1. Introduction

When a patient is suffering from a terminal illness, the physicians oftentimes are confronted with the issue of how much the person should know about their condition and if it is beneficial to withhold information from them. This issue has two main facets: 1) the medical evaluation – will the patient’s awareness improve treatment capabilities or hinder them? and 2) the moral issue – evaluations of the impact of the knowledge on the patient must also follow the ethical system that we live by. Including within this issue are the questions: Is it proper for one to know that their disorder is terminal or perhaps is it better for them to remain unaware? Should one know of their cancer diagnosis or not? Does the physician have the right to withhold information from a patient and decide what is best for them to know? Is there a requirement to tell a patient about his medical condition in order to allow them the ability to repent and perform the vidui confessional, deal with their estate, and say goodbye to their family?

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 question of whether to tell the truth to a patient is an age-old question. The value of truthfulness is a fundamental moral principle that mandates providing full and correct information to the patient, yet in certain situations we are faced with the issues of the wellbeing of the patient and the obligation to do no harm, when our evaluation dictates that their health status would be better if they were not aware of their condition.

In the past, the medical community had adopted a paternalistic approach, according to which the doctor was considered to know what is best for the patient and therefore would determine how to treat him. However, in the second half of the 20^th century the autonomy approach assumed the mantle the paternalistic approach once held, under which man is responsible for his own body and should be able to make decisions regarding it independently. According to this, there is ethical value and a requirement for the patient to receive full information regarding their disorder¹.

Aside from the values of truthfulness and autonomy, there are practical reasons to abstain from withholding information from patients nowadays, when treatment requires complex therapies and different medical authorities. In order to build patient trust in the medical system there has to be an aura of truth around the patient. If the patient suspects that the medical team is lying to him, he will lose his trust in the staff. Different procedures require patient cooperation, and knowing the truth may increase the chances of a successful treatment. The fear of not being told the truth can have a negative impact on the patient psychologically, while knowing the truth may lead them through a process of self-discovery ultimately helping them deal with their illness better. Ultimately in this day and age, withholding information is almost impossible, and therefore it is proper for the patient to receive the information in an organized and proper fashion, making sure not to expose it offhandedly or in a way that could impair them. Alongside these considerations is the legal aspect: medical teams that withhold information are subject to lawsuits from the patient and their family.

On the other hand, there are ethical and practical considerations that support withholding information from patients. The underlying obligation of the medical team is to conserve the health of the patient and prevent harm. The values of truth and autonomy are not absolute, and it is possible that when the evaluation is that telling the truth will cause harm to the patient, the inherent value of life and its preservation take precedent. At times, knowing the truth can bring a patient to a loss of hope, depression, or even suicide. Additionally, not knowing the truth can strengthen hope, which in itself can provide crucial support in the healing process. There are patients that are not interested in knowing all the information and choose to ignore reality or to stay partially informed. In these situations the doctor needs to honor the request of the patient and act accordingly.

In practice, the balance between telling the truth and withholding information when necessary is dependent on the culture and varies from country to country. Not only do the legal status and medical policies differ by place, but also the public’s view towards whether one should withhold information changes via place and time. In America and many Western European countries, the paternalistic approach of withholding information from patients is not accepted, and the obligation to tell the truth generally dominates².

According to the law in Israel³, a patient needs to provide ‘informed consent’ for a procedure, and in order to achieve this one must provide them with all the required medical information. The provider is allowed to withhold information only if an ethics committee confirms that telling the patient this information would cause serious harm to their health.

3. The Jewish Position

3.1 Truthfulness

Truthfulness is an exalted and lofty value. The Torah not only prohibits falsehood but even warns one to distance themselves from it: “From a matter of falsehood distance yourself” (Shemot 23:7). Chazal emphasized the importance of truthfulness, saying “on three things the world stands – on judgement, on truth, and on peace” (Pirkei Avot, 1:18). Even so, Chazal determined that telling the truth is not an absolute value, and “it is a mitzvah to deviate [from the truth] for the sake of peace”⁴. Since the value of preserving life is a holy virtue, the value of truthfulness is rejected in its place, and it is a mitzvah to deviate from the truth when it could harm the wellbeing of the patient⁵. However, usage of this principle of deviation should be done in a limited and calculated fashion, and usually only withholding of truth is permissible and not lying outright.

3.2 Man’s Ownership Over His Body

Elsewhere⁶ we have expanded on the discussion surrounding to what extent man is considered master of his body, and there we have established that a person of sound mind is permitted to make decisions regarding their body – even in situations where the decision seems to be incorrect. Since the patient is the primary source of determining treatment plans, no other authority has the right to withhold information regarding their condition.

3.3 Withholding Information for the Good of the Patient

We found a few sources that allow withholding information from a patient for their wellbeing (Moed Katan 26b):

“Our rabbis taught: [regarding] a sick person whose relative passes away – we do not inform them that they have passed, for perhaps their sanity will be impaired. And we do not tear kriyah in front of him, and we quiet the women in his presence”⁷.

