1. Introduction

A patient who is sick with severe and painful disease or a condition for which the treatment causes intense pain will generally be treated with painkillers. Oftentimes, these medications cause tremendous fatigue, to the point where they sleep almost constantly, and even in the little time they are awake – they only minimally communicate with the environment. The question asked in situations such as these is whether there is room to lower the dosage of these medications with the assumption that the patient wishes “to experience” the world around them more and talk with their relatives, etc. This issue understandably arises in cases where it is unclear what the patient’s wishes are and at this time, he is not communicative; it is clear that if the patient says when fully conscious that they are interested in the prior dosage, this is the proper thing to do – for the doctors are first and foremost obligated to heal the patient according to his needs.

The issues dealt with in this position paper are very serious. Any small change in case details can change the conclusion, and therefore one should not decide the halacha directly from this paper. For practical advice, reach out to Tzohar’s call center at *9253.

2. The Ethical Dilemma

On the one hand, doctors are obligated to prevent or lessen the patient’s pain and therefore they should not lower the dosage of painkillers administered following prolonged treatment. Aside from the inherent value of preventing patient suffering and improving quality of life, it is reasonable that reducing the pain level helps the person deal with their condition and leads to prolongation of life and their recovery (even if painkillers at times cause weakening of body systems that can shorten a person’s life). On the other hand, perhaps the patient wishes to communicate with their children and relatives and therefore one should act in accordance with this desire (following the principle of patient autonomy). Additionally, we are dealing with a reversible process – even if it has a temporary price – for if the patient wishes, he may at any time return to the higher dose. The fundamental question, thus, becomes what is proper to do in cases of doubt: should the starting assumption be that the patient desires painkillers and one must prove that he wishes to decrease them, or is the starting assumption the opposite, i.e. that the patient does not want painkillers and to lose their alert state?

3. The Jewish Position

3.1 The Sanctity of Life

In Jewish law, the value of the sanctity of life holds a unique and significant position, and because of this there is a severe prohibition against performing actions that actively shorten a person’s life.¹

3.2 The Value of Alertness

As a general principle, Judaism prefers that a person live their life fully and takes advantage of each moment to do good² – with their actions, but also with their speech and thought. These matters are true even regarding suffering patients, and there are Rishonim who derive from this an obligation to save the life of a person even for an extra moment³, because granting them this moment may allow them to have stirrings of repentance or allow them to confess their sins.⁴ Aside from this, when dealing with pain that is not tremendous, one should assume that the patient themselves wishes for the fullness in life accompanied by a state of alertness where they can be active and communicate with their family members. The more complex question is: what should we do in a situation where the patient suffers extreme pain?

3.3 The Approach to Pain and Suffering

3.3.1 Introduction – The Weight of Suffering: Suffering understandably has very significant weight and there is an obligation to prevent it. It is considered a disease which doctors are commanded to heal⁵and is mentioned in halacha as a justification to abstain from fulfilling mitzvot or a reason to override specific prohibitions (in certain circumstances).⁶As will be explained shortly, suffering should be given significant weight in halachic dilemmas connected to suffering patients.

3.3.2 Painkillers for the Terminally Ill: The accepted position of many halachic authorities allows taking painkillers even when it is known that these medications shorten the life of a patient in the long term, on condition that it is not known that a single dose will harm the patient and on condition that administration of the medication is performed for the sake of alleviating the pain and not shortening the patient’s life.⁷

3.3.3 The Permit Not to Prolong a Suffering Patient’s Life: According to the majority of halachic authorities, when dealing with a patient who is suffering tremendously and is not interested in being treated, there is no obligation to treat them in a manner beyond providing nutrition, oxygen, and medications that prolong life.⁸There are authorities who write that a person who chooses to employ this form of treatment, prolonging their life despite the pain and purifying themselves through the suffering, is worthy of divine reward;⁹  according to them, there is a spiritual value to suffering that a person bears (similar to ‘taking advantage’ of time to do good) however even according to them this is not an obligation and the choice to bear it is the patient’s.

