It is important to recognize that though there
are numerous Jewish views on the question of euthanasia, all
valid views come from within the same Halakhic (constitutional)
framework. Thus, the Jewish values in this paper are my interpretation
and usage of Rabbi Elliot Dorff's interpretation. They all have
a common underlying theme: sanctity of life. The difference between
them is their application and weighing of different principles.
E.g. vitalism places infinite value on the sanctity of life and
will maintain it at all costs.. Anyone interested in my sources
for Jewish views may generally find them in Rabbi Dorff's footnotes.
Since this is a secular paper, I have decided to omit them. I
rely on his book as a popularly accessible source for Jewish discussions.
Whether for people with and without faith, the end of life is a confusing time. We may have certain conflicting notions about the occurrence to the body and soul during and after death. But one thing we have in common is that we do not understand death. Consequently, making decisions about euthanasia is inherently laden with conflicting assumptions and controversial. In the secular American system, the principle used to solve this conundrum and confusion is the expression of patient autonomy. If the patient is incompetent near time of death, we look to previous expressions of will or the opinions of close relations to grasp what the patient 'would have really wanted.' Substitute judgement is even required for patients who have never been considered mentally competent. Discussions of what to do usually only discuss whether the patient's autonomy has been maintained. This reliance on the autonomy principle to make these kinds of decisions is a flagrant admission of the lack of any moral direction. We need to have a moral direction. Therefore, drawing from the Jewish sources and legal framework, I argue for sanctity of life through prohibited active euthanasia and excused passive euthanasia. The first half of this paper is concerned with understanding the principles involved in considering a euthanasia case, the second half in applying them.
We may posit that we should do what the patient wants or would have wanted. But, who is to say what the patient wants is the right thing? (Wolpe, 54). One must admit that in complete reliance on the autonomy principle, what the patient chooses does not matter, as long as he chooses something. This case is most obvious when the patient is incompetent. Rather than discussing what is right or wrong, we look to Advanced Medical Directives (AMD) such as the Living Will or Durable Powers of Attorney for Health Care (DPAHC). In cases where the patient's will has not been satisfactorily expressed, such as Quinlan, we see quite plainly that the legal-medical system does not have any proven means for dealing acceptably with the case. This is being corrected in Illinois law where, without an AMD, the family may still decide. (This information is included in the Patient Self-Determination Act of 1990 admission document). "In the absence of unified moral communities, pluralism is translated into a radical individualism where all moral voices have equal valence" (Wolpe, 50). The patient autonomy principle silences the religious voice, which tends to be strongest defender of justice. I therefore present a moral dimension to the decision-making process.
Depending on your particular philosophy, you may
believe different sources for morals or moral principles, or that
they exist not at all. As I understand Martin Buber, 'religious
morals come from God; ethics come from man. ' If we
can only find the right principles, a moral that resonates with
man, then we can apply a moral ethic. The first and primary principle
of my case, drawn from the Jewish religious system, is the sanctity
of life. I believe it is an unassailable principle, perfectly
acceptable in the secular world. One may substitute for sanctity
words such as importance, priceless value, etc. but the thought
remains that human life is not ordinary. All morals in my case
flow from here and contend with it. The question of doctor-assisted
suicide and active euthanasia are clearly ruled out from this
first principle. I will now outline how Jews generally view the
implications of the principle, then I will return to its implications
and relevance to the secular bioethics.
The Torah says, "do not stand idly by the blood of your brother." (Leviticus 19:16) This means, foremost, that one must help a fellow in mortal danger. All the more so we should not assist in killing a man. (Dorff, 196) "Jewish ideology and law therefore strongly oppose committing suicide or assisting others in doing so, for life is sacred regardless of its quality or usefulness" (Dorff, 1998). God created the world, including human beings. We are his property and are not allowed to treat it poorly. "Suicide is an act of theft from God" (Dorff, 1998). Now, where has this supposition gotten us? By positing life's sanctity, we have very easily reasoned that life is not something we can usually choose to end. The only cases in which killing would be required would be capital punishment (which exists in Jewish Law) and indirectly in the case of war. In the cases of self-defense and saving another man from an assailant, one is excused in killing the offender if that is the only way to stop him. It is by no means required. In all these cases, the man being killed is an aggressor or criminal. A man requesting active euthanasia does not fit any of these molds for required death. It is not mercy; mercy-killing is not a God-given right.
