Can You Ever Pull The Plug? Life Support And Jewish Law
Since Joan Rivers’ death, several people have sent us questions about life support issues in Judaism, similar to the way that Robin Williams’ death piqued people’s curiosity about suicide in Jewish law, particularly as an effect of mental illness. I recognize that this is a sensitive topic and I address it with two caveats. The first is that issues such as this are far above my pay grade. Accordingly, while I am striving to impart information, I am definitely not attempting to rule in any matter of law. If anyone ever has a question of practical application in this area, he should contact a recognized Torah authority. (This is beyond the usual “ask your local Orthodox rabbi.”) The second caveat is that there are no doubt readers who have had occasion to address such end-of-life issues. Some of these readers may have acted counter to what I will soon say is Jewish law. No one is judging you. Having a terminally-ill loved one is a terribly difficult situation and no two cases are exactly alike. As the mishna in Pirkei Avos (2:5) says, we are not to judge another person until we have been in his or her place.
That having been said, the Jewish philosophy on life support is predicated on the belief that all life is sacred and is to be protected at virtually any cost. If a person will die from fasting on Yom Kippur, not only may he eat, he is required to do so. Similarly, in a life-threatening situation, one must violate Shabbos to call an ambulance or take someone to the hospital. Any mitzvah must be violated to preserve human life except for murder, incest/adultery, and idolatry.
Also integral in Jewish law’s outlook on this topic is the fact that Judaism has no concept of “quality of life.” All human life is equally sacred. An adult is not more entitled to life than an infant. An adolescent is not more deserving of life than a senior citizen. All of us – male or female, wise or foolish, able-bodied or infirm – everyone has an equal claim to survival.
This includes the terminally ill.
The Talmud (Shabbos 151b) tells us that one who closes the eyes of a dying person, hastening death by mere moments, is a full-fledged murderer. One who performs an act of euthanasia on a dying person could be executed for murder, the same as one who kills a healthy person (Mishneh Torah Hilchos Rotzeiach 2:7).
The idea that we don’t evaluate a person’s “quality of life” is a very good thing in that it keeps us from drawing lines between those we think have a reason to live and those we might deem to have no cause to keep on breathing. Our position is that everyone has a reason to live. We may not always understand another person’s “quality of life” but G-d does and He has told us to preserve life. This can be challenging, however, when dealing with end-of-life issues. If someone is in a coma or in pain, our emotions may tell us otherwise. But G-d does not want us to start picking and choosing who we, in our limited wisdom, think deserving of life. Our job is to preserve it.
On the other hand, we also have an obligation to alleviate suffering. This, as they say, is where things get interesting. We might do what we can to reduce a dying patient’s pain, even though some treatments may be life-shortening. Or perhaps we refrain from forms of treatment that might extend the patient’s life. (Remember: every case is different and a competent Torah authority must be consulted!)
When prolonging life and alleviating suffering clash, there are a number of factors involved in the decision-making process. Is the person going to die regardless of whether or not the treatment is administered? Is he or she undergoing great suffering? Do we know their wishes? (A living will is highly advisable to make one’s wishes known!) These are some of the main factors in evaluating such a case.
Pain medications like morphine are often given to terminal patients in order to alleviate their suffering. However, in addition to lessening pain, such drugs may also cause them to pass away sooner. Despite this unfortunate side effect, such drugs should not be withheld. Jewish law permits these narcotics to be administered provided that the intention is strictly to relieve the patient’s suffering and not to hasten his passing.
It must be noted that there is a difference between forgoing potentially life-extending treatments like surgery or chemotherapy and withholding food, water or oxygen. These things are considered to be staples of life and withholding them from the patient may be the functional equivalent of murder. (Imagine withholding food from an infant. Why should keeping it from someone on life support be any different?)
Lots of issues fall into this category. For example, is a DNR (a “do not resuscitate” order) permitted under Jewish law? What about a DNI (“do not intubate” – i.e., putting someone on a respirator)? The answers to these and other questions may vary from case to case. I cannot stress enough the need to contact someone well-versed in this area of Jewish law.
