Should Terri Schiavo Live or Die? (According to Jewish Teaching)

It is a denial of the Jewish ideal of the fundamental value of life that drives the forces that wish to remove Terri Schiavo's feeding tube.

The Terri Schiavo saga in Florida, where a patient in a vegetative state has recently had her feeding tube reinserted by order of the legislature and governor, reminds us of the reality of modern life. An inescapable result of the extraordinary technological progress of the last several decades has been that critically ill patients who would have died early in their illnesses, often in the relative comfort of their homes, are now kept alive much longer in hospitals, often suffering great pain.

In addition to the component of human misery involved in discussions of medical treatment of the irreversibly ill, the skyrocketing cost of healthcare, particularly the large percentage of healthcare consumed in the last six months of life, have led to calls to limit "futile" treatments. Today, when there are almost limitless therapeutic options but limited economic resources, society may not be willing to provide "useless" therapies to patients who will not benefit.

In secular ethics discussions, medical futility encompasses several issues only loosely related to one another. Futility of treatment is often confused with "futility" of life. The Torah teaches us that every moment of life is intrinsically valuable; life itself is never futile. Rabbi Shlomo Zalman Auerbach, a leading halachic authority of the past generation, points out that we have no "yardstick" by which to measure value of life. Even for a deaf, demented elderly man, incapable of doing any mitzvot, we must violate the Shabbat to save his life.1 It is not within our moral jurisdiction to decide what quality of life is "not worth living" and therefore unworthy of treatment.2

The only components that are open to halachic debate are those involving futility of treatment. From a Jewish perspective, we must ask whether the physician may withhold, and whether the patient may refuse, futile therapy.

The intrinsic value of life does not necessarily imply that every patient must be treated in every instance. Nor does this mean that we do not appreciate that death may be preferable to a life of extreme pain.3 As Rabbi Auerbach writes, we may pray for the death of a terminally ill patient4 who is in great pain, but we must never do anything to hasten his death. He also recognizes that inaction is sometimes the best approach when life is "bad and bitter."5 Despite the obligation to treat even the sickest patients, it is well established that patients do have limited autonomy in refusing treatment for terminal conditions, particularly when they are in intractable pain.6

Medical futility is a recognized concept in Jewish law.7 A treatment that will not reverse the condition to which it is being applied, even if successful, is an example of true medical futility. Performing CPR on a terminally ill patient whose heart has stopped -- not because of a cardiac abnormality, but because the patient has reached the point at which his body can no longer support life -- is truly futile and may be withheld.8 Reviving the patient may be possible, but cardiac arrest will almost certainly recur within a very short time.

This can be contrasted with performing CPR on an otherwise healthy individual who develops an irregular heart rhythm that will result in sudden death. If resuscitation is successful, the arrhythmia may be treated and the patient may live a long life. It goes without saying that this second patient must be resuscitated because the therapy is helpful and sometimes even curative.

But, independent of the aspect of futility, in the case of the first patient, halacha would likely dictate that intervention is forbidden because of the principle of "goses" (the moribund patient). A patient on his deathbed, for whom no cure is possible and death will inevitably occur within three days, may not be disturbed at all and must be allowed to die.9 The Mishna compares the life of the goses to a flickering flame that will be extinguished if even slightly disturbed.10

Interestingly, the "goses" may not be touched at all except for comfort measures.11 Practically speaking, this means that when a patient is approaching death, one may not take his temperature, measure his pulse or blood pressure, and certainly may not draw his blood unless curative therapy or comfort measures will be applied based on the test results.12 In circumstances such as these, the physician may grounds in Jewish law to refuse to administer the "futile" therapy.

