Position Paper – Artificial Nutrition in Terminally Ill Patients

Rabbi Yuval Cherlow, Rabbi Uriel Ganzel and Rabbi Shaul Bruchi

1.Introduction

The question of whether there is an obligation to provide artificial nutrition or whether there are halachic grounds to withhold sustenance of this nature arises in different medical contexts. 1  Terminally ill patients will at times express a desire to abstain from artificial nutrition – both in the moment or as an advance directive. In certain cases, the medical staff will bring up the question of whether or not it is worthwhile to feed a patient for whom treatment will not provide a positive prognosis. Even amongst patients who are not terminally ill, there are cases where the patient finds their quality of life unsatisfactory and are not willing to undergo this treatment. Is it valid to consider not inserting a feeding tube, and if so, which cases allow for lack of artificial nutrition and which allow for stopping feeding altogether?2

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

Withholding nutrition, like withholding any form of treatment, puts us at a crossroads between values: the value and sanctity of human life and the value of autonomy over one’s body and one’s quality of life. Sanctity of life requires penultimate focus on preserving life, however it is possible in certain cases to allow for quality of life to trump life’s inherent value. Quality of life is for the most part subjective, and therefore cannot usually act as the main determinant for withholding of treatment. The more significant value conflicting with life’s inherent value is autonomy. Autonomy dictates that a patient of sound mind should be the ultimate decider regarding their own care. Despite this, the weight which we grant a patient’s desires is dependent on the type of treatment; anything regarding direct treatment of a disease allows for greater patient consideration. On the other hand, the patient’s wishes are taken into account less when dealing with supportive/palliative care. Artificial nutrition falls under the category of supportive medical treatment.3

3.The Jewish Position

3.1 Sanctity of Life and the Obligation to Preserve Life

Sanctity of life is a tremendous value, and Chazal expounded, “’And you should live by them’ – and not die by them” (Sanhedrin 74a). From here the Gemara learns that the majority of mitzvot are pushed aside for pikuach nefesh, barring the three major sins. One can learn from this that the value of life is a lofty one, but it does not trump all. Life’s inherent value mandates maintaining a healthy lifestyle, and therefore one who is sick is commanded to seek out treatment, and medical professionals are commanded to heal him.4The obligation to preserve life includes a ban on suicide as well, but in cases where there is no expected recovery – this medical obligation does not exist, especially when discussing situations of tremendous pain.5

The Gemara (Sotah 46b) recounts that the city of Luz that the angel of death was not allowed to enter “rather, when the elders decided they had reached the end [of life] – they would exit the city walls and die”. The wording of the story teaches that halacha recognizes that in certain situations one can withhold life-prolonging treatment from themselves.6Additionally, the story of Rabbi Chanina ben Tradyon (Avodah Zara 18a) implies that from a certain perspective it is even permissible to actively remove something preventing the death of a person.7

3.2 Man’s Ownership Over His Body

The debate over whether a patient can make decisions regarding his body which may shorten his life touches on a question that divided the Achronim: does man have ownership over his own body? It is worthwhile to note that even according to those who hold that man does have ownership over his body, this refers to partial ownership with God and does not grant the right to cause himself bodily harm. 8 From a halachic perspective, the question of man’s ownership over his body has ramifications on the extent of one’s responsibilities to it: when is he misusing his body and in what situations can the owner (God) demand its return without man being responsible to fight for his life?

3.3 Artificial Nutrition

The halachic status of artificial nutrition is different than the status of other medical procedures. Eating and drinking are not inherently medical activities but a vital need for man’s life and part of his natural functioning. For this reason, even though under certain conditions one may withhold medical treatment, withholding nutrition under similar conditions is considered starvation, and there is an element of murder in prevention of access to sustenance.9 To make matters more severe, Chazal determined that death by starvation is the worst form of death.10

Even so, there are medical situations where a terminally ill patient can live for a sustained period without feeding and withholding nutrition would not be considered starvation, not to mention that insertion of a feeding tube in the long-term could result in infections and complications. Therefore, when a patient requests that he shouldn’t be fed, it is imperative to find ways to convince him about the necessity of eating. If despite this he refuses to be fed, one should not force feed him.11

Even when discussing a patient who is suffering and has exhausted all possible methods of recovery, one shouldn’t stop feeding him entirely. Despite this, one may consider feeding in a way that minimizes suffering, even if it is a less effective method. For example, it is permissible to stop parenteral nourishment and opt for a feeding tube, or even to provide only water and sugar intravenously. There are extenuating circumstances (see paragraph 6.4) where withholding nutrition is permitted, preferably through prevention of renewing nourishment (such as when the IV is turned off and there is a need to renew it).12

It arises that just as one cannot force nourishment upon a patient who does not want it, so too one cannot force nourishment upon a patient who has explicitly expressed his desire not to be fed when he was of sound mind.13

4.Conclusions

4.1 Eating and drinking are basic needs and part of man’s natural functioning. Therefore, withholding food and drink, even from a dying patient, is prohibited unless the medical position dictates that the feeding process is shortening his life or ineffective. 

