Matters of Life and Death
April 2004
Banner photo: ©SEKAI BUNKA PHOTO
Jewish Bioethics
Mrs. L is an 85-year-old resident of a Jewish long-term care facility who has vascular dementia, controlled heart failure and diabetes mellitus. The gastrostomy feeding tube she received two years ago has begun leaking and needs to be replaced. Her daughter, who has become her surrogate since the recent death of Mrs. L's husband, has indicated that if the tube were to come out, she would not consent to the insertion of a new tube: a decision she feels would be in accord with her mother's true wishes. She would not, however, request that the tube be deliberately removed. The staff are concerned that, by not replacing the tube, they would be failing to maintain the current level of treatment. They feel that this would amount to taking the mother's life without any substantial decline in her clinical condition. The daughter acknowledges the concern and devotion of the staff and her mother's unchanged clinical status but reiterates her belief that her mother would prefer to be allowed to die rather than to continue with feeding through a gastrostomy tube.
Duty-based Approach
Although discussions of medical ethics can be found in Jewish writings since ancient times, modern medical technologies have placed new challenges before interpreters of Jewish tradition. The zeal with which these questions have been addressed has given rise to the field of Jewish medical ethics over the past 40 years. In keeping with Jewish ethics generally, Jewish bioethical inquiry appeals to the principles found in Jewish scriptures and commentaries and applies them to clinical decision-making. In doing so, it takes a duty-based approach rather than the predominately rights-based approach characteristic of contemporary secular bioethics. As the late Benjamin Freedman pointed out, bioethical deliberations that are focused on rights may do well in solving the procedural question of who gets to decide a particular question, but they do not necessarily offer guidance as to what the best decision might be. Framing a dilemma in terms of the duties owed to those involved can clarify the issues and suggest a satisfactory course of action.
Interpersonal behavior in Judaism is traditionally conceived as the execution of duties within the context of relationships. From this perspective, a preoccupation with rights implies the relative isolation of individuals making claims upon one another; this further implies an implicitly or overtly adversarial relationship. In a "regime of duty," participants seek to enable each other to satisfy the obligations inherent within relationships, including professional relationships. Judaism urges one to perform mitzvoth (good deeds), that is, to act in accordance with one's duties, and this applies in the health care setting no less than anywhere else.
A Variety of Interpretations
Traditional Jewish legal and ethical thinking is based on reading and interpreting three main sources, each of which is vast, varied and complex. The oldest and most authoritative is the Bible, which includes the five books of Moses (the Torah), the Prophets and additional writings. The second source is the Talmud, which is composed of multilayered commentaries on biblical texts and oral traditions by learned rabbis of the second to fifth centuries C.E. To make the voluminous Talmud more accessible, several great codifications of Jewish law emerged that attempted to summarize the Talmud's primary teachings. The third main source of Jewish legal authority is the Responsa literature, in which prominent Jewish scholars through the centuries have given opinions on contemporary matters as interpreted through the Bible and Talmud. Responsa are the continuation of a 2,000-year-old interpretative tradition, which creates an intellectual link to the past, helping keep the law relevant and vital to the present.
A Russian choir at the newly established Jewish community center in Frankfurt (Oder) [R. Maro/version-foto.de] Bioethical questions are treated by Jewish authors in a variety of ways, which reflect different orientations toward Judaism and degrees of strictness in the interpretation of Talmudic texts and cases. Pioneering work in contemporary Jewish medical ethics in the 1960s and 1970s came primarily from Orthodox Judaism, in which the authority of God, as expressed through the Torah and Talmud, underlies the deliberative process. Much Jewish bioethics literature comes from this perspective, which assumes that, through the proper interpretation of Talmudic texts and commentaries, answers to the most difficult questions can be discovered. In practice, the rabbi whose opinion is sought for an ethical answer serves as an "expert counsellor" to physician and patient, interpreting Halachic (Jewish) law for the situation in question. A local rabbi or chaplain may, in turn, consult more learned Halachic authorities in difficult cases.
Inspired by these Orthodox sources, Jews from the more liberal Reform and Conservative movements have also made contributions to contemporary bioethics. The interpretative method and texts used are basically the same, but their rulings are often more flexible than those provided by Orthodox rabbis.
Common Principles
Although traditional Jewish scripture expresses many principles worthy of ethical consideration, there are a few foundational tenets that ground much of the Jewish bioethical tradition. One commentator identified three main principles: "human life has infinite value; aging, illness and death are a natural part of life; and improvement of the patient's quality of life is a constant commitment." Other important principles are that human beings are to act as responsible stewards in preserving their bodies, which actually belong to God, and that they are duty-bound to violate any other law in order to save human life (short of committing murder, incest or public idolatry). Compared with secular values, these principles suggest a diminished role for patient autonomy. The duty to treat illness or preserve health overrides any presumed right to withhold treatment or to commit suicide.
