A Guide for the End of Life A Review of Behoref. Hayamim/In the Winter of Life: A Values-Based Jewish Guide for Decision Making at the End of Life. edited by David Teutsch and Deborah Waxman (Reconstructionist Rabbinical College Center for Jewish Ethics, 2002) BY NATAN FENNER he Center for Jewish Ethics reminiscent of Reform responsa or at the RRC has produced a Conservative interpretations/conclu- useful, thoughtful, accessible sions of halakha; however, the book is andT topical guide for decision-making much more a guide and conversation- at the end of life. It provides concep- starter than a compendium of defini- tual frameworks, reasoning and guid- tive pronouncements and formulae. ance for making Jewishly informed, ethical decisions around end-of-life is- Values-Based Decision Making sues. The point of departure is a medi- cally up-to-date, academically grounded The opening chapter, “Jewish Val- and liberal Jewish perspective. ues and Decision Making,” by David Behoref. Hayamim contains a series Teutsch, provides an orientation to and of chapters drawing on each author’s an explanation of values-based deci- experience in the fields of medicine, sion-making, and of the key Jewish medical ethics, congregational and values and terms that inform much of Reconstructionist movement leader- the discussion of end-of-life care in the ship, chaplaincy and Jewish healing. succeeding chapters. One finds a clear The chapters address decisions and resonance with the Reconstructionist concerns commonly faced in end-of- approach to communal decision mak- life care, including: advance directives, ing in Teutsch's summary of the pro- life support and resuscitation, informa- cess of values-based decision making: tion-sharing and communication be- determine facts, alternative actions and tween patient and caregivers, pain man- their outcomes, and relevant beliefs and agement, bedside advice for those of- values; examine relevant scientific and fering emotional and spiritual support, social-scientific approaches to under- assisted suicide and Jewish burial and standing these; consider the historical mourning practices. Some authors and contemporary context, including reach conclusions or make arguments the history and rationales of Jewish Rabbi Natan Fenner serves at the Bay Area Jewish Healing Center in San Fran- cisco, and on the board of the National Association of Jewish Chaplains. 76 • Spring 2005 The Reconstructionist practice; look for norms that might for individuals who are or should be exclude some actions; weigh the rel- considering or drawing up or revisit- evant attitudes, beliefs, and values; for- ing their own advance directive, a cat- mulate decision alternatives; seek con- egory that arguably includes anyone sensus . ; [and] make the decision over forty. Pages 22 to24 include a con- (5-6). cise explanation of the content, ap- Among the Jewish values and con- proaches, common complications and cepts identified in this chapter as rel- strategies of advance directives. The evant to the end-of-life conversation: chapter also brings a helpful discussion pikuah. nefesh (saving a life); eyt lamut of some of the inducements and im- (there is a time to die—accepting pediments — both from common ex- death’s inevitability); kevod habriyot perience and from those particular to (human dignity); b’tselem elohim (each the Jewish milieu — to completing ad- human being’s infinite worth derived vance directives. from being created in the image of In “End-of-Life Technologies,” Kav- God); and rahmanut. (compassion/ esh explains some of the medical pro- mercy). It also addresses terms more cedures most commonly addressed in specific to and commonly used in Jew- advanced directives relating to life-sup- ish bioethics discourse on end-of-life port, together with rationales for us- issues: terefa (a person certain not to ing or declining them. Particular atten- recover from a terminal illness) and tion is given to cardio-pulmonary re- goses (in talmudic literature, one whose suscitation (CPR), ventilators (artificial medical condition has so irreversibly respirators) and feeding tubes. deteriorated as to be expected to sur- In addition to outlining a medical vive no more than three days). This perspective on these technologies, Kav- introduction addresses both lay and esh makes frequent reference to professional readers, laying out a halakhic and ethical sources (mostly method for study and a foundation for from Conservative and Orthodox lit- a Jewish moral perspective on the ques- erature — the one citation of a Reform tions raised by the other authors. responsum in Behoref. Hayamim occurs in a footnote to Chapter 9), and to gen- Advice for Caregivers erally held Jewish values. “Taking Control of Difficult Deci- Feeding Tubes