Kol Tikvah location map

Rabbi Janet Offel
Yom Kippur Morning 5768
Temple Kol Tikvah

A FINAL ACT OF HUMAN DIGNITY

             Every year, I find myself inextricably drawn to the powerful images of Yom Kippur morning.  The commanding words of our Torah portion, exhorting us to choose life, the phraseology of the Unatana Tokef prayer, reminding us that we have little if no control over what may befall us in the coming year, and the symbolism behind the wearing of white on this day; a day on which we figuratively die and are reborn.

             In thinking about topics for a Yom Kippur morning sermon, my mind always travels to issues that call us to struggle with the deeper significance and meaning of life, to issues that are often secretly pondered, but rarely openly addressed by many of us.  Having been a hospice chaplain for over four years, I am perhaps more used to swimming in the seemingly murky waters that juxtapose life and death, to giving voice to the fears, concerns and questions that many people have but are afraid to summon from the depths of their being.

             Earlier this year, for the third time in as many years, a legislative bill wound its way through the California State Assembly modeled after the 1994 Oregon Death With Dignity Act, a measure that provides legal immunity for doctors who prescribe lethal doses of medication to patients deemed “mentally fit.”  Proponents of this “right to die” insist that theirs is the most compassionate response to the end of life, providing people with terminal illness the opportunity to end their suffering with dignity, offering the ultimate gift of choice in a world in which personal autonomy is of the utmost importance.

             Now, of course, I can already sense it—some of you who are here with us this morning are ready to “flip the switch” so to speak and tune me out, not wanting to be pressed to listen to such talk that touches the rawest nerves of our being. 

             Yet I believe that in a democratic society, and as Reform Jews, we have a responsibility to address this very issue, an issue that is sure to touch each of our lives at one time or another.

             Realizing that you all read the same secular newspapers and magazines that I do, and watch the same news shows and television commentators that I do—that is as long as you watch CNN, Anderson Cooper and Keith Olberman, I’m not here to provide you with the same analysis that you can find just as easily yourself.  But as a rabbi, I do believe that it is imperative that you are at the very least aware that Judaism has something to say about this issue.  For if Judaism is seen only as pertaining to holidays and lifecycle ceremonies it loses its very essence as a prism through which to help us understand the most complex matters of our day.

           Thus this morning I would like to discuss the issue of death with dignity from a very Jewish point of view.  I say that with a bit of trepidation because, as we all know, 2 Jews, 3 opinions.  The perspective I am proposing, while a reasoned and judicious one is not the only one in our tradition.  It is a standpoint though that I hope you will consider in your own contemplations with respect to this topic.  For whereas through a Jewish lens choosing death with dignity is considered kiddush hashem, a sanctification of God’s name, demanding the right to take one’s own life is considered chilul hashem, literally a desecration of God’s name.

 To begin the discussion, it is imperative to remember that we live in a very different world, particularly with respect to medical technology, than even 50 years ago.  To give you a little background:

 During World War II, an Army Air Corps pilot by the name of Forest Bird began a life-long exploration into respirators, beginning from the need for gear that would allow pilots to breathe at higher altitudes.  In 1955, Bird introduced the first universal mass-produced medical respirator.  And it wasn’t until 1970 that Bird invented a pediatric respirator that greatly reduced infant mortality rates for babies with respiratory problems.

 Another medical marvel that is common place today: renal dialysis.  The first “artificial kidney” as it was called was perfected by Willem Kolff in the 1940’s.  Interestingly, at the time, many people in the medical field were scandalized by the notion of kidney dialysis, calling it “an abomination.”  And right through the middle of the 20^th century, treatment for chronic renal failure was seen as an impossibility.

 And then there is CPR or Cardio Pulmonary Resuscitation.   Initially developed in 1960, the first mass citizen training in CPR wasn’t held until 1972 but quickly became known as a life saving technique to be administered in all cases.  Indeed, in a clinical algorithm developed by the U.S. Department of Health and Human Services for the Evaluation and Care of Patients with Heart Failure, death isn’t even an option.  Resuscitation, pharmacological management and heart transplantation are the only alternatives available on the closed-loop chart developed by our federal government and in use to this day.   Imagine that, as far as our own federal government is concerned, in the case of heart failure, no matter what the age, no matter what the circumstances, death isn’t even considered an option.  Over the past thirty to forty years an environment has been created in which death is seen as the ultimate enemy during a time in which, thanks to increasing medical technology, the end of life itself has become more and more difficult to define.

