Treatment of the Elderly and the Sick – “Until 120”?

Rabbi Yuval Cherlow

Chapter 7 – Palliative Care

Palliative care is the intermediate stage between the attempt to heal a condition (or at least bring it to remission, an absence of symptoms) and giving up on all treatment and waiting for death. The fundamental principle of treatment such as this is directed at providing quality of life for the patient and improving their current condition as much as possible. Palliative care deals mainly with symptomatic treatment – for pain, weakness, and consciousness – and does not address the underlying disease and its etiology.

The status of palliative care – and whether it is appropriate for a patient and their family to be referred to this treatment and recognize that at a certain stage they should focus on the quality of life of the patient – are also dependent on the public perception of the ‘Jewish position’ on the matter. The reasons for the importance of the Jewish perspective in this context are varied. First, a large portion of the Israeli population feels obligated to halacha to some degree and defines themselves as ‘Masorti’ (Traditional), if not ‘religious’ or ‘Chareidi’. Secondly, as death approaches, and from the moment where it is considered part of the decision-making process, the wishes of the family and the patient not to do anything against God is prominent, for it is possible the patient will greet Him shortly. On top of this, one may add the fact that the laws of the State of Israel which touch on these topics – such as the Patient Rights Law, the Patient Nearing Death Act, The Determination of Respiratory-Brain Death Law, etc. – are heavily influenced by Jewish law. Therefore, many request to make a decision in line with the halachic or ‘Jewish position’.

Also here, as described earlier, the widely perceived notions of the population regarding the established ‘Jewish position’ are – naturally – based on false perceptions and not on analysis of the essential principles. As previously stated, there is a widespread notion that Judaism requires prolonging a patient’s life at all costs, without considering their quality of life, suffering, wishes, and desires. Adages such as “you do not know the value that a minute of life has in the eyes of God” or “Life does not belong to man – and therefore he is not permitted to forego it” are exceedingly present in the public domain; practically, this is one of the reasons Tzohar established the free service ‘Tzohar Ad 120’ which assists families in making these difficult decisions and ensuring the right approach.

Yet, in light of the discourse brought earlier, we have begun to recognize palliative care. The different sources mentioned, as well as many additional sources that will be brought later on in this compilation, bring up many practical issues regarding palliative care. First and foremost: at what stage is it permissible to stop fighting for recovery and turn to palliative care? The concepts used in law (such as the Patient Nearing Death Act) are not halachic concepts and are thus not able to assist us in the halachic discussion. Halacha uses different terminology (mainly the terms ‘temporary life (chayei sha’ah)’, ‘actively dying (goses)’, etc.) and requires defining the medical condition that allows for removal of preventative objects delaying death, and even prior – the condition in which it is permissible to deal with quality of life and not recovery. These issues are present whether the patient is able to express their wishes (or when he has an advance directive), and whether he is unable to do this and those around him (the family, medical team, ethics committee, and at times the court) are required to estimate his wishes.

Beyond the practical difficulties involved in making these decisions, it is extremely difficult to decide from a psychological standpoint, well demonstrated by the difficulty of agreeing to donate organs. Vital organ donation is performed only when brain death has been determined, yet the body systems are still artificially functioning via technological processes. The family around the bed of the deceased see that the patient’s body temperature is normal, the heart is beating, the oxygen saturation in the blood is normal, etc., and it is difficult to accept that he is practically dead and that artificial methods are enabling this. Similarly, it is very difficult for the family to let go and agree that treatment of a terminally ill patient will be focused on ensuring quality of life and not on prolonging it. Despite this difficulty, at times this is the proper thing to do.

Additional approaches to halacha’s perspective on palliative care are connected to what medical practices are permitted and prohibited in this treatment plan. An example of this paramount discussion is the issue of administering painkillers that can have a negative effect on the patient’s outcome: on the one hand we are dealing with a vital need in the field of patient wellbeing and we are at the stage where this is permissible; on the other hand, we are dealing with actions that can be considered actively shortening a person’s life, which as stated are unequivocally prohibited. The issues are similar from the reverse perspective: what practices are considered interrupting the death of a person and are prohibited to perform? 

The very existence of these discussions is evidence of the culture of divisiveness in Judaism, and it is difficult to speak in the name of ‘halacha’, for there is no person who is qualified to represent the exclusive position of halacha. However, one can definitively say that the familiar statements of “life does not belong to us” are only relevant when dealing with active procedures that shorten life (which are prohibited not only be halacha but also legally), yet they are not sufficient to obligate one to continue to suffer and not allow them the passage into palliative care. 

One must add to all this a complete set of literature supporting the underlying foundation of palliative care. The accepted Jewish opinion relating to extreme suffering was expressed by Rebbe Yochanan already in the first pages of the Talmud Bavli: “not [suffering] and not their reward [is worthwhile to endure]” (Berachot 5b). We do not have a religious culture which values pain and sees positive value in maintaining it. When suffering comes upon a person against their will – one should of course not ignore it, but a person should always choose not to suffer when possible. Humanity and compassion are an integral part of the proper approach to distress. In Talmudic literature situations are described where people even prayed for redemption from suffering. One of the most dramatic accounts deals with two brothers-in-law – Rebbe Yochanan and Rebbe Shimon Ben Lachish. Rebbe Yochanan went mad knowing that he caused the death of his brother-in-law, and the Sages prayed for his death (Bava Metzia 84a). An inseparable part of the halachic world deals with ‘human dignity’ (Kavod HaBriyot), and the attention one must pay to a person’s condition. All these provide a large amount of support towards palliative care and the consideration of primarily improving the patient’s wellbeing. From a halachic perspective we can see the recognition of the paramount importance of approaching both aspects of treating a terminally ill patient. On the one hand, one should strengthen the fortified wall prohibiting active procedures that shorten lifespan, for halacha strongly disagrees with the notion of turning taking a life into a legitimate medical procedure. On the other hand, we are obligated to strengthen the recognition of the importance of deciding to move to palliative care, which deals with improving the patient’s wellbeing, their dignity, remaining steadfast to their wishes, and processing death. The recognition of the stage where we step back and see our primary mission as doing all in our power to prevent suffering and pain and becoming partners in the departure from this world is an important message that has a basis in the world of Jewish law.

Next Chapter

Treatment of the Elderly and the Sick – “Until 120”? – Introduction and Table of Contents

For Additional Reading:

  • Palliative Care, Nutrition, and Making Decisions in Cases of Dementia – The 3rd Conference on Dementia and Jewish Values 
  • The Jewish Perspective on Palliative Care
  • At the End of the Road

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