Ask the Rabbis: In counseling end-of-life care, what Jewish principles are most valuable?

INDEPENDENT

Comfort. Judaism’s zealous obsession with life—staying alive, saving lives, extending life—does not include torturing someone by force-feeding or actively prolonging his or her suffering in other ways. When we see that a patient is in severe agony and that keeping him on life support machinery is only prolonging it, we need to consider his dignity and to facilitate as peaceful and painless a death as possible—upon the patient’s request, or on his behalf if he is unable to communicate. Ancient Jewish law does not permit actively expediting someone’s death, but it does permit the removal of factors that are keeping the suffering person alive (Talmud Bavli, Avodah Zarah 18a). In the early 20th century, Rabbi Naftali Trop, leader of the ultra-Orthodox Yeshiva of Radun, was suffering intensely while dying. His colleague, Head Rabbi Moshe Lundinski, ordered his disciples to stop praying for his life, and then, sensing that the physicians in attendance were only prolonging Rabbi Naftali’s suffering, admonished them as well: “Allow him to die,” he shouted at them. “Why are you tormenting him?  Allow him to die!” (Sefer Bish’vi’lay Ra’din, pp. 254-254).

Care should be taken to ensure that the dying person has complete peace and quiet so that the soul can leave with ease when the time comes. Those present should try to refrain from grieving in front of the dying person, as this would only add to his suffering (Talmud Bavli, Nedarim 40a and Eyvel Rabati 1:5; Shulchan Aruch, Yorah De’ah 335:8). We must never close the eyes of the dying, for that is akin to extinguishing the remaining spark of life and causing the soul to depart before it is ready (Talmud Bavli, Eyvel Rabati 1:4).

Rabbi Gershon Winkler
Walking Stick Foundation
Thousand Oaks, CA

HUMANIST

Thirty years ago, when my mother was terminally ill with ovarian cancer at the age of 58, a morphine drip was gradually increased in her final weeks and days.  The purpose was, first, to mitigate any pain, and second, to allow her to relax and sleep and possibly help her to die.  I saw both of these goals as consistent with my Jewish values of compassion, alleviation of suffering and preservation of my mother’s dignity.

Judaism teaches that we should neither hasten nor delay death. But we can withdraw or withhold treatments that prolong life unnecessarily. The classic story is of the dying person who is distracted by the sounds of a nearby woodcutter. It is only when the woodcutter is removed that the person can peacefully expire (Sefer Chassidim, 234 and 723).

Some believe we should always go the extra mile to extend someone’s life. But sometimes our best end-of-life care—as proxy for the dying person—is, with empathy and kindness, to help his or her family members let go. Even when death is not imminent, we can call for comfort-only measures. I have done this for my 93-year-old father, who has been ready to die for a number of years already but whose otherwise good health thwarts him in this goal. When our own time comes to die, let us hope that we too can face this final stage of life with courage, dignity and the steadfast support and comfort of our loved ones.

Rabbi Peter H. Schweitzer
The City Congregation for Humanistic Judaism
New York, NY

RENEWAL

I have put before you life and death, blessing and curse; choose life so you and your offspring may live. (Deuteronomy 30:19)

Choose life. It seems an easy choice. Most of us want to live, and many are afraid of dying—so afraid, in fact, that we do not talk about it. We do not discuss what happens when we die, and we do not prepare for it in any meaningful way.

As a rabbinic pastor and chaplain, I encourage people to discern what is important in their lives and to discuss their thoughts about dying. Choose life, so you AND your offspring may live. This might involve the writing of two separate documents. First, a Living Will, stating the treatments a person may or may not want administered at the end of life, may prevent arguments that tear families apart. Second, and perhaps just as important, I encourage people to write Ethical Wills in which they express their beliefs, understandings, joys and disappointments.  This old Jewish custom provides a way for them to live planted deeply in the hearts of their offspring. When people record the gems of their lives—their stories, pictures, lessons—they choose life and continue living in the lives of their loved ones and those who read their Ethical Will.

Rabbi Shulamit Fagan
Director, Rabbinic Pastor Program, ALEPH Alliance for Jewish Renewal
St. Petersburg, FL

RECONSTRUCTIONIST

Modern medicine is marvelous, miraculously prolonging life. But with this, we’ve nearly lost sight of how and when to die. We know consciously that for birth, life and love to be possible, death must inevitably follow. It’s hard to let go. But holding on “until the bitter end” can make the end bitter, indeed.

Judaism is all for saving and extending life, until one is truly ready to die.  When Rabbi Yehuda HaNasi was ready, his disciples gathered, praying nonstop for his survival.  His maid caused a loud noise, distracting the disciples, ceasing their prayer; with this “life support” discontinued, nature took its course, and he died in peace (Ketubot 104a). The maid saw not the great Rav, but a suffering man. I counsel families to see their loved ones as the maid did, and to do the right thing when the end is near.

