When a person knows that he is going to die within weeks or months. When the illness has already taken its toll in physical pain, emotional turmoil and ongoing indignity. When the burden on loved ones is obvious. When there seems to be nothing more to hope for, only more of the same with ever-growing intensity. He may say to his doctor, she may plead: “Give me the pill!” And we, standing close bye someone we love, feeling totally helpless, we wish the doctor would mercifully respond to the plea and help the person to die. This November, we, in Massachusetts, will have an opportunity to make it legal for a doctor to prescribe a lethal dose of medication for a person to self-administer, if he is mentally competent and has no more than six months to live. Formally the ballot proposal is called “Prescribing Medication to End Life.” Sometimes labels reveal biases. Supporters label it the “Death With Dignity Act.” Opponents: “PhysicianAssisted Suicide” I participate in a community-based bioethics committee -- an eclectic group of lay people brought together by Harvard Medical School’s Department of Medical Ethics. We studied the legislation carefully and debated for many months. We arrived at the term: “Choosing Medically Induced Death. This may be the most challenging personal question ever asked of us regarding a public policy issue. The principle at stake is at the core of our collective morality. There are many ethical implications for us as individuals, for the medical profession and for our society. Our opinion on this matter, beyond morality and ethics, reflects our fundamental spiritual beliefs about the nature of life and human agency. I want to share with you the result of my personal struggle. Hopefully, no one in this room will ever face a horrendous end-of-life situation for himself or for a loved one. (And if you have, I apologize, if even broaching this subject is painful for you.) But on November 6 you will be asked your opinion. I hope you will agree that given the gravity of the question, thinking about it before hand is a good idea. I. Autonomy: The circumstances addressed by the proposed law awaken our deepest feelings of compassion. The patient’s future is bleak, hopeless. Death is inevitable at the end of a long, slow, progressive decline. That reality may cause the patient inestimable anguish, fear of pain, despair at helplessness? Is it not an act of mercy to allow a person to end it all? My first inclination was to support the legislation, based upon the belief in our obligation to respond to suffering compassionately and on the principal of Individual Autonomy. In our free society we cherish the liberty to govern our lives as we see fit. Willingly we give up some of that freedom for the common good. We pay taxes, obey traffic laws, and follow communal rules because we know that such measures are necessary to create an ordered and peaceful society. But we bristle if the government or a dominant religious group or law enforcement agencies try to close in on what we consider to be the prerogatives of our personal lives. 1 Woman's right to govern their reproductive health, public education for our children free from the Christian majority's influence and our choice of physicians and health care systems are among the major areas where we fiercely protect our autonomy. The ability to determine the time and the method to end one’s life is another example of autonomy exercised. “Whose life is it, anyhow?” sums up the argument voiced from time to time in varied media or whispered by someone you know who is experiencing unrelenting physical pain or existential suffering. Can there be any more intimate realm where we want to preserve the right to govern our lives more than in the ultimate control over when and how we die? At first reading my liberal social value system said “Yes, this is a good law.” But I remained troubled that I and my government were giving license to kill, even though under carefully proscribed circumstances and recognizing that the experiences with similar legislation in Oregon and Washington have been judged positive. I turned to the corpus of Jewish Law (Halachah) and tradition for help. II. Jewish Perspective Almost without exception, orthodox, conservative, reform and reconstructionist movement opinions condemn physician-assisted suicide. You would expect this response from orthodox and right-leaning conservative interpreters of Jewish Law. But liberal conservative rabbis -- who also function within the framework of Halachah. -- and virtually every official opinion offered by the Central Conference of American Rabbis, the collective voice of the Reform Rabbinate, suggest that when a physician hands the patient the script to purchase medication that has no other purpose, but to bring about the end of life, that doctor is participating in an act of Euthanasia. Even with a purely merciful goal the prohibition against murder is being violated. The rabbis’ discussions, unfolding over more than fifteen centuries, examine the few narratives which seem to hint at a place for aiding in the death of someone whose suffering is relentless. But in every example a distinction is made between active participation in the death of a person and passive acquiescence to the reality. Even the apparent suicide of King Saul, who falls on his sword, rather than suffer humiliation and torture by his enemies, is explained as a unique case, applicable only to the king. Throughout Rabbinic literature there is extreme sensitivity to the presence of suffering. We are obligated to do all within our power to relieve pain. There is widespread support for withholding or withdrawing artificial measures which are prolonging life plagued with suffering. We can even pray for the death of the sufferer, petitioning God. But the weight of Jewish thinking prohibits us from fulfilling that prayer with our own power. As a liberal rabbi I do not adhere strictly to the guidance of Jewish Law. I work hard to align my modernity and my respect for Jewish tradition. When the two clash often I tend to follow my liberal impulse. But in considering the question of consciously ending a life, the overwhelming weight of Jewish opinion gave me reason to pause before signing on to a measure allowing physician-assisted suicide.. My experiences in recent years, working with the frail elderly and the gravely ill tipped the balance away from my support of the bill. A patient in steep decline looks in my eye and says, “Tell me how I can die.” I have an answer, but I am reluctant to voice the words, lest I become an active party to his demise. Should I agree with a clear 2 thinking 76 year old woman who says “Six years of dialysis is enough. I am too tired to continue”? or to a ninety year old grieving widower who declares, “ I have lived my life. I want to die. No more food”? If I remain silent am I encouraging their death? Even the noble task of guiding a family to understand that comfort care is a gift for their deeply demented parent... such counsel is never offered without pondering if it is the right course. In standing that close to the