Artificial Respiration Administration in the Terminally Ill - Obligation or Prohibition? From the Jewish Ethical Perspective of a Family Physician

Sody A Naimer, M.D.
Specialist of Family Medicine, Goosh Katif, Israel.
Email: snamir@hotmail.com
* A paper from the Second Bioethics Roundtable on Israel in Asian Bioethics held at BGU in August, 1998, in cooperation with the Eubios Ethics Institute.
Eubios Journal of Asian and International Bioethics 9 (1999), 7-8.


The case presented, in which I served an active participant, involved a 14 year old boy who was diagnosed 3 years previously as suffering from acute lymphocytic leukemia. Following orchiectomy, which diagnosed a relapse despite full chemotherapy for the first outbreak of the disease, He then followed a downhill course. The setting in which the current discussion focuses on - is 10 days after release from a major pediatric oncology center. Observing that the disease failed to respond to the strategies attempted, disease spread from bone marrow to the CNS and intestinal system; the youngster was released from hospital and the family was told: "there is nothing further to be done and we must leave nature to take its course." During the long days that followed the family took full control of the boy's maintenance and supplied fluid support and pain relief round the clock. It was at this point that the patient's mother who asked if I would agree to administer artificial respiration -should her son reach respiratory failure approached me.

Realizing the acute stress of the family- I offered help as requested, but the situation aroused various issues which I hope to present in this discussion. In this case the fact that both the patient, his family and myself are all observant religious Jews made the discussion all the more relevant and committing regarding the conclusions. If I may, I would like to present my personal beliefs and convictions, which I believe, help me enormously in approaching difficult cases such as these. I was reared in an orthodox Jewish home in Canada. And arrived in Israel for the sole purpose of Biblical "Torah" learning for one year. During this period I fully adopted a devoutly religious lifestyle requiring Torah learning and adherence to its laws and principles. This forms the basis of our faith. The Torah's teachings guide our day to day actions and decisions. I spend at least 2 hours learning every day, studying in essence, ethical questions pertaining to all aspects of life.

The written scriptures or Old Testament provide the fundamental laws that are interpreted in the oral scriptures: Mishnah and Talmud. The elaboration of views and ideas that evolved over the last 2500 years are modern applications of the very same rulings and laws which have been challenged and survived the changing faces of history. This concept is critical in deriving a sense of security since leaning back on the shoulders of our sages facilitates the process of decision making. When currently confronted with the demand to judge a grave matter, I can literally consult with religious authority and rest assured that the conclusions reached become a dictum and are agreeable with the views of Jewish scholars of all times. Although the answer may not always be firmly clear cut - as in this case, still the prime benefit is that if the outcome of the ruling proves successful, I need not be too proud of myself since it was not my personal set of ethics that were tested. Likewise if the outcome seems a failure I need not be overcome by feelings of guilt- since the result may have been the best possible under these circumstances.

Back to analyzing this case: The source in the Bible to heal stems from the statement in Deuteronomy(1): "Thou shall return it to him" relating to a lost object and applies to any loss of the fellow man. Maimonides(2) is explicit in stating that this statement includes the human body itself to be retrieved by the fellow man when possible. Therefore we may conclude that denying any form of intervention eventually leading to death is prohibited. According to Jewish law, even seconds of life have an absolute value and therefore everything should be done to sustain them. If so, are there no concessions whatsoever and must attempts to lengthen a life outweigh all other considerations including the patient's will and the minor integrity left of his well-being? There is a wide consensus, in the world of Jewish law that any active deed directly causing a patient's death is considered murder with all its consequences. Alternatively, sources dating as far back as 800 years ago quote allowances to deny various interventions suggested to elongate life in certain situations.

At the point of dying the soul is said to be a parable for the flickering flame about to extinguish therefore unnecessary handling may cause it to blow out. Touching the dying at these last moments is forbidden if not for the patient's sole benefit. A scholar the '"Rama" states that one is permitted to remove any obstacle preventing the soul's exit since this is no other than removing the restraint(3). For example, a composition "sefer Chassidim" specifies that one may not scream at the dying at the time of the soul's exit which may cause the soul to return and result in further suffering, since as king Solomon said in Ecclesiastics(4): "a time to be born and a time to die.." Thus if we can predetermine the precise moment preceding death, this would not be the time to perform any intervention. Although the greater difficult is in extrapolating these terms to present problems. Is a respirator considered an "obstacle postponing death? Present scholars have dealt with this question and the views are divided. One individual of the many, rules that switching off the artificial respirator in certain situations is permitted. The vast majority advocates that once begun we have no right stopping any form of artificial existence already reached. But our basic question is to what extent are we obliged to initiate therapy? The first approach is plainly passive. Namely, the interpretation of the Bible's command to retrieve one's body holds valid when this can potentially be completely fulfilled, but when the best to be expected is barely in the range of continued endurance of artificial existence or a mechanical vegetative state - this is not desirable, thus we may refrain from performing any intervention procedure whatsoever.

The second approach, based on the very same sources encourages the extension of life even through major intervention while the patient's consent or suffering serves as the main limiting factor. If the treatment proposed diminishes pain while extending life: this would be recommend by all accord. But in the instance that there is no apparent strategy known to benefit the continuous agony of disease- we are obliged to supply the bare necessities only, as fluids and oxygen. Antibiotics and hemodynamic support are probably included in this policy. This view still recognizes the value of perpetuation of life on its own and praises the potential of repentance, living under such conditions. Therefore if the patient is prepared to endure further suffering we are obligated to assist, in supplying any form of therapy known to delay his death. Current dispute revolves round the question: how do we relate to the patient who has not expressed his will towards intervention and further suffering? Do we automatically presume one would rather not be tormented by continuing this state, or for instance, at onset of the loss of consciousness read a state of freedom of pain and then reinstitute therapy? I personally raise the question, which stems from being confronted with this situation numerous times. Do we predominantly consider as an aim the overall suffering of the patient, in other words, refraining from taking any active course of response such that his disease and life is shortened but suffering in the long run is prevented? Or does the immediate state of the sick: say, sepsis or respiratory failure amenable to treatment and at least easing of the stress- dictate whether we will intervene or not. I venture to say that ignoring present suffering by denying all modern medicine has to offer to ease the current stressed state is wrong and somewhat like fighting for peace. In conclusion, in this case, as unpleasant as it may be, the proper course of action seemed to be consulting with the boy whether he would be willing to undergo respiration would he reach a state that it would be indicated to stabilize his deteriorating condition . If this is his request, performing intubation and respiration as demanded is appropriate. If not, oxygen alone would be administered. The family is often not objective in such a situation, therefore their view should not be sought and their desires should not seem to reflect the patient's will.

Epilogue

We were called to his bedside 2 hours after the onset of Cheyne Stokes breathing - completely unconscious the boy finally succumbed to his disease supported by fluids and an oxygen mask. Four years later I happened to meet the mother again who turned to me and said: I was meaning to ask, how was it that the evening we were all so worried about our son's condition both you and the nurse felt secure leaving the neighborhood for your own purposes?--This is when I definitely felt glad I have a firm basis of ethics to rely on.

References
1 22:2.
2 Peirush Misnayot, Nedarim 4:4.
3 Sulchan Aruch, Yoreh Deah, Laws of visiting the ill;339.
4 3:2.


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