Biomedical Ethics: A Conservative Jewish Perspective
From The United Synagogue Review
In recent years, the topic of biomedical ethics has received considerable publicity. Secular views are best known to the public, including Conservative Jews, since issues of patient autonomy, the right to die, living wills, and abortion, come to us largely from the secular realm. Physicians also incorporate this secular approach through their reading of professional journals and through participation in local hospital biomedical ethics committees.
What sources of learning are available to Conservative Jewish physicians and to patients interested in the Movement's viewpoints on these matters? While some articles have appeared on these issues, such writings are limited, and are not generally available to physicians or patients when particular situations arise. The Conservative Jew is generally advised to consult with his or her own rabbi, but indications are that this is not done very often. In addition, conferences based on Conservative views have been limited and local or regional in scope.
The challenge, therefore, is to bring together rabbis and physicians to begin to review these issues comprehensively. This was done in a 1 1/2 day conference on November 1 and 2, preceding the USCJ Biennial Convention. Not only do rabbis and clinicians need to share their knowledge and experiences, but secular ethicists should also be heard, since differences between the Judaic and the secular must be explored and clarified. Decisions of the Conservative Movement's Committee on Jewish Law and Standards (CJLS) need to be better understood and discussed. Challenges from the clinical realm need to be heard, to suggest areas for future halakhic determinations by the CJLS or policy approaches of the USCJ.
The purpose of this 11-hour conference, therefore, was not only to exchange information and views in an interdisciplinary fashion but also to encourage further rabbinical-medical dialogue here and throughout the Movement. This course also established the Jewish Biomedical Ethics Network, encouraging knowledgeable communications among healthcare providers, rabbis, and others particularly interested in Conservative Jewish biomedical ethics and bringing its message to broader audiences within our Movement.
Rabbi Kassel Abelson, chairman of the CJLS, and I, a cardiologist experienced in biomedical ethics issues, organized the conference with these aims in mind. The major speakers were Rabbi Eliezer Diamond, Assistant Professor of Rabbinics at the Jewish Theological Seminary of America, Rabbi Elliot Dorff, Rector and Professor of Philosophy at the University of Judaism, and Dr. Thomas Murray, Director of the Center of Biomedical Ethics, Case Western Reserve University School of Medicine. Other speakers included six additional physicians, two secular ethicists, and a healthcare economist. Below we will survey some of the ideas discussed during the conference.
Some Principles of Jewish Medical Ethics
Rabbi Dorff stressed the first principle: Based on biblical verses and subsequent rabbinic interpretations, human beings do not own their own bodies. Since each one of us is created in part by God, we do not have an absolute right to do with our bodies what we will. This is in sharp contrast to secular ethics, in which the doctrine of autonomy is an overriding principle. Suicide, as well as active euthanasia, is prohibited in Jewish law because we are not permitted to destroy that which we do not own; namely, our bodies. Furthermore, it is incumbent upon human beings to take care of our bodies, not to harm them in any way, to do preventive care, to seek medical attention when we become ill. Autonomy in the Jewish model involves selecting a reasonable course of treatment among alternative therapies, once the physician has been consulted. In reality, this amounts to a joint decision by patient and physician.
The second principle is that the body and soul are morally neutral and potentially good. The ancient Greek philosophers posit an important distinction between body and mind; the body is the animal and the mind is that which makes us human. In certain Christian traditions, the body is sinful and should be suppressed in order to elevate matters of the mind or the soul. In an American secular ethic, one may see -- particularly in the media -- the body as a source of pleasure, used as a means of gratifi-cation. In the Jewish tradition, the body and soul are an integrated whole. In the case of serious neurological disease, such as Alzheimer's, even as we may lose memory or other aspects of "mind," we retain other aspects of "nefesh," or soul, created in the image of God, and therefore retain our status as a human being. In our tradition, the body is neither inherently good nor bad, but with an inclination toward the good if we follow God's instructions as given to us by our tradition.
The third overriding principle is the permission and obligation to heal. Some of our sources suggest that God inflicts illness and God must therefore be the ultimate healer. What then is the role of the physician? It is the clear consensus of our tradition that mankind is not expected to sit back and allow God alone to do the healing. The long history of Jews in medicine bears witness to the strong encouragement of the healing art within our tradition. Not only does one have permission to heal in the Jewish tradition, but one has an obligation to do so. Members of the community are obligated also to care one for another, as a communal obligation. The physician in this regard is in partnership with God, or an agent of God. The physician and the public must be aware of the limitations of the healing art. The practice of medicine is to be carried out with humility, and there should be no expectation on the part of physicians or patients that all disease can be cured. In contrast, the American "can do anything" philosophy posits that the body is a machine which is broken and needs to be fixed. This view may give rise to unrealistic expectations. The Jewish approach to medicine is less mechanistic and takes into account that natural processes will play a role in healing. Therefore, one goes to a physician for treatment but also needs to say mi sheberach for God to participate in the healing process.
