Sunday, March 27, 2005

La posizione dell'ebraismo riformato sull'eutanasia

Questions
and Answers
about
Jewish Tradition
and the Issues of
Assisted Death
Dr. Harvey L. Gordon

W H E N I T H U R T S T O O M U C H T O L I V E


A Publication of
The Union of American Hebrew Congregations

Department of Jewish Family Concerns
Committee on Bioethics, in cooperation with
the Central Conference of American Rabbis
Task Force on Assisted Suicide
Copyright © 1998 by Harvey L. Gordon
Manufactured in the United States of America
A Word of Welcome
Shalom.
For the past few years, the debates over physician-assisted
suicide (PAS), voluntary active euthanasia (VAE), and the
associated issues of pain and suffering have increasingly become
part of personal, familial, and communal dialogue. The rapid
changes in medical technology, the rise in challenges and
options with regard to caregiving, the aging of our population,
and the perception on the part of many that we can do with our
bodies what we wish have brought these discussions to our
Jewish consciousness. For many of our people, such private
moments of decision making are too often spent without benefit
of the guidance of our sacred tradition.
At a recent meeting of the UAHC Committee on Bioethics, the
decision was made to create a guide that could be used by a rabbi
and congregant or in a more formal classroom situation as a
teaching tool. The question-and-answer format seemed to be the
most appropriate because often, when we are faced with such
issues, we immediately ask the question, What does my Judaism
teach about this? Under the superb direction of chair Dr. Harvey
L. Gordon, the Bioethics Committee met frequently and had
numerous additional conversations about how to create this
document. It is designed to be used both as a teaching tool for
and an aid to dialogue and discussion. We hope that it will find
its way into classrooms and forums sponsored by individual synagogues.
It is designed to present an overview of how Jewish tradition
and contemporary Jewish thought look at the issues of
physician-assisted suicide and voluntary active euthanasia. We
hope that the question-and-answer format will convey the
power of our tradition and will help inform and guide individual
and family decisions. To assist in the overall teaching aspect of
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the document, we have included a brief section called
Additional Sources that may be helpful for individual or group
education. In addition, we have included the text of the 1995
UAHC Resolution on matters dealing with end-of-life decisions,
palliative care, and hospice. It was this resolution that sparked
the development of this document.
Also, a sincere thank you to the members of the UAHC
Committee on Bioethics, who were so helpful in contributing
their ideas and thoughts. A major note of thanks to Rabbi Neil
Kominsky, chair of the CCAR Task Force on Assisted Suicide,
who worked on the document and whose task force gave it their
approval.
Finally, great appreciation, thanks, and love to Dr. Harvey
Gordon of Houston, Texas. Dr. Gordon, who chairs the
Bioethics Committee of the Department of Jewish Family
Concerns, embraced this project and shepherded it through a
number of incarnations. His dedication to Reform Judaism and
the truths that are ingrained in its rich fabric is his gift to all of
us.
Rabbi Richard F. Address
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When It Hurts Too Much to Live
Questions and Answers about Jewish
Tradition and the Issues of Assisted Death
FROM THE TALMUD
The dying of Rabbi Judah ha-Nasi was painful and prolonged. His
disciples gathered in the courtyard, where they prayed incessantly that
he might live. Moved by the anguish of her master, his maidservant
shattered a jug in the courtyard, thus disrupting the prayers of the
disciples that the rabbi would not die and allowing his soul to depart.
ANOTHER STORY
Convicted of teaching Torah during the Hadrianic persecutions, Rabbi
Hananiah ben Teradyon was condemned to be wrapped in the Sefer
Torah and burned at the stake.
Seeing his torment, his disciples urged him to open his mouth, breathe
in the smoke, and thus die more quickly. He refused, saying, “It is better
that God who gave life should take it and that I do not kill myself.”
To prolong his suffering, the Romans placed water-soaked packets on
his chest lest he die too quickly. Upon seeing his agony, the executioner
offered to remove the wet cotton if the rabbi promised him eternal
life. Hananiah promised, and the executioner complied. As Hananiah
died, the executioner jumped into the flames. A heavenly voice
announced that both of them had a place in the world to come.
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INTRODUCTION
Never before have so many people reached old age. The medical
advances made during the past century have virtually eliminated
many of the common killer-diseases of the young. We reach
the later years of life, but we are often beset by strokes, dementia,
heart disease, cancer, and other conditions. The technology
that allows us to survive can also prolong interminably what was
once a quick death.
Torah commands us to choose life. For most of us, that is an easy
commandment to follow; we are glad to be alive. Traditionally
we greet each morning with a prayer of thanks for one more day
of life. But not all of us can give thanks for another day. Facing
weeks or months of incessant pain and helplessness, some of us
awaken to despair. We turn away from life; we pray for death.
Some of us want to stop the medical treatment that keeps us
from dying. A few of us, impatient and weary of a lingering
death, want to take our own lives. There are those among us
who, given the option, would choose a quick and painless death
at the doctor’s hands.
