Rabbinical Thoughts Regarding Massachusetts “Death with Dignity”/“Physician Assisted Suicide” Initiative, Ballot Question 2 in this upcoming Nov. 6, 2012 Election by Rabbi Benjamin J. Samuels, Congregation Shaarei Tefillah, Newton, Massachusetts
I have been asked by numerous people within and without our Synagogue to share an Orthodox rabbinical position regarding Ballot Question #2. Judaism certainly has strong views on the value and dignity of life, the obligation to alleviate human suffering, and considerations of when life should and does end. On these issues, as in all aspects of life, the Jewish tradition models complexity and nuanced thinking despite our often ardent desire for simplicity and clarity.
I will present below a brief summary of halakhic (Jewish legal) positions on suicide. Even if there is a definitive halakhic prohibition against suicide for a terminal patient and its assistance, be the patient and/or physician Jewish or Gentile, there is still the open question of whether an observant Jew is required to impose this prohibitory standard on general society through the ballot box. Put in halakhic language: Is there an obligation for Jews to advance Gentile compliance with the Noahide Laws? The Noahide Covenant expresses Judaism’s essential vision for society’s moral foundation and is comprised of seven binding mitzvot (Divinely commanded obligations) upon all of humanity , i.e., the prohibitions against idolatry, murder (including suicide), theft, adultery, blasphemy, eating the limb of a living animal, and the affirmative duty to establish a judicial system. Attendant to this halakhic question is the more general public health policy assessment of whether legalizing physician assisted suicide is good for society and its valuing and dignifying of all human life. Finally, voters must also consider whether Ballot Question # 2, as formulated, makes for good law.
Although I will conclude this short essay with my personal view, my goal is not to prescribe for others how to vote this coming Tuesday. Rather, I aim to empower Jewish voters with an understanding and knowledge of their religious tradition’s wisdom, as well as stimulate serious consideration of whether or not Physician-Assisted Suicide truly helps individuals facing the end of life and progresses human society. Whatever the outcome of this coming Tuesday’s election, now as before, an observant Jew facing end of life decision-making will still need to consult with his or her Rabbi for halakhic and ethical guidance and spiritual support.
1. Jewish Views on the Value and Dignity of All Human Life
The Jewish tradition consider the value of human life to be near-absolute. The saving of life trumps all mitzvot, save the cardinal sins of idolatry, adultery and murder. In case of medical necessity, one can eat on Yom Kippur, set aside the laws of the Sabbath, eat non-kosher food, etc., regardless of the quality or duration of the life being preserved. Although Judaism accords individuals a good deal of personal autonomy regarding decision-making affecting their person, such autonomy is not unlimited, and personal choice regarding healthcare is principally understood through the metaphor of a custodian’s responsibility for guarding a bailment, i.e., God entrusted us with the use of our bodies during our lifetimes and we are obliged to safeguard this loan of life. Every human being is created in the image of God which affords three essential dignities: infinite value --- i.e., saving a single life is akin to saving an entire world; equality --- no human being is more valuable than another; and individuality --- no too people are exactly alike (Mishnah Sanhedrin 4:5). Judaism has long championed that no individual’s blood is “redder” (i.e., life of greater value) than another’s (BT Sanhedrin 74a). This holds true at the beginning of life as well as at the end of life. Life-Boat ethics that challenge us to triage choices about who to save in extreme, tragic scenarios do not undermine the Jewish truism that every person’s life is of equivalent, infinite value. The first question at hand that a Jewish voter must consider is whether legalizing physician-assisted suicide for terminal patients (who are not in an imminent, active process of dying, which raises other types of end-of-life questions) establishes a cultural valuation that some lives are less worth living?
2. Jewish Views on Suicide, Assisted Suicide and Euthanasia
On a recent Shabbat afternoon at Congregation Shaarei Tefillah, I presented an hour-long shiur covering halakhic views regarding Suicide, (Physician-)Assisted Suicide and Euthanasia. Even an hour-long study was insufficient to a full consideration of these issues. Nonetheless, I shall summarize our study in brief.
In Genesis 9, after Noah and his family, and all the animals, emerge from the Ark after the flood, God blesses Noah and his family and enters into covenant with them. The Torah says: “But --- ve-Akh, for your own life-blood I will require a reckoning: I will require it of every beast; of man, too, will I require a reckoning for human life, of every man for that of his fellow man! Whoever sheds the blood of man, by man shall his blood be shed; For in his image, did God make Man” (Genesis 9:5-6). From the phrase, “for your own life-blood I will require a reckoning,” our Sages learn out that suicide, i.e., murder of self, is included in the Noahide covenantal proscription of murder. Jewish law stigmatizes the person who commits suicide and denies the perpetrator of suicide a standard Jewish burial and denies his/her family the rites of mourning, e.g. eulogy, Shiva (Shulkhan Arukh, Yoreh De’ah, section 345). Assisting suicide is tantamount to aiding and abetting self-murder (the halakhic prohibitions of lifnei 'iver and mesayei’a), and thus should be viewed as a heinous sin in and of itself. Customary halakhic practice judges contemporary suicides as persons acting under psychological duress and thereby grants them a Jewish funeral and allows their family the Jewish rites of mourning (Sh”A Y”D 345:3). It should be noted that one of the hallmarks of the pending ballot legislation is that the decision of a terminal patient to commit suicide is not done under psychological duress, but made soberly with full cognitive faculties and thoroughly considered informed intent and consent. If so, the text-book, but not normally practiced, halakhic strictures regarding a suicide would arguably attach and very likely deny such a suicide traditional Jewish death, burial and mourning rites.
