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Personal Considerations with Illness, Dying and Passing
Ten years ago, approximately 80% of American lives ended in hospitals. This
number has dropped by a small percentage with the role of Hospices. It has
been my personal experience that many Jewish families and their sick family
members are not informed of Jewish ethical, spiritual and traditional
considerations involved with illness, dying and death.
When these situations strike families, along with all of the other attendant
problems, many begin to grapple with these issues. Advice is difficult to
obtain, as their own Rabbis may be unschooled and cannot give these suffering
people information to make informed decisions. Worse, they may be 'told', or
'ordered' what they should or should not do, by a Rabbi, not of their sect
of Judaism, and then have regrets later, when they learn the facts and their
options.
When Rabbi Hillel, as recorded in Tractate Talmud Bavli Shabbat 31b, was
asked to define Judaism by a Roman soldier, while standing on one foot, after
summing it up, with the famous "What is hateful unto you, do not do to your
fellow, ma d'alach seni l'chavercha la ta'avid " he also stated, "Now, go and
study, zil gamur."
While Jews had the well earned reputation of being the 'people of the
Book,' for the past 60 years, most have not studied, and do not know basic
concepts, or think they do, acting on misinformation. A Rabbi on a hospital's
chaplain staff, and on its Ethics committee, can play an invaluable role,
especially one who believes that it is his job to inform Jews of their options, so
that they can make informed intelligent choices of what to do, or not to do.
With the advent of Reform Judaism in the early 1800s in German and its
spread to the United States, with more than half affiliated Jews, belonging to
Reform Temples, the variation of practices involving Jewish ethical, spiritual
and personal considerations with illness, dying and passing are quite varied.
With more than 60% of American Jews not being affiliated at all, the first
time they may face decisions of a Jewish nature with illness may be with a
hospital's Rabbi.
Further, with people traveling, families being split with parents in
retirement centers, or folks simply getting ill on vacation, Jews, who consider
themselves a people and tend to celebrate holy days, holidays, and Sabbaths in
groups, can feel quite isolated, in a hospital, if away from family and their
traditions.
The Hebrew faith is 4000 years old, but Judaism, born out of the ashes of
the First Temples destruction in 586 BCE, in Babylonian captivity, is 2500
years old. Judaism eventually replaced Hebrewism when the Second Temple was
destroyed in 70 CE.
There are approximately 13 million Jews in the world, with about 5 million
residing in the United States and 5 million in Israel. Judaism covers a wide
range of traditions and practices, from the unobservant and unaffiliated to
most observant Orthodox. Many families have generational gaps with enormous
divides in belief and religious practice. While it is impossible to pinpoint
any one type of Jew, it is possible to present Talmudic views and traditions
associated with illness, death and dying.
Visiting the sick, bikkur cholim, is one the highest mitzvoth and good deeds
one can perform. Bikkur cholim is an act which we are told in Talmud Bavli
Tractates Sotah 14a and Bava Metziah 86b, is performed even by G!d, who
visited Abraham when he was recuperating from his circumcision. When we perform
the mitzvah of bikkur cholim, we are acting in the image of G!d and modeling
ourselves on G!d's behavior.
Tractate Nedarim 39b goes so far as to say when we visit the ill, we take
away one sixtieth of their illness.
The shortest Jewish healing prayer on record is Moses' simple and direct
petition to G!d, "El na, refa na la; Please G!d, please heal her," spoken when
his sister Miriam was stricken with leprosy.(Numbers 12:13).
I have had wonderful experiences visiting Jewish patients and shut-ins
before Erev Shabbat, with two small candles, a mini bottle of wine, and a
challah, and performing with them, a short Shabbat ceremony. If candles are deemed
unsafe, two small electric ones will do for one's spiritual health. I have
also visited and read Psalms, and have just chatted, or held a hand. All of this
of course is with the patient's and/or the family's permission, as well as
the nursing staff and attending physician.
When a person's health is compromised, well-meaning gestures can sometimes
do more harm than good. To prevent this result, the sages offer guidelines for
bikkur cholim. They permits only relatives and close friends to visit the
patient within the first few days of his taking ill. Casual friends and distant
acquaintances should wait three days, so that the situation has a chance to
stabilize.
