A. Relationship between religion/spirituality and palliative care

The relevance of religion to health care generally and to palliative care in particular is embedded in the very word “religion.” The “lig” in that word comes from the same Latin root from which we get the English word “ligament,” which is connective tissue. The Latin root means to connect, tie, or bond, and part of what religions do is that they give us a picture of how we are tied to our family, our community, the larger human community, the environment, and the transcendent element in our experience (imaged in the three Western religions as God). Religions provide a lens through which we see the world, a group of concepts and values that tell us who we are and who we should strive to be. Philosophies do the same thing, but whereas religions are generally connected with communities that try to live by the particular religious vision, philosophies are often created by one person and then sometimes are later adopted by nations or communities (e.g., China adopted Communism).

What we know as American secular ethics is not objective or universal at all; it is actually rooted in a particular philosophical lens, namely, Western liberalism, beginning with the work of John Locke. That is an important way of looking at life, but not the only possible one – or, for that matter, the only morally sensitive or wise one. From it we Americans have learned the vital values of individual freedom and creativity, but that view tends to be weak on other areas of life, in particular the human need for community, for connection to other human beings, to the rest of creation, and to God. Those relations are important throughout life, but they come into play particularly strongly when someone is sick. Because illness is not only debilitating but infantalizing and isolating, it is precisely when we are sick that we most need the companionship and support of those who are near and dear to us, including God.

Furthermore, religions are important to understand the moral elements of life. Concrete moral norms are rooted in the broad pictures of the world provided by religions and philosophies. Whether I should fight against all odds to remain alive, regardless of my quality of life, or whether I should instead acquiesce to my dying and simply seek comfort care, or whether I should even refuse comfort care because suffering is salvational depends critically on how I understand the nature of human life and its proper goals in the first place.

It is therefore critical that those involved in health care discussions in general and end-of-life decisions in particular recognize the religious/spiritual side of life for two reasons: (1) People are likely to base their decisions about specific moral issues relevant to their care on their religious views of who they are as human beings and who they should strive to be; and (2) Religions provide an important antidote to the exaggerated individualism of American life in providing a web of relationships with other human beings and with God. The patient is, after all, a whole person and not just a machine that needs to be fixed or dismantled, and a vital part of many people’s lives is the religious or philosophical way in which they understand their place in life.

B. Metaphysical

Western philosophy beginning with Plato describes the human being as consisting of two
separate parts: the body is the animal in us, and the mind is what makes us distinctly human. Assuming that dichotomy, a stock issue in Western thought ever since is “the mind-body” problem – in other words, if the body and mind are separate, how are they connected? Early Christian sources assume a similar dichotomy between body and soul.

In sharp contrast to this, the Jewish tradition asserts that we are integrated wholes, that our body, mind, emotions, and will are all connected within us and that these faculties all affect one another. The Talmud (Sanhedrin 91a-91b) tells the story of the owner of an orchard who leaves it in the care of a blind man and a lame man, telling them not to eat any of the fruit of the orchard. As soon as the owner leaves, the blind man says to the lame man: “This is easy. I’ll put you on my shoulders, you will show me where to go, we’ll eat the fruit and the owner will never figure out how we did it.” And that is what they do. When the owner returns, he notices that some of the fruit is missing, and he says to the workers: “I thought I told you not to eat of any of the fruit of the orchard.” The blind man says: “I could not possibly have eaten any of it because I am blind, and I cannot see where it is.” The lame man says: “I could not possibly have eaten any of it because while I can see where it is, I cannot get there.” So the owner puts the lame man on the shoulders of the blind man and says, “This is how you did it, and this is how you will be judged.” Similarly, says the Talmud, the body says, “I could not possibly lead a person to sin, for without the life-breath (neshamah, soul) within me, I am like an inanimate stone, who cannot do anything.” The soul says, “I could not possibly lead a person to sin, for without the body I am like an ethereal bird flying in the air that cannot do anything.” So God throws the soul into the body and says, “This is how you did it, and this is how you will be judged.” It is a simple story, but it flies in the face of much of Western philosophy and Christianity, for it asserts that body and soul are one. The Rabbis maintain that not only in how we are going to be judged, but also in their recipe of how best to live life, for they say (M. Ethics of the Fathers 2:1) that a person should not merely study Torah or merely work, for either of them by themselves may well lead one to sin; one should instead combine study of Torah (one of the ultimate spiritual experiences in Judaism) with work, for the combination of them causes people to abandon sin and live morally.

This integrated view of who we human beings are has immediate implications for how patients must be treated. It is not enough to attend to either the physical side of illness or the spiritual side of it; people need help with both. It may not be the same people who fulfill those two needs, but people need both of them, and each will have a significant effect on the other. Thus spiritual care alone is not enough: the Talmud requires that Jews live in cities where a doctor is available and that they obey the doctor’s orders in their effort to preserve the health and life of their bodies, which, ultimately, are owned by God. Conversely, physical care is not enough either: people will not be motivated to follow a medical regimen – especially a difficult one – unless they have a will to live, and people need other people and God to restore their will to live when suffering the debilitating effects of illness.

