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Who Will Live, and Who Will Die

Rabbi Toba Spitzer

Yom Kippur 5773

PDF:  YK Talk 5773 - Who Will Live.pdf

Rabbi Alan Lew, the wonderful writer and teacher, has noted that the ten days from Rosh Hashanah to Yom Kippur are like a compressed voyage from birth to death.  Rosh Hashanah celebrates birth - the creation of the world, the birth of humanity - and Yom  Kippur is the day we “rehearse” our own death - by wearing white, like the shroud we’ll be buried in; by reciting the viddui, the confessional that we also recite on our deathbed; by not eating or indulging other bodily pleasures.  During the Yizkor and Eleh Ezkereh services on this day, we mourn our losses, and remember those who are no longer with us.   And later this afternoon, during the Musaf service, we chant the powerful Unetaneh Tokef prayer - contemplating “who will live, and who will die” in the new year. 

This fall, another question of life and death that looms before us.  On November 6th, Massachusetts voters will be asked to vote “yes” or “no” on a ballot question entitled “Prescribing Medication to End Life.”  If passed, this initiative would allow a physician licensed in Massachusetts to prescribe medication, at a terminally ill patient’s request, to end that patient’s life.

The physician would write the prescription, but the ill person him or herself would be the one to actually take the terminal dosage.  To qualify, the patient would have to be a Massachusetts resident who has been diagnosed as having an incurable, irreversible disease that will cause death within 6 months. He or she would have to be medically determined to be mentally capable of making and communicating health care decisions; and would need to voluntarily express a wish to die and to have made an informed decision.

This is a big question that we’re being asked to vote on, and it’s something that I’ve been wrestling with personally. I’m still unsure as to how I’ll vote, and I wanted this morning to share some of my own wrestling with you. And I would also like to talk a bit about how this question relates to our task here today on Yom Kippur.

A few Shabbats ago, in parshat Nitzavim, near the end of the book of Deuteronomy, Moses tells the Israelites:  You have a choice before you, two paths.  There is the path of good, of life, and the path of the negative, of destruction - of death.  Choose life, Moses says.  And this has become one of the central teachings of Judaism - choose life.  In our religious tradition, our souls and our bodies are understood to be gifts that are on loan to us for a period of time.  While we have them in our care, we’re to take good care of them.

The highest principle in Judaism is pikuach nefesh, the preservation of life.  Any and every mitzvah can be violated in order to save a human life, for humans are created b’tzelem elohim, in a Godly image.  As the Mishnah states – the person who saves one human life, it as if she has saved an entire world.

And yet, as much as it celebrates life, Jewish tradition does not shy away from the reality of death.  Rabbi Amy Eilberg writes:

Jewish tradition is rich with texts that cultivate our awareness of mortality as a part of the divine plan for humankind. Death is as predictable a part of living as being born and growing, as well as a necessary end to a life well-lived. Jewish sources that cultivate this perspective emphasize God’s role as Creator, and the immenseness of God and the Universe in contrast to the short span of human life. Somehow, there is some comfort in this: this is the way life is supposed to be–full and rich, and finite. (Behoref Hayamim: In the Winter of Life)

We can find this teaching in our High Holydays liturgy, when we chant:  “Adam yesodo k’afar…All of humanity is founded on dust—of dust we are made, and to dust we shall return…Like grass we wither, like flowers we fade, like shadows we pass, like clouds, we become empty.”

The awareness that Rabbi Eilberg describes, of “mortality as a part of the divine plan for humankind,” is embodied in Jewish burial and mourning customs.  There is great care taken with a deceased body, honoring the physical vessel that has carried us throughout our life.  In a ritual called tahara, the body is washed gently and lovingly, while verses from Psalms are recited.  Once the body has been prepared for burial, there is the custom of shmira - making sure that the body is never left alone.  We see this awareness in traditional Jewish mourning practices which allow mourners the time and space to attend to their grief, and to honor the loss they’ve experienced.  Unlike modern American culture, which manages somehow to simultaneously exalt violence while denying the reality of death, Judaism prizes life while reminding us that there is holiness in death as well.  

