Judaism and End of Life Care

Jeremiah R. Grosse
January 1, 2011
Reproduced with Permission

When it comes to issues such as medical ethics, it is more difficult to speak of a "Jewish" position than it would be of a "Catholic" position. A great deal would depend upon which branch of Judaism one is referring to. It is true that there are some very consistent basic principles which would be taught by rabbis across the three major branches, namely Orthodox, Conservative, and Reform Judaism. For example, Judaism teaches that in regard to the topic of abortion the most important consideration is the physical, psychological, and spiritual life of the mother.

Orthodox Judaism is the most traditional of the three branches. Orthodox Jews believe that the entire Torah was given to Moses by God at Mount Sinai and remains authoritative for modern life in its entirety.1 They are also the branch of Judaism which would maintain the Kosher dietary laws, lighting of the Oneg Shabbat (evening before the Sabbath) candles on Friday night, and many of the other customs associated with traditional Jewish worship and belief.

Reform Judaism arose in Germany in the early 1800s as a reaction against the perceived rigidity of Orthodox Judaism, and as a response to Germany's increasingly liberal political climate. Among the changes made in 19th Century Reform congregations were a de-emphasis of Jews as a united people, discontinuation of prayers for a return to Palestine, prayers and sermons recited in German rather than Hebrew, the addition of organ music into the synagogue service, and a lack of observance of the dietary laws. Some Reform rabbis advocated for the abolition of circumcision and the Reform congregation in Berlin shifted the Sabbath to Sundays to be more like their Christian neighbors. Early Reform Judaism retained traditional Jewish monotheism, but emphasized ethical behavior almost to the exclusion of ritual. The Talmud was mostly rejected, with Reform rabbis emphasizing the ethical teachings of the Prophets.2

Modern Reform Judaism; however, has restored some of the aspects of Judaism that their 19th Century predecessors abandoned, including the sense of Jewish peoplehood and the practice of religious rituals. Today, Reform Jews affirm the central tenants of Judaism - God, Torah, and Israel - while acknowledging a great diversity in Reform Jewish beliefs and practices. Reform Jews are more inclusive than other Jewish movements, women may be rabbis, cantors, and congregation presidents, interfaith families are accepted, and Reform Jews are "committed to full participation of gays and lesbians in synagogue life as well as society at large."3

Conservative Judaism is a moderate sect that seeks to avoid the extremes of Orthodox and Reform. Conservative Jews wish to conserve the traditional elements of Judaism while also allowing for reasonable modernization and rabbinical development.

The teachings of Zacharias Frankel (1801-1875) form the foundation of Conservative Judaism. Frankel broke away from the Reform movement in the 1840s, insisting that Jewish tradition and rituals had not become nonessentials. He accepted both the Torah and Talmud as enduring authorities but taught that historical and textual studies could differentiate cultural expressions from abiding religious truths.

Conservative Jews observe the Sabbath and dietary laws, although some modifications have been made to the latter. As in Reform Judaism, women may be rabbis. In 1985, the first female rabbi was ordained in a Conservative synagogue. Conservative Jews uphold the importance of Jewish nationalism, encouraging the study of Hebrew and support Zionism. Beyond these basic perspectives, beliefs, and practices among Conservative Jews can range from Reform to Orthodox in nature. It is more a "theological coalition rather than a homogeneous expression of beliefs and practices."

Conservative Judaism holds halakah (Jewish law) as normative, i.e., that it is something that Jewish people must strive to actually live by in their daily lives. This would include the laws of Shabbat (the Jewish Sabbath), the laws of kashrut (keeping kosher), the practice of thrice daily prayers, observance of Jewish holidays and life-cycle events. In practice, the majority of people who have come to join Conservative synagogues only follow all these laws rarely. Most do follow most of the laws some of the time, but only a minority follow most or all of the laws all of the time. There is a substantial committed core, consisting of the lay leadership, rabbis, cantors, educators, and those who have graduated from the movement's religious day schools and summer camps that do take Jewish law very seriously.4

When it comes to Jewish medical ethics, devotion to halakah determines what a given rabbi will or will not recommend to a congregation member who is asking for advice. A cardinal principle in Judaism is that human life is of infinite value. The preservation of human life takes precedence over all biblical commandments, with three exceptions: idolatry, murder and forbidden sexual relationships such as incest. Life's value is absolute and supreme. Thus, an old man or woman, a mentally retarded person, a handicapped newborn, a dying cancer patient and their like, all have the same right to life as you or I. In order to preserve a human life, the Sabbath and even the Day of Atonement (Yom Kippur) may be desecrated or set aside and all other rules and laws, save the above three, are suspended for the overriding consideration of saving a human life. The corollary of the principle is that one is prohibited from doing anything that might shorten a life even for a very short time since every moment of human life is of infinite value.

