1. Introduction: The Caretaker’s Identity
Treating parents with dementia is one of the greatest struggles a family can endure. This is due to the difficult reality of the situation as well as the fact that the parents have a limited ability to express their wishes (or to affirm previously given directives). At times this ability can be absent altogether. There are many discussions surrounding the ethical, halachic, and humane aspects of this complex situation, one of which is the caretaker’s identity. Is it proper for the son or daughter to take care of their parents or is it preferable for someone else to administer their long-term care?
The factors employed in these discussions are very complicated and gravitate to opposing views. On the one hand, medical and nursing care requires close contact between caretaker and patient, and the patient may specifically feel uncomfortable with bringing a close relative into their personal space. On the other hand, the personal connection between parent and child can ease the parent into the idea of receiving treatment. This is not the only issue of conflict. It is reasonable to assume that a relative can most precisely understand the needs of the patient, yet at times the distance and neutrality of a third party allows for a better understanding of their needs. Finally, some aspects of care require degrading activities that may impact the honor and awe of one’s parents. However, one can view these actions as the highest honor that a child could give to their parents. There are unique prohibitions of the child towards their parents (such as the prohibition of inflicting a wound or preserving their modesty) yet performing these actions can be the explicit will of the parents. Issues such as these become exacerbated when the demented patient refuses treatment, such as bathing for example, and one must force them to accept their care: is there a preference for the child to be the caretaker, and hopefully their relationship will lessen the amount of resistance to the treatment, or perhaps it is preferrable that someone else cares for their parent, since the shame of the parent to undergo coerced and forced treatment may be greater when the child is the caretaker?
2. The Ethical Background: Medical Care Performed by a Relative – The Position of Modern Medicine
The accepted position in modern medicine advises against people performing medical treatment on a relative1. Granted that a relative who is a doctor will be more available and more dedicated to their patient, as well as able to assess the wishes of the patient in the best possible fashion, but the emotional connection of a relative can impair the quality of care and does not allow for professional objectivity that a doctor is expected to employ. Therefore, the starting point for our discussion is that it is proper for a physician not to treat their relatives. However, like in all ethics, this starting point is not a definitive conclusion, since there are unique circumstances where it would actually be preferrable to have a relative care for the patient. This discussion has room for deliberation dependent on a number of factors: the urgency of the medical problem, the appropriate professional response and treatment, the availability of other doctors capable of treating this condition and their skillsets, and of course – the wishes of the patient2.
3. Treatment of a Parent by a Child: The Halachic Position
The fundamental obligation of honoring one’s parents, “feed him and bring him drink, dress him and cover him up, bring him in and out [of the home]” (Kiddushin 31b), addresses the reality of an elderly parent who requires assistance. This is the child’s obligation, and therefore the starting point of the discussion is that it is their responsibility to take care of their parents. However, when dealing with cases where there is a concern of shaming the parents or when there is violation of their privacy and modesty, one should prioritize a different caretaker3.
Another aspect of this dilemma deals with caretaker children who at times will suffer a significant psychological burden. This is expressed in the Talmudic account of Rav Assi, who was not able to cope with the demands of his mother and emigrated to Israel (Kiddushin 31b). Based on this story, the Rambam rules (and the Shulchan Aruch, Yoreh Deah, 240:10 follows his approach) that “one whose father or mother is mentally incompetent should try to act in accordance with their wishes until [God] has mercy on them. And if they cannot persist because they have become exceedingly demented, one should leave them, go on their way, and instruct others to act in the appropriate manner for them”4. The poskim learn from this that there are situations where it is preferable to transfer the care of a parent to a third party5.
3.1 Using Force When Necessary
When there is the need to restrain the parent6, it is proper that someone else treat them instead of their child. However, if the restraints are implemented in order to prevent injury to the parent one can be lenient7. When the parent requests to leave the home in a shameful manner, the child is permitted to rebuke them yet is prohibited from using force in order to prevent this. If another person is caring for them, they are allowed to use a limited amount of force8.
3.2 Bathing Parents
In Tractate Pesachim (51a) it is stated that a child is prohibited from bathing with his father9. There are those who write that specifically bathing together is prohibited due to reasons of modesty, however when the child is clothed and the father is not entirely exposed (such as when applying ointment etc.), there is no prohibition – since in this situation the issue of modesty is less prominent and the child is occupied in his work and his thoughts will not wander10; there are those who prohibit this unequivocally11.
