Are You Prepared to . . . LIVE ?

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Life expectancy of the average white male in the United States increased by a whopping 60 percent — from age 47 to age 75 — in the century between 1900 and 2000. As a consequence, the American Social Security system, which was first enacted when only a small percentage of workers lived more than a few years past retirement and many never even reached it, is headed for insolvency.

Longer lives are unquestionably salutary. But like all advances, those in medicine come with a cost. The longer we live the less likely we are to die peacefully in bed at home, and the more likely we are to pass to the Next World in a hospital, with multiple machines attached to us.

Death was once a more natural event and a regular occurrence of everyday life. As Thomas Jefferson wrote to John Adams on July 5, 1814, when he was already over 70, "But our machines have now been running 70 or 80 years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will at length be giving way; and however we may tinker them up for a while, all will at length surcease motion."

Today, however, as Dr. Sherwin Nuland writes in How We Die, "Many hospitalized patients die only when the doctor has decided that the right time has come." And that is highly problematic.

Doctors, in Nuland's words, have appointed themselves "the only proper judges of how their skills are to be used." That judgment is less and less likely to be consonant with the Torah view of life as an intrinsic good to which no value can be assigned or compared.

The guidelines of the College of Physicians and Surgeons of Manitoba (Canada), for instance, specifically provide that "physicians have the authority to make medical decisions to withhold or withdraw life-sustaining treatment without the consent of the patient or the patient's family."

When the children of Chaim Samuel Golubchuk went to court in 2008 to prevent doctors in a Winnipeg hospital from removing ventilation and a feeding tube, the Canadian medical establishment rose up to ensure that decisions about when the provision of care is "hopeless" or otherwise not worth it, "are left to physicians, not judges."

The regulations of the Ontario College of Physicians and Surgeons require doctors who for religious reasons are opposed to physician-assisted suicide to nevertheless refer the patient to a doctor who will assist the suicide or risk losing their medical license. As a result, a number of religious physicians have been forced to leave the field of palliative care altogether, even though there is a critical shortage in the field.

From the secular perspective, the Nazis yemach shemam, who began their murderous regime by eliminating "mental defectives," gave euthanasia a bad name for about half a century. But that time has passed (as for the similar bad name that they gave to anti-Semitism).

At least two federal circuits in the United States have recognized a "right to die," and a growing number of states allow physician-assisted suicide. True, physician-assisted suicide is justified, in contradistinction to the Nazi precedent, in terms of personal autonomy and patients' rights. But as Justice Gorsuch demonstrates in his excellent book The Future of Assisted Suicide and Euthanasia, based on the experience of the Netherlands — the country with the longest experience in physician-assisted suicide — the right-to-die quickly morphs into the duty-to-die, as elderly patients worry about becoming a burden to their families.

In any event, the Torah explicitly rejects the idea of the autonomous individual with an absolute right to terminate his own life: Suicide is forbidden. (For an excellent concise summary of the contrast between the Torah viewpoint and modern medical ethics see Rabbi Tanchum Burton's Life or Death: Facing End of Life Issues in the Modern World.)

As the pendulum swings toward evaluations of the quality of life, even the medical judgments of physicians become suspect. Three of the top neurosurgeons in New York City told the son of an 80-year-old Auschwitz survivor that the benign brain tumor that had left her wheelchair-bound and unable to speak was inoperable.

But when her son showed her x-rays to an Orthodox Jewish neurologist, the latter immediately saw that the tumor was near the scalp and fully operable. When the son returned to the experts he had consulted, two of the three explained that by inoperable, they had simply meant, "She's lived long enough." After surgery, the woman was able to speak and walk again within days.

Numerous doctors told a friend of mine in Toronto that her mother had one or two days to live. And when the 84-year-old mother professed her wish to live, not die, the hospital sent in a team of psychiatrists to convince her otherwise. Yet she lived another fifteen months, during which time she worked out daily with weights and on the elliptical machine at the gym, read prodigiously, and was present to witness the marriage of two grandsons and the births of great-grandchildren.

In few other areas are the issues so manifold or the necessity of awareness and advanced planning so great. Besides those mentioned above, end-of-life issues include: the decision whether to be buried in the Holy Land or closer to home; how to draft a will consonant with halachah (Jewish law) and legally enforceable; and how to convince non-observant Jews to opt for Jewish burial and not cremation. (Doron Kornbluth has full-length book on the subject, Cremation or Burial?, which is addressed to non-observant Jews.)

Every Jew who desires his end-of-life medical care to be in accord with halachah must designate a healthcare proxy, with authority to make treatment decisions in the event the patient is incapacitated. The person should also specify the halachic authorities with whom the proxy should consult in making decisions.

The rabbi designated must be expert in the many complex issues that arise. For instance, if and in what circumstances may a terminal patient or his proxy decline aggressive treatment (this doesn't mean oxygen, water, or nutrition) when that treatment might entail pain or discomfort? How should doctors deal with a goses, who generally may not be touched, when the patient's swallowing mechanism has failed and an operation is required to supply nutrients?

Ideally, that rabbi should also possess a degree of medical knowledge and sufficient presence that the doctors will listen to him.

As the process of dying becomes ever more prolonged, it is not uncommon for an estate accumulated over a lifetime of hard work to become exhausted in the final stages of life. And when that happens, the sandwich generation may be left in the untenable position of having to choose between dipping into savings to provide necessary care for beloved parents or using that money to marry off children.

Supplementary insurance to cover assisted-living facilities, caregivers in the event of incapacitation, and nursing-home care beyond that covered by Medicare should be part of each person's financial planning. Here, too, awareness of the problem is half the solution.

Finally, not all end-of-life issues can be handled on the individual level. Some require communal action. While doing research for the biography of Rabbi Moshe Sherer, I was astounded by how much of his time and that of Agudath Israel of America under his leadership was occupied with various end-of-life issues.

The issues are no less pressing today. For instance, a statutory religious exemption from legislation making brain death the standard of death is only a first step so long as insurers cut off payments after a determination of brain death, or major healthcare providers determine just what level of medical care they will or will not reimburse for the terminally ill or elderly.

Whether the Orthodox Jewish community, in alliance with other religious groups and those concerned with protecting the sanctity of life, can win legislative battles involving some form of health care rationing remains to be seen. But the first step to doing so is heightened communal awareness of where the threats lie.

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