Simon Jackson
Legal Advisor to Torah MiTzion

 

While the new law permits a doctor to refrain from administering treatment to an incurably ill patient (whether at the start of treatment or whether by failing to continue treatment already initiated by the doctor), it continues to forbid the cessation of continuous treatment because to disconnect a life-support machine would be a direct act to cause the patient to die.

Delayed response Shabbat timers as means of circumventing the problem of withdrawing mechanical ventilation

In this regard, the new law proposes an innovative possibility: to connect the life-support machine for a time interval which would transform the artificial respiration from continuous treatment (treatment which is given constantly and without interruptions) to discrete treatment (treatment that begins and ends in well-defined cycles, e.g. chemotherapy or dialysis). A delayed-response ‘Shabbat timer’(!) built into a patient’s respirator will now be the main solution to the problem of how to let the terminally ill end their lives with dignity. The timer operates for 24 hours at a time and sets off a red light or alarm after 12 hours as a reminder to reset it. This allows time for appropriate discussion among patients, family members and healthcare providers. The patient or his representative could at any time request an extension, but if the dying person insists he does not want his life extended, the timer would turn off the respirator at the end of the cycle, providing the patient is under appropriate sedation. The ventilator would thus be turned off without human intervention.

The withholding of nutrition and active euthanasia would not be permitted because they violate Halacha, but the legislation now allows the halting of ongoing support using the timer device. No longer will families have to appeal to a court for specific permission to halt artificial means for keeping terminal patients alive against their will. Indeed, Prof. Avraham Steinberg has noted that since the idea of the timer became known abroad, many non-Jewish doctors abroad have expressed interest in it, because medical teams of all views and backgrounds feel uncomfortable turning off a dying patient’s respirator and causing his death.

Bioethical analysis of the use of Shabbat timers

Prof. Vardit Ravitsky was a member of the Israeli public committee on the dying patient during 2000-2002. In a fascinating article published by the British Medical Journal, she asks the following profound series of questions:

”What is the bioethical meaning of this proposed solution? If the reluctance to disconnect a patient from a ventilator is based on the belief that the act is ethically wrong, timers could be perceived as deceptive devices meant to disguise an unethical act as a legitimate one. In such a case, a mechanical device that transforms what is in essence withdrawal into what externally looks like withholding has controversial ethical implications. Do timers represent the “displacement of ethics by trickery?” Will they enable Israeli physicians to perform in practice what their principles otherwise forbidthem from doing, thus eroding a well founded ethical intuition and encouraging wrongdoing?”

She answers that timers are not a “ruse to an unethical outcome.” This is because the termination of continuous treatment is prohibited by Halacha, not because it leads to an ethically wrong outcome, but because “it uses an ethically questionable procedure to achieve that outcome, as in the case of using tainted evidence to achieve a justified conviction.” The difficulty of accepting withdrawal, she writes, is not based on a belief that the life of a suffering dying patient should be prolonged at all costs, “but on a cultural approach that is ethically opposed to human intervention to terminate life.”

Creating an alternative procedure thus allows the Halacha to overcome the obstacle and proceed towards achieving the desirable outcome. “Finding an alternative procedure to a desirable outcome is a typical halachic approach. It allows adaptation to changing circumstances without requiring the halachic legislator to contradict legal principles or precedents.”

Timers convert “commissions into omissions” and are thus intended to enable healthcare providers to overcome a procedural obstacle to achieve an ethically justified outcome. They may also allow them, writes Ravitsky, to overcome a possible emotional difficulty of terminating life support treatment. “Timers should therefore be perceived as an appropriate way of bridging the gap between the ethically justified outcomes of respect for individual autonomy, avoidance of prolonged suffering, and death with dignity, on the one hand, and Israeli communitarian values that echo the halachic approach on the other.”

Next Column: Passive Euthanasia and Halacha