Tzav 5765

 And the fat of the beast that dies of itself, and the fat of that which is torn by beasts (treifah), may be used in any other use; but you shall in no wise eat of it. …Leviticus 7:24

Fifteen years ago, Terri Shindler Schiavo was a vibrant and lively 26 year old woman. She loved music—she even wrote to John Denver to ask if he would play at her wedding—and was fond of animals. She had been happily married to Michael Schiavo for five years.

And then in an instant, life as she knew it came to an end. Terri had a sudden heart attack, brought on by a potassium imbalance. She went unconscious, fell into a coma, and has been comatose ever since.

All of the activities we associate with the joys of living—going for walks, talking with friends, reading a book, going to a movie, eating a meal with friends—have not been part of Terri’s life for the last fifteen years.

Her higher brain functions have essentially shut down. For several years, her husband Michael worked for her rehabilitation. He studied nursing so he could take better care of her. He had Terri flown to California for experimental surgical treatments, sleeping on a cot in her room.

After a few years of those efforts, Michael came to realize Terri’s situation was hopeless. The doctors diagnosed her as being in a Persistent Vegetative State (PVS). There is only one person known to have recovered from PVS, ever; and he had only been in that state for 20 months. Michael came to the conclusion that Terri was never going to be able to regain normal consciousness. He decided that the artificial measures, feeding Terri through a tube, that were keeping her alive should be discontinued, and his wife should be allowed to die. He believes this is what she would have wanted.

Terri’s parents, Bob and Mary Shindler, disagree. They dispute Terri’s diagnosis—they claim she is responsive. They dispute Terri’s wishes: they believe as a Catholic, Terri would have agreed with the teachings of the Catholic Church on the sanctity of life, totally regardless of the quality of that life.

Both sides feel so strongly that they are defending what Terri wants that they have pursued every possible legal device, including multiple appeals to the Supreme Court of the United States, and the passage of an extraordinary bill in Congress over-ruling the traditional separation of states powers to allow a Federal court to rule on an appeal.

This is an extremely complicated and emotional situation. The rhetoric has been extremely impassioned. Pat Buchanan had the nerve to compare what Michael Schiavo is doing to his wife to what the Nazis did to prisoners in the Holocaust. Such comparisons are truly absurd, odious, and an affront to the memory of those who perished at the hands of the Nazis. If Terri Schiavo were capable of eating, there are plenty of people who would feed her. The situation is not the same.

I’m NOT going to talk this morning about what the courts should have done, or whether it was proper that Congress passed a special bill. I have my opinions, but I don’t think the Torah has a lot to say about whether Federalism is a good thing or a bad thing, or the roles of the various branches of the US government. But this sad case does raise a few questions we need to think about.

What if, God forbid, such a thing were to happen to your loved one, what would you do? Where would you turn for guidance?

The Shindlers are Catholic. They are trying to follow the teachings of their church. The Vatican does not usually comment on individual cases, but they made an exception for Terri Schiavo because of all the publicity. The Vatican’s position is as follows:

“By any decent count, Mrs. Terri Schiavo can be considered a living human being, deprived of full conscience, whose legal rights must be recognized, respected and defended. The removal of the feeding tube from this person, in these conditions, can be considered direct euthanasia.”

The Catholic Church’s position would say that even if it was Terri’s desire not to be fed, she would be committing a mortal sin to refuse the feeding tube. A typical Catholic Church approved advance medical directive reads “In no circumstances would I wish basic care, including (if appropriate to my condition) the assisted administration of food and fluids, to be withdrawn with the aim of ending my life.” Note it says “in no circumstances.” No matter how much pain the person is in, how unlikely recovery, or how far gone already.

The Vatican statement said removing the tube would be “Direct euthanasia.” In other words, the Catholic Church says that removal of the feeding tube is an act of murder.

What would the Jewish tradition say about removing the feeding tube?

The first issue we need to consider is what is Terri’s status? Is she alive, dead, or in some kind of in between state?

Judaism does not view life as a digital phenomena: on or off. Life is not something that begins precisely at the moment of conception and ends precisely at the moment breathing stops. The Jewish view is that life is something we come into gradually in stages and we exit gradually in stages.

Terri is not dead. Even though traditionally death was defined as cardio-pulmonary death, the vast majority of rabbis today accept brain-death as death. However, since her brain stem is still functioning, Terri does not meet the usual criteria of brain death.

This week’s Torah portion, Tzav, has rules and regulations about all different kinds of sacrifices. Amongst all the rules is one that refers to an animal that is a treifah, which literally means “torn.” We cannot eat or offer as a sacrifice an animal that is a treifah. The same word in Yiddish usage, treif, came to mean anything that is not kosher.

However in halacha, in Jewish law, there is another usage for the term treifah. A person who has a terminal illness is called a treifah. An animal that had been ripped open by something like a wolf was called a treifah, and in some ways was considered almost as if dead already even if it was still moving around—death was inevitable.

The Jewish tradition holds that saving lives is one of the very highest of values. We disregard any of the commandments except for three to save a human life. For someone who is otherwise healthy, we would go to extraordinary lengths to save them. However, once someone is a treifah, once they have a terminal illness, their status changes somewhat. If you came across two people drowning and could only save one, and you knew one was a treifah, was suffering from a terminal illness, you would be justified in choosing to save the one that was NOT a treifah. Traditionally, someone is defined as a treifah if they have less than a year to live. One problem of course, is that we all know people who the doctors said had way less than a year to live who made a recovery—I recall a case where two years ago the doctors said a congregant of mine was within 24 hours of death, and he made a recovery and is still with us, alert and living an almost normal life.