But the laws of this country and those of most industrial nations
do not favor that option. Physician-assisted suicide (PAS) is
presently illegal in most states and jurisdictions in the United
States and Canada and throughout the Western world. The
Northern District of Australia passed a law to legalize PAS, but
it was overturned by the courts. In the United States, Oregon
voters are reconsidering a law enabling PAS that they passed in
1994 but whose implementation was enjoined by the courts. A
singular exception is the Netherlands, where PAS and Voluntary
Active Euthanasia (VAE) have been decriminalized for nearly
two decades.
It is clear that the present legal climate doesn’t reflect consen-
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sus. We are all aware that too many of us suffer and too many of
us linger in our dying. And so, many of us—Reform Jews as well
as others—have begun to call for the legalization of PAS.
A recent poll found that 57% of Americans favor legalization.
Retired pathologist Jack Kevorkian, who has flouted Michigan
law, has never been convicted for assisting in over forty suicides.
Federal Courts of Appeals in New York and Washington have
found laws against physician-assisted suicide to be in violation of
the Constitution. Although both decisions were reversed by the
United States Supreme Court, which found no constitutional
right to assisted suicide, the issues raised brought forth a spate of
wide-ranging, thoughtful, and often passionate opinions. The
action of the Supreme Court encourages further debate and
leaves open the door to state legislation that would permit PAS.
It appears that if PAS were legalized, many of us might choose
PAS rather than endure suffering at the end of life.
Let us assume that you are dying in pain and anguish. Would you
rather prolong your suffering or curtail it? If that question
squarely framed the issue, there could be little disagreement.
What we should be asking ourselves is, “When is death the best
response to suffering?” In this debate we are hearing only
voices of compassion. In discussions about the role of assisted
death, there is honest disagreement among people of goodwill.
Moreover, decisions about physician-assisted death impact not
only those who are dying but also their families, their friends,
and all of society. Such choices are painfully difficult, but they
must be made.
How shall we choose? In discussing the authority of Jewish law
for liberal Jews, Mordechai Kaplan once said, “The past has a
vote, but not a veto.” We must balance the authority of Jewish
tradition with modern insights that encourage autonomy in our
decision making. To help us make an informed choice, the
Union of American Hebrew Congregations Committee on
Bioethics has prepared this booklet.
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Q.
W H Y A R E W E D I S C U S S I N G T H I S ? I
T H O U G H T I T W A S A N I S S U E F O R T H E
L A W M A K E R S A N D T H E C O U R T S .
The courts and legislatures will decide whether it is legal to end
suffering in this way, but patients and their doctors must look
elsewhere for moral guidance. A generation ago the Supreme
Court struck down the laws that made abortion illegal: Roe v.
Wade affirmed a woman’s right to choose an abortion. The court
determined that a woman’s right to privacy outweighed any
interest the state might have in whether or not she remained
pregnant. But while affirming a woman’s right to choose abortion,
the court was properly silent about whether it is right for
her to do so.
Neither science nor the law has answers to such metaphysical
questions as: Is there meaning in suffering? Is the preservation of
life always the highest value? Can life come to an end before
physical death? Can a physician be a healer if he or she takes a
life? We seek answers to these questions in our own traditions,
beliefs, and values. The role of government is not to impose a
single vision of what is right but to protect our right to act on
our own vision. Jews find their moral roots in Torah. With the
help of our texts, our traditions, and our teachers, we must reach
our own conclusions about PAS.
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Q. D O E S J U D A I S M A L L O W S U I C I D E ?
Suicide is explicitly forbidden by Jewish law. It is the Jewish
belief that our bodies belong to God and that life is a gift. As the
talmudic stories cited on page 3 illustrate, only God, who gives
life, has the right to take life. But our tradition contains suggestions
that the law against suicide is not absolute. Martyrdom,
even by suicide, may be preferred to violating kiddush Hashem,
the “sanctity of God’s name.” The rabbis teach that it is better
to die than to commit murder, incest, or idolatry. I Samuel
voices no disapproval when King Saul, who is grievously wounded,
slays himself to avoid torture and humiliation by his
Philistine captors. But such exceptions are rare, and nowhere in
Jewish law do we find permission to commit suicide in order to
avoid suffering.
Nonetheless, the rabbis were reluctant to condemn a suicide.
If it could be determined that the suicide acted “under duress,”
then the person was not held responsible for his or her action.
Based on their assumption that no rational person would take
his or her own life, the rabbis were able to conclude that the
person must have been under duress. This reasoning allowed for
a suicide to be given the traditional burial rites not otherwise
allowed by Jewish law. By invoking the talmudic principle of
lehatchila lo, bediavad iyn (before the fact, no; after the fact, yes),
the rabbis were able to accommodate human weakness while
preserving the divine code.
