When a Jew Requests Assisted Suicide

by R. Jason Weiner

When a Jew Requests Assisted Suicide: Towards a More Nuanced View of Euthanasia

On the one hand, there is little room for any nuance when it comes to euthanasia (i.e., a physician hastening the death of a patient), or physician-assisted suicide ^[1]It should be noted that those who support physician-assisted suicide object to it being referred to as “suicide” and prefer the term “physician aid in dying” or “medical aid in dying.” (i.e., patient performs the final act of taking their own life). Any manner of active hastening of death is antithetical to Jewish values and strongly prohibited by Jewish law. This is because Judaism teaches that our lives are not just needed for utilitarian purposes, but that each person has infinite value, having been created in the image of God, and is thus sacred regardless of one’s relative quality of life or usefulness. ^[2]Mishnah, Sanhedrin 4:2; Rambam, Mishneh Torah, Laws of Murder & Guarding the Soul, 2:6-7; Shulchan Aruch, OH 329:4 & Biur Halacha “Ele Lefi.” Furthermore, not only is human life itself of infinite value, but every moment of life is of infinite value as well, and there is thus an obligation to attempt to save all life, regardless of how much time a person may have left to live. ^[3]See Nishmat Avraham YD 339:4. Similarly, in Jewish Law, hastening death is considered murder, even if the victim is about to die anyway. ^[4]Rambam, Mishneh Torah, Hilchot Rotzeach 2:7; Minchat Chinuch, Mitzvah 34; Gesher HaChaim 1:2(2) note 3; Aruch Hashulchan YD 339:1; Jakobovits, Jewish Medical Ethics (New York: Bloch, 1959), 123-125. This is true even if a person wants their life taken from them, ^[5]The Tzitz Eliezer 9:47 (5) argues that even if a patient begs not to be saved because his suffering makes him feel that death is preferable to life, everything must nevertheless be done to save and … Continue reading because of the belief that God owns us ^[6]See for example: Shulchan Aruch HaRav, Choshen Mishpat, Laws of Bodily Damages, 4; Radbaz, Sanhedrin 18:6. and that we thus have very limited autonomy. ^[7]See for example: Mor Uktzia, OH 328. Judaism also prohibits most forms of bodily damage, ^[8]Rambam, Mishneh Torah, Hilchot Chovel U’Mazik, 5:1. suicide, ^[9]Rambam, Mishneh Torah, Hilchot Avel, 1:11; Tur, YD 345. For more discussion see Gesher HaChaim 25. Regarding the prohibition to take one’s own life even if they are in severe pain, see Responsa … Continue reading and assisted suicide. ^[10]This can be inferred from the prohibition against suicide. A person who convinces or enables someone to commit suicide violates the biblical rule against placing a stumbling block before the blind, … Continue reading Causing death indirectly is also a biblical prohibition. ^[11]R. Goren, 77 & Steinberg, Encyclopedia of Jewish Medical Ethics, 1057, based on Rambam, Hilchot Rotzeach V’shmirat Hanefesh, 2:2. Jewish Law does not demand that we always pursue “heroic” measures, and there are certainly situations in which Jewish Law permits withholding aggressive life-sustaining treatments, but even “passive euthanasia” is sometimes prohibited when it involves the omission of certain therapeutic procedures or withholding medication, since physicians are charged with prolonging life. ^[12]Bleich, Bioethical Dilemmas I, 72.

