End of Life Issues

By Rabbi Joshua Flug

For technical information regarding use of

.this document, press ctrl and click here
I. Introduction- This shiur outline will provide the sources relating to end of life issues. It
will include discussions about withholding treatment, time of death determination and
organ donation.
II. Withholding treatment
a. There are two factors that must be considered regarding any case of withholding
treatment:
i. The prohibition of lo sirtzach includes cases where death is caused indirectly.
Although there is no misas beis din for killing someone indirectly, Rambam
(1138-1204) states that you are chayav b'dinei shamayim. {}
ii. There is a mitzvah of lo sa'amod al dam rei'echa. {} If there is an obligation
to save someone's life, ostensibly, one cannot be passive in allowing someone
to die.
b. With this introduction, there is a comment of Rama (1520-1572) that seems very
puzzling. Rama states that it is prohibited to hasten the death of a goses and
therefore, one may not dig his grave (as this is thought to be a sakanah for the
patient), one may not remove the pillow from under his head (as it is thought that the
feathers in the pillow are keeping him alive), one may not place the keys of the
synagogue under his head. However, if there is a woodchopper chopping wood, one
may ask him to stop. One may also remove the salt from under his tongue because
the salt is only preventing his death and "hasaras hamonei'a" is permissible. {}
c. There are a number of questions one can ask on this ruling:
i. Why is it permissible to perform acts that are only considered "hasaras
hamonei'a?" Even if it is not considered retzicha, the obligation of lo sa'amod
al dam rei'echa should require one to do whatever possible to prolong the life
of the patient?
ii. What is the difference between removing salt from his tongue and removing
the pillow?
d. The approach of R. Moshe Feinstein (1895-1986):
i. The Gemara records the story of Rebbe's death. When he was very ill, the
rabbis were praying for his recovery. At that point, Rebbe's maidservant
noted that there was a conflict between the heavenly court who wanted Rebbe
and the students who wanted to keep Rebbe. She prayed that the students
should win the conflict. When she saw that he was suffering, she changed her
mind and prayed that Rebbe should die. She then distracted the students
which caused their prayers to stop. At that moment, Rebbe died. {}
ii. Ran cites this Gemara as proof that there are times when one can pray for
someone's death. {}
 1. The chiddush of Ran's statement is that he confirms that the actions of
Rebbe's maidservant were proper. One could have argued that what
she did was not correct and what the students did was correct.
iii. R. Moshe's analysis: {}
1. When someone is suffering and there is no known way of healing the
patient, only of prolonging his life temporarily, there is no obligation
to take measures to prolong his life.
2. Rama's leniency to remove the salt is specifically dealing with a case
of a patient who is suffering.
3. What emerges is that the obligation of lo sa'amod does not apply to
someone in a situation that is not curable and he is suffering.
iv. What's the difference between the feathers and the salt (R. Moshe doesn't
address the question, but this fits in with his approach).
1. R. Shabsai Kohen (Shach 1621-1662) answers that the problem with
the feathers is not the fact that you are removing the feathers. Rather,
the problem is that you would have to move his head in order to
remove the feathers. {}
2. Aruch HaShulchan- If not for the fact that removing the feathers
requires moving the goses, it would be a mitzvah to remove the
feathers in order to alleviate his suffering. However, you can't violate
the prohibition against moving a goses in order to alleviate suffering.
{}
e. The approach of R. Eliezer Waldenberg (Tzitz Eliezer 1915-2006): { & }
i. The case that Rama is dealing with is someone who has no "independent life
force."
ii. In such a situation, it is permissible to remove the external force that is
keeping him alive.
iii. However, even in that situation, you can't do something active to end the life
of the patient.
f. Until now, we have seen two basic approaches as to whether it is permissible to
withhold treatment in certain situations. There are a number of important discussions
in deciding how to apply some of the details:
i. What is the standard where one can decide to withhold treatment?
1. R. Moshe the patient must be suffering.
2. R. Shlomo Zalman Auerbach (1910-1995) mentions suffering, but
doesn't say that it's the only factor. He also adds that if the patient has
 cognition, it is preferable to try to convince him that he is better off
remaining alive and he should try to endure the pain. {}
3. R. Zalman Nechemiah Goldberg writes that any situation where "death
is better is life", one may withhold treatment. {}
ii. Whose decision is it?
1. When the patient is capable of making these types of decisions, it is
certainly his decision. Nevertheless, R. Hershel Schachter notes that
this decision must be considered a decision that other people would
make. If for example, a person has a tooth infection and would rather
die than have a root canal, we don't empower him with such a
decision. {}
2. When the patient cannot decide on his own, there are three approaches
regarding the decision process:
a. R. Eliyahu Bakshi-Doron (b. 1941)- The power of decision
goes to the person who is most involved with the care of the
