IN-DEPTH FEATURES
Murder in a White Coat

One month ago, at 11:59 p.m. on December 31, 2000, great tension could be felt in one of the rooms of a small hospital in Groningen, Holland.

The international media was busy preparing a wide variety of in- depth stories to mark the end of the year according to the Gregorian calendar, but this event--which was reported on one of the networks--was of a distinct nature.

The atmosphere was tense. The people gathered in the room constituted a typical hospital scene--patients, a doctor and family members--however it was in contrast with what was about to take place over the following 60 seconds.

Peter W. Hollem, 59, a patient who was wasting away, had expressed a desire to "end his life of constant suffering." The physicians on the staff had agreed to his request. Their hearts went out to the miserable patient, and they saw no need to burden the health budget. The family members had suggested it be carried out, symbolically, "just as everyone says good-bye to the old year," timing that also ensured that the media would take an interest.

The instant the clock sounded the last of its twelve chimes, the doctor injected the substance that was to put Peter to sleep forever. "We told Father we love him, we said our last good-bye, and that was it," recounted Hollem's daughter, describing the chilling act. "We felt sad, but it was a touching moment."

This abominable crime, for which, almost anywhere else in the world, the perpetrators and others involved would be put on trial for murder or as accessories to murder, would have passed almost unnoticed in Holland if not for the significance of the time at which Hollem's doctor and family members assisted him in putting an end to his life.

In Holland, where "mercy" killing has been a long-standing practice, a bill to formally legalize euthanasia was passed in the course of the year 2000. Now Dutch doctors are legally authorized to terminate a patient's life by administering a fatal drug without having to worry about facing any legal repercussions.

The homicidal procedure is supposed to be carried out only in limited circumstances based on rigid criteria. But figures so far indicate that euthanasia, or as the Dutch prefer to call it, "life termination by request," has quickly turned into widespread murder of helpless patients who were never asked if they wanted to die. Unconscious patients who are certainly not apparently suffering, the retarded and the incurably disabled, one-day-old infants with congenital birth defects, atrophied elderly patients who have lost their cognitive abilities, and others -- are all on the list.

The results of this Pandora's box can be acutely felt in Belgium, Australia, and in the U.S. in Oregon and other states. "Enlightened" Holland, of course, is leading the way.

In Israel as well, a gradual decline can be detected in this area, known locally as "the right to die with dignity." The final hope may be in the hands of the Committee for Public Ethics set up by the Health Ministry in order to finalize a consensus that would win the consent of halachic authorities. But even once the recommendations have been formulated, it is no secret that there are a considerable number of doctors and health-care professionals who already do not shirk from "gracefully" shortening the life of the patient, Rachmono litzlan, or withholding vital treatment from terminal patients and even "regular" elderly patients suffering from a number of diseases and health problems.

Professor Avrohom Steinberg, a senior neurologist at Sha'arei Tzedek, director of the Center for Medical Ethics, a leading expert in medical ethics and the author of the Encyclopedia of Medicine and Halacha, is pessimistic regarding international developments. "The world is heading toward the present situation in Holland," he says.

In an exclusive interview with Yated Ne'eman, Professor Steinberg reviewed the rapid decline, saying, "The moment the fences are removed -- when the universal taboo of `Thou shalt not murder' which was accepted by every nation around the world for thousands of years is defied -- it won't stop there."

Murder Without Bureaucratic Intricacies

Dutch euthanasia advocates, including the Minister of Health, are definitely pleased. As a whole, in that pastoral land, wooden clogs and windmills go hand in hand with fatal injections. The country's medical establishment is constantly engaged in perfecting the method employed to carry out the act. Half of all doctors have performed euthanasia at least once, in order to prevent their patients from undergoing inordinate suffering. The legislation essentially comes as a reinforcement of an established norm.

In Holland no one can recall a case of a doctor-killer who was thrown in jail, even though euthanasia was illegal up until now. Previously, according to the penal code, the maximum sentence for abetting suicide was twelve years imprisonment. Doctors who performed such "benevolent" acts of "kindness" upon their patients, and sometimes even took the decision upon themselves that the patient would be better off dead, had to live in fear of one day being brought to trial. They also had to face an exhausting set of intricate bureaucratic and legal procedures to absolve them from legal repercussions.

