Community and Society Archive

Welcome to Community and Society where you will find the latest thoughts and reflections by CLAL faculty and associates on the changing nature of community and society in America today and on the challenges and opportunities these changes represent for the Jewish people in America at the dawn of a new century. Every other week you will find something new and (hopefully) engaging here!

To access the Community and Society Archive, click here.

To join the conversation at Community and Society Talk, click here.

Our authors are especially interested in hearing your responses to what they have written. So after reading, visit the Community and Society Discussion Forum where you can join in conversation with CLAL faculty and other readers.

When Jews Make End-of-Life Decisions

By Vanessa L. Ochs

Jewish tradition is created out of diverse strands. Elliot N. Dorff, a Conservative rabbi and respected member of the American biomedical ethics community, teaches us this in his book, Matters of Life and Death: A Jewish Approach to Modern Medical Ethics. Sacred texts form one strand (that is: the Torah, the Mishna, the Talmud, and commentaries and rabbinic responses to real-life questions that continued to be developed). People's stories, history, language, and ethnic patterns of behavior, memories, associations, and hopes form another. There is great wisdom here. Texts created, transmitted, received and interpreted by the Jewish community's generations of mostly male, mostly elite scholars can tell us only part of the picture when we want to understand how everyday Jewish people (who come from different denominations and who choose to observe their Judaism in different ways) think and act as Jews when they are making biomedical choices that arise at the end of life. I am not suggesting that people of different faith traditions may not act in some or all of these ways, but I am saying that anticipating these ways of being can be helpful for Jewish patients and their families, as well as for clergy and health care professionals who work in Jewish communities.

Here, I wish to explore the strand of cultural attitudes shared by diverse members of Jewish communities, Jewish ways of being that become especially relevant when biomedical-ethical decisions need to be made at the end of one's own life or the life of a loved one. The issues I particularly have in mind include donating organs, defining death, beginning and terminating all forms of life support, and choosing whether or not to pursue treatment. The strand of relevant sacred texts illuminating such issues can be readily discovered in Dorff's excellent text or in the late Benjamin Freedman's book, Duty and Healing: Foundations of a Jewish Bioethic. It's important to know that even when there are Jewish approaches to these issues that have their sources in sacred texts and are explicated by leading rabbis with expertise in biomedical decision making, the implications for taking action are rarely clear-cut. Relatively easy decisions and the more complicated ones, particularly those that cause extraordinary stress and potentially divide families, typically require some mediation by an external authority so that the individuals can do what is right in their particular situation.

The strand of relevant Jewish ways of being upon which I want to focus is less accessible. These are beliefs and practices that often go unspoken or are communicated inarticulately, but they are, all the same, both deeply felt and powerfully important sources of wisdom and orientation that are brought into play at times of difficult decision making. These ways of being compel action and hold people together; even though we might not be able to name them as specific sensibilities or teachings, they are so much a part of us that they motivate us, propelling us toward certain choices and away from others. Because these ways of being are not explicitly written down, and also because they are profoundly taken for granted by patients, family members and clergy, health care professionals may not have easy access to them, or any access at all. To complicate matters, while these internalized ways of being sometimes support the written laws and rabbinically approved practices, they do not always do so.

What are aspects of Jewish tradition that speak to the spiritual state of patients and their loved ones near the end of life? What might Jews hope that health care professionals -- doctors, nurses, social workers and bio-ethical consultants -- understand about us that will help them better support and guide us as we make difficult end-of-life decisions for ourselves or loved ones?

I suggest the following principles describe some of the relevant internalized ways of being Jewish:

1) Kavod: Honor

Kibbud av v'em: Honoring your parents (or elders who are like parents) in the way THEY would want to be honored; honoring parents in the way that other members of the family believe that parents ought to be honored. Failure to honor appropriately induces guilt.

Kavod hatzibur: Honoring the community. Choosing to act in a way that will bring one honor and not shame in the eyes of the community. That is, the choices you make will become public knowledge. Thus, while you might prefer not to be an organ donor, the pressure to be well thought of in the eyes of the community might move you to consider donation. Even though you might want to let a loved one go, you may feel that your community's pressuring you to do everything to sustain life (whether on not this is literally the case), and you are afraid they may criticize the choices you've made.

2) Goral: Fate

Mi ba'esh, umi bamayin: Who by fire, and who by water? (from the High Holidays liturgy) God sends illness as a punishment for those who have failed to measure up or to repent. There are consequences for the way you've lived your life, some that seem fair and others that don't.

T'shuvah, t'fillah, tzedakah ma'avirin et ro'ah hagezeirah: Repentance, prayer and charity will avert the severe decree from the High Holidays liturgy. You can make deals with God, negotiating one's fate: If I do "x" (and repentance, prayer, and charity), then I expect you to help me.

3) Rofeh cholim: Healer of the sick

Doctors are God's agents in healing, and some are better than others. You are obligated to find the best doctor and to demand that, as God's emissary, the doctor does absolutely everything possible, and that you have access to all relevant information.

4) Tzelem elohim: Being in the image of God

How do we define what dignity means? For each individual, it will be variously understood at different times of life.

5) Pikuach nefesh/Chai bahem: Saving a life/Living (and not dying) by the commandments

We go to extremes to save a life. But we also need to know and respect when the angel of death has come. There are real limits to how much pain and suffering a person should have to endure. One should recognize when it is time to let go, and not stand in the way of death.

6) Menschlikeit: Being a really good person

To be a real person is to be someone who acts with extreme compassion towards others, being attentive, making sacrifices, and simply knowing what the right thing to do is without its having to be spelled out. Not being present when you are needed by the ill person and other family members is considered unacceptable. You also expect that others will act to you in a menschlich way when you are facing illness and crisis, being present for you, visiting, helping, searching for medical experts and relevant information, and going the extra mile.

7) Shalom bayit: Keeping the peace

There are certain decisions or gestures you make not because you think they are correct, but because you think that they will serve to keep the peace or keep a family together, creating harmony instead of divisiveness. You will consider, for instance, engaging in a treatment that doesn't seem promising (provided it isn't harmful) for the sake of not alienating the one family member who believes it must be done.

8) B'shert: It's meant to be so

Certain things feel as if they were meant to be. Reality speaks. It is important to change what can be changed, but when a situation seems final, it is best to see it as b'shert, intended by God. Barukh dayan emet: God is the true judge. That means we are aware we need to recognize God's will, even when it isn't what we'd ourselves desire.

Questions to readers who have wrestled with end-of-life decisions: How would you describe the relevant Jewish ways of being that characterized your own situation? Are there ways of being that have not been included in this list?

Please respond to : vochs@clal.org