Granted that we are not discussing a case of withholding medical information from a patient, but one can learn from this Baraita that in certain cases a secondary body can determine that information must be withheld from a patient – and it is possible to expand this to the category of medical information.

An addition source, this time aggadic, also points us in this direction (Kohelet Rabba, Parsha 5):

“When [King] Chizkiya became ill the Holy One Blessed Be He said to Yishaya: go say to him ‘Set your affairs in order, for you are going to die, you will not live’ (Yeshayahu 38:1). Chezkiya said to Yishaya: Yishaya, the general custom of the world is that a man who visits a sick person says to him ‘the heavens should have mercy upon you’ and the doctor goes to him and says eat this and do not eat that, drink this and do not drink that, and even if he sees him dying he will not say to him ‘get your affairs in order’, in order not to weaken his resolve, and you say to me ‘Set your affairs in order, for you are going to die, you will not live’?!”

Granted that the Midrash Kohelet Rabba is a later midrash than the Talmud and is not an obligating halachic source, especially considering that we are dealing with an aggadic statement and not a halachic one. Yet despite this one can learn from here that: firstly, the accepted custom was not to tell the patient about their condition in order not to weaken their resolve, and he who acts differently is worthy of criticism⁸; Secondly, that the main consideration should be the good of the patient, and therefore if the assumption is that the truth will benefit their prognosis – one should tell the patient the truth⁹.

3.4 Revealing Information in Order to Allow for the Vidui Confessional

Contrary to this, there is a source in the Talmud that supports the obligation to reveal information (Shabbat 32a):

“Our rabbis taught: [regarding] one who is sick and dying, we should say to him: confess, for all those who are put to death perform confession”¹⁰.

From here we learn that there is value to telling a patient they are about to die, in order to allow them the ability to confess and prepare themselves for the transition to the World to Come. Granted, all this has been stated regarding a patient whose death is close, but if there is an assumption that there is still time before his passing, the consideration of impairing sanity takes precedent¹¹.

4. Conclusion

4.1 A patient is entitled to be fully informed of his condition, and the physician is obligated to hand over this information.

4.2 When there is concern that giving over the information will harm the patient, the medical system must work with the family to consider whether to withhold certain aspects of the information from the patient.

4.3 Even when there is a viable reason to withhold information, if there is concern that the information will reach him from a different source, it is proper to expedite his exposure to the matter and perform it in the proper fashion, with gentleness and sensitivity.

4.4 Regarding a patient who has lost someone, it is proper to withhold informing him as well as performing mourning rituals in front of him. However, one should consider whether the information will reach the patient from a different source; if there is concern that it will, one must find the right time and conditions to tell him the news.

4.5 Regarding a patient who has no chance of recovery and is approaching his time of death, it is proper to offer him to perform the Vidui confessional, on condition that there is no concern the offer will damage his health. At earlier stages, one should abstain from mentioning the Vidui.

4.6 One may tell a patient about his condition in order for him to arrange his personal matters, such as a will and anything pertaining to his family and property.

