53 Jewish bioethics
Mrs. G is an 85-year-old resident of a Jewish long-term care facility who has vascular dementia, controlled heart failure, and diabetes mellitus. She is bed bound and occasionally recognizes her daughter with a slight smile. The gastrostomy feeding tube she received two years ago has begun leaking and needs to be replaced. Her daughter, who has become her surrogate since the recent death of Mrs. G’s husband, has indicated that if the tube were to come out, she would not consent to the insertion of a new tube: a decision she feels would be in accord with her mother’s wishes. She would not, however, request that the tube be deliberately removed. The staff are concerned that, by not replacing the tube, they would be failing to maintain the current level of treatment, and she would starve. They feel that this would amount to taking the mother’s life, without any substantial decline in her clinical condition. The daughter acknowledges the concern and devotion of the staff and her mother’s unchanged clinical status, but reiterates her belief that her mother would prefer to be allowed to die rather than be force fed through a gastrostomy tube.
What is Jewish bioethics?
Judaism
Judaism is the religion of the Jewish People. Judaism is a 3500-year-old tradition based on foundational stories in the Pentateuch – the five books that make up the Torah. In the first book, Genesis, the Jewish people become defined as the descendents of the monotheists Abraham and his wife Sarah. The Torah chronicles the people’s covenant with God, deliverance to the holy land, exile and slavery in Egypt, acceptance of the laws of Moses at Sinai, and ends as the people are delivered back to the promised land of Israel. The rest of the Hebrew Bible (Tanach/Old Testament) tells of many centuries of prophets and kings, tribal rivalries, and conflicts with neighbors, as well as the temple in Jerusalem and the priests who kept the holy books. It ends with another story of exile and return, this time from Babylonia. In the ensuing centuries, from 500 BCE on, temple ritual and sacrifice evolved into synagogue-based communal prayer and study. With the temple’s final destruction in 70 CE, ancient oral traditions became written in the Talmud. The practice of seeking wisdom through ongoing study of the holy books became a central feature of Jewish existence that persists and thrives today. In the past century, the Jewish people have suffered the trauma of losing six million people to Nazi genocide, and the joy of returning to full nationhood once again when the State of Israel was established in 1948.
Jewish bioethics
Although discussions of medical ethics have been recounted in Jewish writings since ancient times, modern medical technologies have placed new challenges before interpreters of Jewish tradition (Green, 1985; Feldman, 1986; Rosner, 1986; Rosner and Bleitch, 1987; Novak, 1990; Meier, 1991). The zeal with which these questions have been addressed has given rise to the field of Jewish medical ethics, which has developed since the 1960s. In keeping with Jewish ethics generally, Jewish bioethical inquiry appeals to the principles found in Jewish scriptures and commentaries and applies them to clinical decision making. In doing so, it takes a duty-based approach rather than the predominantly rights-based approach characteristic of some contemporary secular bioethical approaches. As the late Benjamin Freedman (1999) pointed out, ethical deliberations that are focused on rights often help in solving the procedural question of who gets to make a decision, but they do not necessarily offer guidance as to what that decision ought to be. Framing a dilemma in terms of the duties owed to those involved can clarify the issues and suggest a satisfactory course of action.
Interpersonal behavior in Judaism is traditionally conceived as the execution of duties within the context of one’s relationships with other humans and with God. Accordingly, a preoccupation with rights implies, firstly, the relative isolation of individuals making claims upon one another and, secondly, an implicitly or overtly adversarial relationship. In a “regime of duty,” participants seek to enable each other to satisfy the obligations inherent within relationships (Freedman, 1999), including professional relationships. Judaism urges one to perform mitzvoth (good deeds); that is, to act in accordance with one’s duties, and this applies in the healthcare setting no less than anywhere else. The clinic thereby provides a relatively new arena in which mutual obligations between patients, healthcare providers, and families can be explored. Such explorations inevitably begin with the established norms of Jewish law and behavior, collectively known as Halacha (literally, “the way”).