Based on these principles, and on an understanding of the medical issues of our day, our historically based Movement requires a central group of decision makers to help our congregational rabbis apply the traditions of the past to the practical issues and dilemmas of today. This is the role of the CJLS. It is particularly important in the field of medicine for Jewish traditions to be applied sensitively and judiciously to the problems at hand. This is what the Committee attempts to do, as do local rabbis who are called upon by their congregants to render opinions on particular cases.
The perspective of the hospital biomedical ethics committee is multicultural, with no specific religious orientation. Comments were offered by Dr. Janicemarie Vinicky, Director of Biomedical Ethics of Washington Hospital Center, as well as by several physicians with experience in clinical bioethical decision making. Much of the work of the hospital biomedical ethics committee lies in fostering effective communication among those with a stake in the outcome of a particular case -- the patient, the family, and the medical caregiver. Understanding the patient's own values and beliefs is a part of successful communication and needs to be taken into account; the patient's own value perspective is often quite important in decision making.
An important common ground emerged between rabbis and clinicians: encouraging optimum communication at a very meaningful level. Clinicians and rabbis present noted that in their experience, discussion between patients and rabbis, or between physicians and rabbis on patients' decision making, is not common, except in regard to hospice care. Rabbinic input might be comforting and helpful to patients and families involved in difficult decision making. Rabbis and other clergy can be called in as "members of the team" on the encouragement of physicians, or when the rabbis indicate an interest in this type of counseling. Furthermore, as triage decisions are becoming part of managed care, it is likely that the bioethical issues will become more difficult and that the views of religious traditions may help in this regard as well.
How Can We Best Help The Dying Patient?
Rabbi Diamond discussed the challenge the healthcare team faces, and our attitude and actions concerning the patient we have no expectation of healing in the conventional sense -- one who is beyond our curative therapy. Bikkur holim, the commandment to visit the ill, is conventionally considered the responsibility of friends and family, but also dictates the attitude brought to the bedside by the physician. There is an absolute obligation imparted by our tradition to visit the ill, not only to improve that person's recovery, but to show concern just by being present. Beyond this, one must put aside one's own agenda to assist patients in any needs they may have. Jewish tradition also demands that one must respect the dignity of the patient himself or herself, must be sure that the visitor will not be a burden on the sick person, and must not cause embarrassment to a person whose physical capacity is limited. The Talmud also deals with the question of visiting one with whom we have not been on good terms, and the importance of proper timing of the visit itself.
Thus, we see a codification of a generous impulse as a sense of religious obligation, a part of the general category of g'milut hasadim, acts of lovingkindness. The physician who enters the patient's room is present not only in a professional role, but in a religious role as well. Doctors are also instructed by rabbinic sources to be generally encouraging, not to deceive patients, and especially to be realistic in discussing the impending death of a patient.
Patients in need of pain relief may require enough medication to bring about unintended death; what does our tradition advise? There is agreement that the patient should be made as comfortable as possible. Beyond this concept, some Conservative halakhic experts permit administration of enough medication to reduce subjective symptoms, even if such dosages risk the unintended side effect of shortening life. This view is similar to today's mainstream secular bioethical thinking. Other Conservative authorities argue that such pain control should not exceed a risk of greater than 50 percent likelihood of shortening life.
Our tradition also has a long and honored custom of ethical wills, leaving a written document explaining not just one's distribution of possessions, but also one's spiritual legacy. This custom, which may be of great comfort to patients and families, is based in the Torah itself and in rabbinic writings.
Dr. Laurence Savett of St. Paul, Minnesota, described a model of patient care which stresses what the physician can do for the patient beyond the technical curative aspects. The patient is personally encouraged by the physician to explore his/her own values, concerns and fears; these are acknowledged and respected by the physician. Such patient-centered care is the embodiment of Rabbi Diamond's description of the classical concept of bikkur holim, which is clearly identified in our tradition as a communal obligation.
Other Issues
Space does not permit discussion of the other issues tackled at the Conference. Questions included: How can ancient talmudic and rabbinic sources guide us in the contemporary medical scene of high-tech medicine? Is there a difference between active euthanasia and murder? Between active and passive euthanasia? When can we stop a ventilator? When can we stop nutrition and hydration? Who is responsible for deciding? Is it permissible to limit care on economic grounds? How do we deal with issues of infertility? Are modern high-tech methods permissible? Under what circumstances is abortion permissible? May fetal tissue be used? Clearly, much work remains to be done.
Biomedical ethics experts agree that we all should take measures to assure that the appropriate and desired level of care will be rendered to us at a time of serious illness whether we can speak for ourselves or not. Furthermore, we have the challenge to obtain care consistent with our religious traditions. How should one proceed with this?Clarify your own values on treatment issues as mentioned in this article. Talk with your family, friends, rabbi and others knowledgeable in biomedical ethics.Speak with your personal physician so that you understand the medical terms relating to your intended choices, that your treatment preferences are consistent with your health status, and that your values become known to your care team. (If you change physicians or health status, this step must be repeated.) Execute a healthcare directive or living will, to make clear your preferences. The Rabbinical Assembly published a "Jewish Medical Directive" in 1994. This educational document is available from the United Synagogue Book Service for $2.95. Physicians at the conference recommend that you consult with your rabbi, physician, and lawyer in order to use this document properly.
