This post will continue our discussion of Rabbi Immanuel Jakobovits and modern medicine from a prior post- here.
From a historian’s perspective Jacobovits was crucial for the dismissal and writing out of Judaism hundreds of years of deathbed rituals and preparations for a good death and easy passage to the afterlife. In the 1960’s the value of preserving human life in the ICU displaced asking about repentance and the angel of death. The biological concerns of preserving of life took precedent over the psychological, spiritual, and metaphysical. Philip Aries, a French historian, spent twenty years investigating the changing attitudes towards death in Western Civilization. In the Middle Ages, the “dying well” ( ars moriendi) came to primacy as one came to terms with their ultimate demise. What was then important was how the dying faced death. In the mid-20th century, advances in medical technology, particularly the development of the respirator, meant that death could now be delayed and occurred in hospital following a ”great war against death.” A death in the ICU is a failure of medicine rather than a good death. Culturally, death is now culturally invisible. The entire process of fighting death shows more belief and focus on medicine than on religious services and the afterlife. There is no culmination of a religious service with the kiss of death.
The social historian Elliot Horowitz describes an Italian controversy from 1556 in which a Jewish man died suddenly without having confessional performed as part of Jewish Last Rites and was thus refused burial. Those on the side of the deceased claimed that the movements of the man’s lips immediately preceding death should have constituted as a confession. Rabbi Tucazinsky’s Gesher Hachaim records that in 1947 Jerusalem they had a person shout confession every day in the hospital so that everyone can affirm a confession before dying.
The Talmud teaches that, “If one falls sick and his life is in danger, he is told: ‘Make confession, for all who are sentenced to death make confession.’” In the Shulchan Aruch’s codification, based on the language in Mesechet Semachot, where it is ruled that the following text should be recited to the terminally ill: “Many have confessed but have not died; and many who have not confessed died. And, many who are walking outside in the marketplace confess. By the merit of your confession, you shall live. And all who confess have a place in the World-to-Come.” The Early Modern works on deathbed procedures, such as those by Rabbi Aharon Brachia Maavar Yabok, were still essentials for the early 20th century despite numerous editions and translations. These works build on Talmudic and Medieval conceptions and create full orders and regulations for the deathbed rituals. (They are also our binding source for the activities of the Chevra Kaddisha’s performance of Tahara on the deceased.) In contrast, Jakobovits states that the “predominantly “this-worldly” character of Judaism is reflected in the relative sparsely of its regulations on the inevitable passage of man from life to death.”
In the Jewish works of dying well, the goal, according to social historian Avriel Bar-Levav, was to preserve self-control, unlike our current ICU deaths. Typically, deathbeds required a confession of the dying before a minyan. However, lacking such control Maavar Yabok (ch 19) states that one who is on his deathbed, the confession is said on his behalf by an appointed messenger who will read the text in the patient’s presence whether he is conscious or not. One gathers a quorum of ten men around the deathbed in order to pray. The moment the soul decides to submit and leave the body is considered the “kiss of death;” this is different from biological death. The prayer said by those standing around the dying person appears in the standard Hamadrikh and begins with verses calling for God’s mercies. It includes the Priestly Benediction and the prayer for God’s angels and protective spirit is called upon. It is important to note, however, that this prayer is said even if the one in one one’s deathbed (goses) is incontinent and cannot hear the prayers. The prayer, according to these authorities, has an effect on the soul and also on those who are reading it. Even Rabbi Yekutiel Greenwald’s 1951 work, Kol Bo Aveilut assumes these practices and even asks questions such as if one has one rabbi for a last rite, do we send him to the bed of the sinner or the rabbi?
In contrast, Jakobovits assumes that only Christian religious literature has devoted much attention to the problem of ascertaining the exact moment of death. In Judaism, however, this problem has little or no purely religious significance, since there are no sacramental rites to be accorded to the dying prior to the soul’s final departure from the body. From the ritual point of view, the only practical distinction in Jewish Law between a live body and a dead body concerns the rules of defilement cuased by the dead body.Whereas originally there would be a process of dying that included the soul, now in Jakobovits’ view we are limited to the body.
In the full deathbed service, in works such as Maavar Yabok, there are important practices to perform for the dying person and for family and friends which signale the transition between realms. Physical death occurs at the end of this ritual process and the ritual serves to help in demarcating the living from the dead. Even after the physical death, the process of the soul leaving the body is to take the full length of the seven day Shiva period. In modern terms, it would mean that even after the clinical signs of death, there is still a transitional process in which the body is still considered spiritually alive for a period of time. Jakobovits does away with this transitional realm and limited the process to the modern clinical realm of the undertaker: “When the patient dies, his body generally passes from the attention of the physician into the care of the undertaker and the religious officials who attend to its interment.”
Jakobovits acknowledges that, “the earliest Rabbinic sources usually speak of death as the “going out of the soul,” they also concede the view that the association between body and soul is not altogether severed until three days after death.” But he trusts in modern medicine’s designation of biological death and considers that doctors are able to ascertain death. This is in distinction to the position of Rabbi Moshe Isserles who “altogether denies our competence ‘nowadays’ to ascertain the exact moment of death.”
Jakobovits leaves us with an acceptance of the modern clinical definition of death. Originally, there was an unknown moment of death described in deathbed rituals as the “Kiss of Death” which signifies was the social moment when we had previously assumed the person had died. Now, that moment is identified entirely with the physical death. Gone are discussions of afterlife or how sickness and death are part of the religious cycle of the community. But equally as important is that we have lost any discussion of the social declaration of death such as how do families and communities note the transition of a member from life to death? The days of death rituals assumed a period between life and death, a process of dying. From the perspective of ordinary cases of end of life , the issues of futility, refusal and withdrawal of care is paramount, while the definition of death is a much rarer concern. Aristotle designates four souls: mineral, plant, animal, and human. Platonists added a fifth: the spiritual. The plant soul is digestion, animal soul is reactive, and human soul is rational or thought processes. Much of the halakhic death debate concerns over the vegetable and animal souls, little is said about the human soul, and much of the traditional process of death is now viewed as a legal moment.
The new approach of medical death in the ICU and the halakhah created for it makes all death a failure of medicine. It turns dying into a moment not a process. The way we deal with the denial of death is to control it through medical definition. Philip Aries showed that there were many stages of dying from becoming sick to maggots on a decaying body, even physical decay was not the end. Once there was the death of the human, the animal and vegetable aspects of human life took until the end of shiva to be completed. The assumption was that the body as organism felt the pain of the grave and the maggots. (For many others, the claim of the dying on his/her body continues until the resurrection of the dead. This position was still held by Rabbi Waldenberg but scoffed as superstition to those with medical models.)
The approach started by Rabbi Jakobovits was continued by almost all halakhic/Orthodox rabbis who deal with medical ethics. Their comments deal almost exclusively with problems of life, rather than with the subject of death. The sociologist Peter Berger notes that death is an essential feature of the human condition that requires people to develop means of coping with it, to neglect death in the ICU death is to ignore one of the few universal parameters in which social and individual life are constructed. The contemporary sociologist Anthony Giddens argues that in our era of `late’ modernity’, there are three changes: the experience of death has become increasingly privatized, there is an increased identification of the self with the body; and the shrinkage of the scope of the sacred. Is there a way to bring back the sacred in an age of hospital death?