General Principles of End-of-Life Care
Key Principles of Decision-Making Regarding End-of-Life Treatment
These principles give a general outline of the values that guide Ematai’s perspective on end-of-life care. All specific questions regarding individual cases should be addressed on a case-by-case basis.
1. Sanctity of Life (kedushat ha-chayim): Judaism greatly values life and mandates almost any action toward saving a life, including violating the Sabbath. As such, Jewish law prohibits intentionally hastening a person’s death, whatever the motivations. For the same reason, Jewish law would require critical care interventions when recovery is a reasonable possibility.
2. Quality of Life: Judaism is concerned about the quality of life. Illness can be associated with unbearable suffering, and the Torah mandates us to try to alleviate such agony. The patient’s assessment and perception of their pain and suffering must be taken into account.
3. The Reality of Medical Uncertainty: The complexities of modern medicine produce many uncertainties. In our efforts toward preserving life, we are frequently confronted with cases in which an intervention may save someone’s life but could also harm them through procedural complications or unintended side effects. Medical procedures with low-success rates prove to be beneficial for some patients but are harmful for many others. We seek the best medical advice that we can reasonably receive but recognize that patients may be forced to make choices in the face of uncertainty.
4. Extend Living, Not Dying: The goal of healthcare decision-making is to extend living, not to prolong dying. We do as much as we reasonably can to prolong life, but we do not want to unnecessarily extend a painful dying process. If no cure or remission can be achieved, nature may be allowed to take its course, with compassionate care focused on pain management.
5. Patient Choice: While Judaism may not accept autonomy in its fullest expression, a patient generally has the right to choose their plan of care, though specifics may vary. A patient may choose a risky treatment in order to attempt to extend life even when it may entail grave risks. So, too, they may sometimes choose to forgo various medical interventions in which reasonable people may conclude that the potential downsides outweigh the potential benefits. A patient, for example, may elect not to undergo a risky procedure which he or she deems may leave then in a state of suffering or indignity that they subjectively deem is worse than death.
6. Palliative and Support Care: Pain is a serious matter that must be treated just like other physical ailments. Palliative care should always be considered at every stage of treatment and is a critical aspect of providing support. Utilizing such treatments does not mean that we are “giving up” on other therapeutic aspects of a patient’s care.
7. Hospice Care: High-quality hospice care might also be appropriate at times, with treatments focused only on comfort and symptoms (such as pain management). Experience shows that terminal patients can frequently live, in greater comfort, under hospice care for as long of a time as they would have while seeking aggressive treatment. Even when we forego aggressive treatments, we never stop caring for the patient.
8. Critical role of families and friends: Conversations between patients and their families, in dialogue with one’s physician and rabbi, can help provide people with many meaningful experiences in their final months. Advanced planning can avoid family strife and bring people together. The family in general and the designated proxy in particular bear a profound obligation to support their loved one and, at times, to make decisions on their behalf. It is critical for them to know the general healthcare preferences and values of their loved one so they can do their best at providing what the patient would want.
9. Rabbis & Doctors / Medicine & Judaism: Health care providers and spiritual mentors should be working in tandem, not in conflict, toward pursuing the patient’s interests. Jewish law recognizes the expertise of healthcare professionals while affirming that the Torah’s ethical teachings can wisely guide modern Jews in the complex dilemmas posed by 21st century medicine. Modern medicine offers many powerful therapies whose implementation must be guided by an ethic that respects the dignity found in all creatures created in the Divine image.
10. Spiritual Opportunity: The process of aging and dying can be a time for spiritual reckoning and an uplifting religious experience. Despite the inherent difficulty of this period, it may be imbued with prayer, reflection, repentance, and heartfelt conversations that provide for meaningful experiences until the very last breath.
The principles were formulated by executive director Rabbi Dr. Shlomo Brody with input from rabbinic advisory board members Rabbi Dr. Edward Reichman and Rabbi Dr. Jason Weiner.
We thank Rabbi Hershel Schachter and Rabbi Mordechai Willig for reviewing this text.