A patient suffering from severe pain is typically treated with medications such as morphine, which relieves pain, sedates the patient, and blurs his senses. Generally, relieving a patient’s suffering will improve his overall condition and prolong his life, and accordingly the prevailing medical position is that the use of painkillers extends the life of the patient. However, on rare occasions there is a concern that painkillers may impair the patient’s health (for example, by compromising his breathing), prompting the question of whether the patient’s suffering should be treated, even at the potential cost of shortening his life, or whether his life should not be endangered despite his suffering.

Another issue to be addressed when the patient’s wishes are unknown is the extent to which we may impair his alertness in order to reduce his suffering. Painkillers often make the patient so drowsy that he sleeps almost all the time, and even in those short periods when he is awake, he has limited communication. Is it permitted, in such situations, to reduce the dose of medication on the assumption that the patient would like to “experience” more of the world around him and talk to his relatives, or alternatively, to enable him to perform mitzvot, since “A single moment in this world in repentance and good deeds is greater than all of the life of the World-to-Come” (Avot 4:17)?

1. In the case of a patient who is in terrible pain, it is permitted to administer painkillers even if there is concern that this will shorten his life, provided that the medicine is given with the intention of relieving his pain, as opposed to shortening his life, and the patient will not be immediately harmed¹.

2. When the patient is conscious, the decision to cling to life despite the suffering, or treat his pain despite the potential life-threatening danger, is his alone².

3. If the patient is unable to express his opinion but has previously stated that he would prefer to be treated for pain, even at the expense of his alertness, he should be given painkillers (see chapter V, subsections 7–10).

4. When a patient’s wishes cannot be determined, the assumption is that a person would accept a certain level of suffering in order to be alert and aware of his surroundings. Therefore, provided the pain in question is a level that a person could likely bear and still be able to function, he should not be given painkillers that would render him unconscious³.

5. It is only when the patient is suffering intense pain, and he feels that “death is better than life” that the dose may be increased and the patient may even be anesthetized⁴.

1. The accepted halakhic position is that a terminally ill patient may use painkillers even when there is a concern that they will shorten his life, on the condition that the medicine is given with the intention of relieving his pain, as opposed to shortening his life, and that it is not known that the medicine will pose an immediate risk to him, or that a single dose will endanger his life. See Minḥat Shlomo, II, (2–3), 86:2 (Rabbi S. Z. Auerbach’s opinion is also cited in Nishmat Avraham, Yoreh De’a 339:4); Tzitz Eliezer, XIII:87; Teshuvot VeHanhagot, III:361; BeMar’eh HaBazak, VI:78; Rabbi Yitzchak Zilberstein, “Giving Morphine to a Terminal Patient Suffering from Breathing Difficulties,” Assia 59–60 (1997), pp. 52–7. The position of Rabbi Feinstein is unclear. In a responsum that does not deal with this topic itself (Iggerot Moshe, Ḥoshen Mishpat, II:73, 1), he writes: “But if there is a medicine that will ease suffering without shortening his life by even a moment, it should be administered when he is not yet dying.” It would thus seem that he prohibits it. But some learn from here that he permits it. According to Rabbi Avigdor Nebenzahl (“Providing Intoxicating Medicines to a Dangerously Ill Patient,” Assia 25–6 (1990), pp. 39–41), giving this type of medicine is not merely indirect murder, it is actual murder, though in practice he accepts the ruling of his rabbi, Rabbi S. Z. Auerbach. See also Encyclopedia of Medicine and Halakha, vol. 5, “A Terminally Ill Patient (a),” pp. 161–62; Nishmat Avraham, Oraḥ Ḥayyim 328:17. The poskim have offered various justifications for this (all the justifications listed below pertain to the positions of the poskim mentioned earlier):