4.2 Cessation of nourishment is prohibited, but prevention of IV renewal when mandated is potentially more lenient.

When the patient’s wishes are known:14

4.3 A person of sound mind may make decisions regarding his body. Even if the decision seems incorrect to us from a medical or halachic perspective, one should try as hard as possible not to force treatment or nutrition.

4.4 Regarding a patient who refuses to eat or requests not to receive sustenance in any other way, one should speak with them emphatically and explain the importance of eating or receiving nutrients artificially. If it is not possible to convince them, one should not force them to receive nourishment. 

When the patient’s wishes are unknown:

4.5 Insertion of a feeding tube: one is obligated to insert a temporary nasogastric tube from which rehabilitation is possible. However, if rehabilitation is unlikely after insertion of the nasogastric tube and the patient will suffer tremendously because of it, there is no obligation to intervene. This matter is dependent on many variables, and one should consult with a rabbi and medical personnel. 

4.6 In cases where a patient is deemed by a physician as beyond recovery and the assumption is that the patient will not suffer from withholding nutrition, it is permissible to even cease feeding, notwithstanding a case where continuation of nutrition increases the risk for infection and could lead to premature death.

4.7 Despite this, it is preferable in this case to switch to less painful feeding methods. If there are no viable alternatives, one may resort to administration of sugar and water intravenously.15