It seems that it is preferred for someone else to bathe the parent and perform treatments that require exposing covered areas. If there is no other person around, it is permitted for a son to bathe his father and a daughter to bathe her mother, even when there is no risk, however they should do this with modesty. When there is another person present, one should convince the parent that it is better for the other person to perform this, but if it is important for the parent for the child to bathe them – it is permissible. When necessary, it is permitted for a son to wash his mother and a daughter to wash her father12, but they are obligated to do this modestly13.
3.3 Medical Care of Parents
The issue of injuring one’s parent arises when dealing with the medical care of a parent. Injuring one’s father and mother, if they bleed, is a more serious prohibition than the prohibition to injure another person. Therefore, the Sages prohibited children from performing medical treatment that causes injury or has risk for causing injury14.
However, when there is no one else and the parent is suffering – one may rely on lenient opinions15. When the parent is interested in having their child treat them, according to most opinions there is no prohibition of causing injury16. When the son will treat them for free and another doctor would charge money, according to some of the poskim it is considered as if there is no other doctor available and it is permitted for the child to heal his parent17. When the son is more qualified than other doctors – it is permitted18. When it is burdensome to go to the doctor, and the child’s treatment is comfortable and readily available, it is considered as if there are no other doctors present19. Similarly, the poskim differentiate between different types of treatments: regarding IV injection, for example, which definitely involves injury to the parent, one may be stringent and prohibit the child from treating their parent when there is another healthcare worker available (unless the parent requests it); However, regarding intramuscular injection, there are those who say that since this generally does not result in bleeding, it is permitted for the child to perform this even when there is someone else available20.
- See Yehonatan Levi, ‘The Doctor as Caretaker for His Parents and Children’, from: Yehuda Shaviv (editor), Matters Without Measure, Alon Shvut 5765, pages 363-369. In the field of mental health, this is considered part of general ethics. The psychologist ethical code states: “A dual relationship exists when the psychologist has a professional relationship with the patient or with their legal representatives, while he fosters a separate connection with them or their relatives. The psychologist should avoid a situation of dual relationship because this impairs the professionalism and interventional psychological benefit…” (The Professional Ethics Code of the Psychologists in Israel, page 18, article 3.6). The accepted position amongst psychologists is that the familial connection is included in the term “separate connection”.
- Different aspects of long-term care by relatives are discussed in the study of Jenny Brodsky et al. Issues in Family Care of the Elderly: Characteristics of Care, Burden on Family Members, and Support Programs. Listed in the paper summary (page 103) are approaches to activities such as bathing, which we discuss later, amongst others, which add great burden and mental stress on the caretaking family member.
- Regarding modesty, see Pesachim 51a and later on in this article. Regarding inflicting a wound, see the Shulchan Aruch, Yoreh Deah, 241:3, and later on in this article.
- Mishneh Torah, Hilchot Mamrim, Chapter 6:10.
- The source of this is the Rambam, ibid. The Ra’avad on site ponders: if the child is unable to treat his parent, what would someone else be able to do? The Radbaz (ibid.) answers “for she is emotionally connected to her son and will not become angry with him unlike with others, and he will not rebuke her and other would rebuke her, and it is possible that by striking her she would recover from her insanity and other similar actions every day, and the child is unable to perform this”. The Nishmat Avraham (article 240:5) writes that nowadays it is clear that there is a difference between treatment by an unexperienced child and a qualified and experienced professional. See also: Tzitz Eliezer Responsa, volume 12, article 59; Shevet Halevi Responsa, volume 2, article 110:7; Rabbi Yigal Betzalel Shafran, ‘Medical Care for Parents Without Their Consent’, Tchumin, 7 (5746), page 344-351.
- Regarding the question of whether the binding itself is permitted, see The Medical Halachic Encyclopedia, volume 3, entry ‘elderly’, alongside footnote 517.
- The Tzitz Eliezer (see earlier endnote 5) writes that it is prohibited for a child to bind their father. The Nishmat Avraham (see earlier endnote 5) writes in the name of Rav Neuwirth that if the binding is performed in order to prevent injury to the parent – it is permitted. See also Rabbi Avraham Steinberg, ‘Medical Care of Parents’, from: Yehuda Shaviv (editor), Matters Without Measure, Alon Shvut 5765, page 158; The Medical Halachic Encyclopedia, volume 2, entry ‘parents’, alongside footnotes 36-37.