A second form of futile therapy involves a treatment that is extremely unlikely to be successful, but is intended to reverse the condition to which it is being applied. An example would be a patient with a cancer that has not been shown to be responsive to standard chemotherapy. The physician may offer the chemotherapy. But clearly, according to Rabbi Moshe Feinstein, if the patient is in intractable pain and the therapy is not proven to be efficacious, the patient may refuse the physician's offer of a "futile" therapy that prolongs life without a reasonable expectation of cure or relief of pain.13

Rabbi Feinstein further states that in such a situation, the patient should not be treated unless a cure or pain relief is possible.14 Rabbi Shlomo Zalman Auerbach writes that while we cannot force the patient to accept the treatment, the patient should be encouraged to accept the therapy because of the intrinsic value of life lived even in extreme pain.15 Nevertheless, this would be a case where a patient can halachically refuse the futile treatment.

It is important to note that Jewish law clearly distinguishes between terminal illness and progressively debilitating illness (a distinction that is often ignored in secular ethics discussions).

An incurable illness which will likely result in the death of the patient within one year is considered terminal with respect to Jewish law. A patient with such an illness or condition is called a "chayay sha'ah,"16 -- one whose life is "timed" or "time-limited." One who is expected to survive beyond a year is considered a "chayay olam" -- one whose life is considered "eternal" in the sense that their life expectancy is presumed indefinite and not limited.

Thus, in halacha, persistent vegetative state and Alzheimer's disease are not terminal conditions, per se, despite the fact that they are progressive, irreversible and inevitably result in death. Halacha insists that patients with these illnesses deserve the same full range of treatment that is made available to any other patient. They are not "terminal" (until the very end stages of their illnesses) and must be aggressively treated without regard to the apparent "futility" of their lives.

Let us take the example of Terri Schiavo. She is not brain dead nor is she terminally ill. She is brain damaged and remains in what appears to be a persistent vegetative state. All of her bodily functions are essentially normal, but she lacks the ability to "meaningfully" interact with the outside world (although her parents claim that she does minimally respond to their presence and to outside stimuli).

Her impairment is cognitive and Judaism does not recognize any less of a right to treatment for one cognitively impaired than one mentally astute.

It is a denial of the Jewish ideal of the fundamental value of life that drives the forces that wish to remove Terri Schiavo's feeding tube. While Judaism does recognize quality of life in certain circumstances (such as the incurable terminally ill patient in intractable pain mentioned above), the Torah does not sanction euthanasia in any situation. To remove the feeding tube from a patient whose only impairment is cognitive is simply murder.

We must ask ourselves when we view images of cognitively impaired patients such as Terri Schiavo whether the pain that we feel is Terri's or whether it is our own. While we may suffer watching movies of the severely brain damaged, it is our own thoughts of the horror of a life without cognition that drives us to project that pain onto the victim who may not be suffering at all.

The key to analyzing any situation is to realize that good ethics start with good facts. One must provide the posek (halachic decisor) with an accurate, honest, and thorough assessment of the patient's medical condition. Only then can a halachically valid and ethically proper decision be made.

Adapted from an article that appeared in Viewpoint: National Council of Young Israel, Winter 1996 entitled: "HALACHIC ISSUES REGARDING FUTILITY OF MEDICAL TREATMENT: Applications To Nutrition And Hydration In The Terminally Ill Patient

1 Auerbach, Rav Shlomo Zalman, "Responsum Regarding a Very Sick Patient," Halacha U'Refuah, vol. 3, p60

2 Auerbach, Rav Shlomo Zalman, "Treatment of the Dying," Halacha U'Refuah, vol. 2, p. 131: "a person is not master of his body to relinquish even one moment"

3 Aruch Hashulchan, Yoreh Deah, 339:1: "...even though we see that he is suffering greatly in his moribund state (a goses) and death would be preferable, nevertheless it is forbidden to do anything to hasten his death, for the world and everything in it belongs to Hashem, and this is His will."

