Medical Ethics Unit 1: "Pulling the Plug"

Terri Schiavo case

From Wikipedia, the free encyclopedia

Theresa Marie "Terri" Schiavo
Terri Schiavo with her mother, in 2001
Born	Theresa Marie Schindler December 3, 1963 Lower Moreland Township, Montgomery County, Pennsylvania, U.S.
Died	March 31, 2005 (aged 41) Pinellas Park, Florida, U.S.
Nationality	American
Occupation	Insurance clerk
Spouse(s)	Michael Schiavo (1984–2005; her death)
Parent(s)	Robert and Mary Schindler

The Terri Schiavo case was a legal struggle over end-of-life care in the United States from 1990 to 2005, involving Theresa Marie "Terri" Schiavo, a woman in an irreversible persistent vegetative state. Schiavo's husband and legal guardian argued that Schiavo would not have wanted prolonged artificial life support without the prospect of recovery, and elected to remove her feeding tube. Schiavo's parents argued in favor of continuing artificial nutrition and hydration and challenged Schiavo's medical diagnosis.^[1]^[2] The highly publicized and prolonged series of legal challenges presented by her parents, which ultimately involved state and federal politicians up to the level of President George W. Bush, caused a seven-year delay before Schiavo's feeding tube was ultimately removed.
Schiavo suffered a cardiac arrest in her St. Petersburg, Florida, home on February 25, 1990. She was resuscitated, but suffered massive brain damage due to lack of oxygen to her brain and was left comatose. After two and a half months without improvement, her diagnosis was changed to that of a persistent vegetative state. For the next two years, doctors attempted speech and physical therapy and other experimental therapy, hoping to return her to a state of awareness, without success. In 1998, Schiavo's husband, Michael, petitioned the Sixth Circuit Court of Florida to remove her feeding tube pursuant to Florida law.^[3] He was opposed by Terri's parents, Robert and Mary Schindler, who argued that she was conscious. The court determined that Schiavo would not have wished to continue life-prolonging measures,^[4] and on April 24, 2001, her feeding tube was removed for the first time, only to be reinserted several days later. On February 25, 2005, a Pinellas County judge again ordered the removal of Terri Schiavo's feeding tube. Several appeals and federal government intervention followed, which included U.S. President George W. Bush returning to Washington D.C. to sign legislation designed to keep her alive. After appeals through the federal court system upheld the original decision to remove the feeding tube, staff at the Pinellas Park hospice facility disconnected the feeding tube on March 18, 2005, and Schiavo died on March 31, 2005.
In all, the Schiavo case involved 14 appeals and numerous motions, petitions, and hearings in the Florida courts; five suits in federal district court; extensive political intervention at the levels of the Florida state legislature, then-governor Jeb Bush, the U.S. Congress, and President George W. Bush; and four denials of certiorari from the Supreme Court of the United States.^[5] The case also spurred highly visible activism from the pro-life movement, the right-to-die movement, and disability rights groups.^[6]Since Schiavo's death, both her husband and her family have written books on their sides of the case, and both have also been involved in activism over its larger issues.^[7]^[8]^[9]

English

What arguments can you think of for removing the feeding tube?

What arguments can you think of AGAINST removing the feeding tube?

What do YOU think is the right thing to do?

What Jewish texts/Values can you bring in which could help answer this?

1. Is her life "worth" saving?
If not, do we have to save it anyway?

יורה דעה של״ו:א׳

(א) נָתְנָה הַתּוֹרָה רְשׁוּת לָרוֹפֵא לְרַפְּאוֹת. וּמִצְוָה הִיא. וּבִכְלַל פִּקּוּחַ נֶפֶשׁ הוּא. וְאִם מוֹנֵעַ עַצְמוֹ, הֲרֵי זֶה שׁוֹפֵךְ דָּמִים, וַאֲפִלּוּ יֵשׁ לוֹ מִי שֶׁיְּרַפְּאֶנּוּ, שֶׁלֹּא מִן הַכֹּל אָדָם זוֹכֶה לִהִתְרַפְּאוֹת.

Shulchan Arukh, Yoreh De'ah 336:1

(1) The Torah gives permission for physicians to practice, and it is in fact commanded under the category of saving a life. Furthermore, if it is withheld from someone, it is equivalent to murder [lit. spilling blood]. This is true even if [the patient] has [another] physician, since one does not get cured by just anybody.

