Friday, February 10, 2012

Dying with dignity versus living without it

My father-in-law works in end-of-life care, so over the years we've had lots of conversations about the topic. While I personally have not experienced close friends or family going into hospice, I have come to have a greater appreciation for the palliative method over a "preserve life at all costs" approach. Still, I understand that this creates a bit of a mind for medical ethics and for those in the medical profession: one long-standing definition of a doctor, connected with the Hippocratic Oath, is the concept of doing no harm. It is one that I think many Jews can connect with as well-- Judaism is supposed to celebrate and venerate life, and I've read that the implication that comes with that philosophical orientation is that there is a very strong bias against ending life if it can be preserved.

However I think that at the end of the day, both Judaism and medicine have enough depth to them that, if one is interested in making the case, there is certainly enough intellectual ammunition to support a more palliative approach. The big question, I believe, revolves around the notion of what harm is and where "quality of life" intersects with the broader category of "life." Just as there are certain mitzvot that traditional Judaism commands Jews not to violate even if it leads to their death, it would seem logical that there are similar scenarios in which it is appropriate to re-evaluate priorities and, potentially, decide to discontinue treatment (particularly aggressive or debilitating treatment) in favor of a more dignified and comfortable end to the patient's life.

I've been thinking about these issues a lot lately as I've been following the news about R. Elyashiv in Israel. He has been a long-running Internet antagonist for the several years I've been blogging, a perfect example of how the Haredi community, particularly in Israel, seems to value authority over discussion, and isolation over engagement. In recent years, R. Elyashiv has banned books without reading them, technology he doesn't use or understand, and condemned whole swathes of people he has never met. In my eyes, he was the best example of the living anachronism that traditional Judaism must struggle to avoid becoming.

But a few weeks ago I read an article in Haaretz that changed my thinking a little.
On the top floor of a Jerusalem hospital lays a very old man. He is slowly dying, but he won't be left in peace. A small circle of courtiers around him continue to issue in his name edicts and rulings, ensure that his signature still appears on letters and when his medical situation improves temporarily, they will remove him from hospital and seat him in his chair at the synagogue, where everyone can see him. The hospital staff grumbles that all this just prolongs the old man's agony, but there is nothing they can do as the retinue controls all the old man's moves. 
Only a tiny handful of relatives and trustees are allowed to talk with him, and they jealously guard his real mental situation while everyone is told that he is fully lucid and talking with his family and doctors, praying and studying as normal. 
This is how the great rabbis die nowadays. These were the circumstances of the last years of the Lubavitcher Rebbe, Rabbi Menachem Mendel Schneerson, as the Chabadniks fought over him, manhandling him to the window of his study so he could wave to the crowds on Eastern Parkway, steadily deifying him as he descended into his last coma. His body died in 1994, at the age of 92, but many of his followers still believe he is with us. 
Rabbi Elazar Menachem Shach suffered similar indignities when visitors to his home in Bnei Brak were shown the volume of Talmud he was studying from, but were not told he had been on the same page for 10 years. Just before he turned 100, he was finally allowed to retreat from the public stage and given a few years of rest before he died at the age of 102. 
The retainers of Kabbalist miracle-maker Yitzhak Kadouri bodily carried him to events well into his 11th decade, making sure he muttered the required incantations, shouting in his near-deaf ear the names of those to be blessed, and continued a brisk trade in his handwritten amulets until death finally liberated him from their clutches at 106. 
By some accounts, 101-year-old Rabbi Yosef Shalom Elyashiv, the great sage of the "Lithuanian" ultra-Orthodox community, is undergoing the same treatment as these words are being written. For months now he is being shuttled back and forth from hospital to his tiny apartment in Mea She'arim; but despite growing reports on his frailty, he still seems capable of publishing momentous rulings on the pages of Yated Ne'eman, such as the one that appeared two weeks ago forbidding Haredi men and women from participating in military or academic vocational courses under non-Haredi auspices. While there are those who treat these verdicts as the word from up on high, speculation is growing that for months now, if not years, Rabbi Elyashiv's name has been appended to endorsements and prohibitions he has never heard of. 
Modern medicine has created an intractable theological dilemma for Haredi Jewry. While it prolongs the lives of rabbis well in to their 90s and beyond, it does not guarantee soundness of mind. But how can a community brought up on the doctrine of "Da'at Torah," rabbinical infallibility, accept that their leaders' memory and reasoning can deteriorate. They liken their rabbis in old age to Moses, whom the Torah tells us that at the age of 120, "his eye was not darkened, nor his moisture ceased." And above all, their mind, this god-given gift to an entire nation, surely cannot fail, only gain strength and wisdom. But that is simply not the way of the human body.
Assuming even half of Anshel Pfeffer's article is true, it raises a fascinating point that, to my embarrassment, I had only half-recognized myself up until now. Yes, it is incredible, bizarre, and rather unbelievable that these gedolim are still giving pronouncements on issues of the day past the age of 100. And the reason it is all of those things is because they aren't actually doing it. These elders are not reading these books, not condemning these technologies. They've never seen them. Most of them spend most of their time going back and forth from home to shul to the doctor. It is their handlers, their advisers, their heirs, who are pulling the strings. In the height of chutzpah, these younger people manipulate, deceive or even impersonate their supposedly venerated leaders, men that their communities see as truly holy, to exert their own desires for power. And while doing so, not only do they undermine their credibility, their independence, and their reputation-- but they also turn them into political symbols to fight their pet battles, regardless of whether the sages know or care about the issue or not.

