'There is a time to be born and a time to die' (Ecclesiastes 3:2a): Jewish perspectives on euthanasia.

Reviewing the publications of prominent American rabbis who have (extensively) published on Jewish biomedical ethics, this article highlights Orthodox, Conservative and Reform opinions on a most pressing contemporary bioethical issue: euthanasia. Reviewing their opinions against the background of the halachic character of Jewish (biomedical) ethics, this article shows how from one traditional Jewish textual source diverse, even contradictory, opinions emerge through different interpretations. In this way, in the Jewish debate on euthanasia the specific methodology of Jewish (bio)ethical reasoning comes forward as well as a diversity of opinion within Judaism and its branches.

Introduction

The Hebrew Bible frequently confronts us with the finiteness of man’s existence. Not only Genesis 3:19b provides this irrefutable wisdom, when uttering the verse “For dust you are and to dust you will return”, a few books further also Ecclesiastes 3:1–2a reminds us of being mortal beings, stating: “There is a time for everything and a season for every activity under heaven: there is a time to be born and a time to die”. Death is an inescapable fact. It is an absolute truth. The certainty of death, however, is covered up with mysteries. Much as our death is certain, the circumstances in which we will die are not predictable. Death’s time, place and circumstances—as a result of old age, accident or illness—are beyond reach of human knowledge. “It is in God’s hands”, so would many religious people—whether Christian, Muslim or Jewish—say. As finite beings, we all are susceptible to death and illness.

Today, the realm of death and illness has changed. During the past decades, biomedical technology has developed significantly. As a result of this medical revolution, the power of humankind within the domain of life and death has increased. Making use of available biomedical technology human beings are not only able to control and cure diseases, but also to regulate their own life project, even their own death. Consequently, during recent years we are all the more confronted with ethical challenges and questions. Human beings, adhering to a specific worldview or religious tradition, deal with these ethical issues in various ways. One’s worldview, one’s conception of transcendence and immanence—in other words, the way everything is according to a situated human being—influence one’s opinion on what ought to be (Newman 2005, pp. 18–19; Gielen et al. 2009), for example what ought to be done when confronted with terminal illness and unbearable pain.

The aim of this article is to explore Jewish perspectives on a most pressing contemporary bioethical issue: euthanasia. This quest is considered within the broader framework of the specificities of Jewish (biomedical) ethics and its methodology. Therefore, this article will first shed a brief light on the Jewish religious tradition as such and attention will be paid to religious convictions and ethical reasoning of the three largest branches of Judaism: Orthodox, Reform and Conservative. After this short introductory note, the central topic of this article is addressed: how does the Jewish tradition cope with euthanasia? First, Jewish textual sources are quoted, which are usually referred to and interpreted when the ethical question of euthanasia is addressed. Next, we show how different rabbis—we made a selection of prominent rabbis and poskim (specialists of Jewish law) from the three largest Jewish branches—reach diverse, even opposite, conclusions with regard to euthanasia, based on their interpretation of these sources. In this way, the threefold aim of this article is met: (1) presenting a non-exhaustive overview of Jewish perspectives on euthanasia, which reflects (2) the characteristic text-centeredness of Jewish (bio-)ethical reasoning and (3) Judaism’s essential diversity and the specific features of its largest branches.

Although Reconstructionism is a full-fledged Jewish movement in the United States, within the scope of this article, we decided not to include Reconstructionist reflections on the matter at hand, as the Reconstructionist movement is substantially smaller than the Orthodox, Reform and Conservative branch of Judaism, considered on a world wide as well as American scale. The 2000–2001 National Jewish Population Survey (NJPS) indicates that only 2% of American Jews considers themselves to be Reconstructionist, in contrast tot 13% Orthodox, 26% Conservative and 34% Reform (Ament 2005). Yet, for Reconstructionist reflections on end-of-life practices and ethics, consult Teutsch (2005) and ‘Behoref Hayamim’ (Reconstructionist Rabbinical College 2002).

Definition of Jewish Identity

Since the purpose of this article is to present Jewish religious opinions on euthanasia, this article covers only a small part of the Jewish world total, for only a minority of the approximately 14 million Jews worldwide can be characterized as religious. Often, it is assumed that because a person is a Jew, he/she adheres to the Jewish religion. S. Brachfeld (2000, p. 9), however, indicates that only 15–20% of all Jews is religious. Yet, exact figures on this do not exist and only estimations can be indicated. Still, it can be argued that the Jewish religion in fact “divides the Jewish people today, perhaps almost as much as it divides Jews from non-Jews” (de Lange 2000, p. 2). The majority of contemporary Jews are only Jewish in an ethnical sense: their Jewishness has nothing to do with religion or with God. These non-religious Jews are secular Jews, whose daily life choices are not guided by the world of Jewish sacred texts. “Some of these Jews may be atheists; many may be simply indifferent to Judaism, about which they know very little. Many nonetheless continue to regard themselves as ‘good Jews’” (Neusner 1975, p. 6). Non-religious Jews perceive the Jewish faith as a “traditional, folkloristic, mystical or historical part of the ancient culture” (Brachfeld 2000, p. 9). Religious Jews, on the other hand, adhere to a specific world view and way of life and are embedded in a religious community (Neusner 2006, pp. 2–3). For them God is central, and their daily life choices are guided by the path God stipulated for them in prescriptions and commandments (mitzvoth). Nevertheless, as will appear in this article, representing religious Judaism one-sided would do harm to its essential variety.

The (Heterogeneous) Specificity of Jewish Ethics

Indeed, characterizing religious Judaism is utmost delicate. Schulweis (1995, p. 25) expresses this inner-Jewish heterogeneity through the symbol of “a broad river with multiple branches running into the sea”. The largest Jewish branches are Orthodox, Conservative and Reform Judaism. Before turning to this in detail, the characteristic properties of Jewish ethics are highlighted.

