Terminally ill patients will generally receive numerous types of medications. Some are designated to treat the illness (to slow progression or to combat the disease entirely) and some are administered to improve quality of life (to prevent suffering as much as possible, limit risk of infection, etc.). The question that arises from this is: when the illness is incurable and the patient is suffering tremendously, can one withhold drug administration? Additionally, when the patient is not able to express their wishes, can the medical team make decisions regarding withholding medication? Elsewhere we have expanded on the fundamental approach of halacha to suffering1. Here we summarize the main issue and relate principally to the aspect of drug administration.
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
The inherent value of life is a highly regarded value in the hierarchy of mankind’s ethics. It demands placing priority on conserving human life against any dangers that befall it. We do not know the deep significance of each minute of life, and thus it is possible that we are not allowed to cease drug administration if it has potential to prolong the life of the patient. However, alongside the inherent value of life is the value of quality of life, and in certain cases this value can override the inherent value of life. Therefore, in circumstances when dealing with a patient in tremendous pain and no chance of recovery, there may be no reason for continuing administration of drugs that prolong their life of suffering. Granted that the value of quality of life is for the most part subjective and relative, and therefore it will not generally be used as the determining factor in withdrawing treatment.
The primary ethical dilemma in this discussion is the conflict between the inherent value of life and the value of autonomy. According to the value of autonomy, man is the master of his body and may make independent decisions regarding it. Therefore, a patient of sound mind should be the decider in whether to continue drug administration. In cases where a patient presents who is unable to express their opinion, there is significant weight given to the evaluation of what their wishes would be in this situation. Despite this, the impact of patient’s desires on treatment plans are dependent on the type of drugs and their goal: medications used to directly treat the terminal illness allow for greater patient consideration, while supportive medications and analgesics involve less patient input2.
3.The Jewish Position
3.1 The Sanctity of Life and the Obligation to Preserve a Life
“The souls of Israel are more precious before God than all the mitzvot”. So writes Rashi (Yoma 82b) in his commentary in the Gemara dealing with pikuach nefesh overriding the majority of the mitzvot, 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 him3. There are cases in which the obligation to preserve life is overridden due to suffering, and it is even possible that the responsibility to save a life does not exist when there is no way to prevent suffering4.
The human life is holy and considered precious before God, yet King Shlomo writes in Kohelet 3:2 “a time to die”, expounded by Rabbi Yehuda Chasid that there is a stage where man is ready to die and one may withhold efforts to save him: “Why does Kohelet say this? It must be that when man is dying and his soul begins to leave him we do not cry out that his soul should return, for he can only live a small number of days and those days would be full of suffering”5. Based on the words of the Sefer Chasidim, the Rema rules that actions causing death to approach faster are forbidden unequivocally, but in the case of a dying patient one can remove an object preventing his death6.
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 harm7. 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 Drug Administration
Elsewhere we have discussed the differentiation between medical treatment and fulfillment of the basic, natural needs of a patient8. Food, liquids, and oxygen are essential requirements for the life of a person and part of his daily routine; therefore, it is prohibited to withhold the fulfillment of these needs, even in cases where withholding medical treatment is permissible. Following this model, the accepted opinion regarding medications is that one should differentiate between medications that are part of routine treatment and medications that deviate from the norm and target the terminal illness of the patient. Medications of routine treatment – such as insulin for diabetic patients – are considered natural and basic needs of man prohibited from being withheld, even if the need is being artificially met. In contrast, one may withhold administration of drugs treating the terminal illness if the medication only prolongs the patient’s life of suffering9.
The differentiation between types of drugs and whether to withhold, limit, or cease treatment becomes less significant as the patient’s condition becomes more severe and death approaches. When a patient reaches terminal, irreversible failure of essential body systems, one may withhold drug administration of both types, even ones given routinely, and one may lower the dosage of medications given continuously1010.
- There is an obligation to continue treatments providing basic needs of a patient, such as food, liquids, and oxygen. Included within this is drug administration that is given routinely to patients, such as insulin to diabetics and anti-coagulants (antibiotics require case-by-case analysis as to whether they are a routine treatment that relieves the patient or lengthen time of suffering)
- As a general principle, withdrawing medical care, even to a terminally ill patient, is prohibited. Therefore, one should not stop administering intravenous drugs, but in certain cases one may withhold renewal of the IV.
- Regarding a terminally ill patient in severe distress that requests that their life should not be extended, one may abstain from administering any medications.
- When a patient cannot express their wishes, one should estimate the patient’s decision regarding how they would act in this situation.
