This article (which I will partially reproduce here) discusses some more aspects of this question:
http://www.daat.ac.il/daat/english/ethic/cohen-3.htmLiving With Pain
Whose Body?
Rabbi Alfred Cohen
Rabbi, Cong. Ohaiv Yisroel, Monsey, N.Y.
Rabbi, Yeshiva University High School
Journal of Halacha & Contemporary Society, Fall 1996
One of the most difficult and painful experiences any person has to go through is seeing a loved one suffering greatly. The feeling of helplessness, of suffering for the sick one, of despair, often lead one to ask - is this really necessary? Must a sick person suffer so much? Is it necessary to try every procedure, no matter how fleeting its benefit and how difficult its implementation, just to buy for the dying person another day, another week - of what? Of pain, of suffering?
Thus, in our age - which has seen marvels of medicine and surgery, developed machines which can breathe for a person, pump his blood, cleanse his arteries, and keep the body alive long after one would have hoped for release - more and more often, the question is asked: is this necessary? Is a person committed to Torah and halacha obligated to do everything possible in order to prolong life? Whether it be one's own life, or the life of another for whom one is responsible, does Jewish law always require that "uvacharta bachclim", you must choose life?
Choosing To End LifeThe Gemara1 relates the existence of a very unusual town. In this town, Luz, no one ever died.
However, the old people there, when their lives became intolerable, would go out beyond the city walls and [there] they would die.What is the Gemara's point in telling us about this practice? Should we interpret it as indicating that when a person "has had enough", he can take steps to bring an end to life?
Certainly that does not seem to be the thrust of Jewish law. Halacha mandates violation of the Sabbath in order to save a life, even if it is only to free someone trapped under the debris of a fallen building, someone so gravely injured that at best he can live only a very short time thereafter.2 This shows how highly halacha regards even a few moments of life, even when there is no chance of saving that life for any appreciable time. Jewish law forbids even moving a person who is dying (gosses), for fear that thereby one may hasten death.3
These few points suffice to indicate why there is so much confusion about what Judaism requires or forbids us to do - the sources are in a sense ambiguous, open to a number of interpretations. While Jewish law is emphatic on the absolute prohibition against euthanasia, and halacha is clear that virtually all other considerations are set aside to save a life, nevertheless, there is some lack of clarity on a number of key questions: If the sick old people of Luz were free to choose when to leave town to die, does that imply that we have control over our deaths? If we may not intervene for a person in the throes of death, does that mean we have no control?4
And if we should desecrate Shabbat for a person who clearly cannot live much longer, doesn't that indicate that every moment of every life is infinitely precious?
The present study will explore this issue from a variety of perspectives, within the context of Jewish law. There is no question here of "assisted suicide", that euphemism for murder or suicide, which is always forbidden. Furthermore, let us understand that we are not dealing with questions to which one can find definitive answers of "yes", "no", "never", or "always". Perhaps, however, a clearer insight will lead to an understanding that some situations require learned religious guidance, not only learned medical advice.
Who Decides?Our purpose is to investigate a very troubling issue, which is increasingly becoming an inescapable dilemma of many people's lives. There is much confusion about what the Torah requires or allows when it comes to taking or choosing not take measures which might extend life, due to the attendant pain.
To what extent, under Jewish law, does a patient have control, or at least a say, over the treatment he chooses or refuses to take? Who has the ultimate decision-making power? The late Rav Yisrael Gustman related to numerous people, including this writer, that Rav Chaim Ozer Grodzinski, his
rebbe, had maintained that the patient's wishes must be taken into account before rendering a p'sak. However, he hastened to add, all the other rabbonim in Vilna did not agree "But then," he mused, "who could compare to Reb Chaim Ozer?"
To return to the fundamental issue: whose body is it anyway? Does the rabbi make the ultimate decision or the doctor, or the patient (or his surrogate)?
The question itself is something of a "hot potato" as seems to fly in the face of all the hard-won acknowledgements which women and the elderly and the handicapped have fought for in the past generation. In the western world nowadays, the accepted wisdom generally is that a woman has the right to final decisions over her own body. Abortion, sterilization, pregnancy - these are her prerogatives, because it is her body. But this is not the approach of Jewish thinking, not for women and not for men.
The power of life over a person's body does not belong to him...not only is a person forbidden to destroy his own life...but even his life is not in any way his.Rav Zevin cites the Ba'al HaTanya, who wrote:
...Because a person has no control whatsoever over his body, to strike it.6He also brings the Radbaz:
...Inasmuch as a person's soul [life] is not his possession but rather the possession of the Holy One, Blessed be He, as it is written, "And the souls are Mine."7These citations are expressions of the fundamental conviction that bodies and souls are entrusted to people for safekeeping, to be returned to their Owner when He sees fit.8 Individuals have limited use of these "items" entrusted to their care, and must carefully adhere to the conditions for their use, as outlined by their Maker in the Torah.9
Halacha recognizes specific instances when it is up to the person to make decisions regarding his body and health.10 For example, if a person feels sick on Yom Kippur and insists that without food he will die, "even if 100 doctors"11 say that he will not die without food," we tell him to eat.12 This ruling is based on the Gemara's supposition that "lev yodea morat nafsho," no one knows better than the individual involved how much pain he is suffering; ultimately, therefore, it has to be his call. He knows best whether he can withstand the pain of not eating.