Jewish (biomedical) ethics—like all ethics—starts from an issue which is experienced as problematic. The specificity of Jewish ethics consists in providing an answer to this question by addressing religious authorities, whose writings are preserved in traditional Jewish literature. In other words, confronted with a (contemporary) ethical question, rabbis address the rich Jewish tradition (of textual sources) in order to provide an answer. Jewish ethical reflection arises out of specific cases: individual Jews—confronted with an ethical dilemma—can ask a rabbi for guidance. In this sense, Jewish ethics is case-based and concentrated on concrete human behavior rather than on general claims of faith and theology (Kellner 1978, p. 5): “It’s a tradition of ongoing questioning rather than one of absolute theological law passed down from above” (Goldsand et al. 2001, p. 221). Noticing this, Jewish ethics makes use of a bottom-up approach.

As Jewish revelation theology indicates, traditionally Judaism has been a law-based religion, with virtually all aspects of life governed by a comprehensive system of laws, called halacha (Newman 1992). Literally, halacha means ‘the way’ and is referred to as the Jewish religious law which can be defined as follows: “normative rules for conduct, laws that instruct the faithful on the sanctification of everyday life” (Neusner 2002, p. vii). The Jewish law consists of a corpus of texts, ranging from the Torah, the Talmud, Codes of Jewish law, to modern responsa—written in question (she’eilah) and answer form (teshuvah)—which try to apply Talmudic discussions and regulations to contemporary circumstances and specific cases. Noticing this, Jewish legal and ethical reasoning consists of an interpretation of these sources. “The Jewish ethicist discovers within God’s revelation norms that can guide us in the present. The traditional rabbi, much like judges in a common law system, finds the proper precedents within this biblical and rabbinic literature and then applies them to the case at hand” (Newman 1992, p. 311).

Of course, in this process interpretation plays a crucial role, as well with regard to getting acquainted with the case at hand, as with regard to distilling relevant literature and principles. The complexity and the contextual nature of halachic questions implies that there is a variety of (halachically valid) answers to one question. The heterogenic characteristic of Jewish ethics is also influenced by the way in which the authority of halacha is perceived. There exists—within Judaism—a range of opinions on the normativity and authority of these traditional texts. As a result, Jewish ethical reasoning depends on rabbis’ and ethicists’ concrete interpretive process and on the perceived status of halacha, as either normative or advising (Ellenson 1995). Nevertheless, the ethical decision-making process is always—exclusively or not exclusively—halachic (Mackler 2003, p. 45; Jage-Bowler 1999, p. 219).

Jewish Branches

The heterogenic characteristic of Jewish ethics has to be situated against the background of an inner-Jewish heterogeneity. In response to modernity and Enlightenment in nineteenth century Germany different movements have originated within the Jewish tradition, whose ascribing significance to the religious tradition when answering ethical questions is quite divergent. Yet, the three largest branches of the Jewish faith tradition—Orthodox, Conservative and Reform—even reflect an inner diversity. Nevertheless it is possible to describe some common tendencies, with regard to theological convictions and ethical reasoning, within each movement. Given that few contemporary Jews world wide and even in the United States consider themselves to be Reconstructionist (Ament 2005) we choose explicitly to stick to the three largest movements of Judaism and not to expand on Reconstructionist Judaism.

The three branches can be situated on an axis, on which the Orthodox and Reform movement constitute the opposite extremes, while the Conservative branch occupies an intermediate position. The Orthodox branch, which originated in response to the Reform movement to protect the integrity of the Jewish faith, is situated on the right side of the axis, being the most traditional of the largest movements, as it considers the Torah as the direct and definite revelation of God’s will (Kellner 1978, p. 16). Orthodox Jews believe that God has revealed the Torah to Moses literally, word by word, “in a form identical to our printed text” (Mackler 2000, p. 7). Consequently, in their opinion, Torah and Talmud are divinely inspired and revealed and are essentially unchanging and immutable. Concerning ethics, halacha is considered as being the will of God, normative for all Jews, living in all times and at all places (Kellner 1995, p. 17; Zemer 1999, p. 41).

Confronted with contemporary ethical issues, Orthodox rabbis or poskim—halachic specialists—address the halacha as an absolute divine norm, believing that Jewish law has to guide Jews through their lives and daily life choices. Their traditional ethical decision-making process is often described as a legal model or as “halakhic formalism” (Ellenson 1995, p. 130), consisting of halachic analysis resulting in interpretations that become normative and binding on Orthodox adherents. Yet, the Orthodox Jewish community is not monolithic, taking for instance the lack of a coordinating Orthodox Jewish body, and consequently, the lack of definitive, authoritative halachic rulings into account. All rabbis have the right to investigate an ethical dilemma and to give a (binding) answer through an interpretation of the sources. The weight ascribed to this decision depends on different factors, for instance the reputation of the rabbi as specialist or posek (in a certain halachic domain) (Flancbaum 2001, p. 31). Anyhow, rabbinic authority is most central (Mackler 2003, p. 52).