Perhaps one may say there is always hope for a complete recovery. Whatever arguments you bring, life is precious and the ending of it to be dealt with carefully. We have seen that reliance on the principle of patient autonomy to decide cases is a moral vacuum. In the Philadelphia Inquirer (December 3, 1998, page A26), two men wrote two very different letters to the editor:
1) Finally, the state legislature has come to its senses and recognized that the wearing of a helmet by motor cyclists should be a freedom of choice (Inquirer, Nov. 27).
The must-wear-a-helmet zealots (including The Inquirer) continue to harp on the alleged cost to taxpayers for those riders who sustain head injuries but are without adequate medical insurance. These zealots believe that, if the law is rescinded, all helmets will be trashed-not so….
Gov. Ridge should sign this bill. It will be one
more step in getting the government out of our private lives.
Norman M. Moore, Newton.
2) As an emergency physician, I've had the opportunity to treat injured motorcyclists who lives an brain function have been saved by helmets (Editorial, Nov. 27). Suddenly and shockingly, I learn my perspective has been too narrow. While I and my fellow emergency, trauma, and neurosurgical physicians focused on the welfare of a relative few, our perceptive legislators apparently have considered a much larger picture.
Even though mandated helmet use saves lives and health-care
costs, and even though a majority of motorcyclists have consistently
supported mandatory helmet use, our state representatives intend
to serve the public welfare by providing the health-care system
with helmetless, brain-dead ex-motorcycling organ donors….
Dr. Laurence J. Gaven, Harrisburg.
It is quite obvious from these two arguments that not only is Dr. Gaven correct that one should wear a helmet, but "if taxpayers pay the doctor bills for repairing the motorcyclist's fractured skull, then there is a reason beyond paternalism for requiring him to wear a helmet" (Klein, 1997). Howard Brody tried to amend the autonomy principle by acknowledging the power relationship between doctor and patient. His conclusions are quite revealing, but remain morally empty with more checks and balances. In submitting a moral principle to consider, I have now decried active euthanasia, which includes physician-assisted suicide, as morally prohibited. One may counter-argue that it is merciful to relieve a person of his pain or to respect his wishes to die. First off, in the case of physician-assisted suicide, what people want is relief from pain and troubles, not death. Death is not the object; no one knows what death is. Secondly, I respond with a scriptural verse "A time to die" (Ecclesiastes 3:2). For a man to take action with intent to end life, he is presuming that he knows it is proper that his subject die at this time. He is presuming that he knows there is no hope to recovery or value of the remaining time for the dying in his last hours. Though you may prefer not to be disabled, you must still live. "Allowing suicide cheapens life" (Dorff, 1998). It implies that the value of living is variable. If one does not believe that life is precious, he has no right to make bioethical decisions for others because he is inherently disrespecting them.
One might raise as a last argument, that thus far
I have been focusing on chronic illnesses (as is the focus of
this paper). What about classical active euthanasia, such as the
case of a man involved in a chemical explosion in the field and
severely wounded. He is in severe pain and asks for a gun. According
to the principle above developed, he should not be given a gun
or even shot. He should be comforted and treated as much as possible
until medical help arrives. Precise details of reacting appropriately
depend on the particulars of the injury and interpretations of
the principle. If he dies in the meantime, then the choice was
correct. If he survives the treatment and lives a debilitated
life, the choice was correct. (I do make a quality of life argument
when I use the word live. The patient must love his being alive).
The doubt comes in where passive euthanasia may have been appropriate,
that he should only have been comforted; treatment should never
have begun. At the very lowest level argument, it is not good
for men to assist in the death of other men for it corrupts their
sensibilities and hangs upon them an unnecessary guilt. He by
no means should be actively killed.