6 Feinstein, Rav Moshe, Igros Moshe, Choshen Mishpat II, Volume 7, siman 74, p.311-315.

7 Eisenberg, Dr. Daniel, "Futility of Treatment," Maimonides: Health in the Jewish World, Vol. 2, No. 3, Fall, 1996

12 Opinion of Rav Auerbach in: Abraham , Dr. Abraham S. The Comprehensive Guide to Medical Halacha, Revised edition, Chpt. 38, p.192, 1996 and Nishmas Avraham, Yoreh Deah, siman 339, sif katan 3, p.444

15 "Treatment of the Dying (Goses)," Halacha U'Refuah, vol. 2, p. 131:: "if the patient is G-d-fearing and mentally intact, try very hard to convince him that better is one moment of tshuvah in this world than eternity in the world to come" 16 Feinstein, Rav Moshe, Igros Moshe, Choshen Mishpat II, Volume 7, siman 75:1, p.315

Abraham, Abraham S.: The Comprehensive Guide to Medical Halacha, revised edition, Feldheim Publishers, 1996

Angel, Rabbi Marc D.: Halacha and Hospice. Journal of Halacha and Contemporary Society XII: 17-26, 1986

Berman, Rabbi Anshel: From the Legacy of Rav Moshe Feinstein, z"l.. Journal of Halacha and Contemporary Society XIII: 5-19, 1987

Bleich, Rabbi J. David: Judaism and Healing: Halakhic Perspectives, Ktav Publishing House, Inc. 1981

Friedman, Dr. Fred: The Chronic Vegetative Patient: A Torah Perspective. Journal of Halacha and Contemporary Society XXVI: 88-109, 1993

Herring, Rabbi Basil F.: Euthanasia. Jewish Ethics and Halakhah for Our Time, Ktav Publishing House, Inc. Yeshiva University Press, 67-90.

Ifrah, Rabbi A. Jeff: The Living Will. Journal of Halacha and Contemporary Society XXIV: 121-152, 1992

Jakobovits, Rabbi Immanuel, The Dying and Their Treatment, Jewish Medical Ethics, Bloch Publishing Company, 119-125, 1975

Rosner, Dr. Fred: Jewish Perspectives On Issues of Death and Dying. Journal of Halacha and Contemporary Society XI: 50-69, 1986

Rosner, Dr. Fred and Rabbi Moshe D. Tendler: Death and Dying, Practical Medical Halacha, Third Revised Edition, Association of Orthodox Jewish Scientists, Ktav Publishing House.

Rosner, Dr. Fred: Rationing of Medical Care: The Jewish View. Journal of Halacha and Contemporary Society VI: 21-32, 1983

Rosner, Dr. Fred: Rabbi Moshe Feinstein on the Treatment of the Terminally Ill, Modern Medicine and Jewish Ethics, Ktav Publishing House, Inc. Yeshiva University Press, 233-246, 1991

Schostak, Rabbi Zev: Ethical Guidelines for Treatment of the Dying Elderly. Journal of Halacha and Contemporary Society XXII: 62-86, 1991

Steinberg, Dr. Avraham: On Death and Dying. A Concise Response: Jewish Medical Law, Beit-Shamai Publications, Inc., 148-154, 1989

Weiner, Rabbi Yaakov: Ye Shall Surely Heal: Medical Ethics From a Halachic Perspective, Jerusalem Center For Research, 1995

Zwiebel, Chaim Dovid: A Matter of Life and Death: Organ Transplants and the New RCA "Health Care Proxy". The Jewish Observer, Summer 1991: 11-14

A Matter of Life and Death-- Revisited. The Jewish Observer, October, 1991: 11-22 (Letters of response by Rabbi Moshe D. Tendler, Dr. Yoel Jacobovits, and Chaim Dovid Zwiebel)

This is always worth a repost ... Terri's condition on December 24, 2004, as seen by her family's attorneys ...

A Visit With Terri Schiavo

Attorney Barbara Weller

This past Christmas Eve day, 2004, I went to visit Terri Schiavo with her parents, Bob and Mary Schindler, her sister, her niece, and Attorney David Gibbs III. The visit took place at the Woodside Hospice for about 45 minutes just before noon.

