Community Magazine July 2014

TAMMUZ 5774 JULY 2014 33 The Sanctity of Life Dr. Abraham S. Abraham, author of Nishmat Avraham , a groundbreaking work on medical halachah , begins his treatment of this very important topic by citing the words of Rabbi Lord Immanuel Jakobovits, who might be described as the “father of modern Jewish Medical Ethics,” emphasizing the inherent value and sanctity of human life in Torah thought: The worth of a person’s life is immeasurable and therefore cannot be divided; each and every fraction of it is infinite. Therefore seventy years of life have exactly the same value as thirty years or a year, an hour or a second. This exacting definition is not only based on pure mathematics or logic, but is based to no lesser extent, on moral values. If the value a human life is lessened because his end is near, the life of man will lose all of its absolute value, being replaced with a relative one – relative to his life expectancy, the state of his health, his value to society, or to any other arbitrary index. It will then be necessary to grade people, and no two people will ever have the same worth. Once we curtail the life of a dying patient because it is no longer of value, we are in fact curtailing the infinite worth of each and every individual’s life, assigning them limited boundaries. Therefore, the sanctity of life is such that under no circumstances will it be permissible to curtail life because of pain and suffering, even if by a second. Even if death’s victory in a short time is absolutely obvious, the patient’s life remains of infinite value, and killing him is no less a crime than killing a perfectly healthy person . This fundamental precept is expressed in several Talmudic passages, which reflect our sages’ belief in the delicate balance that must be maintained between the sanctity of human life and the importance of mitigating suffering. Rabbi Hanina ben Tradyon In Masechet Avodah Zarah (18a), the Gemara tells the famous story of Rabbi Hanina ben Tradyon, one of the ten famous martyrs executed by the Roman government, who was sentenced to be burnt at the stake for violating the ban on Torah study. In order to prolong his suffering, the executioners wrapped him in a Torah scroll and placed upon his heart rags of wool that had been soaked in water so he would die slowly. While the flames were burning, Rabbi Hanina’s students begged him to hasten his death by opening his mouth so the flames could enter his body, but he refused. The executioner then offered to increase the flames and remove the rags to hasten his death, and the rabbi agreed, guaranteeing the executioner a share in the world to come in exchange for this act of compassion. Rabbi Yehudah Hanassi In Masechet Ketubot (104a), we read of Rabbi Yehuda Hanassi (Judah the Prince) who was suffering on his deathbed as his loyal students prayed for his recovery. The students’ prayers were effective in keeping the great sage alive, but did not alleviate his suffering, essentially prolonging his painful death. His knowledgeable maidservant saw his suffering and realized that his students’ prayers were extending his pain. She therefore climbed to the rooftop and threw down a plate to disrupt the students’ concentration, and at that moment, Rabbi Yehuda Hanassi passed away. On the basis of these accounts, modern-day halachic authorities differentiated between actively shortening an individual’s life to mitigate suffering (for instance, euthanasia) and withholding treatments that can prolong one’s life. In both incidents mentioned in the Gemara, external impediments to death were allowed to be removed. Rabbi Hanina allowed the executioner to remove the soaked rags, and Rabbi Yehuda’s maidservant disrupted the students’ prayers. Since these measures did not directly cause death, but rather eliminated obstacles to death, they were permitted. However, the poskim emphasize that this does not permit removing a patient from life support, actively discontinuing intravenous medications that maintain a patient’s blood pressure, or disconnecting a patient from a ventilator. In these cases, the treatment is supporting a basic bodily function, either breathing, or a minimal blood pressure necessary to live, and thus terminating the treatment is considered directly terminating life. The poskim explicitly forbid actively removing a patient from life support if this will lead to immediate death, noting that doing so is tantamount to murder. 1 What, then, are the minimal requirements that must be given to a terminally ill patient who is suffering? Rabbi Shlomo Zalman Auerbach and Rabbi Moshe Feinstein ruled that basic needs such as nutrition, hydration, oxygen and antibiotics must be provided, as well as insulin for a diabetic and blood transfusions when this is necessary. However, aggressive treatments that will only cause pain or that extend beyond standard care are not necessary, and in some instances should be discouraged. 2 Cardiopulmonary resuscitation (CPR), including mechanical ventilation, is not required if it will only add to the suffering. (Indeed, CPR is a very painful treatment, commonly resulting in broken ribs.) There is, however, an important distinction that needs to be drawn between actively discontinuing treatment and not resuming a treatment that had been discontinued on its own. For example, in the case of a patient who has little hope for recovery, and is on intravenous medications to maintain a minimal blood pressure (vasopressors), it may be permissible at times to allow the medication bag to finish, and not replace the bag. In this case, the treatment has not been actively stopped, but rather not resumed. 3