The New Law

The new law, which was drafted in cooperation with the Health Minister of Holland, releases the doctors from liability for committing murder. "This is a lofty humanistic step," declared the Justice Minister in response to concerns over unscrupulous applications of the law. The Justice Minister need not worry about falling out of favor with the public--92% of Dutch citizens support the law.

The new Dutch law establishes rigorous parameters that determine when a doctor is permitted to snuff out the patient, including the following stipulations: the patient has to be incurable and suffer from unbearable pain that cannot be treated; the request has to be made by the patient himself; the patient has to clearly express a desire to die after the consequences of his consent have been explained to him; the doctor must receive approval from a special committee before carrying out the procedure; and the patient's life must be terminated through proper medical means in order to avoid the appearance of a "regular" crime.

Ask the Child

This "humane" law would have been passed long ago if it were not for one minor clause that held up the legislation: the "right" of children twelve years and older to decide to end their lives.

Even the liberal Dutch, or at least a portion of them, found it difficult to agree to a law that would permit doctors to perform euthanasia on children as well, even on the condition that the parents consent, as per the provisions the Ministers of Health and Justice wanted to include in the law. They even stipulated that when one of the parents objects to the decision, the consent of the other parent is sufficient if the child asks to end his life. "These are cases of cancer patients, for example, who are constantly in and out of the hospital, and undergo severe suffering, vomiting and hair loss. At some point such a child could decide that he has had enough." And through the graces of the doctor, his suffering can be terminated.

The Dutch people objected to the proposal. How could a twelve- year-old child, who is not considered legally capable of making relatively minor decisions based on reason, make such a fateful resolution?

Opponents claimed the law was diabolical. According to the legal definition, children are minors and are not authorized to sign a legal document or a contract without a legal guardian, yet here, in a life-and-death decision, they would be granted the right to choose!? Eventually the controversial clause was removed, although it is another matter whether this will make any difference to doctors and parents who come to the conclusion that the child's decision has to be honored.

If you still find it hard to believe that there are doctors who do such deeds, it is worthwhile to take a look at figures from Belgium, Holland's next-door neighbor.

A study performed simultaneously at two Belgian universities, Brussels and Ghent, revealed remarkable findings: One in every ten incidents of death in the country is the direct result of euthanasia, and in three percent of the cases patients were given fatal substances without making any such request!

In one out of every five incidents of death, i.e. 20 percent of all deaths, doses of pain-killers were administered in order to hasten the patient's death. Once again, without the knowledge of the patients themselves.

These figures are from Belgium, and not Holland, where the debate surrounding the issue has yet to be settled. Belgian law still views euthanasia as a punishable offense. The doctors surveyed in the study of course remained anonymous to avoid exposing themselves to punitive measures.

Another statistic: in 16% of the cases the doctors reached the decision to discontinue medical treatment independently, without consulting the patient or his relatives. Many of them did not deny that they had clear intentions of ending the patient's life. Oy lerosho, oy leshecheno!

Valuing Life or Valuing Autonomy

"The dilemma over euthanasia is an inherent aspect of medical advancement, which now allows life to be prolonged more than ever before but not always with the quality of life to make it appear worthwhile to some people," explains Professor Avrohom Steinberg.

Until a few years ago, according to the prevailing world view, the value of life was perceived as an absolute, requiring that every effort be made to preserve it, in any form. This was in contrast to the ideal of autonomy and respect for the rights of man, which gives individuals dominion over their bodies and the power to decide what is done to them.

The approach that has developed over recent years imposes no common values and "sanctifies" the autonomous will of the individual as a supreme value. The will of the individual, according to this point of view, is an absolute value, based on two conditions: the person has the power of judgment (which excludes minors, the insane and the retarded); and the execution of his will does not come at the expense of others. If a terminally-ill (or even another) patient wants to die, he has the right and it is permissible, according to this approach, to assist him in bringing about his death.