End-of-life issues are never easy. Trying to do what’s best for the patient is difficult to assess as the course of action to end their suffering may not always jibe with the course of action to extend their life. As trying as the situation is, the Torah provides us with the tools we need to walk that tightrope, all based upon the underlying premise that the patient’s life and well-being are just as valuable and important now as they ever were. (Click here for a discussion on organ donation and brain death in Jewish law.)
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Five days before Christmas 1983, I did not have to ask that The Plug be pulled on my mother. Per her long-term request, I asked that it not even be plugged in. I live in Maryland; when I told my sister in San Diego about this, she said that she would have put Mom on life support anyway, despite her wishes. I said, “That’s why she made me administrator of her estate & not you” and hung up.
Dear Jew in the City,
I normally do not comment on your posts, as I think they are normally well done and inspiring. This topic however hits home for me in my medical career and I feel the need to reply.
First, the use of the phrase “pulling the plug,” is troubling. This phrase is never used when physicians communicate with patients and families about the end of life. The decision to withdraw life support, is a complicated decision, and never taken lightly. It is often done with the assistance of a multidisciplinary team that includes clergy. Using the phrase “pulling the plug,” ultimately makes families feel like they are hastening or even causing their loved one’s death. The phrase and the picture you chose for your article perpetuates the imagery of causing and contributes to our collective inability to have frank discussion about end of life care in the United States. When the discussion to withdraw care is made, no medical provider goes over to the wall and pulls anything. What occurs is a carefully planned intervention that includes keeping the patient comfortable and making sure that the family is informed of the events that will follow. At the end of life, we stress to families that they are not making the decisions that cause death but are instead relieving suffering, honoring their loved ones wishes, and allowing a natural death.
Second, physicians do not hurriedly assess the patient’s “quality of life” and if deemed poor, withdrawal care. These situations are fraught with emotion for both physicians and families. As physicians we are trained in saving lives and so the move to withdraw care and allow natural death is often against our very being. We have many discussions with the patient and family, sometimes over many weeks, months or even years about their opinion on their own quality of life and what they, the patient, consider to be a good quality. The patient’s wishes, with the help of shared decision making between all parties involved, are then ultimately followed. The ventilator is not removed from patients who have said they want to stay “alive” even if they are bed bound, unable to communicate, and have a very poor prognosis. This fact is evident in the numerous long term care hospitals across the country. Places like these are care for patients who are in persistent vegetative states or who are otherwise attached to ventilators, requiring 24 hour care. Unfortunately, what patients and families do not realize is the suffering the follows when that decision is made to remain on the ventilator. Being attached to the ventilator is not without risk. Pneumonia, bed sores, delirium, aspiration, urinary tract infections, blood stream infections and bleeding are some of the many complications, not to mention the emotional toll of loss of independence, the inability to speak and being tethered to a machine. Eventually, there comes a time when medical care can no longer sustain “life,” and the care becomes futile.
Third, you make reference to treating pain with morphine causes hastening of death. This commonly held belief, even held by some physicians, is false. This has been studied and reported in the medical literature. Morphine or other narcotics have a predictable set of side effects with increasing dosages. Physicians and nurses notice other side effects such as drowsiness, confusion, and then loss of consciousness all before the breathing is compromised. Moreover, should respiratory depression occur, there is an antidote that can reverse the effects of the morphine. The same type of side effects happen to all people and that is why providers are judicious about prescribing an appropriate and safe dose.
Fourth, you discuss the withholding of food or water. At the end of life, it is natural to have a decreased appetite and decreased thirst. These are thought to be compensatory mechanisms as it causes the body to release hormones such as ketones and endorphins that ultimately lead to some relief and feeling of wellbeing. Additionally, it has been studied in the medical literature that terminal feeding or hydration does not change the outcome; it only lead to invasive procedures, prolongs the suffering and the dying process. While not eating or drinking is alarming to the family, especially since food is so ingrained in our culture, physicians help families understand that this is part of the natural dying process. However, if someone is on a ventilator, and it is medically indicated, patients are given nutrition through a feeding tube or the intravenous route. It is often started very early on in disease course as we know that good nutrition is important in the healing process.
In your article, you stated that “It must be noted that there is a difference between forgoing potentially life-extending treatments like surgery or chemotherapy and withholding food, water or oxygen. These things are considered to be staples of life and withholding them from the patient may be the functional equivalent of murder.” The American Medical Association makes no distinction between withdrawing or withholding life sustaining medical treatment. It is important not to forget that the social commitment of the physician is to sustain life and relieve suffering.
