In the field of general ethics, questions that relate to medical treatment involve a delicate balancing act between different ethical principles.

While these questions are often similar to some questions addressed by halakha, the conclusions often differ, as Jewish law is guided by a particular approach to decision-making. Let us therefore summarize the general ethical discussion, which will then serve as an introduction to the halakhic debate.

When faced with the question of discontinuing medical treatment (or at the very least withholding such treatment) for a patient with very limited chances of recovery, someone who is suffering, or someone who refuses to receive treatment, we encounter a certain tension between two opposing values: The value of life itself, versus the value of a person’s autonomy over his body and quality of life.

The value of human life ranks high on a scale of human values, and demands that we protect life from any significant danger or threat. That said, there are other values that carry weight as well. In the context of medical care there are two primary values: The first is the importance of quality of life, which functions as an ethical consideration in medical decisions; the second is the value of an individual’s autonomy and his right to choose what he believes is best for him.

In the past, the world of medicine was dominated by a paternalistic approach based upon which the physician knew what is best for the patient, and consequently would determine the course of the patient’s treatment. However, in recent decades the paternalistic approach has been gradually replaced by an emphasis on patient autonomy. From this viewpoint, a person owns his body, and may therefore make independent choices that affect his body. The principle of autonomy indicates that if a patient has the capacity for judgment, his opinion is the decisive factor in medical decisions; it is he who determines how he will be treated – if at all.

Accordingly, even when the patient does not have the ability to make informed decisions, it is necessary to try and evaluate what his opinion might have been in the given situation, and this understanding has significant weight in the final decision.

The currently accepted approach seeks balance these viewpoints, by taking into account both the patient’s right to autonomy and the other ethical values. The appropriate balance between these values ​​may vary from one society to another¹, and accordingly the legal context will differ from country to country².

1. See the Encyclopedia of Medicine and Halakha, vol. 2, “Informed Consent,” pp. 633–717, esp. 636–41; vol. 3, “The Patient,” pp. 460–62; vol. 5, “A Terminally Ill Patient (a),” pp. 171–76; vol. 7, “General Ethics,” pp. 890–946, esp. 932–36; the position paper of the Israeli Medical Association: “Medical Ethics and the Treatment of Patients with Incurable Diseases and Futile Treatments,” October 2019 (https://bit.ly/3gigj8k); Avinoam Reches (ed.) Medical Ethics: Principles and Position Papers, pp. 121–22 (https://bit.ly/3Idu8l0); Daniel Sinclair, “Patient Autonomy and the Synthesis of Judaism and Democracy in the Dying Patient Act, 2005,” HaMishpat 21 (2016), pp. 224–29 (in this section of the article the author summarizes the status of the patient’s autonomy in Anglo-American law; later he discusses the status of autonomy in halakha); Ofra Galon and Sharon Bessen, “Artificial Feeding at the End of Life,” Refua UMishpat 31 (2004), pp. 41–6; Ram Yishai, “Feeding a Terminally Ill Patient and the Right to Die,” HaRefua 141.2 (2002-); Roy Gilbar, “Until the Final Breath – On the Cessation of Artificial Respiration in Terminally Ill Patients in Light of the Ruling: Opening Motion (Tel Aviv) 16813–11–14, John Doe v. the Attorney General” Mivzakei He’arot Psika 42 (May 2015), pp. 35–9; David Stein, “Terminally Ill Patients and the Sanctity of Life” HaShiloaḥ 20 (2020), pp. 65–5. A large part of Issue 51 (July 2019) of the Refua UMishpat journal was devoted to the topic of “Treating the Terminally Ill Patient – Corrective Arrangements in the Clinical and Legal Field in Light of the Dying Patient Act,” which included nine articles. The articles appear on the website of Inbal – The Unit for Risk Management in Medicine (https://bit.ly/39PbYrM).
2. The Israeli legislative system addressed these ethical and halakhic dilemmas and acted to resolve them in the form of various laws. The Patient’s Rights Act establishes that “Every person in need of medical care is entitled to receive it” (Patient’s Rights Act, 5756–1996, 3:1). Conversely, this law also states that “No medical care shall be given unless and until the patient has given his informed consent” (ibid., 4:13). The Dying Patient Act distinguishes between a “terminally ill patient” and an “end-stage patient”: The first is suffering from an incurable medical problem and his life expectancy does not exceed six months (even with medical treatment); in the second case, several of the patient’s vital systems have failed and his life expectancy does not exceed two weeks. According to the law, if a terminally ill patient is capable of making decisions and does not want his life extended, his wishes must be respected and we must refrain from giving him medical treatment, although an effort must be made to convince him to receive oxygen, food, and fluids, even by artificial means. If the patient is unfit to make a decision and it is determined that he does not want his life to be prolonged, we may withhold additional medical treatment for his disease, but ancillary treatments such as the provision of food and fluids should be provided. When the patient is in the final stages of life, these treatments may also be withheld, but fluids should still be given (see sections 8, 15–7 of the Dying Patient Act, 5766–2005). The law was written in consultation with Rabbi Professor Avraham Steinberg and is consistent with the halakhic principles presented in this pamphlet. See Rabbi Avraham Steinberg, “The Halakhic Basis for the ‘Dying Patient Act’ Proposal,” Assia 71–2 (2003), pp. 25–9. Some of the articles listed in the previous footnote discuss this law, its pros and cons, and how it has actually been implemented in the medical system.