12/11/2018
Understanding Jewish Religious Values & Their Role In Health Care A View From Jewish Tradition Rabbi James A. Gibson, Temple Sinai, Pittsburgh, PA
Where Does Jewish Teaching Come From?
Torah (5 Books of Moses) Genesis, Exodus, Leviticus, Numbers, Deuteronomy (compiled from 1850-650 BCE) Seen as source of God’s authority in the world Understood by Jews as God’s will for the Jewish people Contains 613 Commandments knows as mitzvot Judaism, despite its many streams, sees its mission and integrity in interpreting and applying these laws to our lives These laws cover our relationship to God through ritual and every conceivable human interchange, from criminal jurisprudence to labor law, from marriage & divorce to how we treat animals
The 3 Parts of our Bible: Torah, Prophets, Writings
Total of 39 books:
Torah – Genesis, Exodus, Leviticus, Numbers, Deuteronomy
Prophets - Joshua, Judges, I/II Samuel, I/II Kings, Isaiah, Jeremiah, Ezekiel, Hosea, Joel, Amos, Obadiah, Jonah, Micah, Nahum, Habakkuk, Zephaniah, Haggai, Zechariah, Malachi
Writings - Psalms, Proverbs, Job, Song of Songs, Ruth, Lamentations, Ecclesiastes, Esther, Daniel, Ezra, Nehemiah, I/II Chronicles
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The Five Books of the Torah Are More Authoritative than All Other Bible Books
Example of Abortion – The Book of Jeremiah
Jeremiah 1.5 The word of God came to me: Before I created you in the womb I selected you; Before you were born I consecrated you; I appointed you a prophet concerning the nations.
This verse is regularly used to infer that the Bible recognizes personhood of a fetus before birth
Because the statement is from the Bible it is presumed to have the highest spiritual authority
BUT…
Torah’s View Trumps Jeremiah
Example of Abortion - From the Torah
Exodus 21.22: When men fight, and one of them pushes a pregnant woman and a miscarriage results, but no other damage ensues, the one responsible shall be fined according as the woman’s husband may exact from him…but if other damage ensues, the penalty shall be life for life…
Torah law says that a fetus is protected with the threat of a monetary fine. A born person is protected with the threat of capital punishment. Therefore, fetal life is not equivalent to born life outside the womb
How Can The Rest of the Bible Carry Less Weight?
Only Torah is given in its entirety by God to the Jewish people in a mass revelation described in Exodus 19
More than 600,000 individuals at Mt. Sinai were there
God wrote the Mitzvot (Commandments) endowing them with ultimate authority and perfection
All other revelations of God’s will are to individuals or small groups. Miracles are not revelations
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613 Laws of The Torah
Fulfilling the Mitzvot correctly is the goal of observant Jews – by doing so they fulfill the will of the Creator of the Universe who gave us Torah as a gift and an obligation
There are (acc. to Rabbinic tradition) 613 commandments/mitzvot in the Torah
248 + commandments (bones in body)
365 – commandments (days of year)
>300 have been null and void since the destruction of the 2nd Temple by the Romans in 70 CE
Study of Torah and Talmud for their own sake is a primary religious act in Judaism
Scholars take up the challenge of applying the laws to everyday modern life
Torah’s laws are considered more authoritative for Jews than any other book or section of the Hebrew Bible – nothing trumps Torah!
Later Rabbis Interpret & Apply the Commandments
Core Rabbinic literature was composed between 200 BCE-550 CE
It is composed of two main works/disciplines:
Midrash – Interpretation of all Torah verses and the laws contained within
Mishnah – Application of Torah laws through reasoning and experience
Talmud – Composed of of Mishnah (200 BCE-200 CE) and the Gemara (200-550CE)
There are two Talmuds, one composed in Babylon (Iraq) the other in the land of Israel (known as the Jerusalem Talmud)
The Babylonian Talmud is considered the more authoritative of the two
Talmud Discussions Redacted Into Codes
Core Legal Codes in Judaism
Mishneh Torah by Moses Maimonides (1135-1204)
Shulchan Aruch by Yosef Karo (1488-1575)
Karo’s code refined because of differences between Jewish practice in Mediterranean countries (Sephardic) and German/Eastern European countries (Ashkenazic)
Moses Isserles (1522-1572) wrote interlinear notes to show how Ashkenazi Jews were to follow the laws set out in the Shulchan Aruch
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When The Law Isn’t Clear, Ask!
Rabbis have served as judges on Jewish legal matters for more than 2,000 years
Individual rabbinic decisions are known as responsa (sing. responsum)
If a traditional Jew is not certain whether an act is permitted or prohibited or is not sure what course of action accords with the Torah, s/he asks a rabbi who either consults other rabbis or issues his own legal ruling
Who Owns You?
Clear in Jewish sources from the Torah through the Talmud that God owns us
Only God has the authority to gives & take life
Human decisions to end life are illegitimate: Murder Suicide (exceptions?) Abortion – a very complicated matter! (not for today)
God Creates Humanity By Infusing Breath
Then the LORD God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living soul (Genesis 2.6)
Breathing is a condition of life
The very word for soul in Hebrew is based on the verb “to breathe”
Question: Does breath have to be initiated by the individual or can it be prompted by machine and still be called human life?
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God Ends Moses’ Life By Drawing Out His Breath
So Moses the servant of the God died there in the land of Moab, by God’s word (literally: mouth). And he was buried in the valley in the land of Moab over against Beth- Peor; and no man knows of his burial place unto this day. And Moses was a hundred and twenty years old when he died: his eye was not dim, nor his natural force abated. (Deuteronomy 34.1-7)
V’chai Bahem – You Shall LIVE by Them (mitzvot)
Leviticus 18.5 implies that we should follow the commandments in order to “live by them”
This is taken to mean that living is itself a commandment and we are to use the means of science, medicine and faith to heal and further life
For example – Normative Orthodox law now prohibits smoking as it causes premature death. Similarly it would ban illegal drug use or other human habits that might shorten life
Why? Again, life is from God!
