The authors report no relevant financial relationships.
Abstract: Consistent with appropriate clinical practice and professional regulations, Jewish medical ethics espouses beneficence, nonmaleficence, justice, and autonomy. The principles of Jewish medical ethics and the intersection with secular law as it pertains to end-of-life (EOL) care in patients are addressed. The exploration of a methodology and doctrine to cover instances when Jewish ethics clashes with clinical judgment is explored. Issues such as refusal of treatment, terminal illness, withholding and withdrawing treatment, informed consent, cardiopulmonary resuscitation and do-not-resuscitate orders, advance directives, nutrition and hydration, and others are discussed. A comparison of Jewish and secular principles in EOL care and differences among Jewish sects is included.
Key words: end-of-life, Jewish medical ethics, secular law, advance directives, nonmaleficence
The end of life (EOL) can be a traumatic time for patients and their families, who often must make a variety of decisions. Clinicians from various health care disciplines, religious leaders and advisors, family members, caregivers, and friends are often involved. The family members may be of different generations, have different education levels, have differing knowledge of religious practices, and be of different branches of the same religion. Some may rely on religious leadership, while others may choose to make their own decisions. Family members may seek advice from clinicians and secular experts, while others choose to follow their religious leaders and teachers.1
The relatively recent advances in medical research and knowledge have given rise to the field of Jewish medical ethics. In the 18th century, Rabbi Yaakov Emden espoused that if an individual lacks confidence in a medical approach, he or she has the right to decline the intervention. Rabbi Emden’s opinion was based on the early-stage, basic level of medical knowledge available at that time. Clearly, ethical queries were less complex at that time. However, with the significant progress realized in the 20th century, Rabbi Moshe Feinstein in 1961 wrote that if all physicians on a case are of the same opinion and in accord, then it is incumbent to treat the patient according to the medical recommendation. It is the gray areas that are most frequently debated and subject to different opinions. In those cases, clear communication is of paramount importance.
While Judaism always considers the value of human life, it also considers that life is finite and that there may be instances where palliative medicine and care at the EOL can be practiced. Furthermore, consistent with appropriate clinical practice and professional regulations, Jewish medical ethics espouses the 4 principles of bioethics: beneficence, nonmaleficence, justice, and autonomy. Discussing treatments for specific issues in accordance with Jewish law and Jewish medical ethics may assist clinicians in their approach to culturally appropriate EOL care for Jewish patients and their family. This can limit contradictions that can complicate family meetings with clinicians and prevent a consensus about religious teachings between clinician and patient.
This article examines the principles of Jewish medical ethics as derived from Jewish law and their intersection with secular medical ethics and secular law as it relates to EOL care. Following a summary of the 4 principles of bioethics, the article reviews EOL issues including life-limiting illness and assisted suicide, refusal of treatment and advance directives, cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders, withholding and withdrawing treatment (eg, pain management, nutrition and hydration, mechanical ventilation), and clinicians and intensive care units (ICUs), from the Jewish law and medical ethics perspective. Finally, the article discusses the role of different sects of Judaism in EOL beliefs and patient care.
Principles of Bioethics
Autonomy is a very important principle in the Jewish discussion of EOL decision-making. The principle has consistently been applied in right-to-die state court cases where it is balanced against countervailing state interests such as preservation of life and the prevention of suicide.2,3 Health care medical ethics recognizes and cherishes the patient’s right to choose among the various possibilities and alternatives. This is the dominant ethical value and the ultimate determinant of decision-making. One of the most important responsibilities of the clinician is to provide the most comprehensive, timely, consistent, and empathetic discussion of all alternatives available to the patient, significant others, relatives, and caregivers. It is the responsibility of clinicians and the multidisciplinary care group to provide this information clearly, at the comprehension level of the patients, family, and caregivers, and without bias.4
Autonomy, within the teachings of Judaism, must provide decision-making consistent with Jewish law. Therefore, in the case of an Orthodox Jewish patient, a difference exists between secular practices and Jewish practices. One may state that rabbinic teachings, patient desires, and medical ethics are equal partners in the discussion and execution of EOL decisions.5,6 On the subject of Jewish medical ethics, halakha (Jewish law, or Jewish legal point of view) takes precedence, and life’s value is absolute and supreme. While the wishes of the patient are paramount, all 3 major Jewish movements in the United States—Orthodox, Conservative, and Reform—prohibit suicide and assisted suicide, even in cases of painful, life-limiting (terminal) illnesses.
Beneficence is the requirement that decisions that are made benefit the patient. Secular medical ethics requires that clinicians design care plans of the most possible benefit to the patient, with the input of the patient’s desires, and, in if patients are unable to communicate or make their own decisions, their surrogate.
