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Good Afternoon:
Thank you for the honor and privilege of speaking before your august group today on the Jewish Ethical, Spiritual and Personal Considerations with Illness, Dying and Passing.
It has been quipped that Jews are just like any other people, only more so.
It has also been said, and not so much in jest, that if there are 3 Jews you will have 3 opinions. Sometimes even 4 opinions, if one of them has a multiple personality disorder.
And we have all read the story of Robinson Caruso and his man servant Friday. Well few know it was based on a true story of a shipped wrecked Jew named Rabinowitz Cohen and his servant Shabbat.
When they were finally discovered, the ship's captain asked what the 3 buildings were all neatly next to each other. Rabinowitz explained: "That one is my Synagogue. This one is Shabbat's Synagogue. And the third one is a Temple neither of us would be seen stepping into!"
As a rabbi, and a retired doctor, is it my job to explain all views to Jewish patients, so they and their families can make informed spiritual choices.
In using the word informed, I explain how these varied opinions in the different sects of Judaism came about.
Some may make sense to some, and some may be held together by strings dangling from heaven needing an extreme faith.
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.
Many times, when rabbis are available in the community, Christian ministers are used as chaplains, causing great consternation among Jews, even if left unspoken publicly.
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.
In the 1920s a Jew travels from his small Polish shtetl to Warsaw. When he returns he tells his friend of the wonders he has seen.
"I meet a Jew who had grown up in a yeshiva and knew large sections of Talmud by heart. I met a Jew who was an atheist. I met a Jew who owned a large clothing store with many employees. And I met a Jew who was an ardent communist.''
''So what's so strange?'' the friend asks . "Warsaw is a big city. There must be a million Jews there.''
"You don't understand,'' the man answers, ''It was the same Jew.''
A Rabbi on a hospital's or hospice'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 Germany 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 hospice's or 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, hospice or home bound, if away from family and their traditions.
The Hebrew faith is 4000 years old, but Judaism, born out of the ashes of the First Temple's destruction in 586 BCE, in Babylonian captivity, is 2500 years old.
Judaism eventually replaced Hebraism when the Second Temple was destroyed in 70 CE.
There are approximately 13 million Jews in the world, with about 6 million residing in the United States and 6 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 God, 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 God and modeling ourselves on God'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 God, "El na, refa na la; Please God, 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 electric candles, a mini bottle of grape juice, and a challah, and performing with them, a short Shabbat ceremony. I have also visited and read Psalms, and have just chatted, or held a hand.
On the Jewish Holy days, rather than sit in Synagogue, I go from Care center to Care Center conducting Jewish services. To see an Alzheimer's patient, awaken and sing along as a I chant the Shema is inspiring. Their Jewish neshemot , souls, are not lost, and their Judaism needs to be respected.
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 permit 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 enumerate 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 recommend 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 falsely 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 that 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
God to ''give me friendship or give me death." and God 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. His students prayed to God so that Rabbi Yochanan would die.
A man comes to the head of the Jewish burial society and he needs loan to pay for the funeral of his wife who has just died.
''But we gave you money to bury your wife three years ago,'' the heard of the burial society tell him.
''Yes, but I remarried.''
''Oh, I didn't know. Mozel tov!''
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 God.
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 God, 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 grave site 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.
However 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, developed in the first part of the 20th century, is that God gave a Jew
his body and his life, and only God can make the decision to take this life away, it is clear from the Sages and true Judaism, 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 an all important Jewish value, allowing one to break Shabbat or kosher to save a life, the dignity of a 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.
This reminds me of the man who goes to the confessional at the church and tells the priest that he is a 90 year old man, married for 70 years, and just made passionate love to a swim suit model.
The priest tells him to do various Catholic forms of penance.
The man says "I cannot. I am Jewish!".
The priest says: "Well what are you telling me about this for?"
And the little old Jewish man says: "You? I am telling everybody!"
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 Lord our God, the Lord is One), the dying one should be helped to
perform this last prayer.
In the Vidui, we say, "My God and God 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 God.
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 Bavli Sanhedrin 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 make the dying process all the more horrific .
There is a true story of Groucho Marx who was coaxed into attending a seance at a spiritualist's home. After two hours of Groucho listening to the malarkey of the spiritualist telling folks that "Aunt Bessie sends her love," and "Uncle Bob is doing well," the spiritualist finally asks Groucho if he has any questions for the ''medium angel.''
Groucho calls out: "What is the capital of North Dakota?"
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 an intelligent well studied Rabbi on a hospital or hospice or ethics committee brings true meaning to multi cultural sensitive issues.
Thank you.
I will now do my best to entertain questions.
Dr. Rabbi Arthur Segal
Rabbi Arthur Segal
RABBI ARTHUR SEGAL: Jewish Ethical, Spiritual+ Personal Considerations with Illness, Dying+ Passing
Acknowledgements to the writings of the Chofetz Chaim, Rabbi Moshe
Feinstein, H. Ross, and un-authored Web Sites.