- Rabbi Yitzchok Zilberstein, ‘Honoring One’s Father with Alzheimer’s’, from: Yehuda Shaviv (editor), Matters Without Measure, Alon Shvut 5765, page 148, 154.
- The Rema (Even HaEzer, 23:6; Yoreh Deah 242:16) writes that the custom is to be lenient, but he is discussing a case of bathing while wearing pants. The Pitchei Teshuva (Even HaEzer, article 23:5) writes: “and due to this, in our times where one does not cover up, there is no heter for this and I do not know what the public relies on to be lenient in this”.
- In the sefer Shema Avraham (article 70) he permits a son to take care of his father and remove leeches from him since the son is clothed and the father is not fully exposed, and because the son is focused on his work and his mind will not wander. See: Nishmat Avraham, Even HaEzer, article 23:10; Rabbi Yitzchok Zilberstein (earlier endnote 8), page 148-150; Rabbi Avraham Steinberg, The Medical Halachic Encyclopedia, entry ‘parents’, alongside footnote 43. They permit bathing a parent and taking care of them if no one else is able, based on the opinion of the Shema Avraham.
- Based on the Aruch HaShulchan (Even HaEzer, article 23:8) and Rabbi Tzadok HaCohen of Lublin (Sefer HaZichronot, Positive Commandment 1) one can infer that it is prohibited even when the father requires it, and their opinions are brought by the halachic authorities mentioned in the previous endnote.
- See Rabbi Yitzchok Zilberstein (earlier endnote 8), page 150.
- See Bahag, Hilchot Kibud Av Ve’Em, who writes that Yosef did not fulfill his father’s instruction ‘place your hand under my thigh’ (Bereishit 47:29) in order not to touch his father’s nakedness. This matter appears in the Targum Yonatan on the verse as well. Rabbi Yitzchok Zilberstein (earlier endnote 8, page 149) permits this when there is no other person, due to the potential risk. The Nishmat Avraham (earlier endnote 8) permits bathing even when one needs to touch the genitals themselves.
- In the words of the Shulchan Aruch (Yoreh Deah, 241:3), “if his father had a thorn stuck in his [flesh], one should not remove it, perhaps it will make a bruise. Similarly, if he was a bloodletter, or a doctor, he should not blood let his father and should not amputate for him, even though he is performing this for medicine”. This is the ruling in the Shulchan Aruch, Choshen Mishpat, 424:1.
- The Rema (Yoreh Deah, ibid.) adds: “What are we talking about? When another can perform this. But if there is no one else who can perform this and he is suffering, he should blood let him and amputate as he is qualified to do”. The Ben Ish Chai writes that the Shulchan Aruch agrees with the Rema. The Bach writes that the Shulchan Aruch prohibits this even when there is no one else, and this is implied from his opinion in the Beit Yosef. This is also the opinion of Rabbi Shlomo Zalman Auerbach (Minchat Shlomo Responsa, volume 1, article 32), and therefore according to him it is proper to be stringent when possible. See the Nishmat Avraham, Yoreh Deah, article 241:1 and endnote 10.
- Minchat Chinuch, Mitzvah 48:2, see as well the Gesher HaChayim, volume 2, chapter 1, page 19. The Gesher HaChayim discusses throughout the chapter the idea of inflicting a wound on one’s parents for medical purposes, and brings the responsa of Rabbis Y.A. HaLevi Herzog, T.P. Frank, and Shlomo Zalman Auerbach (responsa mentioned in the previous endnote). See also the Nishmat Avraham (earlier previous endnote); Rav Steinberg, ‘Medical Care of Parents’ (earlier endnote 7), page 155-158; The Medical Halachic Encyclopedia, volume 2, entry ‘parents’, pages 537-544. The details brought in the following subarticles are discussed in the aforementioned sources; see also the Minchat Yitzchak Responsa, volume 1, article 27-28.
- According to the Gesher HaChayim and Rabbi Shlomo Zalman Auerbach it is considered as if no one else is present and permitted; Rav Herzog and Rav Frank disagree (see their responsa in the previous endnote).
- Aruch HaShulchan, Yoreh Deah, article 241:6; Shevet Halevi Responsa, volume 10, article 159.
- Minchat Yitzchak Responsa, volume 1, article 27.
- Gesher HaChayim and Rabbi Shlomo Zalman Auerbach (earlier endnote 16) and see the opinion of Rav Steinberg (earlier endnote 16).