The ballot initiative on prescribing medication to end life challenges us with questions at this nexus of honoring life and accepting death. It raises one of the most perplexing moral and ethical choices we will ever encounter:  what is the right thing to do in the face of human suffering and the certainty of death?  Is one human ever justified in facilitating the death of another?  Is a person ever justified in hastening his or her own death?

Jewish law is very clear when it comes to suicide.  American law does not actually prohibit suicide; Jewish law does.  Our religious tradition holds that our lives are precious and God-given, and it is considered a profound violation to end a life prematurely.  Based on this premise, the organized Jewish community has been clear in its opposition to any attempts to legalize euthanasia or physician-assisted suicide (although our own movement has never taken a formal position on this issue). 

Yet on the more general question of not prolonging life when there is no hope of cure, there is more diversity of opinion.  Many rabbinic authorities do allow for the removal of life support in some situations, when it is clear that those forms of life support have become obstacles to dying more than enhancements to living.

There is a famous Talmudic story that illustrates the complex issues at play when it comes to treatment of the terminally ill. It is a story about Judah HaNasi, the leader of the Jewish community in the land of Israel in the 2ndcentury C.E.  He was so important that he was known simply as “Rabbi.”  The story goes like this:

On the day that Rabbi was dying, the rabbis decreed a public fast and offered prayers for heavenly mercy. They furthermore announced that whoever said that Rabbi was dead would be stabbed with a sword.  Rabbi Judah’s handmaid ascended to the roof (of his home, where she worked), and she prayed:  “The immortals desire Rabbi to join them, and the mortals desire Rabbi to remain with them; may it be the will of God that the mortals may overpower the immortals.”  When, however, she saw how often Rabbi had to go to the outhouse, painfully taking off his tefillin and putting them on again, she prayed:  “May it be the will of the Almighty that the immortals may overpower the mortals.”

As the rabbis continued their prayers for heavenly mercy, the handmaid took a jar and threw it down from the roof to the ground. For a moment they ceased praying, and the soul of Rabbi departed to its eternal rest.   (Talmud, Ketubot 104a)

You might say that Rabbi Judah Hanasi’s handmaid, whose name we never learn, invented the concept of hospice.  In this story, no one is ready for Rabbi to go.  The other rabbis, his colleagues and students, refuse to even entertain the possibility of his death, and their prayers act like a kind of life support system, keeping him alive even though his time has come.  His handmaid, who knows Rabbi Judah so well, at first joins her prayers to theirs, trying to keep the great man here on earth.  Yet when she sees how difficult his life has become, how much he is suffering, she ingeniously interrupts the prayers of the rabbis, and in that moment, when the life support is removed, Rabbi Judah Hanasi can finally die.

This story brings another element into the discussion around preserving life and acknowledging death, and that is compassion for the one who is suffering. It is on this basis of compassion and relieving suffering that many feel strongly that medically assisted suicide should be an option for those who are terminally ill and who feel, for whatever reason, that they can no longer bear to be alive.  This option exists legally today in Oregon, Washington and Montana.

The Oregon law has been in effect the longest, since 1997, and it is from here that there is evidence of the effects of having such a law on the books.  There were a number of fears about the law when it passed, legitimate fears that we also hear today in regard to the proposed Massachusetts law.  These include a concern that people would flock to Oregon to avail themselves of this option, and the fear that the most vulnerable people, those whose lives might appear the least “valuable,” would be at risk of being pressured into choosing medically assisted suicide when they became terminally ill. 

So far, the evidence does not seem to bear out either of these concerns.  Since the Oregon law went into effect, in 1997, through the year 2008, about 400 patients made use of it, which represents an estimated 19 deaths per 10,000 total deaths in that time period. 

The average age was 70, with the large majority suffering from cancer.  The majority have been white, college-educated, and had have health insurance – thus allaying concerns that those who are poor, ethnically in the minority, or whose treatment was not covered by insurance would be at risk of coercion into taking this step or of feeling that financially it was a necessity. 

