Is it morally permissible to remove artificial nutrition and hydration from a patient who would otherwise continue to live?
by Mark Washofsky
In its final weeks and days, the ordeal of Terri Schiavo riveted the attention of a nation. The media focused on the dramatic and at times outlandish elements of the case: the quarreling relatives, the intervention by state and federal politicians. Yet at its core lay a single, simply put question of medical ethics: Is it morally permissible to remove artificial nutrition and hydration from a patient who would otherwise continue to live for an indefinite period? How do we determine right from wrong on this matter of life and death?
As Jews, we ask another question: What answers do our sources provide? I say "answers," in the plural, because it is far from certain that Jewish tradition offers a single, correct answer; we can only say for certain that Jewish texts present us with resources for argument and ways of considering and framing questions about end-of-life issues. A number of passages from biblical, rabbinic, and halachic literature are relevant to the ongoing Jewish debate over whether to provide or withhold sustenance from the terminally ill.
The Distinction Between Killing and Letting Die
First and foremost, Jewish tradition uniformly rejects euthanasia. The killing of a terminally ill person is forbidden, no matter how "compassionate" the motive for doing so. As the rabbinic text Semachot 1:1 puts it: "The dying person (goses) is like a living person in all respects." In the Shulchan Aruch, the preeminent compilation of halachah (traditional Jewish law), R. Yosef Karo comments that any action which hastens a dying person's death is forbidden, for "one who touches him has shed blood." (Yoreh De'ah 339:1)
It is, however, permissible to "let nature take its course," to remove any factor that would hinder the otherwise imminent death of the goses. As the Ashkenazi scholar R. Moshe Isserles points out, should there be present a factor that hinders the departure of one's soul--for example, if the sound of a woodchopper can be heard close by the house, or if there is salt on the dying person's tongue--it is permitted to remove this noise or the salt. Neither of these actions would be considered a positive act (ma'aseh) towards death, but rather the removal of an impediment (Yoreh De'ah 339:l). Extending this idea, some leading halachic commentators have argued that we are also forbidden to take any positive action that might unnecessarily delay the death of a dying person. Applying this line of thinking to a modern-day context, we might conclude that we are entitled to remove, to discontinue, or to refrain from undertaking medical therapies that do not contribute to healing but merely lengthen the process of dying.
There are, however, problems with this position. Some observers question whether we can draw any useful comparisons between the world of our texts, which speaks of woodchoppers and salt on the tongue, and the sophisticated technology of contemporary medicine. Others doubt the clarity of the distinction between "killing" and "letting die." Take, for example, the famous talmudic story of the death of Rabbi Yehudah Hanasi, or "Rabbi" (Ketubot 104a). As Rabbi lay dying, his disciples gathered in prayer to prolong his life. Their unceasing prayers were unable to restore him to health, sufficing only to keep him alive in great pain and suffering. Seeing this, his maidservant climbed to the upper chamber of the house and tossed a glass vase to the ground. The crashing sound interrupted the praying, and Rabbi died. The Talmud does not condemn her action, implying approval of it, but it is not clear whether by breaking the vase she had committed a positive act to hasten Rabbi's death or had merely "removed an impediment" to it. Similarly, when we "pull the plug" on a dying patient, do we hasten his or her death or simply allow it to happen naturally?
The Commandment to Heal
A problem with these sources is that they speak of the goses as one who would die almost immediately once the impediment is removed. They do not refer to a person who, though diagnosed as terminally ill, could potentially, with aggressive treatment, live for an extended period of time. And they clearly do not refer to a person such as Terri Schiavo, who could live for an extended period without "aggressive" treatment but simply through the maintenance of nutrition and hydration. In such a case, does Jewish tradition support the decision to forego potentially life-extending medical treatment? Or, because he or she has not yet entered the classification of goses (dying person), is withholding treatment tantamount to assisted suicide or murder?
In a 1994 decision, the Central Conference of American Rabbis' Responsa Committee sought to address these questions through a different conceptual framework. Rather than apply the distinction between killing and letting die, the responsum proposes that we consider the question in the light of the moral duty--the mitzvah--to practice medicine. This duty is never stated explicitly in the Torah, but the rabbis derive it from the existence of other mitzvot: from the obligation to preserve life (pikuach nefesh, which the tradition learns from Leviticus 18:5); from the positive duty to rescue those whose lives are in danger (Leviticus 19:16); and even from the mitzvah to restore a lost object to its owner (Deuteronomy 22:2), since one's life is the most important "object" that one possesses. In other words, because we are commanded to save life, we are commanded to heal, to practice medicine. But what, precisely, does this duty entail? The responsum suggests that we define it according to the standard of therapeutic effectiveness: a particular drug, surgery, or therapy is regarded as "medicine" to the extent that it contributes to healing, to the successful treatment of a patient's illness. By "successful treatment," we mean a therapy that can cure the disease, arrest its progress, or control it to the point that the patient achieves a reasonable degree of function. In the halachic tradition, such therapy is called refu'ah bedukah (or vada'it), a "proven" remedy, one that the physician is morally obligated to offer and that the patient is morally obligated to accept. By contrast, if a particular drug or procedure is judged to be therapeutically ineffective, the patient and the physician are under no moral obligation to use it. If a particular therapy is at first therapeutically effective and later ineffective in treating the illness, perhaps because of the patient's deteriorated condition, then that therapy is no longer regarded as "medicine" and therefore no longer obligatory.
