Lessons from a "Goses"--a Dying Person

Thirty-five years ago, when I was an attending physician in my hospital’s intensive care unit, I started to ponder the ethical issues involved in the use—and misuse—of increasingly powerful medical technology. Twelve years before that, in 1968, during my internship, there were few end-of-life ethical conundrums: We treated every patient as aggressively as possible—always. Death was the enemy, and we employed every medical intervention to avoid the demise of our patients. Our technology was primitive by today’s standards, and we could not prolong the process of dying significantly.

A mere 10 years later, when I was an attending physician in the intensive care unit, medical technology had advanced greatly, and the lives of many ICU patients were saved by respirators, dialysis machines, and powerful new drugs. I soon realized, however, that there was a group of patients who could not be cured with these interventions, but whose dying was prolonged significantly—with much suffering for both them and their families.

I needed guidance in how to deal with these ethical dilemmas. As someone who took his Jewish religion seriously, I began reading articles and books on Jewish medical ethics. In the course of my readings, I came across a curious and powerful statement written some 800 years ago by a Jewish scholar from the Bavarian town of Regensberg, Rabbi Judah the Pious. He wrote in Sefer HaHassidim, The Book of the Righteous: “We do not compel a person not to die quickly.” What a strange but insightful statement, I thought. The rabbi gave an example: If a person is a goses and someone near his house is chopping wood so that his soul cannot depart, one should remove the woodchopper. One does not put salt on his tongue in order to prevent his death….”

In Jewish law, a goses is someone who is moribund, someone who is actively dying. In the thirteenth century, people had fixed ideas about events surrounding death and felt that loud noises or the pungent taste of salt could delay that final moment when the soul departed the body. Removing the woodchopper was viewed as removing an impediment to one’s peaceful death.

I learned from yet another source written a thousand years before Rabbi Judah the Pious the same principle: that one should remove an impediment to a peaceful death. In the Talmud, the story is told of the death in the third century of Rabbi Judah the Prince. He was the foremost Jewish sage of his era and was suffering with an intestinal disease. His disciples, overcome with the dread of losing their beloved teacher—but seemingly unaware of the degree of his suffering and of the hopelessness of his terminal illness—continued to pray for his recovery. It was only the rabbi’s housemaid, who, seeing his torment and the inevitability of his imminent death, was determined to silence the prayers of his followers, which she believed were preventing him from dying peacefully. She cleverly threw an earthenware vessel to the ground. The noise of the shattering vessel stunned the praying crowd so that they ceased their prayers for an instant, during which time Rabbi Judah’s soul departed. Just as in the case of the woodchopper, the handmaid acted to remove an impediment to a peaceful and quick death: in this case, the prayers of his students.

When, as a young ICU attending, I first read these sources, I was intrigued by the idea that the wise Jewish scholar of 800 years ago, who could never have dreamed of our medical technology, had ruled that one must remove an impediment to imminent death, and that a compassionate handmaid a thousand years earlier, had intuited the same humane principle.

In today’s ICUs, the woodchopper and the prayers of devout followers have been replaced by ventilators, dialysis machines, ventricular assist devices, and extra corporeal membrane oxygenators. Might not Rabbi Judah the Pious, rounding in our ICUs today, be dismayed at how often his introductory principle—“we do not compel a person not to die quickly”—was being routinely violated by our modern-day incarnations of the woodchopper? Whether because of the understandable grief of families unable to let go, or the injunctions of some rabbis that every moment of life must be preserved, or the poor judgment of physicians who do not recognize when the battle for life is lost, aren’t patients too often compelled “not to die quickly?”

Take the case of my patient Ben. When he was 88 years old, he came to see me for mild chest pain, and brought with him an x-ray that showed a mass in his lung. His daughters requested that I not share with their elderly and frail father my diagnostic impression of cancer. They were a deeply religious Jewish family, and it was their custom not to share bad news with elderly parents. Indeed, Ben was too frail, with heart and kidney disease, to undergo surgery, chemotherapy, or radiotherapy. He and his daughters had agreed, however, to a needle biopsy of the mass in view of the possibility that it might be a treatable non-cancerous process. Unfortunately, my fears were realized; the lesion was malignant. Ben was uninterested in the biopsy result, and he was sent home with medication for pain.

