Alzheimers can shake Jewish principles, ethicist says

Even though Luxembourg's parents had promised the grandparents never to separate them, and though the Torah commands Jews to honor thy father and thy mother, the Luxembourgs put Grandpa in a home.

Luxembourg, a doctor at the Jewish Home for the Aged in San Francisco, shared his family's predicament with other doctors and medical students who attended the ninth annual International Conference on Jewish Medical Ethics last week in Burlingame. His story presents one of many ethical dilemmas that accompany Alzheimer's cases.

Luxembourg, a geriatric specialist, was no stranger to such dilemmas when his family predicament arose. He has grappled for years with the care of Alzheimer's patients at the Jewish Home. Most families learn about coping with the disease the harder way — one day at a time.

With diminishing mental capacity, patients can become disoriented, demanding, psychotic and even violent, severely stressing family and caregivers.

Unfortunately, there is little guidance in the Torah or Talmud specific to Alzheimer's disease. But Orthodox Rabbi Moshe Tendler, an expert in medical ethics and a professor at Yeshiva University in New York, gleaned a few principles from halachic teachings that he shared with the audience of some 200 doctors.

Tendler prefaced his Torah talk with common-sense advice. He urged individuals in the early stages of the disease to sign a power-of-attorney contract giving another family member the right to make future medical and legal decisions for them.

Alzheimer's also can have a deleterious effect on family, caregivers, particularly when the patient no longer recognizes them. For this reason, Tendler suggests writing a religious contract that would grant a future divorce at the point when three experts — usually doctors and rabbis — conclude that the patient is no longer competent. At that point, the marriage would be dissolved retroactively to the date the contract was written. An infidelity committed after the contract was written would not be considered adultery.

Such agreements were commonplace when men left their wives to fight in the army of King David, Tendler said.

When the patient — usually, a parent — needs extraordinary care, Tendler said the commandment "Honor thy father and thy mother " is the best advice.

In practice, this means that the adult children care for and house an ailing parent until the parent's condition deteriorates to the point that the son or daughter can no longer honor them in a dignified manner. At such a point, Tendler explained, it would be best to send the parent to a nursing home.

But "patients cannot be shunted off until [their condition] becomes literally unbearable."

Jewish law does not require a person to pay for his or her parents' convalescent needs. The Torah maintains that "payment for the father's care must come from his estate." That doesn't mean that one should not help financially with a relative's medical needs. But such cases constitute charity, which is another matter, Tendler said.

When it comes to difficult medical decisions, such as withholding therapy required to maintain longevity, the rabbi stressed that the primary consideration is sanctity of human life.

Doctors can prolong the mental functioning of an Alzheimer's patient with estrogen, but such treatment raises an ethical question even Tendler couldn't answer: "Do you stop estrogen at the [point where it no longer helps] and allow the natural process [of dying]?"

Halachah does not require prolonging a patient's life by unnatural means such as using life-support systems, he explained. At the same time, life should be preserved aggressively until the individual can no longer survive on his or her own.

If a patient loses interest in living, halachah is very clear that it is the family or doctor's responsibility to intervene, Tendler said.

"An Alzheimer's patient may have lost competence, but they have not lost humanhood."

Also speaking at the conference sponsored by Hebrew Academy of San Francisco was Vernon Neppe, director of the Pacific Neuropsychiatric Institute in Seattle. He presented findings that suggest Alzheimer's disease will become more common as human survival rates advance. Currently, one in nine people over the age of 65 has the disease. By 2030, that figure could be one in five.

The good news, he said, is that "the later one develops the disease, the milder will be the case."

Panel speaker Allen Roses, a genetics researcher who specializes in muscular dystrophy and Alzheimer's, suggested that researchers are fast approaching the ability to definitively predict a future Alzheimer's case as well as the age of onset.

The greater challenge, Roses said, will be to persuade a major drug company to sponsor research for a cure.

Lori Eppstein

Lori Eppstein is a former staff writer.