One might have thought that the proscription against suicide in Judaism is absolute, and yet, there are several cases of seemingly tolerated, if not admired, cases of suicide in Tanakh (the Hebrew Bible), rabbinic literature, and Jewish history. A battle injured King Saul falls on his own sword rather than allow himself to be taken captive by the Philistines (I Samuel 31:3-7; cf. Bereishit Rabbah 34:13); four hundred Jewish boys and girls enslaved by the Romans and who were being transported by ship jumped into the sea and drowned themselves rather than endure a life of forced prostitution (TB Gittin 57b); during the First Crusade in 1096, the Jews of Germany committed preemptive suicide, and even preemptive homicide of their children, rather than be forcibly converted to Christianity by the marauding crusader forces. Some of the Ba’alei HaTosafot (12th century Franco-Germany) permitted suicide as an option when facing the threat of forced conversion or grievous torture. Others vigorously disputed this position. Rabbi Shlomo Luria (Poland, 1510-1574) prohibited suicide even in such cases, but would allow it if one held information that if extracted through torture would endanger many more lives. Rabbi Shaul Berlin (1740-1794) in Besamim Rosh (a pseudopigraphic forgery attributed to the Medieval halakhic authority Rosh; for more info click here and here) ruled that suicide is only forbidden if an act of rebellion against God or for if done for a philosophical reason, but not if done to avoid personal suffering. This ruling was widely criticized and universally dismissed. The question of suicide in the face of anti-Semitic persecution, torture and great suffering, emerged time and again throughout Jewish history, most recently during the Holocaust. Rabbi Ephraim Oshry, the rabbi of the Kovno Ghetto, found halakhic justification for those who chose to commit suicide rather than watch their family being brutally murdered. However, he ultimately counsels against suicide for both halakhic, spiritual and social policy reasons (Shut Mimamakim 1:6). Furthermore, according to some authorities, Israeli soldiers facing capture by enemy forces may consider suicide rather than be taken captive, tortured and possibly reveal strategic information that may endanger others. The former Chief Rabbi of Israel, Rabbi Shlomo Goren (1917-1994), justified the suicides of the people of Masada, and his arguments have been applied to the question of suicide by a Jewish soldier facing capture.
Medieval and Modern Halakhic authorities have thus brought complexity and nuance to an issue that would have seemed clear-cut forbidden. However, please note that despite the fact that end-of-life suffering has always been part of the human condition, there has never been a Jewish consideration of suicide as an end-of-life healthcare decision. Suicide has only been countenanced, and even then hotly disputed, in the face of overwhelming persecution. It should also be noted that given great advances in palliative care and psychological therapeutic support, it is very difficult to justify Physician-assisted in light of physical and/or emotional suffering for terminal patients. Thus, the second question at hand is that given the prohibitory weight of Jewish tradition regarding suicide for a terminal patient, physician-assisted suicide or euthanasia, should a Jewish voter support this measure? For further study see “Physician-Assisted Suicide Under Jewish Law” by Professor Steven H. Resnicoff, and “Physician-Assisted Suicide: A Halakhic Approach” by Rabbi Yitzchok Breitowitz.
3. Are Jews Halakhically Required to Vote to Impose or Prevent Laws in Conformity with Traditional Jewish Understandings of Gentiles’ Noahide Obligations?
This important question deserves a full analysis which unfortunately is beyond the scope of this essay. Please consider reading two articles by my teacher and friend Rabbi Michael J. Broyde on this topic: “The Obligation of Jews to Seek Observance of Noachide Laws by Gentiles: A Theoretical Review” and “Jews, Public Policy and Civil Rights: A Religious Jewish Perspective.” In brief, Rabbi Broyde demonstrates that an individual Jew is not required to vote to impose the restrictions of the Noahide covenant upon the general Gentile and Jewish population. Rather, the Jewish voter can make his or her choices based upon a larger consideration, including the vision of the Noahide Covenant, of what is best for society more generally, as well as for its Jewish citizens, more particularly.
This halakhically liberal position on political choice jibes well with a historical observation and inferred generalization: namely, Jews have fared better in more legally liberal societies that maximize individual and group liberties than in more legally conservative societies in which Jews often had to seek legal exemptions through religious accommodations. This is not meant an endorsement of one political party over another or a preference for one candidate over another in this upcoming election. In the moment, many of us try to make our election decisions based on the particular issues and needs of our time rather than on historical generalizations. At the same time, there is in general a Jewish interest in a society that extends broad liberties to its citizenry.
