THE HOSPICE

QUESTION:

In 1967, an English doctor, Cecily Saunders, opened a new sort of institution which was called St. Christopher’s Hospice. The basic purpose of the hospice was to ease the process of dying for terminal patients. The hospice proved so popular that similar institutions and organizations with the same motivation have spread rapidly across the United States. The question has now been raised whether the motivations and the methods of the hospice idea are in conformity with the spirit of Jewish legal tradition. (Asked by Sonia Syme, Detroit, Michigan.)

ANSWER:

A DISCUSSION of this question involves an analysis of the motivation for the hospice as an institution and a movement and its relationship to present medical practice with regard to a terminal patient. Dr. Saunders, herself a practicing physician and undoubtedly working in hospitals, had come to the conclusion, with which many now agree, that a hospital is not the proper place for a dying patient. A hospital is primarily directed to the task of curing a curable patient. So, for example, certain practices directed to the task of curing are followed in a hospital. The patient, when needed, receives all sorts of medicines, injections, and is often attached to various tubes, etc. Also, in general, visiting by relatives and friends is kept to a minimum. All this is deemed by the hospital to be necessary to the process of curing and is, therefore, quite justified.

But suppose it has become clear that the patient cannot be cured. Even so, the hospital practice in dealing with this incurable patient will tend to follow the practice used for a curable patient. There will be a continuation of the chemotherapy and tubes and electrical machines as if the patient could still be cured. Also, the patient is still kept relatively isolated from his family and thus often dies in loneliness, even though this isolation was no longer necessary, since no cure was possible. Therefore, because hospitals tend to follow with the incurable the methods for the curable, Dr. Saunders established, one might say, a special sort of hospital, one specifically for the dying. It is a bright building where relatives come as often as they wish. The patient, of course, gets medical relief for pain, but above all, he spends his last weeks surrounded by his dear ones and is allowed to die in dignity.

The hospice idea has spread in the United States. But so far there are only one or two special buildings provided for this purpose. Mostly there are, in most American cities, organizations devoted to the essential hospice idea, namely, that the dying patient is allowed (as it is believed) to die in dignity, helped and consoled by the presence of his or her dear ones, and without being forced to undergo such medical treatments as are no longer necessary. Also, there will be religious and psychiatric help for the patient, providing him or her with the mental and emotional means to face the inevitable end with equanimity. This is the aim which is now sought for in institutions or through the hospice idea in the dying patient’s home. Even in the original institution, St. Christopher’s in London, the patients spend most of the time at home. The question now is, what is the attitude of Judaism to this idea and method?

The first question that concerns us is this: How does the patient know that his case is terminal? If part of the hospice idea is to inform the patient that he is no longer curable and that he is dying, and this is the first step in the hospice process, then it must be stated at the very outset that to tell a patient that there is no longer any hope for cure, even if this is a fact, is contrary to the spirit of Judaism. We are told in the Talmud (Berachos 10a) that when King Hezekiah was sick, Isaiah said to him, “Put your house in order because you are going to die.” But Hezekiah rejected this dire prophecy and said, “I have it as tradition from my father’s house [i.e., David’s] that even if a sword is hanging above a man’s head, he should not give up hope for deliverance.” As a matter of fact, Isaiah’s prediction that Hezekiah’s case was terminal proved to be wrong, and King Hezekiah recovered. This idea of not telling a patient that he is going to die finds its expression in Jewish law (Yore Deah 338). If, for example, we ask a terminal patient to make confession of his sins (based onb. Shabbat 32a), we must reassure him by saying, “Many make confession and do not die.” Furthermore, we do not suggest confession in the presence of ignorant people or of women and children, lest they burst into tears and sadden the dying man. The exact words used are “lest they weep and break his heart” (based on the Tur, ibid.). No coffin must be brought where the patient will see it. No weeping relatives must be allowed in his presence (cf. Tur, ibid.). However, we may assume that in modern times a patient does not have to be told outright that his case is hopeless. He generally gets to know it in one way or another. So we may well assume that the hospice will not need to tell the patient that he is going to die, but is dealing with patients who already know that they will not recover.

Now the purpose of the hospice is to change the hospital practice of keeping the patient undisturbed and alone, except, of course, for the reluctant permission given to the closest relatives. Instead, the hospice encourages the family to be present through all the terminal stages. This idea that the dying should not die alone is fully in accordance with Jewish law. The Shulchan Aruch states (in Yore Deah 339:4) that when a person is dying, it is actually forbidden to leave his presence, so that his soul should not leave him while he is alone. See, also, Isserles, who says that it is actually a mitzvah to be in the presence of the patient as he is dying, and Moshe Rifkes, in his Be’ er Hagolah, says that the purpose of this is that the person should not die in a state of sorrow. In other words, the idea of the hospice that there is consolation in the presence of dear ones and friends at the time of dying is an idea which is fully in accord with Jewish tradition.

As for the final purpose of the hospice—that a dying patient should not be subjected to all the tubes and other methods which prevent him from dying, but which cannot possibly prevent his death but only delay it—all such forcibly keeping of the dying patient alive is contrary to Jewish tradition. A man has the right to die in dignity. (See all the references involved in this question in Modern Reform Responsa, pp. 197 ff., the responsum entitled “Allowing a Terminal Patient to Die.”)

To sum up, then, it would be contrary to the spirit of Jewish law to tell any patient that there is no hope and that he is going to die. However, if the patient already knows this, then the purposes of the hospice idea—namely, that the patient should be surrounded by his dear ones during his last days, and that he should not be surrounded and subjected to useless medical apparatus and practice—all this is fully in accord with Jewish tradition.

It might be added that since part of the work with the dying patients in the hospice may involve the transmission of religious ideas which are consoling, there is a great deal in Jewish tradition which would well be usable for this purpose. Just to mention three instances: Job (3:13), speaking of death, refers to it as a quiet sleep. He says, “For now [i.e., had I died] I would have lain still and been quiet; I should have slept and then had been at rest.” In fact, even more than the idea that death is peace and rest is the thought ascribed to Rabbi Meir (Genesis Rabba 9:5) that death is one of God’s most blessed creations. He refers to the fact that God, having performed the work of Creation, commented and said, “It is very good.” Rabbi Meir said that among the things that God considered very good, i.e., a boon to mankind, in His Creation, was also the blessing of death.

Also, because Scripture says of Moses and Aaron that they died by the Mouth of God (Numbers 3 3:3 8, Deuteronomy 34:5) i.e., the Word of God, the Talmud (Berachos 8a) takes this to mean that they died with God’s Kiss. Since then, every peaceful, quiet death is described as mayss b’n’shika, “death by the Kiss of God.”