As we recite Unetaneh Tokef, reminding ourselves of the stark reality of mortality, we not only think about who shall live and who shall die, but also how we shall live and die. While the prayer-poem draws attention to the drama of fire and water, warfare and wildlife, earthquake and plague, most of us wonder whether our lives and deaths will be tranquil or troubled, calm or tormented.
There is little disclosure about what is next in life. Yes, there are classes for people planning marriage and childbirth, but we have only cursory discussions about the challenges of caring for children and parents, becoming empty-nesters, or aging. When he was 99, Eubie Blake, the great ragtime composer and pianist said, "If I'd known I was going to live this long, I'd have taken better care of myself."
We often see ads, usually featuring smiling, good-looking, grey-haired couples, offering us, our parents or grandparents life insurance, Caribbean cruises or special medical care.
The Torah mandates that people stand and demonstrate deference to the elderly. The Psalms speak of remaining fruitful and verdant. The Book of Job teaches that wisdom and understanding come with length of days. According to a rabbinic midrash, Avraham was blessed with grey hair and the appearance of aging, so that others might properly honour and respect him. Nothing there about arthritis or osteoporosis, diabetes or cardio-vascular challenges, a demanding prostate or failing eyesight.
Hymie, the resident of a Jewish
retirement home in Florida, announced that he is getting married again. “Mazal
tov, mazal tov”, chorus the other residents. “So tell us, is she
beautiful?” ”Nah, not especially” the groom-to-be replies.
“So is she wealthy?” “Nah, not especially.”
“So at least is she witty, does she sparkle in company?” “Nah, not especially.”
“Then why are you getting married again?”
Hymie shrugs and replies: “She drives at night.”
Aging is not only for our parents and grandparents. Some of us sense that the nextkaddishis for us, and we are beginning to look at dying with the same intensity as we looked at wedding ceremonies and baby namings just a few years ago.
Rabbi Joseph Soloveitchik was one of the great rabbis of the 20th century. The acknowledged head of talmudic studies at Yeshiva University, known simply as “the Rav”, Rabbi Soloveitchik was acclaimed for his classical knowledge and philosophical insights and greatly respected by all streams of Judaism. But sadly, this brilliant and incisive mind spent his last years sitting silently in his rocker. He became a shadow of himself, his body outliving his mind by several years. This is a familiar image or fearful possibility for many sitting here. We live with the painful reality of watching aging parents and other relatives forget, unable to remember details of their lives and the lives of their families. We worry that our own memory gaps might be early stages of dementia. We anxiously observe the erosion of memory and personality of our loved ones.
Two sons came to meet with me about their mother. No longer verbal, unable to indicate her desires, she is gradually weakening. She communicates with her eyes. What is their obligation for her care? They decide to support her in a residential hospice, where she is subsequently able to celebrate her birthday. Her eyes communicate her delight.
Another case: a daughter has come in from Asia to be with her dying father. He is sustained by machines and medication. The doctors attending thought that he would already die, but there is a strong biological imperative for life. The daughter has to return home. If her father dies while she is still here, she can attend his funeral. The family decides that the respirator is no longer necessary. The daughter and family grieve; she returned to Asia following the first days of shivah.
Over the years, I have spoken with you about challenging ethical concerns: why abortion is permissible but not desirable. How an ethical will can give consolation and direction to a family. The permissibility and desirability of organ donation. The importance of regularly updating a medical health directive. The value of a family discussion about end of life care. The importance of seeking life-partners early and not delaying children. Respect for those who don’t marry. The desirability of artificial reproductive technology, and dignity for those couple who do not have children. Why organ donation forms should be signed when applying for drivers’ licenses. The imperative to discuss with infirm, but independent individuals the risks to themselves and others if they continue to drive.
When a person knows that he is going to die within weeks or months. When the illness has begun to or already taken its toll in physical pain, emotional turmoil and ongoing indignity. When the burden on loved ones is obvious. When there seems to be nothing more to hope for, only more of the same with ever-growing intensity. He may say to his doctor, she may plead: “Give me the pill!” And we, standing near someone we love, feeling totally helpless, what do we want? Should the doctor respond to the plea and help the person to die?
