Illness and Death – Jewish Decision Trees – Rosh Hashana sermon by Rabbi Stephen Roberts

Editor’s Note: This sermon was delivered by Rabbi Stephen B. Roberts at Temple of the High Country, Boone, NC, on Rosh Hashana morning.

My father, of blessed memory, was a highly educated physician. He wrote a medical textbook that was a basic book for medical students for a whole generation of doctors. He constantly received referrals from around the country from people with illnesses who no other doctor could diagnose their illness. He knew medicine and he knew the body.

Further, my father was a highly educated and well-read Jew. He got up each morning of his life and prayed the morning prayers. He religiously engaged in Jewish study, particularly in the area of Jewish ethics. He had one of the strongest grasps of the intersection of medicine and Judaism of almost anyone I have ever known.

When my father developed progressive congestive heart failure, my father was faced with making a decision. Dialysis or no dialysis. My father was absolutely clear. Given what he knew about the full process, the risks and benefits given that he now had end stage heart failure, he made a decision that he shared with the whole family. He did not want dialysis. He spoke to all of us about his decision. He was clear. He understood the decision he was making. It was clear to him that dialysis as that end point in his life would only extend his dying, and thus, he refused the option and elected for hospice – to die in his own bed and not in a hospital. And when his condition worsened, my whole family understood his decision process that he had made from a strong Jewish perspective.

My father died in his own bed of decades, surrounded by my mother, my siblings, my father’s sister, and many other cousins and relatives. We knew what he wanted. And knowing what he wanted, and knowing that his wishes were followed, that he was in control of his life and his health until the his last breath, that knowledge helped us so much during his illness and then his death.

My father often spoke about the Unetanneh Tokef prayer which we read on page 108 earlier in the service. As a physician and as an active and involved Jew who wrote on Jewish issues often, he often spoke that the prayer, read on Rosh Hashanah and Yom Kippur, was intended to remind us, in the clearest of terms that we ARE going to die. He knew as a physician, one who worked long and hard to heal illness and help people live to the fullness of their days, He knew it was NOT a matter of IF, but WHEN.

In the words of the prayer which he quoted often – we are reminded:

• On Rosh Hashanah it is written and on Yom Kippur it is sealed
• How many will leave from the earth and how many will be conceived;
• Who shall live and who shall die;
• Who will die at a ripe old age and who before their time;

• וּבְיוֹם צוֹם כִּפּוּר יֵחָתֵמוּן בְּרֹאשׁ הַשָּׁנָה יִכָּתֵבוּן

Our holy day liturgy does not take an easy way out. It states, repeatedly, our core belief as Jews that all of us are going to die. Further, it does not hem and haw, it states directly that some of us will live to old age and that others will die way too young.

To be human, according to our holy day liturgy, is to know that today could be our last day on earth – and to live accordingly.

And with this knowledge emboldens us in a couple areas. The first area is that it provides more power and meaning and imperative to act in regards to the Elohai Nishamah prayer which I spoke about last night – the prayer in which each of us is reminded that we do have a pure soul and that we CAN hit the mark that is intended of us in this world, if we ACT in righteous and just ways.

The Unetanneh Tokey prayer cries out to us not to wait until tomorrow to do deeds of righteousness; to act today in a Godlike manner; to find ways to make this world a better place today. There may not be a tomorrow for us, today may be our last day on earth, so do not waste it or let it slip by.

The second area that the Unetanneh Tokey prayer inspires us is to “pay attention to” our plans and wishes regarding illness and death – as it did with my father.   We have a choice: first – we can accept the teaching from this specific prayer and from the holy days in general that death is part of life and of living ; then act upon this religious belief; or 2^nd -we can ignore this teaching and do nothing.

And the action that this prayer impels us forth to do what you may ask? This prayers reaches out to us and pronounces – plan ahead; you will reach a point where you are going to die; before then first discuss the issue of illness and death from a Jewish perspective with your family and close friends; and then second, instruct your family, friends, your doctor on your Jewish wishes around illness and death. As my father did with me and my larger family.

Speaking not only as a rabbi, but also a hospital chaplain with years of experience working in ICUs I implore you today, on Rosh Hashanah, Do not make your family and friends guess about your wishes! There is nothing worse for a family than to try and guess what someone would would want regarding treatment when they find themselves either in an Emergency Room –suddenly having been waken up in the middle of this night by a phone call alerting them there was a family emergency; or in an ICU after a long illness, not really knowing what their loved one really wants done.

When you state your wishes clearly and in advance, you are taking control of your own life until you have no more breath. You are actively helping those around you, who love you and care for you with all their soul, to be guilt free because they are following your wishes and further, that your wishes are known and clear to them.

In the words of the Unetanneh Tokef what you are doing when you struggle in advance with what you want done regarding treatments around serious illness is living the words of the prayer – U’teshuvah, U’tefillah, U’tzedakah – in this case Tezdakah. Tezdakah – the Hebrew not meaning charity but a clear biblical meaning which calls a person Tezdakah – meaning that they are acting before God and the community with righteousness – with goodness and mercy.

Judaism is not a “one size fits all” religion. When it comes to illness and death, we have what are known as “Jewish decision trees” in which we and other family members or other members of the Jewish community can decide to make different decisions looking at the same medical situation.  From my years of working in ICUS and Emergency Rooms, I have met other Jews, who faced with my father’s same medical condition, have chosen dialysis. They both came to the same point on a Jewish decision tree around medical decisions – but they chose different branches – both accepted within Judaism.