Life with suffering is regarded as being, in many cases, preferable to cessation of life and with it elimination of suffering. The Talmud (Jewish oral tradition for interpreting the Torah), Sotah 22a, and Rabbi Moses Maimonides (1135-1204), Hilkhot 3:20, indicate that the adulterous woman who was made to drink "the bitter water" (Numbers 6:11-31) did not always die immediately. If she possessed other merit, even though guilty of the offense with which she was charged, the waters, rather than causing her to perish immediately; produced a debilitating state which led to a protracted termination of life. The added longevity, although accompanied by pain and suffering, is viewed as a privilege bestowed in recognition of meritorious actions. Life with pain is thus viewed as preferable to death. It is this sentiment which is reflected in the words of the Psalmist: "The Lord has indeed punished me, but He has not left me to die" (Ps.118:88).5

The cardinal principle of the preserving life is extended to include saving the life of an endangered person. This is derived by the Talmud from the verse; "Neither shalt thou stand idly by the blood of thy fellow" (Lev. 19:16). The Talmud and the various codes of Jewish law offer specific examples of situations in which a moral obligation exists with regard to rendering aid. These include the rescue of a person drowning in a river, assistance to one being mauled by wild beasts, and aid to a person under attack by bandits.6

While the cardinal principle certainly has merit, it is not without theological and philosophical difficulties. Religion prescribes providential concern to God and thus views sickness as part of a divine scheme. God does not allow His creatures, over whom He exercises providential guardianship, to become ill unless the affliction is divinely ordained as a means of punishment, for the purposes of expiation of sin or for some other beneficial purpose entirely comprehensible by God, if not man.

Rabbinic teaching recognized that intervention for the purpose of thwarting the natural course of disease could be sanctioned only on the basis of specific divine dispensation. Such license is found, on the basis of Talmudic exegesis, in the scriptural passage dealing with compensation for personal injury:

And if men quarrel with one another and one smiteth the other with a stone or with the fist and he does not die, but keeps to his bed…he must be pay for the loss entailed by absence from work and cause him to be thoroughly healed. (Ex. 21:18-19)

Even though this Exodus passage deals specifically with the financial compensation of one who has been injured by another, there is reference made to liability for medical expenses. Therefore it follows that liability for such expenses implies a Biblical license to incur those expenses in the course of seeking the assistance of a practitioner of the healing arts. Thus the Talmud, Bava Kamma 85a, comments, "From here [it is derived] that the physician is granted permission to heal."7

Since death is a natural part of the life cycle, what does Judaism teach with regard to dealing with those who are dying?

A goseis (a dying person) is to be considered alive in all respects and according to Jewish law. Nothing can be done to a dying person which would cause the nefesh (soul) to leave the body before the proper time. Placing cooling vessels or metal on his navel, tying the jaw shut, moving the patient, and removing his bedding are all forbid. Reflecting upon the Shulhan Aruch (a legal code composed by Rabbi Joseph Caro in the mid-1500s), Moses Isserles (1520-1572), a renowned scholar known as "the Maimonides of Polish Jewry", wrote his Mapah ("Tablecloth") to serve as a supplement to Caro's writings. Isserles distinguishes between accelerating the death of a goses and simply removing obstacles impeding death, which he considers proper. If something or someone is present which is preventing the nefesh from leaving, for example, a person chopping wood nearby it is permissible to remove the woodchopper. The same is true if there is salt on the person's tongue. These distinctions where seen by many later Jewish authorities as sanctioning certain forms of passive euthanasia. The practice of euthanasia -- whether active or passive -- is contrary to the teachings of Judaism. Any positive act designed to hasten the death of the patient is equated with murder in Jewish law, even if the death is hastened only by a matter of moments. No matter how laudable the intentions of the person performing an act of mercy-killing may be, his deed constitutes an act of homicide.

