Should Religion or Science Define Death?
Wednesday, November 12, 2008; 11:00 AM
As a D.C. Superior Court considers whether or not Children's National Medical Center can allow the heart of a brain-dead 12-year-old boy to stop, over the objections of his Jewish Orthodox parents, we look at the medical and ethical debate behind the case.
Rabbi Dr. Edward Reichman was online Wednesday, Nov. 12 at 11 a.m. ET to take your questions about the theological and scientific definitions and interpretations of death.
Send in your questions and comments before or during the show.
Reichman is an associate professor of emergency medicine at Montefiore Medical Center and associate professor of philosophy and history of medicine at the Albert Einstein College of Medicine of Yeshiva University. He'll discuss the thinking behind the case.
Edward Reichman: Welcome to this morning's chat. It's nice to be here today to be able to answer your questions on this most challenging and agonizing case. Our wishes are with the family today as they struggle with this very difficult and emotional case.
Concord, N.H.: How does the Orthodox Jewish religion view removing the boy from life support to determine if his body can breathe on its own? It seems though a machine could indefinitely keep the child's systems functioning, but it is a false sort of functioning.
Also, are the family's views really in line with traditional Orthodox views?
Edward Reichman: Regarding the approach of the Orthodox Jewish religion to removing the boy from life support ... This is the crux of the issue: The definition of the status of this boy in the eyes of Jewish law. This child has been diagnosed with a medical condition called brain-dead. This definition has been accepted by society as a definition of death for the last few decades but is a relatively new definition in the history of medicine.
Prior to that point death was always defined as cessation of heartbeat. When this new definition came on the horizon rabbinic authorities analyzed the issue from a Jewish legal perspective. The rabbis approach this issue in a sophisticated, legal and medical fashion and there is currently a debate as to whether brain death is considered legal death in the eyes of Jewish law.
Both opinions are respected opinions in the Jewish Orthodox tradition. There are rabbis as the rabbi of this particular family who maintain that as long as there is a heartbeat, even if the child is sustained by artificial breathing, that child is legally alive and should be accorded the rights of any living human being.
This is a mainstream position. There is also another mainstream position that accepts brain death as legal death and would consider such a case as constituting legal death.
Kingsland, Tex.: One can easily tell if the heart and breathing stops, but it is not so easy to tell if the brain stops working. How does one actually tell if the brain stops working?
Edward Reichman: As to how one actually tells if the brain stops, that is a medical assessment. There are sophisticated medical criteria that assist the physician to make the determination that brain death has occurred. The criteria are both clinical and can be assessed by physical exam as well as through imaging of the circulation and function of the brain.
Bay City, Tex.: Rabbi, If Hashem is the decider of life and death, how does keeping anyone "technically" alive on machines square with this? Plus, what is life?
Edward Reichman: The statement that if God is the decider of life and death, how do we play a role in this process ... is an important theological concept and exactly on point. Medicine has a physiological definition as to when they believe death has occurred. Jewish law believes that the definition of death is not exclusively a medical one but is also a theological one and should be decided in the theological or religious arena. The two obviously work together to some extent but the final arbiter is the religious determination.
Washington, D.C.: Theology has no role here. A child is -- tragically -- brain-dead, with no chance of recovery, and scarce resources are being used to keep him breathing instead of to help others whose lives actually might be saved or improved. Nobody's religious beliefs should have the right to continue such a misuse of the resources.
Edward Reichman: This question states that the child has no chance of recovery. The question assumes that there is a notion of quality of life while in general in our society quality of life plays a role in end of life decision-making and it is acceptable in many circumstances to withhold or withdraw medical care to patients which will lead directly to their death. Jewish law does not countenance such actions.
Firstly, we have a different notion of quality of life not based on consciousness or productivity. We believe in the sanctity of human life in all cases. To remove care from a patient considered alive in the eyes of Jewish law that would lead to the patient's immediate demise would be tantamount to homicide in the Jewish tradition.
Family Involvement: There are a lot of rumors and speculation in this case. There have been contradictory reports about how often the parents are visiting their child. But all accounts agree that weeks pass when no one is visiting the child. Is there a possibility that the parents are coming to terms that their child is dead but are being unduly influenced by religious leaders to take this stance?
Edward Reichman: A number of people have commented on the involvement of the family with the care and visiting of this child. All these rumors are without verification and entirely irrelevant to the theological discussion about the care of this child. Each family deals with end of life issues in their own unique fashion and there is a rabbinic adage, "Don't judge your fellow person until you have experienced the identical circumstance."
Washington, D.C.: Thank you for taking questions Mr. Reichman. What bothers me about this case is that it seems as though these parents are using this uncertainty in Jewish law to keep their child on a machine so they can touch him and hug him, not because they truly want to represent this as a civil rights issue in the courts. I understand their desire to hold their son and do not begrudge them for that. However, if I had a child in that situation I am certain this would have already ended. The doctors would have given me time to be with my child, turned off the machines and referred me to grief counselors. Simply because I do not follow religion means I have no claim to stake in wanting to keep my child alive? These parents should accept the reality of the situation and say goodbye. Using the resources of the hospital on someone who is dead is good neither for them or the rest of us who may need a bed in that hospital one day.
Edward Reichman: Allow me to clarify that this is not an uncertainty in Jewish law. It is a matter of genuine debate. The family's rabbinic authority espouses the position that death does not occur until the heart has stopped beating. This is the legal decision that has been rendered from a Jewish perspective in this case. It is not an uncertainty.
It is absolutely not motivated by the family's desire to "hang on to the child" for a longer period of time. This dimension is not a factor in the rabbinic decision.