It also appears, based on the Oregon evidence, that many more people fill the prescription for a terminal dose of medication than ever take it.  It may be that much of the power of this option is just knowing it’s there, regardless of whether one ever actually uses the medication.

As I’ve been thinking about this issue, weighing the different opinions and arguments I’ve heard, I’ve felt a bit like Tevye in “Fiddler On the Roof.”  “On the one hand….but on the other hand…”  There are some complex issues that this raises, and I’ll share both hands that I’ve been considering with you.

Most fundamentally, from a Jewish perspective, is the sanctity of life. As I’ve mentioned,  Jewish tradition maintains that all human life is sacred, and affirms that every human being is created b’tzelem elohim, in a divine image.  This teaching is beautifully articulated in a letter that a group of local Reform rabbis has written in opposition to the ballot initiative:

“Judaism has always understood that life is a gift and that ultimately life belongs to God.  If the doctrine of life’s essential holiness means anything at all, it means that we must stand in reverence before the very fact of life, the gift of God that renders us human. This reverence does not diminish as human strength declines; a dying person still possesses life, a life stamped indelibly with the image of God until the moment of death. Even when our intentions are good and merciful, it is an awesome and awful responsibility to determine to end the life of another human being.”

A related concern is that we must be very careful when it comes to implying that some kinds of life simply aren’t worth living.  There is a legitimate fear of a “slippery slope” if we start making societal distinctions between which kinds of life are more valuable than others.  What might from the outside look to one person as a complete lack of “quality of life” may be, to the person whose life it is, meaningful and beautiful.  Disability advocates have been very outspoken against death with dignity laws, fearing that a lack of physical or mental ability might become a pretext for encouraging suicide among the disabled.

But on the other hand…The story of Rabbi Judah’s handmaid instructs us in the complexities at the heart of honoring life. Her first impulse is to pray to keep her employer in this world–to keep him in life.  Such is the impulse of any person who loves and respects another.  Yet seeing his suffering, his diminished capacity to actually live, she changes her prayer.  She is ready to let him go, and feels that that is in his best interest as well.

Implicit in the Talmudic story is an acknowledgment that simply being physically alive does not entirely meet the standard of “life.”  A person’s suffering, their capacity to live a life that gives them purpose and dignity, is important to take into account.  Where that line lies is different for each person.  This is where the distinction between a person deciding to hasten his or her own death - as opposed to some third person deciding whose life is “worthwhile” - becomes extremely important. 

Another core spiritual issue is that of control.   Birth and death are the two most significant things that happen to us, and they are the least in our control.  Most of us are happy about having been born, but a bit more ambivalent when it comes to facing our own mortality.  The great spiritual challenge of Yom Kippur is to do precisely that:  to look our own mortality in the face, as it were, and to say - yes, I know.  What I don’t know is how many more days I have left.  So let me make the most of what I have. 

It is a compelling argument to say that choosing to end our lives, even in the face of impending death due to illness, is an ill-conceived attempt to exert control over something we simply can’t control.  If we know the end is near, we can acknowledge that, we can let go and prepare ourselves to die, we can enter hospice and give up the struggle to prolong our life.  And then we wait. It is perhaps the ultimate spiritual challenge and lesson: to relinquish control, to bless whatever we are able to bless in each day left to us, and to leave the final moment of our lives in the hands of That which brought us into this world. 

But on the other hand…You could say that with a terminal diagnosis, we have already surrendered control.  We know the end is coming, even if we would have preferred many more years of life.  Faced with the reality of our own imminent death, and with the reality of the mental and/or physical suffering that that entails, the argument can be made that a decision to take the end into our own hands is less an exertion of control, than a desire to shape how we leave this world, more than when.

I wanted to share a story with you from a rabbinic colleague who worked for a number of years in Oregon, after the Death with Dignity law had passed there.  I had asked a few of my Reconstructionist colleagues for their experience, and he shared this with me:

“The father of this family made the choice to end his life after being diagnosed with terminal cancer that had spread all over his body.  There was simply no hope - only pain - in his future.  I could not imagine asking him to bear that pain, nor asking his family to watch his suffering, all in the name of not violating Jewish tradition.  It did not feel moral or ethical to me.  I have been present for many deaths but none as peaceful and gentle as this. Unlike many suicides which are not assisted, this felt quite natural and calm.  The father took the medication provided by the hospice attendant assigned to him by the State.  He sat with his children and listened to the Beatles one last time.  He fell asleep.  About 30 minutes later his heart stopped beating.”