In discharging his responsibility with regard to prolongation of life, the physician must make use of any medical resources which are available. However, he is not obligated to employ procedures which are themselves hazardous in nature and may potentially foreshorten the life of the patient. Neither is either the physician or the patient obligated to employ a therapy which is experimental in nature.

The attempt to sustain life, by whatever means, is the expression of the highest regard for the precious nature of the gift of life and of the dignity in which it is held. Only the Creator, who bestows the gift of life, may relieve man of that life, even when it has become a burden rather than a blessing.

In his commentary on Leviticus 26:11, Moses Nahmanides (1194-1270) argues that a patient may justifiably reject medical treatment and, when he is prompted to do so because he has placed his trust in God, renunciation of further therapy is even meritorious. Moses Maimonides argues that such line of reasoning is faulty; stating that if one follows this reasoning to its logical conclusion that even partaking of nourishment would undermine one's faith in God. Were a person to become hungry and seek bread he would undoubtedly be cured of the severe malady of hunger and would no longer rely upon God. In actuality, Maimonides declares, just as one gives thanks to God upon eating for having created food with which one might assuage hunger, one gives thanks to God for having created the cure for one's illness.8

Another criterion to be considered is that of a tereifah (a terminally ill person). While a goseis is someone in the last stages of life, a tereifah is one whose death may not be imminent, but will not recover from his or her illness. Taking these two criterions into consideration we will examine such issues as withholding artificial nutrition and hydration (ANH) and pain management.

When dealing with a goseis, Jewish law prohibits withholding or withdrawing medication and ANH as long as the treatment is believed to be beneficial. Treatment should be continued as long as it is effective and the patient's request is to continue. Jewish law maintains that the patient's decision regarding treatment is to be accepted as the final word.

Withdrawing/withholding medication is allowed when dealing with a tereifah. Every person must be afforded normal food and liquids; however, ANH could be viewed as closer to medication than food and water depending upon the patient's condition and their ability to take nourishment.

Pain management (hospice) should not cross the line where the effect of the treatment could hasten the death of a goseis or a tereifah. The reduction of suffering should be the main concern when offering pain management to someone who is dying. The withholding or withdrawal of life support systems is permissible provided that doing so is simply allowing nature to take its course.

Jewish law does not allow one to commit suicide nor assist in the suicide of another. The withholding or withdrawing of life support systems does not qualify as either active or passive euthanasia according to Jewish law.

There are some Reform rabbis who have advocated for assisted suicide when the patient is experiencing severe suffering and there is little to no hope of recovery; however, based upon my research these rabbis appear to be in the minority regarding rabbinical teachings.

In the Winter 1976 issue of Jewish Life magazine, J. David Bleich wrote an article entitled "The Quinlan Case: A Jewish Perspective" which looked at this case from the stand point of Jewish law. While Karen Ann was not Jewish, it is important to be able to reflect upon this landmark decision from the stand point of Jewish law.

For the benefit of those who are unfamiliar with the case of Karen Ann Quinlan, I will offer a brief summary. In 1975, Karen, age 21, attended a party at a friend's home and suffered cardiopulmonary arrest after ingesting a combination of alcohol and drugs. After being transferred from Newton Community Hospital in Newton, NJ to St. Clare's Hospital in Denville, NJ, she subsequently went into a persistent vegetative state (PVS). The hospital neurologist described her as no longer having cognitive brain function but retaining the capacity to maintain the vegetative parts of neurological function. She was able to make facial expressions, utter sounds, and maintain a normal blood pressure; however, she was unaware of anyone of anything around her. The doctors stated that she did have some brain stem function, but that, in her case, it could not support her breathing. She had been on a respirator since her admission to the hospital.

Joseph and Julia Quinlan, Karen's parents, requested that she be taken off the respirator and allowed to die. However, the hospital refused because she did not meet the Harvard Criteria for brain death (no brain stem function). Based upon the medical standards of the time, a doctor could not terminate a patient's life support if that patient did not meet the legal definition of brain death. According to the Harvard Criteria, she could not be declared legally dead, and the physicians believed she would die if the respirator were removed.

Joseph Quinlan went to court to be declared Karen's guardian (since she was over 21) and to gain power to authorize "the discontinuance of all extraordinary procedures for sustaining Karen's vital processes." The court denied the petition to have Quinlan's respirator removed and also refused to allow him to be appointed her guardian.