Compassion

On the other hand, physician-assisted suicide is becoming legal in many states, and we know that even where it is illegal, certain forms of euthanasia and physician-assisted suicide still happen regularly. ^[13]E.J. Emanuel, D.L. Fairclough, and L.L. Emanuel, “Attitudes and desires related to euthanasia and physician assisted suicide among terminally ill patients and their caregivers,” Journal of … Continue reading What is the most appropriate attitude towards people who choose to pursue this forbidden activity, and what approach should we take when asked for guidance from an individual who is considering this? Although some might think that it is proper for a religious individual to always take a firm stance against physician-assisted suicide, research out of those states where it is legal is beginning to point towards a more effective strategy. Paradoxically, it turns out that a non-judgmental, supportive approach from clergy has been more effective in allowing patients to consider alternatives, and to ultimately change their minds, than active opposition to the patient’s decision. ^[14]Ganzini L, Dobscha SK: “If it isn’t depression,” Journal of Palliative Medicine 2003; 6:927-930. The authors point out that patients who explore physician-assisted suicide are often very strong … Continue reading

A rabbi cannot permit physician-assisted suicide, but it is still possible to have compassion for the suffering of terminally ill individuals contemplating such a decision while not endorsing or even condoning it. After all, there are certain cases of suicide, such as that of Saul recoded in the book of Samuel 1 (31:3-4), which Jewish Law does not endorse, yet for which it offers sympathy and permits traditional burial and mourning practices. ^[15]Ramban, Torat HaAdam, Shaar HaSof – Inyan HaHesped 18; Rabbeinu Asher on Moed Katan 3:94; Shulchan Aruch YD 345:3; Tzitz Eliezer 5:Ramat Rachel 29:2. For this reason, as a general rule rabbinic authorities assume most cases of suicide are not willful and instead “look for any mitigating circumstances such as fear or anguish or insanity on the part of the one committing suicide, or if they thought it was a meritorious act to prevent other transgressions.” ^[16]Aruch Hashulchan YD 345:5. In fact, there are even times when Jewish Law may permit praying for a suffering terminal patient to die, ^[17]Ran, Ketubot 104a; Aruch Hashulchan YD 335:3. yet at the same time obligates us to do everything possible, including violate the laws of Shabbat, to prolong their life. ^[18]Minchat Shlomo 1:91:24. We thus see that even while prohibiting this behavior in practice, there is room for showing some level of understanding and compassion to the patient. ^[19]Many of the points in this paragraph are articulated by R. Mordechai Torczyner, with much more depth and clarity, in his talk available here: … Continue reading

Identifying and Addressing the Root Causes

Furthermore, it is crucial to understand why patients seek physician-assisted suicide, so that we can offer the most effective interventions and appropriate alternatives. Studies of patients who opt for physician-assisted suicide in Oregon consistently show that the primary motivation for making this choice is a desire for control. ^[20]Ganzini, et al., “Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide” New England Journal of Medicine, 347:8, 2002, 584); Ganzini, et al., … Continue reading These patients tend to express a strong desire to control the circumstances of their death (time and manner), to die at home, as well as to address their worries related to eventual loss of dignity and independence, being a burden on others, quality of life, self-sufficiency and ability to care for themselves. Interestingly, it turns out that these issues are more prevalent than concerns related to depression, poor social support or uncontrolled pain and physical symptoms, which some had predicted would be the primary motivations to seek physician-assisted suicide. ^[21]Ganzini (2009), 489.

In light of that finding, the best way to encourage people who are seeking physician-assisted suicide to explore other options would be to focus on interventions that help them maintain a sense of control, independence, and the ability to care for themselves, ideally in a home environment. ^[22]Ganzini et al., “Oregonians’ reasons for requesting physician aid in dying” Archives of Internal Medicine, 2009;169(5),489, 491. Instead of trying to convince people about how wrong physician-assisted suicide is, it seems that it is most effective for clinicians to focus on eliciting and then addressing worries and apprehension about their future, with the goal of reducing anxiety about the dying process, educating them about how their disease may progress, and offering information about how to manage pain and discomfort while maintaining function and cognition, if that is what they would prefer. ^[23]Ganzini, 2007,156 For rabbis, this means providing information to empower the patient and modeling a non-anxious presence, while allowing the patient to work through their fears so they can make another choice. Many of the patients studied report sensing a lack of purpose and meaning in life as a reason for pursuing physician-assisted suicide, which implies that assessing their existential concerns may be crucial in enabling them not to pursue this option. ^[24]Carlson et al., “Oregon hospice chaplains’ experiences with patients requesting physician-assisted suicide” Journal of Palliative Medicine, Vol 8, No 6, 2005, 1165.

