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The Obligation to Prolong Life Under All Circumstances?

Continuing from last week’s article, we turn this week to the important issue of the obligation to prolong life.

As we saw, suicide is among the most heinous of crimes, as indicated by the fact that one does not mourn for a suicide. The cases in which it a person is permitted to take his own life are few, and according to many halachic authorities such cases don’t exist altogether.

It is important to follow up the discussion by addressing the issue of prolonging life. Are there circumstances in which the obligation does not apply? Does a patient’s suffering have any bearing on this matter? Is it permitted to discontinue a course of treatment?

We will address these delicate questions in the present article.

Definition of a Goses

By way of introduction, it is important to set forth the definition and basic laws of a goses.

The experience of being a goses – being close to death – is referred to as gesisah. According to Torah law, a very large majority of those who become a goses die within seventy-two hours (see Iggros Moshe, Choshen Mishpat II:75; see also Rosh, Mo’ed Kattan 3:97). Thus, if someone sees that a close relative is a goses and then loses contact with that relative for seventy-two hours, the laws regarding mourning apply because it is assumed that the goses has died (Shulhan Aruch, Yoreh De’ah 339:2).

Similarly, although Jewish law does not allow a woman to remarry unless there is proof that her husband has died, some authorities rule that testimony that her husband was a goses seventy-two hours earlier is sufficient to permit her to remarry in the absence of more direct evidence of his death (Beis Shmuel, Even Ha-Ezer 17:18, 17:94; but see comments of Dagul Mervavah).

Although the Rema identifies a number of symptoms that indicate that a person is a goses, most authorities do not specifically require these symptoms, and rather rely on medical knowledge and on the experience of those who regularly witness death (see Iggros Moshe, loc. cit.).

Halachos of a Goses

With respect to most aspects of Jewish law, a goses is just like any other person. A goses is considered no less alive than anybody else, and the punishment for killing a goses is thus the same as that for killing a non-goses (Shulchan Aruch, Yoreh De’ah 339:1; see Rambam, Laws of Mourning 4:5). 

In the words of the Minchas Chinuch (34), “Even if Eliyahu would come and tell us that a particular person will live only an hour or a moment, still the Torah does not distinguish between one who kills a lad who would live many years or one who kills an old man who has little more to live.”

However, there are two halachos that specifically concern a goses. One halachah states that it is forbidden to move a goses, because, in light of his condition, movement may hasten his death (Yoreh De’ah 339:1, and Shach). The goses is likened to a candle whose flame is about to expire. If one places a finger on it, it is extinguished (Shabbos 151b).

A second halachah, which is stated by the Rema (citing from Sefer Chasidim 723), is that one may remove “anything that prevents the departure of the soul, such as a clanging noise [such as the sound of a nearby woodchopper] or a grain of salt that is on his tongue … since such acts do not quicken death but merely remove an impediment to death.”

Prolonging the Life of a Goses

The second halachah cited above is particularly intriguing. If, as noted, a goses is considered no less alive that any healthy person, why is it permitted to remove something that prevents the departure of the soul? Surely there should be an obligation to save the life of the goses by any possible means?

Indeed, a number of authorities point out that the status of a goses is not different to any other person in terms of prolonging life (see Shevut Yaakov I:13; Gilyon Maharsha, Yoreh De’ah 339:1; Tzitz Eliezer VIII, Ramas Rachel 28; Nishmas Avraham, Orach Chayim 329:4). Accordingly, so long as it is not clear that the goses is definitely dead, he is called a live person for all purposes, and a doctor is obligated to treat him in every way that is possible and appropriate – even if the chances of his recovery are very slim (see below for more details).

The principle source for this ruling is the fact that there is no Talmudic source indicating that the obligation to save a person’s life does not apply to a goses. The absence of such a source is especially noteworthy given the halachic requirement to desecrate Shabbos to rescue even those who face imminent death. Because the Gemara makes no distinction between a goses and others, it seems clear that the obligation to extend life applies fully to a goses. Indeed, one case mentioned by the Gemara (Yoma 85a; the case involves somebody whose skull was crushed) appears to explicitly mandate treating a goses on Shabbos (see Shulchan Aruch, Orach Chaim 329:4).

An explanation must therefore be given for the Rema’s ruling whereby it is permitted to remove the source of a noise that is keeping the goses alive. A possible solution is that the Rema refers to the last stages of the gesisah period, when the person’s soul is trying to escape the body (see Tzitz Eliezer, Vol. 13, no. 89, sec. 14). This is a time of extreme suffering for the person.