sions,” by William Kavesh, contains information and advice about advance The section on the “effectiveness of directives that are helpful, particularly feeding tubes” is more accurately a de- for individuals who are or may be des- piction not of their utility and condi- ignated as caregivers, proxies, surrogate tions for likely success, but rather of decision-makers or as having healthcare their ineffectivess and risks, and ration- power of attorney. In fact, this chapter ales for forgoing them. For readers not provides useful questions and direction current with the medical literature and The Reconstructionist Spring 2005 • 77 “best practices,” it reads like a critical The dying person and his or her famil- re-examination or reframing of an over- ial and professional caregivers have dif- used technology. In Kavesh’s view, tube ferent roles, obligations and challenges feeding shifts from a medical interven- in this regard. Wolpe cites a number of tion that is widely used and seen as an midrashic sources containing vignettes aid to life to an “impediment to the on healing in the context of peer and departure of the soul from the body.” caregiving relationships. (59-60) This chapter includes a sensitively Without including a rationale for written section on appropriate roles for when in a patient’s life this reclassifica- caregivers in helping someone in their tion of tube feeding becomes appro- meaning-making efforts as they con- priate, the logic behind this view could front illness or death. As many profes- be seen by some as unduly biased or sional caregivers who work with people overly broad in its application. The in hospice or with terminal illness know, chapter could benefit from Kavesh’s healing is possible — and the hope for perspective on why or when, and for healing can be a powerful motivator — what kinds of underlying conditions, even in the last days and hours of life. a feeding tube — still commonly of- Wolpe enumerates some areas where fered or prescribed by physicians in dying persons and those supporting many settings — might be an appro- them might seek healing (refuat ha- priate treatment option. This perspec- nefesh v’refuat haguf), including study, tive would lend the reader a greater prayer and communal and familial sense of balance or context for discern- ritual. ing how to respond, or what questions Among his more takhlis (practical) to ask or consider, when making such suggestions, Wolpe highlights the im- a decision. On the side of refuat ha- portance of having or arranging com- nefesh (healing of the spirit), Kavesh panionship and emotional support notes that it can be very reassuring for when “bad news” (i.e., a grave or po- family members to try feeding their tentially shocking diagnosis) is to be loved one orally after the removal of a delivered to someone, particularly if the feeding tube (61). physician or other bearer of such news is not prepared or in a position to re- The Role of Relationships main with the receiver of the news and offer that support. Wolpe also explains “Forming New Relationships,” by that in the often chaotic and emotion- Paul Root Wolpe, examines the role ally stressful setting of such conversa- and impact of relationships in refuat tions, designating a member of the per- hanefesh. The quality and intensity of sonal or professional care team to our primary familial, communal and record or remember important infor- professional caregiving relationships mation can be invaluable, as details are may significantly distress us, comfort easily forgotten, conflated or recalled us or otherwise shape our experience. out of context or out of proportion. 78 • Spring 2005 The Reconstructionist Acknowledging that some families others, only when the patient is not able prefer to keep significant medical (or to convey his/her wishes directly. In- ancillary) information hidden from a cluded in this section is a helpful clarifi- loved one whom they feel to be in a cation of the distinction between and ap- precarious condition, Wolpe advocates propriate places for substitute judgment for truth-telling as a general rule. In a and best-interest decision making. discussion that is essentially directed to Much of the discussion in this and physicians and family members of the other chapters focuses on the domain affected person,Wolpe notes the ten- within which terminally ill or dying sion placed on the entire caregiving persons are no longer able to make or system when it is asked to maintain a consent to medical decisions on their conspiracy of silence or outright decep- behalf. Wolpe notes some of the com- tion. In his view, truth-telling may in fact mon ways that families run into con- support greater trust and hope (read also: flicts over end-of-life treatment and care healing) on