Unpacking the Iggerot: Davening for Death

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Davening for Death / Iggerot Moshe, H.M., vol. 2, #73

Summarizing the Iggerot

One of the hallmarks of Rabbi Moshe Feinstein’s legacy is undoubtedly his significant contribution to the field of Jewish medical ethics. His writings are vast, and the subsequent literature which builds on his rulings is all the more so. In this column we will explore his approach to end-of-life issues, with a focus on quality of life, patient autonomy, and abortion.

In the early 1980s, as his own health was waning, R. Feinstein was forced not only to contemplate his own mortality, but to provide much needed guidance for countless other Jews whose days in this world were winding down. While some are fortunate enough to pass away peacefully in their sleep, the reality for many spending their final days in a hospital bed, hooked to equipment, is anything but that. Two doctors inquired what, if anything, could be done to end the suffering of a terminal patient.

As a prooftext, R. Feinstein, in his creative fashion, proffered not a legal passage, but an account of the final days of Rabbi Yehuda HaNasi:

On the day that Rabbi [Yehuda HaNasi] died, the Sages decreed a fast, and begged for [Divine] mercy [so that he would not die]. And they said: Anyone who says that Rabbi [Yehuda HaNasi] has died will be stabbed with a sword. The maidservant of Rabbi Yehuda HaNasi ascended to the roof and said: The upper [realms] are requesting Rabbi [Yehuda HaNasi], and the lower [realms] are requesting Rabbi [Yehuda HaNasi]. May it be the will of God that the lower [worlds] should impose [their will] upon the upper [worlds]. When she saw how many times he would enter the bathroom and remove his phylacteries, [and then exit] and put them back on, and how he was suffering [with his intestinal disease], she said: May it be the will of God that the upper [worlds] should impose [their will] upon the lower [worlds]. And the Sages [meanwhile] would not be silent, from begging for mercy [so that Rabbi Yehuda HaNasi would not die]. So she took a jug and threw it from the roof to the ground. [Due to the sudden noise, the Sages] were [momentarily] silent and refrained from begging for mercy, and Rabbi [Yehuda HaNasi] died.

Based on the Ran (Nedarim 40a), R. Feinstein infers from this Talmudic passage that one may,  and perhaps even should, pray for the passing of one who is irreversibly suffering during his final days, in accordance with the deeds of Rabbi Yehuda HaNasi’s maidservant. Moreover, while halakha unequivocally forbids euthanasia, R. Feinstein ruled that the doctors were only mandated to provide the basics such as food, water and oxygen—but not additional drugs that would only delay the death of the suffering patient.

Connecting the Iggerot

While R. Feinstein in principle believed in the propriety of praying for a patient’s passing, he qualifies that such a measure is limited to when one can ascertain that his or her prayers for healing are of no avail. In his responsum to R. Shalom Tendler (H.M. vol. 2, #74, sec. 1 and 4), R. Feinstein notes that only righteous people of great stature who can be confident that they have exhausted their ability to pray for healing may then reverse course and beseech God to ease the suffering individual’s passing.

While R. Feinstein would not permit actively ending life, he drew upon ample precedent to distinguish between the artificial facilitation of death versus enabling nature to run its course. One of his precedents is the passage in the Talmud which describes how during R. Hanina ben Teradyon’s martyrdom, he encouraged the executioner to remove the wet sponges so that he might die faster (Avoda Zara 18a). R. Feinstein does not appear to view this source as dispositive since it is possible that non-Jews are regulated by laxer restrictions than Jews in these matters.

The “star-witness,” if you will, is actually a later ruling codified by the Rema (Y.D. 339:1):

It is likewise forbidden to hasten the death of one who is in a dying condition, e.g., one who has been in a dying condition for a long time, and could not depart — [the law is that] we may not remove the pillow or the mattress from under him [just] because some say that there are feathers from some fowl which cause this [prolongation of death]. He may likewise not be moved from his place. It is also forbidden to place the Synagogue keys under his head in order that he may depart. However, if there is aught which causes a hindrance to the departure of the soul, e.g., [if] near that house there is a knocking sound, viz., a wood-cutter, or there is salt on his tongue, and these hinder the departure of the soul, it is permitted to remove it therefrom, for there is no [direct] act [involved] in this, since he merely removes the hindrance.