Based on this text, what interventions MUST her doctor/family perform for Terry Schiavo?

Does this text allow any room for a doctor not to insert a feeding tube in a PVS patient?

According to this text, could a doctor simply stand back and not intervene?

Eisenberg “should terry schiavo live or die”
NUTRITION AND HYDRATION IN THE TERMINALLY ILL PATIENT
The general consensus in halachic literature has been that certain treatments, such as oxygen, nutrition, and hydration are obligatory for all patients, regardless of the severity of their medical condition. This obligation is predicated upon the assumption that there are certain bodily needs that all people share, regardless of their prognosis, and that failing to provide for these needs constitutes a breach in the obligation to care for one's fellow man.
This line of reasoning considers breathing, eating, and drinking to be normal activities of daily living, and the providing of oxygen, nutrition, and hydration to be extensions of normal physiologic processes rather than medical interventions. Rabbi Shlomo Zalman Auerbach calls these treatments routine, and therefore not open to refusal or withdrawal, unlike certain other more "extraordinary" treatments that need not necessarily always be provided. He considers nutrition, hydration, and oxygen to be absolutely required, similar to antibiotics, insulin, and blood transfusions.

Does Eisenberg think a feeding tube is food or medicine? Why?

Is a feeding tube medicine or food, in your opinion? How do you make the distinction?

If it is medicine, could you think of a halachic argument for witholding it?

Elliot Dorff, "A Jewish Approach to End Stage Medical Care"

4. Removal ofNutrition and Hydration from the Terminally Ill. Applying these principles to two other cases is harder and more controversial, but we must address them. While most would agree that, at least at some stage, withdrawing or withholding medications from the terminally ill is halakhically justifiable, there is considerably more debate concerning artificial nutrition and hydration. Every person must be afforded normal food and liquids. This is an obligation of the community with regard to the poor,72 and if a sick person cannot afford normal food and liquids, it becomes part of the duty of the community and its agent, the physician, to provide them as part of the individual's medical care.
When the person cannot or will not ingest food and liquids through the mouth, however, may the community- or must it- feed the patient

through tubes? In the Cruzan case, the United States Supreme Court determined that it did not have enough evidence of how Ms. Cruzan would want to be treated if comatose. That was relevant because if there were a sufficiently clear expression of her will, the justices needed to balance the American values of personal autonomy and liberty against the state's rights to assure the welfare of its citizens. The Jewish question, however, is somewhat different. It is this: in light of the individual's duty to take care of God's property (Policy #B-1), may an individual, or a person acting on his or her behalf, refuse to ingest nutrition and/or hydration intravenously or enterally (that is, through the intestines) when it is not possible to do so orally?
Most rabbis who have written on this issue have answered negatively, even if the patient is terminally ill. They draw a distinction between medications, on the one hand, and nutrition and hydration on the other, permitting the withdrawal or withholding of the former but not the latter. They reason that medications are, by definition, an unusual substance introduced into the person's system to cure an illness, and therefore they may be removed or withheld if they have little chance of functioning in that way. Nutrition and hydration, however, are needed by everyone. Therefore the burden of proof shifts: one needs to justify the use of medications, but one needs to justify the failure to provide nutrition and hydration.
I accept this analysis, but I think that its burden can be met in one of three ways:
(a) First, one should note that what we are calling "nutrition and hydration" fulfills the function of normal food and water, but in form and administration it is much closer to medication. We are, after all, talking about inserting tubes into a patient and running liquids through them into the patient- just as we introduce medications when the patient cannot swallow. This would argue for assimilating nutrition and hydration, administered intravenously or enterally, to medications rather than to normal food and water.
Furthermore, there are halakhic grounds for such an analogy. The Torah, after all, expressly forbids us several times from eating blood (e.g., Genesis 9:4; Deuteronomy 12:16), but we are nevertheless permitted to accept blood transfusions because from the Talmud on, we, in contrast to Jehovah's Witnesses, do not consider the insertion of blood through tubes to be a case of "eating" interdicted by the law.73 (Even if it were, of course, we would permit eating blood to save a life, but we do not need to use that justification because our tradition has already restricted "eating" to what we swallow orally.) Similarly, I would argue, intravenous or enteral administration of nutrition and hydration is essentially different from providing food and water in the

usual sense, which we must do. If the patient cannot swallow normal food and water, however, we may, but also may not, administer such nutrition and hydration intravenously. The decision is a medical one, based upon the likelihood of the patient to be cured or at least to benefit -just as it is with all other medications. ...