הערת שוליים

  1. The accepted methods of artificial nutrition are nasogastric tube, percutaneous endoscopic gastrostomy (PEG), and parenteral nutrition. The nasogastric tube is a plastic tube inserted via the nostril into the digestive tract. Nutrition via a nasogastric tube is administered mainly to patients with temporary dysphagia and, while not painful, is extremely discomforting. PEG is a tube with one end attached to the gastric wall and the other protruding externally to the stomach. PEG use is appropriate for patients with dysphagia or patients who are unable to intake a sufficient quantity of food orally. Total parenteral nutrition (TPN) is a method of administering liquidated food via an IV through a central catheter, generally in the chest, reaching the heart directly. This method is only used temporarily and does not ensure complete nutrition for a prolonged period. Each method has its own complications, risks, and inefficiencies in certain patients. For more information, see for example: “Alternative Nutrition Methods (Nasogastric Tube) in the Elderly”, Ofra Golan and Sharon Bassan, ‘Artificial Nutrition at End of Life”, Medicine and Law, 31 (2004), pages 41-66.
  2. We have expanded on the topic of halacha’s perspective on suffering elsewhere. See position paper ‘Suffering in the Context of Medical and Halachic Considerations’. Here we have summarized the fundamental issue and engaged mainly with analysis of artificial nutrition.
  3. See: The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill (1)’. Pages 171-176; Golan and Bassan, ‘Artificial Nutrition at End of Life’ (above, endnote 1); Ram Yishai, ‘Patient Nutrition in Terminal Stages and the Right to Die’, The Medicine, 141.2 (5762). For additional reading and descriptions of the current legal perspective in Israel, see position paper ‘Suffering in the Context of Medical and Halachic Considerations’, endnote 2. A related ethical discussion is the question of force feeding a hunger-striking patient. This presents the doctor with the moral dilemma of whether to do all that he can to save the life of the hunger-striker or whether to honor the wishes of the hunger-striker refusing to eat. This dilemma also includes the question of whether or not to listen to the law regarding force feeding a hunger-striking prisoner, against the physician’s own moral compass. See Avinoam Reches (editor), Medical Ethics: Principles and Position Papers, pages 106-107, as well as the position paper of the Israel Medical Association, ‘Artificial Nutrition, Force Feeding and Resuscitation 2’. For the position of Tzohar, see position paper ‘Force Feeding Hunger-Strikers’.
  4. See position paper ‘The Obligation to Be Healed
  5. See Igrot Moshe, Choshen Mishpat, volume 2, article 74:2. According to him, in cases where there is no way to heal the person and treatment options involve suffering, there is no obligation to treat the patient. Even in cases where the patient’s wishes are not known – the underlying presumption is that his death is preferred to his life. See the opinion of Rabbi Hedaya in the responsa Yaskil Avdi, volume 7, Yoreh Deah, article 40. Compare this to Tzitz Eliezer, volume 5, Ramat Rachel, article 29; ibid, volume 10, article 25, sections 5-6. According to this opinion, even in cases of suffering there is no room for withholding treatment. See The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill (1)’, pages 133-135 as well.
  6. Rabbi Tzvi Shachter (‘Laws of Death and Gavra Ketila’, Assia, 49-50 [5750], page 136) learns from here that saving the life of a person who has lost the will to live does not constitute pikuach nefesh. In contrast, Rabbi Waldenberg explains that the people of Luz experienced a miracle and leaving the city restored their natural state, therefore one cannot expound from this story. For additional discussions and stories relevant to the discussion of withholding treatment, see position paper ‘Suffering in the Context of Medical and Halachic Considerations’, specifically endnote 4 there.
  7. The law of removing an object preventing death is explained by the Rama, Yoreh Deah 339:1. The poskim discuss the question of whether the consent of Rabbi Chanina ben Tradyon for removal of the wool was permitted due to ‘removing a preventative object’, whether the action is generally prohibited but was permissible as a hora’at sha’ah (temporary order), or because the performer himself was not Jewish. See: Yabia Omer, Yoreh Deah, volume 2, article 24; Igrot Moshe, Yoreh Deah, volume 2, article 174; ibid., Choshen Mishpat, volume 2, articles 73-74; Nishmat Avraham, Yoreh Deah, article 339:8.
  8. According to Rabbi Shlomo Yosef Zevin, (In Light of Halacha, pages 318 onwards; ibid., Halacha and Medicine, 2 [1981], pages 93 onwards), man does not have ownership over his body. Rabbi Shaul Yisraeli (The Torah and the State, 5-6 [5713-5714], page 106; ibid., Amud HaYemini, article 16:16 onwards) disagrees and believes that there is dual ownership with God. See The Medical Halachic Encyclopedia, volume 2, entry ‘consent’, pages 673-674. Even if man does not have ownership over his body, it seems that he is permitted to make decisions relating to his body and his life, provided that these decisions follow Torah law. See Rabbi Yuval Cherlow, ‘Withholding Treatment in Terminally Ill Infants Infected with Invasive Bacteria’ Assia, 85-86 (5769), page 58.
  9. Mishneh Torah, Hilchot Rotze’ach Ve’Shmirat Hanefesh, Chapter 3, Halacha 10.
  10. Bava Batra 8b
  11. Igrot Moshe, Choshen Mishpat, volume 2, article 74. According to Rabbi Shlomo Zalman Auerbach (Minchat Shlomo, volume 1, 91:24), one must feed a patient even without their consent. See also the psak of Rabbi Yosef Shalom Elyashiv, Rabbi Shlomo Zalman Auerbach, Rabbi Shmuel Halevi Wosner, and Rabbi Shmaryahu Yosef Nissim Karelitz, Yated Ne’eman, 20th of Kislev 5755 (23.11.94), page 1 (see The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill [1]’, page 153-155).
  12. See Yaakov Levi, ‘Prevention of Passing Away’, Noam, 16 (5733) page 58-59. According to him, withholding nutrition falls under the category of murder, but withholding renewal of nutrients is not. Withholding replacement of food may classify as violating “do not stand idly by the blood of your friend”, but when there is no hope for saving the patient there is no inherent obligation. Compare this to the opinion of Rabbi Yitzchak Yedidya Frankel (‘The Sanctity of Man and Saving Life vs. Death and Cessation’, Assia Books, 3 (5742), pages 463-466) who holds that even withholding renewal of nutrients classifies as “do not stand idly by”. Regarding the distinction between the prohibition “do not murder” and “do not stand idly by”, see Ba’Ohala Shel Torah responsa, volume 1, article 56:4.
  13. See Teshuvot Ve’Hanhagot, volume 3, article 363:4. The eth

    ical dilemma in this case is more complicated due to the doubt as to whether the person who requested in advance not to be fed understood how much suffering is undergone due to starvation, and whether they would have made the same decision having understood this fact. Therefore, as long as there are doubts regarding the patient’s wishes and there is a way to understand them differently, one should continue administering nourishment, unless the nutrition endangers his life or causes suffering.

  14. We are referring to a conscious patient of sound mind, or a patient that has stipulated his requests in the past. Regarding the latter, see the disclaimer in the previous endnote.
  15. See The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill [1]’, page 147 and footnote 251, matters spoken in the name of Rabbi Shlomo Zalman Auerbach and Rabbi Shmuel Halevi Wosner.

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