If the patient becomes critically ill immediately, however, everyone should
visit as soon as possible. There is no obligation to wait. But this again
needs to be done with the patient's and family's permission.
When a person takes ill, much is occurring on the physical plane. Much more,
however, is occurring on the spiritual plane, and the visitor must take this
into account also when he makes his visit. The Talmud teaches that the
Shechinah — the Divine Presence — rests at the head of a sick person. The visitor
is therefore prohibited from sitting at a level significantly above the
patient. One may sit on a chair next to the bed, even if it happens to be
slightly higher.
Equally important to understanding the obligation to visit the sick is
understanding the obligation to leave the patient alone if that is better for him.
The sages enumerates certain types of illness in which the patient may be
better off without personal visits. Someone with digestive problems who is
unable to control his elimination processes is one such case because of the
embarrassment he may have. Someone with severe headaches or eye problems, or
someone for whom speaking is difficult, may also in some cases be better off
without personal visits.
This does not mean, however, that such people should be left alone. The
rabbis recommends visiting outside the patient's room, inquiring of his relatives
or caretakers about his condition so that he knows someone is concerned. The
message should be conveyed to the patient that his friend has come and asked
for him, is praying for him and willing to help in any way that is
appropriate.
Even when a person is in no condition to accept visitors, the knowledge that
others care about his well-being is as vital as ever. A person may not want
others to see him in his weakened state. He may not want to feel obligated to
carry on a conversation. He may not want company, but more than anything
else, he does not want to be forgotten.
"The value of human life is infinite and beyond measure, so that a hundred
years and a single second are equally precious." However the notion that
traditional Judaism does not consider quality of life as a factor in administering
health care is false. "What might seem a poor quality of life for some may
be acceptable for others," thus discounting quality of life as a factor with
respect to health care treatment .
The belief that one cannot use low quality of life as an excuse for
withholding treatment or even hastening death is not Talmudic, although, you will
find many rabbis, stating this very untrue fact. The true Talmudic Jewish view
of health care is not in contrast with the American system that takes
quality of life as a primary consideration in making end-of-life patient care
decisions.
The story is told in Talmud Tractate Ketubot 104a and Bava Metzia 85a how
Rabbi Judah ha Nasi, the redactor of the Mishna, was very ill, and was in so
much pain, that putting on and off of his tephelin was a hardship. Yet his
students and other rabbis stood outside his window praying for him day and
night, to get well. Finally, his nurse maid, threw an urn out the window, making a
noise, and momentarily stopping the rabbis from praying. At the moment, the
angel of death, mercifully took Rabbi Judah to Heaven.
In Tractate Ta'anit 23a, Rabbi Choni the Circle maker, who worked miracles,
slept for 70 years. When he awoke, he came to the Talmud academy. He heard
students speaking of his wonders and of his scholarship. He declared who he
was and no one believed him. His quality of life became so bad, that he begged
G!d to ''give me friendship or give me death." and G!d took him.
In Tractate Sotah 46b, the sages record how in the town of Luz, the scholars
were so righteous that the angel of death would not enter and men could live
forever. However, as they aged, their quality of life was horrid. They would
go outside the gates of the town, for the angel of death to take them and
let them die.
In Bava Metzia 84a, Rabbi Yochanan was so distraught over the death of his
brother-in-law , friend, and study partner, that he could not be taken out of
his depression.
_http://rabbiarthursegal.blogspot.com/2008/01/talmud-discourse-wasted-friendship.html_
(http://rabbiarthursegal.blogspot.com/2008/01/talmud-discourse-wasted-friendship.html) . His students prayed to G!d so that Rabbi
Yochanan would die.
The most telling story is of Rabbi Chanina. He was caught by the Romans
studying Torah, which was forbidden. His punishment was being burnt to death. The
Roman executioner, to be cruel and slow his death, wrapped him in a wet
Torah and wet wool. His students urged him to open his mouth and breath in the
fire to die quickly. Rabbi Chanina said he could not take away from him that
which was given to him by G!d.
