CCAR RESPONSA

Hospital Patient Beyond Recovery

5750.5

She'elah

A man in his seventies suffered a stroke, but was expected to recover. During this period he received his nourishment through a feeding tube. However, recovery did not take place and for the past four or five months he has been in a semi-comatose condition, with no hope for improvement. Family and doctor wonder whether it is permissible to withdraw the feeding tube and let him die. (Rabbi Sheldon Ezring, Syracuse, NY)

Teshuvah

In order to consider the she'elah some additional information about the patient and his condition was solicited and was supplied by the attending physician:

The patient had been an intellectually and psychologically sound septuagenarian who developed a massive left sided cerebravascular accident secondary to emergency thoraic surgery. A nasogastric feeding tube was placed early after the onset of his stroke as all thought that a "meaningful recovery" would ensue. It did not. He remains mute and usually asleep. He barely responds to his name spoken -- he might slowly and in a delayed fashion move his head toward the speaker. Occasionally he would be found rubbing his scalp. When his eyes are open, his stare is almost always "blank." At most, he makes brief eye contact. There is no consistent response to voice command such as appropriately moving an extremity.

All of this remains the case greater than 4-5 months past onset of his stroke. His CT scan demonstrates massive left brain permanent damage.

The physician then posed some questions and proceeded to answer them:

1. Does he fulfill the criteria of persistent vegetative state? No! [sic]

2. What is his quality of life? As we can ascertain it, close to zero.

3. Will any further measures be undertaken besides oxygen or feeding tube? No.

4. Would he have wanted to be kept alive at this "level" based on pre-admission conversations? No.

5. Does the family view his quality of life as meaningful? No.

6. Can they ethically bring him home and stop feeding him through a feeding tube?? [sic; the doctor added the extra question mark and did not venture an answer.]

Withdrawal of life support systems.

The matter of withdrawing life support systems from a dying patient has been dealt with in a responsum by R. Solomon B. Freehof.1 The question put to him was as follows:

A terminal patient was dying as a result of a series of strokes. Two physicians, one of whom was the patient's son, decided -- with the consent of the family -- to hasten the end by withdrawing all medication and fluids given intravenously. Is such procedure permitted by Jewish law?

In a wide ranging discussion Freehof drew, inter alia, on Joshua Boaz who stated that while one must not do anything to hasten death, one may remove the causes of the delay of death.2 Freehof concluded:

If the physician actively attempts to hasten the death, that is against the ethics of Jewish law. In the case as described "to hasten death" is perhaps not correct, or at least should be modified. The physician is not really hastening the death; he has simply ceased his efforts to delay it.

We see no reason to depart from Freehof's decision, but must raise two questions:

a. whether our patient may be considered terminal;

b. if so, whether the nasogastric tube, which was originally a means of hoped-for recovery, may now be considered a "heroic measure" which might be discontinued.

Is the patient considered terminal?

Ad a. The physician's letter does not suggest that the patient is near death, that is, in halakhic parlance, a goses. The writer denies that the patient's state can be described as "persistent vegetative," (sub 1 ) but also does not affirm that death is imminent or even near and merely says that no further measures, beyond oxygen and feeding tube, will be undertaken (sub 3 ). We therefore deal with a patient who is not facing imminent death but may be considered hopeless as far as recovery is concerned. In this regard his condition is similar to that of the Quinn girl in New Jersey some years ago.3

Ad b. Since the patient is not at death's door the question becomes moot.

We must therefore conclude that Freehof's discussion and teshuvah , which deal with a goses, do not to apply to the she'elah before us. Rather. we deal with a different question: May a feeding tube be withdrawn from a patient who, without such action, might remain alive for an unknown time? The she'elah is therefore about the permissibility of euthanasia.

Euthanasia and Jewish law.

This question too has been discussed with both in traditional sources and Reform responsa.

A teshuvah by the CCAR Responsa Committee (1980) dealt with a patient who had sunk into a deep coma and was kept alive solely by artificial means. The Committee was of the opinion that it would be permissible to remove life support systems once all signs of "natural independent life" had disappeared and brain death, as defined by the ad hoc committee of the Harvard Medical School, had occurred. The ruling concluded by saying: "We would not endorse any positive steps leading toward death...We would reject any general endorsement of euthanasia..."4

This was in keeping with an earlier report to the CCAR by a special committee, chaired by R. Israel Bettan (1950), which studied the permissibility of euthanasia in general terms and, reaffirming the Jewish ideal of the sanctity of human life and the supreme value of the individual soul, considered euthanasia "contrary to the moral law." A spirited floor debate followed in which contrary opinions were brought forth. The Conference itself did not vote to endorse the report, but instead merely received it and referred it to the Executive Committee.5 This meant, in effect, that the report stands as the opinion of the Bettan committee but not as a resolution of the Conference. In that respect it has the same standing as a report of the Responsa Committee.

We are dealing with a patient who is neither dying nor even in a deep coma. On a greatly reduced level he still responds to some external stimuli. In all precedent considerations of similar conditions, the removal of the feeding tube would be seen as an act of euthanasia.

But what of the argument, contained in question 5 of the physician's letter, that, in the opinion of the family, there is no further "meaningful quality" to the patient's life, and that therefore the family would endorse removal of the tube? A more recent responsum by the CCAR Responsa Committee dealt with this very question (1985), when it addressed itself to the case of a person who was unable to communicate because a segment of the brain which provided intelligence seemed to be damaged beyond repair.

Judaism does not define human life only in terms of mental activity. Every person has been created in the image of God, and so even those individuals who may be defective...have always been considered as equally created in the image of God; their life is as precious as any other. It is necessary to guard their life and protect it just as any other human life. This is also true of an elderly individual who has lost some... mental ability or power of communication....6

The underlying concern of this teshuvah was that we really do not know what "quality of life" really means. Furthermore, we still have an incomplete understanding of what goes on in the mind of the paralyzed patient who is unable to communicate properly. We are prone to assume that he would not wish to keep on living and may in fact have talked about such a situation at some previous time (Doctor's question no. 4 ). It is indeed possible that he now wishes to die and then again, he may wish to live, either because he still hopes to recover or because he has an active mental life of which we know little. As long as this uncertainty exists we need not address the question of whether we would have a right to help our patient die if indeed he wished to end his life.

To be sure, there is also the emotional and financial drain on the family, a drain that is undoubtedly severe. But this responsum can hardly be expected to rule on a person's life and death on such grounds. The responsibility for the former remains the family's, and for the latter rests to a significant degree with society at large, which must provide a safety net for catastrophic illness.

In sum, since the patient is not dying the withdrawal of the feeding tube is not permissible in the light of Jewish tradition, as confirmed by precedent responsa. Though we have the deepest empathy with the unfortunate circumstances we have no choice but to confirm a larger principle.

Notes

  1. CCAR Yearbook Lxxix (1969) pp. 118-121, reprinted in full in American Reform Responsa, ed. Walter Jacob (New York: CCAR, 1983), pp. 257-260.
  2. Shiltei Ha-giborim, commentary on B.T. Mo'ed Katan, ch.3 (16b in Vilna ed., Alfasi).
  3. In that case a court permitted the parents to cease "heroic" measures. This was subsequently done, though intravenous feeding was not ended. It was expected that the girl would die shortly, but to everyone's surprise she lived on for some months, sustained merely by the feeding device.
  4. American Reform Responsa, op. cit., no. 79.
  5. Ibid., no. 78.
  6. Walter Jacob, Contemporary American Reform Responsa (New York: CCAR, 1987), no. 83.

If needed, please consult Abbreviations used in CCAR Responsa.