On the other side of the spectrum, on the left side of the axis, Reform Jews hold to a dynamic and progressive revelation. Torah is mainly seen as a human writing, based upon human beings’ understanding of God’s will. Similarly, the Talmud is considered not to be divine, but human in origin, as a human analysis of the laws of the Torah as they were understood in Talmudic times (Jacob 1987, p. xx). As the “God-given authority” (Freehof 1960, p. 21) of rabbinic literature is denied, Reform Jews reject halacha as eternal and universal norm which exceeds space and time (Freehof 1960, pp. 5, 20). Indeed, the early Reform movement was even “averse to the rabbinical literature, the Talmud and the codes, which were the source of the rabbinical authority” (Freehof 1960, p. 15), stressing its biblical and prophetic inspiration. The halachic tradition was viewed as “rigid and arcane, a relic of another time” (Newman 2005, p. 133). In the contemporary Reform branch, this antinomian tendency “remains part of the Reform perspective” (Jacob 2004, p. 72), but it is weakened to a large extent. Nowadays, looking for an answer to a contemporary ethical question, halacha is addressed. It can offer guidance to individuals but has no binding authority (Freehof 1960, pp. 21–22, 1969, p. 7; Cohen 2005; Newman 1995, p. xxi). Although a rabbi can give advice, “individual autonomy remains predominant” (Mackler 2003, p. 52; Plaut and Washofsky 1997, p. xv). At the same time, Reform thinkers warn for unbridled autonomy (Plaut and Washofsky, pp. xvii–xxi) and plead for a “harmony between discipline and freedom, between loyalty and individuality” (Freehof 1974, p. 6). Thus, the responsa of the Central Conference of American Rabbis (CCAR) try to guide and advise Reform Jews with regard to their daily (autonomous) life choices (Freehof 1960, p. 22; Plaut and Washofsky 1997, p. xxviii).

The Conservative movement, which originated as a traditionalist response to Reform Judaism, occupies an intermediate position. It constitutes a compromise between the Orthodox and Reform branch. Torah and Talmud are regarded as both divine in origin, but significantly shaped “by human reception, transmission and interpretation” (Mackler 2000, p. 7; Mackler 2003, p. 48; Küng 1992, p. 429). In contrast to Orthodox Judaism, Conservative Jews do not consider Torah as a literal account of God’s words. The Jewish people’s divine experiences are the source and essence of halacha, which is liable to changes and historical developments. Yet, although being a historical developed entity, halacha plays a definite and normative role. Conservative Jews assume that qualified rabbis can reinterpret and change Jewish law, as the historical context of the Biblical times does not necessarily reflect our contemporary context. The rabbi is looked upon as a halachic guide, who interprets Jewish law from a contemporary perspective, taking into account its historical development. In this sense, the ethical model triumphing in this movement is “tradition and change” (Küng 1992, pp. 430–432; Mackler 2000, p. 7). Within the Jewish Conservative community the Committee on Jewish Law and Standards (CJLS) of the Rabbinical Assembly, decides upon halachic questions. The CJLS can proclaim official halachic positions of the Conservative movement. Yet, also deviant opinions, without official recognition of the committee are tolerated. Moreover, as stated on the website of the Rabbinical Assembly, the advice of the local rabbi has to be taken into account. When deciding upon an ethical dilemma the individual’s and rabbi’s authority are usually balanced (Mackler 2003, p. 53).

Summarizing, within each movement halachic literature is addressed when rabbis are confronted with an ethical dilemma. Diversity between the Jewish branches does not consist in a consultation or rejection of halacha, but in the way halacha and its interpretation is perceived, as binding or advising. Simultaneously, we must beware of giving a biased and simplistic portrayal, as Reform, Conservative nor Orthodox Judaism are entirely monolithic. The Reform branch has a non-halachic side (Jacob 2004) and alternative approaches to Jewish ethics are found in all movements (Newman 1995, p. 138–147). Anyway, Jewish ethics is founded on the Torah as primary source—but not necessarily exhaustive or exclusive—and presupposes reference to the Jewish tradition (of interpretation) (Newman 2005, p. 117).

Jewish Religious Sources on Euthanasia

In order to give an overview of Jewish opinions on euthanasia it is essential first to quote some Jewish religious texts which are widely adopted and interpreted when rabbis are discussing euthanasia as an ethical topic. In the next section of this article an overview of Orthodox, Conservative and Reform opinions based on these textual sources is presented. Working in this way we meet the characteristic property of Jewish ethics, namely searching an answer to a concrete ethical concern starting from the textual tradition. Often, from one textual source diverse, even contradictory, opinions emerge through different interpretations.

The first important source, Semahot 1:1–4, is described within the literature of Jewish medical ethics as the laws of goses. Within Jewish religious law a goses is defined as a person who is expected to die within 72 h or 3 days and is recognizable by the death rattle (Jakobovits 1959, p. 349). Because of the weakened condition of the goses and “in order to avoid any risk that an individual caring for a goses would inadvertently shorten his or her life and be liable to capital punishment” (Kinzbrunner 2004, p. 564) the care of the moribund person was enclosed with some strict rulings, such as the prohibition to touch a goses. The Jewish law considers a goses as a living person in every respect and, being even in his last moments of life, he has to be treated according to this living status (Jakobovits 1959, p. 121; Sinclair 1989, p. 9; Sinclair 2003, p. 181).

A dying man is considered the same as a living man in every respect. […] His jaws may not be bound, nor his orifices stopped, and no metal vessel or any other cooling object may be placed upon his belly until the moment he dies, as it is written, Before the silver cord is snapped asunder, and the golden bowl shattered, and the pitcher is broken at the fountain (Eccl. 12:6). He may not be stirred, nor may he be washed, and he should not be laid upon sand or salt, until he dies. His eyes may not be closed. Whosever touches him or stirs him sheds blood. Rabbi Meir used to compare a dying man to a flickering lamp: the moment one touches it he puts it out. So, too, whosever closes the eyes of a dying man is accounted as though he has snuffed out his life. There may be no rending of clothes, no baring of shoulders, nor eulogizing, and no coffin may be brought into the house, until the moment he dies (Semahot 1:1–4).

The second important rabbinic source often cited and interpreted when rabbis and ethicists reflect on euthanasia is Bavli Avodah Zarah 18a, telling about the martyrdom of Rabbi Hanina ben Teradion who was executed by the Romans because of ignoring a Roman prohibition to study and teach the Torah.

