End Of Life Issues From A Jewish Perspective

By: Drs. John D. Loike and Ruth L. Fischbach, Center for Bioethics, Columbia University College of Physicians and Surgeons

Date: Wednesday, June 25 2008

Mr. Goldin (not his real name) was a 60 year-old man in good overall health, when he was struck by a car that ran a red light. He had suffered a catastrophic brain injury and was admitted to the neurological Intensive Care Unit (NICU). After three days in the NICU doctors declared him brain-dead. The Organ Donor Network then contacted Mr. Goldin's next of kin, his two daughters, to ask them about donating their father's organs. The older daughter, like Mr. Goldin, is a traditional Jew, but not Orthodox. The younger daughter is Orthodox.

The older daughter accepts the diagnosis of brain death and is in favor of donating the organs, saying that it is what their father would have wanted. The younger daughter, however, does not accept the notion of brain death, noting that her father is warm and has a pulse. She insists that she cannot allow organ donation, stating that she consulted with her rabbi and donation is against Jewish law.

Troubling cases like this one come up frequently at Columbia University's hospitals. The Medical Ethics Committee, led by Dr. Kenneth Prager who is also a member of Columbia's Center for Bioethics, often is called to help the family and the healthcare professionals resolve these complex issues.

In response to the increasing frequency of Orthodox patients facing end of life issues in the hospital, the Center for Bioethics organized an innovative one-day symposium to discuss the religious and secular issues that arise as life ebbs. To establish a dialogue between leaders representing the religious and secular perspectives, nationally- renowned Orthodox Rabbinical scholars (Rabbi Moshe Tendler and Rabbi Mordechai Willig of Yeshiva University) and international medical experts (Dr. Avraham Steinberg, recipient of the I999 Israel Prize in Medical Ethics, Dr. Muriel Gillick of Harvard University, as well as Drs. Prager and Stephan Mayer of Columbia University College of Physicians and Surgeons) presented their views on a wide variety of medical end of life issues informed by neurology, emergency medicine, geriatrics, palliative care, and medical ethics. More than 200 religious leaders, health care professionals, university students, and community members joined together on May 23 to attend the symposium titled "End of Life Issues from a Jewish Perspective."

The Symposium, was organized by Dr. Ruth L. Fischbach, director of the Center for Bioethics, Dr. John D. Loike, director of special projects at the Center, Dr. Jeremy Simon and Dr. Prager, and was made possible by generous funding from the Lucius N. Littauer Foundation, from the Joseph N. Muschel Memorial Foundation, and The Jewish Press.

This exceptional symposium offered a comprehensive educational initiative focused on Jewish/Halachic issues in end of life care. Topics included treating terminally ill patients, medical futility, euthanasia, brain death, cardiac death, organ donation, pain management, palliative care, and advance directives.

Using presentations and challenging case-based discussions led by Dr. Prager, the educational objectives addressed an overview of Halachic principles and how these relate to secular practices of end-of-life care. To promote optimal care of the dying patient, the ultimate aim of the symposium was to develop guidelines for healthcare professionals that advance understanding and respectful care for patients in the Orthodox Jewish community.

Dr. Avraham Steinberg began the symposium by emphasizing that end-of-life issues and caring for the dying patient are some of the most troubling and critical issues of modern times. The Orthodox community is generally divided on the issue of how death is defined. Dr. Steinberg and Rabbi Tendler presented the view that brain death is the primary criterion in this regard and they outlined both the medical methodology and rabbinical sources (including Rabbi Moshe Feinstein, Rabbi Ovadia Yosef, and Rabbi Shlomo Auerbach) in support of their view. Dr. Mayer presented the physiologic changes that occur with brain death and how it is diagnosed.

L-r Kenneth Prager, Dr. Muriel Gillick, Dr. Avraham Steinberg, Rabbi Mordechai Willig, Dr. Ruth L. Fischbach, and Rabbi Dr. Moshe Tendler

Applying Halachic principles to the case study of Mr. Goldin, Dr. Steinberg and Rabbi Tendler supported the view that under proper guidelines, Mr. Goldin could in fact donate vital organs such as heart and lungs to save the life of another human being. The sacredness of life is an important value in Judaism and the gift of a vital organ can be the gift of life.

Rabbi Willig, using a combination of Halachic sources and some modern medical data, presented the other view that death is essentially characterized by cardiac arrest and that the orthodox daughter was within Halachic guidelines to allow only non-vital organs, such as the cornea, for organ donation.

Even though there are disagreements on the definition of death, other case studies presented at the symposium highlighted a general consensus between the rabbis and physicians regarding how to care for the dying Orthodox patient, especially with respect to providing food, water, and palliative care.

One major difference between the physicians and rabbis was that physicians supported full autonomy of the patient and the family in making terminal medical decisions, whereas Halachic Judaism views limited autonomy as the norm. Therefore, within halachic Judaism, patients or family members caring for the dying patient do not have the authority to request withdrawal of a ventilator.

In addition, Halachic Judaism distinguishes between withholding treatment and withdrawing treatment. This means that aggressive treatments that have no possibility of saving life and even a very low probability of prolonging life can be withheld from the dying patient whereas the ventilator cannot be withdrawn.

While sufficient food and water must not be withheld from the dying patient, Dr. Gillick described dying patients as often unable to eat or uninterested in food and fluid. Putting food in their mouth can lead to choking and aspiration.

Dr. Steinberg, the featured luncheon speaker, described how he and his Israeli committee facilitated the passage of a unique and innovative law that focused on the dying patient. The passage of this law was a magnificent lesson in diplomacy and politics as they were able to gain approval of the leading rabbinical authorities of Israel as well as approval of lawyers and physicians. The new Israeli law defines brain death as the major criterion of death and represents the first real Halachic law passed by the Knesset.

After the symposium, the speakers met together to draft a set of guidelines that will be presented to the healthcare professionals serving Columbia University's medical centers. It was remarkable and a Kiddush Hashem that there was widespread consensus among the rabbis and physicians regarding how to draft these guidelines for physicians serving the Orthodox Jewish community.

Various novel proposals in dealing with the dying patient were debated and are being reviewed by all the speakers before these important guidelines are finally issued. In this way, healthcare professionals will gain a better appreciation and sensitivity to the moral imperatives within Halacha that guide the religious Jewish patient and the family at the end of life.