Rabbi Lord Immanuel Jakobovits (1921-1999) was largely responsible for founding Jewish Medical Ethics, now an established academic field. The phrase “Jewish Medical Ethics” first appeared as the title of Rabbi Lord Immanuel Jakobovits’ doctoral thesis submitted to London University in 1955. Jakobovits built medical ethics as a form of ethics, not as a legal concern, rather in the sense in which what it is understood in Roman Catholic moral philosophy. Jakobovits’ main focus was moral problems raised by medicine and medical practice as opposed to those raised by Jewish law. “Judaism considers that the great moral principles are profoundly enough rooted in the religious conscience of the nation to make it possible to tolerate exceptional cases… It acts thus in conformity with its general spirit which is to be strict in its principles, but human and clement in its application as it concerns the individual person. Or in sum, “it is the human factor of the ethical code which will complete the lacunae of the law.

An underreported side story was his connections to Christiaan Barnard, the South African surgeon who performed the first heart transplant in 1967. It seems that the Chief Rabbi and the surgeon exchanged formal letters on medical ethics and spoke both by phone and in person. These conversations seem to have created a common language even when the two differed. They appeared in public together and presented themselves as completely opposite opinions on when to allow passive euthanasia, the doctor would refuse the patient even basics such as food and the rabbi distinguished between basics and extra-ordinary procedures. But on many other issues they seem to frame their discussions in similar terms. Barnard wrote Good Life Good Death: A Doctor’s Case for Euthanasia and Suicide (Englewood Cliffs: Prentice-Hall, 1980). In the book and in several prior articles the doctor discussed his conversations with the Chief Rabbi.

Barnard writes that immediately after the first heart transplant on 26 December 1967, was performed in South Africa, he wrote to Rabbi Jakobovits asking for his opinion. The Rabbi’s reply, in part, was the following:

An organ may never be removed for transplantation from a donor until death has been eventually established. The prohibition of nivul hameth would then be suspended by overriding consideration of pikuach nephesh. Hence, I can see no objection in Jewish law to the heart operations recently carried out, provided the donors were definitely deceased at the time the organ was removed from them.

In his book, Barnard was a vigorous advocacy of passive euthanasia based not on vital signs, but on a quality of “being alive.”

And by living I do not mean simply exhibiting one or two vital signs, such as respiration or the registration of heartbeat. I mean rather the whole conglomeration of sensual experiences that the patient calls “being alive”—the experiences that by their very complexity and subtlety are not amendable to measurement or statistical analysis and are usually known only to the patient, his closest associates, and his doctor. Today’s sophisticated medical technology can lead to situations in which few of the rules apply. For example, it is possible to have a heart beating for many hours in a body that is dead, and conversely, a patient can be very much alive even though the heart’s beat has stopped for hours.

Barnard turned for religious guidance to determine life and death. He found that the modern issues was first broached “in 1957 when, at the international Congress of Anesthesiologists in Rome, Pope Pius XII was asked, “When does death occur?” Barnard was satisfied with the Pope’s reply that “human life continues for as long as its vital functions, distinguished from the simple life of the organs, manifest themselves spontaneously without the help of artificial processes.” What is important in this Papal definition is the insertion of the word “spontaneously” and without “artificial processes” to determine life. The Pope added that, “The task of determining the exact instant of death” was that of the physician.” This definition was given even before the widespread use of heart/lung machines or the ability to perform organ transplants. Barnard adopted this definition as his own:

A person will be considered medically and legally dead if, in the opinion of a physician based on ordinary standards of medical practice, there is an absence of spontaneous brain function; and if based on ordinary standards of medical practice, during reasonable attempts to either maintain or restore spontaneous circulatory or respiratory function in the absence of aforesaid brain function, it appears that further attempts at resuscitation or supportive maintenance will not succeed, death will have occurred at the time when these conditions coincide. Death is to be pronounced before artificial means of supporting respiratory and circulatory function are terminated and before any vital organ is removed for purpose of transplantation.