This case is complicated in Jewish law by virtue of our strong stance against making judgments on the basis of the quality of a given life. Every life is precious in God's eyes, we aptly say, and so we may not decide to remove or withhold treatment from people just because we would prefer not to continue living under such circumstances. This principle serves the crucial role of reminding us that people handicapped in some way must be treated with the full respect which their divine image warrants, that, indeed, we must bless God for such variations among creatures, even if (or, especially if) we would much prefer not to be like them.

When it comes to the person in a persistent vegetative state, however, this principle is tested in the extreme. Arguments based upon minimizing pain to the patient become less plausible since the patient has lost all neocortical function and thus, by definition, is incapable of experiencing pain. Similarly, with regard to a non-terminal patient it would be hard to make the case that, because of the elevated risks of infection involved, intravenous feeding effectively hastens the patient's death rather than extending his or her life ([4b] above); the patient, after all, is not in the process of imminently dying, and so we cannot plausibly talk of hastening his or her death. Triage considerations would apply to heart and lung machines and other advanced technology, but the tubes necessary for nutrition and hydration per se are generally not in short supply.
There are, then, only two arguments which I can see to justify removal of nutrition and hydration from such patients.
One is a version of (4a) above. That is, if nutrition and hydration are to be categorized as medicine, one might argue that, since they are not curing the patient, they may be removed, as long as we offer normal food and water to the patient, even though we know he or she cannot possibly ingest them.
Dr. Nevins, the subcommittee's consultant whom I mentioned earlier, urged us to take this line. We should recognize, he told us both orally and in writing, that in all cases of people in a persistent vegetative state, it is the underlying disease that causes the death rather than the

withholding or removal of treatment - even though the latter action would, of course, be the proximate cause of death. The same is true for people with advanced Alzheimer's disease. In such patients, the failure of the swallowing reflex should be seen as a system failure which the feeding tube seeks to circumvent. Thus, even though such a person is not dead by the standards of either cessation of respiration and circulation or cessation of whole brain function, he or she should be allowed to die. Treatment of such a person, then, including artificial nutrition and hydration, should, in his opinion, be considered optional.
The other possibility is to follow those in the medical community who would define brain death as the irreversible cessation of the functions of the neo-cortex (the upper brain) rather than of the whole brain. Permanently unconscious people would then be classified as dead, and nutrition and hydration tubes could be removed. As Rabbi A vram Reisner points out in his paper on these issues, Maimonides may provide a basis for this line of reasoning through his concept of ensoulment. Maimonides writes:
The vital principle of all flesh is the form which God has given it. The superior intelligence in the human soul is the specific form of the mentally normal human being. To this form the Torah refers in the text, "Let us make a human being in Our image, after Our likeness" (Genesis 1:26). This means that the human being should have a form that knows ... Nor does (this) refer to the vital principle in every animal by which it eats, drinks, reproduces, feels, and broods. It is the intellect which is the human soul's specific form. And to this specific form of the soul, the Scriptural phrase "in Our image, after Our likeness" alludes.77
Rabbi Reisner argues against this line of reasoning, pointing out that this would impugn the sanctity of the vessel that carried God's image. Moreover, he points out the risk inherent in this theology of medicine, as it were, for if followed, one could easily argue that one should discontinue treatment of the mentally ill, who, after all, do not exhibit the rational soul of which Maimonides spoke. I agree with Rabbi Reisner's objections to this approach.
Like Dr. Nevins, however, I do think that the first analysis of this situation (that tubes are medication and therefore may be removed as an inappropriate medical intervention in some cases, even when the patient is not terminal) should make it unnecessary to use nutrition and hydration tubes to treat PVS and advanced Alzheimer's patients. Like him also, I think that the slippery slope can be contained; indeed, as I have stated previously, the essence of developing moral sensitivity is to recognize that moral principles cannot be applied indiscriminately, that acute moral judgment must be used in deciding when and how to apply and balance our moral concerns. Such careful balancing of goods is, in fact, essentially our understanding of the nature of the halakhic process- at least when the halakhah is addressing predominantly moral issues.