Straightaway they took hold of him, wrapt him in the Scroll of the Law, placed bundles of branches round him and set them on fire. Then they brought tufts of wool, which they had soaked in water, and placed them over his heart, so that he should not expire quickly… […] ‘Open then thy mouth’ [said they] ‘so that the fire enter into thee.’ He replied, ‘Let Him who gave me [my soul] take it away, but no one should injure oneself.’ The executioner said to him, ‘Rabbi, if I raise the flame and take away the tufts of wool from over thy heart, will thou cause me to enter into the life to come?’ ‘Yes,’ he replied. ‘Then swear unto me’ [he urged]. He swore unto him. He thereupon raised the flame and removed the tufts of wool from over his heart, and his soul departed speedily (Avodah Zarah 18a).

Bavli Ketubot 104a is another Talmudic source often cited regarding euthanasia, a story about the death of Rabbi Judah HaNasi, the compiler of the Mishnah.

On the day when Rabbi died, the rabbis decreed a public fast and offered prayers for heavenly mercy. […] Rabbi’s handmaid ascended the roof and prayed: ‘The immortals desire Rabbi [to join them] and the mortals desire him [to remain with them]; may it be the will [of God] that the mortals may overpower the immortals.’ When, however she saw how often he resorted to the privy, painfully taking off his tefillin and putting them on again, she prayed: ‘May it be the will [of the Almighty] that the immortals may overpower the mortals.’ As the rabbis incessantly continued their prayers for [heavenly] mercy she took a jar and threw it down from the roof to the ground. [For a moment,] they ceased praying, and the soul of Rabbi departed to its eternal rest (Ketubot 104a).

“Two Jews, Three Opinions”. Jewish Opinions on Euthanasia

The Jewish folk saying “two Jews, three opinions” illustrates the wide diversity of opinions within Judaism on a range of topics. Also with regard to euthanasia there seems to be no definitive Jewish stance. Although rabbis belonging to different Jewish movements base their judgments on common Jewish sacred texts—such as those cited above—they often do not reach the same conclusion (Ellenson 1995). Reviewing opinions and interpretations with regard to euthanasia of prominent American Orthodox, Conservative and Reform rabbis, who have (extensively) published on the matter, a diversity between and within the largest Jewish branches appears. In contrast to the Conservative and Reform branch of Judaism, in the Orthodox movement, reviewing the literature, we did not find any advocate of euthanasia.

Given the central aim of this article—(1) reflecting upon the specific, text-centered nature of Jewish (bio-)ethical reasoning, by (2) describing diverse Jewish viewpoints on euthanasia—it would not be feasible nor useful to give an exhaustive overview of virtually all opinions of important poskim, rabbis and non-rabbinic academic scholars with regard to the issue at hand. Therefore, we made a selection of opinions of prominent rabbinic figures.

Orthodox Movement

Rabbi David Bleich’s Arguments Against Euthanasia

On the Orthodox side Rabbi David Bleich is a radical opponent of euthanasia and an advocate of an absolute sanctity-of-human-life approach. Consequently some characterize him as a “vitalist” (Thomasma 1999, pp. 59–60; Cohen-Almagor and Shmueli 2000, p. 125). According to Bleich (1981, p. 135, 2010, p. 25) not only human life in general is of infinite and inestimable value, but even every moment of life, since “the quality of life which is preserved is never a factor to be taken into consideration” (Bleich 1979a, p. 19). According to him this is illustrated by the Talmudic assertion that even on Sabbath efforts to free a victim buried under a collapsed building must be continued even if the victim is found in such circumstances that he cannot survive longer than a brief period of time. Additionally, he refers to a passage in tractate Sanhedrin (37a) of the Babylonian Talmud which provides most eloquently the view that the value of human life is extremely important and takes precedence over virtually all other considerations:

For this reason man was created alone, to teach that whosever destroys a single soul of Israel, scripture imputes [guilt] to him as though he had destroyed a complete world; and whosever preserves a single soul of Israel, scripture ascribes [merit] to him as though he had preserved a complete world.

According to Bleich this source provides the basis of pikuah nefesh, the duty to save and preserve human life. This commandment is based on the Jewish religious conviction that human beings are only stewards of their body: “never is he [man] called upon to determine whether life is worth living—this is a question over which God remains the sole arbiter” (Bleich 1979a, p. 19). As God’s creation, we do not own our human body. Instead, it is God’s property. Consequently, in Bleich’s opinion “man does not enjoy the right of self-determination with regard to questions of life and death” (1979b, p. 269). Human life has no instrumental, but an intrinsic value. It is a “bonum per se” (Bleich 1993). Man’s task is to preserve, to dignify and to hallow this divine gift.

Bleich interprets the Jewish religious source Semahot 1:1–4 literally. His conclusion when reading it is: “Accordingly, any movement or manipulation of the dying person is forbidden” (Bleich 1981, p. 137) since the candle’s flickering flame risks to become extinguished by the slightest touch. Briefly referring to a codification of Rabbi Moses Isserles in this regard, Bleich takes the view that the death of a goses may not be speeded, but there is also “no obligation to perform any action which will lengthen the life of a patient in this state” (Bleich 1979a, p. 33). When reading Bavli Ketubot 104a he recognizes the fact that the female servant prayed for the death of Rabbi Judah. Following some rabbinic authorities Bleich concludes that “although man must persist in his effort to prolong life, he may, nevertheless, express human needs and concerns through the medium of prayer” (Bleich 1978, p. 302, 1979b, p. 271, 1981, p. 143). Further on he states that there is “no contradiction whatsoever between acting upon an existing obligation and pleading to be relieved of further responsibility […] But ultimately the decision is God’s, and God’s alone.” (Bleich 1978, p. 302, 1979b, p. 271, 1981, p. 143). Taking these textual interpretations into account Bleich is of the opinion that the practice of euthanasia is contrary to the teachings of Judaism. According to Bleich, in Jewish law every positive act which hastens death is equated with murder, “no matter how laudable the intentions of the person performing the act of mercy-killing may be” (Bleich 1981, p. 136). Despite the noble intent and “no matter how hopeless or meaningless continued existence may appear to be in the eyes of the mortal perceiver” (Bleich 1993, p. 139), the life of a human being may be reclaimed only by the Author of life and death.

