Every oncologist in Israel knows that on Sunday mornings – the beginning of the
Israeli work week – a busy clinic awaits. The weekend provides ample time for
symptoms to develop, be noticed and be questioned.
On the morning of
Sunday, December 2, 2012, several patients greeted me. Nearly all offered me two
First, they gave me their reactions to my op-ed about Iron Dome,
the air defense system designed to intercept short-range rockets. The piece had
been published in these pages on that day.
Second, my patients conveyed
their fright at having learned of a more abstract “missile” – their terminology
– which, that day, had landed, metaphorically, in Israel. It had been alleged
that Dr. Mordechai Shtalrid, a department head at Kaplan Hospital, had carried
out euthanasia – so-called “mercy killing” – on his terminally ill 33- year-old
daughter before committing suicide. The news rocked the cancer patients that I
My patients were curious to discover whether I knew Dr. Shtalrid
and, if so, what I thought of the gruesome scenario. Even though we practiced in
related fields, I had been introduced to Dr. Shtalrid only once, at a
professional meeting. We had exchanged pleasantries but had by no means come to
know each other.
IT’S NOT uncommon, of course, for physicians to wrestle
with the problem of an incurably ill, suffering patient. In
Dr. Shtalrid’s terrible situation, the incurable, suffering patient was
also his child. The story has prompted two types of questions; the answerable
and, mostly, the unanswerable.
I’ve been bombarded by numerous queries
for which I have no answer. For example: To what extent was Keren Shtalrid
suffering? To what degree were efforts made to alleviate her pain? Why did Dr.
Shtalrid take his own life if he believed that he was doing the best thing for
his daughter? Was he afraid of criminal repercussions? Was Dr. Shtalrid more
interested in relieving his daughter’s pain or dealing with his own perceived
helplessness? Were any attempts made to overcome, or at least compensate for the
“intractable pain” with non-medical modalities such as meaning-making
techniques? On the other hand, the questions to which we can formulate answers
pertain to what we might elect to do as the end of life approaches for us and
our loved ones. In considering those questions, I offer a three-part model
comprised of autonomy, religiousness and spirituality.
The model, which
presumes overlap among the various factors, can be represented by a Venn
diagram. Individuals gravitate to the respective factors in varying
Autonomy is typically defined as the ability of a
person to make his or her own decisions. In a medical context, patients exercise
autonomy most often when they provide informed consent prior to participating in
clinical trials and while reflecting on end of life decision
Today, many people feel that the ability to make such decisions
for themselves is an inviolate core value.
In fact, when sensitive
medical decisions must be made, patients and family members tend to assert that
they alone are at liberty to make such judgments. From that, one can deduce that
people do not want society to meddle in personal choices involving “good
Most Western religious traditions place a premium
on what many refer to as “the holiness of life.” Non-theological philosophies
don’t necessarily minimize such sanctity, but in a non-religious view, the
holiness of life is unlikely to trump all other considerations.
Roman Catholic religion seems to propose blanket condemnation of active
euthanasia, the Church generally sanctions passive euthanasia. Protestantism,
according to Anglican minister Joseph Fletcher, offers “all possible colors in
the spectrum of attitude toward euthanasia.” The former chief rabbi of England,
Lord Immanuel Jakobovits, points out that “any form of active euthanasia is
strictly prohibited and condemned as plain murder, but Jewish law seems to allow
for withdrawal of any factor which may artificially delay death in the final
phases of a person’s life.” These heady concepts are harder to comprehend when
one considers them for the first time only when someone is
There may be no completely satisfying definition of
spirituality. I choose to define the word in an indirect fashion as referring to
that which uplifts the soul. It is readily apparent, however, that my definition
is subjective, even tautological.
Dr. Thomas Moore refers to “loss of
soul” as the great malady of our time. Society in general and physicians in
particular have lost interest in the soul and the spiritual dimension of life.
We lack professionals who task themselves with healing the soul. But by caring
for the soul, we may be able to find relief from distress. Most would agree with
Victor Frankl that, on an intuitive level, the soul craves meaningfulness. When
facing the specter of death, we may derive considerable solace if we persevere
to find meaning even when we cannot avert the outcome.
IN 2005, the
Knesset passed comprehensive legislation known as The Dying Patient Act that
attempted simultaneously to respect patient autonomy and affirm the sanctity of
human life. The law invites us to find a balance between prolonging life and
In theory, the law represents a giant step forward
for professionals, dying patients and their families, all of whom must navigate
the multiple ethical, legal and cultural dilemmas that arise at the end of life.
However the law can be only as good as the way in which people adopt
The DPA is relatively new, and the level of its success is unknown,
as is the degree to which physicians are able to use the tool to help patients
evaluate the relative weighting of autonomy, religiousness and spirituality to
their own lives.
In the USA, a growing number of states endorse a program
known as POLST (Physician Orders for Life Sustaining Treatment). POLST seeks to
provide a user-friendly template for recording the types of interventions that
patients want and don’t want as death looms. American writer Ellen Goodman
launched another popular program, The Conversation Project. Goodman intuited a
way to bring conversations about death into the mainstream, so that they “could
even be discussed around the dinner table.” One may download a starter kit from
The case of the Shtalrids has, in fact, landed
unexpectedly, like a terrifying missile. But even beforehand, death had been
waging an unrelenting campaign against humankind. In this battle, there is no
external system like Iron Dome which can shield us from the daunting nature of
our own mortality. Rather, we must contend with death anxieties as individuals.
Each of us might do well to begin to envision and grapple with various
end-of-life scenarios. It shouldn’t take a tragic occurrence to get us to
contemplate a tragic reality.The author is chairman of the Institute of
Radiotherapy at Tel Aviv Medical Center and co-founder of the organization
Life’s Door. His blog (“52”) is hosted on JPost.com