“And there is no control over the day of death” – from the day that death was decreed upon the world, one of the most influential foundations of all of human life has been hidden in the knowledge that one’s days in this world are limited and he will not be able to do away with the notion that one day he will depart from this world and will find his place in the next. The influence of the awareness of the temporary, impermanent aspects of life as well as its finality is powerful, and many consider it one of the central creative motivators of man, and a motivator for his desire to bring children into the world. Not only is a person not able to prevent their death even when they greatly wish to prolong their life, halacha forbids impacting the day of death by shortening life and determines that inflicting one’s hand against their soul is part of the prohibition of murder. Man’s natural death is determined by God.

Between the prohibition of shortening life and the inability to prolong it is an ever-growing domain. The tremendous success of medicine, by the grace of God, allows us to perform many things that were not possible in past generations. A variety of treatments, ventilation capabilities, connection to a heart-lung machine, surgeries, transplantations, nutrition in a variety of manners, dialysis, etc. – all these and additional technologies allow us to have a tangible effect on the process of death. The Israeli public was exposed to these capabilities through the actions of the medical system after Ariel Sharon underwent a severe stroke event, and this was only a thin sliver exposing the many medical possibilities available. The range of possible medical procedures brings about many halachic and ethical questions at the stages which a person crosses before their death.

The great success of medicine in prolonging life expectancy has brought about, amongst other things, more pronounced situations of divide between the body and mind. At times consciousness is at its strongest, however the body is failing, at a much faster pace and for a much longer period than Kohelet describes at the end of his word; at times the situation is reversed – the body continues to function at full capacity, but the mind has become demented, and the person sinks into non-communicative isolation from the world. The number of families dealing with the issue of older parents and the need to make difficult decisions grows by the day. I estimate that there is no rabbi in Israel who hasn’t been asked questions in these fields, and from my personal experience as someone who has dealt with these topics an innumerable number of times, I have learned that we are dealing are huge populations. This is an inseparable part of the blessing of medicine.

In the past it was generally accepted that halacha’s response was uniform: there is an obligation to fight for one’s life until the last breath, for we do not know the value of each minute of life, and we are only entrusted with our lives, but they do not belong to us. Not only this, but we find authorities who also require prolonging the life of a patient against their wishes as part of the obligations a person has within halacha. The large shift in this halachic perception can be found in the words of one of the greatest halachic authorities of the past generation – Rabbi Yaakov Kanievsky zt”l, who describes with sincerity the opposition to this assumption:

“Regarding the basis of the fundamental principle that whatever one may do to prolong the life of a patient (even if only temporarily) must be done – the truth is that I have also heard this saying in my childhood, and I did not know if it was reliable. But in my eyes this matter requires great analysis, for in Yoreh Deah article 339 it is explained that it is permitted to remove an object preventing the death of a patient, and only active procedures are prohibited to perform. Therefore, I do not seemingly find a prohibition in passively abstaining (instead of adding on suffering) [from treatment], and just the opposite: one should learn from this to abstain from [treatment] […] However, anyone who is living only temporarily life and there is no actual life-saving [treatment] is comparable to the status of a dying person (גוסס), for a dying person is considered alive in all manners, and all of this requires great analysis (Kiryana DeIgrita, Letter 190).

Rabbi Kanievsky zt”l refers to the opinion of the Rema, who instructs that the actions which one is prohibited to perform are ones that expedite the death of the person and in the same halacha rules that it is prohibited to prevent a person from departing this world, and we even remove the items preventing him from doing so. We are not dealing with a contradiction within halacha, but the need to define the line between what is prohibited to perform that expedites death, and what is prohibited to perform in order to prevent it. However, this line is not entirely clear, and many of the Shulchan Aruch’s commentators discuss this issue.

The “Kehilot Yaakov” is not a sole opinion in this ruling, and many Torah greats permit raising one’s hands and ceasing the fight for one’s life in certain conditions. One must be precise in his wording and note that it is possible that from a certain point onwards one is not only exempt from fighting for life – it is also prohibited to do so, and one should let the person pass comfortably and with dignity. He also brings the fact that he knows that it is accepted not to believe there is such a situation and that one must do everything possible, but with great halachic bravery he challenges what has been accepted by other authorities. As a side point, I will note a phenomenon that requires discussion in and of itself: alongside our basic conservativism in the halachic world, everyday life, synagogues, marriage, and divorce, kashrut, and conversion, etc., there are powerful changes occurring in the world of halacha regarding genuine cases of life and death, and it is possible that they are dependent on each other: the capability to do this is rooted on the sturdy, steadfast branch of halachic tradition and conservative continuity.