Some people, including a few Jews, have suggested that
the value-laden term “suicide” should not be applied to the
terminally ill. To describe a dying person who takes action to
accelerate the process, terms like “self-deliverance” have been
suggested as more descriptive. However, this distinction has not
been widely accepted by either rabbis or ethicists.
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Q.
D O E S N ’ T A U T O N O M Y G I V E M E T H E R I G H T
T O D I S P O S E O F M Y L I F E A S I S E E F I T ?
W H Y S H O U L D T H I S M A T T E R B E T H E
C O N C E R N O F A N Y O N E E L S E ?
Our society gives great weight to the principle of autonomy.
Many believe that our personal freedom stops only when it
impinges on someone else’s rights. When moral issues are debated,
however, there is often more than one principle involved.
For example, we must take into account how a particular choice
will benefit or harm the person, how it will benefit or harm
others, whether it is in keeping with our shared ideals, to name
but a few such principles. When these principles are in conflict
with one another, should autonomy always prevail?
Whether we live or die has importance not only to us. We are
members of a family, of a society, of a people. None of us lives in
a vacuum; we are each enmeshed in a vast network of relationships.
When we consider that each of us may be a parent,
a child, a spouse, a sister or brother, a friend, a teacher, an
employer, or a worker, we begin to grasp that society has a
strong interest in opposing suicide. Certainly that interest is
weaker when the life at stake is already flickering to a close.
If we say that autonomy gives us an absolute right to choose,
however, then we must honor that right for everyone.
Legally competent persons of any age and in any state of health
would have the same right to assisted suicide. Autonomy can’t
be respected only for those who are terminally ill.
An autonomous decision is one that is independent, free from
outside coercion. People who are terminally ill know that caring
for them places heavy physical, emotional, and financial
burdens on their family and friends. Rather than continuing to
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impose those hardships, some patients may feel obligated to
choose the quickest death possible. Moreover, studies show that
most patients who are very ill follow their doctor’s recommendations
and that those who are indigent or poorly educated are
the most likely to do so. It might be difficult for these people to
refuse the doctor’s offer of help in the form of suicide. A sense
of obligation to loved ones—or a physician’s suggestion that
assisted suicide is the best option—may well coerce a decision
for assisted death.
Although Reform Judaism gives autonomy great weight, it conflicts
with the authority of Jewish tradition as well. The halachah,
the body of Jewish law, speaks not in terms of our rights but
always in terms of our duties. Moreover, Judaism has always
taught that life is a gift, that it ultimately belongs not to us but
to God. Whenever autonomy collides with other principles,
Reform Jews and others are left to wrestle with conflicts that
can’t always be reconciled.
Q.
W H A T I S E U T H A N A S I A ? I S I T L E G A L ?
Euthanasia is a Greek word meaning a “good death.” Often a
distinction is drawn between passive and active euthanasia.
When a terminally ill cancer patient contracts pneumonia,
choosing not to treat the infection with antibiotics will allow
the person to die sooner. Similarly, if dying is being prevented
only by a mechanical respirator, removing the patient from the
respirator will enable a quicker death. These are examples of
passive euthanasia, when the doctor’s action—or lack of
action—allows the unopposed disease to progress more rapidly
until death. A physician may legally and ethically provide
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passive euthanasia at the request of a patient or, in cases of
patient incompetence, his or her surrogate. Generally speaking,
Reform Judaism permits passive euthanasia.
When a physician injects a dying patient with potassium chloride
in order to produce cardiac arrest, that is an example of
active euthanasia. In this case, the direct cause of death is not
the underlying disease but the lethal injection in and of itself.
A critical distinction between passive and active euthanasia is
that in the latter case, the physician’s action is the direct cause
of the patient’s death and the action would be lethal even if the
patient were not terminally ill. Active euthanasia is illegal in the
United States and Canada.
It is not surprising that there is no reliable data about how often
physicians violate the law. Death that occurs as an unintended,
although foreseeable, consequence of treating pain is not euthanasia.
Few if any physicians would risk prosecution by administering
a poison, but who can determine the motive behind
injecting a dose of morphine strong enough to control severe
pain but also likely to induce respiratory arrest?
Some ethicists argue that since the goal of both active and
passive euthanasia is the patient’s death, there is no moral
difference between them. Most ethicists, however, draw an
important distinction. When the physician withholds or withdraws
treatment, the patient is killed by the disease, whereas
when the physician gives a lethal injection, the patient is killed
by the physician.
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Q. W H A T I S T H E J E W I S H P O S I T I O N O N V A E ?
Active euthanasia violates Jewish law. The rabbis make no
exception for taking the life of a person in the last stages of
dying; it is the same shedding of innocent blood as murder.
Although a few recent commentators claim to have found
permission for active euthanasia in traditional proof-texts, most
Reform thinkers disagree with such reinterpretations.
Q. D O E S J U D A I S M R E Q U I R E T H A T A P E R S O N
B E K E P T A L I V E A T A L L C O S T S ?
Judaism teaches that we are responsible for the bodies entrusted
to us by God. Maimonides said that a Jew may not live in a place
where there is no physician. We must see a doctor when we are
sick and follow the medical recommendations that are likely to
restore us to health. However, if we are terminally ill with no
prospect for recovery, we could refuse treatment, and doing so
would not be considered suicide.
Judaism affirms that pikuach nefesh, the “saving of a life,” generally
takes precedence over all other considerations. The talmudic
stories quoted on page 3, however, contain some exceptions.
For Rabbis Judah and Hananiah, death was both inevitable and
imminent. The act of dying was being prolonged in one instance
by the disciples’ prayers, in the other by the executioner’s wet
packets. In each situation, it was permitted to remove the
impediment to dying. The law concerning a goses, defined by the
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rabbis as “one who is within three days of death,” is that one may
not do anything to shorten the person’s life, even to relieve his
or her suffering. On the other hand, it is permitted to remove
something that is only impeding death. The rabbis believed that
because the mechanical sound of a woodchopper might deter
the soul’s departing, the woodchopping could be stopped. Some
Jewish bioethicists invoke the “principle of the woodchopper” in
removing a ventilator that is the only last impediment to death.
Q.
I D O N ’ T W A N T T O S P E N D M Y L A S T F E W
W E E K S C O N N E C T E D T O T U B E S A N D
M A C H I N E S . C A N I R E F U S E M E D I C A L
T R E A T M E N T ? W H A T A R E M Y L E G A L
R I G H T S ? I S T H E R E A J E W I S H P O S I T I O N ?
Civil law gives every competent person the right to refuse medical
treatment. A physician who treats you without your
informed consent is committing the felony of “battery.” You may
also refuse to eat or drink or to receive artificial nutrition and
hydration by tube or by injection. Although as Jews we are
commanded to accept a physician’s treatment to preserve life,
we are not obligated to undergo treatment that serves only to
prolong the act of dying.
Doctors, however, are sometimes so intent on treating our
disease that they may lose sight of where their efforts ought to
stop. Some patients are kept alive by treatments that they
or their surrogates have explicitly rejected. Increasingly,
patients are making doctors and hospitals aware that choosing
a natural death is not only a matter of preference, it is their
legal right. We must not only make our wishes known—
we must insist that they be honored. Beyond the legal requirement,
a physician has a clear moral duty to abide by your refusal.
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For a Jewish physician it is a mitzvah, a “religious obligation,” to
honor your choice.
While most ethicists do not consider giving food and liquids by
an intravenous or a stomach tube different from other forms
of medical treatment, the Jewish position is less clear. Although
most rabbinic authorities permit the withholding or withdrawing
of “medicine” that can no longer restore health, some
distinguish between nutrition and hydration—required by all
living beings—and “medicine.” Reform opinion with regard to
this issue is divided.
Q.
W H A T I F I A M N O L O N G E R C O M P E T E N T T O
M A K E H E A L T H C A R E D E C I S I O N S ?
You can protect youself from receiving unwanted medical treatment
when you are no longer competent by preparing advance
directives. A living will allows you to stipulate what you would
choose under a variety of medical circumstances. You may be as
specific as you wish. But because no document can anticipate
every possible medical event, you should also appoint someone
as your health care proxy to make choices for you. You should
select someone who knows you well and with whom you have
discussed the choices you would make. Although the details and
specifics vary from state to state, United States federal law
affords all patients the right to self-determination of medical
treatment at the end of life. (A Time to Prepare is a readily available
guide from the UAHC Press for anyone wishing more
detailed information about advance directives.)
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Q.
W H A T I F M Y D O C T O R S T I L L
I N S I S T S O N T R E A T I N G M E ?
After a frank and assertive discussion, it is unlikely that your
doctor will persist. There is no substitute for clear communication;
where there is mutual understanding, controversy is rare.
Should there still be disagreement, all hospitals provide avenues
for the resolution of differences between doctors and patients.
You have the right to limit your treatment to what you believe
is appropriate, and your decision must be honored.
Q.
W H A T D O E S J U D A I S M S A Y A B O U T S U F F E R I N G ?
D O E S G O D W A N T U S T O S U F F E R ?
Few Reform Jews interpret suffering as punishment meted out by
God, nor do we gain merit by pursuing it. God doesn’t “want” us
to suffer, but suffering is part of the human condition. Most of us
will know suffering in our lives. Some will grow spiritually from
the experience. For example, one who has suffered may be
better able to fulfill the mitzvah of bikur cholim, “visiting and
comforting the sick.” It is our understanding that we do God’s
will when we seek to ease suffering in the world.
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Q.
M U S T W E S U F F E R A T T H E E N D O F L I F E ?