This is an issue that we in Canada are starting to face. The case of Sue Rodriguez in the mid 90s has given way to more court proceedings in this decade. The faces and facts of Susan Griffith of Manitoba, Lee Carter and Gloria Taylor of British Columbia have appeared in the Star, the Globe, CBC and other media. What does Judaism have to teach about this? What wisdom might our tradition have to share with us and the world?
Judaism holds two principles paramount: “Choose life” and “There is a time to live and a time to die”. Let me explain how they might interact.
The Torah tradition considers human life to be sacred. “For the human has been created in the image of God” states Genesis. Leon Kass a leading bio-ethicist explains, “[The human being] has special standing because he shares in reason, freedom, judgment, and moral concern, and, as a result lives a life freighted with moral self-consciousness. …. To put it simply, the sanctity of human life rests absolutely on the dignity– the god-like-ness — of human beings.[xxviii]
Judaism teaches that life is bestowed by God. My colleague, Elliot Dorff, uses the idea of a steward, with full responsibility for guarding what has been entrusted to us. God entrusted us with the use of our bodies during our lifetimes and we are obliged to safeguard this loan of life. Individuals have significant personal autonomy regarding their bodies, but we do not have unlimited authority and autonomy.
The saving of life supersedes all mitzvot, except the sins of idolatry, incest/ adultery and murder. In case of medical necessity, one may eat on Yom Kippur, set aside the laws of Shabbat, consume traif food, regardless of the quality or duration of the life being preserved.
Because every human being is created in the image of God, each individual has three essential dignities:
· infinite value --- saving a single life is akin to saving an entire world;
· equality --- no human being is more valuable than another; and
· individuality --- no too people are exactly alike (Mishnah Sanhedrin 4:5).
Judaism has emphasized that no individual’s blood is privileged as being “redder” than another’s (BT Sanhedrin 74a). This is the case for vulnerable infants and for frail elderly, for the well and the disabled. Even when we have to make triage choices about who to save in extreme situations, this does not undermine the core teaching that every person’s life is of equivalent, infinite value.
While families want the best treatment for a loved one and physicians are given a sacred task to provide life-giving care, I already see some of the ideal fraying. While some families can’t release/ let go of loved ones, others are too quick to give up. I have seen people whose families have been willing to end treatment when the person is still capable of recovery.
I worry about allowing a “right to die”, because I fear it slowly shifting into a “duty to die”. My colleague Jack Reimer has observed that we run the risk of creating a culture that makes people who are old or sick feel guilty about living”. Perhaps, wanting what’s best for their surviving dear ones, terminally ill patients may simply choose death by pills or injection as a means of saving their family the financial and emotional burdens of long-term care. Societal pressures to preserve precious, communal resources might lead to a disregard for those ones who would be the least likely to counter such pressures; those who are most vulnerable, namely the elderly, the mentally ill, minorities, and the poor.
The notion that “it is better to be dead than disabled” can be very powerful, particularly for someone who has not yet experienced disability or who is surrounded by persons who reinforce this negative stereotype. Whether or not a person experiences a loss of dignity that can influence their attitude towards life is highly contextual. A person’s sense of human dignity and belonging to the community at large is closely linked to the concern and respect accorded to groups to which he or she belongs.
Talk of “death with dignity”, and “physician assisted death” communicates a message: that death is being accepted as the rational choice for persons with significant life challenges. Instead of suicide being recognized as irrational, or a “cry for help”, with suicide prevention as the goal, striking down the prohibition on assisted suicide ensures these suicide attempts will succeed. It reverses the norm of actively discouraging suicide.
I am concerned that assisted suicide – whether by family or physician - threatens that absolute sanctity and respect for the individual. This may contribute to a changing cultural perspective that sees some lives as less worth living. We must avoid any move toward devaluing some lives, for once that process has begun, we do not need Margaret Atwood to warn us about its dangers. We should cautiously curb our desire and capacity for unlimited control over our lives.
A man in steep decline looks in my eye and says, “Tell me how I can die.” Should I become a partner to his demise? How should I respond to a clear-thinking 68 year old woman who says “Six years of dialysis is enough”? Or to an almost ninety year old grieving widower who declares, “I have lived my life. I want to die”? If I remain silent am I encouraging their death? If I speak, what should I say?