I recognize, though, that there is something which is, minimally, highly unaesthetic in removing feeding tubes from such patients. After all, since their brain stem is intact, they are, by hypothesis, still breathing on their own. Clearly, then, in line with current practice, PVS patients should be maintained on nutrition and hydration at least for some time-especially if they need no scarce resources - to guard against the possibility that they were misdiagnosed as being PVS patients and were instead in a reversible coma. Triage considerations do apply to the other machinery necessary to sustain such patients; but, like many physicians, I would give up on such patients only reluctantly and after trying to revive them for some time. I am, in any case, comforted by Dr. Nevins' point that these cases are extremely rare, that in 25 years of practice he himself never had one and that he knows of only one in his hospital.

Dorff explores a number of possible arguments that could be made for removing a feeding tube. How many can you find? Are any of them compelling for you?

What gives a human life value, and makes it deserving of our efforts to save it?

Are we obligated to save a life that apparently has no value? If we start making such decisions, what are the ethical dangers?

סנהדרין ל״ז א:י׳-ט״ו

מתני׳ כיצד מאיימין את העדים על עידי נפשות היו מכניסין אותן ומאיימין עליהן ... לפיכך נברא אדם יחידי ללמדך שכל המאבד נפש אחת מישראל מעלה עליו הכתוב כאילו איבד עולם מלא וכל המקיים נפש אחת מישראל מעלה עליו הכתוב כאילו קיים עולם מלא ומפני שלום הבריות שלא יאמר אדם לחבירו אבא גדול מאביך ושלא יהו המינים אומרים הרבה רשויות בשמים ולהגיד גדולתו של הקב"ה שאדם טובע כמה מטבעות בחותם אחד כולן דומין זה לזה ומלך מלכי המלכים הקב"ה טבע כל אדם בחותמו של אדם הראשון ואין אחד מהן דומה לחבירו לפיכך כל אחד ואחד חייב לומר בשבילי נברא העולם

Sanhedrin 37a:10-15

Man was created alone to teach you that anyone who causes one Israelite life to be lost, the text accounts to him as if he caused a whole world to be lost. And anyone who sustains one Israelite life, the text accounts to him as if he sustained an entire world. And for the sake of peace among the creations--so that no man can say to his friend, "My father is greater than your father." And so that heretics will not claim "There are multiple powers in the heavens." And to testify to the greatness of the Holy Blessed One. For a man forges many coins from the same mold and each one is identical. But the King of kings of kings, the Holy Blessed One forges each man from the same mold of the original man and no one is like his fellow. Therefore each and ever person is obligated to say, "For me was the world created."

Why is a human life valuable, in your opinion?

Is this the basis for the prohibition on murder, or is there a different basis?

Why is a human life valuable, in the text's opinion?

Is the value of a human life ontological (i.e. based in some essential truth of reality) or utilitarian (i.e. practical)? (see the article I posted on "deontological vs consequentialist")

Can you think of any practical applications of the notion of the infinite vaue of human life?

According to this text, was Terry Schiavo's life "infinitely valuable"?

Immanuel Jakobovits on The Value of Human Life
The value of human life is infinite and beyond measure, so that any part of life - even if only an hour or a second - is of precisely the same worth as seventy years of it, just as any fraction of infinity, being indivisible, remains infinite. Accordingly, to kill a decrepit patient approaching death constitutes exactly the same crime of murder as to kill a young, healthy person who may still have many decades to live. For the same reason, one life is worth as much as a thousand or a million lives - infinity is not increased by multiplying it. This explains the unconditional Jewish opposition to deliberate euthanasia as well as to the surrender of one hostage in order to save the others if the whole group is otherwise threatened with death [footnotes omitted].
Immanuel Jakobovits,Medical Experimentation on Humans in Jewish Law, in J. David Bleich and Fred Rosner (eds.), Jewish Bioethics, 379

http://www.jlaw.com/Articles/phys-suicide.html :
...man should not assume that he understands what the divine purpose is. Instead, man is supposed to regard life as an intrinsically and metaphysically valuable experience - not as a means to an end. Consequently, man is not entitled to evaluate the "quality" of a life by considering what that life may accomplish. Indeed, there exists no system of measurements that is capable of evaluating the quality of a human life. (Shlomo Zalman Auerbach, Minhat Shlomo 9)

What do you think of this concept? Do you agree?

