Journal ofmedical ethics 1994; 20: 93-100 J Med Ethics: first published as 10.1136/jme.20.2.93 on 1 June 1994. Downloaded from Jewish ethical guidelines for resuscitation and artificial nutrition and hydration of the dying elderly Rabbi Zev Schostak Gurwin Jewish Geriatric Center, New York, USA Author's abstract nasia for the elderly and a Michigan doctor to create The bioethical issues confronting the 7ewish chaplain in and use the so-called 'death machine' (1). Jewish law a long-term carefacility are critical, particularly as life- vigorously asserts that life, even that of a terminal, support systems become more sophisticated and advance demented, elderly patient is of infinite value; it must directives become more commonplace. May an elderly be preserved no less than the life of a young and alert competent patient refuse CPR in advance ifit is child with a hopeful long-term prognosis (2). perceived as a life-prolonging measure? May a This bold position is presented in a classic case physician withhold CPR or artificial nutrition and (Yoma 83a) where the Mishnah directs that one hydration (which some view as basic care and not as must immediately remove debris that has fallen therapeutic intervention) from terminal patients with upon someone on Shabbat, even though the victim irreversible illnesses? may only live for a short time. Jewish legal codes and In this study ofJewish ethics relating to these issues, responsa (3) elaborate that he or she must be saved copyright. the author carefully examines the moral implications even though his or her skull was crushed and he or and legalprecedents in the literature. Jewish ethics, she may live for only a few minutes. Though he may affirming a 'sanctity oflife'position, suggest that while have been moribund, mentally incompetent, or a an elderly person may direct in advance that CPR not minor ... his life must be saved (4). This ruling is be administered in most instances, in the absence ofa based on Judaism's attributing infinite value to DNR (Do Not Resuscitate) order, CPR must be human life. 'Infinity being indivisible, any fraction of http://jme.bmj.com/ performed. In reference to 'tube-feeding', while there is life, however limited its expectancy or its health, some debate about whether elderly patients may refuse remains equally infinite in value' (5). A more the initiation of 'tube-feeding', there is a consensus that dramatic illustration of this principle is that of a once initiated, it may not be withdrawn. triage decision in a facility which has only one respirator. The machine is connected to a deathly ill, disoriented 90-year-old. May this patient be I: Jewish ethical perspectives removed from the respirator in favour of a young The age-old legal-ethical system known as halacha, accident victim who has just arrived, who will surely on September 28, 2021 by guest. Protected governs virtually every aspect ofJewish life and offers die without it, but will probably recover with it? much direction in the area of medical ethics and Here, too, halachic authorities rule that the dying conduct. In medical decision-making, halacha elderly patient already on the machine may not be would deem the sanctity of life, the preciousness of removed from the respirator (4). By removing the every moment, as the uppermost consideration. In old man from the respirator in favour of the young fact, the imperative to preserve life supersedes, with one, we would be, in effect, declaring that the old few exceptions, concerns about the 'quality of life' in man's life is less valuable than that of the young one. medical decision-making. Arguments for the 'quality De facto, we play God when we pass judgement on of life' - limited medical resources for an ever- the 'quality of life'. However, in such cases where growing population, patient rights, and death with neither of them has been placed on the respirator, dignity - while superficially appealing are perceived priority is, of course, given to the young accident as nothing more than man playing God, unduly victim who has the better prognosis for long-term intervening in the eternal processes of life and death. recovery (6). Quality-of-life concerns have, in fact, prompted a Every life-saving measure - even extraordinary former Governor of Colorado to advocate eutha- ones - must be utilized to prolong life, with few exceptions - the most common being severe, unremitting pain and suffering. The source of this Key words concept is found in the Talmud, (Ketubot 1 04a) Jewish ethics; artificial nutrition and hydration; which describes the fatal illness of the great Rabbi resuscitation; elderly Judah the Prince, known simply as 'Rebbe'. Rebbe's 94 Jewish ethical guidelines for resuscitation and artificial nutrition and hydration of the dying elderly J Med Ethics: first published as 10.1136/jme.20.2.93 on 1 June 1994. Downloaded from pious maidservant, upon seeing her master's noted when the