Balancing Competing Values in End-of-Life Decisions

Written by Rabbi Daniel Rose on . Posted in Features

Perhaps in no other area have scientific advancements posed as difficult halachic questions (questions pertaining to Jewish law) as in the realm of medicine, especially end-of-life medicine.

Advanced age or disease often brings us face to face with two competing Jewish values. On the one hand, the Torah teaches that life is precious. Life is valuable even when it will last only a few days or hours longer; it is valuable even when it is severely compromised, and even if the patient cannot communicate or perform any meaningful function. If someone is seriously ill on the Sabbath and could live only a few more hours even in the best case scenario, we still violate the Sabbath to save him or her and secure those few additional hours.

On the other hand, halacha (Jewish law) takes pain and suffering seriously as well. One is not obligated to extend the life of someone who is suffering significantly and has no hope of meaningful recovery; indeed, sometimes it is even forbidden. As a result, the halachic approach is not one of extreme aggressive measures; it is one of moderation.

This has major implications. At the very end of life, there often comes a point when there is no longer any medical cure possible. The treatment options that exist serve only to prop up the body for a short time until the disease takes its inevitable course. Broadly speaking, when someone is suffering, the halacha says that such treatments should be stopped because they are prolonging death, not extending life.

This does not mean, however, that nothing is provided to the patient. The halacha generally requires us to continue providing the basic elements that the body needs to function. Typically, this means that all patients continue to be provided with nutrition, hydration, and oxygen, among other things. In short, life is supported but not extended.

In the modern medical culture, this approach is not always understood. Typically, treatment of an end-of-life patient is seen as an all-or-nothing question: We should either do everything possible to treat this patient, or we should do nothing at all and “let him go.” Providing nutrition to someone with days to live is often seen as superfluous. With careful advocacy and respectful dialogue, medical staff will come to understand the values and logic of the halachic approach to end-of-life care. (It should be said as well that this is one area in which hospice care is helpful. Because hospice is focused on meeting the personal wishes of the patient and family, they are naturally attuned to the need to follow a religiously-informed plan of care.)

It goes without saying that any decision involves a great deal of nuance and a good understanding of the medical situation. This is an area where close consultation with a rabbi is crucial. Ideally, the rabbi will communicate directly with the medical team so that the issues and plan are clear. In addition, the halacha as presented here is the mainstream approach but is not universal. There may be rabbis who advocate for a different approach, depending on the circumstance.

The other major implication of the halachic approach to end-of-life care involves making decisions about risky treatments. Sometimes, a person reaches a point in their disease where the only treatment options left are risky, painful, or given a very small chance of success. In such cases, the halacha often says that a person may choose whether to pursue those treatments.

Often, there are good reasons to pursue such treatments, especially if they provide hope for adding meaningful time to life. Nevertheless, there can be many reasons why a person might choose not to pursue last-chance treatment or might prefer not to endure further suffering for limited benefit. Obviously, these decisions can be fraught and emotional for everyone involved. But is important to know that the halacha does not require that everything must be done at all costs.

It must be stressed again that for Jews who follow halacha, consulting a rabbi who understands the patient’s wishes, the medical reality, and the halachic details is critical. These conversations are most effectively held before a crisis arrives. Someone who is committed to halacha will identify a rabbi in his or her medical directive, with instructions that the rabbi be consulted on any major treatment decision. In this way, Jews who desire to can continue their commitment to halacha until the very end of their lives.

Rabbi Daniel Rose 

Rabbi Daniel Rose is the rabbi for Jewish Hospice Services for Seasons Hospice and Palliative Care. He is also the assistant rabbi at Bnai Jacob Shaarei Zion Congregation in Baltimore.