Should Terri Schiavo Live or Die?
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Should Terri Schiavo Live or Die?

Should Terri Schiavo Live or Die?

It is a denial of the Jewish ideal of the fundamental value of life that drives the forces that wish to remove Terri Schiavo's feeding tube.

by

The Terri Schiavo saga in Florida, where a patient in a vegetative state has recently had her feeding tube reinserted by order of the legislature and governor, reminds us of the reality of modern life. An inescapable result of the extraordinary technological progress of the last several decades has been that critically ill patients who would have died early in their illnesses, often in the relative comfort of their homes, are now kept alive much longer in hospitals, often suffering great pain.

In addition to the component of human misery involved in discussions of medical treatment of the irreversibly ill, the skyrocketing cost of healthcare, particularly the large percentage of healthcare consumed in the last six months of life, have led to calls to limit "futile" treatments. Today, when there are almost limitless therapeutic options but limited economic resources, society may not be willing to provide "useless" therapies to patients who will not benefit.

The Torah teaches us that every moment of life is intrinsically valuable; life itself is never futile.

In secular ethics discussions, medical futility encompasses several issues only loosely related to one another. Futility of treatment is often confused with "futility" of life. The Torah teaches us that every moment of life is intrinsically valuable; life itself is never futile. Rabbi Shlomo Zalman Auerbach, a leading halachic authority of the past generation, points out that we have no "yardstick" by which to measure value of life. Even for a deaf, demented elderly man, incapable of doing any mitzvot, we must violate the Shabbat to save his life.1 It is not within our moral jurisdiction to decide what quality of life is "not worth living" and therefore unworthy of treatment.2

The only components that are open to halachic debate are those involving futility of treatment. From a Jewish perspective, we must ask whether the physician may withhold, and whether the patient may refuse, futile therapy.

MEDICAL FUTILITY IN HALACHA

The intrinsic value of life does not necessarily imply that every patient must be treated in every instance. Nor does this mean that we do not appreciate that death may be preferable to a life of extreme pain.3 As Rabbi Auerbach writes, we may pray for the death of a terminally ill patient4 who is in great pain, but we must never do anything to hasten his death. He also recognizes that inaction is sometimes the best approach when life is "bad and bitter."5 Despite the obligation to treat even the sickest patients, it is well established that patients do have limited autonomy in refusing treatment for terminal conditions, particularly when they are in intractable pain.6

Medical futility is a recognized concept in Jewish law.7 A treatment that will not reverse the condition to which it is being applied, even if successful, is an example of true medical futility. Performing CPR on a terminally ill patient whose heart has stopped -- not because of a cardiac abnormality, but because the patient has reached the point at which his body can no longer support life -- is truly futile and may be withheld.8 Reviving the patient may be possible, but cardiac arrest will almost certainly recur within a very short time.

This can be contrasted with performing CPR on an otherwise healthy individual who develops an irregular heart rhythm that will result in sudden death. If resuscitation is successful, the arrhythmia may be treated and the patient may live a long life. It goes without saying that this second patient must be resuscitated because the therapy is helpful and sometimes even curative.

ON THE DEATHBED

But, independent of the aspect of futility, in the case of the first patient, halacha would likely dictate that intervention is forbidden because of the principle of "goses" (the moribund patient). A patient on his deathbed, for whom no cure is possible and death will inevitably occur within three days, may not be disturbed at all and must be allowed to die.9 The Mishna compares the life of the goses to a flickering flame that will be extinguished if even slightly disturbed.10

Interestingly, the "goses" may not be touched at all except for comfort measures.11 Practically speaking, this means that when a patient is approaching death, one may not take his temperature, measure his pulse or blood pressure, and certainly may not draw his blood unless curative therapy or comfort measures will be applied based on the test results.12 In circumstances such as these, the physician may grounds in Jewish law to refuse to administer the "futile" therapy.

REFUSING THERAPY FOR THE TERMINALLY ILL

A second form of futile therapy involves a treatment that is extremely unlikely to be successful, but is intended to reverse the condition to which it is being applied. An example would be a patient with a cancer that has not been shown to be responsive to standard chemotherapy. The physician may offer the chemotherapy. But clearly, according to Rabbi Moshe Feinstein, if the patient is in intractable pain and the therapy is not proven to be efficacious, the patient may refuse the physician's offer of a "futile" therapy that prolongs life without a reasonable expectation of cure or relief of pain.13

Rabbi Feinstein further states that in such a situation, the patient should not be treated unless a cure or pain relief is possible.14 Rabbi Shlomo Zalman Auerbach writes that while we cannot force the patient to accept the treatment, the patient should be encouraged to accept the therapy because of the intrinsic value of life lived even in extreme pain.15 Nevertheless, this would be a case where a patient can halachically refuse the futile treatment.