I had not heard from him for a year when he returned to my office, accompanied by his daughters. He looked thin, drawn, and breathless, but he maintained his sweet smile and greeted me warmly.

His pain was now worse, and he had developed a large collection of fluid in his chest cavity. It was clear that he was near death. Given the absence of therapeutic options, I suggested to his daughters that their father return home with hospice care, which would maximize his comfort and treat symptoms as they arose. His daughters consulted with their Orthodox rabbi, who stated that all measures be taken to keep Ben alive and comfortable as long as possible. Every moment of life was considered sacred, and if hospitalization could prolong his life, he should remain hospitalized and be treated aggressively. I offered the option of discharging Ben home with follow-up by home hospice, but the family declined. Rather than have his shortness of breath treated with as-needed doses of morphine at home under the supervision of a team of home hospice professionals, his family requested that he stay in the hospital and have a chest tube inserted to remove as much fluid as possible and thereby alleviate his breathlessness and probably prolong his life. When asked about his preferences, Ben deferred to his daughters.

A chest tube was placed, and although his breathing temporarily eased, Ben remained uncomfortable and quickly became weaker. Despite the chest tube, his breathing soon became more labored and I suggested to his daughters that he be allowed to pass away peacefully without placing a breathing tube in his throat—intubation—and connecting him to a respirator. After a long discussion among themselves and with their rabbi, it was concluded that since intubation would prolong Ben’s life somewhat, they felt religiously compelled to request ICU transfer and ventilator support. At this point, I tried once again to gently ascertain Ben’s wishes but whenever the discussion became too specific, his response was, “ask my daughters.”

As Ben’s breathing became more labored and it was clear that he would die imminently, he was transferred to the ICU, intubated, and connected to a respirator. As we were intubating Ben, the thought occurred to me that he was a goses and that we were ignoring Rabbi Judah the Pious’ admonition to avoid compelling a person “not to die quickly.” Ben was sedated for comfort and, despite the ventilator, died a day later. His family agreed at the last moment not to attempt cardiac resuscitation when his heart stopped beating.

Although one might criticize under these circumstances the rabbi’s decision to preserve Ben’s life as long as possible—while attending to his pain and shortness of breath—the importance of the concept of the sanctity of life in the Jewish religion cannot be overstated. Judaism is a religion that treasures every second of life. Although Judaism accepts the notion of a hereafter, the entire corpus of Jewish law and lore focuses on life in this world, and stresses the importance of sanctifying every moment of existence by carrying out good deeds, adhering to God’s laws, and deriving as much happiness and pleasure as possible within the bounds of halakha. If a person can be kept alive for one more day, that person might use that time to do a mitzvah reflect on life, do teshuvah (repentance), or pray to God.

I also feel that the Holocaust continues to have a significant impact on the way rabbis and Jewish laypeople think about the sanctity of life, especially when confronting end-of-life issues. Because a mere 70 years ago one out of every three Jewish men, women, and children on earth was murdered by the Nazis and their henchmen, the notion of the sanctity of life has been reinforced, leading many rabbis to ordain that every moment of life, even as life is ebbing, be preserved by whatever means possible.

Returning to the concept of a goses: Although the classical sources I quoted above admonish us not to prolong the dying process of a moribund person—“we do not compel a person not to die quickly”—there is a very important flip side to this ancient concept. The Talmud prohibits actions that are intended to hasten the death of a goses, “who is regarded as a living person in all respects.” The Talmud enumerates such prohibited actions. One may not move the patient, close his eyelids, or bind his jaws—actions that should not be carried out until after death. The goses was likened to a flickering candle that becomes extinguished with the slightest perturbation. Clearly, the rabbis warn physicians to beware of the temptation to extinguish the flickering candle of life by, for example, administering a higher dose of morphine than is necessary to alleviate suffering. When such drugs are used with the intent to hasten death, regardless of the humane motives of the physician or the family, this is clearly prohibited.