Generally, passive euthanasia is excusable. Whether or not passive euthanasia is appropriate for a particular situation or not is debatable. Why this sudden departure from the vitalist argument? I believe that man should generally prefer to suffer than to die, because at least while suffering he is alive. But this does not mean that his suffering must be prolonged. I answer with the story of Rabbi Judah, the president of the Jewish Court in the 2nd century. The example following is of ceasing prayer, but I maintain that it closes the door on the vitalist argument that life must be maintained at all cost.
Rabbi Judah, president of the Sanhedrin and editor
of the Mishnah, is dying, and his students are keeping him alive
through their prayers. Seeing what a difficult time he has in
eliminating bodily waste, his handmaid prays that he be allowed
to die and then crashes a jug so that the noise will interrupt
the students' prayer. In that instant, Rabbi Judah dies. The talmudic
story records no objection to what the handmaid did; quite the
contrary, one gets the distinct impression that the students themselves
were at fault. They should have paid more attention to Rabbi Judah's
condition and stopped their prayers of their own accord so that
he could be relieved of his pain in death. (Dorff, 197-198)
As one can plainly see, Rabbi Dorff also uses this source, although perhaps in a different way, to allow for passive euthanasia. It is debatable whether the Jewish Legends found in the Talmud may be used to decide Jewish Law. This story appears to be a case in which the consensus, that the Rabbi's life be prolonged, was incorrect. Life still has an infinite worth; prolonging it unnecessarily, however, is not the correct approach to respecting it. Once this point is accepted the reader becomes susceptible to the whole wealth of passive euthanasia arguments.
Rabbi Dorff in his book Matters of Life and Death draws a distinction between justification and excuse, principle and rule. A rule must be followed without deviation; a principle is something to keep in the moral balance; it is what we generally do. (203). There is no justification for suicide, but there are excuses for it. In the Jewish Tradition, one may martyr himself for three things 1) being forced to murder another 2) being forced to act in incest or adultery 3) being forced to perform idolatrous practices (Dorff 203). And yet I only recently showed that suicide is prohibited and considered one of the worst crimes. One may kill another in self-defense or the assailant chasing another man. But by no means is he required to kill these people. It is only excused; if it happens, there are no negative consequences. Thus, we see that the vitalist argument does not hold. The sanctity of life is a principle, not a rule.
The direct consequence of this analogy is that active euthanasia is prohibited and passive euthanasia may be excused. Thus, from a belief in the needs for both justice and sanctity we have arrived at a morally acceptable system.
Some sources argue "that we should use the benefit
to the patient as the primary criterion for determining a course
of action rather than our ability to accomplish a limited, medical
goal (like keeping one or more organs functioning)" (Dorff,
203). "What may once have been the high moral position [vitalism]
has ceased to be that, for aggressive medical treatment comes
at considerable cost in pain to the patient" (Dorff, 205).
A vitalist will admit that people must die. What
he will not agree to, is that they may die now. The vitalist line
of reason preserves life at all costs. It might not be so unreasonable
to follow this logic under the circumstances that technology is
flawed and people will eventually die of device failure. Unfortunately
the real result of their vitalist assertion, in the face of improving
technology will become evident. Eventually, an increasing number
of people will 'last' on 'body-support' machines. I say 'last'
because they are not being treated on the machine, but being kept
in a painful limbo between life and death. People are not meant
to live forever; we must always keep this in mind when making
decisions. "Even if some cure is just around the corner,
we are not responsible for knowing that" (Dorff, 201). Further,
to think we could "cure every illness… would be to engage
in a form of idolatry, making idols of ourselves and our abilities"
(Dorff, 201). Hopefully, if you had disagreed with my exception
to the vitalist argument till now, your eyes are now opened to
its immorality. One may respond that my arguments kill hope; if
so, he has completely missed my point. Here I and arguing for
the exception from the vitalist argument. The decision when to
apply this exception, passive euthanasia, is much more complicated
and can really only be applied in individual situations. It will
be addressed in a later section.