3.3.4 Hallucinogens for Suffering Patients: according to the majority of halachic authorities, it is permitted for a patient to take drugs in order to alleviate their suffering, even if there are halachic, moral, and legal prohibitions for a healthy person to do so.¹⁰

3.3.5 The Permit Not to Wake a Person in a Vegetative State from their Coma: there are authorities who permit abstaining from treatments that could wake a patient in a vegetative state from their coma if the matter will cause them great suffering.¹¹

4. Conclusions

4.1 If a patient expresses that they are interested in pain management, even if they will lose consciousness, one should perform this. It seems that even a reasonable indication that this is the patient’s intent is enough to permit this.

4.2 When there is no bearing either way, the starting point is that a person wishes to be awake and aware of their actions up to a certain degree of suffering.

4.3 Therefore, as long as we are dealing with pain that a person may assume the patient desires to bear and can still function, one should not give them painkillers which sedate them.

4.4 Only when dealing with severe pain at the level where a person feels that ‘better is their death than their life”, should one not lower the dosage.¹²

1. See a detailed discourse of this matter in our position paper ‘Treatment of a Patient in a Persistent Vegetative State (PVS)’, article 1.3.
2. See: Mishnah Avot 2:4; ibid. 16; Mishnah Sanhedrin 3:3. Many works of Mussar expand on this concept, see for example: Peleh Yoetz, entry ‘Halicha’; Shmirat HaLashon, 2:6.
3. Yoma 85a.
4. Beit HaBechira, ibid., ד”ה אמר המאירי
5. Tzitz Eliezer Responsa, volume 13, article 87.
6. An important source for this concept is the statement of the Gemara that if Chananya, Mishael, and Azaryah had been administered lashes, they would have bowed to the idol (Ketubot 33b). The Rishonim on site interpret that this was not a genuine idol, yet nevertheless even according to them the matter indicates the severity of suffering (see also Rabbi Amit Kola, ‘Proposed Legislation “Physician-Assisted Euthanasia” From a Halachic Perspective’, Tchumin, 37 (5777), pages 118-119). For halachic discussions regarding fulfilling mitzvot in a state of suffering see the overview brought in the Minchat Asher, Bereishit 39. For sources regarding the permit to violate biblical prohibitions due to suffering, see Shulchan Aruch, Yoreh Deah, 157:1; Shach, ibid., subarticle 3; Tzitz Eliezer Responsa, volume 19, article 16.
7. See Minchat Shlomo Responsa Tinyana, article 86; Tzitz Eliezer Responsa (earlier endnote 5); BeMar’eh HaBazak Responsa 6, article 78; Teshuvot VeHanhagot Responsa, volume 3, article 361. Compare this to the Igrot Moshe Responsa, Choshen Mishpat, volume 2, 73:1. One who analyzes the responsa of the halachic authorities can identify the different explanations behind this concept. See position paper, ‘Using Painkillers That May Shorten the Life of a Patient’ and endnote 9 there.
8. Minchat Shlomo Responsa, volume 1, 91:24; the ruling of Rabbi Shmuel Wosner, Rabbi Yosef Shalom Elyashiv, Rabbi Shlomo Zalman Auerbach, and Rabbi Nissim Karelitz (brought in The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill [1]’, pages 153-155); Igrot Moshe Responsa, Choshen Mishpat, volume 2, article 73 (subarticles 1-4) – perhaps according to his opinion there are situations where there is no need to provide nutrition or medication. For expanded discourse see what we have written in position paper ‘Treatment of a Patient in a Persistent Vegetative State (PVS)’.
9. See for example Minchat Shlomo Responsa (earlier previous endnote), based on Sotah 20a.
10. Rabbi Yosef Shalom Elyashiv, brought by Rabbi Yitzchok Zilberstein, ‘Drugs for a Dying Patient; Chemotherapy for a Pregnant Woman; Emancipating a Daughter from Her Mother’s Domain’, Techumin, 23 (5763), pages 213-216; Rabbi Avraham Resnikov, ‘Cannabis for Medical Purposes’, Techumin, 37 (5777), page 105-110.
11. Shevet HaLevi, volume 8, article 253.
12. See Igrot Moshe Responsa, Choshen Mishpat, volume 2, 73:1. Rav Feinstein writes there that it is prohibited to extend the life of a terminally ill patient who is suffering, however in later responsa (see ibid., article 74:1; article 75:1), Rav Feinstein places the matter in the hands of the patient. By combining the responsa it seems that one may assume that a standard patient is not interested in a life of tremendous suffering.