Jewish medical ethics obligates clinicians to provide treatment to heal and improve the life of the patient. Patients are obligated to seek beneficial treatment. In Jewish teachings, patients are to consider their life as being not theirs to give away, and we are not the proprietor of all human life.7
Nonmaleficence is consistent with the Hippocratic Oath (“first do no harm”). However, in secular medical ethics, clinicians must be careful in treatment choices. For example, many medications have side effects that must be considered. Glucocorticoids, antihypertensives, cardiac medications, antimicrobials, and many other medications are associated with predictable adverse reactions.8 The risks and benefits of these treatments, especially in EOL care, must be weighed and considered by clinicians and patients.
Jewish medical ethics is consistent with these issues, but the individual also has a specific obligation to care for his or her body and to avoid harm.
Justice in secular health care ethics includes the principle that care must also be good for society as a whole, in addition to being beneficial for the individual. Discussions of prevention, avoidance of transmission of communicable diseases, and impact of lifestyle choices on future health must be considered. The impact of smoking, obesity, and nonadherence to treatment on limited health care resources must be considered.
Jewish law defines and determines societal good. Patient priority is based upon urgent and emergent need for care and the length of time since presentation at the health care facility. While more serious medical problems are given priority, the first patient will receive the care that he or she needs. For example, teachers, rabbis, and physicians would come first. Limitations of health care based on resource availability is permissible according to Jewish medical ethics.9
Thus, in these 4 cardinal values of medical ethics, similarities and differences exist between secular and Jewish medical ethics, and these differences form the basis for understanding ethnically appropriate EOL care.
Life-Limiting (Terminal) Illness and Assisted Suicide
Life-limiting illness is an incurable illness resulting in a limited life expectancy of typically 1 year or less.10 Actively dying is typically the last 3 days of life.11
Various forms of medically assisted dying are legal in 4 European countries, and court and legislative action has been taking place in many more. Three US states—Oregon, Washington, and Vermont—now have “Death With Dignity” laws, also referred to as right-to-die measures. Two additional states, Montana and New Mexico, permit physician-assisted dying, and various measures for legalization have been introduced in about 24 states.12 The laws generally require the patient to be 6 months or less from expected death and require 2 or more requests to a physician.13
While some countries have established euthanasia, the US federal government has not.14 The lack of a federal right to euthanasia is consistent with the Jewish prohibition against active euthanasia as referred to in writings pertaining to goses, or one who is one’s deathbed. Under Jewish law, suicide, assisted suicide, and euthanasia are forbidden.15
Passive euthanasia is defined as the withholding of treatment that can prolong life.16 It is more permissive and would apply to those deemed to have a life expectancy of not more than 3 days. Refusal of medical treatment is permitted if it is deemed futile or ineffective. In addition, if it causes incremental suffering and complications to the patient, other alternatives may be considered.17
Refusal of Treatment and Advance Directives
Beginning in 1891, a long line of US judicial opinions recognized the legal right of a mentally competent adult patient to refuse medical treatment for any reason, even if it would hasten death.18 Nursing home patients have a constitutional right to refuse treatment under the Patient Self-Determination Act.19 State laws then address the requirements for health care providers to honor that right. In New York, the law does allow for exemptions for “reasons of conscience.”
Jewish law and ethics allow the refusal of noncurative, harmful treatments (some forms of chemotherapy that are not deemed curative in the literature) in the terminally ill patient. While noncurative treatments may be withheld, treatments that have already commenced usually cannot be withdrawn. This does not refer to palliative care.
The right to refuse treatment is a corollary to the doctrine of informed consent, where the patient must be informed of the nature, means, and likely consequences of treatment or withholding treatment. Secular health care regulations now incorporated in statutory law in a number of states, and much legal precedent,20 require informed consent for treatments that are initiated or withheld from competent patients. In the case of Cruzan v Director, Missouri Department of Health, the Supreme Court determined that the right of competent adults to refuse unwanted treatment is a liberty interest protected by the Fourteenth Amendment of the US Constitution.20 The New York law specifically states, “Every patient shall have the right…to refuse medication and treatment after being fully informed of and understanding the consequences of such actions.”21
The patient’s condition should be disclosed to the patient himself or herself, unless this could cause harm.22 That is, Jewish principles require a sensitive disclosure of health status to a patient but permit the withholding of truth if it is believed that this disclosure will be harmful to the patient.9
The question as to whether a patient can refuse treatment in a curative yet compromised quality-of-life situation was addressed by Rabbi Shlomo Zalman Auerbach, who was a renowned Orthodox Jewish rabbi and head of the Kol Torah yeshiva in Jerusalem, Israel. Can a patient refuse amputation of a leg if it will result in prolonged life? Rabbi Auerbach’s opinion was that if the patient would be unable to adjust to a dependent lifestyle, and it consequently would negatively affect his or her physical state, resulting in depression, then the patient has the right to refuse treatment. Similarly, with regard to dialysis, if the patient does not want to be a burden to his children or family members, the prerogative is ultimately his or her own with regard to treatment.