WHAT IS NON-TERMINAL ILLNESS?

It is important to note that Jewish law clearly distinguishes between terminal illness and progressively debilitating illness (a distinction that is often ignored in secular ethics discussions).

An incurable illness which will likely result in the death of the patient within one year is considered terminal with respect to Jewish law. A patient with such an illness or condition is called a "chayay sha'ah,"16 -- one whose life is "timed" or "time-limited." One who is expected to survive beyond a year is considered a "chayay olam" -- one whose life is considered "eternal" in the sense that their life expectancy is presumed indefinite and not limited.

Thus, in halacha, persistent vegetative state and Alzheimer's disease are not terminal conditions, per se, despite the fact that they are progressive, irreversible and inevitably result in death. Halacha insists that patients with these illnesses deserve the same full range of treatment that is made available to any other patient. They are not "terminal" (until the very end stages of their illnesses) and must be aggressively treated without regard to the apparent "futility" of their lives.

THE CASE OF TERRI SCHIAVO

Let us take the example of Terri Schiavo. She is not brain dead nor is she terminally ill. She is brain damaged and remains in what appears to be a persistent vegetative state. All of her bodily functions are essentially normal, but she lacks the ability to "meaningfully" interact with the outside world (although her parents claim that she does minimally respond to their presence and to outside stimuli).

To remove the feeding tube from a patient whose only impairment is cognitive is simply murder.

Her impairment is cognitive and Judaism does not recognize any less of a right to treatment for one cognitively impaired than one mentally astute.

It is a denial of the Jewish ideal of the fundamental value of life that drives the forces that wish to remove Terri Schiavo's feeding tube. While Judaism does recognize quality of life in certain circumstances (such as the incurable terminally ill patient in intractable pain mentioned above), the Torah does not sanction euthanasia in any situation. To remove the feeding tube from a patient whose only impairment is cognitive is simply murder.

We must ask ourselves when we view images of cognitively impaired patients such as Terri Schiavo whether the pain that we feel is Terri's or whether it is our own. While we may suffer watching movies of the severely brain damaged, it is our own thoughts of the horror of a life without cognition that drives us to project that pain onto the victim who may not be suffering at all.

The key to analyzing any situation is to realize that good ethics start with good facts. One must provide the posek (halachic decisor) with an accurate, honest, and thorough assessment of the patient's medical condition. Only then can a halachically valid and ethically proper decision be made.

Adapted from an article that appeared in Viewpoint: National Council of Young Israel, Winter 1996 entitled: "HALACHIC ISSUES REGARDING FUTILITY OF MEDICAL TREATMENT: Applications To Nutrition And Hydration In The Terminally Ill Patient

FOOTNOTES
1 Auerbach, Rav Shlomo Zalman, "Responsum Regarding a Very Sick Patient," Halacha U'Refuah, vol. 3, p60

2 Auerbach, Rav Shlomo Zalman, "Treatment of the Dying," Halacha U'Refuah, vol. 2, p. 131: "a person is not master of his body to relinquish even one moment"

3 Aruch Hashulchan, Yoreh Deah, 339:1: "...even though we see that he is suffering greatly in his moribund state (a goses) and death would be preferable, nevertheless it is forbidden to do anything to hasten his death, for the world and everything in it belongs to Hashem, and this is His will."

4 Ran, Nedarim 40a

5 Auerbach, ibid.

6 Feinstein, Rav Moshe, Igros Moshe, Choshen Mishpat II, Volume 7, siman 74, p.311-315.

7 Eisenberg, Dr. Daniel, "Futility of Treatment," Maimonides: Health in the Jewish World, Vol. 2, No. 3, Fall, 1996

8 Nishmas Avraham, Yoreh Deah, siman 339, sif katan 4, p.445-446

9 Shulchan Aruch, Yoreh Deah, 339:1

10 Shabbos 151b and Smachos 1:4

11 Igros Moshe, Choshen Mishpat II, Volume 7, siman 73:3, p.305

12 Opinion of Rav Auerbach in: Abraham , Dr. Abraham S. The Comprehensive Guide to Medical Halacha, Revised edition, Chpt. 38, p.192, 1996 and Nishmas Avraham, Yoreh Deah, siman 339, sif katan 3, p.444