In general, traditional Judaism prohibits suicide, euthanasia, withholding or withdrawal of treatment, abortion when the mother's life or health is not at risk and many of the traditional "rights" associated with a strong concept of autonomy. For example, an observant Jew would not consider it his or her right to seek physician-assisted suicide as a way to avoid present or future suffering from metastatic carcinoma. Exceptions to these prohibitions are sometimes made in extreme circumstances.
The problem faced by Jews in end-of-life decisions is not usually in determining the appropriate Halacha; a greater challenge is determining the moment when hope for continued life is lost and the process of death has begun. Jewish law is relatively clear that life is not to be taken before its time. It is equally clear that one is not to impede or hinder the death process once it has begun. Lenient rulings in such cases may well be based on the same texts as strict rulings; one authority may see continued treatment as prolonging life, where another may see it as prolonging death. Working through this dilemma is a common feature of Jewish end-of-life decision-making. Both the duty to treat and the duty not to prolong death must be considered in light of the more general duty to care for one's parents in old age or ill health.
To traditionally-minded Jews, Jewish bioethics is a subset of Halacha, which guides all of their activities. To more secular Jews seeking guidance in difficult decisions about their health, Jewish bioethics offers helpful lessons and considered opinions from the sages. Many nonreligious Jews welcome traditional views to help ease the uncertainty inherent in difficult ethical decisions, even though they may not live according to traditional religious practice. An understanding of Jewish bioethics can help anyone, Jewish or not, who wishes to explore the many ways people think about difficult ethical issues.
Even without accepting the authority of the Bible and the Talmud, physicians may benefit from seeing how principles or norms can be derived from authoritative texts, how minority opinions can be incorporated into such deliberations (the Talmud consistently records these), and how grappling with tough questions in this structured way can increase sensitivity to ethical and decisional nuance. Perhaps the most important lesson to be learned is that there are few easy answers to complex problems.
Rabbi Jamie Korngold (right) presides over a baby girl's naming ceremony [Courtesy of www.AdventureRabbi.com] Jews do not have a guidebook that explicitly tells them what to do in every situation. Rather, their guidebook is cryptic and requires them to consider thoroughly the range of possible answers to ethical dilemmas. It is a tradition of continued and ongoing questioning rather than one of absolute theological law passed down from above. Furthermore, familiarity with Jewish bioethics would give the practitioner the perspective to consider ethical dilemmas through the lens of duty rather than of rights, asking the question, "What are the obligations of each of the parties involved in this discussion?"
In terms of how to respond to the needs of different patients, the patient's life history might have some bearing on the type of treatment approaches he or she requires. Older Jews might be more likely to appreciate a rabbi's input, as they are often more traditional than their children. Also, there are still a considerable number of Holocaust survivors, some of whom have significant psychological associations stemming from traumatic experiences.
Very traditional or religious Jews may have concerns about modesty in the health care setting, and many might appreciate being cared for by nurses or physicians of the same sex. Some Jewish patients may also appreciate brief periods set aside for prayer or other ritual obligations.
The Case
Mrs. L's daughter is undoubtedly trying to respect her mother in not consenting to the insertion of a new gastrostomy feeding tube, but she will find it difficult to get rabbinical support for reducing or withdrawing treatment that would result in her mother's death without a prior serious decline in Mrs. L's overall condition. How best to respect her parent is not easy to determine, but usually Judaism teaches that prolonging life is more respectful than assuming an incompetent patient wishes to end her suffering prematurely.
There is a clear duty to "cause to eat" in the Jewish tradition that her daughter should not, according to the Halacha, violate unless Mrs. L is deemed to be a goses (a person in the throes of dying), in which case treatment or feeding that would hinder the dying process would not normally be allowed. Even as death approaches, performing duties as articulated by Jewish law is the essence of traditional Jewish life, a source of joy and fulfillment for both patients and families, and Jewish bioethics suggests that the articulation and performance of such duties be the focus of clinical decision-making. The daughter agrees to have the gastrostomy tube replaced. She and the health care team determine conjointly the basis for future care within a palliative care framework. Mrs. L succumbs comfortably to pneumonia some months later.
Contributors, (left to right), Gary Goldsand, Zahava R. S. Rosenber and Michael Gordon. A longer version of this article first appeared in the Canadian Medical Association Journal in January 2001. The authors were, variously, affiliated with the Joint Centre for Bioethics at the University of Toronto and the Baycrest Centre for Geriatric Care.
