Death and its complications

Jewish Ethics and the Care of End-of-Life Patients. Edited by Peter Joel Hurwitz, Jacques Picard, and Avraham Steinberg. KTAV Publishing House, Inc., in association with The Institute for Jewish Studies, University of Basel, Switzerland.

End-of-life decision making is now often left to specialists. This book presents their deliberations in a way meant to be accessible to the layperson. It is a dissection, perhaps over-specific, of general questions that many of us will face when we and our families get old and sick: when is the right time to die? What are the right criteria, and who decides?

Orthodoxy finds in the classic texts, Talmudic passages as well as later decisors, not just guiding principles but specific legislation, with one overarching conclusion: that every moment of life is to be actively preserved, even at the price of decreased quality of life. Every end-of-life decision is to be met with the same standards, and nearly every deliberation can find its relevant source in the classical texts. If the circumstances of terminal illness are different today, and death can be drawn out over long weeks of desperation and indecision, this should not divert our gaze but focus it even more intently on the principles that matter. On the other hand, Reform thinkers have pointed out for years that such texts are open to multiple interpretations – generalizations are risky, and every case should be considered according to its unique circumstances.

This book, in short, presents a canonical spectrum with familiar opposite ends: the Orthodox insistence on the eternal relevance of Talmudic passages (even to vastly changed modern circumstances) whose interpretation can change only glacially, and the classical Reform deconstructive approach to Jewish law.

A second question has to do with the many treatments which are given to (or foisted upon) the terminally ill. When the time comes to die, when there is nothing more to be done (or when what is being done is clearly inhumane or futile), how can we decide what to turn off? How can we stop impeding death without actively causing it – or is there a difference? In this book, the bioethicist Vardit Ravitsky considers Israel's new law concerning the terminally ill, which has something important to say about these matters.

The best-known element of this law is a technological compromise. Some explanation is in order. Many thinkers recognize a distinction between the hastening of death in the living patient (forbidden) and the removal of impediments to the death of a terminally ill patient (required). In other words, life must be maintained -- but death, once unavoidable, cannot be artificially kept at bay. This distinction, important in traditional Jewish law, is sometimes so unclear as to appear a contradiction.

These terms have been connected to a corresponding pair in secular bioethics: withholding treatment versus withdrawing treatment that has already been given. The claim is made that withdrawing treatment, once given, corresponds to "hastening death," while withholding treatment, in terminal illness, is just refusing to place an impediment in the path of a dying patient.

Here enters the technological compromise: a timer connected to a respirator. The timer converts a treatment continuous in time (and thus one impossible to stop without "withdrawing") into a "discrete" sequence of decisions whether to continue the use of the device -- that is, whether to "withhold" or not.

Ravitsky's analysis helps us understand why such a halachic-technological compromise is necessary. If the distinction between "withdrawing" and "withholding" were of ethical import, the timer -- designed to circumvent it -- would be an instance of deception. However, Ravitsky agrees with the position of the current Western bioethical literature, that this distinction is erroneous. There is no real difference between withholding and withdrawing. Therefore, "timers may be perceived as devices that enable individuals to overcome an emotional difficulty in order to do what is ethically right. They thus become an appropriate and clever way to bridge the gap between the desired moral outcome (death with dignity and respect for individual autonomy) and a cultural atmosphere (grounded in religious tradition and ingrained values) that does not allow renunciation of the distinction."

That is, Israel is confronting, albeit on a larger, public-policy scale, exactly what American Jews confront - a conflict between moral outcome and religious tradition. The editors have performed a valuable service in collecting thoughtful essays discussing this conflict from various points of view. It's another question whether laypeople -- who don't like to discuss death -- will pick up this book.