Conservative Movement

Rabbi Elliot Dorff & Rabbi Avram Reisner: Fierce Opponents of Euthanasia

Within the Conservative branch Rabbis Elliot Dorff and Avram Reisner are both opponents of euthanasia. How do they interpret the cited Jewish sacred sources? First of all, considering the laws of goses, they not only mention tractate Semahot 1:1–4, but they also take—more extensively than Bleich—the codification of this tractate by the sixteenth century Rabbi Moses Isserles into account:

It is forbidden to do anything to hasten the death of one who is in a dying condition…. If, however, there is something that causes a delay in the exit of the soul, as, for example, if near to this house there is a sound of pounding as one who is chopping wood, or there is salt on his tongue, and these delay the soul’s leaving the body, it is permitted to remove these because there is no direct act involved here, only the removal of an obstacle (quoted in Dorff 1998, p. 199).

Following this Dorff and Reisner make a distinction between euthanasia and the withholding and withdrawing of life-sustaining treatment. Latter is (more) acceptable, whereas the former is strictly forbidden. In other words, according to these rabbis, a distinction is to be made between the maintaining and prolongation of human life on the one hand and the prolongation of the death process on the other. Although the Jewish tradition asks for the pursuit and maximization of life, the irrefutable wisdom “there is a time to die” of Ecclesiastes 3:2a must be respected: “we are not to stand in the breach to ward off death in its time” (Reisner 2000, p. 252). In the opinion of Dorff (2000, p. 313) the objective of medical care is to act for the patient’s benefit. Consequently the pain of the patient can prevent doctors to decide to continue aggressive treatment when there is no reasonable chance of recovery from a terminal illness.

Referring to Bavli Avodah Zarah 18a, the story about the martyrdom of Rabbi Hanina ben Teradion, Reisner (1991, p. 55, 2000, p. 243) urges us to keep in mind those words of Rabbi Hanina affirming the traditional Jewish prohibition to hasten death and the mitzvah of self-preservation: “Let Him who gave me [my soul] take it away, but no one should injure oneself.” Although Dorff does not quote this source literally, he states that there is no inviolable and unexceptionable rule in Jewish law that all life is sacred. The—Orthodox—interpretation of Jewish sacred sources that even small moments of human life—whatever its quality—must be preserved is “a mistaken reading of tradition” (Dorff 2000, p. 312). Dorff stresses that there are cases in which Jewish law requires us to give up life or to take one, for instance when Jews are forced to one of the three cardinal sins—idolatry, murder and forbidden sexual relations, such as incest and adultery—Jewish religious law commands its adherents to choose death. In the case of Rabbi Hanina—a case of martyrdom—taking one’s life is an act of Kiddush ha-Shem, the sanctification of God’s name.

The message Reisner distills out of Bavli Ketubot 104a resembles Orthodox Rabbi Bleich’s interpretation: as human beings we are called to follow the tracks not only of the pro-life praying rabbis surrounding Rabbi Judah, but also of Rabbi Judah’s handmaid by responding mercifully in situations of suffering, for instance by requesting God that He would offer a quick and merciful death to the sufferer (1991, p. 56). Without denying the efficacy of the prayer, Reisner (2000, p. 245) does affirm clearly that not the female servant ended the life of Rabbi Judah, but God did. God was the final arbiter, who determined his death.

Taking these traditional Jewish sources into consideration, Conservative Rabbis Dorff and Reisner both conclude that euthanasia is forbidden, while—in certain circumstances and under certain considerations—it may be permitted to withhold and withdraw a life-sustaining treatment.

Rabbi Byron Sherwin’s Pro-arguments

Within the Conservative movement, Rabbi Sherwin declares himself to be an advocate of euthanasia. Taking a look at the Talmudic story of the martyrdom of Rabbi Hanina he concludes that life is precious and of intrinsic value, but there are exceptions to the preservation of life, for example killing in self-defense. This “and other forms of ‘justified homicide’ have been sanctioned as ‘necessary evils’ by rabbinic tradition” (Sherwin 1995, p. 365).

Whereas in various situations killing another human person may be justifiable and permissible according to Jewish Law, in instances where martyrdom is indicated, killing oneself, allowing oneself to be killed, or killing another person, may be required by Jewish Law. Precisely because martyrdom represents the ultimate expression of the human sacrifice to God (Kiddush ha-Shem), it has been considered throughout most of Jewish history to be the most exalted virtue—transcending the obligation to preserve human life at any cost (Sherwin 2000, p. 41).

According to Sherwin pikuah nefesh—preservation of life—is not always an absolute moral imperative (1990, p. 93). To substantiate this thoroughly he makes use of another Talmudic source, which tells the story of 400 children drowning themselves in the sea to prevent being abused by their capturers.

On one occasion four hundred boys and girls were carried off for immoral purposes. They divined what they were wanted for and said to themselves, If we drown in the sea we shall attain the life of the future world. The eldest among them expounded the verse, The Lord said, I will bring you again from Bashan, I will bring again from the depths of the sea. ‘I will bring again from Bashan,’ from between the lions’ teeth. ‘I will bring again from the depths of the sea,’ those who drown in the sea. When the girls heard this they all leaped into the sea. The boys then drew the moral for themselves, saying, If these for whom this is natural act so, shall not we, for whom it is unnatural? They also leaped into the sea. Of them the text says, Yea, for thy sake we are killed all the day long, we are counted as sheep for the slaughter (Bavli Gittin 57b).

Taking these sources into account, Sherwin interprets them meaning: “to avoid sufferings certain to result in death, it is permitted to take one’s own life, and in such instances it is required to violate the injunctions against injuring oneself” (2000, p. 50). Based on a few additional sources, such as Bavli Ketubot 104a—which, according to him, indicates the permissibility of actively praying for death (Sherwin 1998, p. 93)—and Bavli Pesahim 75a uttering the verse: “therefore, choose an easy death for him”, Sherwin concludes that euthanasia may be a halachic option (Sherwin 2000, pp. 35, 61).

