CARR 142-144

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.