End Of Life
T’reifa – A person “…known for certain that he had a fatal organic disease and physicians say that his disease is incurable by human agency and that he would have died of it even if he had not been killed in another way.”
Goses/Goseset – One who is dying, usually within 3 days of death
Physician determines status of patient
Rabbi yields to physician on the physical condition of the patient
Niftar/Nif-t’ra – One who has died (literally, departed)
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Are We Allowed To Hasten Death?
And so it is forbidden to cause the dead person to die quickly. Such as one who was dying for a long time and he could not separate, it is forbidden to remove the pillow or the mattress from underneath hum, because they say that there are feathers of some birds that cause this, and similarly they should not move him from his place.
And similarly it is forbidden to place the keys of the synagogue under his head, in order that he take leave. But if there is something there that is causing delay in the departure of the soul, such as if there is a banging noise next to that house, such as a wood chopper, or there is salt on his tongue, and these are preventing the departure of the soul, it is permitted to remove it from there, that in this there is no activity at all, rather he removes the barrier. (Shulchan Aruch/Yoreh Deah 339.1)
Responses Of Different Streams: Orthodox
Orthodox Judaism teaches:
“Any positive act designed to hasten the death of the patient is equated with murder in Jewish law, even if death is hastened by only a matter of minutes.” Rabbi J. David Bleich, quoted by Fred Rosner in Modern Medicine and Jewish Ethics, Ktav Publishing, NYC, 1991
YET…
“However, he is not obligated to employ procedures which are themselves hazardous in nature and may potentially foreshorten the life of the patient. Nor is either the physician obligated to employ a therapy which is experimental in nature.” (ibid.)
Reponses Of Different Streams: Conservative
“[An act taken] with proper precautions to insure that such decisions are taken seriously...a decision to remove modes of medical intervention from such people in given cases may be taken in good conscience and in consonance with Jewish law, even though such action will lead to their deaths.” (from “A Jewish Approach to End- Stage Medical Care,” Rabbinical Assembly (Conservative Rabbis’ Association, 1991)
“If the goses category is to be used to regulate care of the terminally ill, this policy permitting the withdrawal and withholding of aggressive treatments from such patients invokes the Jewish tradition's distinction between sustaining the life and prolonging the death of the moribund. The definition of the person to whom it applies (the goses), however, is broader than most Orthodox rabbis make it- but.. more in keeping with the intent of the tradition.” (ibid.)
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Responses Of Different Streams: Reform
“When, however, a patient has entered the final stages of terminal disease, medical treatments and procedures which serve only to maintain this state of existence are not required. A cancer patient, for example, would accept radiation and/or chemotherapy so long as according to informed medical judgment these offer a reasonable prospect of curing, reversing, or controlling the cancer. Once this prospect has disappeared and the therapies can serve only to increase suffering by prolonging the patient's inevitable death from the disease, they are no longer to be regarded as medicine and may therefore be withdrawn.” (CCAR Responsa- “On The Treatment Of The Terminally Il; 1994)
What About Nutrition & Hydration?
Orthodox Judaism: “Any positive act designed to hasten the death* of the patient is equated with murder.” (quoted above, Rabbi J. David Bleich)
Conservative Judaism: “There are, then, only two arguments which I can see to justify removal of nutrition and hydration from such patients. One is, if nutrition and hydration are to be categorized as medicine, one might argue that, since they are not curing the patient, they may be removed, as long as we offer normal food and water to the patient, even though we know he or she cannot possibly ingest them…”
“…even though such a person is not dead by the standards of either cessation of respiration and circulation or cessation of whole brain function, he or she should be allowed to die. Treatment of such a person, then, including artificial nutrition and hydration, should, in his opinion, be considered optional.” (ibid.)
*Death defined as based on respiration and circulation
What About Nutrition & Hydration?
Reform Judaism: “Does there not come a point in a patient's condition when, despite their obvious life-saving powers, the sophisticated technologies of modern medicine--the mechanical respirator, for example, or the heart-lung machine--become nothing more than mere "salt on the tongue," mechanisms which maintain the patient's vital signs long after all hope of recovery has vanished?” (Ibid)
“Answering "yes" to this question, some contemporary poskim allow the respirator to be disconnected when a patient is clearly and irrevocably unable to sustain independent heartbeat and respiration. Even though the machine is considered part of routine medical therapy (for patients are as a matter of course connected to it during emergency-room and surgical procedures), it has at this juncture ceased to serve any therapeutic function. They can no longer aid in the preservation or prolongation of life.” (Ibid)
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Nutrition & Hydration (cont.)
Once their therapeutic function is exhausted, the machines "merely prolong in an artificial way the process of dying. We must disconnect the patient from the machines, leaving him in his natural state until the soul departs.”
Persistent Questions
If God is author of life, what is the role of medicine in prolonging it?
If we are stewards of life (cf. Gen 1) how can we evade our responsibility to nurture life?
Does nurturing life as a gift of God mean all life is good and necessary and must be maintained despite pain, hardship and cost?
Who do hospital workers speak to about this in the Jewish tradition?
Conclusions
Life is a positive good, a gift from God – except when it isn’t
We are not required to do something medically because it is possible – it must benefit the patient
Religious teaching anchors our difficult, modern decision-making in time honored values and thought. We do not stand alone, rather on the shoulders of the greats who wrestled with these issues before us
We carry the burden of free will and our intentions matter greatly in life-threatening situations
Certainty is an ideal not attainable in most end-of-life situations
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