patient. He has the chiyuv hatzalah and therefore, it is his
decision to decide anything related to his treatment. However,
his decisions must be for the interests of the patient and not his
own interests. {}
b. The editor of Minchas Shlomo quotes R. Shlomo Zalman as
saying that regarding making decisions whether to perform a
surgery, the consent of the patient is critical. If a timely
decision must be made, the relatives of the patient try to assess
what the patient would want. {}
i. The implication is that any decision that is not critical
to the survival of the patient requires absolute consent
of the patient.
c. R. Moshe Feinstein, in dealing with the decision of whether to
perform a certain procedure writes that the family can make the
decision. If the family is not available, a beis din can make the
decision. {}
iii. What can be withheld?
1. R. Shlomo Zalman: You can only withhold treatments that are causing
suffering to the patient and are not standard treatments. You can't
withhold treatments simply because they will prolong the life of the
patient. Therefore, food, oxygen and antibiotics must be provided to
the patient. {}
 2. R. Moshe Feinstein: Food and oxygen are natural needs of people and
animals and therefore you can't withhold food and oxygen even though
they don't come to patient naturally. {}
iv. What is considered active and what is considered passive?
1. R. Zalman Nechemiah Goldberg- If you take part in the process that
kills an individual that is considered active. If you remove something
that the patient can use to remain alive for longer, it considered
passive. Therefore, Rama allows removing the salt or the
woodchopper because those are just allowing the person to remain
alive for longer. According to R. Zalman Nechemiah, removing food,
oxygen or medicine from a patient is not considered g'ram retzicha if
the patient later dies from lacking these things. {}
2. R. Levi Yitzchak Halperin disagrees and maintains that Rama's case is
dealing where the patient has no independent means of life. Removing
the woodchopper or the salt is not comparable to removing food or
medicine. {}
3. It should be noted that although R.Shlomo Zalman and R. Moshe don't
allow withholding food and oxygen, it is not because they consider it
to be g'ram retzicha. Rather, they feel that the chiyuv hatzalah always
exists for these things.
4. Disconnecting a ventilator (this is not withholding oxygen; a ventilator
provides air directly to the lungs)
a. R. Moshe Feinstein- You cannot remove a ventilator, but when
it is time to service the ventilator, you can check whether the
patient is breathing. If there is no sign of independent
breathing, there is no obligation to replace the ventilator. {}
b. R. Shlomo Zalman, if the patient is on a ventilator and there is
no detectable sign of autonomous breathing, you can turn off
the ventilator to verify that this is true. {}
III. Determination of Time of Death and Organ Donation
a. Introduction- The question of organ donation is generally not a question of whether
organ donation per-se is permissible. Rather, the question is whether the current
techniques used to procure organs are halachically valid. Most of the questions center
around determination of time of death. If a patient is brain dead, you can physically
procure the organs. Therefore, if a brain dead patient is considered halachically dead,
it is permissible to procure the organs. If the patient is not halachically dead, removal
of his organs violates retzicha. Additionally, there are rare situations where you can
procure organs after cardiac arrest. If you consider the patient to be dead at that
point, it is halachically permissible to remove his organs. If not, it is considered
retzicha.
b. Is brain death considered halachic death?
i. There is a lot of literature on this topic. Most of it can be found at
http://www.hods.org/English/h-issues/articlesE.asp. R. Breitowitz's article
summarizes the issues well.
ii. In this piece, we are just going to present the major mareh mekomos on the
topic and how they are interpreted by both sides. The critical question is
whether one can consider a patient who cannot breathe on his own as dead
even though his heart is still beating.
iii. The Gemara, Yoma 85a {}
1. The Gemara discusses a case of someone who fell under a pile of
rubble on Shabbos. If there is any possibility of saving his life, we
would violate Shabbos to save him. However, if he is for sure dead,
there is no heter to dig him out of the rubble.
2. The Beraisa discusses what happens in a situation where you uncover
part of his body and he shows no sign of life. The Beraisa cites a
dispute how far one should dig until he can definitively say that the
person is dead. According to the first opinion you check until his
nostrils. According to the second opinion you check until his heart.
3. Rav Papa comments that the entire dispute is only relevant if they are
uncovering him feet first. If they are uncovering him head first and
discover that he is not breathing, he is to be considered dead and no
further action may be taken on Shabbos.
4. Does this prove that respiration is the ultimate determinant of whether
someone is considered alive or dead?
a. R. Moshe Sofer (1762-1839) questions whether the
establishment of breathing as the ultimate determinant of
whether someone is alive or dead is a function of the scientific
knowledge of the time or whether it is a tradition that we have
from Sinai. He seems to assume the latter approach. {}