Honoring patient preferences is critical in providing quality EOL care. Hospitals and nursing homes must provide information on advance directives at the time of admission as required under the Patient Self-Determination Act.19 The New York State Department of Health has developed a specific physician order form, “Medical Orders for Life-Sustaining Treatment (MOLST),”23 intended for patients with serious health conditions who want to avoid or receive any or all life-sustaining treatment; who reside in a long-term care facility; and/or who might die within the next year. It is the only authorized form in New York for documenting both nonhospital DNR and do-not-intubate orders. The use of advance directives such as a living will and health care power of attorney are available to assist in the decision-making process.24
A living will refers to instructions issued by patients for some future time when they may not be able to communicate their wishes to clinicians at the time when health care decisions need to be made. A health care power or attorney, or health care proxy, is the designation of someone to make health care decisions on behalf of a patient. It is issued, signed, and witnessed at a time of patient competency to be used at a time when the patient is no longer competent to make decisions. Both documents are revocable at any time according to communication of the patient’s wishes.
Secular law and Jewish law agree on the utilization of these documents. The health care system use of advanced directives is permitted, providing that there is rabbinical involvement. Patient competence, as in secular regulations, is the driving force behind the execution of advanced directives.25
CPR and DNR Orders
CPR refers to all medical treatments to prolong life when the heart or breathing stop, including being placed on a respirator. Specifically, it is defined as restoration of cardiac output and pulmonary ventilation following cardiac arrest and apnea, using artificial respiration and manual closed-chest compression or open-chest cardiac massage. DNR refers to an order to allow natural death and means not to begin CPR. Secular and Jewish principles allow withholding of CPR if there is consensus among clinicians, patients, caregivers, and a rabbi. This consensus would include advance directives, risks and benefits, and prognosis.26
Withholding and Withdrawing Treatment
Withholding and withdrawing treatment are permitted by secular health care law based upon issues such as patient prognosis, cognitive status, pain and suffering, and patient and family wishes. In 1976, the first reported appellate case in the United States ruled on the discontinuation of life support from a patient in a vegetative state.27 Nursing homes that have policies regarding withholding or withdrawing treatment must communicate those policies in advance to residents and have the residents acknowledge those policies.28
In Jewish law, a distinction must be made between withholding and withdrawal of treatment.5 Treatment may be withheld if it will only delay death and not provide improvement in health or relief of pain and suffering. It is not permitted to withdraw life support and other measures that prolong life once they have been initiated.29 Rabbi Auerbach indicated that any action that will lead to the immediate death of the patient is prohibited; included are the removal of respirators, pressors, and any therapy that will cause the patient to die immediately.30 The use of antimicrobials, surgery, chemotherapy, and radiation treatment have similar guidelines in secular and Jewish law. They may be refused or withheld if they only delay the dying process and do not provide relief of pain and suffering.31
One response to this dilemma is the Israeli Dying Patient Act of 2005, which regulated the treatment of dying patients. It upheld the distinction between withholding therapy and withdrawing continuous therapy that has already commenced. This caused some dissonance in clinicians trying to preserve patient autonomy in decision-making.6 However, there is some feeling that no moral basis exists for the distinction between withholding and withdrawing treatment.
Mechanical ventilation presents additional issues, as well as the need to distinguish between withholding initiation of ventilation vs discontinuation in a patient who is already receiving mechanical ventilation. Within the decision to commence ventilation, therefore, is a fear that the patient will be “locked in” to a mechanically ventilated life. This may result in the withholding of mechanical ventilation because of its potential to become a life sentence.32
The discussion of pain management is consistent across disciplines. Both physical and emotional pain must be treated. Rabbis allow patients to be as comfortable as possible or to choose lower pain control to allow consciousness. On the other hand, it is permissible to provide pain medication for relief of suffering, even if it worsens the patient’s overall condition.26 Rabbi Eliezer Waldenberg—one of the most respected halachic authorities of the modern era and a trailblazer in the field of Jewish medical ethics—permitted administering morphine to a very ill patient despite the potential risk; morphine depresses the respiratory system. In contrast with pharamacotherapeutic intervention, a surgical procedure to eliminate pain is prohibited. Surgery is permitted to treat disease and save a life. Surgery involving risk to eliminate pain and/or enhance one’s quality of life is not permitted.
