Tragically, many terminally ill patients can be kept alive yet suffer greatly from their sickness or alternatively remain in a comatose or vegetative state for a long time. One of the critical pieces of technology that allows them to remain alive is a mechanical ventilator (or “breathing machine”) that provides artificial respiration. This invasive treatment keeps a patient oxygenated and the lung structures intact.
In ideal situations, the ventilator is meant to serve as a “bridge” to help patients get through a difficult period until they can be removed from this artificial support. However, the ventilator can frequently maintain respiration for a long time even when there is no hope for recovery. In such circumstances, the ventilator becomes a “bridge to nowhere,” raising the question of whether the artificial respiration can be stopped to allow nature to take its course.
In general, Jewish law supports employing palliative measures to reduce suffering, such as those utilized at hospices. This even includes gradually increasing morphine injections as long as one intends to reduce pain and not to hasten a patient’s death. At the same time, Jewish law prohibits suicide or so-called “mercy killings.” For this reason, Israel and many other countries do not permit active euthanasia or even the slightly more moderate model of physician-assisted suicide whereby healthcare professionals provide the necessary tools for the patient to take his own life.
Jewish law on withdrawing or witholding treatment from the terminally ill
However, Jewish bioethicists significantly disagree regarding “passive euthanasia,” which can constitute either the withholding or withdrawing of treatment from the terminally ill. In the 16th century, Rabbi Moshe Isserles codified three major principles regarding the treatment of patients approaching death (goses): (1) One should not cause them to die more slowly; (2) One may not do any action that hastens the death; (3) One may remove something that is merely hindering the soul’s departure. Unfortunately, these principles remain subject to different interpretations. The examples given in the code, including placing salt on the tongue and synagogue keys under the pillow, remain difficult to correspond with modern technologies, to say the least.
Regarding the withholding of medical treatments, Rabbi Eliezer Waldenburg and others contended that the value of every moment of life remains infinite and absolute. One must therefore administer, even under the most miserable of circumstances, all life-extending interventions, including a ventilator, even if this would be against the patient’s will. The mainstream approach today follows the opinions of rabbis Shlomo Z. Auerbach and Moshe Feinstein, who asserted that one may withhold life-prolonging treatment from terminally ill patients experiencing intense anguish.
Following this line of thought, one may fill out a halachic living will to enable, in cases of terminal illness and suffering, the withholding of life-prolonging treatments, such as resuscitation (DNR) or intubation (DNI). Following the same rationale, one may also choose to withhold the next round of intermittent or cyclical treatments, such as dialysis or chemotherapy, which is deemed as an act of omission. Some decisors assert that basic substances for bodily maintenance, such as oxygen, nutrition, and hydration, can never be withheld. Others, like rabbis Zalman Nechemia Goldberg, Mordechai Willig and Hershel Schachter, deem these items as medical treatments that the patient or their proxies may choose to withhold. The primary goal of care at this stage should be maintaining the comfort of the patient.
When doctors administer a continuous life-prolonging mechanism, like a ventilator, it becomes more difficult to withdraw this treatment. Former Tel Aviv Sephardi chief rabbi Chaim David Halevi classified an artificial respirator as a mere impediment to death that doctors should disable to prevent the inappropriate prolonging of the death process. The more mainstream approach, advocated by rabbis Auerbach and Feinstein, contends that one cannot remove an artificial respirator, as this will directly hasten the patient’s death, even if intubation is no longer deemed medically advisable. One would not, however, need to reconnect the machine if its functioning had to be interrupted anyway to service it or suction the patient.
To prevent prolonging the deaths of intubated patients, two possible solutions may become advisable. Firstly, many decisors will allow extubating if the patient will not die immediately. Some believe that the person would still need to be able to survive for two days. Many others, however, speak of “a number of hours,” or even less, for the patient to remain stable.
Another possible solution was endorsed by rabbis Auerbach, Willig and Shmuel Wosner, who allow the oxygen rate of the ventilator to be carefully lowered to the level found in the normal air which we breathe, provided that the patient can still breathe on his own. Unfortunately, these two solutions aren’t always logistically possible, and as with many issues in Jewish law, not all decisors agree with them.
In 2006, a 59-member committee representing the full spectrum of Israeli ideological worldviews, led by the esteemed Prof. Avraham Steinberg, attempted to form a halachically defensible national policy regarding ventilators and end-of-life care. The Steinberg committee proposed a compromise position that mandated operating all respirators on a timer, thereby allowing it to shut off automatically, should the hospital committee deem this act of omission appropriate given the patient’s condition.
Unfortunately, the Israeli health system has not been able to implement this proposal. In its absence, many families are left without an appropriate solution, while some healthcare providers may take actions that are more questionable under Halacha (or Israeli law). One hopes that the new government will address this issue and provide a suitable solution for this difficult situation.
The writer is the director of the Halachic Organ Donor Society, which is rebranding and expanding to provide guidance on all end-of-life care dilemmas. director@hods.org