What is the basis of a life's value on this opinion?

Do you agree that Terri Schiavo's life as valuable as a fully functional person?

According to Rav Auerbach, what makes any given life valuable? What kind of thinking is he against?

What is the ethical danger of evaluating the quality of a life?

Can you think of any societies which have evaluated different lives differently?

Do we as a society ever, in fact, evaluate the value of a life?

Can you interpret the Sanhedrin text in a way which does NOT support Rav Auerbach?

סנהדרין ע״ד א:י״ב-כ׳

א"ר יוחנן משום ר"ש בן יהוצדק נימנו וגמרו בעליית בית נתזה בלוד כל עבירות שבתורה אם אומרין לאדם עבור ואל תהרג יעבור ואל יהרג חוץ מעבודת כוכבים וגילוי עריות ושפיכות דמים

רוצח גופיה מנא לן סברא הוא דההוא דאתא לקמיה דרבה ואמר ליה אמר לי מרי דוראי זיל קטליה לפלניא ואי לא קטלינא לך אמר ליה לקטלוך ולא תיקטול מי יימר דדמא דידך סומק טפי דילמא דמא דהוא גברא סומק טפי

Sanhedrin 74a:12-20

R. Johanan said in the name of R. Simeon b. Jehozadak: By a majority vote, it was resolved in the upper chambers of the house of Nithza in Lydda18 that in every [other] law of the Torah, if a man is commanded: 'Transgress and don't be killed' he may transgress and not be killed, excepting idolatry, incest, [which includes adultery] and murder...

And how do we know this of murder itself? — It is common sense. Even as one who came before Raba27 and said to him, 'The governor of my town has ordered me, "Go and kill so and so; if not, I will slay thee"'. He answered him, 'Let him rather slay you than that you should commit murder; who knows that your blood is redder? Perhaps his blood is redder.'

What do you think Rabbah meant when he said "who knows if your blood is redder"?

Do you agree with the concept as you understood it?

רש"י על סנהדרין ע״ד א:מ״ב:א׳

מה רוצח יהרג ואל יעבור - ואם אמר לו הוי רוצח והרוג את הנפש ואם לאו הריני הורגך יהרג ואל יעבור:

Rashi on Sanhedrin 74a:19:1

"Since with murder, that he should be killed and not transgress"--If someone said to him "be a killer and kill this person, and if you don't, I will kill you," he should be killed and not transgress.

רש"י על סנהדרין ע״ד א:מ״ב:ב׳

סברא הוא - שלא תדחה נפש חבירו דאיכא תרתי אבוד נשמה ועבירה מפני נפשו דליכא אלא חדא אבוד נשמה והוא לא יעבור דכי אמר רחמנא לעבור על המצות משום וחי בהם משום דיקרה בעיניו נשמה של ישראל והכא גבי רוצח כיון דסוף סוף איכא איבוד נשמה למה יהא מותר לעבור מי יודע שנפשו חביבה ליוצרו יותר מנפש חבירו הלכך דבר המקום לא ניתן לדחות:

Rashi on Sanhedrin 74a:20:1

"It is logical"-That the soul of his fellow should not be set aside, since there would be 2: destroying a soul, and a sin. With his life, there is only 1: the destruction of his soul. And he should not transgress, since when God said to transgress a commandment based on "that you will live," it is because a Jewish soul is valuable in His eyes. Here, with the murderer, since eventually there will be a destroyed soul, who would it be permissible to transgress? Who knows that his soul is dearer to his creator more than the soul of his fellow? Therefore, the decree of the Omnipresent cannot be placed aside.

רש"י על סנהדרין ע״ד א:מ״ד:א׳

מרי דוראי - אדון עירי ונכרי הוה:

Rashi on Sanhedrin 74a:20:2

"Governor"-A non-Jewish head of a city.

