CCAR RESPONSA
Contemporary American Reform Responsa
85. Surgery at Ninety-Six*
QUESTION: A
ninety-six-year-old woman who lives in a nursing home has recently been informed that severe
hardening of the arteries necessitates the amputation of her foot. As a result of the shock of
hearing this news, she has become severely disoriented. Her family was subsequently advised of
her situation and several alternatives were presented. She may submit to amputation with a
chance that her condition will be permanently corrected. However, there is no assurance that she
may not die during surgery or soon thereafter. Furthermore, her other foot may be similarly
affected, or her rehabilitation may not be successful. The alternative is a slow and painful death
which can be partially relieved by sedation. The family wants the mother to make the decision.
She refuses to sign the release for surgery. But as her lucid moments are brief, it is not clear
whether that is what she actually wishes. Should there be surgery or should matters simply be
allowed to take their course? (Rabbi, Illinois)ANSWER: We shall look at both the
traditional and modern components of this question. Rabbinic tradition from Talmudic times
onward has encouraged the utilization of all possible medical procedures for life threatening
situations. Sanhedrin (23a) advocates this direction on the basis of “you shall not stand idly by
the blood of your fellow” (Lev. 19.16). Baba Kama (85a) bases itself on “he shall cause him to be
thoroughly healed” (Ex. 21.20). There are other parallel passages in which the citations are a
little less clear. Nahmanides, (13th century) in his commentary on Leviticus 25.36 (“and your
brother shall live with you”), followed this path, earlier proposed by Hai Gaon (10th century).
Yehuda Lev Zirelson (20th century) applied this line of reasoning to less dangerous, non-life
threatening situations (Teshuvat Atzei Levanon #61). The general principle that medical
intervention is to be widely used has thus been established. We must ask three further
questions. Is this appropriate when the procedure is dangerous? Is there an age limit beyond
which tradition would not advocate rigorous medical intervention? Shall this ninety-six-year-old
woman face the trauma of an amputation? The fact that considerable risk may be
undertaken to save or restore life is based on a Talmudic discussion (A. Z. 27b), which interprets
a story from II Kings (7.3 f). In this tale a group of lepers about to starve in the siege of Samaria
decided to risk the mercy of the Syrian army rather than face certain death in the city. The
Talmud used this discussion to show that in life threatening situations one might place
oneself even into the hands of idolaters. In modern times this passage has been cited in order to
permit the use of drugs whose side effects may be hazardous (J. Reischer, Shevut
Yaakov III, #85; Posner, Bet Meir Yoreh Deah 339.1). There are further discussions
about use of hazardous drugs when the chance of survival is low. Eliezer Waldenberg (Tzitz
Eliezer 10, #25, Chap. 5, Sec. 5) felt that a 50% survival rate was necessary to recommend
usage. Others like Mosheh Feinstein (Igrot Mosheh, Yoreh Deah 2, #59) felt that
hazardous procedures and drugs may be used even when there is only a remote chance of
survival. This path was also followed by I. Y. Unterman (Noam 12, p.5). There is
considerable debate on this matter. It is quite clear, however, that the use of medical procedures
with a high risk have been encouraged by traditional Judaism whenever there is an opportunity
to save a life. In the literature cited, and in other instances, there has been no discussion of an
age limit beyond which such procedures should not be utilized. If an individual is close to death,
she should be permitted to die peacefully, and it is not necessary to subject them to needless
pain through therapy which can not succeed (Sefer Hassidim #723; W. Jacob,
American Reform Responsa # 79). However, if there is a chance for success, it should be
undertaken. Although the life span throughout the rabbinic and Biblical period was low,
the Psalmist’s ideal of three score years and ten, or by reason of strength four score years (Ps.
90) and Moses’ life of one hundred and twenty with his “eyes undimmed and his vigor unabated”
(Deut. 34.7), as well as the ages of patriarchs and others, pointed to the ideal of an advanced
age. As medical practice has advanced and made a longer life possible, we, too, should
encourage medical procedures on individuals who have reached an advanced
age. However, we must also take into consideration the psychological factors which
our forefathers only partially considered. In this instance even the news of a possible amputation
was devastating, and the woman was not able to overcome it. This indicates a doubtful prognosis
for her future. Here the psychological disadvantages may outweigh the medical advantages. We
must remember that the efforts of tradition was solely concerned with saving life and not with its
quality. The medical prognosis is doubtful in our case and the psychological prognosis
negative. Under these circumstances we would be reluctant to encourage an operation and
inclined to let the woman live out her remaining days with the help of drug therapy to provide all
possible comfort.September 1984
If needed, please consult Abbreviations used in CCAR Responsa.