1. The human body needs fluids to survive, and discontinuing provision of fluids is therefore prohibited. However, there is room to consider reducing the amount of fluids that a patient receives and providing the patient with minimal amounts¹.

2. Food is a basic human need and therefore the patient must continue to be fed naturally or artificially, unless there is clear medical indication that artificial feeding increases risks, complications, or significant suffering².

3. In some exceptional and unusual cases, artificial feeding is withheld and a discontinued IV is not restarted. In practice, beyond for medical clarification purposes, one should also consult with a rabbi, as noted throughout this pamphlet³.

4. In the case of a conscious, lucid patient who refuses to eat or requests not to be fed in some other manner, he should be gently spoken with and the importance of eating should be explained, and he should be persuaded to eat, or receive nutrition through artificial means. If he cannot be persuaded, he should not be force-fed⁴.

5. With regard to a patient who is not conscious or who is not lucid, but who had expressed in advance his unwillingness to be fed, his basic status is the same as a patient who is currently able to expresses himself. It is possible, however, that when he expressed those desires, he was unaware of the distress and torment that would come with hunger. As such, when there is concern that he is suffering from hunger and the instructions he gave can be interpreted in various ways, he should continue to be fed⁵.

6. When a patient, who is not conscious or who is not lucid and we have no way to know his preferences requires a nasogastric tube to be inserted, if this involves inserting a tube for a short period, with the assumption that the patient will subsequently be able to manage without the tube, it is obligatory to do so. However, if this will entail long-term use of a nasogastric tube, because the patient will not be able to subsequently survive without the tube and it will eventually cause him to suffer, there is no obligation to proceed. Such a case requires analysis based on many factors (such as the life-threatening danger of the patient removing the nasogastric tube), and the medical team and a rabbi should be consulted in each specific case⁶.

7. When we do not know the patient’s wishes, and the doctors’ assume that there is no chance of saving him and it can be presumed that he will not suffer from the withholding nutrition (a patient in such a state can survive for a long time without sustenance), it is even permitted to stop feeding him⁷. This is certainly the case when continued feeding increases the risk of infection and brings the patient closer to death. In these situations, the use of “mercy feeding” should be considered, i.e. feeding that focuses more on the patient’s quality of life as opposed to supplying him with his caloric intake.

8. That said, even when it is permitted to stop feeding a patient, it is better to resort to feeding him through less painful methods. If this is not possible, liquid solutions containing salts and glucose can be used for subcutaneous or intravenous administrations⁸.

1. For the halakhic view on artificial administration of food and fluids, see the next footnote.

   In standard medical practice, artificial nutrition is administered via a nasogastric tube, percutaneous endoscopic gastrostomy (PEG), or intravenous feeding. A nasogastric tube is a plastic tube that is inserted through the nostril into the gastrointestinal tract. This method of artificial feeding is used primarily for patients with temporary swallowing disorders, or as a preparatory step before the introduction of a PEG tube, although at times it is used as a regular means of feeding. Inserting the tube can be painful, and the subsequent presence of the tube often causes a great deal of discomfort. Percutaneous endoscopic gastrostomy (PEG) consists of a tube that is attached on one end to the inside of the stomach, with the other end protruding beyond the abdominal wall. A PEG tube is used for patients who suffer from swallowing disorders or who are unable to intake sufficient amounts of food orally. In intravenous feeding (TPN – Total Parenteral Nutrition) liquid food is delivered directly into a vein through a central venous catheter that is usually inserted into the arm, and reaches the large blood vessels at the entrance to the heart. This method is usually used only temporarily and carries the risk of infection which increases over time. In addition, intravenous nutrition has not been shown to be effective in prolonging life, improving nutrition, or closing pressure ulcers, as well as other medical parameters in patients with advanced cancer or patients with advanced dementia. For these reasons, this method is almost never used to treat terminally ill patients. Each method has its own disadvantages, complications, and risks and is ineffective for some patients. For further discussion, see: “Alternative Feeding (Nasogastric Tube) for the Elderly” (https://bit.ly/39GnuG4); Ofra Galon and Sharon Bessen, “Artificial Feeding at the End of Life” Refua UMishpat 31 (2004), pp. 41–6. One ethical issue that relates to the problem of feeding a patient who refuses to eat is the question of feeding someone on a hunger strike. See our comments in the position paper, “Artificial Feeding of a Terminally Ill Patient,” footnote 3 (https://bit.ly/3raU1Mt).

