Patient Choice and Control at End of Life

 

In Montpelier a vigorous debate is underway on a measure called “Patient Choice and Control at End of Life.”  

 

Opponents of the measure call it state-sanctioned assisted suicide, while proponents call it death with dignity.   You can see why the measure is controversial:  whenever death is the topic there will be strong opinions.

 

Our governor, Peter Shumlin, has made this bill’s passage a legislative priority for this year’s session.   

 

As of today an alternate version of the bill was passed in the State Senate. More on that in a moment.

 

First let’s look at the introduction of the original bill: an act  to allow, subject to appropriate safeguards, a mentally competent person diagnosed as having less than six months to live to request a prescription which, if taken, would hasten the process of dying, that is, would result in certain death.  This language echoes similar language used in an Oregon death-with-dignity measure which has been in effect there for the past 15 years.  This measure was approved by the voters of Oregon. Over the 15 years that it has been legal 673 people have utilized it.  By comparison, Vermont’s population is 1/6th Oregon’s.  

 

The act understands that the person who would take the medication is acting through free-will, is not being coerced, and that the person has decided after full consideration that this is the best course for alleviating further suffering, suffering that could include severely diminished capacity for self-care, fully relying on others, and the possibility of immense pain as death draws close.

 

Safeguards written into the Vermont measure include the six month terminal diagnosis, confirmed by another physician, and an evaluation by a mental health professional.

 

The measure that passed the State Senate was changed dramatically as the original language was changed and the bill now is one that provides legal immunity to physicians who prescribe a lethal dose and those present at the time of death.

 

This language will now go to the House where the option exists for adding back in the original language.

 

Death is never easy to talk about.

 

Most of us do not know when we will die or what we will die from.

 

This legislation is written specifically for a small number of people who are already sick and whose physicians believe that they are within six months of the end of life, a time referred to as “end of life.”  

 

What I seek to do tonight is to present the arguments of the proponents and opponents, as well as the multivalent perspectives from the Jewish tradition, including from rabbis and doctors who are part of our congregation.

 

Let us start with the proponents of the measure.  They argue that:

 

  • having a choice to end suffering is psychologically beneficial, especially to those who while fully in their mind do not wish to inflict suffering on loved ones on their way to being totally incapacitated

  • the person suffering is given choice to end the suffering, even while using all palliative measures, some of which may not be effective in reducing pain

  • these individuals have the choice to act freely to end their suffering

  • with some terminal illnesses, such as ALS, the brain and intellect do not diminish making a person fully aware of their suffering, making it that much more of a heinous ending when patient choice is absent

  • as much as the individual knows that his/her death will cause others to suffer as they mourn the individual, it allows the person near-death to fully say goodbye to their loved ones

  • it makes legal what has often been done “off the books” to help people end their suffering by compassionate physicians

 

Rabbi Bob Alper, an ICM member, is a public proponent of the measure.  “My wife Sherri's Aunt Rosie, who endured grim last years of her life, was barely able to breathe and occasionally not able to breathe at all.  It would have been helpful for her if she'd had the choice to end her own enormous suffering.  The interesting fact is, despite her pain, she was still not eligible under Death With Dignity, since her doctors couldn't say that she had less than six months to live.  That's just one example of how very cautious this bill is, and how, despite misinformed voices in opposition, abuses are prevented.”  

 

Rabbi Alper argues that if he found himself in a dire situation at the end of his life he would like to legally have the ability to choose to end his life.  

 

Opponents object to anything that the state would do to condone a person ending life under any condition.  

 

These objections include:

 

  • medical treatments are readily available to reduce the amount of pain and suffering that a terminally ill person experiences, especially through our evolved hospice care available readily in Vermont

  • A diagnosis of “six months to live” can only be an educated assertion by doctors when sometimes people live longer, sometimes much longer

  • religious objections that we do not do anything to hasten death as the body is a vessel in the image of God

  • people who are terminally ill are inevitably depressed and are not mentally competent to make such a decision

  • medical professionals take an oath to “do no harm” to the people that they treat

  • sometimes “miracles” do happen

 

A medical doctor here at ICM told me that his father as a cancer doctor would regularly increase medications for terminal patients, knowing that the end result would be death.

 

Of course, he notes, people who have a good relationship with their family doctor can do that.  Given that, this doctor does not feel that we need legislation to “make it kosher.” 

Another congregant, also a doctor, wrote that he is also opposed to the measure.  The Vermont Medical Society’s spokesman is also opposed saying that the bill would take attention away from more urgent health care issues. “We don’t think there should be any legislation one way or another dealing with physician-assisted suicide,” the Medical Society spokesperson said. “We feel this is an issue better left to patients and physicians and using the resources currently available.”