The previous argument for passive euthanasia dealt
with a patient being kept alive on a machine, an obvious intervention.
The purpose of the respirator is to prolong life for a period
of time. And it is often necessary to tide the patient over a
difficult time. But what about the patient with a non-terminal
debilitating illness such as Parkinson's or is in a Persistent
Vegetative State (PVS)? In this case, passive euthanasia will
likely consist of the removal of nutrition and hydration, as they
are called. This is a distinction between food and water, which
every person has a right to receive and is not an invasive medical
technique. The argument in Dorff is pretty extensive regarding
this. He points out how difficult and technical this distinction
is. The difference between water and hydration, is its administration.
Water is made available. Hydration is given. Removal of hydration
is prohibited if the patient rationally requests that it be continued.
(He knows the value of his life better than anyone else). It is
permitted if the patient requests that it be discontinued or is
incompetent. Here, the autonomy principle has entered the picture.
Since we are dealing with people, it makes sense that what people
think be taken into account. A consensus of physicians and relations
must then be attained for the removal of care. It must seem like
a reasonable request and that the patient has little to live for.
I realize these definitions are problematic, but the moral works
such that the details can only be determined on the individual
level and one must hope they are being applied correctly. The
doctor must treat the patient beneficently and the family must
be caring and considerate. For the PVS patient, the family and
physicians must wait a period of at least three weeks (Lieberson,
1998) before removing treatment. The details of their decision
to let the patient go, all respecting his human dignity, are too
particular to be discussed here.
Now I have well established that the excuse to let a patient die, passive euthanasia, is valid. Let us examine a case of passive euthanasia involving a non-terminal Parkinson's patient (Whitney, 1996). As Mr. K's disease progressed, he became unresponsive to the medicines available. "He is awake and alert but locked inside a body that does not move" "For Mr. K, the quality of his life was more important to him than the sanctity of life." When I introduced this paper, I pointed out that we do not truly know what happens with death. Here, Mr. K believes that his death would be superior to continued existence in his body. Is this a competent request? Competence means two things, 1) that he is fully able to assess his situation rationally and 2) that we agree his decision is rational (my definition). Whitney approached this case from an autonomy point of view, and asked these questions. She also asked if the patient was informed, how to weigh life's quality vs. sanctity, how to resolve the conflict of responsibility to do good with that to prevent harm, if it would be legal to comply with the decision, and if the hospital need care for him once treatment cease. These are similar to the questions I would ask if approaching the situation from the moral point of view. The patient is in pain, he has a debilitating, irreversible illness-he may choose whether to live or be let die.
"Mr. K believed that life in its present state was worse than death" (Whitney, 1996). How could it be that anyone know this? For whom is his life worse than death? For him or his family? If he had chosen life our decision would have been easy. Yet, now, we must balance the sanctity of life with what kind of life he is living. (It is only a quality of life issue insofar as the patient also believes it is). What is he being kept alive for? There is no hope of a cure or relief on the horizon. He is unresponsive to drugs. We cannot force him to value his life. We must decide if we are preserving or prolonging his life.
Unfortunately, I only know of this case from the review published. I sensed hints that Mr. K's family might have been an influence on his choice for death. Was Mr. K's pain and suffering great enough that his life was being prolonged rather than preserved until a cure? Two choices lay before us: we may choose to remove his nutrition and hydration as he requests, or we may decide that he does have something to live for and override his request. His family supported his decision. Would they also have supported his decision to live? This is an important point. If they would have supported his decision regardless, then we know that they have conceded they lack the measurement device to determine what to do. They would gladly support his choice to live and continue to pay for and care for him. But this is not what Mr. K chose.
Life can be preserved a while longer; death is a final decision (Lieberson, 1998). Thus, a careful evaluation must be made of the opinions of physicians, family, and attorneys regarding the futility of the case as was done here. Lastly, Mr. K's physical ability to communicate was limited to raising his fingers to answer yes/no questions. Setting up a system whereby he could change his mind was developed taking his physical considerations into account. Therefore, every argument was considered why he should be overruled. In my estimation, the purpose of searching for a consensus was to ensure that he was not let to die solely because he wanted to but because the circumstances permitted his lack of hope for a meaningful future.