The executioner, realizing he had a true holy person, asked if the rabbi
could, in today's parlance, put in a good word for him with G!d, if he would
take away the wet Torah and the wet wool, which would hasten his death. This
Rabbi Chanina agreed to, as taking in fire into his mouth was an act of
euthanasia, while allowing the removal of the wet wool and wet Torah, was withholding
measures that would prolong life. (Talmud Bavli Tractate Avodah Zarah
17b-18a)
When a patient is expected to die in 3 days or fewer, he is termed a goset
in traditional Jewish sources. Despite this distinction, a goset is still to
be treated as a living person in all respects. In fact, Jewish law does not at
all connect the goset state with regulations regarding treatment of the
dead. It is prohibited to perform any traditional death preparations on a goset.
For example, one must not "tie his jaws, anoint, wash, plug open organs,
remove the pillow from underneath him, or place him on the ... ground," as one
would do as part of Jewish rituals for a deceased person. Further, society may
not act in anticipation of the goset's death, hence a prohibition against
arranging for a coffin or a gravesite before the actual arrival of death.
Interestingly, the maximum duration for which one can remain in the goset state is
3 days. After that period, the goset is considered to be dead, and his
relatives must mourn for him, since death is assumed to be 3 days or closer when
one enters the goset state. (Talmud Bavli Tractate Arachim 2a et.al)
In modern times one is dependent on a physician to determine if one is a
goset. Prediction of such a state is increasingly difficult with modern
medicine. "In the light of modern technology, does the goset state apply to a
patient who would have died without life support, or does it only apply to a
patient who will die immediately, even with life support?" The answer depends on
the purpose of the treatment. Is the patient receiving artificial life support
to improve his chances of survival, or merely to prolong the dying process?
Should the definition of a goset be amended to one for whom life support
only prolongs his last days, without setting a specific number of days?
Jewish law contains several principles regulating the treatment of a goset.
The foremost of these is the idea that death should approach according to its
own schedule. No one should disturb the goset from maximum comfort for fear
of either hastening or preventing the natural onset of death. One may,
however, remove barriers to death's natural approach. In addition, health care
professionals are not obligated to perform any action which, according to Rabbi
Moses Isserles, the 14th century sage, "constitutes a hindrance to the
departure of the soul."
This can be interpreted into modern health care as a prohibition against
carrying out unnecessary tests on an individual who is in the midst of his final
days. For example, once an individual is no longer receiving curative
therapy, he should be allowed to "rest in peace" without being subjected to having
blood samples drawn, and extensive monitoring. The concept of a 'living will'
setting down one's choices if one becomes terminally ill, was already laid
down for a Jew in the Talmud 2500 years ago.
The Talmud also speaks of the terefah, one who is critically ill, but not
within 3 days of death. The terefah is, like the goset, ill from a "fatal
organic disease, incurable by humans.".However, unlike the condition of goset,
time does not constitute the primary factor in defining a terefah .
A terefah is distinguished from a goset in terms of the treatment he must
receive. One should strive only for comfort and the natural onset of death when
treating a goset, a terefah must be treated "exactly as any other patient
would be. Full resuscitative measures must be carried out, even if they will
prolong life only for a short while."
When a Jew is considering treatment decisions for a dying family member,
most patients today are terefahs. Although a terefah may become a goset he
deserves the fullest treatment possible up to that point.
The above discussion can be distilled to explain to family members of the
Jewish view of the importance of life and treatment, but of the importance of
the quality of life as well. While the Orthodox view is that G!d gave a Jew
his body and his life, and only G!d can make the decision to take this life
away, it is clear from the Sages, that Jews have always had freedom of choice in
the matter.
As far as euthanasia, the Greek word for a 'good death,'' the Talmud
teaches that this along with suicide is not allowed. Active euthanasia, like
removing a pillow from under one's head is not allowed, as this in ancient times
would be disturbing to the patient and hasten his death. (We are not to
confuse modern nursing care and think this means Jews want to lie in dirty sheets
and on dirty pillows, which could cause infection and hasten death.) On the
other hand, one is allowed to stop the noise of a wood chopper from outside a
dying person's window, as this is inactive euthanasia, as the noise kept the
soul occupied and kept death from occurring.