Many of us won’t suffer at the end of life. Having been made
comfortable, we will slip peacefully into a final coma. Yet even
under the care of good and caring physicians, too many of us still
die in pain and anguish. There are several reasons. Some state
laws aimed at controlling substance abuse put doctors at risk for
prescribing large doses of narcotics. Furthermore, while most
doctors are skilled in treating disease, few are as skilled in treating
the symptoms of dying. Medical students and physicians in
training have generally not been taught how best to provide
“comfort care” for the terminally ill. Only recently has the
United States joined Canada and Great Britain in recognizing
the specialty of Palliative Medicine, whereby physicians are
trained and certified as specialists in providing the kind of
comfort care often associated with the hospice movement.
Q.
W H A T I S H O S P I C E ?
Hospice is a comprehensive program designed to provide care
that seeks neither to cure us nor to lengthen our days. When
such goals are no longer achievable, we turn to hospice to give
quality to the time that remains. Hospice care isn’t concerned
with our underlying disease. It focuses on lifting the physical,
emotional, and spiritual burdens that prevent us from living our
last days with dignity and in comfort. Hospice allows us to find
meaning and value in life as it is coming to an end.
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Patients who enter hospice generally have a life expectancy of
less than six months. Although an in-patient facility is often
available for support, most hospice patients live at home. Teams
of physicians, nurses, social workers, clergy, and volunteers work
together on the many problems that can make it so hard to
“choose life.” The pain of ninety-five percent of cancer patients
is controlled without sedation. Nausea and troubled breathing
are usually kept to a tolerable level. Family tensions are
addressed. Spiritual counseling is offered. Ninety percent of the
chronically ill who say that they want to commit suicide are suffering
from clinical depression, a medical condition that can
be recognized and successfully treated. “I don’t want to live”
usually turns out to mean “I don’t want to live like this.”
Consequently, patients who enter a hospice program asking only
to die usually withdraw their request for assisted suicide. Most
are grateful for their last few months of life and usually find the
“good death” many of us seek: to die at home, free of pain, and
in the presence of those we love.
Q.
I S N ’ T H O S P I C E A C H R I S T I A N P R O G R A M ?
I S T H E R E J E W I S H H O S P I C E ?
The history of hospice dates back to the medieval church. It was
the name given to places of shelter for pilgrims journeying to a
religious destination. Less than forty years old, modern hospice
offers shelter from pain and suffering on our final journey.
Hospice may have a religious or a secular affiliation. The
principle of comforting those who suffer is firmly rooted in Jewish
tradition. There is Jewish hospice, both nationally and locally in
some cities. Unlike its medieval namesake, modern hospice has a
universal, nonsectarian mission.
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Q.
T H E N I S M O R E A N D B E T T E R H O S P I C E
T H E A N S W E R ?
For those who choose it, hospice can go a long way toward
solving many end-of-life problems. But even if all of us had
access to the most skilled hospice care, some unrelieved suffering
would remain. Many of the late complications of AIDS seem
to defy palliation. Other examples are neurologic diseases like
amyotrophic lateral sclerosis (ALS), popularly known as Lou
Gehrig’s disease, which may end in complete paralysis. However,
ALS is not immediately fatal; barring a lethal complication, it
can result in years of suffering. How are we to respond to the
anguish of a patient who is forever unable to communicate,
unable to move a single muscle, “locked in” although fully
conscious? When we have no other way to ease suffering, it
would be hard to refuse such a patient a quick and easy death.
Q.
I N C A S E S L I K E T H A T , D O N ’ T D O C T O R S
S O M E T I M E S T A K E S T E P S T O S H O R T E N
P A T I E N T S ’ L I V E S ? I S N ’ T T H A T A C T I V E
E U T H A N A S I A ? I S N ’ T T H A T A G A I N S T T H E L A W ?
Anonymous surveys confirm that they do. Some doctors have
provided medications that could be used by a patient to commit
suicide. Others have themselves administered lethal drugs.
Because such acts are illegal, there is only anecdotal evidence for
how often and under what circumstances they occur. However,
there is little indication that the practice is abused. In most cases
the final step is only the last in a long series of caring and
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compassionate acts that resulted from the covenantal relationship
between a doctor and a patient. Physicians are reluctant to
take that step when there are viable options, and the question
only arises when all other possibilities have been exhausted.
With continuing progress in end-of-life care, assisted death will
become less compelling a choice.
But what of those few cases for which no humane alternative
exists? Even for such cases some suggest an option that is within
the law. A physician can provide support and comfort to a
patient who chooses to stop eating and drinking. Without
suffering, the patient will, in a matter of days, slip into a
terminal coma. Some would argue that helping the patient die
of self-imposed starvation and dehydration is also assisted
suicide, albeit a slower and less efficient form. Others counter
that in this instance, the physician doesn’t provide the patient
with the means necessary for suicide but only follows the historic
tradition of keeping a patient comfortable until the end.
Some fear that recent changes in our system of health care delivery
will make obsolete the long and intimate doctor-patient
relationship underlying some of these solutions. They observe
that as patients are increasingly being treated by a group rather
than by a single physician and as patients are being forced to
change doctors when their employer changes health plans, the
“personal physician” may become the ideal rather than the rule.