“Rabbi, what does Judaism say?” Entrusted with a responsibility to guide a family in perilous situations, standing close to the nexus of life and death, I have learned to tread cautiously. I am entering God’s realm. Life is a sacred gift. “Mortal: yesodo me’afar, your origin is dust and your end is dust.” Although we know what happens on a biological model, we do not fully comprehend the origin of life. We do not completely control its course. “And God breathed into Adam the breath of life”. We are stewards of the life breathed into our bodies and as long as the breath of life is within us we must take exquisite care of that gift.
Let me teach you a Hebrew word that I wish you will never have to apply to anyone you know. Goses in Jewish law refers to someone on the threshold of dying, and caring for a goses was a matter of serious concern. In the great code of Jewish law, the Shulhan Arukh (Yoreh Deah 339:1), we are taught that a goses is considered a human being in every aspect, and we are forbidden to hasten that person’s death. Rabbi Moshe Isseles explains and expands the rule of Rabbi Yosef Karo by stating, “It is forbidden to hasten death. However, if there is an impediment preventing the soul’s departure, … it is permissible to remove it.”
Notice the careful distinction between introducing an agent to hasten death – which is expressly forbidden- and removing something which prevents death from occurring, which is permitted. At the end of life do nothing to hasten or delay death. Take care lest you extinguish the “flickering flame” of life. There is a limit to our autonomy, a boundary between the Creator of life and human beings. We may not unnecessarily kill a person endowed with life nor destroy ourselves. Autonomy stops at the door where we might assume to take absolute control of life itself.
From the Talmud to today, over 1500 years of accumulated wisdom highlights great sensitivity to suffering. Asked whether pain can inspire, a teaching that is emphasized in other religious traditions, one rabbi responded, “I desire neither the suffering nor its rewards.” In our prayers on Yom Kippur, we ask God to purify us of our flaws, aval lo al y’dey yisurim holim, but not through painful suffering.”
We are obligated to do all within our power to relieve pain. Medication that as a side-effect will effect breathing capacity is permitted as a palliative for pain. Much depends on intention. Is the doctor carefully measuring the dosage only to reach the point of the patient’s comfort while aware of possible secondary effects? Or is it the doctor’s mindful and sole goal to assist the patient to die? Both are motivated by deep compassion. Both are employing medical science. But those favoring physician assisted suicide believe they are simply taking the next logical step in providing care. While others of us believe that an intentional action crosses a bright line which our society and religious traditions have maintained throughout the ages.
Some will argue that a patient’s decision to decline treatment or to stop eating or to withdraw artificial life-supports is no different than voluntarily taking a prescribed lethal drug. Again, there is an enormous difference between letting nature take its course -- putting one’s self in God’s hand, so to speak -- and actively and consciously taking life prematurely. The former respects the limits of our ability to control our destiny; the latter loudly declares, nothing is beyond our power.
Despite the fact that
end-of-life suffering has always been part of the human condition, suicide has
never been an end-of-life healthcare decision. In the martyrology tomorrow, we
shall read of the suffering of Rabbi Hannaya ben Teradyon. This is the Talmudic
tradition about his torture at the hands of Roman authorities:
Hananyah ben Teradyon, was wrapped in a Torah scroll and placed on a pyre of brushwood; to prolong
his agony wet wool was placed on his chest. … His students asked: “Master, what
do you see?” He answered: “I see the parchment burning while the letters soar ascend.”
His student advised him to open his mouth so that the fire might enter and end
his sufferings; but he refused, saying, “the One who gave the soul should also
take it away: no one may hasten his death.” The executioner offered to remove
the wet wool if Hananyah would promise him a place in heaven. Hananyah
promised, the executioner removed the wool and increased the flame. Then he too
jumped into the fire.
Whether Hananyah’s death
or that of martyrs during the Crusades, such an end has been only grudgingly
accepted and only because of overwhelming persecution.
Some point to our pets as a model for compassion. animals have become part of families, worthy of being saved. They are often treated with specialized veterinary medicine. But when we do euthanize them, we do so because they have become a burden to their owners. We don't put down pets only out of love. We do it because caring for them becomes too expensive or burdensome. We "let them go" for selfish reasons, not just compassion. So do we want to treat people like our animals? "Let them go" because they are a burden?
