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What happens when your deepest religious convictions collide with a patient suffering from metastatic cancer and no miracle in sight? Medical student Jonah Rocheeld shares the raw tension between his Orthodox Jewish upbringing and the medical ethics he is learning in clinical training, based on his KevinMD article, “End-of-life care and religion: Reconciling Jewish law and medicine.” He unpacks the distinction Jewish law draws between withholding and withdrawing care, why that boundary feels certain in a classroom but fractures at the bedside, and how a heated debate with a fellow Jewish medical student forced him to confront where faith ends and patient suffering begins. You will hear why he believes any mature faith must evolve from rules-based absolutism toward nuanced moral reasoning, and what advice he offers religious medical students struggling to separate personal identity from clinical duty in end-of-life care. If you have ever wrestled with where your own ethics stop and your obligations as a health care professional start, this conversation will stay with you.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Jonah Rocheeld. He is a medical student. Today’s KevinMD article is “End-of-life care and religion: Reconciling Jewish law and medicine.” Jonah, welcome to the show.

Jonah Rocheeld: Thank you so much for having me, Dr. Pho. It is an honor to be here.

Kevin Pho: All right, so tell us what led you to share this article on KevinMD and then talk about the article itself for those that didn’t get a chance to read it.

Jonah Rocheeld: What led to the article is that it was the product of a Jewish upbringing and the tension that it created with medical school and medical ethics, which I have been experiencing more and more obviously as I continue medical school. So I grew up as a Jewish Orthodox person, and in that context, you end up with a lot of discussions about ethics and end-of-life care specifically. There are a lot of very strong opinions out there. Obviously, I grew up going to a Jewish school, so that was a big part of my life and that was kind of all I knew.

At the same time, I grew up always wanting to be a doctor. I think a lot of people experience this before they come to medical school: Your perspective and perception of what medical school is like, what clinical experience is like, and how patients actually are in real life is wildly different. The more time I spent having ethical discussions or in-person experiences with patients, the more I felt this tension. My Jewish upbringing and teachings were teaching me one thing, and what I was learning in medical school was wildly and vastly different. The way people’s lives are is just not that simple compared to the way I grew up learning.

How that came into the article is that one of the Jewish perspectives out there on end-of-life care is that they draw a distinction between withdrawing and withholding care. Withholding care is more legally accepted within the Jewish faith and Jewish law, but withdrawing care from somebody that is, say, on a ventilator, for example, is considered almost universally forbidden, accepting specific edge cases like brain death. So that became a sticking point with me. Throughout my M2 year, we were having these end-of-life discussions, talking about whether it is ever justified to withdraw care from somebody.

Synthesizing those experiences and working in the hospital more through shadowing, my gap year, and just being in school created this tension that led to what I was talking about in the article. In summary, it felt like Jewish law was prioritizing justice. This is the law, and this is what we have to do. It doesn’t matter if there is necessarily a real human cost because the tradition is what matters above everything. Then in medicine, what we are learning in school is that humanism is the number one thing. We have to value autonomy, beneficence, and justice, and that is really all there is to it. If a person wants to withdraw care, we have to have an open conversation and leave all the options on the table.

Kevin Pho: When confronted with these tensions, and you mentioned in the article that you have these discussions in small group settings, how do you, as a future Jewish physician, reconcile these tensions? Tell us about some of the emotions and thoughts that were going through your mind as you were discussing these cases.

Jonah Rocheeld: Absolutely. I mean, I think it is very difficult and it was especially powerful in the moment that inspired this article. I was actually having a very heated discussion with another Jewish student, and they were vigorously defending their ideas based on the Jewish faith, saying you are absolutely not supposed to withdraw care under any circumstances. I was sitting there wondering how you square that with the reality of somebody, like the composite I mentioned in the article, who has metastatic cancer. There are no miracles. We want to believe miracles happen, but miracles usually don’t happen, which is why they are miracles. Are we really, as doctors, supposed to just say: “I’m sorry, you just have to live in pain until time takes its course and until God’s will decides that your life is over?”

