Jewish Teaching and Cancer Care

Jewish law answers almost every question about accepting cancer treatment with one principle. It is pikuach nefesh: saving a life overrides nearly all other commandments. The Talmud derives it in several ways. The one most quoted in modern rulings takes the verse that a person shall carry out the commandments "and live by them." It reads that as meaning "and not that he should die by them." Another puts it directly: "Shabbat is given into your hands, and you are not given to it to die on account of Shabbat."

Classical law has three exceptions. None of them comes up in cancer care. For practical purposes, if something is needed to save your life, Jewish law wants you to have it.

That principle does a great deal of work. Calling an ambulance on Shabbat. Traveling to hospital. Receiving treatment. Taking medication that would otherwise raise kashrut questions. Eating on Yom Kippur when fasting would be dangerous. For a patient whose life is at risk, these are not grudging exemptions. Several are obligations.

Accepting treatment is the easy part. Stopping it is where Orthodox, Conservative and Reform authorities part ways. The differences are real, and flattening them would be misleading.

Orthodox. The Rabbinical Council of America's 2009 guidelines are blunt. "Removal of a respirator, when it will directly result in the patient's immediate death, is unequivocally prohibited." They do allow that a do-not-resuscitate order "may be halachicly appropriate" in some circumstances. They also warn that staff often misread DNR as "do not treat." On feeding, the presumption runs in favor of providing it. But they allow that there may be circumstances in which it is stopped in accordance with halacha. The process itself is different too: "All end-of-life issues and questions should be presented to a Halachic authority."

Clinical guidance for Orthodox patients draws a distinction that explains a lot of what teams see at the bedside. Stopping a cyclical treatment, such as chemotherapy or dialysis, may count as an omission. That is more likely to be permitted. Stopping a continuous treatment, such as a ventilator, counts as an act. So an Orthodox patient may decline the next cycle of chemotherapy and still refuse extubation. That can look inconsistent to a clinician. It is not.

Conservative. On 12 December 1990 the Committee on Jewish Law and Standards approved two papers on the same day. Both remain valid. Rabbi Elliot Dorff's paper treats the dying cancer patient under the category of terefah. It permits withdrawing artificial nutrition. It also permits pain medication in doses strong enough to dull pain, even where that may hasten death. That is an intent test. Rabbi Avram Reisner's paper works within the stricter category of goses. It holds that nutrition and fluids may not be withdrawn while they are still doing good. And it caps medication at the point where its probable effect would be to hasten death. That is a probability test.

The committee's own comparison document exists precisely because the two differ. A Conservative patient may follow either. Neither one is "the" Conservative position.

Reform. Responsa from the Central Conference of American Rabbis say that "there are times when it is ethically permissible to withdraw most forms of medical treatment, to allow nature to take its course and to let the patient die without further heroic measures." They also hold that "we are forbidden to practice active euthanasia or assisted suicide." Reform decision-making puts the most weight on the patient's own judgment.

Classical law treats a goses as "a living being in all respects." A goses is a person in the immediate process of dying. The Shulchan Arukh lists a series of apparently trivial bans. Do not move the pillow. Do not close the eyes. The point is that nothing may be done that hastens death, even by a moment. The Talmud compares the dying person to a guttering lamp. Touch it and it goes out.

Alongside that sits another principle. You may remove an outside obstacle to death, as long as you do not act on the person. The classic examples are stopping a noise outside the house, and taking salt off the tongue. Nearly every modern responsum permitting a ventilator to be turned off works through that opening. How far the analogy stretches is exactly where the movements part company.

You will sometimes see goses defined as the final seventy-two hours. The classical texts contain no clock. The definition is based on symptoms. Treat the number as one authority's usage, not the rule.

All three movements permit it. The Orthodox guidelines are the most emphatic: "The alleviation of pain and suffering is a mitzvah and should not be withheld out of concern for potential adverse effects." Clinical guidance notes that Jewish patients usually accept pain relief in proportion to their symptoms. They accept reduced alertness as part of the trade.

One disagreement is live. How far does this go when the medication may shorten life? That is the Dorff and Reisner split described above.

• Kosher food. Check that hot and cold portions arrive sealed and labeled, and that both are meat or both dairy. Trays assembled in a hospital kitchen are the common failure point. Bring wine and challah for Kiddush. Hospitals rarely stock them.
• Medication. For a patient with a life-threatening illness, guidance permits any needed medication where an equally effective kosher alternative is not readily available. Swallowed capsules, including gelatin ones, count as an uncommon way of eating. They are permitted for a sick person. Flavored liquids and chewable forms raise more questions. One published workaround is to dilute a required teaspoon of elixir in at least two ounces of water or juice.
• Shabbat admissions. Ask about a Shabbat elevator. Ask about alternatives to the electric call button. Warn the team in advance that your family may be unreachable by phone over Shabbat, and agree another way to reach them. That is the single most useful thing to arrange before an admission that will span Shabbat.
• Scheduling. Raise Shabbat and festival dates with the radiation scheduler at the planning stage, not after the course is booked.

A hospital chaplain gives spiritual support and helps you find your way through the system. That includes a rabbi-chaplain, who generally serves patients of all faiths. Your own rabbi makes rulings. For an Orthodox patient that ruling is usually decisive. Ask for both. And give the team your rabbi's contact details early, rather than during a crisis.

Jewish practice moves faster than hospitals expect, and paperwork is the usual obstacle. Burial is required as soon as possible, traditionally within twenty-four hours. Routine autopsy is contrary to Jewish law, as a desecration of the body. There are recognized exceptions. The law sometimes requires one. And findings may save identifiable others, which can include a family with a suspected hereditary cancer syndrome. Embalming and cremation are outside traditional practice. The body is not left alone before burial, and a chevra kadisha performs the ritual washing.

Tell the hospital in advance. Say that you want to be notified immediately. Say the body should not be moved without notice. Say you decline routine autopsy and embalming pending rabbinic consultation. Say you intend burial within about a day. And tell them who your funeral home is.

Jewish law is much more permissive here than Catholic teaching, and the reasons are worth knowing. An embryo outside the body is not treated as a person. Having children is a positive commandment. So preservation serves an obligation rather than being merely tolerated. The halakhic obstacle is about how a sperm sample is obtained, and there is a recognized hierarchy of methods.

There is genuine Orthodox disagreement about an unmarried man banking sperm before chemotherapy. And there is one further point patients are rarely told. Several authorities hold that stored material has no legitimate use after the man's death, unless he explicitly said otherwise. So if you bank, document your wishes about posthumous use in writing at the time.

Raise fertility at your first oncology appointment either way. The window is usually days.

• NCI — Spirituality in Cancer Care (PDQ), Patient Version
• NCI — Advance Directives
• NCI — End-of-Life Care for People Who Have Cancer
• NCI — Male Fertility and Cancer
• Rabbinical Council of America — Halachic Guidelines for End-of-Life Medical Decisions (2009)
• Rabbi Elliot N. Dorff — A Jewish Approach to End-Stage Medical Care, adopted by the CJLS on 12 December 1990
• CJLS Biomedical Ethics subcommittee — Mai Beinaihu?, comparing the Dorff and Reisner papers
• Central Conference of American Rabbis — Responsum NYP no. 5763.3, on determining death