Euthanasia in Israel
“Stop the world I want to get off”
The question of euthanasia in Israel is complex and has multiple levels: medical, ethical, and moral. An additional element is Jewish religious practice which regards the sanctity of life as cardinal.
Advocates of euthanasia stress a person’s right over his own body, the right not to suffer and the right to choose between the option of terminating life or a life without dignity. Opponents stress the sanctity of life and the danger inherent in the decision to end it (“the slippery slope”).
The enormous progress in scientific and medical knowledge, as well as technology, has significantly extended average life expectancy. Today, progress in technology and medicine enables terminal patients to continue living beyond what was previously possible.
However, extending life does not always guarantee quality of life and, sometimes, the patient may suffer critical organ failure, physical pain, impaired cognitive function as well as severe physical and mental distress.
Euthanasia comprises four types:
Active - Administering of a drug by a third person with the intent of euthanizing
Passive - Withholding treatment/medication
Indirect - Administering a dosage of painkillers that could end life, with the intention of relieving suffering
Assisted suicide - Doctor’s assistance with termination of life at the request of the patient
Active euthanasia and assisted suicide are accepted in several western countries, with the issue still in debate elsewhere.
Countries permitting these two courses of action include Switzerland, Belgium, Holland, Canada, Spain, Luxembourg, New Zealand, and some states in the USA and Australia.
Switzerland is the only country that allows a non-citizen patient to terminate his life at the time of his choosing. The organization Dignitas, located in Zurich, recognizes the right of any person to decide on the time and manner to terminate his life. It is important to stress that anyone wishing to do so through Dignitas must be of sound mind since it is an assisted procedure in which the patient independently takes the drug prescribed by a Swiss doctor.
Legal status in Israel
In 2005 Israel passed the Terminally Ill Patient Act. This law regulates the medical care to be provided for a terminal patient and seeks an appropriate balance between the sanctity of life, the patient’s personal wishes, and quality of life.
The law is based on the values represented by the State of Israel, as a Jewish and democratic state, and the fundamental principles of morality, ethics, and religion. Furthermore, the law defines the underlying principle according to which the sole considerations in the case of a terminal patient are the medical condition, personal volition, and level of suffering.
The Terminally Ill Patient Act defines in what instances and under what conditions a person is permitted to make the decision on the medical treatment he finds acceptable, provided that the medical condition has been diagnosed as incurable and that life expectancy will not extend beyond six months even if treatment is provided (these are the parameters defining a “terminal patient”).
In 2016 the Knesset rejected an amendment to the law which proposed adding the clause “death by medical prescription.” The amendment (which was rejected), also proposed that a terminal patient who is a competent adult be permitted to request that a personal physician provide the prescription for a lethal dosage of an anesthetic drug to be taken unassisted.
What is illegal in Israel?
Euthanasia is illegal in Israel. The Terminally Ill Patient Act does not permit complete freedom of action, although the request of a terminal patient to withhold treatment is generally respected.
Active euthanasia is illegal: i.e. any action intended to cause the death of the patient, or which would probably result in the death of the patient, is illegal.
Assisted suicide is illegal.
Termination of ongoing treatment: It is against the law to terminate any medical treatment whose termination may cause the death of a patient. It is permissible to withhold renewing an ongoing treatment that was interrupted unintentionally and in a manner that is not against the law. It is permissible not to renew treatment administered by means of periodic medication.
Withholding nutrition: In the case of a terminal patient who is not competent, it is not permissible to withhold fluids or palliative and associated care, even if the patient has specifically requested to terminate the treatment. The patient may request to withhold any kind of artificial nutrition procedures.
What is permitted in Israel?
Passive euthanasia does not contravene the law. This means withholding, either by inaction or the termination of a periodic action, any initiative intended to extend life.
Ways in which the medical staff can assist (while continuing to provide palliative care and fluids):
Withholding periodic treatment, i.e. medical treatment that is administered periodically at regular intervals providing a clear distinction between the end of one cycle of treatment and the beginning of the next.
Reducing oxygen to 21%, which is equal to the proportion present in the air
Removal of a ventilation tube following a slight improvement in the patient’s breathing
Refraining from adjusting a ventilator in order to improve performance
Termination of drug treatment, such as antibiotics
Withholding the start of new treatments
Palliative sedation – a medical treatment allowing the attending staff to induce sleep to the point the patient is no longer suffering. Sometimes very deep sleep is required and at other times relatively shallow sleep is sufficient. It should be noted that this is to induce sleep and not to terminate life.
Options for prior legal planning
The Terminal Patient Act stipulates the instances and conditions that permit a patient to decide on a treatment, if at all, that he is willing to accept provided that he has been diagnosed as suffering from an incurable illness and that life expectancy is no more than six months, even with treatment.
In this case, there are two possible scenarios:
Scenario 1: Terminal patient of sound mind
The Terminally Ill Patient Act broadens the right to refuse or accept treatment by providing the opportunity to stipulate the decision prior to being diagnosed as a terminal patient.
If during the stage defined as ‘terminal’ several of the patient’s vital systems fail and even with medical treatment life expectancy does not exceed two weeks, any form of resuscitation, artificial respiration or artificial nutrition may be withheld.
Scenario 2: Terminal patient not of sound mind
The Terminally Ill Patient Act allows a person to prepare in advance for the possibility that he may not be of sound mind by submitting, in advance, a designated document issued by the Ministry of Health known as a Power of Attorney for Issuing Directives as to the Medical Care of a Terminally-Ill Patient.
This enables the patient to appoint a Trustee, in advance, who is authorized to decide on the medical treatment to be provided should he no longer be of sound mind when diagnosed as a terminal patient.
The law also allows a patient to submit a designated document issued by the Ministry of Health known as Advanced Directives as to Future Medical Care Of a Terminally-Ill Patient. In the document, the patient stipulates his wish, regarding a predefined list of future medical treatments, in the event he is declared a terminal patient not of sound mind, regarding withholding a medical treatment or receiving an unconventional treatment to prolong life. The patient stipulates prior instructions regarding which of the treatments listed in the document are to be withheld. For example, the patient can give a prior instruction to terminate a periodic treatment such as dialysis, chemotherapy, radiation, etc. if the treatments are intended for an incurable illness. The medical staff will carry out the prior instructions only when the patient is no longer able to say what he wants (e.g. impaired ability to communicate with his surroundings) or if he is no longer competent to make decisions (not of sound mind).
The Ministry of Health maintains a database storing advanced directives and powers of attorney issued under the terms of the Terminally Ill Patient Act. The documents can be accessed by the medical staff when the need arises to clarify the wishes of the patient. Furthermore, regardless of any documentation signed under the terms of the Terminally Ill Patient Act, it is also advisable to prepare a Durable/Enduring Power of Attorney. This is a legal document enabling a person to plan ahead for the possibility of no longer being competent to make decisions independently (not of sound mind), by giving power of attorney to one or more trustee's, to handle both medical and property issues.
It is important to emphasize that the Ministry of Health documents for a terminal patient address solely the issue of a person who has been diagnosed as a terminal patient (i.e. life expectancy does not exceed six months). Therefore, in addition to those documents, it is of great importance to plan ahead by preparing a Durable/Enduring Power of Attorney which grants power of attorney to someone who will make medical decisions in cases that do not fall within the domain of the Terminally Ill Patient Act.