   • Pain is a component of disease, and treating pain is part of “the permission to cure” extended to physicians. By its very nature the “the permission to cure” includes treatments involving the low-level risk that the patient will die from treatment. This opinion is expressed in the Tzitz Eliezer, based on the comments of the Ramban in Torat HaAdam, Sha’ar HaMiḥush, Inyan HaSakana [Chavel edition, pp. 41–3], as well as in Teshuvot VeHanhagot.
   • This is the standard treatment for patients who are in pain, and as such, the rule that “The Lord protects the simple-hearted”(Psalms 116:6) is in effect.
   • Pain management in and of itself makes the patient feel better and enables him to eat and drink more, thereby prolonging his life (see Tzitz Eliezer and Minḥat Shlomo).
   • The obligation to extend the patient’s life is limited and does not apply when his medical situation is hopeless, and he is suffering greatly. A patient who suffers terrible pain is not obligated to make the effort to live (for further discussion, see footnote 56, above; see also Minḥat Shlomo). It should be noted that even Rabbi Eliezer Waldenberg, who maintains that despite a patient’s suffering we may not refrain from giving him life-prolonging treatment, justifies the lenient ruling in his responsum by saying that since it is not possible to save the patient’s life, treating his pain takes precedence.
   • Each act in and of itself does not shorten life. It is only the combination that may endanger life. This is stated in the name of Rabbi S. Z. Auerbach in Nishmat Avraham, and in Rabbi Nebenzahl’s essay. In the Teshuvot VeHanhagot, Rabbi Moshe Sternbuch writes that it appears that a ruling that is more lenient than the position of Rabbi S. Z. Auerbach is in order, and even when the patient might die from a single injection it may be administered if the aim is to treat his pain. He did not elaborate on this point, given that in practice it cannot be determined that a single injection would indeed harm a patient.
   • Painkillers are not lethal drugs that directly harm the body; rather, they do so only indirectly. Rabbi Zilberstein, who cites this rationale, adds that although this claim cannot stand on its own, it can be combined with the argument that the patient is not obligated to prolong his life in this situation.
   • The choice between life-prolonging treatment and palliative care is the patient’s prerogative; see chapter V, subsection 4.

   • In general, being alert is a value. According to Judaism, a person should live his life to the fullest and use every moment of his time to do good – in deed, in speech, or in thought. See Mishna, Avot 2:4, 17; Sanhedrin 3:3. The Ba’alei Mussar (authors of literature for the improvement of moral character)elaborated on this point, see e.g., Pele Yoetz, “Halikha”; Shemirat HaLashon 2:6. These ideas apply even to suffering patients, and some Rishonim cite this example to support the idea that one is obligated to save another’s life, even if he will live for only a few brief moments, because he can use that time to think about repentance or confess his sins (Beit HaBeḥira, Yoma 85a, s.v. Amar HaMeiri). In addition, when it comes to pain that is not particularly acute, it must be assumed that the patient himself would prefer to live as completely as possibly, in a full state of awareness, in which he is active and can communicate with his family members. Nevertheless, as stated above (footnote 56), most poskim agree that one is not obligated to prolong a life of suffering.

     Poskim disagree over whether we must lower the dose of pain medication given to a terminally ill patient to enable him to confess his sins, even though he will suffer as a result. See Rabbi Yehoshua Weisinger, “Reciting the Pre-Death Confession in Various Medical Conditions,” Teḥumin, 38 (2018), pp. 139–40. Similarly, some poskim permit doctors not to provide treatment that might cause a person in a “vegetative” state to wake up from his coma if this will cause him immense suffering (Shevet HaLevi, VIII, 253). Rabbi Moshe Feinstein (Iggerot Moshe, Ḥoshen Mishpat, II:73:1) writes that it is prohibited to prolong the life of a terminally ill patient suffering from pain, but in later responsa (ibid. 74:1, 75:1) he says that this depends on the patient’s wishes. Looking at these responsa together, it seems that he assumes that a patient would not want to live a life of terrible suffering. Rabbi S. Z. Auerbach (Minḥat Shlomo,I:91:24) writes that we should explain to the patient that “A single moment in this world in repentance and good deeds is greater than all of the life of the World-to-Come” (Avot 4:17), but if the patient is insistent, it is permitted to refrain from administering medical treatment that will cause him suffering. It thus seems that the decision to prevent suffering at the cost of impairing the patient’s alertness is left to the patient’s discretion, and when his view is unknown the assumption is that a person is willing to bear a certain level of suffering in order to be awake and aware of his actions, though in a case of unbearable pain we should treat the patient’s suffering even when his alertness is thereby impaired.

   • See previous footnote.