Q.
W I L L A C H A N G E I N T H E L A W A L T E R T H E
T R A D I T I O N A L R O L E O F T H E P H Y S I C I A N ?
Some people place physician-assisted death squarely in the
tradition of preventing pain and suffering. Others observe that
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never before has our society made the physician a taker of life.
They warn that reversing the physician’s historic role as a preserver
of life would threaten the medical profession’s integrity.
Many fear that it would irreparably harm the doctor-patient
relationship, based as it is on the fundamental assumption that
physicians heal. The controversial Jack Kevorkian epitomizes a
physician whose only relationship to the patient is to provide a
means of death. To some, he is a hero and a pioneer; to others,
a monster. Does he represent our new role model for doctors,
or does his popularity signal only our fear and rejection of the
status quo?
Q.
W H Y C A N ’ T W E P R O T E C T D O C T O R S A N D
L E G A L I Z E P A S , A T L E A S T F O R T H E
“ H A R D C A S E S ” ? C A N ’ T T H E R E B E
S A F E G U A R D S T O P R E V E N T A B U S E ?
Respected physicians like Dr. Timothy Quill have proposed
safeguards against abuse. The statute to allow PAS that was
initially passed by the Oregon legislature carefully controls the
circumstances under which a physician may assist in a suicide.
Most proposed guidelines would ascertain that the patient was
suffering greatly, that the patient was deemed terminally ill by
more than one physician, that the patient was competent to
make a choice, that the request had been made on more than
one occasion, and that there was agreement among physicians
that no remedies had been unexplored. Yet many thoughtful and
respected critics still doubt that there can be effective protection
against abuse.
Let’s look at the Netherlands, a country where for two decades
physicians who follow stringent guidelines have been able to
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provide PAS and VAE without fear of prosecution. Studies show
that in actuality, the guidelines are violated in fully one-third of
the patients put to death by VAE. Moreover, the indications for
providing VAE have been extended from patients with terminal
illness to patients with chronic illness, from those with physical
suffering to those with mental suffering as well. In addition,
second opinions have become perfunctory and automatic
endorsements, a technical requirement rather than a safeguard.
What are some of the risk factors for a society considering
PAS/VAE? People who lack access to good medical care are
more likely to choose assisted death. Those whose medical
expenses threaten to impoverish the family may be subtly
coerced to “do the right thing.” It is likely that a society that is
increasingly aware of the escalating costs of health care will
decide that death is the least expensive solution to end-of-life
suffering. The right to die could become a duty to die. People
without political strength would be more vulnerable to coerced
death. Unethical physicians could violate the guidelines for
appropriate utilization of PAS/VAE. In comparing the United
States to the Netherlands, observers note that the Dutch, unlike
Americans, enjoy universal health care. They have no unempowered
underclass. There is no reason to assume that Dutch
physicians aren’t just as ethical as their American colleagues.
These are just some of the reasons cited by critics who project
that there would be more irregularities and abuses here than in
the Netherlands.
20
Q.
I S N ’ T T H E R E A W O R L D O F D I F F E R E N C E
B E T W E E N P A S A N D V A E ? W E ’ R E O N L Y
T A L K I N G A B O U T L E G A L I Z I N G A S S I S T E D
S U I C I D E W O N ’ T T H A T B E S A F E ?
Champions of PAS express the hope that legalizing PAS would
be a step on the path to VAE. Once the right to assistance in
dying is affirmed, it would be difficult to deny it to those physically
or emotionally unable to participate actively in their own
suicide. By the same token, opponents see PAS as a step onto a
slippery slope that would lead at the very least to voluntary active
euthanasia. Both sides agree that legalized PAS would soon be
followed by legalized VAE.
Our century has seen the dark side of euthanasia. After World
War I, Germany was in financial ruin. Maintaining asylums for
the insane threatened the shattered economy even further.
Dwelling on their incurably wretched existence, some German
physicians argued that euthanasia would be a humane and economically
sensible measure. Only the ascension of Nazism was
needed for the German government, in the name of compassion
and economic expediency, to implement such a policy.
Physicians joined the Nazi party in greater percentages than
those in any other profession. Quietly and secretly, first by lethal
injection and later by carbon monoxide asphyxiation, chronically
ill and insane patients fell victim to their own doctors and
nurses. Indications for killing moved from the medical sphere to
the social and political spheres, including homosexuals, Jews,
Gypsies, political dissidents, and other “undesirables.” What
began as euthanasia soon became the Holocaust. History makes
us pause to reflect before we decide whether or not to expand
the physician’s role to compassionate killer.
21
Even in an America that is economically stressed, few can envision
euthanasia for the unwilling. Yet there are terminally ill
patients, suffering greatly, who are physically or mentally unable
to request euthanasia. Many Dutch physicians admit to having
provided a compassionate, unrequested lethal injection, sometimes
without the patient’s knowledge. Critics see that as a step
down the slippery slope from voluntary to nonvoluntary to
involuntary euthanasia. There is also concern that while most
Dutch physicians perform mercy killing only infrequently, some
have become specialists to whom colleagues refer cases in which
they themselves are hesitant to perform euthanasia.