A variety of approaches
Traditional Jewish legal and ethical thinking is based on reading and interpreting three main sources, each of which is vast, varied, and complex. The oldest and most authoritative is the Hebrew Bible, which includes the five books of Moses (the Torah), the Prophets, and the Writings. The second source is the Talmud, which is composed of multilayered commentaries on biblical texts and oral traditions by learned rabbis of the second to fifth centuries CE. To make the voluminous Talmud more accessible, several great codifications of Jewish law emerged that attempted to summarize the Talmud’s primary teachings (Karo, 1965; Asher, 2000). One of the most notable, the Mishne Torah, comes from Maimonides (1962), the noted twelfth century physician and scholar. The third main source of Jewish legal authority is the Responsa literature, in which prominent Jewish scholars through the centuries have given opinions on contemporary matters as interpreted through the Hebrew Bible and Talmud (e.g., Waldenberg, 1990; Feinstein, 1994). Responsa are the continuation of a 2000-year-old interpretative tradition, which creates an intellectual link to the past, helping to keep the law relevant and vital to the present. (Descriptions of codes and Responsa can be found in Freedman [1999] and Rakover [1994], or in any general guide to the sources of Jewish law.)
Bioethical questions are treated by Jewish scholars in a variety of ways, which reflect different orientations toward Judaism and degrees of strictness in the interpretation of Talmudic texts and cases. Pioneering work in contemporary Jewish medical ethics in the 1960s and 1970s came primarily from Orthodox Judaism, in which the authority of God, as expressed through the Torah and Talmud, underlies the deliberative process ( Jakobovits, 1959). Much Jewish bioethics literature comes from this perspective, which assumes that, through the proper interpretation of Talmudic texts and commentaries, answers to the most difficult questions can be discovered. In practice, the rabbi whose opinion is sought for an ethical answer serves as an “expert counselor” to physician and patient, interpreting Halachic law for the situation in question. A local rabbi or chaplain may, in turn, consult more learned Halachic authorities in difficult cases.
Inspired by these Orthodox sources, Jews from the more liberal Reform and Conservative movements have also made contributions to contemporary bioethics (Feldman, 1974; Borowitz, 1984; Maibaum, 1986; Dorff, 1990). The interpretative method and texts used are basically the same, but their rulings are often more flexible than those provided by Orthodox rabbis. Even within Orthodox Judaism, there exist multiple interpretations of most texts, with a resultant variability of rulings. Jews of the Reform movement are often more open to “extra-Halachic Jewish ethical analysis” (Grodin, 1995), in which Halacha becomes only one of several sources of moral authority.
Common principles
Although traditional Jewish scripture expresses many principles worthy of ethical consideration, there are a few foundational tenets that ground much of the Jewish bioethical tradition. One commentator identified three main principles: “human life has infinite value; aging, illness and death are a natural part of life; and improvement of the patient’s quality of life is a constant commitment” (Meier, 1991, p. 60). Other important concepts are that human beings are to act as responsible stewards (Freedman, 1999) in preserving their bodies, which actually belong to God (Davis, 1994), and that they are duty bound to violate any other law in order to save human life (short of committing murder, incest/adultery or idolatry). Compared with secular values, these principles suggest a diminished role for patient autonomy. When a treatment is efficacious (refuah bedukah) there exists a duty to seek or preserve health, which overrides any presumed right to refuse/withhold treatment or to commit suicide. However, when the efficacy of the treatment is uncertain (refuah she’einah bedukah), then the individual is permitted to decide and possibly refuse (Flancbaum, 2001).
The problem faced by Jews in end of life decisions is not usually in determining the appropriate Halacha; a greater challenge is determining the moment when hope for continued life is lost and the process of death has begun. Jewish law is relatively clear that life is not to be taken before its time. It is equally clear that one is not to impede or hinder the dying process once it has begun (Feldman, 1986). Lenient rulings in such cases may be based on the same texts as strict rulings; one authority may see continued treatment as prolonging life, where another may see it as prolonging death. Working through this dilemma is a common feature of Jewish end of life decision making. Both the duty to treat and the duty not to prolong death must be considered in light of the more general duty to care for one’s parents in old age or ill health.
Why is Jewish bioethics important?
Today approximately 13 million Jews live in many parts of the world. Israel’s population of more than six million is over 80% Jewish, and a similar number live in the USA. Russia and France have large Jewish populations, followed closely by Argentina, Canada, and the UK. While the majority of Jewish people have secularized to varying degrees and adopted the language and customs of their local countrymen, a significant minority remain committed to upholding the laws of the Torah through prayer, study, adherence to tradition, and commitment to the covenant with God.
