According to the Talmud, a famous rabbi named Judah lay dying. His was so revered by other rabbis that a fast was declared, and prayers were chanted continuously for heavenly mercy. Rabbi Judah’s handmaid ascended to the roof of the home and prayed, “The immortals desire Rabbi to join them, and the mortals desire Rabbi to remain with them; may it be the will of God that the mortals may overpower the immortals.” Later, when she observed him to be suffering, she prayed, “May it be the will of the Almighty that the immortals may overpower the mortals.” Soon after, the handmaid threw a jar from the roof to the ground which interrupted the rabbis praying for mercy. In that moment of quiet, the soul of Rabbi Judah departed to its eternal rest. (Talmud Ketubot 104a)
One of the most important principles in Judaism is the preservation of life or pikuach nefesh. As it is mentioned in the Mishnah (the first section of the Talmud which coincidentally was collated by Rabbi Judah), “The person who saves one human life, it as if he/she has saved an entire world.” The death of Rabbi Judah illustrates the difficult issues when dealing with the terminally ill: the choice between doing everything to save a life, stopping treatment to allow for peaceful death, or providing the means to facilitate death. The handmaid’s course of action was determined by her compassion, her desire to relieve suffering. When she realized how difficult life became for Rabbi Judah, she interrupted the other rabbis’ prayers (his life support system) so he was finally able to die.
Rabbi Judah’s story highlights the complexity of honoring life while accepting death. When is someone justified in hastening his or her own death? While there is no American law prohibiting suicide, Jewish tradition affirms that life is sacred, and it is a violation to end God-given life prematurely by committing suicide. But what is the right thing to do in the grip of misery and terminal illness? There are no simple answers. Oregon’s Death from Dignity Law which went into effect in 1997 gives us insight of the three major end-of-life concerns: loss of autonomy, decreasing ability to participate in activities that made life enjoyable, and loss of dignity. The vast majority of patients who have participated in their program were older than 65, mostly white and well-educated, enrolled in hospice, and died at home. Since the law was passed, 1327 people were prescribed prescriptions to end their life, and 859 died from ingesting these medications. (Many patients never took the medication, but had it available if desired.) In the California right-to-die bill which was signed on October 5th, safeguards were included such as possessing mental competency, life expectancy less than 6 months substantiated by two physicians, patients’ choice whether to take the drugs, and prescriptions to be taken by the patient without assistance. I have cared for many terminally ill patients during the course of my career, and I never have been asked for help to end a person’s life prematurely, legality aside. I think it may be because I have always made it a priority to keep my patients comfortable and limit any suffering. The only time I participated in any active means was when I disconnected a respirator from a brain-dead patient. I felt my action was merciful and worthwhile as probably Rabbi Judah’s handmaid did. When I witnessed the relief of family members after the respirator was disconnected, I realized that pikuah nefesh in a situation like this pertains to help surviving family members endure. Despite this experience, I don’t think I would be able to write a prescription that could lead to the death of a terminally ill mentally competent patient. Preserving life, a central thesis in Judaism, is a core belief of who I am as a physician.
Once a year at Yom Kippur we are reminded of the finite nature of our existence. We don’t usually have a choice of when we depart the world, but we might have some control over the circumstances how we depart it. It is important for everyone to talk to family, friends, and their doctor before they get sick, and to complete an Advanced Health Care Directive. This helps prevent confusion and disagreement if patients become too ill to make decisions about what they want or don’t want. The form also lets patients identify person(s) whom they designate as health care agent(s), to help ensure that their wishes are followed. One does not need a lawyer to complete an AHCD. Forms can be downloaded at kaiserpermanente.org.
It is the compassionate thing to do.
Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.
Editing acknowledgement: Ellen Saliman
Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider.