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Confronting terminal illness and death in religious Jewish society
Ruben Schindler

 

INTRODUCTION

The literature on death and dying has given contem¬porary society insight into the plight of the terminally ill. The works of Kübler-Ross and others have become standard texts both for laymen and the professional in understanding man's struggle with finality. One should recognize that certain cultures and societies have specific directives which add hope and dignity for man facing death. Traditional society in Israel, and more specifically the Jewish religious community, has adhered to a highly structured format in dealing with man's struggle with death. As the shiva 1 forms uniform behavior for bereavement, so is the period of terminal illness and confrontation with death highly structured. Whether terminal illness is short or prolonged, whether it occurs within moments or is a matter of months, the Jewish attitude and outlook is one of deep human concern for man. The focus of this inquiry will thus be related to both the attitudes and practices in man's struggle with finality.

THE TERMINALLY ILL — A JEWISH VIEW

In Jewish thinking human life is valued as supreme. The preservation of human life is paramount and one is obligated to do all even if life is extended for only a short period of time. The value of human life is infinite and beyond measure so that a hundred years and a single second are equally precious. The Talmud notes that one can desecrate the laws of the Sabbath "even if an individual is found crushed in such a manner that he cannot survive except for a short while." 2 It is a Jewish view well known throughout the centuries — the duty to promote life and health. It is obligatory to disregard laws conflicting with the immediate claims to life and suggest that such action is hallowed.

Persons facing severe illness express a multitude of behaviors. The pioneering work of Kubler-Ross ident¬ifying the stages of shock, anger, bargaining and accept¬ance has given attention to man facing finality. Comfort and hope are the anticipatory responses expected from helping professionals, relatives and friends? Within a similar context Williams has suggested "that many patients have not only physical discomfort but also much emotional upheaval. . . . A genuine display of interest and determination to help can be very beneficial."' Goffman has stated that the patient may perceive hospitalization as an act of betrayal on the part of the family. If the patient does view hospitalization as a betrayal, his confidence in the family as a source of support will deteriorate.5

The Jewish view is to counter isolation and a sense of alienation by placing obligations upon the family. Therefore relatives and friends are encouraged to visit the sick at once.' There is no limit to the frequency of visitations on a single day. The time for patient visitation permeates time and day. Callers are encouraged to visit on the Sabbath? This in spite of the fact that such visitation may induce grief for the caller because it is contrary to the spirit of the Sabbath which is a day of delight.

Jewish thought was also specific as to times when visiting the sick was not encouraged, reflecting sensitivity to man in discomfort and crisis. Maimonides states that visitation should be avoided if the illness presents a source of embarrassment to the patient.' For the visitor early morning and late evening hours were also avoided. As to the former, the patient may feel abnormally well in the early morning, so that one may not be stirred to seek mercy for him. And abnormally ill at the end of the day, so that one may despair of praying for his recovery.' It should be stressed that one of the main purposes of visiting the sick is for the caller to be moved to plead for mercy on the patient's behalf.10

Within Jewish teaching the idea of hope as a force in man's belief toward recovery is central. For the devout, man turns to the Omnipotent and calls for a "perfect healing to all our wounds," and the specific petition of a healing of soul and body to the sick. The book of Psalms presents a touching picture of man having reached old age and hope. He pleads:
Cast me not off in the time of old age when my strength faileth, forsake me not...
But as for me, I will hope continually.11

In the contemporary context, Ross has stated, "It is this glimpse of hope which maintains them through days, weeks and months of suffering. . . . It gives the terminally ill a special mission in life which helps them maintain their spirits." 12

It is interesting that Freud. stressed the dimension of hope in his pioneering work. He noted:
Our interest is most particularly engaged by the mental forces that [exert] the greatest influence on the onset and care of physical diseases. Fearful expectation is certainly not without its effect on the result ... the contrary state of mind in which expectation is colored by hope and faith is an effective force with which we have to reckon in all our attempts at treatment and cure. 13