R. Feinstein rules (H.M. vol. 2, #74, sec. 2), based on this Rema, that if a patient is in great pain, it is not merely permissible to remove that which is impeding his death, but it is a mitzva to do so.

As noted, R. Feinstein would not go so far as to permit outright euthanasia. Moreover, he required that the doctors provide the patient with standard sustenance, claiming that withholding such basic needs would constitute an active killing of the patient (H.M. vol. 2, #74, sec. 5). Nonetheless, he did permit some active measures such as removing the prostate, effectively castrating the patient, even if it only eased his suffering without buying him more time (H.M. vol. 2, #73, sec. 9).

In addition to R. Feinstein’s incorporation of the patient’s “quality of life,” he also recognized the patient’s personal autonomy as a factor in limited medical scenarios. In principle, a doctor is required to render treatment that will actually heal the patient, even without the latter’s consent (Y.D., vol. 4, #24). There are, however, several exceptions to this:

 Practically, if the patient refuses the treatment and forcing him would risk further deteriorating his condition, it would be counterproductive to pursue such a course of action. Rather, the doctors and those caring for the patient should attempt to persuade him and allay his concerns so that he will accept the treatment by his own volition.

Secondly, the concept of forced-treatment presupposes that the procedure will be successful. When the outcome is far from certain, R. Feinstein allowed the patient’s personal preference to act as a decisive factor (H.M., vol. 2, #73, sec. 5).

The third exception appears in R. Feinstein’s responsum (H.M., vol. 2, #75, sec. 1) to his son-in-law, R. Dr. Moshe Dovid Tendler, who possessed a Ph.D. in microbiology from Columbia University and was his primary consultant in understanding the facts-on-the-ground in the medical field. If a patient is in decline and the doctors cannot offer any viable path toward healing, R. Feinstein ruled that the patient is not required to prolong his own death and may refuse further medical intervention, aside from providing his most basic needs. In R. Tendler’s words, we have a mitzva to prolong life, not to delay death.

R. Eliezer Waldenberg zt”l (1915-2006)

Challenges to the Iggerot

Leading the charge against many of R. Feinstein’s critical medical rulings was R. Eliezer Waldenberg, the halakhic authority of Shaare Zedek Hospital in Jerusalem, and author of the monumental responsa Tzitz Eliezer. R. Waldenberg was flabbergasted (Tzitz Eliezer, vol. 5, Ramat Rahel #5) by R. Feinstein’s citation of the deeds of R. Yehuda HaNasi’s maid-servant as an halakhic prooftext. In the Talmudic account, the Sages prayed to keep their teacher alive while the lone maidservant sought to facilitate his passing. One would think, R. Waldenberg argues, that in a dispute between religious scholars on one side and a maid-servant (righteous as she may be) on the other side, that we ought to take our halakhic cues from the former.

R. Waldenberg takes further issue with R. Feinstein’s underlying premise that suffering and distress are grounds for giving-up on the patient. R. Waldenberg (ibid., #28) adduces a recurring theme in Rabbinic literature that one can acquire his share in the World to Come in a moment of sudden repentance. The power of one moment is invaluable and accordingly the doctors are required to persevere against all odds. He further supports this from the Mishnah in Sota (22b) which indicates that it is preferable for a sota’s life to be prolonged in pain rather than to perish immediately (ibid., #29). Both the soul and the body belong to their Creator and it is not mankind’s prerogative to forfeit them (Tzitz Eliezer, vol. 10, #25, ch. 6).