Conversely, when a person perceives that fasting will cause his death but refuses nevertheless to eat, many consider that he is liable for causing his own death. The Radbaz castigates him as a "Chassid shoteh," a pious fool.13
Nevertheless, Tosafot grant the patient the option not to eat rather than transgress the holiness of Yom Kippur.14 According to them, he is entitled to refuse to engage in behavior which is permissible in order to save his life, if he prefers to observe the Torah stricture.15 As an example, although the rule is that all Torah prohibitions are waived (with the exception of idolatry, murder, and sexual immorality) in order to save a life, according to Tosafot, a person is allowed to say, "I don't care if you kill me, but I won't eat non-kosher food."16
To sum up the position of Jewish law: except for extraordinary situations, a person generally does not have the option to refuse to go on living. Life is a gift from the All-mighty, and only He can decide when to end it. Our concern now will be to investigate the parameters of this general statement and to see if there are circumstances which mitigate it.
Rav Moshe Feinstein has ruled that one may not simply abandon a patient who might recover; even an old person must be given full medical treatment. We are not allowed to say - he's old, what's the point? Even a patient who himself says, "I don't want to go on living. I'm old and tired" - we do not listen to him but try to cure him.17
There are some situations wherein a person may want to hasten his own death. Take the case, for example, of a gravely ill person who is in great pain; the doctors propose an operation or medication which can prolong his life but which cannot alleviate the pain. Must the patient agree to this? Not according to Rav Moshe Feinstein, who writes,
However, in a situation where the person suffers pains for which there is no known cure [for his sickness] nor a way to reduce his pain - in such a case, a person prefers to die rather than to live a life of such pain...it is not mandatory to give medical treatment to a person ..if he doesn't wish it, with medical treatments that prolong his life with such pain. And even in cases where it is not possible to know the patient's opinion, generally speaking we can assume that the patient would not want nor is there any requirement to give him medical treatment.18In this ruling, R. Moshe Feinstein grants the sufferer the right not to prolong his suffering. We shall see that even R. Moshe did not consider it to be either an absolute or an unequivocal right. Nevertheless, it is evident that the Torah only gives a doctor the right to heal or to alleviate suffering. Extending a life of pain is beyond his prerogative. Now he is intruding into the sphere of the Ribono shel Olam.
Limits Of Patients' RightsWe have already noted the opinion of R. Moshe Feinstein that in certain cases, a patient may refuse treatment. Rav Feinstein's voice is not the only one raised to champion the patient's right - Rav Shlomo Zalman Auerbach was of a similar mind: In a situation where a woman needed an operation to save her life, but the surgery might leave her a paraplegic for life, he ruled,
Nevertheless, since ultimately the life of paralyzed persons is very bad and bitter, so that they consider death preferable to life, in such a case it makes sense that there is no obligation to make the choice of having the operation.19But his contemporary, Rav Eliezer Waldenburg, does not equivocate in ruling otherwise:
We must do all that is necessary to save a life, [even] against the wishes of the patient, and every person is commanded [to do] this, arising from [the biblical directive], "Do not stand by your fellow Jew's blood" [i.e., do not passively allow another person to die]. And the matter is not dependent upon the choice of the patient, nor is he given the option to destroy his own life.20Thus, we find two opposing bodies of thought: Rav Moshe Feinstein and R. Shlomo Zalman Auerbach are among those who allow the patient to choose not to undergo further medical treatment in order to end suffering; intervention which will only prolong pain and the process of dying is not required. But Rav Waldenburg expresses the view of those who maintain that one is not permitted at any time to forego treatment which might prolong life, albeit pain would also be prolonged. According to this position, even if the patient refuses medical treatment we should force him to have it because it is not his body to destroy; that is the option of G-d alone. As Rav Waldenburg cites the Talmud, "even a moment in this world is beautiful."21
Before we proceed in our inquiry, it is important to clarify that the differences of opinion between rabbis and poskim are not a function of their personal predilections. Rav Auerbach and Rav Feinstein do not rule a certain way because they are "more compassionate" to the sufferer; those who are strict are not "insensitive" to human needs. Let us be very clear - these are questions of Jewish law, not of emotions. The rabbis arrive at their conclusions on the basis of their understanding of Torah law.
There are certain situations where halacha gives the sick person the right to choose. For example, if a person is very sick, the doctors may offer him the following scenario: "Don't do anything, and the disease will kill you in a relatively short time;22 if you do choose to have an operation, it might cure you. On the other hand, it might kill you right away." This is a difficult choice - can the person gamble with the life span he is assured of, on the chance of gaining more time?