Apart from these, a very important source within his pro-euthanasia argumentation scheme is a passage in tractate Sanhedrin (78a) of the Babylonian Talmud, making a distinction between a goses and a terefah. According to Jewish law a terefah is a terminally ill person, not yet in the process of dying, whereas a goses is a dying person, who is expected to die within 72 h or 3 days, as a result of illness or of old age. Consequently, not every goses can be considered a terefah. This seemingly tiny distinction is crucial within Jewish law, which states that a person who kills a terefah is not liable to punishment—it is only in God’s power to judge and to punish him—because a terefah is considered to be a gavra katila, a person who is already dead. His blood is considered to be less red in comparison with that of a goses, who is regarded as a living person, though in a moribund state in which death is imminent (Sinclair 1989, pp. 19–69). Taking Jewish law into account on this remarkable point, Sherwin concludes that a physician may be legally blameless for practicing euthanasia.

Conscious of the fact that he is a stranger in his midst when defending this pro-euthanasia opinion, Sherwin (2000, pp. 60–61) concludes:

In view of contemporary realities, I have felt it necessary to defend a position within the framework of classical Jewish sources that would justify active euthanasia in at least certain circumstances. I believe that patients whose last days are overwhelmed with unbearable agony, who have no hope of recovery, who have irreparable organ damage, and who have exhausted all medical remedies should be able to advocate and to practice active euthanasia without feeling they are criminals […] To be sure, Judaism instructs us to ‘choose life’ (Deut. 30:19), but Judaism also recognizes that ‘there is a time to die’ (Eccles. 3:2).

Reform Movement

Central Conference of American Rabbis (CCAR) Rejects Euthanasia

On the basis of the goses laws, mentioned in Semahot, in its responsa, issued by several rabbis (Freehof, Jacob, Bettan, Plaut and Washofsky) the Reform Central Conference of American Rabbis (CCAR) asserts that man has no right of ownership over his/her body, and consequently has no authority to bring his/her life to a premature end (Freehof 1960, pp. 117–122, 1971, pp. 197–303, 1983, pp. 257–260; Bettan 1983, pp. 261–270; Jacob 1987, pp. 138–139, 1995a, pp. 127–130, 1995b, pp. 131–133, 1998, pp. 153–156; Plaut and Washofsky 1997, p. 337–363). Their holding to a prohibition of euthanasia is also based on the interpretation of the Talmudic sources mentioned earlier.

In the CCAR’s responsum ‘On the Treatment of the Terminally Ill’ (Plaut and Washofsky 1997, pp. 337–363), Bavli Avodah Zarah 18a and Bavli Ketubot 104a are interpreted. With regard to the source narrating the martyrdom of Rabbi Hanina, responsa of the CCAR argue as follows. At first glance, the behavior of Rabbi Hanina in this story is contradictory. On the one hand, Rabbi Hanina refuses to open his mouth and let the fire enter there, in other words he refuses to hasten his death. On the other hand, Rabbi Hanina asks his executioner to remove the wet tufts of wool and to raise the flame and promises him life into the world to come. According to the CCAR (Plaut and Washofsky 1997, p. 357) this is but an apparent contradiction, since we have to keep in mind that this story is a case of martyrdom. Consequently, this story cannot be interpreted as if Rabbi Hanina can appoint the executioner to do anything, for the guard is not the rabbi’s agent but his executioner—he is the agent of the Roman authorities. Considered in this way, Rabbi Hanina does not act to participate directly in the hastening of his death, either by his hand or through an agent.

Regarding Bavli Ketubot 104a the CCAR (Plaut and Washofsky 1997, p. 358) asserts that there is a moral difference between taking action to hasten a person’s death and withdrawing treatment so as to allow death to occur. The death of Rabbi Judah was not a result of action, but of inaction. Not the servant’s prayer for his death causes him to die, but the ceasing of praying by the surrounding rabbis. Moreover, this source does not provide guidance for euthanasia, but it does for the withholding and withdrawing of life-sustaining treatment, for one may not delay death unnecessarily. Importantly, Freehof (1960, p. 119, 1971, p. 200, 1983, p. 258) and Jacob (1987, p. 139) add that asking God to be relieved of suffering is permissible.

Reacting against the minority of Jewish advocates of euthanasia on the basis of Jewish law the CCAR declares: “As Reform Jews we consider ourselves free to ascribe ‘new’ Jewish meanings to our texts… in this case, though, we fail to see why we should do so… The unequivocal voice of the halakhic literature renders it difficult to sustain an argument, based upon the citation of a few stories from the Bible and the Talmud, that the ‘Jewish tradition’ permits euthanasia” (Plaut and Washofsky 1997, p. 340). Similarly, in their responsa Rabbi Bettan (1983), Freehof (1983) and Jacob (1987, 1995a, b, 1998) affirm that (active) euthanasia is irreconcilable with the Jewish tradition.

Rabbi Leonard Kravitz and Rabbi Peter Knobel Accept Euthanasia

In spite of the clear statement uttered by the CCAR, the Reform movement has its convinced supporters of euthanasia. We highlight the argumentation of two Reform rabbis, Leonard Kravitz and Peter Knobel. Citing the laws of goses and the additional rabbinic codification of Rabbi Moses Isserles, to which Bleich, Dorff and Reisner too refer, Kravitz concludes that stopping the woodchopper or removing the salt from the tongue of the dying person are actions being done: “one must go to the wood chopper to tell him to stop and one must reach into the patient’s mouth to remove the salt. There is certainly an act involved!” (1995, p. 18). Stating this he rejects the distinction often made by rabbis—see also the argumentation scheme in the CCAR’s responsa described above—between action—being done—and inaction—action refrained from being done (2006, p. 86). In the same manner Kravitz goes on interpreting the account of the execution of Rabbi Hanina (1995, pp. 14–15, 2006, pp. 80–82). He argues that this source is often incorrectly interpreted as opposing euthanasia and accepting withholding/withdrawing of life-sustaining treatment, on the basis of Rabbi Hanina’s utterance “it’s better that He who gave me my soul should take it and let no one harm himself”, while at the same time asking the executioner to remove the wet tufts of wool. Rejecting this wrong interpretation, Kravitz asserts that Rabbi Hanina, faced by death and experiencing terrible pain, changes his mind and facilitates his own death. For, in the opinion of Kravitz—the conversation between Rabbi Hanina and the executioner has the character of a contract.