רש"י על סנהדרין ע״ד א:מ״ו:א׳

מאי חזית דדמא דידך סומק טפי - מי יודע שיהא דמך חביב ונאה ליוצרך יותר מדם חבירך הלכך אין כאן לומר וחי בהם ולא שימות בהם שלא התיר הכתוב אלא משום חביבות נפשם של ישראל להקב"ה וכאן שיש אבוד נפש חבירו לא ניתן דבר המלך לדחות שצוה על הרציחה:

Rashi on Sanhedrin 74a:20:3

"Who says your blood is redder"-who knows that your blood is dearer and more beautiful than the blood of your fellow? Therefore, you cannot apply "live by them and don't die by them" here, since the scripture only permitted it out of God's love for Jewish souls.

רש"י על סנהדרין ע״ד א:ל״א:א׳

יעבור ואל יהרג - וחי בהם ולא שימות בהם:

Rashi on Sanhedrin 74a:12:2

"Sin and do not be killed"--"You shall live by them," and not die by them. (Lev 18:5)

According to Rashi, what is the meaning of the phrase "whose blood is redder"?

According to Rashi, what is the basis for the value of a life? Is it deontological or consequentialist? (See the distinction at this article, pp. 2-5 )

Does this agree or disagree with the Rabbis quoted above (e.g. Rav Auerbach)?

Can you think of other bases for the value of a life?

Reisner, A Halachic Ethic of Care for the Terminally Ill

PVS: Persistent Vegetative State: A special complication is posed by cases of extended, irreversible coma and PVS, persistent vegetative state. Such unconsciousness follows upon destruction of the higher brain while the brain stem remains largely intact. Patients in this condition may maintain spontaneous reflexes, including heartbeat and respiration, circadian wake/sleep rhythms, eye-movements and gestures, but are altogether without consciousness and must be nourished artificially. Physicians feel confident of their ability to diagnose this state, given a flat EEG and lack of responsiveness or of any purposive action with no change over a period of one month. Certain other confirmatory tests, such as CAT scan, MRI (Magnetic Resonance Imaging), blood flow studies and carbon dioxide levels would be used to support such a diagnosis. If maintained, such patients can live for years (the longest recorded case being 37 years).58 Increasingly, the courts in this country, on the basis of the literature of biomedical ethics, have considered these cases under the rubric of benefits and burdens as cases of no conceivable life benefit to the patient, and therefore, cases in which life-sustaining treatment (including nutrition and hydration) may be withheld or

withdrawn. Recently, that question centered around the removal of a feeding tube from PVS patient Nancy CruzanWe do not accept that burdensome life is dispensable, and such a patient is manifestly not in the process of dying.60 Does that mean that we must maintain patients in such condition until their natural deaths?
If vegetative life is life, the answer would appear to be that we must. We have expressly rejected quality of life calculations, nor are such patients able to appreciate the quality of their lives. Here, it appears that we have been cast by God in the role of custodians of a life that He has harshly reined in but allowed to continue. We do not maintain the patient in hopes of some future cure, which would be too slight a hope to maintain, nor against the possibility of error in the diagnosis of irreversibility, though any remediable uncertainty in the diagnosis must be pursued.61 We maintain the patient because it is not within our domain to choose to terminate life. But these cases remain deeply troubling. Is such a life really life? Has not the soul departed while the body, in some aberrant glitch, refuses to shut down? If so, what courtesy do we owe such a soulless body - surely not all the reverence we accord human life? Yet when we see the body of a patient breathing and moving before us, though unconscious, and, to the best of our medical and scientific knowledge, destined never to be conscious again- can we be certain that this patient's soul (a soul we cannot quantify in scientific terms) has departed? When the family of Nancy Cruzan, the principal in the case argued before the Supreme Court, spoke to her at her bedside, they said things to the effect of, "We do not know if you are there, if you can hear us ..." The relief they sought for their daughter was not predicated on her being dead, but on the undesirability, even horror, of living with no interaction with the human world. Their question to her was to the point, and as for the answer-we have no way of knowing. Facing an evidently living being, not knowing the state of its soul, we are left with the bazakah (the legal presumption) of life, and the requirement to treat that life as we would any other life.62

According to Reisner, what makes a human life valuable/deserving of our care?

