. Death” – for facilitating the suicides of the suffering, impaired and terminally ill. Today, physician assisted suicide in many such situations is legal in a number of states and lobbied for in others.
Judaism places infinite value on life of any quality or expected duration.
Value 3: There is a Time to Die
Despite the great value we place on life, we recognize that there may come a time where we suspend the pursuit of life. This recognition was brought out by the author of the 13th Century “Sefer Chasidim” (n. 234), who noted that King Solomon (Koheles 3:2) included death amongst all those matters for which there is an appropriate time: “There is a time to give birth and a time to die.” Yet all the other items listed are activities in which we choose to engage, and regarding which we are taught that there are appropriate times. Death, however, is not typically a choice. As such, what practical guidance is provided by declaring that there is a time to die?
Sefer Chasidim explained that death may indeed be a choice. At times when a person is deathly ill and his soul is clearly ready to leave him, the option exists to engage in loud screaming that may agitate him (the example given by the Sefer Chasidim), or to perform chest compressions, thus keeping him alive for a few more days of suffering. In such situations, King Solomon counsels us to submit and recognize that there is a time to die, and we must step aside and let the patient go. A similar ruling is codified in the Shulchan Aruch (The Code of Jewish Law, YD 339:1, Rema), in situations where there is something artificially and externally stopping the soul’s exit from the body.
According to the mainstream consensus amongst widely respected Halachic authorities, this ruling would not justify the withdrawal of life support, nor the withholding of basic elements of human sustenance, including artificial hydration and feeding. It would however discourage extraordinary measures such as resuscitation or intubation of an end stage or very frail patient, in whom such efforts have no hope of accomplishing more than granting a few additional painful days.
There is a time to accept our mortality. This would not justify the withdrawal of life support, nor the withholding of basic elements of human sustenance.
When the soul is clearly struggling to leave, and nothing we can do will restore to the patient any kind of stable equilibrium, it may be time to recognize that there is a time to die and shift to helping the patient through that process. We may use every tool science has to offer to help us conquer disease, but ultimately the God Who grants us life will eventually take it away. We would do well to recognize that and to submit humbly to that reality.
The gifted surgeon and author Atul Gawande said it best:
“Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could, and how to surrender when he couldn’t, someone who understood that the damage is greatest if you fight to the bitter end.”
As believing Jews, we recognize our human limitations and understand that there is a time to accept our mortality.
Value 4: Practice Kindness and Sensitivity
Ultimately, medicine should be an expression of human compassion, rather than the exercise of a technical skill. As such, medical practitioners must never lose sight of their obligation to bring care and sensitivity to the patient. And while life of any quality is of primary and infinite value, there may be times when fulfilling that value will cast too onerous a burden upon the patient, in the form of continued and irremediable physical or emotional pain.
The Talmud (Ksubos 104a, Bava Metzia 84a, Ran Nedarim 40a) gives examples of situations like these where indeed the pursuit of life seemed to be suspended, as people shifted to pray for the patient’s demise. These sources led the most widely respected Halachic authorities to rule that while life may be worthy of pursuit at all times, we cannot and do not compel the patient to do so if it will lead to real and enduring pain and suffering. This ruling was limited to situations that featured active physical pain or exceptional emotional torment, and did not include cases of diminished activity and function, such as dementia or coma.
When we reach the point where the soul is indeed visibly struggling to leave, or where we recognize that our efforts will at best leave the patient to suffer interminably, we must continue our efforts to care for patients and family, but in a different modality. Instead of focusing on conquering or healing the disease, we must ensure that they are not left alone, that their pain is addressed as best as possible, and that they are given an environment and circumstances where their comfort is an active goal.
This is the goal of hospice care and the field of palliative care. There are elements of the philosophy and practices of these movements that are often at odds with our values. They may pursue life with less zeal than we do; they may advocate for the withholding of artificial nutrition and hydration, which we would provide to all but the sickest of patients whose systems can no longer absorb them. These are attitudes we cannot accept and which we can and must address. But we must welcome their thoughtful and refined attention to caring for the comfort of the patient. Indeed, some studies have shown that compared to aggressive care in an ICU, the hospice model can in fact increase the longevity of the sickest patients.
As we pursue life and provide medical care for patients, we must consider and be mindful of the attendant costs in pain and suffering.
Four core values: The pursuit of life, and the valuing of life of any quality or duration. Recognition that there is a time to die and that in the pursuit of life modern medicine cannot ignore pain and suffering. These values are always at play and often in conflict.
As Jews, these values as expressed in the Halacha must guide our critical health care decisions. By executing a Halachic Living Will – Advance Directive, we can do ourselves and our loved ones a great kindness by making clear to them that we subscribe to these principles, and that we wish our health care decisions to be made accordingly. We can also make clear our wish for them to seek the guidance of a Rabbi who is well-versed in these laws and who is able to understand the input of and interact effectively with the medical team. And we can share with our loved ones the extent to which we would want to go for our continued life.
NASCK and Agudath Israel have made available Halachic documents for most states. You can follow this link (Download Halachic Advance Medical Directive.pdf) to a Halachic Advance Medical Directive prepared by Rabbi Hauer based on the standard Maryland Form.