Know end-of-life issues in the Jewish religion

Judaism is practiced in many diverse ways in the United States, yet sometimes even non-practicing Jews still observe Jewish laws at the end of life, suggests Barry Kinzbrunner, MD, chief medical officer for VITAS Innovative Hospice Care in Miami.

Kinzbrunner, who is also a rabbi, was trained as an oncologist; however, he says that in the last decade he has become more interested in spiritual care and diversity "as most people have, and have [chosen] my interest in Jewish medical ethics based on my own faith, in trying to understand, especially, how the people in my faith who are traditional really approach end-of-life care."

"We have traditional, Orthodox Jews who are people who basically believe that God revealed himself to Moses . . . who gave the 10 Commandments, and in fact, gave the entire Five Books of Moses, which are the basis for Jewish law. And everything that religious Jews do is based on that Jewish law that has since been interpreted over the generations," Kinzbrunner told an audience at a conference sponsored by the National Hospice and Palliative Care Organization.

According to Judaism, Moses also provided additional information, which the religion calls the "oral law." That law then was thought to have been passed down from Moses to Joshua and from Joshua to the prophets, and it has gone through several iterations since, resulting in the "Mishnah, which became the Talmud, as well as a table of law called Shuchan Aruch," he explains.

"So, that's where we get the Jewish legal system in a sense, and for Orthodox Jews, they follow that law, and therefore, they do everything that God wants them to do based on that law," he says. "Now, if you move toward Conservative and Reform Judaism, they have modified and reinterpreted what they believe Jewish law means in the context of a more modern world," Kinzbrunner notes. "When we talk about Jewish medical ethics, in very many ways they tend to be more in keeping with the secular points of view when there are differences between how they view things and how traditional orthodoxy views Jewish law."

Secular values defined by Jewish law

In secular medical ethics, the "primary core values" are those of autonomy, beneficence, nonmaleficence, and justice, "with justice divided into social and distributive justice," Kinzbrunner says.

"In Judaism, what the rabbis have done -- and in the modern context of medical ethics -- is people have interpreted these ethical values according to their understanding of Jewish law and given them Jewish definitions based on Jewish law," he says.

A Jewish person who is traditional therefore makes decisions on whatever they do, which includes healthcare decisions, that are "consistent with God's law, with whatever God wants him or her to do," Kinzbrunner says.

Many people, however, do not understand what it is that God would have them do or the decisions they should make, particularly at the end of life, he says. As a consequence, Kinzbrunner maintains that patients and their families in such instances "need the advice of a rabbi who is an expert in God's law to guide them." This place is where the core secular values as defined by Jewish law come into play in patients and physicians making healthcare decisions. One of the core secular values, nonmaleficence, essentially means avoidance of harm. The Hippocratic writings for physicians states that physicians must "do no harm."

"The secular ethicists question how much of a role it plays, because most treatments have risks," he says. "There's always risk, so therefore, are we really following the "first, do no harm" [obligation]? And the answer is really no."

As with all hospice care, in Jewish law, decisions are made on a case-by-case basis, he says. "So, where there are rules or the [cases where] we say, 'This is what the rule is,' there is always the ability to make exceptions to that rule," Kinzbrunner notes.

But end-of-life care and end-of-life decision-making "only applies to patients who are terminally ill," which has been determined as those with a year or less to live.

Another end-of-life definition in Jewish law is called the goses. "A goses is somebody who is actively dying; the hallmark in physical findings is . . . the death rattle, the upper airway secretions." In the Talmud, it was defined as "the last three days of life," Kinzbrunner says. "The important thing about a goses is that you're not allowed to do any interventions other than basic needs," such as to those necessary to keep a patient clean and dignified. Also, in the Talmud, Jewish law says that if someone touches a goses and the goses dies, "you're responsible for the death," Kinzbrunner explains.

"Withdrawal of life support and other interventions [are] generally not permissible, according to Jewish law, unless the intervention is clearly viewed as an impediment to death," he says. "... Food and fluid, in traditional Judaism, are considered basic needs by most rabbis, even when it's delivered artificially."

However, he also notes that if food or fluid would be provided without benefit or it is actually harmful, "then you might be able to avoid artificial nutritional support after consultation with the rabbi. And one may not forcibly feed a goses, because the putting in of the line or tube is a medical act, and you can't do that to a goses."