Redefining Withholding and Withdrawal of Life Support: Patient Autonomy vs Jewish Religious Law
As used in clinical ethics, withholding of life support means that a treatment or procedure which could keep a patient alive who, without the treatment, would die is not given or performed. Withdrawal of life support is an expression which means that a treatment or procedure which is currently being applied to a patient and which is keeping the patient alive is stopped and not resumed. Both the withholding and withdrawal of life support have been accepted by the ethics community and by law in the United States and elsewhere in the world as ethical and legal for patients or their surrogates who have autonomously requested them. It is the consensus that both withholding and withdrawal are equally ethical. However in some religious and non-Western cultures, this may not be so.
Even in the United States, some physicians, healthcare providers, patients and families may not fully accept the absence of ethical distinction between withholding and withdrawal. Withholding is then considered a passive act and in appropriate cases and at the request of the patient is acceptable. There is also the possibility that, with some treatments or procedures, in the specific patient, the treatment/procedure might not even be life supporting in the first place. Withdrawal, on the other hand, may be considered as an active action. In this case, a treatment or procedure which has already been shown to be effective in supporting the patient’s life is being terminated with the intent and understanding that, as a consequence, the patient will die.
It is this conflict and the relationship to patient autonomy vs Jewish religious law that was written about by Vardit Ravitsky in a February 2005 issue of the British Medical Journal titled “Timers on Ventilators”. The following extract details the issue as interpreted by the Jewish religious law called the Halakha.
Within Halakhic literature, withholding treatment at the end of life, generally perceived as a permitted noninterference in the natural process of dying, is traditionally distinguished from interventions involving direct contact with the body or immediate environment of the dying person—for example, the withdrawal of treatment that has already started. This distinction stems at least in part from the religious approach that humans should not have an active role in the dying process, which should remain in the hands of God. Jewish religious law does not approach the issue from a consequentialist perspective, where the moral value inheres only in the end result. Rather, the procedure leading to the outcome has independent moral value.
The Halakhic literature reasons using a metaphor of the dying person as a "flickering candle," and the idea that one should not be "placing one's finger on the candle." In his book Alternatives in Jewish Bioethics, Noam Zohar notes that "this clearly excludes an understanding of the forbidden hastening of death in consequentialist terms: the deed's wrongness is not determined by its result—namely, the fact that the patient is dead at a certain earlier moment—but rather by its symbolic characterisation as extinguishing the candle." This means that withdrawal of treatment is perceived as forbidden even if the death of the patient at that point in time is an ethically appropriate outcome.
To resolve this issue, an Israeli committee was formed in 2000 and in 2002 came up with a proposed law with regard to life support by ventilator. It revolves around a declaration that life support should be distinguished between “not continuing discrete treatment" (treatments which are potentially intermittent) which would be considered as “withholding life support” and “not continuing continuous treatment” and which would be considered as “withdrawing life support.” By this definition, patients would be able to order the termination of discrete treatments by not resuming the next treatment (such as dialysis) but not continuous treatments such as the ventilator. However, if the continuous treatment could be established in advance as discrete by, for example, applying a timer to the treatment the treatment would now become discrete and the patient could request that when the timer expired it should not be restarted. This explains the title of the article. The proposed law, according to information I have received as I post this thread is that the law is not as yet in effect. Read the article and then come back and discuss your view of withholding and withdrawal and the Israel committee’s solution to preserve autonomy and yet hold to Jewish religious law. ..Maurice.