The next stage in the dying process is called the goses. A goses is someone who is in the process of dying, which halacha defines as within three days of death. It is halachically permissible to do things like turn off a ventilator for someone who is a goses because medical intervention is no longer seen as preserving life, but rather is seen as dragging out the process of dying. As my teacher Rabbi Elliot Dorff put it, God only has so many ways of taking us: with artificial hydration, nutrition, and ventilation, we can be seen as trying to foil the will of God that a person’s time on this earth is up.

We are all mortal and will pass away. The Jewish tradition considers it an honor to be present when a person passes from this world to the next. I have had the honor to be present numerous times when a person has passed on. When someone is on a ventilator, unconscious, and their organs are shutting down, it is usually pretty clear when the end is imminent. Families I have been with have been comforted to know that it is OK within the Jewish tradition at that point to turn the ventilator off and allow the person to leave this world without dragging out the dying process.

Prior to the removal of the feeding tube, Terri Schiavo was certainly NOT a goses, within three days of death. If you consider nutrition through a feeding tube an artifical measure sustaining life, similar to someone who could only live with a ventilator, one could argue that she is a treifah, someone who would die within a year without extraordinary medical intervention.

But even if she does not have the status of either a goses or a treifah, it would be permissible for her husband to remove the feeding tube. It would also be permissible to leave it in.

It is generally accepted that people have a right to refuse medical treatment if they feel it will not help cure their condition. In Terri Schiavo’s case, an important question then is whether feeding someone through a feeding tube counts as “nutrition” or “medication.” There are rabbis with different opinions on the issue.

I go with the opinion of Rabbi Elliot Dorff, who wrote that “artificial nutrition and hydration is medicine because it does not have important characteristics of food — specifically, it does not have taste, temperature, or texture, and it comes into the body through tubes rather than through the mouth which then chews and swallows it. Therefore, I think that we should intubate (insert a tube) or extubate (remove a tube) according to whether it is in the best interests of the patient.”

So from a Jewish perspective the question regarding whether or not to keep a feeding tube in Terri Schiavo would be whether it is in the best interests of the patient. Her own wishes make a big difference—a person can refuse medical treatment if they think it is not helping.

There have been arguments about the facts in the case and the status of Terri Schiavo. The Florida courts have ruled in accordance with the doctors who say she is in a persistent vegetative state (PVS). People who are in a PVS because of loss of blood flow to the brain, like Terri, never recover, so administering artificial nutrition is not benefiting her—it is only keeping her in a state from which she will never recover consciousness. As Rabbi Dorff says, “As Jews, we have a strong mandate to heal, but when we cannot, we must recognize and accept the fact that we are mortal (this goes back to the Adam and Eve story). As Kohelet says, “There is time to be born, and a time to die.” To deny the reality of death is both psychologically unhealthy and religiously perverse.”

Millions of dollars in medical expenses, legal fees, and gas for Air Force One could have been saved if Terry Schiavo had filled out an Advance Medical Directive, a living will.

In an advance medical directive you fill out a form which stipulates how you want these issues to be dealt with.

Often older people will fill out a medical directive because they start seeing mortality staring them in the face; the more funerals you go to, the more aware you become of the fact that some day it will be your turn. Young people, like Terri Schiavo, rarely think to fill out such a directive.

But the truth is, we ALL need to fill one out. I’ve been in car accidents, a motorcycle accident, and an airplane accident. Any one of them could have turned out much worse than it did. I was given a powerful reminder of the need for all of us to fill out a medical directive last month. I was out running one morning and slipped on an icy sidewalk on the UT campus. My legs went right out from under me, and I came down very hard, flat on my back. I hobbled home, called my wife Lauri, and had her come home and take me to the emergency room where they gave me some powerful pain killers and muscle relaxants—I had given myself whiplash. I was quite fortunate: a few visits to the chiropractor and a few sessions of my yoga class and I was as good as new. But I also realize that with that fall my head probably came within a couple of inches of striking the pavement hard enough to put me in a coma. And I did NOT have an advance medical directive filled out!

I believe in practicing what I preach, so yesterday Lauri and I filled out our advance medical directives. We did it together, discussing the different issues. It’s not a fun session. It’s uncomfortable to sit with your loved one and consider things like whether you would agree to having a limb amputated if you were unconscious and had a life threatening infection. But I’m very glad we filled it out together, because even with me being a rabbi and she being a lawyer, there were issues we needed to discuss and think through.

The Conservative Movement’s Rabbinical Assembly has prepared a document called “Jewish Medical Directives for Health Care,” available online, click on the link.  If you have filled out a standard secular living will, you might want to consider replacing it with this one, which reflects specifically Jewish teachings on these issues.

In the Mishnah Torah Rambam (Maimonides) explains there is no “coming to be” without a “passing away.” Psalm 49 affirms “For all the glory that they cherish, men die, even as the beasts that perish.” Whenever that day comes, you can help prevent needless anguish and strife amongst your loved ones if you make your wishes known in writing ahead of time.

May it be God’s will that no one needs to look at your advance medical directive until you are 120!!!

Shabbat Shalom.