But it is interesting that limited attention has been given to hope as an important supportive principle. The reason for this has been insightfully stated by Orne. He suggests:
Perhaps one of the reasons why the importance of hope has not been explicitly recognized is the implication that it refers to archaic primitive mechanisms more appropriately discussed in the context of religion than that of science. Such a mechanism is juxtaposed against logic, reason, or rational secondary thought process. This dichotomy is inappropriate.14

Hope thus played an important part in both secular treatment oriented fields and in Jewish thought. As for the latter it is Solomon who perhaps put it most succinctly: "Hope deferred maketh the heart sick. But desire fulfilled is a tree of life." 15

NAMING ANEW

As mentioned above the idea of hope has been inextricably tied to Jewish thought. For the terminally ill patient all avenues are explored in bringing the person to recovery. Within Jewish tradition adding a name to the patient reflects the hope that a new living spirit can revitalize the patient to recovery. Furthermore there is hope that the evil decrees will be cancelled. This, it should be noted, is not mere ceremony but reflected in religious teaching. The Talmud has stated that "four things cause an evil decree passed on man to be cancelled: they are charity, prayer, adding a name and change of action." 16

The ancient custom of adding a new name to a sick person is carried out by means of casting lots. A Bible is opened and the first name that appears in the text is chosen. This is followed by a prayer for the ill referring to significance of changing one's name. Hope is expressed that "as his name was changed, so may the evil decree passed on him change from law to mercy, death to life, illness to perfect cure." 17

The source for change of name goes back to Biblical days. In the book of Genesis we encounter the story of Sarah and Abraham. The former had grown old and had not conceived any children. The texts proceed to tell us that G-d had said to Abraham, "As for Sarai thy wife, thou shalt not call her name Sarai but Sarah (shall be) her name." 18 The Scripture proceeds with the following passage: "And I will bless her and moreover will give thee a son of her, yea I will bless her." 19 The major commentator of the Pentateuch, Rashi, asks, "And what will be the blessing?" And he replies, "That she be returned to her youth." 20

Naming anew should not be taken literally as returning to one's youth. But what is implicit is that through one's change of name, a sense of optimism prevails and that recovery is possible. When the state of the patient has reached the point, however, when there is certainty of death, the confession service is introduced.

CONFESSION

In Jewish thought the formal confession through an intermediary is non-existent. When confessional periods do emerge such as the high holidays, the confession is between the individual and G-d. When the person has reached his final hours, relatives and friends are en¬couraged to turn to the confessional. They state the following passage:
Do not fear that evil may result for many who confessed became well and did not die. . On the contrary as a reward for having confessed your life will be prolonged.21

But it is not only hope that is conveyed through the confession. Its purpose is to enable the patient to play an active role in his final hours. It is an opportunity to return to the spiritual roots that the religious patient seeks. It is to counter what Glaser and Strauss have observed as "the failure to understand a patient's at¬tempts at achieving psychological closure in his life and . . . the patient's increasing isolation." 22 Confession thus provides man with an opportunity for religious expression in a formal sense though his thoughts may be confused and often incoherent. It is also a time for atonement and a time for prayer that the last hours may be free of affliction.

It was King Solomon who in Proverbs wrote of the efficacy of confession. "He who confesses and forsakes his sins will obtain mercy." 23 It should be noted that no special form of death-bed confession existed in ancient times. The theme of the confession is largely a com¬pilation of traditional phrases in use since the medieval philosopher Nachmanides (1194-1270). On the death-bed the person recites the following prayer:
I acknowledge . that both my care and my death are in Thy hands. May it be Thy will to send me a perfect healing. . . . O may my death be an atonement for all the sins, iniquities and transgressions of which I have been guilty against Thee 24

The confession is an essential part of repentance. And certainly the last moments are devoted for return to God. The Rabbis have stated that the moment a man is willing to see himself as he is and make the confession, from that moment the powers of evil lose their control over him. But it is not only the dying patient who is the focus of attention during this most difficult and trying time.

The Rabbis were also sensitive to the patient's state of sickness and his family. The Rabbis noted that when the confession is recited:
the above words should not be spoken in the presence of ignorant persons . nor of children, for it may cause them to shed tears and this may cause the sick person to become dejected. 25

The confession also directs its attention to prayer for the patient's spouse and his children. He requests divine protection for his family. Stated in rather simple but touching words:
Father of the orphan and Judge of the widow, protect my beloved kindred with whose souls my soul is bound up. 26

If the terminally ill person is not able to confess verbally, the Rabbis state that he should be told to make a mental confession with the major thought relating to atonement. "May my death be an atonement for all my sins" being the central theme.

