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Topics in this digest: Tzav 5765
by Rabbi Dr. Barry Leff
Congregation B'nai Israel
Toledo, Ohio
Fifteen years ago, Terri Shindler Schiavo was a vibrant and lively 26 year
old woman. She loved music—she even wrote to John Denver to ask if he
would play at her wedding—and was fond of animals. She had been happily
married to Michael Schiavo for five years.
And then in an instant, life as she knew it came to an end. Terri had a
sudden heart attack, brought on by a potassium imbalance. She went
unconscious, fell into a coma, and has been comatose ever since.
All of the activities we associate with the joys of living—going for
walks, talking with friends, reading a book, going to a movie, eating a
meal with friends—have not been part of Terri’s life for the last fifteen
years.
Her higher brain functions have essentially shut down. For several years,
her husband Michael worked for her rehabilitation. He studied nursing so
he could take better care of her. He had Terri flown to California for
experimental surgical treatments, sleeping on a cot in her room.
After a few years of those efforts, Michael came to realize Terri’s
situation was hopeless. The doctors diagnosed her as being in a
Persistent Vegetative State (PVS). There is only one person known to have
recovered from PVS, ever; and he had only been in that state for 20
months.
Michael came to the conclusion that Terri was never going to be able to
regain normal consciousness. He decided that the artificial measures,
feeding Terri through a tube, that were keeping her alive should be
discontinued, and his wife should be allowed to die. He believes this is
what she would have wanted.
Terri’s parents, Bob and Mary Shindler, disagree. They dispute Terri’s
diagnosis—they claim she is responsive. They dispute Terri’s wishes: they
believe as a Catholic, Terri would have agreed with the teachings of the
Catholic Church on the sanctity of life, totally regardless of the quality
of that life.
Both sides feel so strongly that they are defending what Terri wants that
they have pursued every possible legal device, including multiple appeals
to the Supreme Court of the United States, and the passage of an
extraordinary bill in Congress over-ruling the traditional separation of
states powers to allow a Federal court to rule on an appeal.
This is an extremely complicated and emotional situation. The rhetoric
has been extremely impassioned. Pat Buchanan had the nerve to compare
what Michael Schiavo is doing to his wife to what the Nazis did to
prisoners in the Holocaust. Such comparisons are truly absurd, odious,
and an affront to the memory of those who perished at the hands of the
Nazis. If Terri Schiavo were capable of eating, there are plenty of
people who would feed her. The situation is not the same.
I’m NOT going to talk this morning about what the courts should have done,
or whether it was proper that Congress passed a special bill. I have my
opinions, but I don’t think the Torah has a lot to say about whether
Federalism is a good thing or a bad thing, or the roles of the various
branches of the US government. But this sad case does raise a few
questions we need to think about.
What if, God forbid, such a thing were to happen to your loved one, what
would you do? Where would you turn for guidance?
The Shindlers are Catholic. They are trying to follow the teachings of
their church. The Vatican does not usually comment on individual cases,
but they made an exception for Terri Schiavo because of all the publicity.
The Vatican’s position is as follows:
“By any decent count, Mrs. Terri Schiavo can be considered a living human
being, deprived of full conscience, whose legal rights must be recognized,
respected and defended. The removal of the feeding tube from this person,
in these conditions, can be considered direct euthanasia."
The Catholic Church’s position would say that even if it was Terri’s
desire not to be fed, she would be committing a mortal sin to refuse the
feeding tube. A typical Catholic Church approved advance medical
directive reads “In no circumstances would I wish basic care, including
(if appropriate to my condition) the assisted administration of food and
fluids, to be withdrawn with the aim of ending my life.” Note it says “in
no circumstances.” No matter how much pain the person is in, how unlikely
recovery, or how far gone already.
The Vatican statement said removing the tube would be “Direct euthanasia.”
In other words, the Catholic Church says that removal of the feeding tube
is an act of murder.
What would the Jewish tradition say about removing the feeding tube?
The first issue we need to consider is what is Terri’s status? Is she
alive, dead, or in some kind of in between state?
Judaism does not view life as a digital phenomena: on or off. Life is not
something that begins precisely at the moment of conception and ends
precisely at the moment breathing stops. The Jewish view is that life is
something we come into gradually in stages and we exit gradually in
stages.
Terri is not dead. Even though traditionally death was defined as
cardio-pulmonary death, the vast majority of rabbis today accept
brain-death as death. However, since her brain stem is still functioning,
Terri does not meet the usual criteria of brain death.
This week’s Torah portion, Tzav, has rules and regulations about all
different kinds of sacrifices. Amongst all the rules is one that refers
to an animal that is a treifah, which literally means “torn.” We cannot
eat or offer as a sacrifice an animal that is a treifah. The same word in
Yiddish usage, treif, came to mean anything that is not kosher.
However in halacha, in Jewish law, there is another usage for the term
treifah. A person who has a terminal illness is called a treifah. An
animal that had been ripped open by something like a wolf was called a
treifah, and in some ways was considered almost as if dead already even if
it was still moving around—death was inevitable.
The Jewish tradition holds that saving lives is one of the very highest of
values. We disregards any of the commandments except for three to save a
human life. For someone who is otherwise healthy, we would go to
extraordinary lengths to save them. However, once someone is a treifah,
once they have a terminal illness, their status changes somewhat. If you
came across two people drowning and could only save one, and you knew one
was a treifah, was suffering from a terminal illness, you would be
justified in choosing to save the one was NOT a treifah. Traditionally,
someone is defined as a treifah if they have less than a year to live.
One problem of course, is that we all know people who the doctors said had
way less than a year to live who made a recovery—I recall a case where two
years ago the doctors said a congregant of mine was within 24 hours of
death, and he made a recovery and is still with us, alert and living an
almost normal life.