Rabbi Milton Steinberg, decades ago, charged us “to hold life at once infinitely precious, and yet as a thing lightly to be surrendered… to clasp the world, but with relaxed hands; to embrace it, but with open arms.”  It’s not easy to prepare ourselves to let go. But when the time comes, let go we must.

Rabbi Fred Scherlinder Dobb
Adat Shalom Reconstructionist Congregation
Bethesda, MD

REFORM

Kavod hamet, showing respect for the dignity of the dead, is one of our highest values in Judaism. We are obligated to show respect for the dead as well as those in the process of dying. We do this by heeding their wishes regarding treatment, care and comfort and by enabling them to find closure in their relationships. We balance kavod hamet with kavod hachai, respect for the integrity of the survivors. It is essential for the survivors to move forward, through mourning, grief and eventually living, knowing that they acted according to their beliefs and values.

The dignity of the dying and the integrity of the living are linked together by the principles of choice and regret. There are many decisions to make when considering end-of-life care. Judaism offers guidance on those very difficult choices. Ultimately, though, we need to make decisions without regret. As the dying and the living proceed down this natural life-cycle path, each person needs to find comfort in having no regrets. Should one find, though, that one does regret decisions made, the Talmud offers us words of comfort: “R. Hanina bar Pappa said: anyone who does a [sinful] deed and regrets it is immediately forgiven.”

Rabbi Laura Novak Winer
Fresno, CA

CONSERVATIVE

The Bible is clear in stating that we are mortal (Adam and Eve), that “there is a time to be born and a time to die” (Ecclesiastes 3). So attempts to overcome what the physicians say is an incurable illness are not only bad medicine (usually producing more pain for the patient) but also bad theology in presuming that we can and should use medicine for every case. Because of advancements in medicine, I often need to answer questions like, “When does our obligation to cure end, and when does our permission to let nature take its course begin?” In his book Matters of Life and Death, Rabbi Elliot Dorff reconciles medical technology and ethics with Jewish law and principles. Some guidelines:

 • When the patient is in a permanent vegetative state or has an irreversible, terminal illness, medications and other forms of therapy may be withheld or withdrawn. Artificial nutrition and hydration may be considered a sub-category of medication in such circumstances and therefore may also be withheld or withdrawn.

• Terminally ill persons may engage in any medical regimen that has the slightest chance of reversing their prognosis. So long as the intention is to find a cure, they may do so even if they thereby simultaneously increase the risk of hastening death.

• Jewish law permits the patient to refuse any treatment he or she cannot bear, including forms of therapy which, though life-sustaining, the patient judges not to be for his/her benefit.

• Terminally ill patients may choose hospice.

• Pain medication may be given even if it hastens the patient’s death.

Rabbi Amy Wallk Katz
Temple Beth El
Springfield, MA

MODERN ORTHODOX 

To the patient and family, I say: Since every human being is in the image of God, then all humans are of infinite value. The dignity of the living sick person is not compromised by the proximity of death. It follows that every moment of life is infinitely valuable, so it is worth every cost and effort to try to extend or save a life. Still, it is no mitzvah to push for treatment that only torments the patient and burdens or breaks loved ones. If intervention will only add suffering and pain in a hopeless situation, then less is more.

To the caregivers and rabbis, I say: Try to give hope and support to the family. They are suffering along with the patient. Be aware that they are only human, so try not to push them beyond their capacity. Communicate to the patient and the family that God/Shechinah is with them—sharing their pain, tasting their tears. Even when the doctors can no longer help and the family’s reach is not long enough, HaShem is holding the sick person’s hand. “The High and Lofty One who dwells in eternity is [particularly] present with the person being ground down and with the troubled in spirit.” [Isaiah 57:15]

To all, I say:  There is nothing more painful than losing a loved one. Yet this is the fate of all human beings. Do not give up hope in a world to come where a future reunion in spirit is possible. Know that “love is stronger than death” (Song of Songs 8:6).  You will discover that your mutual love continues after death.  Then you will realize that despite the fierce pain and devastating loss, the undying love was worth it.

Rabbi Yitz Greenberg
Riverdale, NY

CHABAD

When death is near, it is often a natural response to want to control the situation, to speed things up or to slow things down. It can be helpful to remember the following: The soul belongs to G-d and it was given to each of us to perform a special purpose in this world. When that mission is complete, the soul will be ready to leave. Just as we cannot choose the moment of birth, it is equally not up to us to determine when it is time for a soul to move on. Every moment that a soul is in a body there is purpose, yet bodily existence does not go on forever. So, in what may seem like a paradox, we embrace life until its very last moment, and yet we respect the process through which all physical life comes to an end.

While we must not accelerate the dying process, we don’t necessarily need to interrupt the natural dying process either. To determine the correct course of action, one should consult a rabbi who is an expert in the Jewish rulings on end-of-life issues.

Rabbi Shais Taub
Editor, Chabad.org
Pittsburgh, PA