Another central theme throughout the confession prayer and one to which more detailed attention will be given later, is the idea of after life. There are numerous statements within the confessional related to this idea. "All who confess have a share in the world to come." "Grant me shelter in the shadow of thy wings and a portion in Gan Eden." "Let me merit resurrection and the life of bliss in the world to come." 27 This message states that while death takes place on this earth there is the belief that a state of existence is found in after life. This solemn and rather touching service takes place during the period of the death watch which is likewise an important facet of man's struggle with finality.

DEATH WATCH AND THE FAMILY

In Jewish law the death watch has a very specific purpose. The Rabbis tell us:
From the moment a person is in the grip of death it is forbidden to leave him, so that his soul may not leave him while he is alone. It is a religious duty to stand by the person at the time his soul is about to separate from his body. 28

In his last moments the dying patient is never left alone. He is comforted, listened to and above all given the psychological support by the physical presence of friends and family. During this time the Rabbis state that great care must be given so that in no way will the physician cut short the patient's life regardless of the suffering encountered. In this context the Rabbis tell us:
Even if the patient be a long time in a dying condition and it cause great suffering to himself and to his next of kin, it is nevertheless forbidden to bring about, even in an indirect way, the acceleration of death. 29

This is another dimension of the death watch. Tra¬ditionally friends and relatives would be with the patient round the clock to ensure that his life would in no way be shortened regardless of humanitarian considerations.

In Jewish law a dying person is considered as a living being in all respects. The Rabbis go so far as to state that it is forbidden to touch the body, and the one who does so is guilty of bloodshed, for it may accelerate the end. However, there is great emphasis on making the dying patient as comfortable as possible. One must make certain that cleanliness in the room is maintained and his physical needs are cared for.

The emphasis upon members and relatives partici¬pating in the death watch has been underscored in the modern period by Glaser and Strauss. They suggest that:
A very important aspect of the death watch is its role in assuring that the patient will not die alone. The death watch is empty time.... Since the death watch is an empty temporal space . . . there is a great temptation to neglect it.30

In Jewish thought the death watch is not an option but rather an obligation. And because it is uncertain when the patient will falter, Jewish tradition places upon the family and friends that visitation periods be immediately observed even if the patient's condition is not severely critical. It is thus a long, often tiring process but it places the dying person as the major focus of concern.

After the departure of the soul the immediate family is given a religiously sanctioned means to express grief by rending their garments. Prior to interment and the formal mourning period the tearing is performed. This is not mere ceremony. It allows the mourner to give expression to his deep anger by means of a controlled, religiously sanctioned act of destruction. The act must be performed by the mourner and cannot be carried out by someone else. According to the Talmud,31 any rending of clothes not carried out in the flush of grief without full emotional involvement is not considered appropriate. The Rabbis are quite explicit that there can be no substitute for this rite through symbolic or other forms. Masochistic or demand behavior, such as cutting one's flesh or rending one's hair is inappropriate and prohibited. An opportunity for psychological release is thus afforded through. the kreiah, the rending of garments. Furthermore it enables the mourners to commence their "grief work" so that process of bereave¬ment can start at once.

It is interesting that partaking of grief is not only left to the immediate family. Everyone present at the separation of the soul are required to rend their garments, reflecting communal grief and respect for the deceased. The duty of rending the garments by those who are not obligated to observe mourning may be discharged by rending the garment slightly, even at its side.

