Last spring, Sandy Buchman, a physician with the Temmy Latner Centre for Palliative Care at Toronto’s Mount Sinai Hospital, received an email from his patient on the morning of her death.
The 57-year Jewish woman had made the decision to die with the help of a doctor and gave Buchman permission to tell her story before she left for Switzerland, a jurisdiction where physician-assisted death (PAD) is available to non-residents.
Buchman says his patient chose to hasten her death. “She wanted to control how she died. She didn’t want to go too soon, but she didn’t want to be too sick to travel.”
Before taking the lethal cocktail, she wrote him to express gratitude for the care she received: “‘Even though I got excellent palliative care, this [PAD] was something I wanted to do,’ she said. ‘It should be an option for people in Canada.’”
It’s an option slated to be available in Quebec at the end of 2015 – PAD was legalized there in June – and the matter is currently being deliberated by the Supreme Court of Canada, which is considering a legal appeal out of British Columbia about whether PAD should be legal for the terminally ill. As the national debate heats up, it’s important to examine the Jewish position on PAD from a religious and medical perspective.
In a 2014 Ipsos-Reid poll conducted on behalf of Dying with Dignity, an organization that advocates for the legalization of PAD, also known as physician-assisted suicide (PAS), 84 per cent of Canadians were in favour of allowing physicians to help competent people die if they are suffering.
While the poll shows broad national support for PAD, it’s hard to say the degree to which these findings reflect attitudes in the Jewish community, because only one per cent of the respondents were Jewish.
The results of this poll support what Rabbi Reuben Poupko refers to as the shift in the public’s attitude to PAD. The spiritual leader of Montreal’s Beth Israel Beth Aaron Congregation, an Orthodox synagogue, says that passage of Bill 52, which legalizes PAD in Quebec, reflects the change in societal values over the last 30 years.
Rabbi Chaim Steinmetz, spiritual leader of Tifereth Beth David Jerusalem, another Orthodox congregation in Montreal, calls the passage of Bill 52 “a social reality.” The public is in favour of PAD, he says. “People are resigned to the decision of Quebec society.”
Rabbi Poupko warns that this legislation could hasten the deaths of terminally ill people, because they may feel social pressure to opt for PAD.
He says society tends to celebrate the courage of terminally ill people who fight to end their lives. “This creates a societal expectation for others to act in a similar manner.”
Rabbi Steinmetz worries that vulnerable people might be bullied into euthanasia by unscrupulous relatives. The legislation may also make it too easy for people with severe disabilities to give up on living when they could have productive lives, like famed scientist Stephen Hawking, he says.
He laments that people are not really aware of the dire consequences of the Quebec legislation. “The choice [Quebec] society has made is a terrible choice.”
It’s also a choice that’s incompatible with traditional Jewish values, according to Rabbi Ronald Weiss, director of the chaplaincy services at Toronto’s Jewish Family & Child, who also serves several medical and correctional institutions.
He says the Orthodox position on PAD is very clear. “It’s murder to help someone die. It’s no different than a physician taking your life… Judaism teaches that every moment of life is precious and of infinite value.”
Rabbi Weiss recognizes that painkillers such as morphine can depress breathing and death can occur if the dose is administered improperly. “The intention of the physician is of paramount concern. Deliberately depressing respiration can be likened to smothering.”
Rabbi Michael Dolgin, spiritual leader of Temple Sinai, says any discussion of PAD is taboo, according to sacred texts. “From a Jewish perspective, we can’t even talk about it, but that finality is an inadequate Jewish response.”
The texts predate modern medicine, he says. “There are many situations now where people’s existence is extended to a point that we must ask if we are extending life or if we are extending suffering?”
He has been present at end-of-life situations with his congregants. “‘We treat our pets better.’ I’ve heard that many times from people. In general they are expressing pain. They are not necessarily looking for an alternative.”
Rabbi Dolgin points to jurisdictions such as Vermont and Oregon, where PAD is legal, noting that safeguards exist there to prevent non-consensual euthanasia.
“There is no evidence to support the notion of a slippery slope that will lead to the killing of people to save money or the ending of lives of people with disabilities.”
