ARR 271-274


American Reform Responsa

79. Euthanasia

(1980)QUESTION: A patient has terminal cancer and has sunk into a deep coma. Only the artificial life support systems are keeping him alive. Would Jewish tradition permit these systems to be shut off? What is the Jewish attitude toward euthanasia? (Dr. N.H., Philadelphia, Pennsylvania)ANSWER: Jewish tradition makes a clear distinction between, on the one hand, positive steps which may hasten death, and on the other hand, avoiding matters which may hinder a peaceful end to life. It is clear from the Decalogue (Ex. 21:14; Deut. 5:17) that any kind of murder is prohibited. The only Biblical case of euthanasia was King Saul (I Sam. 31:1ff; II Sam. 1:5ff), who asked his servant to slay him after his own attempt at suicide failed (II Sam. 1:5ff). In the Tannaitic period, the Mishnaic tractate Semachot (1.1) considered a dying person (goses) as a living individual in every respect. That point of view has been followed by later codes such as Maimonides’ Yad and Caro’s Shulchan Aruch. It is clear from the Mishnaic statement that none of the acts usually performed upon the dead should be done to the dying, nor should a coffin be prepared or matters of inheritance be discussed. The additional later discussion made it clear that no positive acts which may hasten death were to be undertaken, so the Sefer Chasidim (723) stated that an individual should not be moved to a different place even if that might make dying easier. It is further quite clear that we must use any medicine or drug which may help an individual. All Shabbat laws may be trespassed to save a life (Yoma 85a; Sh.A., Orach Chayim 196.2, 319.17; Ex. 31:14; Lev. 18:5), and even the death of an individual who is seriously ill should not be hastened (Sh.A., Yoreh De-a 339.1). In all these instances, some vague hope remained. However, these injunctions were modified with a dying individual (goses) in the throes of death. In that case, it was considered appropriate for an individual to stop praying for the lives of those dear to him or pray for their release (Ket. 104a; Ned. 40a; Rema to Sh.A., Even Ha-ezer 121.7 and Choshen Mishpat 221.2). Furthermore, it was thought appropriate to stop acts which would hinder the soul from a departure, so Sefer Chasidim (723) stated that if a dying person was disturbed by wood chopping, it should be halted so that the soul might depart peacefully. Isserles (to Sh.A., Yoreh De-a 339.1) stated that anything which stood in the way of peaceful death should be removed. Solomon Eiger, in his commentary to the same passage of the Shulchan Aruch, stated that one should also not use medicine to hinder the soul’s departure; he based himself on Beit Ya-akov (50). Clearly, as long as some form of independent life persists, nothing should be done to hasten death and all medicines which may be helpful must be used. Once this point has been passed, it is no longer necessary to utilize further medical devices in the form of drugs or mechanical apparatus. We must now attempt to define the turning point, when “independent life” has ceased, and we can best do so by looking carefully at the Jewish and modern medical criteria of death. The traditional criteria were based on a lack of respiratory activity and heart beat (M. Yoma 8.5; Yad, Hil. Shab. 2.19; Sh.A., Orach Chayim 329.4). Lack of respiration alone was considered conclusive if the individual lay as quietly as a stone (Responsa Chatam Sofer, Yoreh De-a, #38). All of this was discussed at some length in connection with the provision of the Shulchan Aruch that an attempt be made to save the child of a woman dying in childbirth; even on Shabbat a knife might be brought to make an incision in the uterus in order to remove the fetus (Sh.A., Orach Chayim 330.5). This statement, however, conflicted with the prohibition against moving a limb of someone who was dying, lest that hasten the death (Sh.A., Yoreh De-a 339.1). If one waited until death was absolutely certain, then the fetus would also be dead. Absolute certainty of death, according to the halachic authorities of the last century, had occurred when there had been no movement for at least fifteen minutes (Gesher Chayim I, 3, p. 48) or an hour (Responsa Yismach Lev, Yoreh De-a, #9) after the halt of respiration and heart beat. On the other hand, a recent Israeli physician, Jacob Levy, has stated that modern medical methods change this criterion, and the lack of blood pressure as well as respiratory activity should suffice (Hama-a-yan, Tamuz, 5731). This discussion was, of course, important in connection with the preparation for burial, as well as other matters. When death was certain, then the preparation for burial had to begin immediately (Chatam Sofer, Yoreh De-a 338; Azulai’s Responsa Chayim Shaul II, #25). In ancient times it was considered necessary to examine the grave after a cave burial to be certain that the individual interred had actually died. This was recommended for a period of three days (Semachot 8.1). This procedure was not followed after Mishnaic times. In the last years, it has been suggested that Jews accept the criteria of death set by the ad hoc committee of the Harvard Medical School, which examined the definition of brain death in 1968 (Journal of the American Medical Association, vol. 205, pp. 337ff). They recommended three criteria: (1) lack of response to external stimuli or to interral reed; (2) absence of movement and breathing as observed by physicians over a period of at least one hour; (3) absence of elicitable reflexes; and a fourth criterion to confirm the other three, (4) a flat or isoelectric electroencephalogram. They also suggested that this examination be repeated after an interval of twenty-four hours. Several Orthodox authorities have accepted these criteria, while others have rejected them. Moses Feinstein felt that they could be accepted along with shutting off the respirator briefly in order to see whether independent breathing was continuing (Igerot Mosheh, Yoreh De-a II, #174). Moses Tendler has gone somewhat further and has accepted the Harvard criteria (Journal of the American Medical Association, vol. 238, #15, pp. 165.1ff). Although David Bleich (Hapardes, Tevet 5737) and Jacob Levy (Hadarom, Nisan 5731, Tishri 5730; Noam, 5.30) have vigorously rejected this criterion, we can see that although the question has not been resolved by our Orthodox colleagues, some of them have certainly accepted the recommendations of the Harvard Medical School committee. We are satisfied that these criteria include those of the older tradition and comply with our concern that life has ended. Therefore, when circulation and respiration only continue through mechanical means, as established by the above-mentioned tests, then the suffering of the patient and his/her family may be permitted to cease, as no “natural independent life” functions have been sustained. We would not endorse any positive steps leading towards death. We would recommend pain-killing drugs which would ease the remaining days of a patient’s life. We would reject any general endorsement of euthanasia, but where all “independent life” has ceased and where the above-mentioned criteria of death have been met, further medical support systems need not be continued.Walter Jacob, ChairmanLeonard S. KravitzW. Gunther PlautHarry A. RothRav A. SoloffBernard Zlotowitz

If needed, please consult Abbreviations used in CCAR Responsa.