The Rabbis have been particularly sensitive to the state of the mourner immediately following death of kin. In psychological terms Lindemann has described the state as one of "unreality; a feeling of increased emotional distance from other people . . . a tendency to respond with irritability and anger, a wish not to be bothered by others." 32 Jewish law describes this state as Aninut.33 An Onen is someone in deep distress and unable to deal with reality at hand. Very much aware of the emotional and psychological dimensions of the bereaved during this period, the Rabbis perceptively pointed out, "there is no one to carry his heavy burden." 34 He is alone with his tragic loss. His ability to concentrate and communicate is limited. As the commentaries state, "Because he has seen the deceased before him, his mind is weakened." 35 Confrontation with death not only breaks the soul but weakens the mind. Rabbi Soloveitchik puts it in these terms:
Aninut represents the spontaneous human reaction to death. Man responds to his defeat at the hands of death with total resignation and with an all-consuming masochistic self-devastating, black de¬spair. Halakhah has never tried to gloss over the sorrowful ugly spectacle of dying man. In spite of the fact that the Halakhah has indomitable faith in eternal life, in immortality and in continued transcendental existence for all human beings. . . . It did not understand man's fright and confusion when confronted with death. It per¬mitted the mourner to be relieved of all mitzvot.36

All religious obligations and ceremonies are thus waived until after interment thus enabling the mourner to harness his strength for the difficult days ahead.

AFTER DEATH — TRANSCENDENTAL EXISTENCE

In Jewish thought death is viewed as natural as creation. Indeed, when God had completed the creation of the world he saw that "it was very good." 37 Upon which Rabbi Meir remarked "it was very good: that is, death." 38 It is suggested that underlying Rabbi Meir's statement is the idea that death is an integral part of the natural order making way for new life and continued creation. But not only is death seen as an integral part of the natural order. After life was also discussed and seen as a central tenet in Jewish thought. The believing Jew is totally committed to the idea of life after death. hough the nature of this existence is debated among scholars, there is uniform opinion of man's resurrection. That God can revive the dead is one of His praises, "I kill and I make alive; and I have wounded and I heal." 39 Maimonides 40 incorporated the idea into the 13 articles of faith. Until the present day pious Jews recite these articles after the morning prayer. Among the 13 articles resurrection is placed last, perhaps giving it special significance. The article reads: "I believe with perfect faith that there will be a revival of the dead at the time when it shall please the Creator." 41 Of those who are skeptical, the late Chief Rabbi of the British Empire, Joseph Hertz comments:
Many people find resurrection incredible, yet it is no more a mystery than birth or the stupendous miracle of the annual resurrection of plant life after winter. If what never before existed, exists, why cannot that which once existed, exist again? 42

This belief is reaffirmed daily by Jews in the recitation of the eighteen benedictions,43 and placed into the daily service to counter the notion of the deathlessness of the soul and its return to God.

Another important idea relating to after life is the concept of Olam Ha-Ba, or future world. The Mishna states that all Israel have a portion in the world to come 44 The future world was not spoken about in great detail by the ancient Israelites and one does not find them recorded in the Scriptures. Marmorstein adds insight into the subject, however, by suggesting that when "Monotheism had definitely consolidated itself .. the doctrine of the future world was preached vigorously and loudly." 45 Indeed, one finds in the Talmud the question: "Who is destined for the world to come?" The reply of the Rabbis is simple and to the point. "The individual who is humble and is a student of the Torah without seeking merit." 46

One can well appreciate that for the pious Jew who believes in after life the very idea can offer comfort. But even for the non-believing the psychological impli¬cations are vast, as Toynbee and Koestler state:
To be afraid of death is natural for people who believe that a human being lives and dies once only… For believers in rebirth death does not have the same finality 47

Certainly in Jewish life this is a cardinal principle, and one that has been inextricably bound in Jewish belief throughout centuries.

CONCLUSION

To confront death in the Jewish religious community, recognition must be given to the time process prior to finality. Structured practices based on Jewish law enable the patient and family to deal with death in a more significant and humane manner. From patient visitation to hope, naming anew, confession, the death watch and the idea of transcendental existence — all these are important components of man's confrontation with death.