Autonomy is the prevailing view in Holland--in its most extreme form. For the time being, most nations are trying to find a balance between the two. In most countries it is illegal for a person to actively shorten the life of another, but on the other hand, the patient's will is honored and he is not obligated to receive medical treatment designed to prolong his life. On this issue there is an essential difference between the two existing options: avoiding treatment or discontinuing treatment.

"By avoiding treatment we are essentially returning to the situation of 200 years ago, when sophisticated medical equipment--such as resuscitation devices--were unavailable. On the other hand, beyond a doubt discontinuing treatment shortens the life of the patient.

"Since no distinction is made between the two in other parts of the world (in parts of the U.S. and in many European countries), this leads to moral decline. Take, for example, discontinuing nourishment to the patient, delivered intravenously or through tube-feeding. Here there is an essential difference: if medical treatment is discontinued then the patient dies from the disease, while if nourishment is discontinued then the patient dies of starvation. This is the closest step to actively killing the patient, which has not yet been introduced, except in Holland."

The moment this bridge is crossed, says professor Steinberg, the decline of the medical profession--referred to as the "slippery slope"--commences. The situation in Holland and Belgium has already been described above, but Professor Steinberg is even more pessimistic where there is no yiras Elokim to be found. "The world is headed toward the situation in Holland, and it won't stop there. Patients diagnosed as terminally ill will become candidates for euthanasia. "Terminally ill" is a problematic term since all of us are terminal; all of us will die some day. Who determines how long a patient has to live? At a later stage death sentences will be handed down to people who do not want to die. After all, the world is very enlightened. This is the fear that lies at the back of everyone's mind."

In fact, this eventuality is not unprecedented: Germany in the 1930s of the Third Reich killed off the sick and the retarded, and soon thereafter, it descended upon the handicapped. It did not stop there.

Here in Israel

What is the situation here in Israel? "No one knows," says Professor Steinberg.

From a legal standpoint, Israeli law prohibits euthanasia. Although so far no doctor has been tried for not prolonging the life of a patient, it is a criminal offense and thus no one would openly admit to doing it, making it impossible to conduct an inquiry into the matter or to generate genuine figures.

From a judicial standpoint there is a High Court precedent for refraining from administering certain types of treatment to prolong a patient's life, but it remains illegal to discontinue treatment and to shorten the patient's life. There were, however, a number of cases in which well-known judges permitted a patient's treatment to be discontinued in the name of "the right to die with dignity."

Other judges are unwilling to get involved in the controversy for one very good reason: this is not a legal question, but rather a moral, religious and social issue.

So who can solve the problem? Many doctors struggle with the issue and hesitate when faced with this weighty dilemma. Meanwhile, other doctors take the matter into their own hands, and are liable to come to commit murder out of a sense of "compassion."

For the chareidi doctor or patient, there is no such dilemma. In a halachic ruling first published in Yated Ne'eman in Kislev 5755 (1995), the leading poskim issued a resolute ruling on the matter: "According to din Torah, all patients, including terminally-ill patients, must receive all routine treatments and medications needed. Hastening the death of a patient in order to reduce his suffering by withholding nourishment or medical treatment is absolutely forbidden, in addition to active means of accelerating the patient's demise."

The psak din enumerates required medical treatments as described by senior physicians: nourishment, intravenous fluid replacement, insulin injections, proper doses of morphine, antibiotics and blood transfusions.

The message of the psak din was also aimed at the general public--doctors and patients facing questions of medical ethics and morality in a variety of related matters. Senior physicians who are not shomrei Torah umitzvos reported that they welcome and agree with a psak halocho that presents the Torah view on the subject.

The Right to Live in Dignity

Dr. Ram Yishai, chairman of the Israeli Association for Medical Ethics, has issued several strong statements against a doctor assisting the patient to shorten his life. This is neither his prerogative nor his job: the doctor's task is to administer treatment and to help the patient.

"Our generation has the ability to treat the patient using very effective means so that the terminally-ill patient need not suffer either. There is no medical reason to uphold the demand for `the right to die with dignity.' We have the means to grant the patient the right to live in dignity until the very end," Dr. Yishai told Yated Ne'eman.