While the majority of cases are dealt with along traditional lines, there are a small number of cases that may warrant a structure for PAD, he says.
“When there is no hope of recovery and extending the pain amounts to suffering, it’s a valid Jewish legal and ethical question to ask whether trying to extend that situation as many minutes and seconds as possible is the right Jewish response.”
If people are afraid to discuss end-of-life options with their rabbi, they could end up “making tragic choices” without support. “A Jewish response means being open to having a discussion. In the vast majority of cases, people are not looking to hasten death, but they need to talk about it.”
Rabbi Eva Goldfinger, life-cycle director at Oraynu Congregation for Humanistic Judaism, says the congregation has supported the Humanistic Judaism movement’s position in favour of PAD since 1995. However, she says Oraynu members will soon be voting on a new draft statement that was created as an update on the issue. “We affirm the sanctity of life, while at the same time we value the right of an individual to choose to hasten the end of life when the suffering is intolerable.”
Rabbi Goldfinger, who is also one of the spiritual leaders at Dying with Dignity, says Oraynu’s statement includes safeguards that call for the protection of vulnerable people and for assessments of individuals wanting to proceed with PAD to ensure they’re properly informed and have full mental capacity.
As well, there are recommendations for the government to provide more professional support to individuals considering PAD and to increase palliative care services.
Dr. Michael Gordon, medical program director for palliative care at Baycrest and a CJN columnist, points out that physician-assisted suicide (PAS), another common term for PAD, is a misnomer. “Technically, PAS means the doctor gives someone a prescription for pills that will bring on death. What people think is PAS is actually euthanasia,” because the physician is actually administering medication to cause death.
He stresses that good palliative care within the scope of medical practice can alleviate much of a patient’s suffering and is in accordance with Jewish law.
The palliative care physicians in his unit “find marvellous ways – complex cocktails to achieve goals of comfort,” he says, but he cautions that these drugs must be administered carefully.
“Sometimes, in order to achieve those goals, you have to give medications that increase comfort, but shorten life. This is a secondary effect of the opiates. If you learn how to use opiates properly, you don’t shorten life, you enhance it.”
Despite the best palliative care, many patients suffer physically, spiritually, psychologically and existentially, and ask to die, says Buchman. He currently provides home-based community care through the Temmy Latner Centre. “A doctor is obligated to investigate a patient’s wish to die,” he says, and when the underlying issues are addressed “it [the wish] often goes away.”
He believes PAD will ultimately be legalized throughout Canada, but referral to a physician may present a potential area of conflict between patients’ rights and doctors’ religious and spiritual values.
“How do you balance the right of the physicians to opt out of making a referral if that goes against their core values and beliefs, but it’s the right of somebody else?”
“The doctors I’m speaking to are shaking their heads in bewilderment,” says Rabbi Poupko about his discussions with Quebec physicians. “The judicial solution, [Bill 52] as they see it, is facilitating or aiding and abetting death.”
Health lawyer Shelley Birenbaum says that if PAD is legalized in Ontario, physicians must follow the guidelines of the College of Physicians and Surgeons, explaining that the regulatory college expects doctors to inform patients when they cannot provide a service that conflicts with their moral beliefs. “They are also obligated to discuss all treatment options that may be available and appropriate, based on a patient’s clinical needs.”
She says doctors’ attitudes are changing: at this year’s annual meeting of the Canadian Medical Association, 90 per cent of the physicians voted to follow their conscience if PAD is legalized.
But Rabbi Poupko argues that the majority of doctors in Canada are opposed to PAD. “It’s their responsibility to heal. Taking a life is not their mandate.”
Birenbaum, an ambassador for Dying with Dignity, urges the Jewish community to engage in more debate on PAD. “We are living longer and this issue is already pressing as more people age and medical technology advances.”
Lawyer and businessman Jack Pasht, a member of the board of directors of Dying with Dignity, views PAD as a social justice issue that should naturally attract interest and support within the Jewish community. “It’s about having autonomy and choice at the end of life when you are most vulnerable. Do you want the justice system to determine how much suffering you must bear, or do you want to be able to discuss it with your family and doctor.