This definition of spontaneous breathing and irreversible condition will be adapted by Jakobovits and, through him, to later authors. In one of his earlier writings, Fred Rosner, writes of an oral communication he had with Jakobovits about irreversible conditions. “A similar conclusion is expressed by Rabbi Immanuel Jakobovits, who states, in part, that ‘the classic definition of death as given in the Talmud and Codes is acceptable today and correct. However, this would be set aside in cases where competent medical opinion deems any prospects of resuscitation, however remote, at all feasible.” (August 1968)

The phrase “spontaneous respiration” originated in 1880s and was used through World War I to refer to resuscitation of a person. It declined in usage between 1915-1969; it resurfaced in terminology during the 1970s and was more concerned with acute pulmonary failure. The adjectives such as “irreversible” and “spontaneous” became the assumed terms for respiration. It seems that it was Jakobovits was the first brought to bring it into Halakhic discourse. The Talmud, not accounting for ventilators or CPR, assumes solely that no breath equates to no life.

Barnard declares that, “most doctors know deep in their hearts that euthanasia is the right form of treatment for some terminally ill patients.” Barnard further muses that he“[W]ould have expected, for example, that those most opposed to it [passive euthanasia] would be Orthodox Jews.” However, he found out when he “conferred with Rabbi Immanuel Jakobovits” and “read his book on medical ethics” and concluded that “the Orthodox Jewish view accepts the legality of expediting the death of an incurably ill patient in acute agony by withholding such medicaments as would sustain his continued existence by ‘unnatural means.’” For Orthodoxy, “there is nothing opposed to passive euthanasia, merely agreement that no special treatment should be used to continue a life that is already at an end.” Barnard concludes that he is “struck by the fact… that euthanasia is more in keeping with religious teachings than it is with medical teaching.

Jakobovits recounts how on a visit to Cape Town, he had a fascinating discussion with Christiaan Bernard. The two were at loggerheads over the definition of death. Barnard was willing to condone almost any form of euthanasia. To which Jakobovits juxtaposes his own view:

The rule remains firmly fixed firmly to the extent that Jewish law cannot accept the concept of “clinical death”. So long as any spontaneous life action by the heart or lungs persists, even “irreversible brain damage” or a flat electro-encephalogram (EEG) reading does not legally establish death. Any action, even at that stage, which would precipitate the patient’s final demise is to be regarded as homicide and strictly condemned.

In principle Jakobovits accepts breathing and heart as the criteria for life, but he does not think that we should prolong artificially a life especially when there is great pain. For Jacobovits, goses means non-spontaneous and irrevocable so in such cases he allows passive euthanasia. In those cases, we let nature take its course.

So long as the heart still functions and the blood circulates, death has not yet set in. But this does not mean that a lingering life, especially when experiencing great pain, must be prolonged at all costs and in all circumstances. While one may not actively cause or hasten the onset of death, and no one may therefore never withhold normal and natural means to sustain life—such as food, drink, blood, or oxygen (or air)—one need not artificially prolong life…by administering antibiotics…to suppress infection. Thus, one may allow nature to take its course by withholding such treatment… There was, however, limitation of care to allow the heart to stop beating as soon as possible within the limits proposed by Jewish law. Invasive and non-invasive monitoring were stopped and antibiotic treatment was withdrawn. There was to be no resuscitation in the event of an arrhythmia, no endotracheal suction, and no renal support. Such patients must be treated as live persons, though one need not apply artificial methods in hopeless cases at the terminal stage. In such cases, it may indeed be wrong to prolong the suffering by artificially maintaining lingering life. If resuscitation fails, the patient is considered as retroactively dead from the time breathing ceased.

So is this like Christiaan Barnard? Where are the similarities and differences beyond the obvious? I am not asking the halakhic debates of 2012, or am I asking about those rabbis who differ with Jakobovits. I am asking how similar or different are these two 1960’s authors? Thoughts? I have more and longer passages of Barnard available if it will help you pin down comparisons and contrasts.