This paper explores the classic Jewish Talmudic sources, Halachic [Jewish Law] and Responsa literature as they relate to the treatment of terminally ill patients. Judaism addresses the concerns of the modern medical setting, including Euthanasia, DNR orders and Living Wills, Quality of Life, and the extent of the responsibility of both physician and patient to provide and accept care. The unique sensitivity of the Torah [Bible] and the Talmud to the sanctity and meaning of life on the one hand, and their concern with the suffering of the patient and his or her family on the other hand, lead the Rabbis to resolutions extraordinarily relevant to contemporary concerns of the healing community. The practical legal nature of classical Jewish sources make them especially helpful in formulating pragmatic approaches to ethically ambiguous situations.
Jewish law, called Halacha, is based on the Talmud's exposition of Biblical passages and principles. The Talmud is a 60 volume compendium of the discussions of the masters of Halacha over the course of over seven centuries, finally sealed in the sixth century of the common era. All subsequent deciders of Halacha base their rulings on sources in the vast expanse of the Talmudic literature.
The Talmud1 describes the circumstances leading to the death of Rabbi Judah the Prince. The Talmud relates that the other sages prayed that Rabbi Judah's life be extended. Rabbi Judah's maidservant, however, noticed Rabbi Judah's great pain and agony, and prayed instead for his death. her prayers were answered. The medieval decisor Rabbi Nissim2 concludes on the basis of this passage that it is permissible to pray for the death of a person in agony. The 19th century Rabbi Yaakov Gezuntheit3 adduces additional proofs for this ruling from the Biblical passages which relate the prayers of Elijah and Jonah the Prophets for their own demises, and a Talmudic passage which relates the similar prayer of the great sage Choni HaMe'agel.4 The Talmud5 relates that the sage Ulah was accompanied on a sojourn to the Land of Israel by two fellow wayfarers. The two entered into a dispute, and the one slit the throat of the other. The murderer then turned to Ulah and asked if his action was proper. Ulah noted his assent, and even enlarged the incision in the dying man's neck. The medieval decider Rabbi Asher in his commentary states that Ulah did this in order to hasten the death of the slaughtered wayfarer. The 19th century Rabbi Shlomo Kluger derives from this comment that it is permissible to hasten the death of a mortally wounded individual (as opposed to one who is dying of a terminal illness - the Halachic status of such an individual is different, and such a person is considered more "alive") when this act will diminish the dying person's suffering.
Rabbi Yehoshua Boaz (16th century)6 records a disagreement he had with his teachers as to the extent to which one may change circumstances that impede the demise of a dying patient. The conclusions of this discussion are codified by his contemporary, Rabbi Moshe Isserles, in his glosses on Rabbi Yosef Karo's definitive code, Shulchan Aruch7: "It is forbidden to cause a dying person to expire more hastily, i.e., if one is dying slowly, it is forbidden to remove pillows and mattresses from underneath him... nor may he be moved... An extrinsic impediment to death, however, such as a wood chopper at work outside, or grains of salt placed on the dying man's tongue... may be removed. This removal is not active hastening of death, but rather the removal of an impediment." Although one contemporary Sepharadic Rabbi8 dissents, the majority of modern decisors9 extract from Rabbi Isserles' ruling the conclusion that a dying patient may not be weaned from an artificial respirator. The respirator is not an extrinsic impediment to death, but rather an intrinsic life support. These modern decisors suggest several halachically viable possibilities to circumvent the prohibition on the removal of the respirator: a) putting the respirator on an automatic timer so it cycles on and off; b) determining brainstem death before removing the respirator; c) letting the respirator run down its oxygen supply.