"Mr. K wanted to die in the hospital so as not to suffer what he perceived as humiliation of having his children perform his care" (Whitney, 1996). Again, not knowing the full circumstances of the case, this quote suggests to me that Mr. K might have wanted to die to spare his family. This is not a pure motive. The motive for dying should be that there is no future, and that living will only be lasting in pain. I have a tremendous difficulty weighing the principle sanctity of life with his theoretical condition. There are no rules for determining this kind of case, and even the principles are difficult to elucidate and apply. We must bring arguments for life but be willing to accept death if all else fails.
The hospital nurses supported Mr. K's decision and would care for him. The ethics committee okayed it and "recommended that a mechanism be established whereby Mr. K would be given an opportunity to change his mind." The author, a clinical nurse specialist, then asked herself what her role is in this. It is to protect Mr. K from harm or foster his autonomy? "My role, along with Mr. K's family and the other members of the health care team, was not to abandon Mr. K and sentence him to a life trapped within his own body, but to make sure he remained comfortable until his death." Strangely, the author states "Mr. K's capacity for agency is somewhat limited because he has the desire to act (die) but he is unable to perform the intentional action due to his immobility." I think it may be his immobility that causes his desire to die. This calls into question her command of the situation, yet she seems to have done a thorough job investigating Mr. K's decision.
People tend to define autonomy as something outside the self , but really, they "decide based on values, beliefs, and goals that probably have been influenced by their religion, family, professional relationship," etc. Autonomy is really just the right to decide for yourself. It is not the right to be uninfluenced. In this case, everyone questioned from psychiatrist to neurosurgeon to spouse agreed Mr. K's wishes should be respected. But what if the patient and physician values had differed? The patient would have been kept alive longer, not a terrible prospect from the vitalist vantage. But what of mercy? Many patients die during the time these discussions take place (Lieberson, 1998). Their delayed deaths are the cost of ensuring life be preserved for the patients that refuse care but deserve it.
This case shows that with a careful investigator the certainty that the correct decision has been made increases. Unfortunately, not all cases are as clear cut. "If the neurologist believed his role was to prevent death at all costs then, the other health care professionals would not have been consulted and, Mr. K's voice would not have been heard" (Whitney, 1996). When the patient has expressed an opinion regarding treatment changes, it should take at least two doctors and a family relation to facilitate the change or deny it. The doctor should not conceal such requests; that would be parentalistic. If the doctor or family refuses however, it would be important for him to discuss with the other their basis for disagreement. This is Brody's conversation model. There should be "open dissemination and discussion of the criteria for determining futility and the application of those criteria to specific diseases should help assure that any unwarranted assumptions are challenged and that all relevant life plans taken adequately into account" (Brody, 184). He also adds that the "patient has some protection from its [physician's power's] abuse when the rules stipulate that it must be employed openly" (Brody, 183). Thus, through mandated open disclosure of decisions, discussion of all decisions between physician, patient and family, and considerations of life plans the correct moral decision may be ensured. One must watch out, however, that he does not involve too many parties because that can cause a mess larger than the case itself (Lieberson, 1998). "Ultimately there will be a major role for intuition in deciding what features of a case are morally compelling and what reasons are worthy of acceptance" (Brody, 244).
My first reaction to this case was the pain Mr. K must have felt during his slow dehydrating death was inhumane compared to the prospects of active euthanasia. I have since overcome that and realized that his decision to die is excusable, but killing him would not be. The sanctity of his life was maintained by not merely heeding his request to die, but considering the larger picture. His chances for recovery or enjoying his life in his present state were investigated. The author indicated that a sufficient job was done forming a consensus and discussing the issues with medical personnel and relatives. An escape route was provided for him whereby he might change his mind. There was no hope in future for any cures that would override his autonomous decision or disagreeable family members or physicians.