When I knew I was going to visit Terri with her parents, I had no idea what to expect. I was prepared for the possibility that the Schindlers love their daughter and sister so much that they might imagine behaviors by Terri that aren't actually evident to others. The media and Mr. Schiavo clearly give the impression that Terri is in a coma or comatose state and engages only in non-purposeful and reflexive movements and responses. I am a mother and a grandmother, as well as one of the Schindlers’ attorneys, and I could understand how parents might imagine behavior and purposeful activity that is not really there. I was prepared to be as objective as I could be during this visit and not to be disappointed at anything I saw or experienced.

I was truly surprised at what I saw from the moment we entered the little room where Terri is confined. The room is a little wider than the width of two single beds and about as long as the average bedroom, with plenty of room for us to stand at the foot of her bed. Terri is on the first floor and there is a lovely view to the outside grounds of the facility. The room is entered by a short hallway, however, and there is no way for Terri to see out into the hallway or for anyone in the hallway to observe Terri.

From the moment we entered the room, my impression was that Terri was very purposeful and interactive and she seemed very curious about the presence of obvious strangers in her room. Terri was not in bed, but was in her chair, which has a lounge chair appearance and elevates her head at about a 30-degree angle. She was dressed and washed, her hair combed, and she was covered with a holiday blanket. There were no tubes of any kind attached to her body. She was completely free of any restraints that would have indicated any type of artificial life support. Not even her feeding tube was attached and functioning when we entered, as she is not fed 24 hours a day.

The thing that surprised me the most about Terri as I took my turn to greet her by the side of her chair was how beautiful she is. I would have expected to see someone with a sallow and gray complexion and a sick looking countenance. Instead, I saw a very pretty woman with a peaches and cream complexion and a lovely smile, which she even politely extended to me as I introduced myself to her. I was amazed that someone who had not been outside for so many years and who received such minimal health care could look so beautiful. She appeared to have an inner light radiating from her face. I was truly taken aback by her beauty, particularly under the adverse circumstances in which she has found herself for so many years.

Terri’s parents, sister, and niece went immediately to greet Terri when we entered the room and stood in turn directly beside her head, stroking her face, kissing her and talking quietly with her. When she heard their voices, and particularly her mother's voice, Terri instantly turned her head towards them and smiled. Terri established eye contact with her family, particularly with her mother, who spent the most time with her during our visit. It was obvious that she recognized the voices in the room with the exception of one. Although her mother was talking to her at the time, she obviously had heard a new voice and exhibited a curious demeanor. Attorney Gibbs was having a conversation near the door with Terri’s sister. His voice is very deep and resonant and Terri obviously picked it up. Her eyes widened as if to say, “What’s that new sound I hear?” She scanned the room with her eyes, even turning her head in his direction, until she found Attorney Gibbs and the location of the new voice and her eyes rested momentarily in his direction. She then returned to interacting with her mother.

When her mother was close to her, Terri’s whole face lit up. She smiled. She looked directly at her mother and she made all sorts of happy sounds. When her mother talked to her, Terri was quiet and obviously listening. When she stopped, Terri started vocalizing. The vocalizations seemed to be a pattern, not merely random or reflexive at all. There is definitely a pattern of Terri having a conversation with her mother as best she can manage. Initially, she used the vocalization of “uh’uh” but without seeming to mean it as a way of saying “no”, just as a repeated speech pattern. She then began to make purposeful grunts in response to her mother’s conversation. She made the same sorts of sound with her father and sister, but not to the same extent or as delightedly as with her mother. She made no verbal response to her niece or to Attorney Gibbs and myself, but she did appear to pay attention to our words to her.

The whole experience was rather moving. Terri definitely has a personality. Her whole demeanor definitely changes when her mother speaks with her. She lights up and appears to be delighted at the interaction. She has an entirely different reaction to her father who jokes with her and has several standing jokes that he uses when he enters and exits her presence. She appears to merely “tolerate” her father, as a child does when she says “stop” but really means, “this is fun.” When her father greets her, he always does the same thing. He says, “here comes the hug” and hugs her. He then says, “you know what’s coming next---the kiss.” Her father has a scratchy mustache and both times when he went through this little joke routine with her, she laughed in a way she did not do with anyone else. When her father is ready to plant the kiss on her cheek, she immediately makes a face her family calls the “lemon face.” She puckers her lips, screws up her whole face, and turns away from him, as if making ready for the scratchy assault on her cheek that she knows is coming. She did the exact same thing both times that her father initiated this little routine joke between the two of them.