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Rabbi Dr. Ruben Schindler lectures in the School of Social Work, Bar-Ilan University, Ramat-Gan, Israel. The above article was first published in ADVANCES IN THANATOLOGY, 5:2, 1982 and is reprinted here with the kind permission of the editors, The Foundation of Thanatology, 630 West 168th Street, New York, N.Y. 10032. Rabbi Schindler has published other articles concerning Thanatology, including: Illness and Recovery: A Jewish Halachic Perspective, JOURNAL OF JEWISH COMMUNAL SERVICE, LIV:2, pp. 129-134, 1977; Reaction to Truth Telling among Israeli Physicians, OMEGA, Vol. 13 (3), 1982-83.
1. Shiva — The seven-day mourning period observed by the immediate family.
2. Bavli, Yoma 85a.
3. Elisabeth Kübler-Ross, On Death and Dying. New York: Macmillan Publishing Co., pp. 50-85.
4. Robert H. Williams, "Management of the Sick with Kindness." In Robert H. Williams (ed.), To Live and To Die. New York, Springer-Verlag, 1973, p. 155.
5. Erving Goffman. Asylums. Chicago, Aldine Press, 1961.
6. Laws of Visiting the Sick 335, 2.
7. Orah Chaim, 287, 1.
8. Maimonides, Laws of Mourning, Chapter 14.5.
9. Laws of Visiting the Sick, 335, 4.
10. Ibid., 4.
11. Psalm 71, 9-8.
12. Ross, Op. cit., p. 139.
13. Sigmund Freud, The Complete Psychological Works of Sigmund Freud, Vol. 7. Translated by James Strachey, London, The Hogarth Press, 1953.
14. Martin T. Orne, "On the Nature of Effective Hope", International Journal of Psychiatry, 5:387, May 1968.
15. Proverbs 13, 12.
16. Bavli Rosh Hashanah, 16:b. Bavli Toanit 15a.
17. J.H. Hertz, Daily Prayer Book, 1955, pp. 1062¬1063.
16. Genesis, 17: 15.
19. Ibid., 17:16.
20. Ibid., Rashi's Commentary.
21. Sanhedrin, 44:B.
22. Barney G. Glaser and Anselm L. Strauss, Time For Dying, Chicago, Aldine Publishing Co., 1968, p. 168.
23. Proverbs, 28: 13.
24. Hyman E. Goldin, HaMadrich, Hebrew Publishing Co., 1956, pp. 105-106.
25. Yoreh Deah, Op. cit., 338:2.
26. Hertz, Op. cit., p. 1064.
27. Goldin, Op. cit., pp. 105-106.
28. Yoreh Death, Op. cit., 339:4.
29. Ibid.
30. Glaser and Strauss, Op. cit., pp. 198-199.
31. Moed Katan, 24:a.
32. Erich Lindemann, "Symptomatology and Manage¬ment of Acute Grief". In Howard J. Parad (ed.), Crisis Intervention, New York, Family Service Association of America, 1965, p. 10.
33. Aninut is the time between death and burial. The mourner is exempt from religious requirements.
34. Berakhot Yerushalmi, 83, 4a.
35. Devarim Rabbah. Vayelech, Moses Mirking (ed.), Jerusalem: Yavnek Press, 1962, p. 250.
36. Joseph B. Soloveitchik, Eulogy for Tolner Rebbe, Abraham R. Besdin (ed.), Rabbinical Council of America, June 1972, pp. 2-3.
37. Genesis, 1:31.
38. Genesis Rabbah, 9:5, that is, because now, death is included in creation.
39. Deuteronomy, 32:39.
40. Maimonides — known in the Rabbinical literature as the Rambam from the acronym (Rabbi Moses Ben Maimon), 1204-1235, codifier, philosopher and royal physician.
41. Daily Prayer Book. Commentary by J.H. Hertz, London, Shapiro Vallentine, 1955, p. 254.
42. Ibid., p. 255.
43. Known as the Shemoneh Esreh in Hebrew, it is the oldest of congregational prayers of the synagogue, giving expression to praise, thanksgiving, confession and petition.
44. Mishna, divided into six orders dealing with Jewish Halacha (Law).
45. Arthur Marmorstein, "The Doctrine of the Resur¬rection of the Dead in Rabbinic Theology". In Studies in Jewish Theology, London, Oxford University Press, 1950, pp. 164-165.
46. Bavli, Sanhedrin, 88:b.only.
47. Arnold Toynbee and Arthur Koestler, Life After Death, London, Weidenfeld and Nicolson, 1976, pp. 30-31.