Halacha is presented, however, with a perplexing challenge: on the one hand, it fights the ever-growing societal perceptions in the world that refer to themselves as liberal, allowing active shortening of life. In some countries, we are dealing with “death tourism” and the ability granted to physicians to assist in the murder of a person requesting this be done to them, when certain condition have been met. In other places it is permitted to disconnect a mechanical ventilator, etc. Halacha prohibits all of these and objects to these actions with full force, seeing them as murder. As part of the struggle against this, we need to abstain from using terminology such as “compassionate euthanasia”, for these words can soften the halachic and ethical meaning of the action.

On the other hand, just like what we have done in the field of organ transplantation, there is a need to change the false perception of halacha. In the past, the perception of halacha was that organ donation is prohibited in all circumstances and situations, for brain-respiratory death is not recognized by halacha. However, in the year 5747, the Rabbis Avraham Shapira zt”l and Mordechai Eliyahu zt”l ruled that halacha does indeed recognize brain death, if medicine follows a certain procedure, and thus began a long journey ending with many rabbis from our Religious Zionist world calling for organ donation from the deceased, despite the fact that other rabbis believe this matter to still be prohibited. Similarly, we find ourselves now faced with decisions regarding man’s journey before death. It is our obligation to change the false perception of people regarding the halachic opinion towards stopping treatment in certain circumstances. 

Halachic decision-making in these topics is very complex, for we are dealing with different layers which join to form a full picture. First and foremost, as the Chazon Ish teaches the methodology of halachic decision-making, one must clarify the facts of the case: what is the patient’s condition? What is his prognosis? Is the assessment that he is suffering? Is he expected to recover from ventilation, etc.? The factual items are not medical alone. Many rabbis find importance in clarifying the patient’s wishes as well – did he leave instructions, and what is the viability of these instructions? Have the family members discussed this and his opinion been presented in this conversation? This is also an opportunity to encourage signing for “appointment of a legal guardian” in order that the discussion of who will make the decisions in a situation where the patient is unable to make them independently – will follow the wishes of the person, not fights amongst the family. The legal path now available to any person for providing different directives is highly recommended, and it is proper to perform this in order to make the decision-making easier in situations where the patient themselves cannot do it alone.

And the halachic clarification must be performed based on these facts: if the halacha permits, or even obligates, not performing CPR in certain situations; if halacha prohibits, permits, or even obligates abstaining from mechanical respiration; is it permitted to lower the dosage of supportive medications; how should one provide nutrition to a person who is unable to eat independently, yet the assessment is that insertion of a nasogastric tube is not possible and not desired; is it permissible to pray for the death of a person, and so on and so forth. These are many, varied halachic questions that we are faced with as we depart this world. The world of halacha deals with them and presents the proper path to take. As in all halachic topics, there are also disagreements, however slowly a halachic consensus is forming amongst the majority, which stands the test of authoritative, halachic sources as well as the test of logic.

And when we reach the practical sides of the ruling – it must be done personally and uniquely for each patient. We are dealing with integration of the medical team, family, and patient representatives, halacha, and also recommended to include counseling and therapeutic professionals, allowing for an internal familial discussion. An inseparable part of the ability to deal with the condition is ensuring a mutual understanding that everyone – the medical team, all the family members, etc. – wants what is best, for without this trust one cannot do that which is truly best for the patient.

This matter is not simple in the slightest. The family is currently in significant distress, due to the great emotional toll involved in making each decision. At times it seems that they forget that the factors that should be considered must be for the patient’s wellbeing and not what the family feels they want for their own sake. This conflict of desires can appear in two opposing directions: a family who, God forbid, wants the death of their relative, because it is very difficult for them to continue with the current situation and the burden they are carrying; a family that, God forbid, is fighting hard for their relative’s life, for they want “to know that they did everything” in order to clear their conscience, and doesn’t wonder if the best thing for the patient is to specifically let them pass with dignity and peace, without continuing to suffer without a purpose, something no one would wish upon themselves.

We do not like to speak about death. There are even those who see this as prohibited, due to the evil eye (ayin hara) that this casts forth. The topic is also very unsettling and threatening. Of course, we do not want to be seen as one whose heart is stone, and we don’t want, God forbid, to cast away the burden of taking care of parents or to prefer the worldview of shortening life. However, it is proper to be introspective in this topic from the other direction: an inseparable part of life is death; a happy marriage generally ends with one of the parties as a widow/er, for we do not die together; specifically facing the topic of death, preparing for it, halachic and moral decisions, creating a dynamic for making decisions when the time comes – is a more deliberate approach, which can bring more light of life into the world.