Reflecting on the Iggerot

This topic is certainly not the only instance in which R. Feinstein and R. Waldenberg went head-to-head. Perhaps the most iconic (and most contentious) disagreement they had was about the nature of abortion. R. Feinstein (H.M., vol. 2, #69; #73, par. 8) classified abortion as murder, while R. Waldenberg (Tzitz Eleizer, vol. 13, #102) classified it as a Rabbinic prohibition, which could be superseded in a case of significant distress, such as a fetus with Tay-Sachs or another condition which would engender physical or psychological agony for the child or parents.

Oddly, in their debate on end-of-life issues, R. Feinstein adopts a flexible stance which takes personal distress into account, while R. Waldenberg advocates fighting until the last breath, regardless of prolonged torment. In the case of abortion, they appear to reverse positions: R. Feinstein becomes inflexible while R. Waldenberg is willing to authorize an abortion in an array of challenging cases.

R. Dr. Harel Gordon (HaRav Moshe Feinstein: Hanhaga Hilkhatit be-Olam Mishtane, 315-316) suggests that rather than view these as two independent disputes, both sides are actually consistently applying the same principles to both scenarios. R. Feinstein looks at the potential: The patient is about to die; the fetus is about to become a full living baby. R. Waldenberg looks at the immediate reality: The patient is still alive; the fetus is not yet a bona fide human being.

We should further note that even R. Waldenberg who propounds a notably liberal position on abortion is not doing so on the basis of Liberal (with a capital L) ideology. His permissive approach to abortion is not predicated on the basis of bodily autonomy. This is both evident from his immediate responsa on the topic and is logically consistent with how he fundamentally opposed R. Feinstein’s proposal of patient autonomy as a factor in the halakhic decision-making process. The soul and the body are God’s—and the debate is only a matter of how we can best comprehend His will.

R. Feinstein has significantly shaped our understanding of Jewish medical ethics, particularly how we approach the most delicate matters of end-of-life. His philosophy is best captured by R. Tendler, who, as we mentioned, served as an expositor for his father-in-law, especially on medical matters:

Judaism espouses the principle of the infinite value of human life and requires that all biblical and rabbinic commandments (except the cardinal three) be waived to save a human life. Physicians are divinely licensed and obligated to heal, and patients are mandated to seek healing from physicians. Any deliberate hastening of death of even a terminally ill patient is prohibited as murder. Active euthanasia is not allowed in Judaism. A physician is only obligated to heal when he has some medical treatment to offer the patient. If the patient is dying from an incurable illness and all therapy has failed or is not available, the physician’s role [transitions] from that of a curer to that of a carer. Only supportive care is required at that stage such as food and water, good nursing care and maximal psychosocial support.

If a patient near death is in severe pain and no therapeutic protocol holds any hope for recovery, it may be proper to withhold any additional pharmacological or technological interventions so as to permit the natural ebbing of the life forces. The physician’s role at that point may be limited to providing pain relief. Experimental therapy, if available, is an option which the patient can accept or reject, particularly if significant side effects are anticipated. Judaism is concerned about the quality of life, about the mitigation of pain, and the cure of illness wherever possible. If no cure or remission can be achieved, nature may be allowed to take its course. To prolong life is a mitsva, to prolong dying is not (Moshe D. Tendler and Fred Rosner, “Quality and Sanctity of Life in the Talmud and the Midrash” TRADITION Fall 1993), 20).

Endnote: While we limited the debate on end-of-life issues to R. Feinstein and R. Waldenberg, there were indeed many other rabbinic giants who opined on these matters. For instance, see Responsa Minhat Shlomo (vol. 1, #91, sec. 22; vol. 2, #82, sec. 4). R. Tendler and Dr. Rosner provide a comprehensive summary of positions at the end of their aforementioned article (fn. 8). See also Petihat ha-Iggerot (462-469; 631-638).

Moshe Kurtz serves as the Assistant Rabbi of Agudath Sholom in Stamford, CT, is the author of Challenging Assumptions, and hosts the Shu”T First, Ask Questions Later.

Prepare ahead for the next column (July 18) on maintaining harmony within a family across divides in levels of religious observance:  Iggerot Moshe, Y.D. vol. 1, #54.