Leib Goldstein is a 65 year old widowed man with Alzheimer’s type dementia that first manifested ten
years ago. Now in the later stages of the disease, he cannot interact meaningfully with his environment,
and his doctors say there is no hope of improvement.
Leib’s only child Shayna is 30 and has been his primary caregiver throughout his illness. This is a fulltime
commitment and, as his condition worsened, has prevented her from developing her career as a
journalist. Leib suggested early on that she put him in a nursing home, but she refused. On the other
hand, Leib was never willing to discuss how she should handle medical issues once he was fully
incompetent, saying that he trusted her judgement.
Six days ago, Leib suffered a heart attack. As a result of the heart attack and resulting heart failure, he
cannot breathe sufficiently on his own and is on a respirator. Leib’s cardiologist also inserted an intra-
aortic balloon pump (IABP) into his groin to assist his heart; absent that assistance, he would die of
organ failure, as his weakened heart would be unable to send enough oxygen to his organs.
Leib has not been stable enough to proceed to surgery until today. As Shayna is legally authorized to
make Leib’s medical decisions, the doctors now present her with the following options:
a) They can try a bypass operation, which will let blood flow around the obstruction that caused the
heart attack, but the surgery is very high risk. The surgeons estimate that there is a 25-30% chance of
Leib dying on the operating table as a result of the operation (overall 1-5% of patients die during bypass
operations). If he survives, they estimate that the operation gives him a 60-70% chance of living out his
normal lifespan. This is the only option that gives Leib a realistic chance of living for several years, and
of leaving the hospital.
b) They can leave Leib as is. Most likely the IABP will fail soon, as it is almost never used for even as long
as a week. Leaving the IABP in place increases other potentially fatal risks, such as gastrointestinal
bleeding, intracranial hemorrhage, and blood borne infection. The doctors can’t specify how long the
pump is likely to last (or whether it can be successfully replaced when it fails), or provide useful odds
regarding the complications. This option would also require Leib to be sedated at all times and never be
awake again.
c) They can remove the IABP and medically manage Leib’s heart disease with medication. However, the
medicines will not prevent his heart from further deteriorating, and it is more than 50% likely that Leib
will die within 30 days. He will almost certainly not live more than a few months. This option would
allow Leib to be awake, although he would not leave the hospital.
Shayna has come before the Beit Din for guidance. The questions the Beit Din must answer are:
1. According to Jewish law, which of these three options is she allowed to approve?
2. According to Jewish law, is there one that she must approve?
3. Shayna is aware that if multiple options are permissible, the decision must ultimately be
hers. However, because she is worried that her own interests and preferences are involved
here, she asks the Beit Din for the clearest guidance it can give as to how she should choose
among permitted options. What guidance would you give to Shayna?
Case developed by Rabbi Aryeh Klapper