b. R. Shlomo Mordechai Schwadron (Maharsham 1835-1911)
notes that lack of breathing is not a definition of death. Rather,
if there is no breathing, one can assume with near certainty that
the individual is dead. Therefore, you can no longer continue
to violate Shabbos in an attempt to save him. However, if one
observes other signs of life, he is certainly still alive. {}
c. R. Shlomo Zalman Auerbach: {}
i. Perhaps when Chazal had this discussion, someone who
was not breathing was considered dead. However, now
 that we have the means of resuscitating someone who
has stopped breathing, you can't consider someone who
is not breathing as dead.
ii. The fact that the Gemara cites a pasuk to prove that
breathing is the ultimate determinant of life does not
mean that you must consider someone dead when they
are not breathing. All it means is that when a person
ultimately dies, we attribute the death to the time when
stopped breathing. Yet, until all hope is lost, one may
not do anything to the body until he lacks any signs of
life.
iv. The Concern for Fainting
1. The Mishna states that certain people who were tamei before they die,
retain that tumah (in addition to being tamei meis, they have added
stringencies) until the flesh begins to rot. {} The Gemara explains that
they retain that tumah out of concern that they didn't really die and
rather they only fainted. {}
2. Does this prove that in general we must be concerned that we can't
really determine definitively when a person is really dead?
a. Chasam Sofer- When an ordinary person finds a dead body, we
should be concerned that he is not really dead and he only
fainted. However, someone with experience in these matters
(e.g. a physician or a member of the chevra kadisha) who
knows how to determine that a person is really not breathing
does not have to be concerned that the person only fainted. {}
b. R. Moshe Feinstein- There really is a concern that the person
may have only fainted:
i. Rambam writes that one should not close the eyes of a
dying individual at the moment of death. Rather he
should wait a small amount of time because he might
have just fainted. {}
ii. Shulchan Aruch writes that if a woman dies on the
birthing stool on Shabbos, you perform a caesarian
section immediately in order to save the life of the
baby. Rama writes that we don't do this anymore
because we are no longer experts in determining the
moment of death and we therefore have to wait a
significant amount of time before we can assume that
she is dead (cutting her before death is not allowed).
By then it is too late for the child. {}
iii. R. Moshe Feinstein explains that there are two ways to
determine that someone is really dead and they didn't
just faint: {}
1. You can observe the person without any
interruption for the amount of time a person can
live without breathing and if there is no
breathing that entire time, the person is certainly
dead.
2. You can check every few minutes for breathing.
If you do so, it is possible that the person caught
a few breaths in between and therefore you have
to wait a much longer time to assume that the
person is dead.
iv. Rambam, in recommending to wait a few minutes, is
referring to the first method of determining death has
occurred. Shulchan Aruch, who allows cutting the
mother open to save the baby, is relying on this method
of determination of death. However, Rama rules that
we are not experts in this method of death
determination and therefore, one must use the second
method to determine death.
v. What emerges from R. Moshe's analysis is that
breathing, while it is the determinant of death, is not a
definition of death, but rather a sign that the person is
dead.
vi. R. Moshe writes in a later teshuva that you can
establish death by removing a patient from a ventilator
and wait the amount of time that a person can live
without breathing. However, if the person was in a car
accident and testing his breathing might not be
sufficient, you should check if there is any brain
activity. {}
1. This comment can be understood in two ways:
a. As a matter of chumra you should also
check the brain activity.
b. You can rely on the brain activity alone.
c. This issue is discussed in the back and
forth in the Jewish Observer, 1991.
(available on HODS website)
 2. R. Shlomo Zalman- If you want to establish
someone as dead for the purpose of removing
his organs, you would have to remove him
completely from the ventilator and wait the
amount of time that a person can't live without
breathing. After that amount of time, you can
restart the ventilator and take the organs.
However, at this point, it is physically
impossible to do so. {} R. Shlomo Zalman
further notes that after R. Moshe established
heart transplantation as a "double murder" it is
not plausible that he would turn around and
accept brain death without mentioning that
based on this criteria you can remove the heart.
{}
v. Decapitation is a definition of death
1. The Mishna implies that if a person or an animal is decapitated, they
are considered dead even if there is still movement (pirkus), similar to
the movement of a lizard's tail after it is removed. {}
2. Can one equate brain death to decapitation and assume that the heart
beat and other bodily functions that continue are just considered
pirkus?
a. This is certainly one of the primary arguments of those who
assume that brain death is halachic death.
b. Gilyon on the Rosh- The rule about decapitation only applies to
animals and not to humans. {}
