Sunday, March 26, 2017

Core Jewish values at the end of life

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…

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…

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.

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…

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.

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