This situation parallels an incident related in II Kings 7:3-5: Four lepers were outside the walls of the city Shomron, which was being besieged by the Arameans. Due to the siege, there was a dreadful famine, and there was no food within the city. The lepers, who were banned from the city in any case, decided to go to the camp of the Aramean army and beg for bread. Their logic was simple - "We are going to die of hunger within a day or so anyway. Maybe the Arameans will give us some food. Although it is true that the Arameans might also kill us, what do we have to lose? We're going to be dead either way! And there's just a chance that we might not die, if we can get some food."23
Rabbinic thinking leans to the view that the patient should undergo a procedure if the choice exists. Nevertheless, he may exercise the option not to do anything.24 This is especially pertinent to the situation which sometimes confronts a cancer patient, where the treatment might succeed in curing him but might also kill him. Experimental drugs or surgery are permitted for a patient who will die without them; this is true also if he is in great pain. If the person is not in a condition to be able to make the choice, R. Shlomo Zalman Auerbach has ruled that the family is relied on to exercise the option which is best for the patient's welfare.25
An essential factor to be considered is the "track record" of the treatment.26 The less sure the doctors are of the possibility of cure, the greater is the patient's prerogative not to have the procedure. Conversely, if the treatment is generally efficacious, the patient has less option to refuse it.27 In those cases where the doctors are not confident of the outcome, he can choose to live whatever amount of time he has left and not take a chance on losing even that short time, or he can take a chance that he will lose everything - but might gain a lot.28
Rav Feinstein returns a number of times in his responsa to the central issue of a patient's right to refuse treatment, and expresses doubt whether a person is required to undergo treatment which will cure his malady but consign him to a life of pain. He tends to the opinion that the decision is really in the hands of the patient, who is entitled to know all the options and make his own decision.29
Rav Auerbach does not give a patient carte blanche to bring a quick end to his sufferings.30 Even against the patient's express will, he must be provided with food and oxygen; however, we should accede to the request for a cessation of further medical intervention,31 even if that cessation will bring a quicker death. Rav Feinstein concurs with this ruling:32
And with a person such as this, who the doctors know cannot recover and live, nor even that he can continue to live but without pain - but it is possible to give him medication to lengthen his life as it is now, with pain - one should not give him medication but rather leave him as he is33....However, if there are medicinal drugs which will relieve his pain but will not shorten his life even a moment, one must give them to him before he begins his death throes [gosses34].35Rav Moshe, too, holds that it is permitted to withhold medical treatment but not food. Every patient must be fed, even intravenously or through a tube if that is necessary. The reasoning is that food is a requirement of nature, for all people and even for animals, in order to sustain life. Food may not be withheld. However, medicine is not part of the "natural process" and must be administered only if it can promote healing or alleviate pain.36
It is necessary to note a significant exception to the above statement: When a person is on his death bed (sh'chiv mira), the requirement to feed him no longer applies. That is because our Sages have taught that it is imperative to follow even the slightest wish of a dying person, for fear that the distress of not having his wishes fulfilled at that time may hasten his death. Thus, if the person does not want to eat, we are not allowed to force him, as we would otherwise have to do. For this reason, rules Rav Moshe in this responsum, one should not force-feed a deathly ill patient, lest we make matters worse.37
The basis for the "permissive" opinions of Rav Auerbach and Rav Feinstein is the ruling of Ramo, who permits one to stop making a noise which is holding the patients attention and thus stopping him from dying.38 Rav Moshe Feinstein reasons that removal of the impediment to dying is permitted in this case only due to the extreme pain which the patient is undergoing. "For if there were no pain, what reason could there be to allow removal of those things which are delaying the exit of the soul [from the body]?"39
Following this rationale to its logical conclusion, we may infer that it is not mandatory to take action to keep alive a person who is in great pain and cannot recover. If it is permitted to remove the distraction which is keeping him alive, it certainly shouldn't be necessary to take positive steps to keep him alive.
Based on what we have seen so far, there seems to be little requirement to attach a dying person to a machine in the first place, if the machine will only prolong pain (or dying) without effecting healing.40 We have also seen that the Shulchan Aruch permits removing an impediment to dying if the person is in pain. Since the mortally sick gosses is certainly in pain and certainly wants to die,41 we should not try to stop the will of the All-mighty.
But if the patient is already hooked up to a machine, may he be removed from it? Is it analogous to the case of a gosses, whom it is forbidden to move?42 Beit Lechem Yehudah43 writes that it is permitted to remove the patient from a machine, and it is not as if we are causing the early demise of the gosses. Rather, he sees it as analogous to removing specks of salt from the tongue of a dying person, which the Ramo allows. However, most poskim do not permit a dying person to be unhooked from the machine which is keeping him alive; they maintain that the Ramo allowed removing the salt (whose sensation was keeping the person alive) but only without touching the gosses.
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