 

Of course when one is dealing with matters of life and death God gets invoked by both sides.  There is no one Jewish answer to what the proponents and opponents are saying, but several.  

 

Originally Jewish views, from the time of the Talmud, said that we can remove obstacles to death but not hasten it.  A person who is dying is known as a “gosis.”  The examples cited in the Talmud include those such as external noise that is controllable being quieted so a person could die.  

 

Today, those earlier ideas are faced with a new reality that modern medicine can prolong life indefinitely, leading to cases like the famous one of Terri Schiavo where the court was petitioned to have her feeding tube disconnected.  One can be dead in everything but name but kept alive whether there is function from the brain-stem or not.

 

Today we have an array of technologies that can technically keep a body alive much longer than was previously conceivable.

 

One example is former Prime Minister Ariel Sharon who seven years ago had a massive stroke and lost brain function.  He is still alive, with a feeding tube and a ventilator.  His life is as it was when he had the stroke:  he is in suspended animation, still in life, but not a life that has cognition and relationships with other people.  Alive in body.

 

The Conservative Movement’s Committee on Jewish Law and Standards has examined this issue seriously.  In multiple opinions some conclude that we cannot hasten death in any way.  

 

Others argue there that a feeding tube needs to be designated as either an instrument for nutrition that will bring a person back to a cognitive place or as life support that would be keeping an otherwise dead person alive.  

 

The Union of Orthodox Jewish Congregations has been heavily involved in efforts, in both Congress and the courts, to restrict physician assisted death. In 2000, Rabbi J. David Bleich, Jewish Law Professor at Yeshiva University's rabbinical seminary and Law Professor at Yeshiva's Cardozo Law School, stated that "Judaism places the highest importance on palliation of pain, particularly in the case of terminal patients," and that "Judaism teaches that suicide is an offense against the Deity who is the Author of life." This position privileges God’s role in creation and asserts that suicide diminishes God.

 

Rabbi Michael Cohen, who trained in the Reconstructionist Movement, a movement that says we have to make Jewish life relevant to the civilization that we live in, said, “I have not explored all the issues related to this very important topic so do not have much to add specifically, but to say as Jews we should add not only our American secular values to our decision when it comes to the question of Death With Dignity but we should also include Jewish values, voices, and insights into that decision.”

 

So one more rabbinic opinion--my own.  I see my role as your rabbi as serving you as being made in the image of God.  When I serve you well, I serve God as I understand God.  In our relationships, I respect your intellect, your ability to think for yourself, and the decisions that you make (even if I don’t always agree with them). There are many times that you come to me with questions about the “Jewish way” to do something.  Then there are many times when you make your own decisions:  about what to think, what to believe, what to do.  I appreciate that as people who can think that there are times for Judaism to weigh-in and other times where the individual conscience must take precedence.   

 

It is my sense that the original law, based on the Oregon measure, is sound public policy and even more so it is humane.  With the advances of medical technology people can live much longer than they used to--the question is what is the quality of that period.  

 

In the absence of this technology, such as breathing aides, a six month diagnosis would come much earlier than it does now.  I have been with many people through end of life.  No matter how long a person has lived it is never easy.  There is always suffering, both for the person dying and for the people around the dying person.  

 

Because death is irreversible, these decisions have to be approached carefully when one decides that they want to leave life on their own terms.  

 

It is my sense that the legislation, as originally proposed, enacts all the necessary precautions to ensure that a person who decides to ask for the medicine to end their own life will be doing so after receiving a diagnosis, deciding with the treating physician that there are no more options to extend a good quality of life (defined as the individual understand it), has the diagnosis confirmed by another physician, has a visit with a qualified mental health professional, is not coerced by family members who either do not want to serve the sick person in his or her debilitated state or have motivation to profit from the person’s early demise.  All of these protections in the law assure me that a depressed person would not be able to use the law.  It is written for a narrow segment of the population who meet the established criteria in the legislation.

 

That all being said, those are my personal opinions.  I invite you to consider what has been said tonight, to make up your own mind, to think about your own life and the lives of people you love, and find your position on this issue.

 

We Jews are a life-intoxicated people. While we are healthy life is worth being in.  Once our bodies do what they inevitably do which is get sick and it reaches a point of a medical professional, a doctor, whom we trust, telling us that we have used up all of our medical options and that it is time for “comfort care” a component of that care should be the option to decide whether to wait for nature to takes its course or opt to take control of the process.  

 

We love being in life.  None of us should approach end-of-life decisions without introspection and conversations with those we love the most.  

© 2017- 2019

Rabbi David Novak