It is a delicate balancing act indeed: Just as Rabbi Judah the Pious and the Talmud would seem to sanction, if not require, intentionally removing impediments to a peaceful death of a goses in order to avoid prolonging the dying process, that same goses should not have his or her death intentionally hastened by actions of the physician or family. The laws pertaining to a goses would seem to indicate that there is a definite, if subtle, distinction in Judaism between an action to remove or withhold treatment that prevents a peaceful death, and an action with the intent of hastening death such as administering a drug to the patient to accomplish this goal. The tension between respecting the sanctity of life by prohibiting actions intended to hasten the death of a moribund patient, and alleviating suffering by permitting the removal of machines or medicines that are impediments to a peaceful death, is a frequent concern of every ICU physician. Thus, the concept of a goses developed centuries ago by Jewish scholars would appear to be relevant and useful even today in end-of-life situations.

Judaism’s stance on physician-assisted suicide is clear given its attitude toward a goses. If a physician may not do anything that will hasten the death of a moribund patient, one is obviously prohibited from prescribing a lethal dose of medication to allow a terminally ill patient who may still live for months, to commit suicide. The changing values of our society, which are increasingly accepting of physician assisted suicide—it is now legal in 6 states—are clearly contrary to the teachings of traditional Judaism.

Many Orthodox rabbis, and Ben’s rabbi must be counted among them, feel that medical technology has rendered the idea of a goses obsolete. After all, they reason, if some patients who were formerly considered moribund can now have their moment of death delayed by medical technology, or even reversed, how, then, can we decide who is a goses? Is the concept still relevant in our technologically sophisticated ICUs?

Perhaps because of my decades of exposure to the sometimes painful realities of patients dying in the ICU, I believe that the concept of a goses remains relevant even in our modern medical centers. In answer to those in the Orthodox community who feel that the concept of a goses is rendered irrelevant because of powerful life sustaining technology, I point to many ICU patients whose death would be imminent without life support, who are comatose or severely obtunded, who suffer pain and indignity, and who have no chance of leaving the hospital alive. Might not such a patient rightfully be called a goses, and should we not be allowed to remove medical impediments to a more peaceful death?

Rabbi Judah the Pious would no doubt insist that in assessing when a critically ill person crosses the line between possible survival and certain death, painstaking efforts must be made by physicians to ensure the accuracy of their prognoses. The concept of a goses is helpful only insofar as the physicians caring for such a patient are mindful of the sanctity of life and assume the awesome responsibility of making an accurate prognosis with humility and skill.

I believe that even today the concept of a goses offers a clear lesson for doctors, patients, and families. In the coming decades, America will face a an increasing number of end-of-life ethical issues as many aged baby boomers will have access to ever more sophisticated medical technology that can prolong life but will often prolong the dying process. The strains on our medical resources, especially in a country where 20 percent of its population dies in ICUs, will be great.

But resource allocation is not the only, nor the most important reason, why we should recognize the wisdom of considering certain dying patients as a goses and allow them a peaceful and dignified death. I have seen numerous examples of patients—Jewish and Gentile—whose final days, weeks, or even months have been marked by unresponsiveness, a hopeless prognosis for survival to discharge, but who have undergone repeated invasive procedures, resuscitations, and diagnostic tests that have served only to prolong the dying process and subject their body to grievous deformities and indignities. Very often, Orthodox families of such patients have suffered by witnessing what their loved ones have had to endure.

The choice is not between the false specter of so-called “death panels” eager to pull the plug on a patient, and those who would use technology to prolong the suffering of dying patients. There is a way to respect the sanctity of life of a goses, while withholding or removing impediments to a peaceful death. But this requires physicians with wisdom, expert clinical judgment, skills of communication, and sensitivity to the value of life and the concerns of families. It also requires sensitive guidance from spiritual leaders, who sometimes view death as an enemy, rather than inevitable, and who should heed the wisdom of Ecclesiates 3:1 that, “There is a time for everything and a season for every activity under heaven…a time to be born and a time to die…”.