Fifth, you separate do not resuscitate (DNR) and do not intubate (DNI). Resuscitate can mean many things and includes cardiopulmonary resuscitation (CPR), antibiotics, defibrillation, vasopressors(medication to augment heart pumping and maintain blood pressure), artificial hydration or nutrition. Resuscitation even includes intubation. Many people do not realize that you cannot separate CPR and intubation. Making the distinction between DNR and DNI is arbitrary and something I discourage patients from doing.
Additionally, I have trouble using the phrase “life support,” because sometimes there is no “life” left to support. I refrain from using it in my practice due to its connotation. For example, in brain death, “life support,” or the medical interventions aimed at taking over the function of the body is instead prolonging the dying process in a person who is already dead. This is especially true in cases when the cause of death is ultimately not reversible.
Pirkei Avot and the Talmud, could not predict the medical interventions that we possess today. Long ago, people died from infection, maternal complications during child birth, starvation or trauma. Today, we can easily treat these issues. No one died from complications from advanced dementia, or metastatic cancer after three rounds of failed chemotherapy. You speak of the negatives of “pulling the plug,” but what about following the patient’s wishes and alleviating suffering. While I encourage all patients to have advance directives or living wills, they are typically vague as we can’t prepare for every situation.
In all the deaths I have been involved in my team has never had to pick and choose who is deserving of life. When it comes down to the decision to withdrawal care, it is typically made after all indicated medical interventions have been tried and failed. At that point, the decision is already in the hands of G-d and we are just fulfilling his work.
Thanks for your comments. Obviously, you are coming at it from a very different perspective. I am not writing for doctors, I’m writing for lay people for whom these issues may be entirely new. This is not the end of a discussion, it’s the beginning of one. So if some things seem oversimplified from your professional point of view, I would think that’s to be expected. To address your comments in order:
(1) I wrote the article but neither the title nor the accompanying image are mine. Somebody else chooses those things for marketing reasons – search engine optimization, whatever. (You’ll note that the phrase “pull the plug” appears nowhere in the body of the article);
(2) Where did I ever suggest that physicians make rushed decisions? In fact, where do I discuss physicians at all? Obviously, such decisions are made in consultation with the physician but I was primarily addressing the emotional roller coaster as experienced by family members;
(3) I’m not going to question your professional knowledge on the subject but I have first-hand experience that supports the dissenters. (I am not in a position to share it in a public forum but I will disclose it privately via email if you would like to contact me);
(4) I am well aware of this; such was the case when my father was in hospice. I was not discussing those who cannot or will not eat (obviously, they should not be force fed!), I was discussing the family making a conscious decision to withhold food, water or oxygen.
Item #5 appears to require no response.
To reply to your closing remarks, I never suggested that physicians pick and choose which patients deserve to live. I was merely informing lay people that, in our belief system, being in a coma or having a terminal illness does not render a person’s life undeserving of continuation. When coupled with other factors, such as suffering, there are many issues to be considered in consultation with both one’s doctor and one’s rabbi.
This is an important issue – with many ethical and legal ramifications.
I enjoyed the article but am disappointed with the tone (not so much the content) of the comment above, perhaps it would have been best to take a deep breath before replying? It’s a bit impolite.
I was faced with a “no-win” situation some years ago when I was the sole caregiver for my mother who had been conscious and on life-support machines. What made this situation even more extraordinary is that she had changed her mind from her advanced directive — and wanted to continue living. It was extremely difficult to communicate properly as she wasn’t able to talk. I visited her everyday at the hospital and skilled nursing facility, and was quite sensitive to her wishes and needs. I did my best to honor her wishes and in the process I have been “disowned by many members of my family. I even consulted a Jewish Rabbi who made it clear that it wasn’t right to end a “life”, and that every moment is precious, whether it be for a day, week, month or year. Sadly I have been greatly misunderstood, and haven’t had a proper family relationship for many years. When the Woolsey fire hit my home and I lost everything, I still haven’t heard from them. This is a type of “pain” that never goes away.. My mom and I had a very special bond, and I truly loved her deeply. This is in spite of their accusing me of being selfish and cruel. Thank you for your most insightful article.