“Who Shall Live ...” A Report from the CCAR Task Force on Assisted Suicide June 11, 2003 – 11 Sivan 5763 Michael Z. Cahana, Chair There are some studies of Jewish law whose modern applications are more theoretical than practical. But in the field of Jewish bio- ethics—particularly those dealing with issues at the beginning or end of life—these discussions have applications that are real and are usually applied when people are at their most vulnerable. Societal norms are often inadequate and insufficiently articulate. As Jews, we look to our tradition to offer guidance at these moments of intense decision-making. As rabbis, we are often called upon to give direction. The answer to the question “What do Jews believe about …?” is rarely a simple one, especially when people are in pain, both physical and emotional. We balance our pastoral duties and compassion with our knowledge and discretion. As members of a rabbinic body, we also have the obligation to influence civil legis- lation that can potentially weaken the fabric of our society by deval- uing our tradition’s deeply held reverence for life. The purpose of this task force is to craft language and a position for the body’s approval on the controversial subject of physician-assisted suicide. 1. There Is Nothing New… Although the terminology “physician-assisted suicide” is relatively new,1 the controversy surrounding the role of the physician at the end of life is not. Some have argued that a phrase in the Hippocratic Oath was inserted as a political statement by those who opposed euthanasia, indicating a rift that was supposedly settled in the fifth century B.C.E.2 The phrase is instructive: “Never will I give a deadly drug, not even if I am asked for one, nor will I give any advice tend- ing in that direction.”3 This phrase points to two arenas that are under the physician’s purview: (1) the active role of the doctor in directly prescribing medications to assist the dying, and (2) the more 42 CCAR Journal: A Reform Jewish Quarterly “WHO SHALL LIVE ...” passive role of providing information or advice to enable a patient to end his or her life prematurely. To understand the issues surrounding assisted suicide, we must also address euthanasia, although they are different in practice. Euthanasia has been continuously discussed both from a societal- needs perspective and within the context of human suffering. The Church, for example, has regularly and vigorously opposed eutha- nasia as simple murder, articulated from the writings of Augustine in the fourth century to Aquinas in the thirteenth.4 Even in the twen- tieth century, as the discussion of euthanasia assumed political meaning, in 1940 the Roman Holy Office condemned all direct euthanasia as a breach of the “natural and divine positive law.”5 Suffering as a virtue to be endured, which at least in part underlies the Christian position, is not generally articulated in Jewish writ- ings. But the halakhic prohibitions against suicide are clear,6 as is the commandment to break the Shabbat laws even for the possibility of saving a life. The classic case is of the victim buried under a col- lapsed building for whom every effort is to be made on Shabbat, even if the victim can not survive for long.7 Less well known is the perspective that life in pain is preferable to no life at all, evidenced by the horrific experience of the soˇah made to drink the “bitter waters.”8 The Gemara and Rambam indicate that the victim did not always die immediately, but if she “possessed other merit,” al- though still guilty of the crime of adultery, the waters would pro- duce a debilitating condition that was only eventually fatal. Although accompanied by lingering pain and suffering, this cir- cumstance was seen as preferable to death.9 2. What Is New Although these religious and cultural perspectives on Euthanasia have been around for a long time, the specific circumstance that has pushed this agenda to the fore centers around modern medical tech- nology and issues of autonomy. Medical technology has made great strides in modern times. Even those diseases still seen as “incurable” are very often “manage- able.” Death itself, while never overcome, is forestalled. This is not so much a new development as an evolving one. A poignant expres- sion of this state of affairs was written by an anonymous woman in an article in the Atlantic Monthly in 1957: Winter 2005 43 CCAR TASK FORCE ON ASSISTED SUICIDE There is a new way of dying today. It is the slow passage via modern medicine. If you are very ill modern medicine can save you. If you are going to die it can prevent you from so doing for a very long time.10 This article, detailing the suffering endured by her husband, which she felt was needlessly prolonged by doctors