 It was in response to this environment that in the 1970’s and 1980’s a movement began to allow people to refuse these life-saving measures that in some cases were being inappropriately applied in a closed loop simply to forestall death.   As more and more people were dying in the sterile environment of hospitals, surrounded by tubes, beeping machines and scurrying medical personnel instead of dying at home surrounded by loved ones, people began to ask the question, where is the dignity in all of this?  We are all human.  Death is an unfortunate consequence of life.  Yet as control over how we die was being eroded by the onslaught of medical technology many Jews continued to operate under the mistaken belief that defiance of death at all costs is the Jewish perspective.  A closer look at our tradition proves otherwise:

             We read in the Talmud that on the day that Rabbi Judah was dying, the rabbis announced a public fast and offered prayers for God's mercy.  Rabbi Judah's handmaiden, a pious and devout woman, climbed to the roof of the Rabbi's house and prayed, "The angels want Rabbi to join them, and the mortals want Rabbi to remain with them; may it be God's will that the mortals overpower the angels."  However, as the day progressed, and she saw how much suffering her master was enduring, she began to pray, "May it be the will of the Almighty that the angels overpower the mortals."  But due to the incessant prayers offered by Rabbi Judah's disciples, his soul remained trapped inside his body and he could not die.  So his handmaiden climbed to the roof again, picked up a water pitcher and threw it down to the ground where the disciples stood.  Startled by the noise, they ceased praying for a moment, and the soul of Rabbi Judah departed to its eternal rest (B.T., Ketubbot, 104a).

In other words, one could argue that whether the closed loop forestalling death is brought on by the incessant prayer of disciples in days of yore, or by the marvels of modern medical technology, our tradition offers a resounding endorsement for allowing nature to take its course when the only alternative is simply forestalling death. 

We also find in the rabbinic law code known as the Shulchan Aruch, written in the 16^th century, that “if there is something that causes a delay in the departure of the soul, such as clattering noise near the patient, as if someone is pounding wood, or if there is salt on his tongue, and these delay the soul’s leaving the body, then it is permitted to remove the hindrances, because there is no direct act involved but simply the removal of an obstacle that prevents death” (Shulchan Aruch, Yoreh Deah, 339:1).  In our tradition, simply forestalling death in its final, difficult throes is not considered death with dignity.  Our tradition realizes that to be human means that we will one day die.  We are not angels, imbued with immortality.  Our wondrous medical technology has the potential to function either as a blessing, reaffirming the precious gift of life, or as a curse, simply prolonging the agonizing final journey into death.  It is the process of exploring that distinction that is most difficult and, in the end, is where our own humanity comes most clearly into play.

But from a Jewish perspective, there is a difference between the right to refuse excessive medical efforts to forestall death and what is being referred to in the current political arena as the “right to die.” 

In an article in the book Jewish Insights on Death and Mourning, Dr. Leon Kass notes, “This demand for a ‘right to die’ is grounded not in objective conditions regarding prognosis or the uselessness of treatment, but in the supremacy of choice itself” (Jewish Insights on Death and Mourning, pg. 248).

My colleague and friend Rabbi Yoel Kahn comments in the same book that such a considered decision about when and how to end one’s own life is often referred to as “rational” suicide (to distinguish it from the more common “emotional” suicide) and is not an idea the Jewish tradition knows.  For “Judaism assumes that no one in his right mind would ever choose suicide and therefore concludes that anyone who does so has to be temporarily out of control.”  Yet “those who are considering rational suicide [in today’s terms, a ‘right to die’] explicitly affirm that they are actively choosing a reasonable course of action in the face of unbearable circumstance.  What today is called [the “right to die”]—the deliberate premeditated ending of one’s own life—is precisely the kind of suicide the historical Jewish tradition theoretically condemned but practically could not imagine” (Ibid, pgs. 247-248).

In other words, the very notion of deciding the time and place of one’s own death is a notion that Judaism cannot even fathom in its focus on the sanctity of life.  Yet in the grey areas between the two very different arenas: one, arguably, a very Jewish notion of the right to refuse excessive medical intervention to forestall death and the other a Judaically unimaginable notion of choosing the time and place of one’s death, we can find a Jewish concept of death with dignity.  An understanding of death that sanctifies life.

In 1967, Dame Cicely Sanders introduced the concept of the modern hospice movement in Great Britain, and opened the first modern residential hospice St. Christopher’s in London.  The very name hospice came from the Latin hospitium, a house of shelter or rest for pilgrims and strangers.  What Dame Sanders hoped to create was a movement to provide an oasis for the terminally ill and their families to experience a comfortable and dignified death, a death outside of the sterile, closed loop hallways of modern hospitals.

In 1974, the first hospice in the United States, Home Hospice in New Haven opened as an aid for cancer patients, and was staffed by volunteers.  It wasn’t until 1982-3 when hospice care became a Medicare approved benefit that the rapid growth of home hospice programs began across the country.

In 1985, the National Institute for Jewish Hospice was launched by Orthodox rabbi and scholar Maurice Lamm.  The NIJH provides a 24 hour toll-free number offering counseling for families, patients and caregivers, and provides locations of hospices, hospitals, health professionals and clergy around the country.  The organization, initiated by this very well respected Orthodox rabbi, has helped launch 55 Jewish hospice programs in the United States and Canada, and assists facilities in planning conferences, training staff and designing appropriate workshops to better serve the Jewish terminally ill.

