In the current difficult climate, a time when the danger of plague continues to envelop large parts of the globe, it is perhaps appropriate to continue our discussion of medical matters which we began several weeks ago. The need to comply with official instructions concerning coronavirus is self-evident, and we will not address this issue in the present article. Instead, we will address a medical topic that applies to end of life situations: the question of euthanasia and physician assisted suicide in halacha.
Suicide itself is among the most heinous of Torah crimes. As we have discussed before, this is reflected in the fact that one does not mourn for a suicide victim—though this halacha knows many exceptions. According to most halachic authorities, there are no cases that permit a person to take his own life, while according to some authorities this might be permitted in extremely exceptional cases.
In the present article, however, we will address the contemporary questions of physician-assisted suicide, and the obligation or otherwise of prolonging life. Are there circumstances in which the obligation to prolong life 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 state of being very close to death is referred to in halachic parlance as gesisah. According to Torah law, a very large majority of those who become a goses die within seventy-two hours (see Shut Iggros Moshe, Choshen Mishpat II:75; see also Rosh, Mo’ed Kattan 3:97). Thus, if someone sees that an immediate 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 (Shulchan 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 the 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 being a goses, most authorities do not 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 halacha, 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 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 had little more to live.”
However, there are two halachos that are written specifically concerning a goses. One halacha states that it is forbidden to touch a goses because, in light of his condition, touching might 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 halacha, which is stated by the Rema (citing 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 latter halachah is particularly intriguing. If, as noted, a goses is considered no less alive than any healthy person, why is it permitted to remove something that prevents the departure of the soul? Surely there should be an obligation to prolong 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 Shut 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 fully applies 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, Yoreh De’ah 329:4).
An explanation must therefore be given for the Rema’s ruling that 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 a person’s soul is trying to escape the body (see Shut Tzitz Eliezer, Vol. 13, no. 89, sec. 14). This is a time of extreme suffering for the person.
Rav Moshe Feinstein (Shut 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 trace 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 removal of 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 halacha when a competent person wants to die because he is experiencing great physical pain? Even if the person is a goses, it is absolutely forbidden for a physician or other party to take any affirmative 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 (Shut 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 a person subject to capital punishment.”
As proof for the position that, notwithstanding physical suffering, a person cannot take an affirmative act to hasten his death, authorities (see Shut Chasam Sofer, Yoreh De’ah 326) cite a the Talmudic passage (Avoda Zara 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 HaShulhan, 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 gesisa 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 should not be prolonged by means of medical treatment. Is it permitted to heed the patient’s wishes, or is there a full 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 the treatment. This ruling is given by Rav 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).
Rav Moshe discusses cases in which the patient is terminally ill, and there is room to argue that for patients that are able to recover from their illness, the halachah will be different. However, in one place he mentions that we do not force a patient – even a non-terminal patient – to undergo treatment that involves a minor danger in order to save him from a major and present danger. Yet, the halachah might still be different in a case where the patient will certainly die without treatment, in which case it is possible that we will treat him against his will.
Even in this case, however, Rabbi Shlomo Zalman Auerbach (Minchas Shlomo 91; Erchei Refuah Vol. 1, p. 74) writes that there is no obligation to force treatment. In discussing the case of an endangered patient who requires an amputation to save his life, yet does not wish to undergo the suffering and to burden his family, he rules that it is permitted to refrain from doing the operation even when this will almost certainly imply the patient’s death.
Rabbi Yaakov Yisrael Kanievsky (the Steipler) likewise 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; for a non-suffering patient, there is of course an obligation to sustain life, and we are obligated to do so even if this involves violating Shabbos.
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 devoted 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 (Minhas Shlomo 91; Iggros Moshe, Choshen Mishpat 2:73; see Ran, Nedarim 40a) – though some dispute the point. Not all commentators, 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).
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 responsible to 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 – though there is room to distinguish between the concept of prayer and the obligation of treating a sick individual.
Another source he mentions 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 – indicating that at least in circumstances of a terminal situation, inaction is permitted (Rav Moshe stresses that it is certainly forbidden to actively hasten 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).
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. Rav Moshe discusses a case of a person for whom the thought of dependence and burdening others with his treatment was too much to bear.
Thus, while it is certainly important to consult with halachic authorities, it is also important (for the patient and his family, as well as for the rabbi) to carefully evaluate the specific circumstances of the case, and to reach the right decision.
We end with a prayer that Hashem will speedily deliver us from the plague that continues to ravage, He should show us His countenance and His grace, and we should suffer no more tragedy in our midst.