It was a very difficult tension, and even now, as a religious Jewish person, it is a tension that I feel. There are a lot of emotions there. There are feelings of betrayal of the faith because this is what I grew up with and this is what I know. At the same time, ultimately, I think everybody has to choose where they draw a line for themselves. They have to choose what is appropriate for them as a physician. How do you feel comfortable moving forward, and you have to live your own life. I think this is a tension that a lot of people experience where their ethics clash with their work as a physician. I think we all have to find a place within ourselves to separate our own personal experiences from what is actually best for the patient. I think that is really one of the core tensions of being a physician.

Kevin Pho: Tell us about the outcome of that heated discussion you had with your fellow Jewish medical student. What happened at the end? Did any perspectives or minds get changed after the discussion? What was the outcome?

Jonah Rocheeld: As I recall, it was a little bit difficult to make a lot of progress in terms of the conversation. I think in those kinds of conversations, especially when people’s identities are involved, it is less about the ideas that are being discussed and more about people’s identities. People experience their religion not necessarily just as a system of ideas they believe in, but really as their identity. I was thinking myself that this is a huge betrayal for me because Judaism is such a huge part of who I am.

In those moments, I think it was important for me to focus on instances where I expressed the reality of a situation, like the case of somebody with metastatic cancer. In those moments, the person I was discussing it with would just go silent because I think we all feel this tension. We are all moved to come to medical school because we feel extremely deep passion for other human beings and we want what is best for them. When we are faced one-to-one with the reality of what happened, something I personally experienced and very often something other people have experienced in their own clinical work, they feel it more deeply than discussing these ideas in the abstract.

I want to say more broadly that I think when Jewish people or religious people express these tensions and say we should never withdraw care, they are not thinking of a specific person they know who had terrible pain at the end of life. They are thinking more broadly and abstractly. But once you are on the wards in the hospital room speaking with the family, people are crying, the patient is moaning, and maybe the painkiller is not working, the reality just completely shifts your perspective.

Kevin Pho: Have you talked to other Jewish physicians or some of your faith mentors about this and how they tackle this tension? What are some other perspectives that you have heard on how your fellow peers have addressed this tension?

Jonah Rocheeld: Yes, it is very difficult because ultimately the Jewish loyalty has to be to the faith. That is kind of what has kept it standing, at least within the modern Orthodox strain or the more far-right strains that are very loyal to the tradition. Strains that are more left-leaning, like the Conservative or Reform movements, have a little bit more leeway there. But speaking strictly in terms of Orthodox Jewish people, I would add as a qualification that there is a lot of room for compassion. There is a lot of effort from Jewish scholars to act as compassionately as possible in very extreme situations.

For example, there is a Jewish law regarding an “agunah,” which in Hebrew means somebody who is chained. This refers to women whose husbands die under mysterious circumstances where there are no witnesses and no clear evidence of death, and they are unable to remarry out of concern that maybe their husband is still alive somewhere. You could see how this would be extremely relevant in war situations where a soldier goes out, crazy things happen in the field, a grenade blows up, and people disappear for a long period of time with no one knowing what happened to them.

Scholars like Rabbi Ovadia Yosef or Rabbi Moshe Feinstein have worked tirelessly within the faith to find ways for these women to marry and find leniencies. But at the same time, you end up with this ultimate issue that the faith and the tradition are what is ultimate and what supersedes everything. That creates these issues day-to-day. So in my conversations with these people, there is a lot of emphasis on being compassionate and wanting to do what is best for people, but ultimately our loyalty is to the faith, and we have to do the best we can within those confines.

Kevin Pho: What about talking to mentors not of the Jewish faith? What are some of their perspectives, and have they offered any insight on some of the tensions that we are talking about today?

Jonah Rocheeld: Leaning outside of the Jewish faith, the people I have spoken to about this try to be as understanding as possible, but the general impression is more in line with typical clinical reasoning. The most common situation discussed is not wanting to provide an abortion if you are a religious physician, as a lot of physicians have a problem with that. You just have to follow hospital guidelines. That is where everybody kind of settles down. It is not ideal, but a secular person would recommend that you move your personal feelings back and do what needs to be done.