This all looks very much like a similar analysis to what the secular system does. The major difference being, that there is a moral which prohibits active euthanasia. Patient autonomy is still an important principle to uphold. When a patient loses competence, however, his autonomy becomes more difficult to employ. Since the moral does not say when one must terminate care, we must attain the consent of the physician and patient or, lacking that, the family.
We cannot know the objective right thing in these cases without knowing the entire case (Brody's description of Richard Zaner's approach, 250). Unless poor motivations may be proven, we must hope that decisions were made with the patient's best interests, how best to benefit him, in mind. There are safeguards such as forming a consensus and having conversations (Brody, 184) to discuss why decisions have been made.
In Rabbi Dorff's appendix he talks about religion's
failure at complete morality. He points out that ethics also is
very important "Since religion is neither sufficient nor
necessary for moral behavior, then, and since sometimes religion
actually produces immorality, some people conclude that religion
and morality logically have nothing to do with each other"
(Dorff, 397). "More pervasively, the blind loyalty religion
summons in its adherents, at least in some forms, works against
their retaining a critical, moral sense that could criticize religion
itself" (Dorff 396). But religion and ethics do interact.
"Judaism places our moral decisions into the context
of a larger vision of the world and our goals within it. Judaism
thereby gives meaning to each of our moral efforts and
provides motivation to meet our moral challenges. The beliefs
of Judaism thus establish moral moorings for our specific judgments
and acts" (Dorff, 400). The advantage of adding religion
is that you are "establishing a moral bottom line" (Dorff,
401). We must remember than in medicine, we are God's partner
(Dorff, 325) never taking over his job or completely submitting
to it. The secular system needs a purpose beyond satisfying the
plurality. We must respect the sanctity of life.
Brody, Howard. The Healer's Power. 1992. New
Haven : Yale University Press.
Dorff, Elliot N. Matters of Life and Death: A
Jewish Approach to Modern Medical Ethics. The Jewish Publication
Society. Phiadelphia, PA: 1998. pp.176-217, 392-400.
Klein, DB. Liberty, dignity, and responsibility:
the moral triad of a good society. Independent Review, Winter
1997 v1 n3 p325 (27).
Lieberson, Alan D. Advance Medical Directives-
1998: A Medical View 12 quinn. Prob. Law Jour. 305
Whitney, C. Refusal of Food and Water By a Man
With End Stage Parkinson's Disease. Journal of Neuroscience
Nursing, 1996 (28):1.
Wolpe, PR. Ed. Devries. Bioethics and Society
Constructing the Ethical Enterprise, "Chapter 3: The
Triumph of Autonomy in American Bioethics: A Sociological View."
1995 Prometheus. pg. 38-59.
Footnotes:
"Even when the individual calls an absolute criterion handed down by religious tradition his own, it must be reforged in the fire of the truth of his personal essential relation to the Absolute if it is to win true validity. But always it is the religious which bestows, the ethical which receives." Buber, Martin. Eclipse Of God: A Critique Of The Key 20th Century Philosophies + Existentialism + Crisis Theology And Jungian Psychology. Atlantic Highlands, NJ : Humanities Press International, 1988. Page 98. I interpret this loosely to mean that all men have a moral instinct, they only need the proper principles to direct it.
My simplified definitions for the two are: active euthanasia involves the direct administration of the death-dealing agent; passive euthanasia involves the removal of a hindrance to a man's death.
I am not concerned in this paper with how punishments should be doled out, only what principles to follow and how to apply them.
Read 'aggressive medical care.' The 'treatment' is not doing anything to heal him.
One can justify a vague term like 'reasonableness' because medicine isn't a science with precise definitions and predictable outcomes. It is a craft, and the data used is statistical. (Brody, 181).
In Jewish Law, one is required to follow the decision of the majority unless it is immoral.
Here I diverge from mainstream ethics by resolving that the right thing has been done, not that the patient's autonomy has been respected. (Though this is also important).
Parentalism is the same as paternalism, just not
sexist.