medical odds for survival are almost suffering, prayed for his demise, and even nil (4)? Is he permitted to perform CPR on this frail interrupted his students from praying for his life. patient (a procedure so severe that brittle ribs are Since the Talmud does not criticize her conduct, often broken) when, in fact, this patient may Rabbenu Nissim, a major Talmudic commentator, possibly be moribund, and, according to Jewish law, concludes: 'There are times when one should pray may not be touched (6)? for the sick to die, such as when one is suffering The chaplain is often called upon to recommend greatly from his malady and his condition is terminal policy in another critical area: What should the ...' (7). Contemporary authorities have applied this facility's position be towards a patient who refuses to passage to the treatment of the critically ill in be 'fed' through a nasogastric tube or through a extreme pain, by allowing them to refuse gastrostomy? Medically, both of these procedures 'extraordinary' life-saving measures, and to receive are similar in that food and hydration are introduced intensive doses of pain-killers (2). into the patient's functioning gastrointestinal tract God entrusts us with our bodies which we must when he is unable to swallow or eat normally. The keep safe and healthy. He grants us the legal status of nasogastric tube is inserted into a patient's nostril a bailee (8), who must make every effort to guard the and is guided through the oesophagus into the article he is given, protecting it from loss and stomach. Though this is a relatively simple pro- damage. Interestingly, this concept of guardianship cedure, it can lead to serious side-effects, such as is expressed clearly in the words ofthe Torah - 'Only pneumonia, aspiration, and diarrhoea (14, 15). guard yourself, surely guard your soul ...' (Deut 4:9), Moreover, it is not uncommon for patients who are which Maimonides (9) and others say refers irritated by larger tubes to pull them out (16). The to protecting one's health. Another primary source more permanent procedure is a gastrostomy, where for saving another's life is the verse: 'And you shall the feeding tube is surgically implanted directly restore it [ie, the lost article] to him'. (Deut 22:2). through the abdominal wall into the stomach, which The Talmud (Sanhedrin 73a) reasons that if one is also presents some risk for seriously ill patients (14). obliged to return lost property to its rightful owner, My colleagues and I have had to grapple withcopyright. then one must certainly restore that 'owner's' life these issues as 'living wills' and health-care proxies and health (10), wherever possible. Once again the have come into more common use. In this paper, I issue of refusal of medical treatment is raised: if the have attempted to formulate resuscitation and rightful owner chooses to abandon his property and tube-feeding guidelines that are medically viable, not seek its return, why can't the seriously ill patient, halachically-sensitive, and compatible with state and under certain circumstances, forego the restoration federal law. http://jme.bmj.com/ of his health, too (1 1)? Others argue that the analogy between property rights and human life is flawed. While one may exercise proprietary rights over one's III: Resuscitation of the elderly possessions, one does not 'own' one's body; it CPR, cardiopulmonary resuscitation, is a relatively belongs to God (12). recent development in medical science, having first Halachic precedents and guidelines for prudent become standard practice in the early 1960's (17). have become almost had decision-making increasingly import- Then, every patient who no pulse or on September 28, 2021 by guest. Protected ant in our fast-paced, sophisticated world of medical respiration was routinely resuscitated. Later, in the technology. With recent legislation for advance mid-70s, there was serious concern that attempts to directives expressed through a living will or a health- resuscitate certain hospital patients could be care proxy (13), we are now compelled to think considered unduly invasive since their prognoses about and articulate our views concerning the were not improved (1 8). Today, in addition to basic initiation or refusal of various medical treatments/ CPR, emergency medical technicians (EMTs) or therapies should we become incapacitated at a later paramedics are trained in the use of sophisticated date. Since the Cruzan case and advance-directives electronic equipment and techniques: rhythm recog- legislation have brought medical-ethics concerns to nition, pharmacology, intubation, intravenous and the forefront, it behoves us to review the issues intracardiac methods and defibrillation. involved. In a skilled nursing-home setting, where many residents are frail and suffer from irreversible ill- nesses, the resuscitation issue is particularly II: Resuscitation/tube-feeding issues significant.