Q.
S U P P O S E I W E R E T H A T R A R E P A T I E N T W H O S E
S U F F E R I N G C A N ’ T B E R E L I E V E D . I W A N T T O D I E ,
B U T I ’ M N O T N E A R D E A T H . I F I S T O P E A T I N G A N D
D R I N K I N G , I T M A Y T A K E D A Y S O R W E E K S F O R M E
T O D I E . E V E N I F I W E R E N O T S U F F E R I N G , I
W O U L D N ’ T W A N T T O P U T M Y L O V E D O N E S T H R O U G H
S U C H A V I G I L . I N O R D E R T O H E L P M E D I E , M U S T
M Y D O C T O R B E W I L L I N G T O B R E A K T H E L A W ?
At present, the risk of prosecution for what transpires medically
at the end of a terminal illness is small. If the death occurs
outside an institution, with the support of family, the risk is
negligible. Anonymous surveys and anecdotal data suggest that
few physicians who want to accommodate the patient are
dissuaded by legal considerations. On the other hand, a doctor
who disagrees in principle with PAS or VAE even under the
above circumstances can’t be expected to participate no matter
what the law is. At the present time, your doctor would have to
risk prosecution for breaking the law, and as long as PAS/VAE
remain illegal, it would be difficult or impossible to determine in
advance if your doctor would be willing to do so.
22
CONCLUSION
There are no easy answers to the questions raised in this booklet.
People of goodwill who take seriously their Jewish heritage
will continue to disagree with one another. We have not
proposed a perfect solution to these problems, nor do we think
that one exists. No matter what position is taken on the issue of
physician-assisted suicide, there will be compromise and there
will be pain. To legalize PAS is to enable those who suffer greatly
and without hope to die swiftly and in peace, but it may also
put many others at risk of an untimely death. If PAS remains
illegal, we must continue to do everything in our power to
provide comfort at the end of life, but we may also deny to some
the only comfort that we can provide. May we each be granted
a heart of wisdom as we confront these issues.
23
COMPASSION AND COMFORT CARE
AT THE END OF LIFE
A Resolution of the UAHC adopted at the 63rd Biennial
Convention of the UAHC in Atlanta, Georgia, December 1995
BACKGROUND: Because the synagogue is the focus of our
communal life and the setting of our collective deliberation
about life’s most important events, we affirm the obligation of
the synagogue community to educate its members regarding
Judaism’s belief in the dignity and sanctity of human life.
As the end of life approaches, the choices before us become difficult
and troubling. Possibilities of survival engendered by medical
technology may also unnaturally prolong the dying process.
Our movement has already affirmed the right to refuse medical
treatment that only prolongs the act of dying, but it is clear that
not all needs are met by withholding or withdrawing medical
treatment at the end of life. There are those who, nearing the
end of life’s journey, would choose to live. We have yet to assert
the obligations that our community has to those who cannot be
cured of their disease but whose future promises nothing but
pain and suffering. While we acknowledge that many would
choose not to endure such a life, most such choices do not need
to be made when adequate palliative care and support can be
provided.
Guided by the mitzvah of pikuach nefesh, we must strive toward
an achievable goal: to provide a quality of life that is at least
tolerable for each one whose journey ends in pain and suffering.
Our effort must ensure that only rarely will that choice be
beyond human strength. We assert that most of the tragic
choices to end life can be avoided through the combined efforts
of caring doctors, clergy, providers, family, and community.
24
By providing caring support for families and assisting in
the development of hospices and similar environments where
spiritual and physical needs are met, our congregations can help
preserve the meaning and purpose of our lives as we approach
the end of the journey.
THEREFORE: The Union of American Hebrew Congregations
resolves to:
1. Address our society’s needs to provide adequate comfort care
at the end of life;
2. Develop and distribute more educational and programmatic
material regarding a liberal Jewish approach to end-of-life
decisions;
3. Develop and distribute material that would raise awareness
of the issues of pain and suffering and quality of life in order
to enable sound decision making by all concerned;
4. Encourage the expansion of opportunities for rabbinic and
cantorial students and rabbis and cantors in the field to
participate in training programs designed to develop skills in
end-of-life issues;
5. Call upon our congregations to develop connections with
Jewish hospice programs in their communities and to explore
their creation where they do not exist; and
6. Call upon the Committee on Bioethics to work with the
Central Conference of American Rabbis Committee on Responsa
to provide us with guidance with respect to physicianassisted
death and active voluntary euthanasia.
25
ADDITIONAL SOURCES
1. A Time to Prepare: A Practical Guide for Individuals and
Families in Determining One’s Wishes for Extraordinary
Medical Treatment and Financial Arrangements. UAHC
Department of Jewish Family Concerns: Committee on
Bioethics. New York: UAHC Press, 1994.
2. UAHC Department of Jewish Family Concerns:
Committee on Bioethics. Congregational study guides:
Voluntary Active Euthanasia-Assisted Suicide, 1993;
Allocation of Scarce Medical Resources, 1994; The Role of
Pain and Suffering in Decision Making, 1996.
3. Death and Euthanasia in Jewish Law. Jacob/Zemer, eds.
Pittsburgh/Tel Aviv: Freehoff Institute of Progressive
Halakha, 1995.
4. CCAR Journal, Spring 1997. Special issue on Assisted
Suicide. See especially p. 11, CCAR Responsa Committee,
“On the Treatment of the Terminally Ill.”
5. CCAR Responsa contains a wide variety of Reform responsa
on the subjects of euthanasia, relieving the pain of dying
patients, the use of drugs at the end of life to relieve pain,
and associated topics, as well as recent volumes of responsa
published by the Central Conference of American
Rabbis. Many of the essential ones are reproduced in the
congregational study guides published by the UAHC
Department of Jewish Family Concerns: Committee on
Bioethics.
6. Tough Choices. Vorspan and Saperstein. New York: UAHC
Press, 1992.
7. Medicine and Jewish Law. Rosner, ed. New Jersey and
London: Jason Aronson, Inc., 1990/1993.
26
8. Modern Medicine and Jewish Ethics. Rosner. New York: Ktav
Publishing House, 1986.
9. A Time to be Born and a Time to Die: The Ethics of Choice.
Kogan, ed. New York: De Gruyter, 1991.
10. Contemporary Jewish Ethics and Morality. Dorff and
Newman, eds. New York/Oxford: Oxford University Press,
1995.
11. Setting Limits: Medical Goals in an Aging Society. Daniel
Callahan, M.D. Washington, DC: Georgetown University
Press, 1987/1995.
12. Health and Medicine in the Jewish Tradition. David M.
Feldman. New York: Crossroads, 1986.
13. Life’s Dominion: An Argument about Abortion, Euthanasia
and Individual Freedom. Ronald Dworkin. New York: Alfred
A. Knopf, 1993.
14. Moral Matters: Ethical Issues in Medicine and the Life
Sciences. Arthur Caplan. New York: John Wiley and Sons,
1995.
15. Tradition and the Biological Revolution: Application of Jewish
Law to the Treatment of the Critically Ill. Daniel B. Sinclair.
Edinburgh University Press, 1989.
16. How We Die. Sherwin B. Nuland, M.D. New York: Alfred
A. Knopf, 1993.
17. Final Exit. D. Humphrey. New York: Hemlock Society,
1991.
18. Death and Dignity: Making Choices and Taking Charge.
Timothy E. Quill, M.D. New York: W.W. Norton &
Company, Inc., 1993.
19. Active Euthanasia, Religion and the Public Debate. Chicago:
Park Ridge Center, 1991.
27
20. Journals. Many journals and periodicals have addressed the
subject of assisted death from a variety of perspectives.
Examples from non-Jewish sources are too numerous to
mention. Indeed, Jewish sources are quite extensive. Some
key examples are: “End Stage Medical Care: A Halakic
Approach,” Conservative Judaism, vol. XLIII, no. 3, Spring
1991; CCAR Journal, Fall 1990 and Winter 1991; “Rabbi
Moshe Feinstein on the Treatment of the Terminally Ill,”
Judaism, vol. 37, no. 146, Spring 1988; Sh’ma: A Journal of
Jewish Responsibility, issues of October 18, 1991, November
1, 1991, May 29, 1992, and November 27, 1992; “Quality
and the Sanctity of Life in the Talmud and the Mishnah,”
Moshe Tendler and Fred Rosner, Tradition, vol. 28, no. 1,
Fall 1993.
21. Matters of Life and Death: A Jewish Approach to Modern
Medical Ethics. Elliot N. Dorff. Jewish Publication Society.
Philadelphia, PA. 1998.
28
The Union of American
Hebrew Congregations
Department of Jewish
Family Concerns
CHAIR
Jean Abarbanel
VICE CHAIRS
Marshall Zolla
Mike Grunebaum
DIRECTOR
Rabbi Richard F. Address
ASSISTANT DIRECTOR
Marcia Hochman
BIOETHICS CHAIR
Dr. Harvey L. Gordon
Printed on recycled paper
REFORM JUDAISM:
WE ARE THE FUTURE.
633 THIRD AVENUE, NEW YORK, NY 10017-6778
UAHC DEPARTMENT OF JEWISH FAMILY CONCERNS
PHONE: (212) 650-4294 • (215) 563-8183
Fax: (212) 570-0960
E-MAIL: DEPTJEWFAMCON@UAHC.ORG
RFAUAHC@AOL.COM
THANK YOU.
Your membership in a UAHC congregation
has made the Reform movement the largest and most
vibrant branch of Judaism.

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