dedicated to main- taining life at all costs, resonated throughout the medical profession and the public during the late 1950s and 1960s. The phrase “death with dignity” was articulated here and has become something of a rallying cry. A movement took hold in the 1970s through the publi- cation of books such as Paul Ramsey’s The Patient as a Person, a hugely popular work in which he held that “the patient has entered a covenant with the physician for his complete care, not for continu- ing useless efforts to cure.” Elisabeth Kubler-Ross’ highly influential On Death and Dying gave a name to an emerging movement that stressed better communication, sensitivity, and palliative care for the dying. The Karen Ann Quinlin case (1976) extended the “right of refusal” idea to patients in comas. A less well-known case, Claire C. Conroy (1985), dealt with such rights for a patient who was mentally and physically impaired but neither brain dead nor in a chronic vegetative state, and not even terminally ill. Her proxies advocated for the removal of artificial feeding tubes. Case law now upholds the right of refusal by both competent and mentally impaired patients. The reasoning is that “their rights of free choice, self-determination, and privacy outweigh medicine’s and the state’s interests in prolonging life, preventing suicide or manslaughter, and protecting the goals and practices of modern medicine.”11 The “death and dying” movement began to take on new meaning in the 1990s with the introduction of “assisted suicide.” The discus- sion began earlier with the publication in 1978 of Jean’s Way, “the true story of one woman’s plans to end her own life toward the end of a terminal [bone cancer] illness.” The article was written by Jean’s husband, then Los Angeles Times reporter Derek Humphry. Hum- phry went on to write Let Me Die before I Wake, a regularly revised book that included personal narratives of persons with advanced illnesses who carried out “rational suicides” with the aid of friends and physicians. In the 1980s Humphry and his new wife founded the Hemlock Society, which championed “self-deliverance through dying.” His 1991 self-help book Final Exit remains a best-seller. The 44 CCAR Journal: A Reform Jewish Quarterly “WHO SHALL LIVE ...” movement’s most visible advocate, of course, was Dr. Jack Kevorkian, whose highly publicized assistance in Janet Adkin’s death in 1990 began a career that eventually led to his imprisonment following the televised death of Thomas Youk, a 52-year-old ALS sufferer. Dr. Timothy E. Quill’s moving personal account of a physi- cian providing life-ending medication to his patient was printed in the pages of the prestigious New England Journal of Medicine in 1991. Dr. Quill and others have maintained that this has been a long- standing but quiet practice among physicians. These popular movements led to legislative actions. Washington state and California both sought to decriminalize euthanasia and physician-assisted suicide under the rubric “Aid in Dying.” Both initiatives failed. But in 1994, Oregon passed the “Death with Dignity Act,” a citizen-led initiative that advanced the right of adults “to request and obtain prescriptions from doctors to end their life.” A second referendum was passed in 1997 and the law cleared all court appeals. The federal government immediately issued a ban from the Drug Enforcement Administration (DEA) that was over- turned in 1998 by Attorney-General Janet Reno. In 2001 Attorney- General John Ashcroft sought to overturn this ruling but was over- ruled by the courts. The U.S. Supreme Court had earlier ruled that states could permit doctors to assist in the suicide of terminally ill patients. In 1999, Representative Henry Hyde introduced legisla- tion to the House to “amend the Controlled Substances Act to promote pain management and palliative care without permitting assisted suicide and euthanasia, and for other purposes.”12 This legislation is still pending. The Oregon legislation gained national attention and debate. Some of the more striking predictions, i.e., that large numbers of people would flock to Oregon to take advantage of this law, have not come true. During 2002, physicians in Oregon gave fatal prescrip- tions to about 75 terminally ill patients; 38 of the recipients used them to commit suicide. The total number of physician-assisted suicide cases in Oregon since the Death with Dignity law came into effect in 1997 is 129.13 The experience in Holland, where the practice of euthanasia and physician-assisted suicide is firmly established, is more striking. A government study estimated that during 1995 alone there were 3,200 cases of euthanasia performed and 400 cases of assisted suicide, out of a population of some 15 million.