Halakhic Considerations

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February 1, 2004
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By Julian Jakobovits

THE CONTEMPORARY explosion of medical technology, combined with the evolving acceptance of personal autonomy and decision-making, have catapulted discussions regarding end-of-life management to the forefront of our national consciousness. As well, Internet access has made everybody a veritable maven and expert, empowered to have significant input into a field that had been generally inaccessible to laymen.

For these reasons, the challenges and opportunities for making informed decisions have grown enormously. What does one need to know in order to contribute to the debate from a Jewish point of view? A rich tradition of authentic Jewish teachings provides explicit halakhic (that is, Jewish law) guideliness. Constraints of space preclude the many details, sources, and references, but the principal guidelines are as follows:

•    Judaism regards all of life, irrespective of its actuarially expected length, to be of infinite value. Hence, if 70 years of life are infinite, so is any subsegment of 70 years infinite in value. In terms of extinguishing innocent human life, it makes no difference whatever if the life expectancy would have been 70 years or one year, or even one month, one hour, or one second. The result of every division of infinity remains infinite. Under no circumstance would the halakhah countenance Kovorkianism, no matter how compassionately motivated or how genuinely wished for by the patient. Furthermore, life is entrusted to us but it is not ours to dispose of at will. Therefore, morally speaking, suicide is regarded as a form of murder.

•    However, though no life may be extinguished, not all life must always be extended. Briefly, lingering suffering life in a terminally ill patient may be allowed to fade and follow its natural course without heroic intervention unless the patient wishes otherwise.

•    The only acceptable criteria by which to distinguish patients is “terminalness.” Other quality-of-life standards, such as cognitive ability, are inadmissible criteria in Jewish law.

•    ?Nevertheless, certain specific interventions, some more liberal and some more restrictive, stand outside these general guidelines. For example, every consideration must be given to the relief of pain. The Hebrew root for the word doctor, rofeh, means to soften. At its minimum, medical practice must endeavor to relieve pain. Therefore, adequate pain medication must be administered even if there is a risk of shortening life by depressing circulation and respiration, provided that the doses used are designed to mitigate pain and are not designed to accelerate death.

•    However, even in the case of terminally ill patients, where it may be appropriate to allow them to die, certain inalienable provisions are always mandated. These include the provision of nutrition and hydration, the relief of air hunger, and the replenishment of blood. At the very least, the biblical mandate “you shall not stand by your brother’s blood” requires this. The practical details of these interventions are beyond the scope of this brief overview.

•    In the Jewish view, all the participants in health care decisions — doctors, nurses, patients, families, hospital administrations — are bound by the same moral standards. Therefore, the notion of consent, which derives from the legal concept of personal autonomy, is foreign to Jewish law.

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Dr. Julian Jakobovits is Assistant Professor of Medicine at the Johns Hopkins University School of Medicine. He maintains a private practice in internal medicine and gastroenterology in Baltimore. He lives, with his family, on the Ner Israel Rabbinical College campus where he is Resident Physician.

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