People are not only integrated in their personal faculties; they are also integrated into families and communities. That is, it is a bad mistake to think of people as isolated individual living on some deserted island; from the moment we are born, we are part of other people’s lives as well. Moreover, we have a strong need to interact with others; that is why, short of execution, the harshest punishment in prison is solitary confinement. Illness, though, is isolating; sick people do not see all the people with whom they regularly interact in the variety of settings they are usually part of. That is why the Jewish commandment of bikkur holim, visiting the sick, is so crucial. We are, as Aristotle noted long ago, social animals, and “people who need people are the luckiest people in the world” – to quote an ancient Jewish source! Thus we must think of the ill still as people who, despite their illness and like everyone else, has deep needs to interact in meaningful ways with other people.

Finally, another important metaphysical foundation for Judaism’s approach to illness concerns its understanding of illness and suffering in the first place. The Torah asserts in a number of places that God, on the one hand, uses illness as one form of punishment for sins and, on the other, is our ultimate healer. The later biblical tradition (especially the Book of Job) questions the first of those assumptions, and in our own day, when we know about germ theory and the many morally good people who have done nothing physically wrong and nevertheless suffer from serious illnesses, we certainly must follow Job’s lead in detaching illness from sin. Bad things do happen to good people, and that is a continuing problem for Jewish theology, but very few Jews would today assert that illness is the product of sin.

The second part of the Torah’s assertions about God’s role in sin, however, is very much still part of the Jewish tradition. That never was interpreted, though, to prohibit human beings from engaging in medicine; quite the contrary, for at least two thousand years, Jews have had a virtual love affair with medicine, with many rabbis also becoming physicians and with many Jews engaged in both medical research and practice. Jewish sources understand the physician as God’s agent and partner in the ongoing act of healing. Thus when Jews are sick, they must both consult a physician and also pray to God.

Judaism’s strong mandate to heal is rooted in its beliefs that one’s body belongs to God, that human beings have both the right and duty to seek to heal, and that suffering should be relieved. There is nothing in Judaism like the Christian doctrine that suffering can be salvational. On the contrary, Judaism would have us alleviate suffering as much as we can as part of our duties to God to help people take care of their body and as part of our duty to love our neighbor as ourselves (Leviticus 19:18).

III. Data addressing hopelessness and forgiveness – Christina is providing this.

IV. Religious Issues in Different Religions

1. Forgiveness of self/others. Unlike Christianity, Judaism asserts that forgiveness has
to be earned. One does that through the process of teshuvah, return to the proper path and to the good graces of God and the community. That process requires that people (a) acknowledge that they have done something wrong; (b) feel and express remorse; (c) attempt to repair the damage (monetary, psychological, social, etc.); (d) ask for forgiveness; and then (e) act differently when the same situation occurs again. The most egregious of sins – such as those committed by Hitler – can never be forgiven, but the Jewish tradition has strong faith that for the vast majority of what we do wrong, we can and should make amends and attain forgiveness. This is based on Judaism’s strong belief in human free will and, coupled with that, individual responsibility. We do not come into the world with original sin; we come in with a clean slate and with the ability to do both bad and good. God does not expect us to be sinless; that is why three times each day Jewish liturgy has us asking forgiveness from God. At the same time, we are not helpless either; we can – and therefore we have the duty to – repair the wrongs we have done and change our ways for the better. Both God and human beings may forgive some wrongs even when the perpetrator does not go through all the steps of teshuvah; contrary to some Christian representations of Judaism that portray Judaism as solely a religion of justice, Judaism makes plenty of room for love and mercy on the part of both God and human beings. It just asserts that normally people have to take responsibility for their actions and do what they can to repair whatever harm they have caused.

2. Hope. The Talmud asserts that we should not depend on miracles. We should instead do what we can to heal each other and the world and simultaneously pray to God to help. When someone has an incurable disease, though, that does not mean that he or she has nothing to hope for; it is just that patients in such circumstances need to be taught for what they can reasonably hope. Such things might include:

• Hope that you will be able to cope with suffering.
• Hope for remission – if not cure.
• Hope for enough time to achieve a particular goal – e.g., to attend the wedding of a grandchild, or to complete a family history.
• Hope for the future welfare of your family.
• Hope to reconcile with family members or others before death.
• Hope to keep your dignity.
• Hope for life after life.

3. Afterlife. Although Judaism does not focus on life after death nearly as much as Christianity does, classical Judaism does assert belief in a life after death. Because nobody has died and come back to tell us what it is like, Jewish sources have multiple depictions of what it might be like, and no vision of that is authoritative. Judaism certainly does not have anything as detailed as Dante’s Inferno or Paradisio. My own favorite Rabbinic depiction of life after death is that we will all study Torah with God as our Teacher. One important feature of Rabbinic Judaism is that, with the exception for notoriously evil people such as Hitler, there is nothing like eternal fire and damnation; that would be inconsistent with God’s love and mercy. Those who will be punished for their sins after death will endure such punishment for at most a year, according to Rabbinic sources, and then be forgiven by God.