The contemporary decisors also take issue with the aforementioned ruling of Rabbi Shlomo Kluger. They note that the medieval commentator Rabbi Menachem HaMeiri offers a different interpretation of the case of Ulah. The Meiri states that in fact Ulah only offered verbal assistance to the murderer, explaining to him how he the murderer himself could hasten the death of his victim. According to the Meiri's approach, there is no basis in this case for hastening death. The principles of Halachic decision making state that in a case of doubt that concerns a possible prohibition of the magnitude of murder, one must adopt the more stringent position which in this case precludes relying on the leniency of Rabbi Asher.10 These deciders also dismiss any extrapolation from Rabbi Nissim's ruling on prayer for a speedier demise. They note that prayer is akin to the removal of an extrinsic impediment, and not parallel to active facilitation of earlier death.11 It is important to note theological explanations found in the 20th century Aruch HaShulchan and Kovetz Biurim. The former explains why others may not hasten the death of a suffering individual. The amount of pain and anguish a person must undergo is determined by God. Physicians have been granted special authorization to attempt to heal this pain but only by way of healing. A physician may not end suffering any other way. The latter source states that Man's body is not his possession, but rather God's possession, and therefore man's jurisdiction over his self is not total. Rabbi Yaakov Emden (18th century)13 mediates between these two principles in his rulings. On the one hand, he rules that if a measure such as amputation will clearly save a person's life, a physician may perform such a procedure even against the will of the patient. On the other hand, if the only possible method of treatment for an ailment even if the problem is only pain, not life threatening illness entails risk to the patient's life, the authorization to heal allows the patient to proceed with that procedure.
The contemporary Rabbi Moshe Feinstein notes in regard to the former ruling that if possible psychological impacts on the patient may outweigh the physical benefit, one should not go ahead with the procedure against a patient's will. Rabbi Feinstein and the contemporary Rabbi Eliezer Waldenberg both note that the treatment of pain is also a form of healing, and therefore allow physicians to administer painkilling drugs to dying patients, despite the possibility that these drugs may shorten the patient's life. Rabbi Waldenberg, is of the opinion, however, that a patient may not refuse life prolonging treatment if such treatment will not increase his pain. Rabbi Feinstein and the contemporary Rabbi Shlomo Zalman Auerbach disagree, and state that all the aforementioned Talmudic and even Biblical references indicate that so long as no active hastening of death is involved, the patient has the right to refuse measures to prolong a painful life. This right, however, is subjective and case specific, and cannot be exercised by a DNR order written in advance of any eventuality. Only the patient and persons who are certain as to what the patient's desires would be may make this decision at the appropriate time considering the specific circumstances involved, in consultation with a Halachic authority. These authorities also rule that just as a patient may not be weaned from a respirator, they may not be removed from an IV hookup. Sustenance derived from the IV is considered to be basic life support, not extrinsic impediment, nor treatment, and as such must be continuously provided.
1. What is Halacha (Jewish Law), and how did it develop? (Sinai, the Talmud, early and later codifiers and decisors - Poskim.)
2. The hierarchy of Halacha: Who is qualified to be considered a Posek and the scale of Poskim. Are English books on Jewish Medical Ethics reliable?
3. Most "ethical" questions are, in the Jewish perspective, really questions of Halacha. There are some exceptions (such as attitudes toward genetic testing).
4. Generally, however, even the rare "ethical" question is referred to a Halachic expert, so he may bring all relevant significant Halachic values to bear.
5. The Torah only authorizes doctors to heal, not to render Halachic decisions. A doctor's role in the decision-making process is only that of a consultant.
6. Generally, patients and relatives also fall into this category. One is usually not considered a master over his or her body, and, in questionable areas, must consult a Halachic expert before reaching any decisions (Nishmas Avraham (NA) v5 p. 200).
Healing: 1. The Torah grants doctors permission to heal, and a doctor who does heal a patient fulfills a mitzvah (Shulchan Aruch (SA) Yoreh De'ah (YD) 336:1). Healing is defined both as curing diseases and alleviating pain (Responsa Tzitz Eliezer 13:87). A doctor may therefore administer painkillers to a dying patient even if those drugs might hasten the patient's death.