Rav Moshe Feinstein (Iggros Moshe, Yoreh De’ah Vol. 2, no. 174; see also Shut Beis Shmuel no. 59) also notes that the moment a person’s soul departs is a time of intense pain – even if doctors are unable to detect it (the pain can be of metaphysical nature). He explains that it is on account of this special pain that it is permitted to remove obstacles to a goses’ death.

Another possibility is that the noise is not considered a tangible and concrete obstruction to death, but rather a mystical cause of postponement. For this reason, its removal is permitted, and we cannot compare this to cases that involve tangible medical factors.

Actively Hastening Death

What is the halachah when a competent person wants to die because he is experiencing great physical pain? Even if the person a goses, it is absolutely forbidden for a physician or other party to take any action to terminate his life. Life and death are determined by Hashem, and the person’s suffering does not change matters at all.

Thus, Rabbi Moshe Feinstein (Iggros Moshe, Yoreh De’ah 2:174) writes: “But doing an act to hasten the death [of a goses] is prohibited … even if he [the goses] is suffering. And doing so constitutes murder, violating the injunction, ‘You shall not kill,’ and renders the person doing so subject to capital punishment.”

As proof for the position that, notwithstanding physical suffering, a person cannot act to hasten his death, authorities (see Chasam Sofer, Yoreh De’ah 326) cite a Talmudic passage (Avodah Zarah 18a) describing the execution of Rabbi Chanina ben Teradion, who was burned alive by the Romans. Rabbi Chanina’s students implored him to end his suffering quickly by opening his mouth and allowing the flames to enter. He replied, “It is better that He who gave [me my soul] should take it rather than I should cause injury to myself.”

Rabbi Yechiel Epstein (Aruch Ha-Shulhan, Yoreh De’ah 339:1) stresses that this ruling applies even to a goses: “Even if we see that the goses suffers greatly from his gesisah and that it is good for him to die, nevertheless it is prohibited to us to do anything that will hasten his death. The world and all that fills it belongs to the Holy One, blessed be He, and such is His wish.”

A similar statement is made by the Chochmas Adam (151:14): “It is prohibited to cause [a goses] to die more quickly even if he has been a goses for a long time and … [he] and his relatives are suffering a great deal.”

Refraining from Life-Saving Treatment

A more delicate question arises when a patient who is in great suffering, requests that his life not be prolonged by medical treatment. Is it permitted to heed the patient’s wishes, or is there an obligation to give life-prolonging treatment, even against his wishes?

A number of recent halachic authorities write that there is no obligation to save the life of somebody who is suffering and objects to treatment. This ruling is given by Rabbi Moshe Feinstein (Choshen Mishpat 2:73), who writes that if there is no way of easing the patient’s suffering, there is no obligation to extend his life (of suffering) by means of medication or machines. He reiterates the principle in two further places (no. 72, sec. 1-2; no. 75, sec. 1).

It is important to note that Rav Moshe discusses cases in which the patient is terminally ill, and does not speak about a case where the illness has a cure. In one place he writes that we do not force a patient – even a non-terminal patient – to undergo treatment that involves a certain danger in order to save him from a condition that involves present and major danger. Yet, where the patient will certainly die without treatment, and the treatment itself does not involve danger of death, the implication is that the patient is treated him against his will.

Rabbi Shlomo Zalman Auerbach (Minchas Shlomo 91:24) likewise writes that there is no obligation to force treatment upon a terminally ill person. Although we would violate the Shabbos to extend his life, Rav Shlomo Zalman writes that where the patient himself refuses treatment due to severe suffering, we do not force it upon him. He gives a similar ruling with regard to an amputation, stressing that in the relevant case the doctors were not certain that the surgery would save the patient’s life.

In spite of the halachic rulings, Rav Shlomo Zalman writes that we should try to convince the patient to undergo the treatment, for one moment of repentance and good deeds in this world are worth more than an entirety of life in the World to Come. In case a person would die and is only kept alive mechanically in order to preserve his organs for transplant, Rav Moshe Feinstein (Yoreh De’ah 2:174, sec. 3),  writes that it is forbidden to extend a life of suffering.

Rabbi Yaakov Yisrael Kanievsky (the Steipler) gives a similar ruling, writing in his letters (190) that he heard in his youth that there is an obligation to do everything in one’s power to sustain life (even a very temporary life of suffering), and proceeding to explain that he does not believe this to be true:

“In Yoreh De’ah 339 we find that it is permitted to remove something that prevents the patient’s death, and only a positive action is prohibited. Therefore, I do not see any prohibition in being passive, and on the contrary, we can derive that treatment should not be given in such circumstances – see Beis Lechem Yehuda who writes that salt should not be given to sustain the life of a goses (it is possible that a goses is different). It seems at any rate that a temporary extension of life, which does not involve a true recovery, is similar to the case of a goses, for a goses is considered equal to every living person.”