Even though Reisner concludes that we are obligated to keep her alive, he suggests some arguments for not keeping Schiavo alive (he rejects them)--what are they?

What do you think of them?

Why does Reisner reject them?

2. Is She Dying (גוסס)

A goses is considered like a living person in all respects .... We may not move him [if this will hasten death] ... until he dies. We may not close the eyes of the goses. One who touches or moves him is a murderer, as Rabbi Meir said, the goses may be compared to a lamp which is dripping. As soon as one touches the lamp, it is extinguished. Similarly, one who closes the eyes of the goses is considered as if he has taken his life. (Smachot 1:1-1:4)

What is a goses?

What can we do to a goses?

What can't we do?

What would this text seem to say about our case?

ספר חסידים תשכ״ג:א׳

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Sefer Chasidim 723:1

(1) One must not cause a person to not die rapidly, for example if one was goses, and there was one close to that house chopping wood, and the neshomoh is unable to exit - they must remove the chopper from there, and they must not put salt on his tongue, in order that he will not die. But if he is goses and says that he is unable to die until they put him in another place – they must not move him from there.

(2) Even though they (the Rabbis) said: “A goses person – they must not move him from his place”, if there is a fire, they must not leave him in the house, and they must take him out.

What is the distinction between the things we should do (e.g. remove the woodchopper) and the things we cannot do (i.e. move the dying person)?

Is there any way in which this contradicts the text from S'machot?

How can you reconcile this with the duty to heal?

יורה דעה של״ט:א׳-ג׳

(א) הַגּוֹסֵס, הֲרֵי הוּא כְּחַי לְכָל דְּבָרָיו. אֵין קוֹשְׁרִין לְחָיָיו, וְאֵין סָכִין אוֹתוֹ, וְאֵין מְדִיחִין אוֹתוֹ, וְאֵין פּוֹקְקִין אֶת נְקָבָיו, וְאֵין שׁוֹמְטִין הַכַּר מִתַּחְתָּיו, וְאֵין נוֹתְנִין אוֹתוֹ עַל גַּבֵּי חוֹל, וְלֹא עַל גַּבֵּי חַרְסִית וְלֹא עַל גַּבֵּי אֲדָמָה, וְאֵין נוֹתְנִין עַל כְּרֵסוֹ, לֹא קְעָרָה, וְלֹא מַגְרֵפָה, וְלֹא צְלוֹחִית שֶׁל מַיִם, וְלֹא גַּרְגִּיר שֶׁל מֶלַח, וְאֵין מַשְׁמִיעִין עָלָיו עֲיָרוֹת, וְאֵין שׂוֹכְרִין חֲלִילִין וּמְקוֹנְנוֹת, וְאֵין מְעַמְּצִין עֵינָיו עַד שֶׁתֵּצֵא נַפְשׁוֹ. וְכָל הַמְּעַמֵּץ עִם יְצִיאַת הַנֶּפֶשׁ, הֲרֵי זֶה שׁוֹפֵךְ דָּמִים.

...וְכֵן אָסוּר לִגְרֹם לַמֵּת שֶׁיָּמוּת מְהֵרָה, כְּגוֹן מִי שֶׁהוּא גּוֹסֵס זְמַן אָרֹךְ וְלֹא יוּכַל לְהִפָּרֵד, אָסוּר לְהִשָּׁמֵט הַכַּר וְהַכֶּסֶת מִתַּחְתָּיו, מִכֹּחַ שֶׁאוֹמְרִין שֶׁיֵּשׁ נוֹצוֹת מִקְצָת עוֹפוֹת שֶׁגּוֹרְמִים זֶה וְכֵן לֹא יְזִיזֶנּוּ מִמְּקוֹמוֹ. וְכֵן אָסוּר לָשׂוּם מַפְתְּחוֹת ב''ה תַּחַת רֹאשׁוֹ, כְּדֵי שֶׁיִּפָּרֵד. אֲבָל אִם יֵשׁ שָׁם דָּבָר שֶׁגּוֹרֵם עִכּוּב יְצִיאַת הַנֶּפֶשׁ, כְּגוֹן שֶׁיֵּשׁ סָמוּךְ לְאוֹתוֹ בַּיִת קוֹל דּוֹפֵק, כְּגוֹן חוֹטֵב עֵצִים, אוֹ שֶׁיֵּשׁ מֶלַח עַל לְשׁוֹנוֹ וְאֵלּוּ מְעַכְּבִים יְצִיאַת הַנֶּפֶשׁ, מֻתָּר לַהֲסִירוֹ מִשָּׁם, דְּאֵין בָּזֶה מַעֲשֶׂה כְּלָל, אֶלָּא שֶׁמֵּסִיר הַמּוֹנֵעַ (הַכֹּל בְּהַגָּהַת אַלְפָסִי פֶּרֶק אֵלּוּ מְגַלְּחִין).