2. Although the study of medicine per se is an optional mitzvah, all are prohibited to remain passive in the face of imminent danger to another, and possess a mitzvah to come to the person in trouble's assistance (SA Choshen Mishpat (CM) 426:1).
3. Many sources discuss whether a person must place his or her self in possible danger to save another who is in definite danger. The accepted approach is that: a) One may not place oneself in high risk situations to save others; b) One is allowed, but not required, to place oneself in moderate risk situations to save others; c) One should be strongly encouraged, but cannot be forced, to place oneself in low risk situations to save others; d) If there is no risk involved, one can be forced to undergo simple pain (as opposed to the aggravated pain of a bone marrow transplant, which would fall into category "C"), to save others (SA Even Ha'Ezer 80:1 and NA YD 157:4).
4. If a true cure or rescue exists for a situation, a person can be forced to undergo that treatment or procedure even against his or her will (i.e., if a person's leg is infected with gangrene it may be amputated against his or her will) (Responsa Maharam MiRutenberg 39). Often, however, in patients in the advanced stages of terminal diseases such intervention does not lead to a cure, and under certain circumstances may be rejected by the patient (NA YD 155:2, v5 p. 157). It should be stressed that each case is subjective and must be decided individually!
5. Generally, a person who has less than a 50 percent chance of surviving a year may reject painful treatments (NA YD 155:2).
6. A patient may never be deprived basic life support. This always includes food (IV) and oxygen, and includes supplies such as insulin for a diabetic (NA YD 339:4). The prevalent opinion is that a brain-stem dead patient may be removed from a respirator (NA v5 p. 175).
7. A "Living Will" has no intrinsic Halachic validity (NA ibid. p. 200). At most, it can mandate more aggressive treatment.
8. A patient may pursue experimental treatment. Any procedure that, if successful, may prolong life is permissible, even if in case of failure it will prove fatal (NA YD 155:2).
9. One may not involve others, such as transplant donors, in the healing process without their consent (even to small risks). A child who is old enough to understand may consent to be a donor, but it is unclear if parents can volunteer an even younger child as a donor (NA v5 p. 199).
10. When treatment of a certain person has already begun, it may not be stopped to treat another, despite that second individual's significance. If two patients come before a doctor with the same life threatening problem simultaneously, he or she should first treat the one most likely to survive (NA YD 152:2). When all other factors are equal, the Talmud (SA YD 151:9) gave a hierarchy to follow which, however, is difficult to follow in practice in our day (NA v5 p. 112).
11. Society is required to spend all money feasible to cure the ill (NA CM 426:1).
1. Ketuboth 104a.
2. Commentary on Nedarim 40a.
3. Tifereth Yaakov on Tifereth Yisrael, end of Kiddushin, Boaz note 3.
4. Ta'anith 23a. Additional references to similar passages: Avodah Zarah 18a, Sotah 46b, Yalkut Shim'oni Ekev, no. 871.
5. Nedarim 22a.
6. Shiltei HaGiborim Mo'ed Katan chap. 3.
7. Yoreh De'ah 339:1. Rabbi Karo's rulings are normative for Sepharadic Jews, Rabbi Isserles' for Ashkenazic Jews.
8. Rabbi Chaim David HaLevi, Chief Rabbi of Tel Aviv.
9. Rabbi Moshe Feinstein of New York (the Igros Moshe), Rabbi Shlomo Zalman Auerbach of Jerusalem, and Rabbi Eliezer Waldenberg, also of Jerusalem (the Tzitz Eliezer), among others.
10. As previously noted, this leniency, in any event, only applies to cases of mortal wounds. Terminal illnesses are governed by Rabbi Isserles' guidelines.
11. These sources also rule that in our day and age one should not even pray for the speedier demise of the terminally ill individual.
12. Mor U'Ketzia, Orach Chaim 328.