Yet as Reed Abelson writes in an article published in the New York Times, “In 2005, only about a third of the 2.4 million people who died in this country were in hospice care.  Perhaps twice as many patients should have been in hospice programs, according to specialists in the field.  And even many of those who entered hospice care did so only at the very end of their illnesses, spending a week or less in a program that ideally would have helped them cope with the final six months or year of life” (New York Times: Health Plans, “A Chance to Pick Hospice and Still Hope to Live”, May 20, 2006).

And in a new twist on traditional hospice care, a movement is growing to allow hospice patients to receive the comfort and social and spiritual support of hospice care while at the same time continuing to receiving sophisticated medical treatments that may slow or even halt their disease.  Referred to as “open access hospice,” it is a response that we, as Jews, can and should be demanding from our legislators as they ponder sweeping changes in healthcare.  For as those who are familiar with hospice care know, the support provided to patients in hospice can sometimes prolong lives for months or even years beyond initial expectations.

In their beautiful book, Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying, hospice nurses Maggie Callanan and Patricia Kelley note that even in the devastation of a terminal illness, the time remaining can be used to share treasured moments of living.  Rather than dying on a continuum, a person can be helped to live until he or she dies, offering a time of personal growth for all involved (Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying, pg. 3).  From a Jewish perspective, the insights offered by Callanan and Kelley remind us of the famous rabbinic dictum: “We did not choose to be born, nor do we choose to die.  The only choice we have is what to do with the days in between.”

From my own experiences as a hospice chaplain, I can describe countless stories of families who found a place of healing in the final moments of a loved one’s life, without death inducing medication.  Deaths that seemed to occur “as planned,” although the plan was clearly outside of conscious human control.  The mother of five who abandoned all of her children at one time or another throughout their lives, and yet, when the final minutes came found all her children surrounding her.  Within moments of her last two children walking into the room, only after a sense of forgiveness encompassed everyone, did she take her last breath.  Or the patient who decided, when he could no longer partake in his beloved activity of swimming, to call for his sister to fly across country, weeks before her intended trip.  She arrived, and within an hour, he died.  Or, sadly the holocaust survivor who lived for weeks beyond what anyone believed she would survive.  Surrounded by her loved ones, she kept reliving the horrors of her life 60 years earlier, but this time as she did the necessary work to prepare herself to take leave of this world, this woman who could not abandon life was held in the arms of her loving son and daughter.

            When comfort for the dying truly takes precedence, death can come with a whisper; a final act of dignity to be shared by family, friends and medical professionals entrusted to “do no harm.”  From a Jewish perspective, we don’t have the right to choose the time of our death, but we do have the responsibility not only to allow our loved ones to die with dignity, but to demand such an opportunity for ourselves as well.

Yet a Jewish discussion of this issue requires that we be sensitive to the emotional toll exacted by this subject.  As Dr. Kass notes, when advocates for the “right to die” movement press us with the most heartrending cases, we should be sympathetic but firm.  The Jewish response to which I too adhere would respond “neither, ‘Yes, for mercy’s sake’ nor ‘Murder! Unthinkable!’ but rather ‘Sorry. No.’” (Jewish Insights, pg. 256).

For above all, demagoguery on either side of the issue diminishes the sanctity of both life and death, and renders each and every one of us a little less compassionate.

Does hospice care always guarantee a dignified end to life, a nurturing, caring environment for the one who is dying and his or her loved ones?  No, of course not—such perfection is impossible to find in our all too human world.  But some of the stories coming out of Oregon, where the right to choose the time and place of one’s death has been granted to its citizenry, point to a less than perfect ending even for those taking matters into their own hands.  For as we all know, the best laid plans in life can sometimes go awry—even for those who legally plan their own death.

In the final analysis, for me, and for many of the patients and family members I have worked with, the most comforting story can be found, again, in the Talmud:

As Rabbi Nahman was dying, Rava said to him, "Do show yourself to me after you die."  Nahman did show himself to Rava in a dream, and Rava asked, "Did you suffer much pain?"  Rabbi Nahman answered, "It was as easy as taking a hair from a pitcher of milk.  But were God to say to me, 'Go back to the world as you were before,' I would not want to go.  For the fear of death is so great there." (B.T., Mo'ed Katan, 28a, as cited in Voices of Wisdom, pg. 501).

Death is not easy to talk about, let alone begin to experience with loved ones.  It is often scary, forbidding, even terrifying.  We don’t want to think about it, for ourselves or those we love, and when it comes, it always comes too soon.

Capable, competent hospice care, not “right to die” legislation, is a Jewish response to the fear of death, a Jewish reaction to the call for dignity on the journey to the end of life.  Each of us must make our own decisions regarding our stance on this issue.  On this day of life, death and rebirth, I hope that each of you will consider this Jewish response in making yours.

Other sermons:

Erev Rosh Hashanah 5768 - Sacred Theater

Rosh Hashanah Day 5768 - A Call To Responsibility

Kol Nidre 5768 Finding Our Own Path to God and Torah

The Paradox of our Time adaptation