c. R. Ahron Soloveichik (RJJ article 1989)- Rambam is in Peirush
HaMishna implies that pirkus is only a localized movement. If
the movement is centralized, it is not considered pirkus and
death cannot be established. {}
d. R. J. David Bleich (Click here to access his article)- Brain stem
death is not equivalent to decapitation. Brain stem death does
not require destruction of the entire brain.
3. Rav Shlomo Zalman Auerbach and the Sheep Experiment
a. One of R. Shlomo Zalman's main hesitations in accepting brain
death as death was the fact that there have been numerous
cases of pregnant women who became brain dead and they
were kept on life support until the baby came to full term. He
took this as the ultimate indicator that the woman is still alive,
even though she was declared as brain dead. {} This is
 especially true in light of the Gemara that states that as a
general rule, if a pregnant woman dies, the fetus will die first
(with certain exceptions). {}
b. An experiment was conducted in which a pregnant sheep was
decapitated and placed on life support. The sheep was able to
keep the fetus alive for twenty-five minutes and then gave birth
to a healthy baby. A write-up of the experiment can found
here.
c. R. Shlomo Zalman was not convinced that this proves that
brain death is equivalent to decapitation: {&}
i. The Gemara was only dealing with a case where the
mother is not hooked up to a ventilator. If the mother is
on a ventilator, it is possible that the mother will die
first.
ii. Although you see that a halachically dead person can be
kept on life support and you can maintain his heart beat,
it does not prove that brain death is necessarily similar
to decapitation.
iii. Therefore, as long as the heart is beating, the only way
to definitively determine that the patient is dead is to
remove him from the ventilator long enough to know
that the brain is definitely dead. However, there are
two problems with this:
1. You can't perform any tests that involve
touching the body during this time because the
patient is considered a goses.
2. Practically, once you wait that long, the organ's
are not harvestable.
c. Non-heart beating organ donations (NHBD)
i. Introduction
1. There is another method of harvesting a heart and other organs and
that is to remove the organs immediately upon death. There are five
different ways in which this is accomplished: (This information is
available here)
a. Brought in dead
b. Unsuccessful resuscitation
c. Awaiting cardiac arrest
 d. Cardiac arrest after brain-stem death
e. Cardiac arrest in hospital inpatient facility
2. Categories 1,2 and 4 are considered uncontrolled in that there is no
way to prepare for such an event and therefore, there is great difficult
in assembling a transplant team and making the necessary preparations
quickly enough to harvest the organs. Categories 3 and 5 are
controlled.
3. In controlled NHBD, there is the possibility to perform cannulation
which is the insertion of a tube that pumps organ preserving fluids to
the organs to allow more time to harvest the organs.
4. One of the critical ethical questions is how long must one wait after
cardiac arrest in order to declare the patient dead?
a. Cardiac arrest (as opposed to a heart attack) is not naturally
reversible. If CPR is not performed, the patient will certainly
die. Therefore, one can argue that in a case where there is no
plan to perform CPR, the patient should be considered dead at
the onset of cardiac arrest.
b. One can argue that the death by definition is irreversible. If the
possibility of resuscitation exists, even if you don't plan on
performing CPR, you can't consider the patient dead.
ii. The Halachic discussions:
1. Cannulation- Would most likely violate the prohibition against
touching a goses. Furthermore, there are some who scientists who
believe that the fluids may actually hasten the death of the patient.
2. Awaiting cardiac arrest- How is this accomplished?
a. If it is accomplished by removing the patient from the
ventilator, you must apply the general discussion about
removal of a patient from a ventilator.
b. If it is a patient that is likely to experience cardiac arrest in the
near future and there is no need for any intervention in order
for that to happen, this aspect does not present any problems.
3. The main question regarding NHBD is: What is the status of someone
who has experienced cardiac arrest and there is no plan to resuscitate
him?
a. On the one hand, it is arguable that cardiac arrest is death and
because there is a DNR (do not resuscitate) order there is no
 practical way of bringing him back to life. Therefore, he is
dead from the moment he experiences cardiac arrest.
b. On the other hand, one can argue that death, by definition, must
be irreversible. Therefore, if the possibility exists to resuscitate
the patient, one cannot declare him dead until that possibility
no longer exists, even if he signed a DNR and there is no plan
to perform CPR.
c. In terms of p'sak, there is not much literature on this subject:
i. R. Shlomo Zalman, in addressing brain death, writes
that when there exists modern technology to bring
someone back to life, one must consider that in death
determination and he cannot be considered dead until
there is no possibility of resuscitating him. {}
ii. R. Baruch Y.Y. Rabinowitz (1913-1999, The
Munkatcher Rebbe following the Minchas Elazar) in
1971, presents the possibility of performing NHBD,
implying that this is not an issue. {}
 ‫‪ .5‬ר"ן נדרים מ‪.‬‬ ‫‪ .1‬רמב"ם הל' רוצח ב‪:‬א‪-‬ב‬