The interactions with her family and our appearance in her room appeared to require some effort and exertion from Terri. From time to time, she would close her eyes as if to rest. This happened primarily when no one was paying particular attention to her, but we were talking among ourselves. After a few minutes or when one of the visitors approached her and started to talk directly to her again, Terri would open her eyes and begin her grunting sounds again in response to their conversations. Although I approached her, leaned close and stroked her arms and spoke to her, she did not verbally respond to me.

Terri’s hands are curled up around little soft cylinders that help her not to injure herself. I understand that these contractures are likely very painful, although there was a time when Terri was receiving simple motion therapy when her hands and arms relaxed and were no longer as constricted. When the therapy was discontinued by order of her guardian and the court, the contractures returned. These contractures would apparently be avoidable if Terri were given the simple range of motion therapy she previously received. It is very sad to observe firsthand these conditions that make her life more difficult, but that would be correctable with little effort.

When we were preparing to leave, the interactions with Terri changed. First, she went through the joke routine with her father and the “lemon face.” When her niece said goodbye to her, Terri did not react. Nor did she react to me or to Attorney Gibbs when we said our goodbyes to her. When her sister went to her to say goodbye, Terri’s verbalizations changed dramatically. Instead of the happy grunting and “uh uh” sounds she had been making throughout the visit, her verbalizations at these goodbyes changed to a very low and different sound that appeared to come from deep in her throat and was almost like a growl. She first made the sound when her sister said goodbye and then, amazingly to me, she made exactly the same sound when her mother said goodbye to her. It seemed Terri was visibly upset that they were leaving. She almost appeared to be trying to cling to them, although this impression came only from her changed facial expression and sounds, since her hands cannot move. It appeared like she did not want to be alone and knew they were leaving. It was definitely apparent in the short time I was there that her emotions changed—it was apparent when she was happy and enjoying herself, when she was amused, when she was resting from her exertion to communicate, and when she was sad at her guests leaving. It was readily apparent and surprising that her mood changed so often in a short 45-minute visit.

I was pleasantly surprised to observe Terri’s purposeful and varied behaviors with the various members of her family and with Attorney Gibbs and myself. I never imagined Terri would be so active, curious, and purposeful. She watched people intently, obviously was attempting to communicate with each one in various ways and with various facial expressions and sounds. She was definitely not in a coma, not even close. This visit certainly shed more light for me on why the Schindlers are fighting so hard to protect her, to get her medical care and rehabilitative assistance, and to spend all they have to protect her life.

I realize that Terri has good days and bad days. There are obviously days when she does not interact with her family, as they had previously told us. There are also apparently days when Terri is even more interactive and responsive to them than she was on the day I visited. Since this visit I am more convinced than ever that the Schindlers are not just parents who refuse to let go of their daughter. There really is a lot going on with their daughter and potentially, it seemed obvious to me, Terri could improve even more with appropriate care and 24 hour a day love that can only come from a dedicated family. As I watched her, my foremost thought was that on the next day, Christmas, Terri should not have been confined to her small room in a hospice center, nice as that room was, but that she should have been gathered around the Christmas dinner table enjoying the holiday with her family.

MEDIA: Call the Gibbs Law Firm Media Director, Mr. Keith Brickell, at O:727-399-8300 or C:727-458-4824 to arrange an interview with Attorney David Gibbs III or Attorney Barbara Weller. He can be reached by email: kbrickell@gibbsfirm.com.

The Terri Schindler-Schiavo Foundation is the official organization responsible for speaking on behalf of the Schindler family. For more information and background on the case, visit the foundation’s website at www.terrisfight.org.

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