The executioner said to him, “Rabbi, if I raise the flame and take away the tufts of wool from over thy heart, will thou cause me to enter into the life to come?” “Yes,” he replied. “Then swear unto me” [he urged]. He swore unto him. He thereupon raised the flame and removed the tufts of wool from over his heart, and his soul departed speedily (Bavli Avodah Zarah 18a).

“That the executioner asked rabbi Haninah to swear to his answer indicates that both executioner and rabbi knew what was to be the outcome and what was to be the consideration, the quid pro quo” (2006, p. 81). Moreover, as Knobel indicates, the story tells that the executioner is granted immediate eternal life for his act of mercy: “In fact one can read this passage to suggest that relief of suffering which hastens death is not only permitted but meritorious, so meritorious that the executioner is immediately ushered into internal life” (1995, p. 43).

The rejection of the difference between euthanasia (considered as action) and withdrawing/withholding life-sustaining treatment (considered as inaction) is also applied to Bavli Ketubot 104a. According to both Reform Rabbis Kravitz (1995, pp. 15–16, 2006, pp. 82–83) and Knobel (1995, p. 44), the physical act of the maid—throwing down the pot from the roof and as a result startling the rabbis and disrupting their prayers—caused Rabbi Judah to die. Moreover, Knobel asserts that she killed him—out of compassion. Rabbi Judah did not die as a result of ‘indirect action’, but “the maid’s act clearly terminated his life” (Knobel 1995, p. 44). Kravitz (1995, p. 14) holds the same view: “She interfered with Rabbi’s life support system. She acted; he died. One may say that she enabled him to die or one may say that she caused him to die; in either case, her act precipitated his death”.

Apart from these sources both rabbis refer to the fact that euthanasia, literally meaning ‘good or easy death’ has its parallel Hebrew term in the Talmud, namely ‘mitah yafah’, meaning “a nice death” (Kravitz 1995, p. 21, 2006, pp. 78–79; Knobel 1995, pp. 45–46). This term is found in the Talmudic tractate Sanhedrin 52a in the context of a discussion of a judicial execution. The Talmud tells us that for the condemned criminal we should choose a nice death, i.e. a quick, non-humiliating death. “If we are to view condemned criminals as our neighbors and compassionately provide them with a rapid and non-humiliating death, what, then, is our obligation to innocent life which is suffering terrible pain and humiliating death?” (Knobel 1995, p. 46).

Based on these considerations of the mentioned sources, both Reform rabbis assert that the preservation of life is valued by the Jewish tradition as an important mitzvah, but biological life is not a supreme value which overrides all other considerations. According to Kravitz (1995, p. 21) euthanasia is only an option in case of someone who is in the process of dying and who suffers unbearably. Knobel asserts that in extreme situations the termination of human life is not a sin, but can in fact be praiseworthy. For him, “the determining factor is whether the termination of life is consistent with the preservation of the person as being created b’tzelem elohim (in God’s image). In other words, does the continuation of biological life violate the sacred character of the individual’s life? Therefore, the aggadah, the sacred narrative of a person’s life, becomes part of the halakhic decision-making process” (Knobel 1995, p. 48).

We conclude this Reform pro-euthanasia view with the words of Kravitz: “Where pain trumps life, where suffering cannot be controlled and recovery cannot be achieved, then if the patient feels that life is no longer worth living, and ‘the game not worth the candle’, there is no need to extend life, and indeed, there may be a need to shorten it” (2006, 93).

Conclusions

Although human life is extremely precious for religious Jews, arguing that the Jewish tradition uniformly condemns euthanasia would do harm to one of the essential characteristics of Judaism: heterogeneity. After all, within Judaism and its diverse movements a central, coordinating Jewish authority that proclaims official Jewish statements is lacking. This Jewish plurality is reflected in the debate on ethical dilemmas, such as euthanasia.

Yet, in our review no advocates of euthanasia were found in the Orthodox movement. The overriding importance of preserving human life was illustrated by the sanctity of life approach of prominent American Rabbi Bleich. Similarly, other Orthodox rabbinic authorities, such as Jakobovits (1959, p. 123), Feinstein (Tendler 1996, p. 60) and Tendler (1996, pp. 138, 142), oppose (active) euthanasia. Indeed, Tendler and Rosner argue that “Jewish law opposes euthanasia without qualification and it condemns as sheer murder any active or deliberate hastening of death, whether the physician acts with or without the patient’s consent” (1993, p. 20, 1996, p. 138). Reviewing liberal Jewish opinions, intra-branch diversity was found. In the Conservative movement, while Rabbis Dorff and Reisner are both fierce opponents of euthanasia, we noticed Rabbi Sherwin’s acceptance of euthanasia. In the same manner we recorded diversity of opinion in the Reform movement: while the Central Conference of American Rabbis holds to a prohibition of euthanasia, we found Rabbis Kravitz and Knobel as convinced supporters of it, referring to the same Jewish textual tradition. Without neglecting this inner-Jewish heterogeneity, it must be stressed, however, that pro-euthanasia opinions are exceptional voices, even within the Conservative and Reform branch of Judaism.