‫‪ .2‬ויקרא יט‪:‬טז‬

‫‪ .6‬אגרות משה חו"מ ב‪:‬עד‬ ‫‪ .3‬רמ"א יו"ד שלט‪:‬א‬

‫‪ .4‬כתובות קד‪.‬‬
‫‪ .9‬ציץ אליעזר רמת רחל ס' כח‬

‫‪ .7‬ש"ך יו"ד שלט‪:‬ז‬

‫‪ .8‬ערוך השלחן יו"ד שלט‪:‬ד‬

‫מאמרו של הגרז"נ גולדברג מוריה תשל"ח‬ ‫‪.12‬‬ ‫ציץ אליעזר יד‪:‬פ‬ ‫‪.10‬‬

‫בעקבי צאן ס' לד‬ ‫‪.13‬‬

‫מנחת שלמה קמא צא‪:‬כד‬ ‫‪.11‬‬

‫נשמת אברהם שלט‪:‬ד‬ ‫‪.17‬‬ ‫תשובות בנין אב א‪:‬נ‬ ‫‪.14‬‬

‫מנחת שלמה חלק ב' ס'פב הע' א‬ ‫‪.15‬‬

‫אגרות משה חו"מ ב‪:‬עד‬ ‫‪.16‬‬

‫אגרות משה יו"ד ג‪:‬קלב‬ ‫‪.21‬‬ ‫אגרות משה חו"מ ב‪:‬עד‬ ‫‪.18‬‬

‫מאמרו של הגרז"נ גולדברג מוריה תשל"ח‬ ‫‪.19‬‬

‫מנחת שלמה תנינא ס' פו‬ ‫‪.22‬‬

‫מאמרו של הגרל"י הלפרין הלכה ורפואה‬ ‫‪.20‬‬

‫חלק ב'‬
 ‫שו"ת מהרש"ם ו‪:‬קכד‬ ‫‪.25‬‬ ‫יומא פה‪.‬‬ ‫‪.23‬‬

‫שו"ת מנחת שלמה תנינא ס' פו‬ ‫‪.26‬‬

‫חתם סופר יו"ד ס' שלח‬ ‫‪.24‬‬

 ‫אגרות משה יו"ד ב‪:‬קעד‬ ‫‪.32‬‬

‫מש' נדה סט‪:‬‬ ‫‪.27‬‬

‫נדה סט‪:‬‬ ‫‪.28‬‬

‫שו"ת חתם סופר יו"ד ס' שלח‬ ‫‪.29‬‬

‫שו"ת אגרות משה יו"ד ג‪:‬קלב‬ ‫‪.33‬‬

‫‪ .30‬רמב"ם הל' אבל ד‪:‬ה‬

‫וכל המאמץ עיניו אם יציאת נפש הרי זה שופך דמים‬
‫אלא ישהא מעט שמא נתעלף‪.‬‬
‫שלחן ערוך או"ח של‪:‬ה‬ ‫‪.31‬‬
 ‫מנחת שלמה תנינא ס' פו‬ ‫‪.35‬‬