Requests for euthanasia are generally made when a terminally- ill patient has difficulty bearing terrible suffering and has no hope in sight. On this issue a fascinating study was recently published, addressing doctors' positions on euthanasia. Surprisingly--and perhaps disturbingly, too-- oncologists, whose patients are the most likely to request euthanasia, oppose shortening the life of the patient.

This was the largest study ever conducted on the subject of euthanasia. The research team, headed by Dr. Yechezkel Emanuel of the U.S. government's National Institute of Health in Bethesda, Maryland, surveyed 3,300 oncologists in the U.S. The findings were published in a professional journal specializing in internal medicine.

According to the study, less than seven percent of the oncologists surveyed support euthanasia even for cancer patients who suffer from severe pain that cannot be controlled through medication. Only two percent responded they would be willing to carry out the act, although 60 percent had received such requests during the course of their work as physicians.

One astonishing figure that emerged from the study was that the rate of euthanasia was four times higher among oncologists who reported administrative and financial problems in providing the best medical treatment available to their patients, in comparison with oncologists who reported that they were able to provide every necessary treatment.

In the report submitted to the medical journal, the researchers wrote: "In general the results of the study stress the need to teach doctors optimal methods for reducing and treating pain. More knowledgeable physicians felt less of a need to perform euthanasia or to assist in carrying it out."

The Most Important Issue--Treatment of the Terminally Ill

The decline of the medical profession in this area presents a difficult and painful problem for us. "Unfortunately, it is a common phenomenon in the medical establishment for doctors to determine what `quality of life' is worth treating and what is not, and they believe investing resources in some patients to be unjustifiable," says Professor Avrohom Steinberg.

Essentially this is the acute problem we face on the issue of euthanasia: in certain wards and medical centers, perhaps many more than we are aware of, the treatment given to elderly and handicapped patients is far from being the optimal care available.

"I can vouch from personal experience that there are wards that are a danger to the elderly and the terminally-ill patients hospitalized there," relates Dr. Menachem Breier, deputy director of Mayanei Hayeshua hospital in Bnei Brak, a hospital renowned for its public activity in the struggle against euthanasia and for its treatment of terminally-ill patients.

On many occasions Dr. Breier has been asked to step in to ensure that elderly patients receive the necessary treatment. In one case he was asked by Health Ministry officials to admit an elderly patient to Mayanei Hayeshua from another hospital where he had been refused medical treatment needed to save his life.

"When we consulted with the rav of Ramat Elchanan in Bnei Brak, HaRav Yitzchok Zilberstein, to determine which goals we should set before us in the matter of medicine and halocho, and which matters we should focus our efforts on and which should be promoted to the general public and the shomrei Torah sector in particular, he said the most important matter is the issue of treatment for the terminally ill," said HaRav Yisroel Zicherman, the rav of Achuzat Brachfeld in Modi'in Illit, at a special conference for rabbonim on medical issues and halocho held last month by the Jewish Organization for the Promotion of Community Health headed by Dr. David Morel.

"There are many Jews in critical condition who, along with their families, face crisis situations. These patients and their families have a tremendous fear of hospitalizing the patients or placing them in hospices set up to provide real help for the patient and his family, and in practice, Rachmono litzlan, we are compelled to say that things take place there that constitute retzichoh mamash.

"Maybe people who have a different world view cover up these acts with all sorts of pleasant-sounding labels like `euthanasia,' but really . . . these things, in many cases, fit the description of a maiseh retzichoh mamash . . . and Am Yisroel, which is supposed to be a light unto the nations, is sucked in, Rachmono litzlan, and it seems to me that it is becoming the number two country in the West in terms of actively performing euthanasia on terminally-ill patients, Hashem yishmor veyatzil."

HaRav Yisroel Zicherman expanded on the importance of the right to prolong life even for a few moments, and made a practical proposal to solve the problem based on da'as gedolei Yisroel: "In the past patients who were truly suffering from fatal illnesses and were about to die spent their last days surrounded by family . . . at home. We would like to bring back this upstanding practice, but of course this cannot be accomplished unless the proper tools are placed at the disposal of families who have terminally-ill relatives; a system like the one set up by the Organization for Community Health could set up a network of health-care professionals that would provide support for these families and help care for patients in the comfort of their homes."