By Neil Gillman
End of life decision-making is complicated. Clinical, economic, psychological, and social values are often in conflict; physicians and nurses, chaplains, social-workers and ethicists, the patient and the patient’s family don’t always agree; and time is short. The process is tension-filled. Appropriately so, for what is at stake is a human life.
Does this case have to be made? Apparently it does, for I detect, in some medical and religious circles, a weakening resolve to view death as the enemy which is to be fought with all available resources to the very end.
I acknowledge the legitimacy of all of the competing values, but I argue for the priority of the traditional Jewish claim that every human life is precious, and that the preservation of a single life is a moral absolute.
We hear about concern for “the quality of life” of the terminal patient. But I am told that more recent medical advances enable us to alleviate even extreme pain. I am skeptical about the distinction between “passive” and “active” measures to extend life, or between withholding and withdrawing nutrition, hydration or medication. Isn’t doing nothing a passive-aggressive way of doing a great deal?
Humanist circles view death as a blessing, a way for nature to revitalize and refresh itself, for everything that lives must die. But I am different than a tree, because I know that I will die and the tree doesn’t. That awareness makes all the difference. And in the most extreme case, we hear of arguments that limited funds for medical research be allocated to diseases of the young because the aged are soon to die, while the young may live for years a view which is the ultimate in dehumanization.
The cornerstone of my Judaism is belief in a God who creates and sustains life, and who commands me to do the same. We pray that this God remember us unto life, for this God loves life, and that God inscribe us in the Book of Life, for God is a “living God.” All of this is in the language of metaphor but metaphor is the only we can speak of God, and metaphors work both ways; this metaphor illuminates both God and human life. That is surely why I can violate every mitzvah in order to preserve and sustain a single human life. Life is a gift from God; we are commanded to treasure it.
Judaism does not idealize death. It finds no redemptive quality in death. The God in whom I believe did not have to die in order to accomplish God’s work. Judaism views my death as one of the ambiguities inherent in the age of history. But, it assures me that, when I die, I enter into hayye olam, eternal life, and that at the end of historical time, God will conquer death.
When all else fails, we are left with hope, the “hope against hope,” that surges within us when all the statistics suggest that we should abandon hope. That kind of hope rejects the imperialism of science. It suggests that there is more, in life, than is accessible to scientific method - fidelity and love, for example, and hope. And what is life without fidelity, love and hope?
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Rabbi Gillman’s opinion about end of life decision-making is detached from the world where I practice geriatric medicine. In my world, feeding tubes, Foley catheters, and continual nursing care can prolong life. But God, who creates and sustains life, and who commands me to do the same, would not recognize this life as being created in His image. Families who have “chosen life” sometimes find themselves watching loved ones exist for years in a state that they did not foresee. Unfortunately, opinions like Rabbi Gillman’s can induce guilt that leads people to make choices that they will later regret. His opinion carries with it all the gravity of the seminary and the rabbinic authority that goes with it. Therefore he should be careful about expressing extreme views without any qualification.
He states that awareness is the quality that differentiates a human from a tree. However, at the extremes of life, awareness recedes into lethargy, stupor, and coma. Is there any point along this continuum at which we do not have to fight death to the end with all available resources? I think that there is such a point. I wish that Rabbi Gillman could spend a day making rounds with me to give me his opinion about real, living, breathing, but insensate people. Does Rabbi Gillman really want me to intubate, hydrate, amputate, and otherwise invade the integrity of my patient’s bodies at the end of life, without there being some point when enough is enough?
Rabbi, this is not a detached, philosophical, academic debate. If you want to help those of us who grapple with problems raised when a person is at the intersection of life and death, you need to give us more than the slogan to “choose life” in every case.
By David E. Galinsky MD