‫משנה אהלות א‪:‬ו‬ ‫‪.36‬‬

‫מנחת שלמה חלק ב' ס' פג‬ ‫‪.34‬‬

‫גליון על הרא"ש אהלות א‪:‬ו‬ ‫‪.37‬‬

‫פירוש הרמב"ם לאהלות א‪:‬ו‬ ‫‪.38‬‬

 ‫מנחת שלמה חלק ב' סימן פג‬ ‫‪.41‬‬ ‫מנחת שלמה חלק ב' סימן פג‬ ‫‪.39‬‬

‫מנחת שלמה תנינא ס' פו‬ ‫‪.42‬‬

‫ערכין ז‪.‬‬ ‫‪.40‬‬

‫‪ .43‬שלחן ערוך יו"ד שלט‪:‬א‬

‫הגוסס‪ ,‬הרי הוא כחי לכל דבריו‪ .‬אין קושרין לחייו‪,‬‬
‫ואין סכין אותו‪ ,‬ואין מדיחין אותו‪ ,‬ואין פוקקין את‬
‫נקביו‪ ,‬ואין שומטין הכר מתחתיו‪ ,‬ואין נותנין אותו על‬
‫גבי חול‪ ,‬ולא על גבי חרסית ולא על גבי אדמה‪ ,‬ואין‬
‫את המקבל לניתוח‪ ,‬וברגע המתאים לנתק את התורם‬
‫מן המכשיר‪ .‬בניתוק זה יהיה רק משום הסרת‬
‫"המונע"‪ ,‬באותו רגע תצא נפשו‪ ,‬יפסיק מלנשום‬
‫ודופקו יעמוד ואז ‪ -‬לפי הדין ולפי הקריטריון הקלסי ‪-‬‬
‫יהיה דינו כמת‪ .‬ברגע זה יתחילו בניתוח להוציא את‬
‫האיבר מגוף המת לשם שתילתו בגוף המקבל‪ .‬ברגע‬
‫קט כזה לא תיפגם חיוניותו של האיבר ואחרי‬
‫שיוציאוהו‪ ,‬אפשר להזינו מחדש בחימצון‪ ,‬כדי שיהא‬
‫ראוי לשתילה‪.‬‬
‫נותנין על כריסו לא קערה ולא מגריפה ולא צלוחית‬
‫של מים ולא גרגיר של מלח‪ ,‬ואין משמיעין עליו‬
‫עיירות‪ ,‬ואין שוכרין חלילין ומקוננות‪ ,‬ואין מעמצין‬
‫עיניו עד שתצא נפשו‪ .‬וכל המעמץ עם יציאת הנפש‪,‬‬
‫ה"ז שופך דמים‪.‬‬
‫מנחת שלמה תנינא ס' פו‬ ‫‪.44‬‬

‫‪ .45‬הרב ברוך י‪.‬י‪ .‬רבינוביץ אסיא תשל"א‬

‫אם ניישם הלכה זו בבעיית שתילת האיברים נמצא את‬
‫הפתרון‪ .‬השאלה הקשה ביותר היא התאמת הניתוחים‬
‫בין התורם ובין המקבל‪ .‬במצב טבעי אי אפשר לדעת‬
‫מראש מתי ובאיזה רגע יפסיק התורם לנשום‪ ,‬ואי‬
‫אפשר להכין אותו לניתוח‪ .‬גם את המקבל אי אפשר‬
‫להכין לניתוח מטעם זה‪ .‬אם יחכו עד שתצא נפשו יהיה‬
‫מאוחר להתחיל בניתוחים‪ ,‬כי תיפגם חיוניותו של‬
‫האיבר‪ .‬אבל אם התורם נמצא צמוד למכשיר המזרים‬
‫חמצן לתאיו באופן מלאכותי‪ ,‬כשמבחינה טבעית אינו‬
‫יכול יותר לנשום בלי עזרת המכשיר‪ ,‬גם הדופק אינו‬
‫טבעי יותר אלא פועל בעזרת משאבת הדם‪ ,‬יודעים אנו‬
‫לכוון מראש‪ ,‬שברגע שינתקו את הגוף מן המכשירים‬
‫תצא נפשו‪ .‬בשעה זו אפשר להכין גם את התורם וגם‬