nexus of life and death I have learned to step very cautiously. It is as if I am trespassing into God’s realm. Life is a sacred gift. We do not understand its origin. We do not completely control its course. We are stewards of the life breathed into our bodies and as long as the breath of life is within us we must take exquisite care of that gift. Take care of your body each day, Judaism urges us. And at the end of life do nothing to hasten or delay death. Take care lest you extinguish the “flickering flame” of life. There is a limit to our autonomy, a boundary between the Creator of life and ourselves as human beings. We cannot unnecessarily kill a person endowed with life or destroy ourselves. Autonomy stops at the door where we might assume to take absolute control of life itself. When we do so, even within narrowly proscribed limits set forth in the proposed legislation, we have crossed a line. We walk out on very steep incline, yes the “slippery slope”. We have moved toward devaluing life and once that process has begun, who knows where it will go? Whether we believe in a transcendent God or espouse Humanism as our faith, there is a need to curb our hubris, our elevation of self to a limitless height. Both birth and death are shrouded in Sacred Mystery. I believe that taking upon ourselves any prerogative of ending life is an expression of unbounded arrogance. Bowing our heads in humility in the face of human mortality -- life’s end -- is the measure of our deepest spirituality. III. Intention Some will argue that there is no difference between the doctor who administers large does of morphine or other medications in order to control pain, aware of the drugs potential side effects, and the doctor who writes the script for the lethal drug. Most biomedical ethicists will disagree. Based upon the principle of the physician’s mindful intent, the difference is enormous. Is the drug being given to relieve pain, the doctor carefully measuring the dosage only to reach the point of the patient’s comfort while aware of possible secondary effects -- Here, the goal of relieving pain is clear and outweighs the potential harm produced by the “double effect.” Or is it the doctor’s mindful and sole goal to assist the patient to die, an intentional action which crosses a bright line which our society and religious traditions have maintained throughout the ages? For some the differences in the doctor’s approaches may be subtle or nonexistent: Both are motivated by deep compassion. Both are employing medical science. Both are using human judgement. But those favoring the measure believe they are simply taking the next logical step in providing care. While others of us believe that the measure represent a sea-change in our society’s moral climate. Again, once allowed, 3 who knows where it will go? Some will argue that a patient’s decision to decline treatment or to stop eating or to withdraw artificial life-supports is no different than voluntarily taking a prescribed lethal drug. Again, there is an enormous difference between letting nature take its course -- putting one’s self in God’s hand, so to speak -- and actively and consciously taking life prematurely. The former respects the limits of our ability to control our destiny; the latter loudly declares, nothing is beyond our power. IV. The Many Faces of Compassion: When all is said and done, we are left with the question, “What is the compassionate thing to do?” I am among those who believe that short of the short of the radical act proposed in this ballot question there are many ways to respond with compassion to a person suffering at the end of life. All of us who are stakeholders need to find within ourselves ever-increasing avenues of response. Questions for doctors, nurses: Will you resist family members who insist upon keeping their loved one alert, even at the cost of their intense pain? Are you willing to guide a patient away from futile treatment? To recommend hospice rather another round of experimental medicine? Or if needed to deal with intractable pain, are you willing to pursue palliative sedation, rendering the patient unconscious until the disease runs its course? For us as family members and care givers: Have we truly exhausted the depths of our abilities to tend our loved ones? Could we be better companions? Will we allow sufficient and proper medication? Can we be more present to reduce anxiety and quell the fear of loneliness? Did we look deep within ourselves to discover new strength to salve the pain and calm the anguish? Have we assured the sick one that we would not abandon her no matter what? It is precisely when life reaches towards its end that we can discover new gestures of compassionate giving. In such moments we may touch new depths of our humanity and experience the Sacred. Without romanticizing the reality of life’s final days and months, can we understand that it can be a time of quiet goodness? Can we understand that in simply allowing another to care for us as life ebbs we are giving them the precious gift of expressing love. Here are opportunities -- who knows how many? -- to be in relationship, to say ‘thank you,’ to remember life’s blessings and joys, to say ‘I’m sorry,’ and allow others to to do so, too. To say ‘I love you’ one more time and share the faintest smile or subtle wink of the eye just once more? There are questions for our community: “Could we have provided more adequate and numerous hospice and palliative care options for the final journey where a peaceful death is the norm, not the exception?” For many years now, some of us have been asking this question of ourselves as Jews. At this moment, Hebrew Senior Life (HRC) is planning to create a hospice to serve our Jewish community. Hopefully, it will guide us to provide more compassionate care for our people at the end of life. It may be costly for our society (and our Jewish community) to offer such care, although not as costly as aggressive medical treatments. But in doing so, ultimately we create a more humane, a more morally elevated society. 4 Compassion is the goal, but acting compassionately is no single act. There is no end to deeds of lovingkindness. Perhaps it is at this time of life that we can most truly comprehend what sacred caring is all about. In the Un’taneh Tokef prayer of this day we contemplate “Who shall live and who shall die” and how the end shall come. The words are fearsome because they focus so vividly on the nature of life: our fragility, our limitations and our mortality. They remind us that ultimately we are not in control of life itself. And yet, in their starkness they turn us back to remember how precious life is and urge us to fill each day we live with acts of kindness and compassion. Let us hold before us the two messages reflected in the liturgy: the reality of human limitation and possibility of human kindness. We should repeat them each day of our lives and keep them in mind next November when we will be asked to respond to this ballot question. Herman J. Blumberg, Rabbi Temple Shir Tikva Wayland, Massachusetts September, 2012 2 Tishri, 5773 5