In this morning’s parasha, we can find the death of Jacob and the death of Joseph. Both death scenes in the Torah are a picture perfect way to leave this world. In our heart of hearts, in the depths of our souls, I think we all pray for a dignified, noble, easy death. And so, this morning, I’d like to share some insight into one issue we can begin to consider in order to help make that happen. But first, let’s take a look at the texts. Page 305, at the bottom of the page, verse 29. After a life of struggle and growth and journeying, he delivers his final instructions, and drew his last breath. Flip forward to page 310, verse 24. Again, a well planned, dignified passing from this world to the next. How we pray and hope for this scene at the end of our days.

But the reality for most deaths these days is very different. Modern medicine and our complex hospital systems complicate the issue. Thank God, we are blessed with modern technology and a hospital system that preserves life and saves lives like no other time in our history. But a consequence of our new found medical technology is a complex series of painful decisions about the end of life. Approximately 2.5 million Americans died each year and 50% of those people die in acute care in hospitals or in hospice where the family is asked to make decisions about the end of life. Our Jewish tradition and our Jewish medical ethicist can provide us with some guidance.

The directive from our tradition to heal is clear and direct. It’s written in the Shulchan Arukh, Yoreh De’ah, 336:1, “The Torah gave permission to heal, moreover, this is religious obligation and is included in the category of saving life; and if the physician withholds his services, it is considered as shedding blood.” Doctors have the permission and the obligation to heal when someone is sick. Another quote from the Midrash: Just as if one does not water and fertilize a tree, it will not live, but die, so with regard to the body. Medicine is the fertilizer and the physician is the tiller of soil.

On the other hand, as advanced as our medical knowledge is, there comes a time to meet our maker. We are mortal, our lives our precious and fragile, and mortal. And when that time comes, we want to be open and receptive to letting go, and going peacefully. RabbRabbi Simcah Bunam of Pshis’cha writes “I have been teaching myself how to die every day of my life.” We want to pass from this world with dignity, courage and respect. The Ba’al Shem Tov writes, “Death is nothing but the passage from one corner of the universe to another.” The great Chasidic master strengthens our courage and allays our fears, almost praying for a comfortable passage from this world to the next.

Many of us who have witnessed or been a part of the end of a life in a hospital. More often then not, the decision-making process is difficult and tortuous. To make matters worse, there is a diversity of Rabbinic opinion on end-of-life issues. One of the key components to achieving a peaceful end is thinking ahead and planning ahead. So this morning, I’d like to present one issue among many issues that requires forethought and pre-planning. The discussion is raised in the document entitled – Jewish Medical Directives for Health Care written by the The Committee of Jewish Law and Standards.

In hospitals, toward the end of life, there are machines and life support systems that can sustain life artificially, for a long, long time. The question is: may one discontinue or unplug the support systems, when the family deems any attempt or chance at recovery is futile?

The course of action in question is: in the case of terminal illness. The support system in question is: is it ever permissible to discontinue artificial nutrition and hydration? Is the act of pulling the plug on artificial food and water considered assisted suicide?

The conservative Rabbis agree that withholding and discontinuing medication is permissible. And today we won’t bring up respiration. But the question is about artificial food and water.

On one hand, Rabbi Avram Reisner says, that it is forbidden to remove artificial nutrition and hydration. And Rabbi Elliot Dorff says that it is permissible. Let’s explore those two opinions.

Rabbi Reisner, who forbids the removal, says that even the most difficult life and that of the shortest duration is God-given and ours to nurture and protect. All nutrition, hydration and medication should be provided whenever these are understood to be effective measures for sustaining life. Some medical interventions, however, do not sustain life so much as they prolong the dying process. Therefore one may withhold and remove medication, but not nutrition and hydration.

On the other hand, Rabbi Dorff finds basis in Jewish law for greater latitude to the patient who wishes to reject life-sustaining measures. He sees a life under the siege of terminal illness as an impaired life. In such a circumstance, a patient might be justified in deciding that a treatment that extends life without hope for cure would not be in his own best interest and may be forgone. He also determines that artificial nutrition is not considered actual food and water because it lacks the essential qualities of food, namely taste and smell. Therefore, one may choose to withhold and remove both medication and nutrition and hydration.

So, according to Rabbi Reinsner, the choices in the Medical Directive would be, artificial nutrition—yes or no. If you would like to approve artificial nutrition, just know that it can’t come out, and may require restraint so that you don’t dislodge the tubes.” Or you can choose not to have artificial nutrition. And that’s one of the options on the medical directive.

There’s another set of options that takes the hallacha according to Rabbi Dorff, which permits the removal of artificial nutrition. It notes that it is inconsistent with Rabbi Reisner’s opinion and says check here if “I would want to receive artificial nutrition and hydration on a trial basis. A decision about continuing treatment should depend on its effectiveness in helping to strengthen my body, improve my well-being or prolong my life.” Or “I would not want to be fed by artificial means at all. I prefer to eat normally for as long as I can, and when I can no longer do that, to let nature take its course.”

Even within the Conservative movement, there is complexity and a range of guidance and diversity of opinion.

Vicki and I are going through these forms this week, as we update our will in accordance with the Texas legal system. I present these issues to you to encourage you to give thought to your opinions and come with directives of your own with the guidance of the Jewish Medical Directives. Contact me in the office, or look for them online. Clarify your directives. Talk to your parents about your wishes, talk to your children about it. Start now.

Ribono shel Olam, help us to remember the lesson from the pious tzaddik, RabbRabbi Simcah Bunam of Pshis’cha. “I have been teaching myself how to die every day of my life.” Grant us vision and give us the strength to face our mortality early, while we are strong and healthy. Give us the strength to face our mortality with courage and peace. Amen.

© Ranon Teller 2006

Sermon Classification: 88