by Daniel J. Lasker

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       I would like to give now one example of a medical issue common at the end of life. One frequently encountered issue centers around the prolonging of life by artificial means, such as respirators and intravenous feeding, even for a person with a terminal illness or in a state of coma.
        What one should do with a dying patient who has no hope of recovery often presents some of the hardest medical and moral problems. The halakhic basis of much of the discussion is the Shulhan Arukh, authored by Rabbi Joseph Karo, and the glosses (Mappah) thereon of Rabbi Moses Isserles (Rema, both sixteenth century). The Shulhan Arukh says that a person who is about to die (a "goses" in technical terms) is to be treated like a living person in all respects. Thus, one may not tie his jaws, close his orifices, move the pillow from under his head, move him, or put him on sand; all of these actions, which are preparatory for a funeral, require some positive activity on the part of those treating the goses. Rabbi Isserles adds that these acts are forbidden since they cause the patient to die more quickly. "However," Rema adds, "if there is something which is preventing the departure of the soul, e.g., there is nearby a knocking noise such as a wood chopper, or there is salt on the patient's tongue, and this is preventing the departure of the soul, it is permitted to remove it, for this is not an action at all, but only the removal of the impediment." ¹ The legal, medical and moral issue often becomes: when does life support extend life, and should be continued, and when does it become an impediment to death and should be removed? One may not hasten death, but one does not necessarily have to extend life. Where does one draw the line?
        Rabbi J. David Bleich (an important American Orthodox authority) presents one extreme position: "The practice of euthanasia - whether active or passive - is contrary to the teachings of Judaism. Any positive act designed to hasten the death of the patient is equated with murder in Jewish law, even if death is hastened only by a matter of moments. No matter how laudable the intentions of the person performing an act of mercy-killing may be, his deed constitutes an act of homicide."
       Bleich is very consistent: he is against the so-called "pulling the plug," in any situation, including irreversible coma or brain death, even when arguably permitted by Rema. Bleich finds way of interpreting the law so that one can never disconnect life support, even if the life support seems to fulfill the definition of an impediment to death. Furthermore, he rules that patients cannot give an order for denial of treatment (e.g., a "DNR," a "do not resuscitate" request). A person has no right to write a living will asking in advance that life support be discontinued in certain circumstances; there is no right for anyone to prevent continued treatment of the dying. Bleich recognizes no such thing as "heroic measures" or extraordinary means which one might choose not to take. He makes only one concession to attempt to hasten death: one may pray to God to end life: "Man may beseech God to relieve him from divinely imposed obligations when they appear to exceed human endurance. But the ultimate decision is God's and God's alone. There are times when God's answer to prayer is in the negative. But this, too, is an answer." ²
       If Rabbi Bleich represents one extreme, one can see a different viewpoint in the works of Rabbi Solomon Freehof, the Reform authority to whom mention was made above. Rabbi Freehof was asked the question about terminal patient, for whom the doctors decided "to hasten the end by withdrawing all medication and fluids given intravenously." Is this permissible? Basing himself on Rema's statement and other precedents, Freehof declares: "A doctor may not take any overt action to hasten death, such as giving him, perhaps, an overdose of an opiate, but he may refrain from doing that which will prevent his dying." Thus, removing an intravenous infusion may shake the patient up, and thereby hasten death, and this is not allowed. Yet, removing the infusion gently or not refilling the bottle of nutrient when it empties out would be allowed. In Freehof's words: "To sum up: If the patient is a hopelessly dying patient, the physician has no duty to keep him alive a little longer. He is entitled to die. If the physician attempts actively to hasten the death, that is against the ethics of Jewish law. In the case as described, the term used in the question, 'to hasten death,' is perhaps not correct, or at least should be modified. The physician is not really hastening the death; he has simply ceased his efforts to delay it." ³ Freehof is basically arguing for the permissibility of starving a dying patient. While one might not necessarily pull the plug of life support to see if the patient survives without it, one can stop feeding the dying patient.
        As I pointed out above, differences of opinion about medical procedures is not always a case of Orthodox versus Reform rabbis. Thus, Rabbi Chaim David Halevi, the late Sefardi Orthodox Chief Rabbi of Tel Aviv (d. 1998) was asked about removing a respirator in the case of irreversible coma. He answered: "In my opinion, doctors are not permitted to continue to prolong life by use of the respirator in such a case. . . It is prohibited to prolong life artificially when there is no longer any hope for the patient. . . Where the patient is in a coma and is insensible. . . in my opinion, not only is it permissible to disconnect the machine, but it is mandatory to do so. The soul of man is the possession of God, who has already called it to him. By the operation of the machine we are causing the soul (rather than the body) to suffer by preventing it from departing and going to its rest and peace." ⁴ Although Rabbi Halevi did not clarify the exact status of the patient for whom it is a mitzvah to disconnect the respirator (e.g., was the patient brain-stem dead?), it is clear that he takes a much more permissive view of the subject than Rabbi Bleich.