He then, subsequently, appealed to the New Jersey Supreme Court to have Karen's life support removed based upon the First Amendment of the United States Constitution. The court rejected the opinion and also declared that this case was not covered under the Eighth Amendment - protection against cruel and unusual punishment - was not applicable either since that amendment dealt with criminal punishment. It declared Karen's circumstances to be "an accident of fate or nature".

The case subsequently made it all the way to the United States Supreme Court based upon the issue of right to privacy. Balanced against her right to privacy was the state's interest in preserving life. Judge Hughes of the New Jersey State Supreme Court argued that based upon the level of "bodily invasion" suffered by Karen, consisting of 24 hour a day nursing, antibiotics, respirator, catheter, and feeding tube, the state's interest in preserving life was secondary to Karen's right to privacy.9

In March 1976 the New Jersey Supreme Court ruled that, if the hospital ethics committee agreed that Karen would not recover from irreversible coma, her respirator could be removed. Furthermore, all parties involved would be legally immune from criminal and civil prosecution. However, after Karen's respirator was removed, she continued to breathe on her own and remained in a PVS until she died of multiple infections in 1985 at Morris View Nursing Home in Morris Township, NJ.

According to Jewish law, Karen would qualify as tereifah. Even though she had brain stem function, Karen was terminally ill. The medication which Karen received during her treatment at St. Clare's Hospital was not needed to alleviate any pain since there was no indication that she was suffering from pain. Instead, it was seen as burdensome on the part of Karen's parents and eventually the New Jersey Supreme Court concurred. There was no reasonable hope of Karen's recovery. She was given nutrition and hydration both at St. Clare's Hospital and Morris View Nursing Home and would definitely have qualified as "alive" following the removal of her respirator, even though she remained in a PVS, given the fact that she was able to breathe on her own and was receiving nourishment.

One issue which Rabbi Bleich addressed in this article and is still being discussed and debated today is the exact mental capabilities of someone in a PVS.

No scientist has ever determined the absolute (as distinct from recordable) threshold of psychic activity. No clinical experiment has ever been conducted to determine at what level of consciousness a comatose patient becomes incapable of remorse or repentance. However, even if possible, such an undertaking would be irrelevant. Human life, regardless of its quality, and indeed, of its potential for even the most minimal fulfillment of mitzvot (offering blessing to God), is endowed with sanctity.

There is a definite conflict between ethical teachings of Judaism and the prevalent moral climate. Unfortunately, Jews are prone to celebrate Jewish thought when it coincides with what chances to be in vogue and to ignore it when it runs counter to ideas or practices heralded by the dominant culture. Judaism has something to say - and to teach - about moral issues. Jewishness is more than a matter of ethnic identity and Judaism more than perfunctory performance of ritual. Jews who take their Jewishness seriously must necessarily search for the uniquely Jewish answers to the dilemmas of life and death which emerge from the Jewish tradition. Judaism teaches that man is denied the right to make judgments regarding the quality of life. He is never called upon to determine whether life is worth living - that is a question over which God remains sole arbiter.10

While Catholic teachings about medical ethics may vary from Jewish teachings in certain regard, the fact that Jewish medical ethics is pro-life cannot be denied. There would definitely be discussions between Orthodox and Reform rabbis regarding the role that Torah would play in making ethical decisions and how much influence the current culture should have in such decisions. These types of discussions are essential for any religion which considers itself to be a living, breathing entity concerned with the well-being of its members.

End Notes

1 "Orthodox Judaism" http://www.religiousfacts.com/judaism/denominations/orthodox.htm [Back]

2 "Reform Judaism" http://www.religiousfacts.com/judaism/denominations/reform.htm [Back]

3 "Reform Judaism" [Back]

4 "ConservativeJudaism" http://www.religiousfacts.com/judaism/denominations/conservative.htm [Back]

5 "The Obligation to Heal in Judaic Tradition: A Comparative Analysis" by J. David Bleich in Jewish Bioethics (ed. by Fred Rosner and J. David Bleich) NJ: KTAV Publishing House, 2000, p. 20 [Back]

6 Judaic Tradition, p. 22 [Back]

7 Judaic Tradition, p. 23 [Back]

8 Judaic Tradition, p. 29 [Back]

9 "Court and End of Life - The Right to Privacy: Karen Ann Quinlan" http://www.libraryindex.com [Back]

10 "The Quinlan Case: A Jewish Perspective" by J. David Bleich in Jewish Bioethics, p. 293 [Back]