Religion - Right to Die
American society has
increasingly come to recognize what is known as the "right-to-die". In
the famous Cruzan case, the Supreme Court of the United States in a 5-4
decision ruled that a patient who has clearly communicated his or her
wishes regarding the use of life support machinery or the provision of
hydration and nutrition has a constitutional right to have those wishes
respected even if the patient is not suffering from a terminal
condition. Jack Kevorkian, the infamous doctor of death, is running
around the country assisting persons in killing themselves. Derek
Humphrey's work FINAL EXIT was a best seller. A referendum in the state
of Washington that would formally legitimate physician-assisted suicides
was supported by almost 50% of the electorate and many feel that within
a few years, such measures will be routinely approved. Under a
recently-enacted federal law, persons entering hospitals or nursing
homes must be informed of their rights to execute living wills or other
advance directives spelling out ahead of time that certain medical
interventions should not be employed. What does the Jewish tradition say
about these matters? Does halacha take positions on advance directives?
Does Judaism recognize a right to die?
Briefly stated, the Jewish tradition rests on a number of assumptions:
1. The preservation of life [pikuach nefesh] is considered to be of
paramount importance, surpassing virtually all of the other commandments
of the Torah. One may and must violate Yom Kippur or the Sabbath, eat
non-kosher food, etc. if there is the slightest chance that human life
may be preserved or prolonged.
2. The quality and/or duration of the life being saved is irrelevant.
Life is of infinite, not relative, value and mathematically, any
fraction of infinity must also be infinite. Once life is assigned a
relative value - once we start making judgments as to which lives are
worth living and which are not, once we assign value to people because
of what they can do instead of what they are we have demeaned the
intrinsic sanctity of existence for all human beings and have embarked
on a dangerous exercise of line drawing. What about the elderly, what
about the severely retarded, what about the handicapped: are they any
less human because their productivity is impaired?
[The reader may legitimately ask what use is the life of a Karen Ann
Quinlan? What use is the life of a person who is comatose and incapable
of any cognitive brain functioning? What use is an anencephalic child?
Keep in mind, however, that a Jew believes in a soul and that the body
is simply a receptacle for the person's true spiritual essence. Souls
come to earth for many, many purposes and we don't know why G-d sends
souls into this life. Sometimes it could be that the spiritual destiny
of a soul is to elicit certain responses on our part. The soul exists to
teach us certain things about the meaning of life and love and how we
relate to the dignity of a human being and when we fail to respond with
sensitivity and respect for the unconditional value of that person's
life, we kill off a small part of ourselves as well.]
3. Judaism rejects the notion of unlimited personal autonomy. Our bodies
and our lives are not our own to do with as we will. They are temporary
bailments given to us by G-d for a specific purpose and duration which
only G-d can terminate and just as we don't have the moral right to kill
or harm others, we don't have the moral right to kill, maim, or injure
ourselves or to authorize other persons to do those things to us.
4. Judaism rejects the notion that the utilization of advanced
technology to sustain life is somehow an interference with G-d's will.
Technology and scientific advancement are not man-made but are in
themselves gifts of Divine revelation to be used for the benefit of
mankind. Thus, the dichotomy that some religions posit between "natural"
and "unnatural" ways of treating illness is essentially foreign to
Jewish thinking.
These four factors standing alone would surely argue against any "right
to die" and would support an absolute affirmative obligation to prolong
life at all costs, regardless of pain and indeed regardless of the
patient's expressed wishes. This is in the fact the position associated
with the eminent Talmudist and bioethicist, Rabbi Dr. J. David Bleich of
Yeshiva University. It is, however, a decidedly minority position.
Halacha, as all well-developed ethical systems, cannot and does not
focus on a single moral value to the exclusion of others but seeks to
balance, accommodate, and prioritize a multiplicity of ethical concerns.
Just as there is a mitzva (a Divine commandment) to prolong life, there
is a mitzva to alleviate pain and suffering. But what happens if one
value can be achieved only at the expense of another? Consider the
patient suffering terminal cancer whose life could be prolonged for no
more than six months but only at the cost of painful, debilitating
chemotherapy or the elderly stroke victim who falls prey to pneumonia
which will kill him swiftly and relatively-painlessly overnight but is
easily treatable by antibiotics. May the patient decline the
chemotherapy or the antibiotics to achieve a quicker, less painful death
or is the mitzva of pikuach nefesh (preservation of life) so absolute
that it admits of no exceptions?
Most rabbinical authorities (Rabbi Moshe Feinstein, for one) have
sanctioned the patient's right to decline treatment provided a number of
very specific conditions were met. First, the patient must be in a
terminal condition - that is, whether the treatment is employed or not,
the patient is not expected to live beyond a year. Second, the patient
suffers unbearable pain and suffering. Third, the patient has indicated
that he or she desires not to be treated. In the event the patient is
incompetent or unable to communicate his decision, next-of-kin may make
such a decision based exclusively on what they feel the patient would
have wanted (Note: This is not based on what they would have wanted if
they would have been the patient but rather what this particular patient
would actually desire). Fourth, assuming the above three conditions are
met, the patient may decline surgery, chemotherapy, and painful invasive
treatments but may not decline food, water, or oxygen (which are the
normal sustainers of life, the withdrawal of which may be tantamount to
murder or suicide). Antibiotics may also fall under the "food" category
because they are generally a noninvasive, nonpainful procedure. There is
also some question whether tube feeding falls in the category of "food"
or in the category of "surgery". Most decisors would place it in the
former but emphasize that even if the patient is halachically-obligated
to take artificial nutrition, he should not be force-fed or
physically-restrained. In no event may the patient or the physician take
any affirmative step that would hasten death. Active euthanasia,
regardless of motive, is morally and halachically equivalent to murder.
On the other hand, halacha would view both the goals and methods of
hospice in a very sympathetic light.
Judaism thus attempts to strike a balance between the great mitzva of
prolonging life and the recognition that life may become unbearably
difficult and painful. The living will, however, which attempts to spell
out in advance which treatments should be employed and which should not
is too blunt of an instrument to accurately mirror the necessary value
judgments. The basis for all of these decisions is the pain and
suffering the patient feels at the time of the illness and this can
simply not be predicted in advance. Conditions that may seem intolerable
to us when we are 35-40 may be quite adequate when we reach 85 and we
realize that the alternative would be death. Keep in mind too that many
patients such as those with advanced Alzheimer's or in comas may in fact
not be suffering though their existence is undoubtedly a hardship to
their families. Moreover, it is almost impossible to spell out all
contingencies in advance, making living wills incomplete almost by
definition.
Far preferable to the living will is the durable power of attorney
(often called a health-care proxy) which simply specifies a
person-family member, friend, clergyman - empowered to make health care
decisions on the patient's behalf in the event he or she is
incapacitated. The power may in addition specify that all decisions
shall be made in accordance with Jewish law and in consultation with a
designated clergyman of the patient's choice. Sample forms - labeled
somewhat inaccurately as "Halachic Living Wills" -have been prepared by
Agudath Israel of America, a national organization headquartered in New
York. This document insures that decisions will be made consistently
with the moral and religious beliefs that the patient holds dear.
Obviously, one should discuss these delicate matters ahead of time both
with family members and spiritual advisers.
Incapacitation and terminal illness are tragic situations. Let us
remember, however, that we come from a tradition that has grappled with
these questions and that approaches these issues with sensitivity,
compassion, and understanding. Hopefully, none of us will ever be faced
with these problems but if we are, let us turn to our tradition for
guidance and support.
Source: Jewish Law
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