Nutrition and Hydration
The issue of nutrition and hydration must be considered carefully. In secular health care, the usual parameters of prognosis, patient suffering, and the wishes of the patient and family are taken into account. In the Matter of Conroy, the New Jersey Supreme Court refused the nephew and guardian of Claire Conroy, an 84-year-old nursing home patient, permission to have her nasogastric feeding tube removed.33 Similarly, in the matter of the Estate of Longeway, the withdrawal of food and water from a 76-year-old irreversibly comatose patient was permitted.34 In 1986, the American Medical Association Council on Ethical and Judicial Affairs took the position that life-prolonging medical treatment such as respirators, nutrition, and hydration may be withheld.35
In Jewish law, one has to be more specific. Are nutrition and hydration supportive or therapeutic measures? Is withholding nutrition actually shortening life and therefore tantamount to assisted suicide? Will the lack of nutrition lead to starvation, pain, suffering, and discomfort? Have the patient’s cognition, prognosis, quality of life, and age been taken into account in this decision? There is much discussion of whether artificial nutrition and hydration is basic care or medical intervention. This may arise from the fact that food and fluids are always considered to be beneficial. However, it must be remembered that artificial nutrition and hydration does have some risk.36 For example, aspiration pneumonia can arise from forcing fluids. Infection can have a portal of entry from intravenous or gastrointestinal tract catheters. Therefore, even if nutrition is considered basic care, one must still weigh the risks and benefits as if it were the most complex medical or surgical intervention.37
Clinicians and ICUs
Rabbi Avraham Steinberg, MD, provides a case-based guide for clinicians in ICUs.38 Professor Steinberg is a medical ethicist, pediatric neurologist, rabbi, and editor of Talmudic literature; Director of the Medical Ethics Unit at Shaare Zedek Medical Center, Jerusalem; and cochairman of the Israeli National Council on Bioethics. One scenario in his guide refers to a patient who was admitted to an ICU with the intention of lifesaving treatment. Complete intensive care was provided, including treatment of infection, cardiovascular control, blood transfusion, intravenous feeding, and ventilation. The patient had failure of 3 major organ systems and, in the opinion of the clinicians involved, all lifesaving possibilities were exhausted, and death was imminent. The clinicians believed that the patient was suffering, there was no hope for recovery, and the patient would wish not to continue suffering.
Obviously, there is a need to balance the halakhic principle of the obligation to save life and the need not to prolong unnecessary suffering without hope for recovery. In this case, the determination was to avoid introducing new treatment and discontinuing diagnostic tests and monitoring. Analgesia should be continued to reduce pain and suffering. However, no action should be taken that would lead to immediate death. From this viewpoint, disconnecting the respirator is not allowed. Withholding of cardiovascular pressors is also forbidden if it will lead to immediate death. This viewpoint allows the gradual lowering of the rate of the respirator and lowering the respirator’s oxygen concentration. Gradual tapering of the cardiovascular pressors is permitted if the changes in blood pressure will not lead to imminent death. If the patient is suffering greatly, this viewpoint allows ceasing total parenteral nutrition and allowing oral feedings or glucose solutions. The use of anticoagulants, insulin, and other injectable medications can be discontinued if the patient is terminal and suffering greatly. Periodic medications (those not given continuously) may be discontinued in the terminally ill suffering patient. However, if these conditions are not seen in the patient, then a rabbinic authority must be consulted in addition to clinicians and family members.38
Table 1 provides a comparison of Jewish and secular law and medical ethics regarding EOL care.
Different Sects of Judaism
Jewish law requires that the patient’s rabbi be included as a decision-maker to ensure that decisions are acceptable under Jewish law.39 During this discussion, it is of great importance to mention that the application of the issues discussed depends greatly upon the different Jewish communities and sect of Judaism that the patient practices or has affiliation with. Clinicians should recognize that the sect of the patient and family will have great bearing upon discussions regarding the EOL care for the ill relative or patient. Variability within sects and the dividing lines are less distinct between certain members of each group.
To understand this, it is necessary to view the differences regarding the source of the law and to review the basic theologic doctrines of the different sects. Table 2 summarizes some of the basic theologic doctrines of the different Jewish sects.