If you really feel uncomfortable with this, they usually recommend just passing it on to another physician. Do I personally feel that that is ideal? If you are somebody who has been coordinating a patient’s care for months on end, and then they are reaching the end of life and you say: “I’m sorry, I can’t handle end-of-life care, I need to refer you to somebody else,” I would say that is highly not ideal. Therefore, I try to draw a line between your personal identity and your physician personality, but we all have to draw a line somewhere.

Kevin Pho: Have you thought about the situation, and I am going to put you on the spot here, because as a future physician, you are going to be talking about very difficult end-of-life situations? If the family wants to pursue a course that is in conflict with your Orthodox Jewish values, have you thought about how you are going to approach that particular situation and scenario when it does come up?

Jonah Rocheeld: Absolutely. I would say that it is something I wrestle with a lot, and it is something I have been working on a lot. I have been doing a lot of reading on secular and Jewish ethics to navigate these tensions because I feel the weight of my role as a physician incredibly strongly. That was really part of what motivated this article. I wanted to reach other people who feel these tensions just as much as I do. I have a lot of older friends who are in residency, who are physicians now, or who are in medical school, and they experience these things day-to-day. I get a lot of positive feedback from them when we have these conversations because it can be very relaxing for them to have somebody who feels these same tensions.

For myself personally, the way I think about it is that the tradition is divine in origin, but ultimately it is filtered through thousands of human beings and scholars over time. What that means is that we don’t necessarily need to treat every single precept or idea or tenet of the faith as absolute across all time and all situations. I think a good comparison is looking at the preclinical years of medical education versus the clinical years. We learn from the textbooks how diseases present, how to handle patients, and what tests to order. Then when you are in the hospital, people are much more complicated than that. Your patients don’t give you a history like a standardized patient would. They give it like a human being would, which is kind of all over the place; they repeat themselves, and they are really nervous and understandably scared about what is going on and what is going to happen to them. Diseases are complicated, and people don’t always present like they do in a textbook. You have to cultivate your own personal judgment. I think any mature faith, as you become an adult, has to transition from rules-based absolutism to morally complex, nuanced, situation-evaluation relativism.

Kevin Pho: Can you share any pieces of advice to early physicians, your fellow medical students, interns, and residents? Because there are many faiths that are going to have ethics in conflict with more secular values. Tell us the type of advice that you could share with other students who may be going through a similar tension to what you are going through, from what you have learned over the last few years.

Jonah Rocheeld: In terms of advice, I would recommend first finding the edges of your own faith. What are the boundaries of your faith? What are the things you could never be comfortable with, and what are things that you feel you could potentially compromise on? Identify what is not necessarily a strict aspect of the faith that is entirely uncompromisable. If that line for you is, say, abortion, and that is your line, then refer to another physician. Or if that line is withdrawing end-of-life care, then that is your line within those confines.

I would add that it is important to be open to having conversations with people and to be open to new experiences. I think even people who have very strongly held beliefs that are part of their identity can be swayed by the reality of life and people’s family situations because that can be incredibly moving. If you asked me five years ago if I would ever compromise on withdrawing end-of-life care, I would say absolutely not in a million years; that is forbidden and against Jewish law. Now, as an adult and a third-year medical student, it is unquestionable that I have to have a conversation. I am fully open to having a conversation. I think it is incredibly important that we consider all options and do what is best for the patient. That is directly the product of experiencing it firsthand. So I would say really just remain open-minded. Have faith in the medical system the same way we have faith in our religion. We have to have faith in the decisions of our forebearers and that the principles we live by as physicians are not just arbitrary; they are core principles that thousands of physicians have practiced. We are really all trying to do our best and square our humanity with reality.

Kevin Pho: We are talking to Jonah Rocheeld, medical student. Today’s KevinMD article is “End-of-life care and religion: Reconciling Jewish law and medicine.” Jonah, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Jonah Rocheeld: I would just say as a take-home message that it is really important to stay open-minded. Have your faith, believe in your ethics, and have your own personality because that is what makes every physician special. Bring something to the profession that makes it special, but don’t let that come at the cost of patient suffering or patient lives. Always try to compromise to do what is best for the patient at all costs within those confines, because at the end of the day, that is what we are supposed to do as physicians. That is our job.

Kevin Pho: Jonah, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Jonah Rocheeld: Thank you so much for having me.