The rabbi goes on, “I too had mixed feelings about assisted suicide - but not any more.  I am a strong believer in it and I don’t feel as though it violates the Jewish prohibition of suicide. That is about the taking of life needlessly.  This is about avoiding suffering and pain, and for me falls under the category of pikuah nefesh for the family that remains.  Watching a relative suffer endlessly is the most detrimental thing to a soul.”

There are other moral and ethical considerations that come into this question.  For some people, the issue at stake is personal choice and integrity - giving individuals ultimate power over their own destiny.  Some people might vote “yes” not because they themselves would ever make this choice, but because they want it to be available for others.

There are also concerns about the involvement of medical professionals in prescribing medication to be used not to sustain life, but to hasten death.  Will a doctor’s commitment to healing come into question if he or she serves as an agent of another’s death?  Will the doctor-patient relationship, a relationship based on trust, become confused in some people’s eyes?

Whichever way you choose to vote this November, either a “yes” or a “no” vote can be an expression of strong and true ethical convictions.  I urge everyone to read the full text of the proposed law, and to seek out a range of opinions, before you cast your ballot.

For us today, the choice facing us at the polls is an opportunity to remember that, however unpleasant and depressing it might be to talk about all of this, it is actually quite important to do some thinking about our own death.  Far too many people that I speak with, and their family members, have done absolutely no planning for an eventuality which, like it or not, awaits all of us. 

We should all have advance directives, letting our loved ones know what our wishes are when it comes to what kind of care we want - and don’t want - in the case of serious illness or injury.  We should talk with our family members about funeral plans, and do more research if we don’t have a clue what we want when the time comes. 

On a spiritual level, we can take this invitation on Yom Kippur to sit with the reality of the finite nature of our existence. If you’re able to stay for Musaf, I encourage you to do so, for the liturgy there brings us closest to this reality.  We chant the Unetaneh Tokef, with its powerful question - who will thrive, and who will not - in the year to come?  This is a rhetorical question - God willing, everyone in this room will be back next year to chant it once again.  But in that question is an invitation to embrace this day, and the day after - because who knows what may happen tomorrow? 

In the Talmud, Rabbi Eliezer taught, ‘Do teshuvah one day before your death.’  His disciples asked him, ‘Does a person know on what day he’ll die?’  R. Eliezer answered, ‘All the more reason he should do teshuvah today, lest he dies tomorrow.’ (Shabbat 153a)

Rabbi Eliezer’s message, and the message of Yom Kippur is: don’t wait.  Is there someone you to need to ask forgiveness from? Do it.  Is there someone you need to forgive?  Maybe it’s time to start a healing process.  Is there something in your way, some habit or obstacle preventing your own happiness?  Maybe this is the time to begin to let it go.

Tonight, in the final hour of Yom Kippur, in the Neilah service, we imagine that the “gates” are closing.  Our tradition teaches that the “gates of teshuvah” are always open, that we can make change at any time.  So why this imagery of the “closing of the gates”?   The Neilah service exists to give us a sense of urgency, to encourage in us a certain resolve.  And that urgency doesn’t come from a sense of fear, a fear that we won’t make it to the finish line, that we’ll die somehow incomplete.  Our urgency comes from love, from the urgency we feel when we want someone to know how much we love them.  And that love is for ourselves.  It’s the urgency of wanting to taste this life with as compassionate a heart, with as courageous a mind, with as open a spirit as possible. 

Because ultimately, we know that we are dust.  We know where we’re going.  What a relief.  The end is written.  All that we need to do is to fill in all the chapters still to come in the most beautiful way that we can.  

G’mar chatima tovah—may we all be sealed in the book of life for a wonderful year to come!

Mon, February 17 2020 22 Shevat 5780