- One can withhold medications to treat a terminal illness if the physician’s evaluation is that it will only extend the time they will suffer and not heal them.
- When a patient receiving continuous administration of medications reaches irreversible and terminal failure of vital organs, one may reduce the dosage, as long as it will not directly change the status of the patient.
- See position paper ‘The Impact of Suffering on Medical and Halachic Considerations’.
- See The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill’, page 171-176. For additional literature and an overview of the legal status in Israel, see position paper, ‘The Impact of Suffering on Medical and Halachic Considerations’, endnote 1.
- See position paper ‘The Obligation to Be Healed’.
- See Ba’Ohala Shel Torah Responsa, volume 1, article 56:4, and see position paper ‘Artificial Nutrition in Terminally Ill Patients’, endnote 11. Halachic decisions of this topic are based on practical accounts from the Gemara, such as the death of Rabbi Chanina Ben Tradyon (Avodah Zara 18a) and more (see position paper ‘The Impact of Suffering on Medical and Halachic Considerations’, and endnote 4 there).
- Sefer Chasidim, article 234.
- Rema, Yoreh Deah, article 339:1, the poskim discuss the meaning of “an action causing death to approach faster is forbidden unequivocally” and what is included in the category of “removal of an object preventing death” that would be permissible in certain cases. See: Nishmat Avraham, Yoreh Deah, article 339:8; The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill ’, pages 124-131; Yisrael Katz, ‘The Law of “Removing a Preventative Object” – The Laws of Dying, from Original Sources to Modern Day’, Assia Books, 16 (5779), pages 258-267.
- Sefer Chasidim, article 234.
- Position paper ‘Artificial Nutrition in Terminally Ill Patients’, article 3.3.
- This is the opinion of Rabbi Shlomo Zalman Auerbach in Minchat Shlomo Responsa, volume 1, article 91:24. See also oral accounts accredited to him, and a summary of this issue primarily following him, in the Nishmat Avraham, Yoreh Deah, article 339:4. See also: Igrot Moshe Responsa, Choshen Mishpat, volume 2, article 73:1,5; ibid., article 74:1; ibid., article 75:1,4. This is also the opinion of Rabbi Yosef Shalom Elyashiv as attributed in the Nishmat Avraham, ibid. Based on this text, a halachic ruling was published in the journals of Rabbi Yosef Shalom Elyashiv, Rabbi Shlomo Zalman Auerbach, Rabbi Shmuel Wosner, and Rabbi Yosef Nissim Karelitz; see Yated Ne’eman, 20th of Kislev 5755 (23/11/94), page 1 (Introduction to The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill’, pages 153-155). Rav Hadaya (Yaskil Avdi Responsa, volume 7, Yoreh Deah, article 40) writes that one should not administer drugs to a patient of who doctors have abandoned hope for recovery. He does not differentiate between the types of drugs. Compare this to the Tzitz Eliezer Responsa, volume 5, Ramat Rachel, article 28-29; ibid., volume 14, article 80-82, whose opinion is that one should heal a patient with all existing methods as long as they are considered alive, and even if treatment must be administered involuntarily. For a summary of these methodologies see Nishmat Avraham, ibid., and The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill’, page 144-146, 152-153. Rav Steinberg writes there that there are those who hold that ceasing drug administration is considered murder, and provides two sources for this in endnote 273, but it seems to us that one must qualify this statement. Granted that Rabbi Moshe Hirschler (‘The Obligation of Saving a Life in Terminally Ill Patients’, ibid. [editor], Halacha and Medicine, 2, Jerusalem 5741, pages 29-34) writes that there is a degree of murder here, but he adds that if doctors have lost hope in saving the patient and there is no chance for regaining consciousness – there is no obligation to save him and administer medication. Considering this, his position is no different than the opinion of Rabbi Shlomo Zalman Auerbach and those that follow him. Rabbi Raphael Baruch Toledano (‘Responsa Regarding Terminal Illness’, Barkai, 4 , pages 52-53) writes that as long as the patient is breathing independently, one should not withhold medication, and his opinion is in line with the opinion of Rabbi Waldenberg. Despite this, he does not write that this action is prohibited due to murderous factors, obligating life-saving procedures due to “do not stand idly by your friend’s blood”.
- See Rabbi Avraham Steinberg, ‘Halachic Protocols for Physician Behavior in the ICU – According to the Opinions of Rabbi Shlomo Zalman Auerbach and Rabbi Shmuel Halevi Wosner’, Assia, 63-64 (5759), pages 18-19. The definition there includes failure of three essential body systems, approval of all the treating physicians, expected death within a short timeframe, and suffering of the patient.