The fact that no advocates of euthanasia were found on the Orthodox side, is not very surprising, considering the fact that liberal Jews—Conservatives in a lesser degree than Reform Jews—consider the halacha as mainly the work of human hands, having an advisory function, and being open to recontextualization in the light of contemporary realities. In contrast, according to Orthodox Judaism halacha reveals God’s will, which is definitive and essentially normative. Thus, the fact that divergent interpretations of the same sources are found is not accidentally, but reflects the essential pluralistic character of Jewish ethical reasoning (Ellenson 1995). The way in which rabbis perceive the (status of the) Jewish textual tradition and the manner in which they reflect on it and distill essential principles from the texts—in confrontation with a contemporary case—influence their statement on an ethical dilemma. Perceiving halacha as normative and binding or as guiding and advising affects rabbis’ coping with and opinion on a (contemporary) ethical question. The authority rabbis ascribe to the Jewish textual tradition, as well as the interpretive process itself gives evidence of pluralism, which even exceeds ‘denominational’ boundaries (Ellenson 1995, p. 135).

Apart from this Jewish inter- and intra-branch heterogeneity the debate on euthanasia discloses as well a continuous element: the text-centeredness of Jewish ethics. Indeed, ethical reasoning is based on the corpus of Jewish law, which consists of Torah and the tradition of rabbinic interpretation. Although rabbis and movements ascribe diverging degrees of authority to (interpretations of) halacha, our analysis shows that it is never completely excluded or dismissed. Though we made mention of an antinomist position in Reform Judaism (Jacob 2004), ethical reasoning in Judaism predominantly presupposes reference to the Jewish textual tradition (Zoloth-Dorfman 1995) thus is—exclusively or not exclusively—halachic.

When caring for Jewish patients for healthcare professionals it is essential to be aware of the influence of the Jewish (textual) heritage on concrete medical decisions. After all, religious Jews’ daily life choices (must) fit in with God’s path. As they wish to follow God’s example (imitatio Dei) (Shapiro 1978, pp. 127–151; Mackler 2003, p. 6) rabbis and poskim (experts of Jewish law) are central authorities for them. Indeed, in virtually all aspects of life—for instance regarding medical decision making—the influential role of rabbis may not be underestimated. After all, rabbis’ casuistic reasoning typifies Jewish ethics. In this way, a concrete rabbinic decision on a given case may differ from abstract, theoretical halachic considerations. Especially among Orthodox Jews, rabbinic involvement in and rabbis’ (binding) advice on everyday life and moral conduct, might appear in healthcare settings (Coleman-Brueckheimer et al. 2009). Nurses and physicians might not be familiar with this. Showing understanding for this (possibly) influential role of rabbis, is part of showing respect for a patient’s autonomy. Throughout the different branches of Judaism, the role of rabbis is variously perceived. While Orthodox rabbis’ decisions are assumed to be binding, responsa of liberal rabbis are ascribed a rather guiding and advising character. Although Judaism’s movements can be distinguished by characteristic tendencies, they are hardly monolithic. Therefore, when dealing with Jewish patients, it is not only essential to be acquainted with Judaism’s diverse branches, exposing the essential Jewish heterogeneity, but as well with a patient’s specific religious context.

As mentioned previously, Jewish voices in favor of (active) euthanasia are rather exceptional and uncommon (Gesundheit et al. 2006). Indeed, emphasis on the supreme value of human life and thus on its preservation is central in Judaism (Jakobovits 1959; Tendler and Rosner 1993; Glick 1999; Rosner 1986, 1999; Freedman 1999). Tendler and Rosner even mention a “unanimity of halakhic opinion that active euthanasia is never condoned” (1993, p. 23, 1996, p. 142). Likewise, the CCAR mentions the “unequivocal voice of the halachic literature” (Plaut and Washofsky 1997, p. 340) in this matter. For healthcare professionals it is important to take the delicacy of this issue for Jews and their hesitance toward quality of life judgments (Schostak 1991; Mackler 2003, p. 108; Zohar 2006, p. 2) into account. On the other hand, among contemporary (Jewish) academic scholars the prevailing Jewish emphasis on life-saving is challenged and debate on the significance of improving a patient’s quality of life is stimulated (Brody 1999; Green 1999; Zohar 2006). Brody and Green for instance argue that the idea that Judaism is committed to the strict doctrine of sanctity of life is a thorough misrepresentation and does not do justice to the nuanced way of thinking of rabbinic casuistry. Orthodox authorities acknowledge that Judaism is concerned about a patient’s pain and suffering, thus his/her quality of life (Tendler and Rosner 1993; Tendler 1996), yet determining “whether life is worth living” (Rosner 1991, p. 44) on the basis of quality of life considerations is for them a bridge too far.

Anyway, it is utmost important to provide care which is sensitive to a patient’s religion, world view and culture. The huge importance of culture-sensitive care, which evidently entails respect for a patient’s autonomy, is demonstrated by the reflections of Jotkowitz et al. (2010a, b) and Gesundheit (2010) on the Canadian Golubchuk case. They point correctly to the importance of training of healthcare professionals “in communication skills and cross-cultural medicine” (Jotkowitz 2010b), a requirement which is indispensable given the multicultural and multireligious outlook of contemporary societies. Indeed, religion and world view have influence on the way people deal with illness and ethical dilemmas, for instance in health care (Gielen et al. 2009; Coleman et al. 2007; Wenger and Carmel 2004; DeKeyser Ganz and Musgrave 2006; Margalith et al. 2003; Musgrave et al. 2001; Ejaz 2000; Leichtentritt and Rettig 1999; Carmel and Mutran 1997). Consequently, hospitals’ need felt to deal with a culturally diverse patient population is high, which is clear from the steady inquiries to our center1 to provide training and clear guidelines in this regard. Nowadays, a holistic approach of patients, paying attention to their (cultural) background and religious convictions, which may impact considerably on medical decision making, is utmost appropriate, as it undoubtedly contributes to providing optimal care.