Pain and suffering: end of life considerations TB Ketubot 104

Murder is a cardinal sin. Suicide including assisted suicide for the patient who is terminally ill is also prohibited. “Since God infuses each human life with inherent meaning by creating each of us in the divine image… and since Judaism views life as sacred and understands human beings to have life on trust from God…and since God’s creation and ownership of our bodies puts the decision of when life is to end in God’s hands… (we hold that) suicide is a violation of Jewish law and of the sacred trust of our lives given us by God. Furthermore, (we hold that) assisting suicide is also a violation of Jewish law…. No human being may take his or her own life, ask others to help them to do so, or assist in such an effort…. Jewish tradition bids us to express our compassion in ways that effectively respond to the patients suffering while adhering to our mandate to respect the divine trust of life.” (CJLS Responsa 1991-2000, pages 398-399, in The Observant Life: The Wisdom of Conservative Judaism for Contemporary Jews, page 796)

The story on daf TB Ketubot 104 concerning Rabbi Yehuda HaNasi’s death begins to carve out some room for compassion for the patient who is suffering. Note it was a woman who had the compassion insight and acted upon it.

“It is related that on the day that Rabbi Yehuda HaNasi died, the Sages decreed a fast, and begged for divine mercy so that he would not die. And they said: Anyone who says that Rabbi Yehuda HaNasi has died will be stabbed with a sword.

“The maidservant of Rabbi Yehuda HaNasi ascended to the roof and said: The upper realms are requesting the presence of Rabbi Yehuda HaNasi, and the lower realms are requesting the presence of Rabbi Yehuda HaNasi. May it be the will of God that the lower worlds should impose their will upon the upper worlds. However, when she saw how many times he would enter the bathroom and remove his phylacteries, and then exit and put them back on, and how he was suffering with his intestinal disease, she said: May it be the will of God that the upper worlds should impose their will upon the lower worlds.

“And the Sages, meanwhile, would not be silent, i.e., they would not refrain, from begging for mercy so that Rabbi Yehuda HaNasi would not die. So she took a jug [kuza] and threw it from the roof to the ground. Due to the sudden noise, the Sages were momentarily silent and refrained from begging for mercy, and Rabbi Yehuda HaNasi died.” (Sefaria.org translation)

We are allowed to pray for death in order to relieve the patient’s suffering as the above story shows. Rabbi Nissim Gerondi (called the Ran, c. 1310-1375), writing in his commentary to TB Nedarim 40a wrote: “It seems to me…that there are times when one must pray for compassion, that person might die-for example, when the patient is suffering very much due to the illness and cannot live.” (The Observant Life, page 798)

The patient may refuse treatment even though this refusal may speed his death. Rabbi Moshe Feinstein (Igg’rot Moshe, Hoshen Mishpat 2, 73:1, ed. New York, 1985, page 304) wrote: “When the physicians recognize that it is impossible to restore health and life, and the patient cannot live as he is without suffering, but it would be possible to administer drugs to extend his life as is, with the suffering, they should not administer those medications, but leave him as he is…. They should do nothing.”  (The Observant Life, page 799)

I’ve had to advise families and their physicians about the end of life treatment for their loved ones. My thinking has been very much influenced by a hospital Catholic nun chaplain. She differentiated between prolonging life and prolonging death. We should do everything humanly possible to prolong life, but refrain from prolonging a person’s death through artificial means. I follow Rabbi Elliott Dorf’s 1990 CJLS response entitled “A Halkhic Ethic of Care for the Terminally Ill”

“We try, in all our dealings, including healing and including death, to act in that way which corresponds to God’s will. The diagnostic problem remains. How do we determine their particular death is ‘natural’ and timely, according to God’s will and plan? ... By doing everything possible medically, biologically, to treat the life systems of the critical patient, while removing impediments to death-items or procedures that interfere with the natural shutdown of the body’s major systems in death-we allow ourselves to see if, indeed, God has ordained the closure of this life… Some of our more recent technologies are mechanical, rather than biological, however, and do not parallel life’s functions. Thus, for instance, a heart-lung machine…does not operate as a biological system, but rather circumvents one. Its function is mechanical, a holding mechanism...against the deterioration and death that would follow on cessation of heart and lung function… Taken alone, however, it offers no curative potential… It is thus a candidate for the category of ‘impediments to death.’ (which one is allowed to remove-gg) (The Observant Life, page 800)