Even now, this is going on with R. Elyashiv.
Rav Elyashiv is listed in critical/stable condition. The gadol hador is in a medically induced coma and connected to a mechanical respirator, fighting the fluid buildup in his lungs, the result of diminished cardiac output as seen in congestive heart failure. 
Family members are in the hospital, where hundreds continue to gather, compelling hospital security and police to deploy additional manpower to keep people outside. Officials report that while the avreichim and rabbonim mean well, they are not assisting the rav’s situation and they are hampering hospital personnel, interfering with them. Additional security has been placed at the second floor entrance to the emergency room, the hospital’s night entrance.
Think about that: R. Elyashiv has not been conscious for days. He is in a coma. He is on a respirator. And yet there are so many people crowding into his room that the staff can't even do their job. I have no doubt the vast majority of the people visiting this man are sincerely there because they care about him. But the lack of understanding about what they need versus what he needs is pretty shocking.

There's yet another dimension to this: the idea that if R. Elysahiv goes, the entire community will suffer a major tragedy. There has been little thought as to who will succeed him, what training or support they might need, ways the community might be able to help the family grieve, etc. A month after another serious hospital visit, several days since he has been in a coma, and R. Elyashiv's community shows no sign of letting go. They will not consider what happens next because they will not admit that he is going to die. To that point: he cannot be allowed to die.

“If Rav Elyashiv in danger,” said Rav Edelstein, “we are all in danger.” 
In his morning shiur, Rav Edelstein linked Rav Elyashiv’s condition to the security situation in Eretz Yisroel, stating that Rav Elyashiv protects us. 
“We are in danger and need protection and are in grave danger… We are a lonely sheep among seventy hungry wolves. In such a situation, we need protection. ” 
The rosh yeshiva then described Rav Elyashiv as protecting the generation. 
...Later, the rosh yeshiva described how the power of the righteous can prevent wars and catastrophes, adding that it is known that before World War II, many gedolim, including Rav Boruch Ber Leibowitz, Rav Shimon Shkop and others,  perished, thus removing these “righteous defenders” from the world. 
“Now in our generation, we have an individual who defends us through his toil in Torah,” said Rav Edelstein. “Now he’s sick and we are compromised. We must all daven and learn Torah.”

This kind of personality worship cannot be healthy. This extreme identification of one mortal person's health with the entire community's well-being verges on the nutty. Sooner or later, R. Elyashiv is going to die. What happens once he does? The way people are talking about him is making it sound like they think he can't die. Are they going to deify him like Chabad did with Schneerson? One can only hope that people like R. Edelstein don't actually believe what they're saying-- in which case, the whole thing becomes one big PR stunt. Which is worse?

Death is part of life. All people die. Judaism, which is rooted in the real world, knows this. Yet some of this pragmatism seems to be getting lost. The elders of our communities should be honored and allowed to pass in peace, not have their accomplishments be sabotaged in their final years by the very people who should be protecting them and preserving their dignity. There is something seriously wrong when leaders don't pass the torch until they reach 100... only to give it to people in their 90s. When did we start acting like the Catholic Church?

I cannot in good conscience wish R. Elyashiv a refuah shleima, a complete healing. I believe he is beyond that. I wish him the same wish I have been wishing for my own grandmother, a woman thirteen years his junior but just as mentally and physically compromised as him. I wish that they both be allowed to go in peace, comfortable, content, and with dignity. Not a refuah shleima, but a sof shleima (complete end). Or, perhaps more poetic, a chayim shleima (complete life).

If R. Elyashiv's people truly respect him, if they truly believe that he is the best of their generation... and if they truly believe their prayers have the power to keep him alive until 120...

They should stop.

And let him go.

1 comment:

MIghty Garnel Ironheart said...

There is a wealth of halachic literature on how and when to switch from "Save him at all costs" to palliative care. "Do no harm" goes both ways. Sometimes you harm a person by flogging his body with chemicals and electricity just to keep his battered heart beating.
But don't pay too much attention to the hyperbole coming out of the Chareidi press. When Rav EE Shach was on his deathbed a few years ago the same hysteria occured and then settled down once Rav Eliashiv had been annointed.
The bigger issue is the one you identified and that I've written about: that the handlers are actually issuing the rulings and pronouncements while these elderly men slowly decline in the back room and unknowingly acquiese to the reign of terror these megalomanics inflict on their masses.