HMS 5765-25: End Of Life Issues II: The Reisner Position

Lessons in Memory of my brother Dale Alan Konigsburg

March 28, 2005 - Number 5765-25

End Of Life Issues II: The Reisner Position

As I write this weeks installment, Terry Shiavo has been disconnected from her feeding tube for ten days. Her situation has prompted this series on the Halacha at the End of Life.
Last week we saw that Rabbi Elliot Dorff of the Committee on Jewish Law and Standards of the Rabbinical Assembly take the position that sustenance and hydration are similar to medication and can be withheld from a patient who is in a persistent vegetative state (PVS).
Rabbi Avram Reisner, who also serves on the Committee on Jewish Law and Standards, set out a different approach from the position of Rabbi Dorff. To Rabbi Reisner, only G-d can make the determination of when a patient will die. We are not allowed to hasten death nor are we to judge quality of life issues. A patient (or his/her surrogate) can choose between courses of treatment, but a patient can not choose to die. A terminally ill patient can not choose to take away hydration or sustenance unless the process has inherent risks (such as aspiration into the lungs or risky surgery). We can not however force a patient to eat against his or her wishes. There is no need to insist on food, water or medication if the situation is futile. Futile in this case means that death is very immanent. It applies only when the underlying disease is causing the death, not the refusal of treatment.
To Reisner, PVS is a special case. He notes that because of the lack of higher brain activity, many courts has held that patients with this condition have no conceivable life benefit from treatment and have permitted sustenance and hydration to be withheld or withdrawn. He asks the question "We do not accept the that burdensome life is dispensable, and such a patient is manifestly not in the process of dying. Does that mean we must maintain patients in such condition until their natural deaths?" ... "Is such a life really life? Has not the soul departed while the body, in some aberrant glitch, refuses to shut down? If so, what courtesy do we owe such a soulless body - surely not all th reverence we accord human life?"
Reisner answers his questions be affirming that we don’t know at all if the body is soulless or not, for we have not good definition of soul nor can we measure if it still is in the body or not. He notes that the reason families often give for withholding medication, food and water is the horror of no longer having any interaction with the patient. In such a situation we just don’t know what it is that we should do and in all such cases, where there is great uncertainty as to what is going on, we make the presumption of life and we treat that life as we would any other life. Rabbi Reisner would not permit us to withhold food and water from such a patient.
Where Rabbi Reisner and Rabbi Dorff agree is on the need for advance medical directives. Judaism requires a person to seek healing but if such a person refuses healing, that is a matter between the individual and his/her G-d. It is therefore vital that a person spell out exactly what course of medical action he or she would like to have performed, or removed in the case where the patient could not speak for his or herself. It should also appoint a medical surrogate to make decisions either based on or strictly adhering to the medical directives. This would help insure that all wishes of the patient will be known to all involved in his or her care.
In consultation with the many physicians that I know, I would add that medical directives alone are not enough. It is also crucial that all members of the family be familiar with our wishes and directives. Hospitals and Doctors should not be relied upon to settle family feuds and squabbles. The most ironclad medical directive may be ignored if one or more members of the family disagree and refuse to abide by those wishes. It is very important that we personally instruct our spouse, children and parents about our wishes to minimalize confusion and conflict. In some cases it may even be important to consult the patient’s Rabbi.
As I noted before, Terry Shiavo is a Roman Catholic. She is not subject to Jewish Law. But her case is a reminder that while this may not be a decision we would want to leave to the courts or the government, it is an important religious issue, one that our faith and legal system attempts to guide us through.

Next week: Judaism and Divorce

Beryl Glansberg asks: I just have one question. Does this Talmudic view apply to Jews and non-Jews alike?
I reply: No, Jewish Law applies only to Jews

HMS 5765-24: End Of Life Issues: Special series on Halacha in the news

Lessons in Memory of my brother Dale Alan Konigsburg

March 21, 2005 - Number 5765-24

End Of Life Issues: Special series on Halacha in the news

I know I promised a different topic this week but with Terry Schiavo in the news there has been a great deal of interest in Judaism and these end of life issues. Terri Schiavo is a Roman Catholic but there are also Jews who also need to know what our faith has to say about such issues.
First of all, the most important Halacha in relationship to all health issues is the commandment to "choose life". We are not asked if we wish to be born, and we are not asked when we should die. Such decisions are in G-d’s hand. We never give up when it comes to preserving life. G-d has placed great healing powers in our hands and we need to use them to help preserve life. That being said, Jewish Law also understands that there comes a time when healing is no longer possible, and then, we are permitted to let the natural progression of life take place, even if it means that the one who is ill will die. It is a mitzvah to bring healing, but when healing is no longer a possible, we can remove what is preventing the person from dying.
Judaism does not believe in active euthanasia, ala Dr. Kevorkian, but passive euthanasia is permitted. To this end, one may remove medical care that is preventing the person from dying. This does not mean that we also refrain from medications that will relieve pain and suffering. Only the medical aids that are keeping the person alive can be removed. This is based on a number of Talmudic references that permit the removal of impediments to death in the case of a patient who can not recover.
It is important that end of life issues should be written down in a document called "medical directives" Each state encourages patients to have such directives, together with a medical proxy, a person assigned to make medical decisions for the patient if the patient is unable to make these decisions for him or herself. The Conservative movement has such a document and it can be purchased through the United Synagogue of Conservative Judaism Book Service (www.USCJ.org).
The question in Judaism is the same as the question in the Schaivo case. Does the removal of impediments to death include the removal of food and water (sustenance and hydration)? The Law and Standards Committee of the Rabbinical Assembly, the committee that examined these laws was in agreement on almost all aspect of end of life care except the case of removing food and water. So difficult was this issue that there was no resolution of the disagreement and both options are included in the movement’s Medical Directives.
The case for removing food and water from a terminal patient was made by Rabbi Elliot Dorff of the University of Judaism in Los Angeles. He claims that most authorities do not permit withholding food and water from a patient so the burden of proof is on the one who fails to provide these necessities. To do this he notes that the kind of food and water given to the patient who can not eat or swallow, this food and water are more like medicine than food. Just as a blood transfusion is not "eating blood" a prohibited act in Judaism, intravenous food and water is not food at all but medicine and as such it can be withheld.
Rabbi Dorff does note, however that for people in a persistent Vegetative state (pvs) like Terry Schiavo, presents a more difficult case. Such people do not need all kinds of medical equipment to stay alive, but they do need food and water. While they may have no functioning in their higher brain, they sill have enough brain stem activity to stay alive. Saving a life in Judaism does not have us judge the quality of that life. A patient with PVS presents us with a very difficult case. If we were not able to provide the food and water intravenously, than that patient would die. This means that the food and water are like medicine and we can withhold it. While we consider brain death to occur when there is no brain activity at all, if the doctor were to say that lack of higher brain function (neo-cortex) could be the sign of death and if such patients are dead, than food and water can be withheld. Because of issues relating to the diagnosis of PVS and Alzheimer’s disease, food and water should be provided for a period of time in order to be sure of the diagnosis.
There is another side to this discussion, that of Rabbi Avram Reisner. We will look at his position next week.

Next week: End of Life Issues II – The Reisner Position