13 Igros Moshe, Choshen Mishpat II, Volume 7, siman 73:1, p. 304

14 Igros Moshe, Choshen Mishpat II, Volume 7, siman 74:1, p. 311-312

15 "Treatment of the Dying (Goses)," Halacha U'Refuah, vol. 2, p. 131:: "if the patient is G-d-fearing and mentally intact, try very hard to convince him that better is one moment of tshuvah in this world than eternity in the world to come" 16 Feinstein, Rav Moshe, Igros Moshe, Choshen Mishpat II, Volume 7, siman 75:1, p.315

End of Life Issues in Halacha English Bibliography

Abraham, Abraham S.: The Comprehensive Guide to Medical Halacha, revised edition, Feldheim Publishers, 1996

Angel, Rabbi Marc D.: Halacha and Hospice. Journal of Halacha and Contemporary Society XII: 17-26, 1986

Berman, Rabbi Anshel: From the Legacy of Rav Moshe Feinstein, z"l.. Journal of Halacha and Contemporary Society XIII: 5-19, 1987

Bleich, Rabbi J. David: Judaism and Healing: Halakhic Perspectives, Ktav Publishing House, Inc. 1981

Friedman, Dr. Fred: The Chronic Vegetative Patient: A Torah Perspective. Journal of Halacha and Contemporary Society XXVI: 88-109, 1993

Herring, Rabbi Basil F.: Euthanasia. Jewish Ethics and Halakhah for Our Time, Ktav Publishing House, Inc. Yeshiva University Press, 67-90.

Ifrah, Rabbi A. Jeff: The Living Will. Journal of Halacha and Contemporary Society XXIV: 121-152, 1992

Jakobovits, Rabbi Immanuel, The Dying and Their Treatment, Jewish Medical Ethics, Bloch Publishing Company, 119-125, 1975

Rosner, Dr. Fred: Jewish Perspectives On Issues of Death and Dying. Journal of Halacha and Contemporary Society XI: 50-69, 1986

Rosner, Dr. Fred and Rabbi Moshe D. Tendler: Death and Dying, Practical Medical Halacha, Third Revised Edition, Association of Orthodox Jewish Scientists, Ktav Publishing House.

Rosner, Dr. Fred: Rationing of Medical Care: The Jewish View. Journal of Halacha and Contemporary Society VI: 21-32, 1983

Rosner, Dr. Fred: Rabbi Moshe Feinstein on the Treatment of the Terminally Ill, Modern Medicine and Jewish Ethics, Ktav Publishing House, Inc. Yeshiva University Press, 233-246, 1991

Schostak, Rabbi Zev: Ethical Guidelines for Treatment of the Dying Elderly. Journal of Halacha and Contemporary Society XXII: 62-86, 1991

Steinberg, Dr. Avraham: On Death and Dying. A Concise Response: Jewish Medical Law, Beit-Shamai Publications, Inc., 148-154, 1989

Weiner, Rabbi Yaakov: Ye Shall Surely Heal: Medical Ethics From a Halachic Perspective, Jerusalem Center For Research, 1995

Zwiebel, Chaim Dovid: A Matter of Life and Death: Organ Transplants and the New RCA "Health Care Proxy". The Jewish Observer, Summer 1991: 11-14

A Matter of Life and Death-- Revisited. The Jewish Observer, October, 1991: 11-22 (Letters of response by Rabbi Moshe D. Tendler, Dr. Yoel Jacobovits, and Chaim Dovid Zwiebel)

See also "The Terri Schiavo Case: Related Ethical Dilemmas."

Published: November 1, 2003


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Visitor Comments: 176

(176) Anonymous, October 12, 2008 10:58 PM

family decision

I think some of you should see someone live this way day by day before you judge. I think it should have been the parents decision, and it could have been done with more medicine, but the parents didn't want it, but each case is different. When a body lays dorman for many many years, and has a g tube, it starts to bleed, the person doesn't digest well, bones start coming through the skin, legs have to be cut off, muscle mass is gone, it is a sad sad situation. No one should judge someone, only God, and if their heart is really for the person who has laid in bed for over 10 years and their body is discinerating, that is hard to watch. I think if her parents had taken her for a while they would have seen this. This should not be a general case decision for every patient, it should be an individualized decision for the condition of the patient with the family.