2. The halakhic status of fluid administration and artificial feeding differs from that of other medical interventions. Eating and drinking are not medical interventions but basic to sustaining life and part of one’s natural existence. For this reason, though medical treatment can be suspended under certain conditions, withholding nourishment under similar conditions is considered starvation and may be tantamount to taking a life (see Rambam Mishne Torah, Hilkhot Rotzeaḥ UShemirat Nefesh 3:10). Furthermore, the Sages have stated that dying through hunger is the worst death of all (Bava Batra 8b). At the same time, patients suffering from certain terminal medical conditions can survive for a long time without nutrition, and thus withholding feeding would not be considered starvation, whereas a lengthy period of artificial feeding can cause infection and other complications. Consequently, when doctors maintain that continued feeding will harm the patient, it should be avoided. See Iggerot Moshe, Ḥoshen Mishpat, II:74; Minḥat Shlomo,I:91, 24; Encyclopedia of Medicine and Halakha, vol. 5, “A Terminally Ill Patient (1),” pp. 146–48.
3. See Yaakov Levi, “Something Preventing a Person from Dying,” Noam 16 (1973), pp. 58–9. In his view, whereas the cessation of feeding is an indirect act of murder, refraining from feeding a patient who will not survive is not, and when there is no chance of saving a person, there is no obligation to save him either. Compare this opinion with the comments of Rabbi Yitzḥak Frankel (“The Sanctity of Man and Saving his Life Versus Death and Cessation,” Sefer Assia 3 (1982), pp. 463–66), who maintains that refraining from restarting feeding is also a violation of the prohibition of “You shall not stand idly by the blood of your neighbor” (Leviticus 19:16). For a discussion of the difference between the prohibition of “You shall not murder” (Exodus 20:13) and the prohibition of “You shall not stand idly by the blood of your neighbor,” see BeOhala Shel Torah, I:56, 4.
4. When there is a medical benefit to eating and yet the patient requests not to be fed, a way must be found to convince him of the necessity of eating. If he remains unwilling, Rabbi Feinstein (Iggerot Moshe, Ḥoshen Mishpat, II:74) maintains that he cannot be compelled to accept food. However, Rabbi S. Z. Auerbach (Minḥat Shlomo,I:91, 24) rules that the patient must be fed, even against his wishes, and this is also the opinion of Rabbi Shlomo Goren, Torat HaRefua, Jerusalem 2011, p. 55. The halakhic ruling of Rabbi Y. S. Elyashiv, Rabbi S. Z. Auerbach, Rabbi Shmuel Wosner, and Rabbi S.Y.N. Karelitz (Yated Ne’eman, 23.11.1994, p. 1 (Encyclopedia of Medicine and Halakha, vol. 5, “A Terminally Ill Patient (a),” pp. 153–55) is consistent with this policy. However, this position should be compared with the opinions of Rabbi S. Z. Auerbach and Rabbi Shmuel Wosner in footnote 78; see also Encyclopedia of Medicine and Halakha, ibid., pp. 146–48. Our inclination to follow the ruling that one should not be fed against his wishes also stems from the fact that forced feeding can harm the patient, and he may even hurt himself in his struggle to avoid this.
5. The ethical dilemma in this case is more complex, because on the one hand it is possible that the person who asked in advance not to be fed failed to grasp how excruciatingly painful starvation can be, and if he had understood the full implications of not receiving food, he may never have asked not to be fed. On the other hand, various studies performed on cancer patients indicate that terminally ill patients do not suffer when experiencing starvation. Consequently, as long as there is uncertainty about the patient’s wishes, and these can be interpreted in different ways, he should continue to be fed him, unless the medical position is that there is no need for feeding or that feeding is endangering his life or causing him to suffer.
6. See the previous footnote, as well as footnote 56.
7. See Encyclopedia of Medicine and Halakha, vol. 5, “A Terminally Ill Patient (a),” pp. 147, and footnote 251, the opinion attributed to Rabbi S. Z. Auerbach and Rabbi Shmuel Wosner.
8. See ibid.