The process of aging – which unequivocally ends in death – is described in the book of Kohelet in a manner that remains steadfast with the medical and cultural perceptions of our time. Death of old age is not a sudden and abrupt event, and it is improper to focus only on the stage in which a person is classified as dead. Death is a process of system failure which begins naturally during “days of evil”, after which different aspects of full life slowly collapse, until returning of “dust to the earth” and the spirit “to God who gave it”. Throughout Tanach we find two narratives for this unique stage in a person’s life: on the one hand we are dealing with a process which is profoundly similar to that which is described in Kohelet – the ‘dimming’ of oneself; on the other hand, this life stage has tremendous respect for the wisdom of the elderly person and their life experience.
Thus, viewing this time period as an all-encompassing process is not innovative or surprising, and in early halachic literature we can find approaches to different states within this process. Halacha obligates giving respect to an elder and standing when confronted by them, as the verse states “you shall rise before the elderly and show deference to the old” (Vayikra 19:32), however this is mainly referring to the mitzvah of honoring one’s parents. It is important to emphasize, and this is what arises from the Torah SheBa’al Peh as well, that despite the general perception in society that the mitzvah of honoring one’s parents relates to how young children are required to act towards their parents, in truth this mitzvah also corresponds to the second half of life. The very fact that the Oral Torah demonstrates how one should honor their parents with the adage “what is honoring?… giving them food and drink, dressing them and covering them up, bringing them in and out [of the house]” (Kiddushin 31b) teaches us that this mitzvah deals with an adult taking care of their aging parents. Even the exemplary stories detailing how the Tannaim honored their parents deal with the adult stages of life and teach us the essence of the halacha and its expectations of a person towards their aging parents.
Alongside this, one cannot ignore the monumental changes in this domain since biblical times – in the context of medical knowledge, the world’s outlook, and the spiritual decisions of this time period. Regarding our knowledge, medical science has reached tremendous heights since the days of the past, and its lofty success brings with it a multitude of effects on the issue before us.
Firstly, life expectancy has considerably lengthened. Granted that in the beginning of the Torah we find descriptions of exceedingly long lifespans, however in Tehillim the poet determines “our years are seventy, and if one has strength eighty years” (Tehillim 90:10). In the Mishnah even later years are described – “seventy years old for fullness of years; eighty for strength; ninety a bent body; at one hundred, as good as dead and gone completely out of the world” (Avot 5:21) – however it is known that practically the life expectancy of the last centuries and millennia have been much shorter. The prolongation of life expectancy means that the time period that Kohelet describes as a process of darkening is longer, and there is a spectrum of conditions that a person can endure for years on end.
In addition to this, prolonging life strengthens two phenomena involving the ever-increasing divide between the body and soul: the collapse of the body until death, and the deterioration of the cognitive domain which at times can be totally disconnected from the physical. Kohelet relates only to the former aspect, and we do not see any relationship to the cognitive world. In Tanach in general – based on the medical practice that was commonplace at the time – the body and soul are synonymous with each other and from a medical perspective deteriorate together. In Tanach there are many descriptions of what happened to the biblical figures in their old age, and it is enough for us to note the visual impairment of our forefathers Yitzchak and Yaakov as well as the heat dysregulation of King David. Yet, none of these describe an impairment to cognitive abilities. Not only is this the case, but throughout Tanach we find that wisdom, proper counsel, understanding, and illuminating guidance to specifically correlate with the world of elderly. “Elder” in the Bible is a considered a distinguished descriptor: a person such as this is a man worthy of advising, providing words of wisdom, and gifting others with their life experience. This matter demonstrates the significant drawbacks of the second approach, which is becoming more prevalent in our generation: states where the body is functioning relatively well however one’s consciousness becomes demented, until they lose contact with reality (or when there is integration of both matters together, such as in Parkinson’s Disease, etc.). These are conditions where, in addition to the physical state of the person, they are unable to express the full extent of their Godly image, and at times are not able to make decisions for themselves or understand their state at all.
Finally, modern medicine can prolong this period in a variety of ways. Even when a person is gravely ill and even when they naturally would have passed away, medicine can enable the prolongation of their life – at times for an extended period. Many medical procedures – such as transplantation, mechanical ventilation, CPR, dialysis, use of an ECMO machine, and many others – were considered in the past as ‘reviving the dead’ and nowadays are an integral part of traditional therapy. Even in the world of medications, the various supportive therapies, methods to administer nutrition and fluids, and quality of life overall – all of these have had a drastic impact on the later stages of life.
Aside from the technological innovations that challenge the halachic world, there are also fundamental changes in society’s outlook toward these issues – and halachic authorities must express their opinion regarding these as well. It seems that the most significant changes to public perception that have occurred in the last couple of decades occurred in the domain of medical ethics. Even if in the past the medical community acted according to certain principles emerging from ethical reasoning, the days of medical ethics are not long-lasting and therefore one can follow with relative clarity after the progression of these values. The most fundamental principle of medical ethics has remained constant: do no harm (despite being mildly challenged in the world of medical experiments); yet the relationship between the other two primary principles demonstrates the difference in their gravity. While in the past the value of ‘sanctity of life’ (in this phrasing or another) acted as a central guide in determining the path of medical ethics, and practically granted a significant portion of the authority that the medical team holds, as of late the value of patient autonomy has become more prevalent and dominant. This value acts as the foremost principle of medical ethics principles accepted nowadays. This difference is expressed in powerful contexts – in legislation, clinical aspects, public perception, and practically in any domain where there are discussions pertaining to medical ethics. This is not the place to analyze the cultural reasons for this phenomenon and the weight of each of these reasons (whether dealing only with ethical perception or also risk assessment and fear of prosecution); and it is enough to relate to the picture that is being illustrated and is present in all of these discussions. One who analyzes the Patient’s Rights Law of Israel, for example, will find that this decision has significant impact, and this is also seen in other laws such as the Patient Nearing Death Act.The wishes of the patient and its perception are part of the halachic psak dealing with medical ethics as well, even if they did not exist in previous generations. The basis of this halachic determination was performed in different manners, ranging from the position that man is the owner of his body and one is obligated to ask for their consent to perform medical treatment, to the principle that ‘the heart knows the bitterness of the soul’ – i.e. the recognition that many times the patient is the best assessor of his medical state, or at least the fact that medical procedures performed against a patient’s wishes can cause greater damage due to the fact that they acted against his wishes. Even the authority the patient has to bring themselves into a situation of potential pikuach nefesh, such as undergoing a dangerous and difficult surgery, in order to be saved from suffering teaches us the place of consent and its importance.1
Practically, this matter is also connected to the fundamental shift that is occurring in the entirety of medicine’s perception. The need for ‘informed consent’ is not just a part of recognizing the value of human autonomy; it emerges from a perception according to which the healing process itself has changed. The doctor is not a professional who is called to repair that which is broken while the patient is just a subject of his work. The recognition nowadays that the patient is an integral part of the rehabilitative process, from taking part in the diagnosis, choosing appropriate methods of treatment for their situation from the various possibilities, up to the need to have their full cooperation in order for the healing process to be successful. From this perspective, there are not two different approaches, and no deliberation as to whether there is a need for the patient’s informed consent.
Next Chapter
Treatment of the Elderly and the Sick – “Until 120”? – Introduction and Table of Contents
For Additional Reading:
- Position Paper: Reducing Oxygen Therapy from the Ventilator of a Terminally Ill Patient
- Rabbi Cherlow: Can One Prioritize Vaccinated Patients Over the Unvaccinated?
- The Halachic Basis for the Patient Nearing Death Act