A Midrash reveals a similar story, in which prayer is the impediment that is
removed to allow a person to die. It happened that a woman who had aged
considerably appeared before Rabbi Yose ben Halafta. She said, "Rabbi, I am much
too old, life has become a burden for me. I can no longer taste food or drink,
and I wish to die." Rabbi Yose answered her, "To what do you ascribe your
longevity?" She answered that it was her habit to pray in the synagogue every
morning, and despite occasional more pressing needs she never had missed a
service. Rabbi Yose advised her to refrain from attending services for three
consecutive days. She heeded his advice and on the third day she took ill and
died. (Yalkut Shimoni)
Withdrawing artificial life support in today's medical milieu is determined
by brain function via the EEG. Jewish thought is if the person can maintain
life independently, than medical care should be provided. With our elderly, if
one is frail, one may wish to live out their days with palliative care and
avoiding stressful invasive procedures. While life is all important Jewish
value, allowing one to break Shabbat or kosher to save a life, the dignity of
person and their personal shalom, peace, is highly valued as well.
A common misconceptions among many Jews is that of 'last rites.' They know
that Christian sects have them, but if asked, will say that Jews do not. This
is untrue. Talmudically Jews do confession (Vidui) daily and certainly upon
death.
I have been with dying Jews, who swore they were atheists or agnostics or
secular humanists, who when they knew their time on this earth was coming to
an end, wanted Jewish last rites. We never force this on anyone. As mentioned
from the start of this discourse, we teach and suggest this as an option that
is available. Many do not know of it.
If it is possible to say the Vidui, before death, and the Shema, (Hear o'
Israel, the L-rd our G!d, the L-rd is One), the dying one should be helped to
perform this last prayer. In the Vidui, we say, "My G!d and G!d of my
ancestors, accept my prayer. Do not turn away. Forgive me for all the time I may
have disappointed You. I am aware of the wrongs I have committed. May my pain
and suffering serve as atonement. Forgive my shortcomings, for against You have
I sinned. May I now live with a clear conscience and in accordance with your
will. Send a refuah shlemah, a complete healing, to me and to all who
suffer." We ask for healing and we are prepared for death.
The Talmud tells us not to fear death, because it is ''as easy as taking a
hair out of milk.'' At the moment of death, the principle of Kavod Ha Met,
respect for the dead, goes into action, and swiftness and simplicity guide us in
bringing the spirit home quickly as possible in its return to G!d. Those
present at the moment of death say the very words that most challenge our
hearts: Baruch Dayan ha Emet, "Blessed is the true Judge." The eyes of the deceased
are closed, a candle may be lit, and we may now ask the dead for forgiveness
of any harm or discomfort we may have caused them during their lives.
Jewish law prohibited organ donation because a goset would be kept alive
past his natural time of death to harvest the organ.This is no longer the case.
Organ donation is compatible with Judaism as "to save one life is to save the
whole world" (Talmud Tractate 37a). Because of some believing in corporal
resurrection, some Jews wanted their bodies left intact. In reality, a study
of Jewish law finds this to pertain to limbs containing bone and muscle and
not the heart, lung, kidney, cornea, et. al. Here is another instance where a
learned Rabbi can teach and give options so that informed decisions can be
made.
Though not every Jew is comforted by the presence of a rabbi, many who would
not otherwise consult a chaplain do find his or her presence helpful in
confronting death and dying. The rabbinic chaplain can be an expert resource in
helping to shape guidelines for incorporating spirituality into the basic plan
of a Jewish patient's care. In addition, nurses may turn to the Rabbinic
chaplains for individual or team counseling when coping with the stress and
grief that are a part of working with dying Jewish patients and their families.
Every Jewish family and patient is unique . Some will reject everything that
traditional Jewish law teaches and others will embrace every tradition as a
means of coping with death. For the majority of American Jews, Judaism is
not sitting upon a single set of "rules." This may be confusing to nurses and
physicians who come from backgrounds with firm concepts regarding death and
'after-life.' Jewish tradition does not define a clear concept of afterlife,
but only calling it Olam ha Ba, the world to come. This sense of uncertainty
can makes the dying process all the more horrific .
Asking Jewish patients and families to explain their religious practices and
wishes helps a rabbinic chaplain develop care that meets each family's
spiritual needs in a culturally sensitive fashion. Having a Rabbi on a hospital
ethics committee brings true meaning to multi cultural sensitive issues.
Dr. Rabbi Arthur Segal
Acknowledgements to the writings of the Chofetz Chaim, Rabbi Moshe
Feinstein, H. Ross, and un-authored Web Sites.
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