1. Regarding this, see position paper ‘The Impact of Suffering on Medical and Halachic Considerations’ and endnote 1 there.
2. See: The Medical Halachic Encyclopedia, volume 2, entry ‘Disclosing Information to Patients’, pages 479-512; Shimon Glick, ‘Reporting the Truth to a Patient’, Assia Books, 7 (5754), pages 15-22. See also: the response of Shimon Glick to Rav Aviner’s paper (cited later on); Assia Books, 3 (5742), pages 497-498; Eran Segal ‘Telling the Truth to Patients: Should One Go All the Way?’, The MRM 10 (2000) Risk Assessment Journal; Sarah Ilan, Shimon Glick, and Alan Jotkowitz, ‘Telling the Truth to Alzheimer’s and Senile Patients in Preliminary Stages of the Disorder’, HaRefuah, 153.9 (2012), pages 537-540; Binyamin Gesundheit et al., ‘Telling the Truth to Patients: A Discourse of Jewish Sources’, HaRefuah, 153.10 (2014), pages 613-616 (https://bit.ly/3jQlyxL).
3. The Patient’s Rights Law, 5756-1996.
4.  Based on Yevamot 65b and many other examples in the Talmud and halachic authorities that determine there are cases where it is permissible and even a mitzvah to deviate from the truth when necessary. See: Responsa of the Rema, article 11; Rav Pa’alim Responsa, article 364. See also: Rabbi Yuval Cherlow, ‘From Falsehood Distance Yourself’, Tzohar, 1 (5760), pages 13-24; Rabbi Yoel Bin-Nun and Rabbi Shaul Bruchi, Verses: A Multi-faceted Analysis of the Torah – Parshat Mishpatim, Rishon Letzion 5778, page 335-345; The Medical Halachic Encyclopedia, volume 2, entry ‘Disclosing Information to Patients’, pages 493-500.
5. Regarding deviation from the truth due to pikuach nefesh see the Mishneh Torah, Hilchot Rotzeach VeShmirat Hanefesh, chapter 12, halacha 8.
6. See for example position paper ‘Artificial Nutrition in Terminally Ill Patients’.
7. This is the ruling in the Shulchan Aruch, Yoreh Deah, article 337:1. From the wording of the Baraita and Shulchan Aruch it seems that it is only permissible to withhold from saying the truth, but the Achronim explain that if a patient asks about the deceased, it is permissible to lie and say that he is alive (Kol Bo on Aveilut, page 17). According to Rabbi Shlomo Zalman Auerbach, if a mourner needs to visit the patient, it is permissible to hide their mourning state, wear shoes, and clothes that are unripped. See Nishmat Avraham, Yoreh Deah, article 337:2.
8. See for example position paper ‘Artificial Nutrition in Terminally Ill Patients’.
9. There are those who hold that it is prohibited to inform a mortally wounded patient about their state, as explained in Igrot Moshe Responsa, Choshen Mishpat, volume 2, article 73. Granted, Rav Feinstein does not deal directly with this issue in the responsum, and Rabbi Yigal Shafran (see later) writes that his opinion applies in situations where in addition the doctors have withdrawn all efforts to save him. Disclosing information was also prohibited by BeTzel HaChochmah Responsa (volume 2, article 55) and Rabbi Shlomo Aviner (‘Informing a Terminally Ill Patient about their Condition’, Assia Books, 3 [5742], pages 336-340). The BeTzel HaChochmah qualifies their statement, writing that even according to those who advocate for not informing the patient of their disorder, one should not deceive them into thinking their situation is not serious. Rav Aviner qualifies his statement and says that in the case of one who is in severe distress and is expected to die, we tell him that shortly death will free him of his suffering. The opinion of Rabbi Yitzchok Zilberstein (‘Is it permitted or ideal to disclose a patient’s terminal illness to him?’ Emek Halacha – Assia, volume 1 [Jerusalem 5746], page 163) is that it is preferable to remain silent and hide the truth, barring cases where it is known for certain that the matter will not harm the patient’s wellbeing. Rav Shafran (‘Telling the Truth to a Patient about their Condition’, Assia Books, 7 [5754], page 23-30) writes that one should tell a patient the truth in most cases, since this is his right, especially actively dying patients, who need to confess and prepare themselves for the World to Come – notwithstanding that it is impossible to hide the truth for a prolonged period. Of course, one should act cautiously and examine each situation independently. Rabbi Shear Yashuv Cohen (‘The Doctor’s Responsibility to a Dying Patient’, Torah SheBa’al Peh, 25 [5744], pages 144-150) accepts the position of Professor Shimon Glick (earlier endnote 2, page 497) that nowadays a patient’s awareness of their condition can abate fear and lessen suffering, and therefore even though one should not say to a patient there is no hope he will live, the matter of what and how much to say is left up to the physician and the family to decide. Rabbi Yuval Cherlow on Tzohar’s ethics website determines that the baseline assumption is to tell the truth, and only if there are genuine reasons to deviate from this should one conceal it (http://bit.ly/37B5om4).  The Nishmat Avraham (Yoreh Deah, article 338:4) differentiates between preliminary exposure of the disorder, when one can still treat it and therefore the doctor must reveal to the patient both the disorder and best treatment methods, and a late diagnosis, when it is already impossible to treat the condition and supportive therapy is the only method of treatment. In most cases such as these one should not disclose to the patient the full extent of the disorder. See The Medical Halachic Encyclopedia, volume 2, entry ‘Disclosing Information to Patients’, pages 503-508.
10. Regarding the obligation and the structure of the vidui confessional for the terminally ill, see what we write in ‘Tefilot and Halachot at the Time of the Soul’s Departure’.
11. The statements of the Baraita are ruled as halacha by the Shulchan Aruch, Yoreh Deah, 338:1. The Bach and the Shach (ibid.) differentiate between a dying patient, who we instruct to confess, and a patient who is not dying, who we do not instruct to confess, in order not to break his spirit. According to the Nishmat Avraham (ibid., subarticle 2), the Shach’s intent is that even regarding a terminal patient, as long as there is no indication that he will die shortly we do not instruct him to confess. However, the Beit Lechem Yehuda states that one should preemptively confess while they still have strength and calmness of mind. See the opinion of the Nishmat Avraham in his responsum as well ‘Terminal Illness vs. Untreatable Illness’, Assia Books, 7 (5754), page 31-32. Those on the side of revealing information to the patient (Rabbi Shear Yashuv HaCohen and Rabbi Yigal Shafran, see earlier) bring proofs from the halachot of vidui, that in any case where the best of the patient would be informing them of their condition, there is an obligation to do so. See The Medical Halachic Encyclopedia as well, volume 2, entry ‘Revealing Information to the Patient’, pages 502-503. Rabbi Shear Yashuv HaCohen sees value in telling the truth to a patient, in order to allow him to get his affairs in order, such as a will and other things relating to his house, family, and property.