(ב) מִי שֶׁאָמְרוּ לוֹ: רָאִינוּ קְרוֹבְךָ גּוֹסֵס הַיּוֹם שְׁלֹשָׁה יָמִים, צָרִיךְ לְהִתְאַבֵּל עָלָיו. דְּוַדַּאי כְּבָר מֵת.

Shulchan Arukh, Yoreh De'ah 339:1-3

(1) One who is dying is like a living person for all his affairs. They do not dye his cheeks, and they do not anoint him, and they do not wash him, and they do not stuff up his orifices, and they do not remove the pillow from under him, and they do not place him on sand nor on clay nor on earth, and they do not place a pot or a trowel or a pitcher of water or a grain of salt on his stomach, and they do not announce about him to the cities, and they do not hire flautists and lamenters, and they do not close his eyes, until his soul departs. And anyone who closes with the departure of the soul, behold this one spills blood...

And so it is forbidden to cause the dead person to die quickly. Such as one who was dying for a long time and he could not separate, it is forbidden to remove the pillow or the mattress from underneath him, because they say that there are feathers of some birds that cause this, and similarly they should not move him from his place. And similarly it is forbidden to place the keys of the synagogue under his head, in order that he take leave. But if there is something there that is causing delay in the departure of the soul, such as if there is a banging noise next to that house, such as a wood chopper, or there is salt on his tongue, and these are preventing the departure of the soul, it is permitted to remove it from there, that in this there is no activity at all, rather he removes the barrier (it is all in the glosses of Alfasi in the chapter "these shave")

2. One who was told "we saw your relative dying three days ago" should mourn, for he has surely died.

Based on this passage, what is the definition of goses?

Is Terri Schiavo goses?

In Sefer Hasidim, what is the difference bewteen removing the woodchopper and removing the pillow?

Is the ventillator similar to the woodchopper or the pillow?

The Difference between the Duty to Extend Life and Permission to Remove an Impediment to Death
Permission to remove anything that impedes death appears to contradict the duty to extend the life even of one who is dying. Three different approaches have been adopted in explaining this apparent contradiction.
(a) The first approach considers whether or not the patient gains in any way from the extension of his life. If there is any useful purpose in extending his life, for example if he is conscious and able to think and maintain contact with those around him by speech or even by signal, there is a duty to extend his last hours even if he is dying and suffering. On the other hand if the patient gains nothing by a short extension of his suffering and his death is preferable to his life, there is no duty to extend his last hours. There is therefore no duty to extend the life of a terminal patient who is in the state of a “vegetable” or who is unconscious such that the extension of his life serves no purpose whatsoever.
(b) The second approach makes a distinction between saving a life by natural means, including the supply of basic necessities such as oxygen, liquids, food and medicine, and the interruption of external impediments to death without withholding basic necessities.
(c) The third approach distinguishes between normal treatment and special treatment. Normal treatment may not be stopped even if it involves breach of the laws of the Sabbath, but there is no obligation to provide special, unusual treatment. It is therefore essential to continue the supply of oxygen, liquids, food and normal medicines, but there is no obligation to operate on a dying patient or to apply resuscitation after his heart has stopped beating.
In this approach there are types of treatment that may be considered normal for one patient but special for another. For example, for one who is undergoing dialysis, such treatment is normal and must be continued to the very end. On the other hand one who is suffering from cancer which in the last days of his life spreads to his kidneys need not be treated with dialysis which can at best extend his last days a little since such treatment is regarded for him as special.
Sources: Nishmat Avraham 2, 339:4; Enc. Hilchatit Refu’it 4 s.v. note lamut (pp. 401-416).
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