Simply assuming that a patient who requests aid in dying is depressed can lead to ineffective, and even harmful antidepressant treatments that don’t address root causes or lead to one changing their mind. Similarly, focusing only on addressing physical discomfort ignores the fact that suffering is often existential and cannot be fully treated by pain management alone, and that not all physical pain can always be fully managed, even by expert palliative care. ^[25]Quill TE: Doctor, I want to die-Will you help me? JAMA 1993; 270:870-873; Sachs GA, Ahtonheim JC, Rhymes JA, Volicer L, Lynn J: Good care of dying patients: The alternative to physician-assisted … Continue reading Nevertheless, symptom management is often a major issue for dying patients, and should of course be attended to. After all, the alleviation of pain and suffering is a mitzvah ^[26]R. Shlomo Zalman Auerbach argues that it falls under the obligation to love one’s neighbor as themselves (Responsa Minchat Shlomo 2-3:86). The Tzitz Eliezer (13:87) argues that severe pain is … Continue reading and should not be withheld out of concern for potential adverse effects. ^[27]Reponsa Minchat Shlomo 2-3:86. The concerns are related to opioids’ potential to suppress breathing; however, current medical data suggest that judicious use of opioids does not usually shorten the … Continue reading It is Halakhically permitted for patients to receive narcotic pain medication, ^[28]Responsa Tzitz Eliezer 13:87; Responsa Teshuvot V’Hanhagot 3:361; J. David Bleich, Tradition 36;1, 2002, Survey of recent Halakhic literature: Palliation of pain; Shiurei Torah L’Rofim, vol. 3, … Continue reading even when it may possibly hasten their death, provided that the intent is only to alleviate pain, not to shorten the patient’s life, and that each dose on its own is not enough to certainly shorten the patient’s life. ^[29]Nishmat Avraham, YD 339:1 (4), pg. 499 in 3rd edition. Some authorities have even permitted permanent/continuous sedation ^[30]This is in contradistinction to “palliative sedation” (also known as “terminal sedation”) which is the sedation of those who are eminently dying, but sometimes includes the practice of … Continue reading for a suffering, terminal patient who so desires. ^[31]Rabbi Dr. Mordechai Halperin, http://98.131.138.124/db/showQ.asp?ID=6936 I thank R. Torczyner for bringing this source to my attention in the lecture mentioned above.

Conclusion

Judaism forbids euthanasia and physician-assisted suicide. Still, the patients who request it should generally be treated with respect and compassion. It is essential that those who work with patients who are considering or requesting physician-assisted suicide take the time to sincerely listen to their patients and explore the reason(s) for their request. Studies show that often simply listening to the patients’ concerns helps to mitigate many of them. ^[32]Matthews DA, Suchman AL, Branch WT: Making ‘connexions’: Enhancing the therapeutic potential of patient-clinician relationships. Ann Intern Med 1993; 118:973-977 Then, one can non-judgmentally provide options for an appropriate “substantive intervention” (medical control of pain or other symptoms; referral to a hospice program, a mental health, social work, chaplaincy, or palliative-care consultation; trial of anti-depressant medication when appropriate), which has also been proven effective in enabling patients to change their minds about wanting assisted suicide. ^[33]Grazini, et al., “Physicians’ experiences with the Oregon death with dignity act” N Engl Journal of Medicine, 2000;342:560. In particular, one should seek to address the patient’s specific concerns, and determine if there is a way to meet them, such as addressing a need for control, without opting for physician-assisted suicide. Hopefully, in this way we can maintain our standards and fealty to Halakhah, while at the same time expressing compassion and finding the most effective method of avoiding physician-assisted suicide or euthanasia.