To traditionally minded Jews, Jewish bioethics is a subset of Halacha, which guides all of their activities. To more secular Jews seeking guidance in difficult decisions about their health, Jewish bioethics offers helpful lessons and considered opinions from the sages. Many non-religious Jews welcome traditional views to help to ease the uncertainty inherent in difficult ethical decisions, even though they may not live according to traditional religious practice.
An understanding of Jewish bioethics can help anyone, Jewish or not, who wishes to explore the many ways people think about difficult ethical issues. Even without accepting the authority of the Hebrew Bible and the Talmud, healthcare professionals may benefit from seeing how principles or norms can be derived from authoritative texts, how minority opinions can be incorporated into such deliberations (the Talmud consistently records these), and how grappling with tough questions in this structured way can increase sensitivity to ethical and decisional nuance. Perhaps the most important lesson to be learned is that there are few easy answers to complex problems. Jews do not have a guidebook that explicitly tells them what to do in every situation. Rather, their guidebook is cryptic and requires them to consider thoroughly the range of possible answers to ethical dilemmas. It is a tradition of continued and ongoing questioning rather than one of absolute theological law passed down from above (Fasching, 1992). Furthermore, familiarity with Jewish bioethics would give the practitioner the perspective to consider ethical dilemmas through the lens of duty rather than of rights, asking the question, “What are the obligations of each of the parties involved in this discussion?” Although the rabbis of the Talmud would have appreciated the procedural question of who gets to decide, they were more concerned with finding the best course of action for the particular case at hand, irrespective of the participants’ wishes.
How should I approach Jewish bioethics in practice?
Both Jewish and non-Jewish healthcare professionals can benefit from being acquainted with Jewish bioethics in caring for patients and their families when issues related to Judaism are raised. Table 53.1 summarizes essential points to keep in mind when providing care to Jewish patients.
The patient’s life history might have some bearing on the type of treatment approaches he or she requires. Older Jews not born in Western nations might be more likely to appreciate a rabbi’s input, as they are often more traditional than their children. Also, there are still a significant number of Holocaust survivors in most Western cities, some of whom have significant psychological associations stemming from traumatic experiences.
Patients who are religious may doubly appreciate hospital attire that preserves modesty. Some Jewish patients may also appreciate brief periods set aside for prayer or other ritual obligations.
A practitioner treating a Jewish patient should not make assumptions about the extent to which the patient would like his or her care to be guided by Jewish tradition. It would be perfectly appropriate to ask a patient whether Jewish opinions are considered in the decision-making processes, and to consult with a rabbi – a specific one if so requested – when the patient wishes to explore the tradition’s wisdom on a particular matter.
In general, traditional Judaism prohibits suicide, euthanasia, withholding or withdrawal of potentially beneficial treatment, abortion when the mother’s life or health is not at risk, and many of the traditional “rights” associated with a strong concept of autonomy. For example, an observant Jew would not consider it his or her right to seek physician-assisted suicide as a way to avoid present or future suffering from metastatic carcinoma. Exceptions to these prohibitions are sometimes made in extreme circumstances.
The case
Mrs. G’s daughter is undoubtedly trying to respect her mother in not consenting to the insertion of a new gastrostomy feeding tube, but she will find it difficult to get rabbinical support for reducing or withdrawing treatment that would result in her mother’s death without a prior serious decline in Mrs. G’s overall condition. How best to respect her parent is not easy to determine, but usually Judaism teaches that prolonging life is more respectful than assuming an incompetent patient wishes to end her suffering prematurely.
There is a clear duty to “cause to eat” (Freedman, 1999) in the Jewish tradition, which her daughter should not, according to the Halacha, violate unless Mrs. G is deemed to be a goses (a person in the throes of dying), in which case treatment or feeding that would hinder the dying process would not normally be allowed. Even as death approaches, performing duties as articulated by Jewish law is the essence of traditional Jewish life, a source of joy and fulfillment for both patients and families, and Jewish bioethics suggests that the articulation and performance of such duties be the focus of clinical decision making. The daughter agrees to have the gastrostomy tube replaced. She and the healthcare team determine conjointly the basis for future care within a palliative care framework. Mrs. G succumbs comfortably to pneumonia some months later.
REFERENCES
Related websites
An earlier version of this chapter has appeared: Goldsand, G., Rosenberg-Yunger, Z. R. S., and Gordon, M. (2001). Jewish bioethics. CMAJ 164: 219–22.