Orthodox Judaism belief centers around the concept that the entire Torah was given to Moses when Hashem revealed himself to him on Mount Sinai, and the Law is authoritative for modern life in its entirety. The fundamental difference between the Orthodox and non-Orthodox groups is the strict adherence by the Orthodox to halakha as defined by the rabbis. The Orthodox population seek the guidance and opinions of their rabbis and follow halakhic decisions. The Orthodox branch is observant of Jewish law and tradition and accepts the rabbi as religious authority and interpreter of Jewish law. Therefore, the counsel of the rabbi is followed in EOL decisions regardless of feedback from clinicians. The roles of men and women are different both in terms of religious observance, duties in the home, and familial relationships.40
The non-Orthodox segments generally are more aligned with the secular perspective. Reform Judaism arose in Middle Europe as a reaction to the rigidity of the Orthodox Judaism that was being practiced at that time. They believe that the law as practiced was authored by humans based upon their interpretation of what came before. In the Reform branch, Jewish law is only a guide to practices and is nonbinding. There is less observance of tradition, and the rabbi is not authoritative. The rabbi is less authoritative than in the Conservative group.8 In this case, advice from clinicians will often be heavily considered. Observance and Jewish identity are interpreted on an individual basis.
Conservative Judaism is between Orthodox Judaism and Reform Judaism and is a reaction to a desire to maintain the traditional elements of Judaism, with an allowance for reasonable modernization and rabbinical interpretation based upon the worldview within the environment. The belief is that the law was delivered and developed by humans with divine inspiration (such as the prophets), retaining the Torah and Talmud as the primary law sources. Orthodox and Conservative sects hold halakha as the standard of how to live life. The Conservative sect has wide variation and interaction regarding traditions and the observance of Jewish law and regulations. There is a reinterpretation of Jewish law to fit modern society. The role of the rabbi is from authority to advisor; the rabbi is advisor but is not as authoritative. Therefore, in conjunction with rabbinical counsel, feedback from family members and clinicians will be likely to be taken into account. Most conservative congregations practice egalitarianism, or equality between men and women.
We must keep in mind that these variations are blurred, since although there are different seminaries for training the different rabbis, and there are different associations to which the various sects belong, each organization and its spiritual leadership and lay leadership determine interpretation of the ritual and custom. For example, there are Orthodox-trained rabbis who believe in egalitarian practice (men and women practice the same way), while there are conservative trained rabbis who teach different roles for the sexes.
Based upon these differences, we can see that the approach in any individual or group discussion regarding EOL must take into account these often subtle differences between sects.
An example is a case where Mr G has a life-limiting illness and diminished capacity. He has a daughter, Ms K, who was not chosen as the health care proxy, and another daughter, Ms G, who follows Orthodox Jewish teachings and has been chosen as the health care proxy. Ms G. has made the decision to continue treatments. Her decision is based upon her beliefs and Jewish law. Ms K indicates that she knows it is the father’s desire to stop aggressive treatment.41
The facts are that Ms G is the legally empowered decision-maker. However, which of the daughters is the appropriate decision-maker? As clinicians in this case, as in many other cases, we do not know the religious beliefs of the patient nor his treatment preferences. We do not know the essence of the relationships between Mr G and each of his daughters. What was the reason for the selection of Ms G as the surrogate? If the father was not as religious, is it appropriate for the religious daughter to apply her values and beliefs to the care of her father, or should she reflect his orientation and values accurately?42 In actuality, halakha addresses this question. According to Rabbi Auerbach, a parent delegates medical decisions to his or her child because the parent is confident that the decision of the child reflects the desire and opinion of the parent had the parent been of condition to render the decision. The decision of the child should not be based on an independent opinion, but rather the child serves as an agent on behalf of the parent.
Life is the fusion of body and soul into a single unit, a single entity. As life progresses, invariably the body will start to fail, initially on a unit organ basis. Ultimately death ensues, and the body disintegrates. Jewish beliefs include the following: (1) do everything possible to sustain life and prevent death; (2) demonstrate the utmost respect for the body when death occurs; (3) memorialize the death, family members mourn but do not despair; and (4) remember the deceased; continue a relationship with the deceased. Although death is the termination of the physical body, according to Jewish tradition the soul lives on. The soul continues to be cognizant of that which occurs in the lives of family members, and similarly remains a recipient of the love from family members. A fundamental principle of the Jewish faith is the belief in “life after life.” In the future, the soul will be reunited with a rebuilt body, and once again the unit will comprise the unification of body and soul.
The issues raised in this article are illustrative of those that arise in EOL patient care that clinicians and staff should be mindful of. Understanding the medical team’s opinion and recommendation along with the overall physical condition and emotional wishes of the patient are key to enabling a rabbinic authority to render an opinion (halakhic determination) on a medical issue. For the believing Jew, the resolution of such issues comes through Jewish Law (Halakha). Respect, encompassing medical knowledge, religion, and culture are key attributes when serving patients from varying backgrounds.
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