This standard, too, is fraught with difficulty, as there is no single, one-size-fits-all definition for terms like "successful treatment" and "therapeutic effectiveness." Each case must be fleshed out and argued separately, sometimes resulting in family disputes and controversies, as in the Schiavo case. We may never be absolutely certain that a particular human being has declined to the point that successful treatment is impossible. So, too, we may never be absolutely certain of the effectiveness of particular treatments. Despite these ambiguities, the 1994 CCAR responsum does provide a criterion for making judgments with moral confidence based on Jewish texts judgments. When a patient has entered the final stages of a terminal illness, medical procedures that serve at best only to maintain this state of existence are not morally obligatory. Therapies that do not contribute toward successful treatment of the illness, that function solely to prolong the patient's inevitable death, are not medicine and do not partake of the mitzvah to heal. We are therefore under no duty to administer them, and we may well remove them from the patient.
Are Artificial Nutrition and Hydration "Medical" Treatment?
How would we apply these texts and interpretations to the Terri Schiavo case? We would reiterate that a patient in a persistent vegetative state, kept alive by means of a feeding tube, is not a goses. Death is not imminent; the patient can survive for an extended period so long as food and water are administered in this way. On the other hand, we might well conclude that any medical therapy that serves to maintain this irreversible condition does not meet the standard of "successful medical treatment." This is not a judgment that this patient lacks a minimal "quality of life" and therefore should be allowed to die. Nor is this a claim that one human life is somehow less sacred or precious or worthy of our moral concern than the life of anyone else. It is, rather, a statement that the maintenance of a persistent and irreversible vegetative state is not a proper and acceptable goal for the treatment of this individual's illness. Medical therapies that prolong this condition are not "therapeutic," and therefore not obligatory.
Nonetheless, even if we are comfortable with this conclusion, the cessation of artificial nutrition and hydration are not necessarily justified. That decision would depend on whether we define the feeding tube as a form of "medical treatment" that may be discontinued once it has lost its therapeutic rationale. The feeding tube can indeed be seen as a medical procedure: it is administered to a patient by medical professionals; it is prescribed in response to disease and as part of the course of a patient's medical treatment; and it entails physiological complications that distinguish it from the normal acts of eating and drinking. From this perspective, the cessation of artificial nutrition and hydration might be allowed because this "medicine" will not contribute to the successful treatment of the patient. However, it is also quite possible to make the opposing argument: that because it delivers nutrition and hydration to the patient, the feeding tube is the functional equivalent of food and water. Because food and water are required by the healthy as well as the sick, they are not "medicine" per se, but are to be administered in response to our duty to feed the hungry. From this perspective, to remove the feeding tube would be tantamount to starving the patient to death, an act of killing, instead of allowing the patient to die from the terminal illness that has brought him or her to this juncture.
Which of these approaches best reflects Jewish moral teachings? On this critical question, rabbinical thought is deeply divided. Although most Orthodox opinion forbids the removal of feeding tubes from a terminal patient, some authorities permit it on the grounds that artificial nutrition and hydration constitutes a medical procedure. The Committee on Jewish Law and Standards of the (Conservative) Rabbinical Assembly has issued two conflicting rulings on the subject. Reform halachic opinion is similarly split: While one responsum opposes the removal of the feeding tube, several others permit it. Surveying this disagreement and finding no substantive argument to tip the scales convincingly to one side or the other, a 1994 CCAR responsum--the Responsa Committee's most detailed discussion to date on the treatment of the terminally ill--concludes: "We cannot claim that Jewish tradition categorically prohibits the withdrawal of food and water from dying patients." The responsum does add, however, that the removal of artificial nutrition and hydration should not become a routine act. "It is preferable that artificial feeding be maintained, so that, when death comes, it will not have come because we have caused it by starvation." Still, because removing the tubes can be justified as the cessation of a futile medical procedure, "the family must ultimately let their conscience guide them in the choice between these two alternatives."
To say that the family must choose does not mean that either choice is as good or as bad as the other. Nor does it mean that the choice will be easy to make. It means, rather, that either choice is an acceptable one, if the family is convinced that, through a prayerful study of the texts and sources of our tradition, it reflects their best understanding of Judaism's moral teachings.
Rabbi Mark Washofsky is professor of Rabbinics at HUC-JIR in Cincinnati, Ohio. For a more extensive discussion of this subject, see the CCAR responsum #5754.14, "On the Treatment of the Terminally Ill," at www.ccarnet.org.
- A Time To Prepare, Revised Edition, edited by Rabbi Richard Address, imparts information on end-of-life issues (organ donation, wills, "good-bye" rituals, and more); serves as a workbook to help individuals consolidate and record all the information they will need when faced with critical illness or death; provides durable power of attorney and health care proxy forms; and more. Contact the URJ Press at www.urjpress.com, 888-489-8242.
- That You May Live Long: Caring for Our Aging Parents, Caring for Ourselves, edited by Rabbis Richard Address and Hara Person, presents, through a series of personal essays, Jewish perspectives on the aging of a loved one, textual references, practical advice, and more. Contact the URJ Press at www.urjpress.com, 888-489-8242.
- A range of Bioethics Study Guides produced by the Department of Jewish Family Concerns address such issues as "Termination of Treatment" (guide #3) and "The Spiritual Challenges of Living with Chronic Illness" (guide #13). A full list of the bio-ethics study guides is available at www.urj.org/jfc/bioethics/studyguides/.
- "Questions and Answers about Jewish Tradition and the Issues of Assisted Death," a booklet written by Dr. Harvey Gordon, explores the issues surrounding assisted death from a Jewish perspective. Contact firstname.lastname@example.org.
- In addition, the Department of Jewish Family Concerns is available to assist congregations in sponsoring teaching sessions on the subject of making sacred decisions at the end of life informed by Jewish texts. Contact email@example.com.