4. Suffering/Role of God – Why Me? Often dubbed “the problem of evil,” this age-old
question has produced many responses in Judaism. One, that of Maimonides, is that God could have chosen not to create us at all, but once God’s love led Him to create us, God could only make us as finite beings, for only God can be infinite. Finitude, though, logically requires limits of time and space, and so we inevitably must die. That is an unfortunate but logical necessity if we are to be created in the first place. From Job on, and especially after the Holocaust and after the advent of germ theory, few Jews believe that we suffer for our own sins; indeed, to claim that after so many innocents died in the Holocaust is an anathema. In the end, we really do not know why some suffer in both life and the dying process while others do not. It is one of the ultimate mysteries of life. The important thing, though, is to focus on what we can do at any moment in time to help God fix the world.

V. Summary of Jewish Medical Ethics at the End of Life

1. Life Support, Feeding. Like all other ancient traditions, Jewish sources could never
even contemplate, let alone deal with, our modern abilities to sustain life. Therefore it is not surprising that rabbis trying to apply the tradition to these new medical abilities sometimes make conflicting decisions.
In general, Judaism’s strong mandate to heal leads Jews generally to be very aggressive in medical care. When it is clear that one’s disease is incurable, though, most rabbis would permit withholding life support systems and artificial nutrition and hydration. Most would also permit withdrawing life support systems under those circumstances, and some would permit withdrawing artificial mechanisms of feeding as well. While some rabbis emphasize the tradition’s push to sustain life, others point out that Adam and Eve were not allowed to eat of the Tree of Life, that we are by nature mortal, and that, as Ecclesiastes says, “There is a time to be born and a time to die.”

2. Organ transplantation, advance directives. All movements in American Judaism support organ transplantation. The Conservative Movement’s Committee on Jewish Law and Standards has even ruled that making your own and your relatives’ bodies available for transplantation after death is not only a permissible and good thing to do, but a positive duty. There is some concern, of course, with regard to heart transplantation, for one may not kill one person in the name of trying to save someone else; but even the Chief Rabbinate of the State of Israel has approved heart transplants, thus accepting full brain death (including the brain stem) as sufficient to establish death.

All four movements in American Judaism have produced advanced directives in accordance incorporating their own understanding of how Jewish law should be applied to end-of-life care.

VI. Rituals

1. Prior to Death. In addition to assuring that the person has left a will to distribute his or her property, and in addition to praying with and for the patient and visiting him or her often, the only specific ritual that Judaism mandates is tzidduk ha-din, a prayer said by or for the patient in which the patient prays for God’s forgiveness and accepts God’s judgment.

2. After Death. After it is clear that the person has died, one of the family member’s closes the eyes of the deceased. Modesty is preserved even in death, and so men deal with a male body and women with a female one. The body is washed for both hygienic and ritual purposes in a process called tohorah and then clothed in takhrikhin, a simple linen sheet. A guardian (shomer) stays with the body overnight, usually reciting Psalms and other religious texts, to indicate that we do not abandon a person in death. Then, as a matter of honor to the dead person and body (kavod ha-met), we do not bury the body in an open casket, for the body disintegrates rapidly after death; we instead bury in a closed casket. While some Reform Jews cremate their dead, Conservative and Orthodox Jews do not, for that represents the ultimate, wanton destruction of the body that belongs to God. Furthermore, after the Holocaust, few Jews want to do their loved ones what the Nazis did to so many Jews. Following burial, a seven-day mourning period (shiva), ensues, in which family and friends visit the mourners at their home to talk about the deceased, to form daily prayer quorums morning and evening, and to take over from the mourners daily chores such as preparing food so that they can focus on mourning their loved one. Parents, children, siblings, and the deceased’s spouse are the ones who are charged with the duty of “sitting shiva,” that is, of staying at home for the week to mourn their dead. After that week, mourners continue to say a memorial prayer for the deceased (Kaddish) as part of daily services until thirty days have passed since burial; for parents, that period lasts eleven months. During these periods of mourning, festivities are avoided. Then, on the yearly anniversary of the death, all of these primary relatives repeat the Kaddish.

VII. Conclusion.

VIII. Bibliography

1) Elliot N. Dorff, Matters of Life and Death: A Jewish Approach to Modern Medical Ethics (Philadelphia: Jewish Publication Society, 1998).

2) Elliot N. Dorff, Love Your Neighbor and Yourself: A Jewish Approach to Modern Personal Ethics (Philadelphia: Jewish Publication Society, 2003), esp. Chapter Seven, “Hope and Destiny.”

3) Maurice Lamm, The Jewish Way in Death and Mourning (New York: Jonathan David, 1969).

4) Maurice Lamm, Consolation: The Spiritual Journey Beyond Grief (Philadelphia: Jewish Publication Society, 2004).