Take, for example, the politically and religiously contentious issue of abortion. Halakhah does not support abortion on demand as a personal choice. Halakhah, however, does confer significant license to terminate a pregnancy under certain psycho-and/or-somatic medical conditions. The consequences of the abortion debate have also proven to go beyond specific scenarios of pregnancy termination and have extended to medical research, such as stem-cell research. It is thus arguably better for Jews to live in a society that broadly allows abortion than in a society that severely restricts reproductive choice, despite the fact that non-medically justifiable, elective abortion would be a transgression of both halakhah for Jews and the Noahide laws for Gentiles. The third question at hand is whether this argument in favor of maximizing personal liberty also holds sway regarding the legalization of physician-assisted suicide?
4. From a Public Health Policy Perspective, is Ballot Question #2 Good for Society? And is it good law?
These questions are currently being vigorously debated. For an excellent presentation of both sides of the issue, consider listening to Tom Ashcroft’s NPR On-Point, featuring as one of the panelists my mentor in Bio-Ethics, Professor Michael Grodin, Professor at Boston University School of Public Health and Resident Ethicist at Boston Medical Center: http://onpoint.wbur.org/2012/10/18/death-on-demand. Professor Grodin argues that Ballot Question #2 is a symptom of wider healthcare problems facing our nation, but not a solution. Proponents of this Ballot Question frame the issue as a matter of autonomy, and indeed there is no greater expression of personal autonomy than the choice whether to continue living or not. However, forty-four million American have no health insurance. Thus, one-sixth of the US population does not have access to adequate end-of-life palliative care or mental health support. In the absence of these fundamental protections, legalizing suicide for many terminal patients creates a false sense of choice. There can be no true choice without the guarantee of the full range of end-of-life treatment and/or support choices. Furthermore, the potential for a privatized for-profit health system to encourage suicide rather than expend extraordinarily costly resources for end-of-life treatment and support is a real slippery-slope concern. $300 for a vial of pills is certainly more cost effective than hospitalization or even hospice. Finally, the law as currently formulated makes no principled distinction as to for whom suicide should or should not be a legal option.
A six-month life prognosis, often a dubious guestimate itself, for a speaking, writing, clear-thinking individual creates an arbitrary scope for the legislation. There is a real slippery-slope concern that should this legislation pass, there will be future attempts to broaden the scope of legalized assisted suicide, and possibly even lean our society toward euthanasia. Once life is no longer sacrosanct and not all lives are equally valuable the door opens to a wider discussion of life valuations and choices for ending lives deemed less valuable. Proponents who argue on the basis of absolute personal autonomy in healthcare and end-of-life decision-making will logically be compelled to allow for a broader legalization of assisted suicide. Thus, the final question at hand is whether Ballot Question #2 is good for society; increases respect for and maintain a maximal valuation of human life; and whether it makes for good law?
Concluding Thoughts:
As mentioned earlier, my purpose is not to decide this issue for anyone else. I believe that every Jewish voter should consider the above four units of questioning in order to cast an informed and reasoned vote. Good Jews and sincere citizens can disagree, at least regarding the last two groups of questions.
In terms of my personal opinion, as an Orthodox rabbi I believe that Judaism does not allow for suicide as an end-of-life decision option for a terminal patient. Assisting suicide would be tantamount to aiding and abetting self-murder. It also contravenes the Noahide covenant, Judaism’s vision of the moral foundation for the good society. I personally believe that the passage of Ballot Question #2 is not essential to the maintenance of a liberal society that affords great personal and group liberties to its citizenry. I have serious concerns that legalizing assisted-suicide will devalue human life and establish that some bloods are “less red” than others in our society. I also am concerned that this legislation will open the door to a more principled consideration of the civil right of people to end their lives at will and enlist the assistance of others, such as physicians.
Of course, the above cold analyses in the abstract cannot compare to cacophony of difficult emotions experienced by individuals and their family and friends in actual end-of-life scenarios. As a rabbi, I have too often sat at the bedside of dying patients and have been present to people experiencing life-ending illness. I have great compassion for individuals facing personal suffering whether in the midst of or at the end of life and have dedicated a significant part of my professional life trying to support people spiritually and emotionally and trying to alleviate their suffering in their moments of pain and crisis. I thus do not take this issue lightly or offer my analysis and opinion glibly. I am deeply thankful that we live at a time when medical technology can treat physical pain through palliative care and alleviate psychic and emotional pain through mental health and social support. End-of-life choices are unfailing difficult. They are not just end-of-life choices, but life choices, as they do not only impact upon our actual end of life, but also express our values and views of life as a whole and the dignity that we afford to it. Vote wisely.
Rabbi Benjamin J. Samuels
Congregation Shaarei Tefillah
35 Morseland Avenue
Newton Centre, MA 02459