How do you make the tough decisions when it comes to medical care?
That’s the question that’s at the heart of the field of medical ethics. Next Thursday, the Hackensack University Medical Center is holding a discussion of medical ethics at the Chabad of Hackensack. (See box.)
Among the participants: Dr. Hannah I. Lipman, the director of bioethics at Hackensack University Medical Center, and Rabbi Dr. Edward Reichman, an emergency room physician at Montefiore Medical Center in the Bronx and a teacher of Jewish bioethics at the Albert Einstein College of Medicine and Yeshiva University.
For Rabbi Reichman, the field of medical ethics allows him to combine his medical and rabbinic interests.
He is not, he said, a posek, someone who decides difficult questions of Jewish law. But he consults with rabbis who do make those decisions.
“I’ll get calls from rabbis who say they have a patient with a particular issue,” he said. “They might want me to clarify the medical situation for them, or they could want me to clarify the halachic issues. Not every local Orthodox rabbi is familiar with medical halacha in a rapidly evolving field.”
When patients call looking for rabbinic guidance, he’ll tell them “what Jewish law has to say in general about the issue. Sometimes I’ll be the go-between for the patient and the posek.”
Sometimes, he said, Jewish law will demand a different course of action than standard medical practice in the hospital.
“At the end of life, disconnecting respirators is not uncommon,” he said. “That is something I would not personally be involved in, due to religious objections to such a procedure. There are scenarios where Jewish law might require treatment in theory for patients with a particular disease who have no specific terminal prognosis but would prefer to die.”
Not that Jewish law speaks with one voice.
“Whether brain death is an acceptable definition of death in the eye of halacha remains an international debate,” Rabbi Reichman said.
DNA sequencing has sparked new halachic discussions, he said.
“The use of DNA for identifying people came to the forefront with 9/11,” he said. “Is DNA evidence sufficient in halacha, which works on testimony? There were a number of men who tragically died in the World Trade Center. The only evidence of their deaths was a small remnant of the body from which DNA could be identified. Does a halachic court accept that DNA as sufficient evidence that the individual died for their widow to remarry? It had never been discussed in Jewish history.”
The acceptance of DNA evidence to help widows remarry carries a flip side. “If a DNA test reveals a man is not the father of his child, is that sufficient to render the child a mamzer,” unable to marry other Jews? “The questions have different answers under different scenarios.”
If much of Rabbi Reichman’s job as a Jewish medical ethicist involves connecting patients to Jewish religious authorities, Dr. Lipman sees her task as a hospital ethicist as helping connect doctors and caregivers to the values of their patients.
The classic foundational principals of medical ethics, she said, include “the obligation to act for the benefit of the patient. The obligation to minimize harm to the patient. The obligation to honor the choices of a capable patient.” Sometimes, a patient needs help thinking through the choices.
“When somebody is hospitalized, the expectation is that whatever they have can be cured or stabilized and their symptoms can be made better,” she said. “People are looking for a cure or life prolongation. The ethical issues may arise when those outcomes are not achievable. Then you have to start weighing competing goals. That’s where people’s values impact what medical choices they would make.
“Given the diagnosis of an illness, one patient might choose to undergo treatment to prolong his life, and another patient might look at the burden of the treatment and say that’s too much, it’s not worth it. Both might be medically reasonable decisions. It’s the patient’s choice on how to prioritize what’s most important. Ethics may help patients sort through their values.”
But, too often, the patient isn’t able to directly communicate his or her choices. In those cases, the ethics consultation has to help figure out what the patient would want.
“I would promote dialogue and empathy for the people involved,” Dr. Lipman said. “Often a dilemma arises when communication is not open or complete. I would look to fill out the features of the patient’s story, and also the story of their family, the people who love the patient.
“What is the story of how this problem has evolved? How has it come to a place where people aren’t sure what is the right thing to do?
“Looking at the features of an unfolding story is a useful lens. During a hospitalization we only see one small snapshot of a person’s whole life and illness experience. We need to broaden the lens to understand the context of an illness to a patient. It’s important to know the framework people come from. The religious framework, and not only religious. Also their spiritual frame and what’s meaningful to them.”
While there’s no way to guarantee that you’ll be conscious and competent throughout your hospital stay, you can make the decision-making process on your behalf much easier by setting up an advance directive, Dr. Lipman said.
There are two types of directives. One is an instruction directive, sometimes called a living will, that indicates what kind of treatments you’d want under what circumstances. Dr. Lipman recommends that people with a serious illness consider an instruction directive. For most people, though, it’s more important to complete a proxy directive, which appoints a person and perhaps an alternate to make the medical decisions.
“Everyone can face a sudden illness, where they can’t make their own decisions,” she said. “It’s important for clinicians to know who should speak on their behalf. Without a proxy directive, a decision-maker is usually designated based on the assumption that most people want their closest family members, spouses, or children or siblings to make decisions. But many people want somebody who is different than who we think is the spokesperson. In those cases, they definitely should formalize their choice in a proxy directive. Telling the doctors who to speak to for you means the person can respond to the facts as they become available, and can work with the clinical team in making decisions on their behalf.
“An ethics consultation may be scheduled when it’s not clear who is the ethically appropriate decision-maker within disagreeing families. Many families make their decisions by consensus. Sometimes there may be a disagreement among the patient’s loved ones. Differing perspectives on what the right thing to do is an ethicist’s bread and butter. We also get called when there’s a disagreement between the clinical team and the patient’s family about what the right thing to do is. We seek to understand what underlies those differences in order to reach consensus. It’s really important to be able to help people over their crisis points and make decisions,” she said.
“Where Hannah and I would differ is in how much of a role does an individual’s wishes have to play in end-of-life decision making,” Rabbi Reichman said. “In the secular world, the patient’s wishes are paramount, and will in most cases be respected. In the world of halacha, there would be cases where the patient would request something and the halacha wouldn’t be able to accept the request. Like assisted suicide, which is forbidden.”
That said, while Jewish law wants the final word in its adherents’ decision, there is no singular Jewish law on many of medical issues.
“There is a landscape of positions,” Rabbi Reichman said. “You ask a different posek, you’ll get a different answer. Different people rule differently.
“At the end of life, you have poskim who would allow you to sign a Do Not Resuscitate order and allow the withholding of certain treatments. Other poskim maintain that all treatments should be given at all times.”
For that reason, some Orthodox Jews put the name of their rabbis on the proxy document. “The other option is that family members be your health care proxy, and either tell them specifically on the proxy or tell them orally which rabbi you want to make the decisions,” Rabbi Reichman said.
What: “From Before Life Until After Death: Medical Ethics and Jewish Law in Conversation”
When: Thursday, June 27, 5:30-7 p.m.
Where: Chabad of Hackensack, 280 Summit Ave., Hackensack
How much: Free, but advance registration at EthicsConversation.com required.