The next stage in the dying process is called the goses. A goses is
someone who is in the process of dying, which halacha defines as within
three days of death. It is halachically permissible to do things like
turn off a ventilator for someone who is a goses because medical
intervention is no longer seen as preserving life, but rather is seen as
dragging out the process of dying. As my teacher Rabbi Elliot Dorff put
it, God only has so many ways of taking us: with artificial hydration,
nutrition, and ventilation, we can be seen as trying to foil the will of
God that a person’s time on this earth is up.
We are all mortal and will pass away. The Jewish tradition considers it
an honor to be present when a person passes from this world to the next.
I have had the honor to be present numerous times when a person has passed
on. When someone is on a ventilator, unconscious, and their organs are
shutting down, it is usually pretty clear when the end is imminent.
Families I have been with have been comforted to know that it is OK within
the Jewish tradition at that point to turn the ventilator off and allow
the
person to leave this world without dragging out the dying process.
Prior to the removal of the feeding tube, Terri Schiavo was certainly NOT
a goses, within three days of death. If you consider nutrition through a
feeding tube an artifical measure sustaining life, similar to someone who
could only live with a ventilator, one could argue that she is a treifah,
someone who would die within a year without extraordinary medical
intervention.
But even if she does not have the status of either a goses or a treifah,
it would be permissible for her husband to remove the feeding tube. It
would also be permissible to leave it in.
It is generally accepted that people have a right to refuse medical
treatment if they feel it will not help cure their condition. In Terri
Schiavo’s case, an important question then is whether feeding someone
through a feeding tube counts as “nutrition” or “medication.” There are
rabbis with different opinions on the issue.
I go with the opinion of Rabbi Elliot Dorff, who wrote that “artificial
nutrition and hydration is medicine because it does not have important
characteristics of food -- specifically, it does not have taste,
temperature, or texture, and it comes into the body through tubes rather
than through the mouth which then chews and swallows it. Therefore, I
think that we should intubate (insert a tube) or extubate (remove a tube)
according to whether it is in the best interests of the patient.”
So from a Jewish perspective the question regarding whether or not to keep
a feeding tube in Terri Schiavo would be whether it is in the best
interests of the patient. Her own wishes make a big difference—a person
can refuse medical treatment if they think it is not helping.
There have been arguments about the facts in the case and the status of
Terri Schiavo. The Florida courts have ruled in accordance with the
doctors who say she is in a persistent vegetative state (PVS). People who
are in a PVS because of loss of blood flow to the brain, like Terri, never
recover, so administering artificial nutrition is not benefiting her—it is
only keeping her in a state from which she will never recover
consciousness. As Rabbi Dorff says, “As Jews, we have a strong mandate to
heal, but when we cannot, we must recognize and accept the fact that we
are
mortal (this goes back to the Adam and Eve story). As Kohelet says, "There
is time to be born, and a time to die." To deny the reality of death is
both psychologically unhealthy and religiously perverse.”
Millions of dollars in medical expenses, legal fees, and gas for Air Force
One could have been saved if Terry Schiavo had filled out an Advance
Medical Directive, a living will.
In an advance medical directive you fill out a form which stipulates how
you want these issues to be dealt with.
Often older people will fill out a medical directive because they start
seeing mortality staring them in the face; the more funerals you go to,
the more aware you become of the fact that some day it will be your turn.
Young people, like Terri Schiavo, rarely think to fill out such a
directive.
But the truth is, we ALL need to fill one out. I’ve been in car
accidents, a motorcycle accident, and an airplane accident. Any one of
them could have turned out much worse than it did. I was given a powerful
reminder of the need for all of us to fill out a medical directive last
month. I was out running one morning and slipped on an icy sidewalk on
the UT campus. My legs went right out from under me, and I came down very
hard, flat on my back. I hobbled home, called my wife Lauri, and had her
come home and take me to the emergency room where they gave me some
powerful pain killers and muscle relaxants—I had given myself whiplash. I
was quite fortunate: a few visits to the chiropractor and a few sessions
of
my yoga class and I was as good as new. But I also realize that with that
fall my head probably came within a couple of inches of striking the
pavement hard enough to put me in a coma. And I did NOT have an advance
medical directive filled out!
I believe in practicing what I preach, so yesterday Lauri and I filled out
our advance medical directives. We did it together, discussing the
different issues. It’s not a fun session. It’s uncomfortable to sit with
your loved one and consider things like whether you would agree to having
a
limb amputated if you were unconscious and had a life threatening
infection. But I’m very glad we filled it out together, because even with
me being a rabbi and she being a lawyer, there were issues we needed to
discuss and think through.
The Conservative Movement’s Rabbinical Assembly has prepared a document
called “Jewish Medical Directives for Health Care.” I believe this issue
is so important I am going to mail a copy of the document to every member
of B’nai Israel, and on the evening of Tuesday, April 12, I will lead a
session for anyone interested in going through the form and answering
questions about filling it out. If you would like a copy right away,
before receiving your copy in the mail, please contact the office. The
document is also available online at
http://r.vresp.com/?RebBarrysTorahCommen/8fa769013e/308136/7f2a79ca74/565f099
. If you have filled out a standard secular living will, you might want
to consider replacing it with this one, which reflects specifically Jewish
teachings on these issues.
In the Mishnah Torah Rambam (Maimonides) explains there is no “coming to
be” without a “passing away.” Psalm 49 affirms “For all the glory that
they cherish, men die, even as the beasts that perish.” Whenever that day
comes, you can help prevent needless anguish and strife amongst your loved
ones if you make your wishes known in writing ahead of time.
May it be God’s will that no one needs to look at your advance medical
directive until you are 120!!!
Shabbat Shalom.
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