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To Die Without Suffering - Israel's First Euthanasia

By Wendy Elliman

Jerusalem

On October 4, a 49-year old fighter pilot named Itai Arad died in the Hadassah Medical Center in Jerusalem, his family gathered around his bed. Arad's life could not be saved: his body was ravaged by a degenerative and incurable muscle disease. But his early death was more than an inevitable tragedy. It was the first officially authorized euthanasia ever performed in Israel. As such, it marks a medical-ethical watershed in a land whose faith holds the saving of human life as one of its key imperatives.

Itai Arad's death was the culmination of a long battle that he and his family fought in Israel's law courts for his right to die without suffering. The battle began when he was diagnosed with the fatal motor-neuron disease whose medical name is amyotrophic lateral sclerosis, but is better known as ALS or Lou Gehrig's disease.

In January 1996, he seemed to have won. Tel Aviv District Court Judge Moshe Talgam made the unprecedented ruling that it was legally permissible to meet Arad's request to disconnect him from his ventilator when the time came. In August 1998, however, when Arad asked the staff of the Kfar Saba hospital where he was being cared for to carry out his request, they refused.

"In Western society, disconnecting a ventilator is seen as no more than passive euthanasia," says Prof. Charles Sprung, who heads the General Intensive Care Unit at the Hadassah-Hebrew University Medical Center in Jerusalem, founded and chairs Hadassah's Institute of Medicine, Ethics and Law, and co-chairs the working group of the European Society of Intensive Care Medical Ethics.

"In the Western ethical system, active euthanasia is performing a life-ending procedure, such as injecting a fatal drug. The Jewish approach, however, is molded by halacha or Jewish law, and views things differently.

"In Jewish law, passive euthanasia is withholding treatment - for example, not attaching a patient to a ventilator in the first place. But once a patient is on a ventilator, disconnecting him (that is, withdrawing treatment) is judged as active euthanasia, since it's an action that results in the patient's death. Jewish law thus makes a crucial distinction between withholding and withdrawing treatment that's not found in the Western approach."

When the Kfar Saba hospital staff refused Arad, he and his family turned to Prof. Avinoam Reches, a senior neurologist at Hadassah and an active member of Hadassah's Institute of Medicine, Ethics & Law. "There's been a major change in the perspective of doctors toward their patients in the last few years," says Reches. "Until very recently, death was considered a medical failure and a doctor's primary goal was to prevent death. Today, however, some of our 'successes' have come to be recognized instead as failures - 'successes' such as mechanical ventilation that keeps severely disabled patients alive for years.

"Think of a patient with ALS, such as Arad, who can't move, but whose senses and mind are intact. If he feels a fly settle on the end of his nose, he can't brush it off. What quality of life is that? To me, quality of life is as important as its duration. If such a patient is mentally and psychologically whole and persistently expresses a wish to end his life, I believe he should be allowed to die."

Reches heard Arad and his family sympathetically, making only one stipulation: that he be authorized to help Arad die by Hadassah's Ethics Committee for the Treatment of Terminally Ill patients. The decision was bounced over to the Committee, who in turn passed it on again - back to Judge Talgam at the Tel Aviv District Court, asking Talgam to reaffirm his decision of two and a half years earlier. He did so on October 1.

In short order, the Hadassah Committee gave Reches its authorization, informed senior members of Israel's health-care community (including the director-general and deputy director-general of Israel's Ministry of Health) - and Reches took the news back to the Arad family.

Itai Arad's consent to the euthanasia procedure was recorded on videotape. On October 3, Reches injected massive amounts of anesthetic into his patient, and disconnected his ventilator. Twenty-four hours later, Itai Arad was pronounced dead, and his suffering was over. For Israel, however, this perilous journey into the ethically unknown has only just begun. With today's medical possibilities and limitations, the Jewish imperative to preserve human life, if only for a few more seconds, is no longer a clear or reliable guide. Today, physicians, judges, philosophers, clergymen and bureaucrats, as well as those struck down like Itai Arad, are all grappling to shape a new medical ethic to guide us safely through the new reality of our times.

Wendy Elliman is a freelance writer living in Israel.