A new U.S. law giving patients a greater say in the type of medical treatment they may accept or refuse has prompted Jewish religious groups to prepare a range of guidance materials to help their members face such decisions.
The law, which went into effect Dec. 1, enables patients to refuse specific medical treatments, even if they are incapacitated, by putting their wishes in writing while they are able.
Patients can also designate family members or friends as proxies to make decisions on their behalf if they become too ill to make them themselves.
The Patient Self-Determination Act, as the federal law is known, requires hospitals, nursing homes and other medical institutions receiving federal funding to inform patients of their rights. But it does not require patients to fill out a living will or list a health-care proxy.
For Jews, the law means that they can direct doctors to consult with their rabbis before beginning or ending treatment. And it means they can be explicit about keeping their treatment in line with Jewish tradition and values.
Twenty-four percent of Americans presently have a living will, proxy or both, according to Joel Roselin, a spokesman for Choice in Dying, a New York-based patient-advocacy group.
Every state but Nebraska and Pennsylvania has passed laws requiring medical care-givers to abide by advance directives; 45 honor living wills and 43 honor the appointment of health-care proxies.
CRUZAN CASE SET A PRECEDENT
But Roselin believes every American should have a living will, even those in states without laws requiring medical care-givers to abide by advance directives.
That is because in the wake of the Supreme Court’s ruling last year in the Nancy Cruzan case, the courts are now likely to rule in the patients’ favor if they provide clear and convincing evidence of their wishes.
Cruzan was the Missouri woman who survived in a vegetative state for seven years after an auto accident.
Missouri would not allow her parents to remove a feeding tube, because she had never explicitly told her friends or family that she would not want to be fed through a tube.
The Supreme Court ruled that medical care may be refused if clear and convincing evidence of the patient’s wishes is provided.
In response to the new law, the various Jewish religious movements are now in the process of designing and distributing living wills that conform to their legal and ethical standards.
For its members and other interested parties, the Reform movement has put together a 44-page booklet called “A Time to Prepare.”
In the view of the Reform movement, each individual has the ethical, moral and legal right to make his or her own health-care decisions.
“A Time to Prepare” includes a detailed health-care directive and space to designate a proxy and detail instructions for organ donation.
But the booklet is more than instructions for death — it is a life-cycle guidebook.
It provides space to detail a personal history and to list specific people to notify immediately after death, including relatives and close friends, a rabbi, a funeral director, even a bank trust officer and pall bearers.
On several pages, space is provided for specific instructions to a rabbi and to a funeral director about what kind of burial the person would like.
INCLUSION OF ETHICAL WILLS
There are also chapters on the Jewish view of the dignity and sanctity of life, on ethical wills and one with a suggested ritual for saying goodbye when a patient is near death.
Ethical wills are a way for someone to leave an explicit version of his or her spiritual and moral legacy, according to Rabbi Richard Address, the editor of the guide.
They are a way “to pass on guidelines and advice on how to live an ethical and decent life,” said Address, who is staff representative for the Union of American Hebrew Congregations on its committees on Bio-Medical Ethics and the Synagogue as a Caring Community.
The Conservative and Reconstructionist movements plan to make their own versions of a living will available shortly.
The Union for Traditional Judaism, an organization of traditional Conservative and modern Orthodox Jews, has been disseminating its version of a living will since 1989, when the Cruzan case was in the headlines.
The Rabbinical Council of America, a centrist Orthodox rabbinic organization, is putting the finishing touches on two living wills — one general and the other more detailed — which it plans to make available later this month.
The general directive has room for the designation of a health-care agent and instructions directing the agent to consult with an Orthodox halachic authority before making decisions.
The detailed version lists several possible medical scenarios involving brain damage and the treatments that the person filling it out would want to accept or refuse.
The person filling out the detailed directive can check off “I want” or “I do not want” for several levels of treatment, including antibiotics, invasive diagnostic tests, chemotherapy, kidney dialysis, major surgery, mechanical breathing and cardiopulmonary resuscitation.
‘HALACHIC WILL’ IS MORE GENERAL
The “Halachic Living Will” being distributed by Agudath Israel of America, a more traditionalist Orthodox organization, is very general and was created that way specifically, according to Rabbi David Zwiebel, the group’s director of government affairs.
A detailed directive “doesn’t allow for the intensive case-by-case analysis that most halachic authorities seem to desire,” he said.
Agudath Israel’s living will is a simple form with room to designate a health-care proxy.
It states, “I am Jewish. It is my desire, and I hereby direct, that all health-care decisions made for me be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition.”
It provides room to list the Orthodox rabbi and organizations with which the proxy should consult when making decisions on the patient’s behalf.
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