The Steipler is certainly referring to a case of a suffering patient; under non-suffering circumstances, the obligation to treat is absolute, even against the patient’s will.

Some authorities, notably the Tzitz Eliezer (9:47; 13:87-89; 5, Ramat Rachel 28; 14:80-12; 18:62), dispute the rulings above, and argue that a person’s life must always be extended, even if it is a life of suffering, and even against the wishes of the patient.

The Death of Rebbi

A precedent often cited for the rulings above is the Talmudic discussion (Kesubos 104a) of the final illness of Rabbi Yehuda Ha-Nasi (Rebbi). Rebbi was sick and suffering greatly. Both the rabbis and Rebbi’s female servant, well-known for her devotion, prayed around the clock for Rebbi’s complete recovery.

As time passed, however, Rebbi’s servant saw that the prayers were not to be fulfilled. Although Rebbi remained alive, he suffered excruciating pain. Finally, she concluded that it would be better for Rebbi if he were to die, and she prayed for that. She soon realized that her prayer would not be accepted so long as the rabbis continued their unabated prayers for Rebbi’s recovery. She therefore threw an urn from the roof of the yeshiva to the ground, smashing it and startling the rabbis, causing a brief halt in their prayers. At that moment, Rebbi died.

Many commentators cite the conduct of Rebbi’s servant as evidence that someone who sees another who is greatly afflicted, and there is no meaningful prospect for alleviating or curing the person’s pain, should pray for that person’s death (Minchas Shlomo 91 sec. 24; Iggros Moshe, Choshen Mishpat 2:73, sec. 1; based on Ran, Nedarim 40a).

Not all authorities, however, agree that one should pray for another’s death even under these circumstances (Tzitz Eliezer, Vol. 5, Ramat Rachel 5; 8:49, Kuntres Even Yaakov, perek 13). Moreover, Rav Moshe Feinstein writes (2:74 sec. 4) that Rebbi’s servant only prayed that Rebbi should die after she saw that the rabbis’ prayers that he should live were not answered. In view of their great power of prayer, this was a clear indication that Rebbi could not live. Today, in generations bereft of such great leaders (with so great a power of prayer), Rav Moshe concludes that people should never pray for a speedy death.

In addition, Rabbi Chaim Palaggi (Chikekei Lev Vol. 1, Yoreh De’ah 50) states that persons who might have an improper bias, such as those who care for the patient, should certainly not pray for the patient’s death.

Rabbi Moshe Feinstein extends the principle of praying for another’s death to refraining from giving life-saving treatment. Rav Shlomo Zalman also notes the Gemara, yet adds that there can be circumstances in which we pray for a person’s death yet we remain fully obligated to save his life, even if this involves desecration of Shabbos.

Another source mentioned by Rav Moshe is the aforementioned story of Rabbi Chaninah ben Teradion. As he burned on the stake, Rabbi Chaninah agreed to the offer of a Roman officer to hasten his death by removing the bandages from his heart. This is taken to imply that at least in circumstances of terminal illness, inaction is permitted. (Rav Moshe stresses that it is certainly forbidden to actively hasten death; we have already mentioned the beginning of the story, where Rabbi Chaninah refused to open his mouth in order to hasten his death.)

Conclusion: Individual Circumstances

In conclusion, it is important to note the significance of personal circumstances. Family members often have to make important decisions concerning different options of treatment and non-treatment, and Rav Moshe (no. 75) notes that the decision should be theirs (and not the doctor’s, especially if he is not a religous G-d fearing Jew).

Although we have provided a basic halachic framework in which decisions can be made, it is important to note the place of the individual patient, and his family, in reaching the decision that is right for him. For some, another moment of life is worth more than all the pain in the world; for others, a life of pain and suffering is simply not life. Much thus depends on individual circumstances.

In summary:

  • For a patient who can be cured from his illness, there is an absolute obligation to cure him, and this must be done even against the patient’s will.
  • For somebody who cannot be cured, many authorities write that it is permitted to refrain from medical treatment where the patient does not desire it and is in great pain.
  • This ruling applies specifically to medical treatments and the use of machines to keep a person alive. However, for natural functions such as eating and drinking, the patient must be given food even against his will.

 

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