How is this you might ask? In Judaism, we have equally valid and often competing Jewish values. Autonomy is a strong and modern Jewish value – it is the basis of most modern streams of Judaism. However, also in Judaism a person is also normally obligated to seek medical treatment – providing the efficacy and utility is well-proven. Treatment that has not been proven to help is known as refu’ah lo bedukah.

Judaism is clear – while nothing positive may be done to hasten death even when someone is terminally ill the corresponding Jewish ethical plank, and this is key, there is no obligation to intervene in a hopeless situation to prolong life.

• Who shall live and who shall die. Who will die at his/her predestined time and who before their time; Who shall be tranquil and who shall be troubled?

Lets take a look at these versus through the lenses of illness but using a Jewish decision tree. Lets say a medical student, Sarah, develops renal disease. We know that dialysis in this situation, unlike my father’s, can help this student live a long life, continue her studies, and possible help her survive to the point of getting a new kidney. Dialysis in this case has been shown to be both effective and well-proven. Here, the Jewish community would strongly encourage the use of dialysis – as it is clear this is, in the terms of the Unetanneh Tokef , well before the student’s time. And a treatment like this allows both the student, the student’s family and friends to face the days and weeks ahead with a sense of tranquility – knowing they are finding ways to live a long life. In some ways, this is the perfect contrast to my father and his decision.

So lets focus now on us, sitting here today – Rosh Hashanah morning in Boone, NC. Do your family, friends, and doctors know your health care wishes? Is it written down in a place that they can easily find and work from? As was the case with my father and with Sarah.

• Who shall live and who shall die. Who will die at his/her predestined time and who before their time; Who shall perish by fire and who by water;

Who by fire and who by water are clear reminders that some do die long before their time – in fact, when they are strong and in the middle of life. A critical question, particularly if something happens to you in the terms of the Untanefh Tokef prayer, “before your time”, do you want to be an organ donor? Have you stated this wish? Is it on your driver’s license? Have you spoken to your physicians and others? I have been in many an ER area or ICU when this situation occurred. I have witnessed time and time again that without the strong consent of the person who died and without that person’s previous encouragement, the family rarely chooses organ donation.

Yet, being an organ donor is about fulfilling the Jewish imperative of saving a life – in Hebrew – pikuach nefesh. Tens of thousands die each year here in the US from the lack of organ donations. Particularly when someone dies “before their time,” most likely in an accident, their providing their organs for donation can help a family and friends see some good come out of a horrific situation.

• Who hall perish by fire and who by plague;

When I hear the word plague in this prayer, I normally think to myself, illness. Judaism has real decision trees when it comes to making decisions around illness. Illness – in one situation a person may say – prolong my life and do everything to treat the illness. In another situation the same person may say – choose quality of life over longevity when you make decision. And the same illness, in a 3^rd situation, the Jewish decision maker may request comfort care only.

Adam is 42, has 3 adorable children aged between 6 and 12, both his parents and his wife’s parents are alive. He was just diagnosed with ALS – also known as Lou Gering’s Disease. The diagnosis came when he was hospitalized for pneumonia. Given his current life and health situation, Adam tells his family, friends and doctors’ he wants everything done to prolong his life.

Now 8 years later, Adam is 50 and has progressed to the point in his illness that he can no longer speak, nor tend to himself, but is fully aware and is able to communicate through the use of a special computer. He is looking forward to his children’s graduation from High School and College. He has developed pneumonia for the 2^nd time and is hospitalized again. He tells his doctor’s he wants everything done IF there is a significant change that he will still have the same quality of life that he currently does – meaning that he can still communicate in the limited fashion, he can see his children on Facetime, and his wife and both his parents and his wife’s parents are still supportive of everything going on.

Finally, Adam is now 62, 20 years after his initial diagnosis. He has been at two of his three children’s wedding. He has been to one of his parent’s funeral. He has been treated multiple times for pneumonia at home. He is still aware but has almost no way left to communicate. In a multi-hour exhausting visit with his family, he indicates to them that anything more medically would just be to prolong his dying, and no longer to prolong his life. Thus, he makes it clear that if he gets pneumonia again, not to treat it nor to transport him to hospital for anything else. On his Jewish decision tree, he has reached another decision – facing the same illness as the last two times.

On this Rosh Hashanah – I ask each of you – have you prepared? Have you first considered different scenarios and then discussed with your family and your physicians your wishes regarding medical treatment. Are your wishes in writing? Do you have signed health care proxies and do your doctors and family have copies of the signed documents?

In Ecclesiastes Chapter 3 – we learn: For everything there is a season; a time for every experience under heaven; A time to be born and a time to die; A time to keep silent and a time to speak.

This coming Shabbat from 12:30 through 3:30 I am running a workshop to give you time to speak – by helping you decide on what you want regarding a series of medical decisions and treatment. I encourage that you attend with family members so you can speak to each other. At the end of the 3 hours you will leave with a document you can then share with your doctors and other family members.

The time between Rosh Hashanah and Yom Kippur is a time of both reflection and action. I pray that you reflect on your wishes around what YOU want done regarding medical treatment, organ donation, and other issues of illness. I pray that you then express those wishes to your family, friends and medical doctors. Through your action – you are indeed affirming your Jewish reality, in the words of the Unetanneh Tokef prayer, that all of us will die – some this year, some next, some a long time down the road, but that all of us will die within the context of Jewish values.

Shanah tovah.