(175) Anonymous, February 11, 2008 6:30 PM

We are a Judo-Christian Family with beliefs firmly based on our Jewis heritage.

We have a precious daughter, Mollee, who is now 20 years of age. She would be classified as profoundly handicapped like Terri. We watched in horror and prayed continually while Terri and her family went through this terrible ordeal. WE are all children of God. He has placed each of us here for a reason and He and only He has the right to call us home when He chooses. When will they decide that Mollee has no value? We are getting older. Who will protect her?

(174) Jamie Mandy Nager, June 27, 2006 12:00 AM

Reply writen and sent by Jamie Mandy Nager 10th grade student

I complietly dissagree with the Doctors' decition of the removal of Terri's feeding tube. The message they let out in doing do was and IS discusting: The people responcible of 9/11 wouldn't have even recieved Terri's pounishment. Instead, this inoccent woman was, in the name of justice, Brutally Murdered in a form that is considered inhuman, all because her only crime was she was incapable of swallowing and had a two-timing @$$ of a husband who decided he didn't want her around anymore! And this is AMERICA!?!
I am still stunned that this behavior was tolerated. Shocked that there was even question as to weither she should be granted life or not. The answer should have been without a shadow of a doubt "Yes. She should and WILL live".
Before the accident, Mr. Schiavo has said Terri has told him that she would rather be dead than be on that form of life support. Weither that is true or not, I can tell you she DIDN'T say "Honey, if I have a bad accident, I wasn't you to have an afair with another women, have children, kill me in the most painful way possible and then deny me any comfort what so ever while I die. Thanks honey! I knew I could count on you!"
This action which happened so many years ago still is dispicable. By the actions of some of our government, they are sending out the message that Hitler had the right idea in the 1940s: All handiecaped people are better off dead.
My next door naghbor is mantally retarded. So are several members of our curch in Pennsylvania. The government has given us the message that if we wanted these people dead, we could do it in the most painful means possible and get away with it... Be considered heros for ridding the world of unwanted vegitables in the prosess.
Worse than that, Terri wasn't a vegitable when she was killed. She was able to talk when she died. There was no Will stating what Terri wanted, all there was was the word of mouth from her husband who was so faithful to his beloved wife, he had already had SEVERAL children with somone else. Well, if that's not love, I don't know what is!
Mr. Schiavo claimed he had his wife's best intarests in mind. In mind maybe. In actions, NO WAY. The Palm Sunday before she died, Mr. Schiavo had squashed any shred of a possibility that he had his wifes best intarests in mind when he denyed her communion: He said no food or liquids. Not even a drop and a crum in honor of her faith. That's not just bad, that's barbaric.
If nothing else, he was breaking the law in preventing someone to practice her religion. He, in the name of a so-called love, denied a suffering human being, not a vegitable, but a person, her religion, her comfort, and her life.
I can only pray that history doesn't repeat itself with this. America was soppost to be special above all other countries. We gave people rights others did't, we gave them freedom and life. Now we have begun to take that away. That's not right. In the name of Christ Jesus, our family and our Country, that's not right. And the government should have known better.

(173) G.Orona, March 29, 2006 12:00 AM

It is a crime both here on earth and in
the laws of God --to destroy a human
being because the person is ill. I don't care in what condition the person is in.
To starve Terri to death might be a warning to all of us if this was an
intentional experiment by the gov.t
to see what is coming up for the baby
boomers--unless we go to war with Terri's case and demand to open an
investigation and to over haul the courts system.
I was very suspicious that all the courts-up to the Supreme Court refused
to lend a helping hand to Terri--and
so patheticly unmoving just dammed her
to death by execution.

(172) Anonymous, April 21, 2005 12:00 AM

I could type a long comment, but the most important point of Terri's case is that the legal system has gotten into the life and death picture. Or, I should say ANOTHER life and death issue when it should have been left to her family to settle their own personal problems surrounding Terri's plight. Who are these people who think that they can impose their uncompassionate and unmerciful decisions on people who help to pay their wages? They are supposed our servants. We're not theirs. What are the limits of their judicial involvement anyway? Obviously, our legal system is wanting as far as compassion and mercy for other human beings, but the question is what are we and what can we do about it?

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