The grief involved for the family which we perhaps don't focus on sufficiently is surely immeasurable. But again, this is not a factor in the religious determination as to whether this boy is alive in the eyes of Jewish law.
Washington, D.C.: One of the arguments in favor of removing this boy from the machinery that is keep his heart beating is that this machinery could then be used for another child that has a chance of survival. Is this nonsense? Are there that few of these devices that other children are suffering, perhaps dying to keep this child's heart beating? Or is this a scare tactic argument? It is so hard to determine what is honest and what is rhetoric.
Edward Reichman: The notion of using scarce resources is not without merit. There are indeed extensive rabbinic discussions about how to use limited resources in society. One of the areas that merits resources is the preservation of human life. As according to the rabbinic decision in this case this child is alive in the eyes of Jewish law it is deserving of these resources. Judaism has extraordinary respect for the sanctity of life and its preservation requires financial support as well.
Practically it is rare in American hospitals that breathing machines would be scarce and that this particular breathing machine would be required to care for another individual. Debates about scarcity of resource find their expression more in a field like transplantation when few organs are available and decisions have to be made about to whom to allocate these organs.
Washington, D.C. again: Rabbi Reichman: You wrote "it is acceptable in many circumstances to withhold or withdraw medical care to patients which will lead directly to their death. Jewish law does not countenance such actions." But the broader society is being penalized here by Jewish law. This country is not ruled by religious law, despite the claims of many that it is a Christian country. So how should we resolve this? I am no more tolerant of allowing religious beliefs to lead to a child's death by withholding any medical treatment, as some do; or allowing mistreatment of female children, as some do; and so on. Why should we not follow the law of the land here? (And yes, I do appreciate the hospital's attempt to talk to the parents, and I do sympathize with those parents.)
Edward Reichman: The issue here is respect for religious beliefs. Acceptance of religious beliefs is one of the strengths of our American society and we generally, with very few exceptions, will allow religious beliefs to be expressed as long as they do not harm other individuals. On the one side, we allow patients to withhold their own care and refuse life-saving blood transfusions even if it means they will die as a result. We should likewise respect that religious freedom for those who want their lives continued in the belief that this is their religious teaching.
Edward Reichman: In fact, this morning there was a news report that a young girl in England was granted the right to refuse life-saving heart transplantation. Of course, each case requires specific analysis and her refusal I do not believe was based on religious considerations but respect for the individual's ability to make decisions about the preservation of cessation of their life is the common denominator.
Burke, Va.: What if it were possible to extract the heart from a brain-dead patient, hook it to a machine, and keep it beating? Could anyone reasonably argue the isolated beating heart constituted a human being? The argument that the presence of a heart constitutes in itself a meaningful definition of "life" doesn't seem to bear scrutiny.
Edward Reichman: It is interesting that the heart has its own independent electrical system and in fact in antiquity scientists removed the heart from animals, placed them on a table and observed them continuing to beat for some time outside the body. However, the human being is more than a composite of its parts. The soul permeates the human body investing it with far more significance than just a body with a pump called a heart.
Your phrase "meaningful definition of life" as mentioned before is a religious or theological definition, not a medical one.
Evanston, Ill.: You say that, "We believe in the sanctity of human life in all cases. To remove care from a patient considered alive in the eyes of Jewish law that would lead to the patient's immediate demise would be tantamount to homicide in the Jewish tradition." Leaving aside the definitional question of "alive" in Jewish law, none of the extraordinarily expensive medical care currently keeping this boy's blood flowing was even imaginable when Jewish law was formulated. To say that society must spend unlimited amounts of money to keep someone nominally alive in an irrevocable vegetative state or else it is committing homicide is outrageous. It doesn't consider the opportunity cost of such expense and relies on dogmatic and ideological assumptions. Nobody is saying that the boy should be prevented from receiving private care just that society shouldn't have to subsidize a lost cause.
Edward Reichman: Let us take your comments to the logical extreme. There are thousands of patients across this country of all ages in a persistent vegetative state. Would it be ethically permissible based on financial considerations, especially in these economic times, to forthwith stop all care for such patients. Surely not. Our ethics and morality should always supersede financial concerns.
You also address the historical argument that none of these treatments were available when Jewish law was formulated. While factually true, the ancient principles of Jewish law are applicable to any new and unforeseen circumstance. Penicillin was not invented in times of the Talmud. Does that mean that Jewish law is incapable of addressing antibiotics and their usage? Clearly these principles have stood the test of time and have been consistently and comprehensively applied in every generation to every imaginable new circumstance.
Silver Spring, Md.: Why are doctors making decisions such as hooking up a child that has no chance of recovery from a brain cancer to "life" supporting machines, including IVs stimulating heart beat and lung functions? Is this a financial decision? First do no harm. With the decision to support a dead person artificially to stay alive, a lot of harm was done to the child and the parents.
Edward Reichman: I would like to clarify that Jewish law does not require all treatments at all times under all circumstances. While it is a matter of rabbinic debate there are many circumstances where it is permissible to refrain from treatments in Jewish law. Each case requires a separate analysis but, for example, withholding a respirator or withholding dialysis or DNR (do not resuscitate) orders may be acceptable in specific cases under rabbinic guidance.
In this particular case the issue is that the disconnecting of the respirator will directly lead to the demise of the patient. Admittedly there are some who consider his current condition of brain death but this family's rabbinic authority maintains that the child is still legally alive. Therefore, removal of the respirator would lead to the child's demise. This aspect is objectionable in Jewish law.
Edward Reichman: Thank you all for your thoughtful and caring questions. This is clearly a complex matter at the interface of medicine, ethics and religion. Let us pray that a resolution to this case will come soon that will be acceptable to all involved.
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