There are many ways to respond with compassion to a person suffering at the end of life. All of us need to find within ourselves ever-increasing avenues of response.
Questions for medical practitioners: Can you resist family members who insist upon keeping their loved one alert, even at the cost of their intense pain? Are you willing to guide a patient away from futile treatment? To recommend hospice rather than another round of experimental medicine? Or, if facing intractable pain, are you willing to pursue palliative sedation, until the disease runs its course?
For us as family members and care givers:
Have we truly exhausted the depths of our abilities to tend our loved ones? Could we be better companions? Will we allow sufficient and proper medication? Can we be more present to reduce anxiety and quell the fear of loneliness? Did we look deep within ourselves to discover new strength to salve the pain and calm the anguish? Have we assured the sick one that we would not abandon her no matter what? It is precisely when life reaches towards its end that we can discover new gestures of compassionate giving. In such moments we may touch new depths of our humanity and experience the Sacred.
Without romanticizing the reality of life’s final days and months, can we understand that it can be a time of quiet goodness? Can we understand that in simply allowing another to care for us as life ebbs we are giving them the precious gift of expressing love. Here are opportunities -- who knows how many? -- to be in relationship, to say ‘thank you,’ to remember life’s blessings and joys, to say ‘I’m sorry,’ and allow others to to do so, too. To say ‘I love you’ one more time and share the faintest smile or subtle wink of the eye just once more?
There are questions for our community: “Could we provide more adequate and numerous hospice and palliative care options for the final journey where a peaceful death is the norm, not the exception?”
We who have volunteered in palliative care units at Baycrest or other hospitals, or who have helped in independent or home hospice settings, know that these programs and places can enhance the quality of life of the individual and family. Those who have been touched by the Temmy Latner Centre of Mt Sinai know that this is not simply about dying, but about making life better – to the very end.
Compassion is the goal, but acting compassionately is no single act. There is no end to deeds of loving kindness. Perhaps it is at this time of life that we can most truly comprehend what sacred caring is all about.
In addition to supportive care in hospice, there is something each of us can do to take greater control of our end-of-life treatments, which is to encourage one another to have those conversations about end-of-life wishes, and how final decisions are to be made. Do you want to pursue all life-prolonging measures, including CPR and mechanical ventilators? Would you ever want a feeding tube inserted or withdrawn, and would you want a “comfort care only” order written, if necessary by your physician? Have you prepared an advance medical directive and determined who will be you decision maker if you are not able to make decisions on your own?
Jewish tradition has always sought to balance our profound commitment to the wonder and sanctity of life, with a devoted compassion for the suffering of the ill or dying. Jewish wisdom has long acknowledged that the boundaries of our human knowledge will necessarily preclude our ability to know, in every case, the precise number of days or weeks remaining for the terminally ill, even as our limited, human understanding will prevent us from grasping in full measure the meaning and value of such time which may remain for the stricken and their dear ones.
As a rabbi, I have often sat at the bedside of dying patients and have been present to people experiencing life-ending illness. I have great compassion for individuals facing personal suffering whether in the midst of or at the end of life and have dedicated a significant part of my professional life trying to support people spiritually and emotionally and trying to alleviate their suffering in their moments of pain and crisis.
I am deeply thankful that we live at a time when medical technology can treat physical pain through palliative care and alleviate psychic and emotional pain through mental health and social support. End-of-life choices are unfailingly difficult. They are not just end-of-life choices, but life choices, as they do not only impact upon our actual end of life, but also express our values and views of life as a whole and the dignity that we afford to it.
In the words of Rabbi Jacob Rudin: “Death will come. Its hand will not be stayed even an instant; nor can we enter into judgement with it. … But this does not mean that we are helpless …. We can … [live] life as long as it is ours …. To ask of death that it never come is futile, but it is not futility to pray that when death does come for us, it may take us from a world one corner of which is a little better because we were there. When we die, and people weep for us and grieve, let it be because we touched their lives with beauty and simplicity. Let it not be said that life was good to us, but, rather, that we were good – TO LIFE!” http://emanu-el-stage.org/category/sermons/sermon-meyer/#_ftn2
