A patient suffering from severe pain is generally administered painkillers such as morphine, which are used for pain management, relief, and sedation. However, painkillers may impair respiration, and there is a concern that a patients receiving morphine injections will suffer from respiratory depression that may shorten their life1. This begs the question: can one treat a patient’s suffering even at the price of shortening their life, or perhaps one should not risk life at the expense of prolonged suffering2?
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
When we are forced to decide between prolonging life and mitigating pain, we are faced with a conflict between the value and sanctity of human life and the value of autonomy over one’s body and one’s quality of life. The inherent value of life and its sanctity demands placing priority on conserving it against any significant dangers that befall it, one of such dangers being the state of suffering. The value of quality of life, as subjective and relative as it is, can in certain cases override the inherent value of life.
How do we decide between these two values and who is qualified to make this ruling? The value of autonomy determines that man is an autonomous entity who therefore has mastership over his body and is able to make independent decisions concerning its wellbeing. From the value of autonomy, we can derive two secondary principles: 1) a patient of sound mind should be the decider in what procedures will be done to him; 2) if the patient is not of sound mind, one should evaluate what their wishes would be in this scenario and grant this evaluation significant weight in the decision-making process. Naturally, the balance between these two values tends to vary amongst societies, and therefore the legal status is different from country to country3.
3. The Jewish Position
3.1 The Value of the Sanctity of Life
Sanctity of life is a tremendous value. 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. The Gemara (ibid. side a) states that it is obvious that even for incurable maladies and the terminally ill do we violate the Sabbath4. Each moment of life has value, even if man’s days are numbered and it is clear they will pass away shortly.
3.2 The Preservation of Health
The responsibility placed on man to conserve his health is a lofty one, and therefore he is commanded to seek out treatment and physicians are commanded to heal him5. The obligation to preserve life includes a ban on suicide as well6.
3.3 The Severity of Suffering
The Gemara (Ketubot 33a-b) raises the logical inference that suffering and pain can be more severe than death. It can be understood from this that under certain conditions pain management is more important that the consideration of prolonging life. Elsewhere the Gemara recounts (Avodah Zara 18a) the story of Rabbi Chanina Ben Tradyon, sentenced to death by fire, and this account is the basis for the halachic discussion surrounding shortening life in situations of suffering. On the one hand, Rabbi Chanina refuses to open his mouth in order to expedite his death; on the other hand, he consents to the offer of the executioner to stoke the fire and remove the sponge covering his heart, bringing his death closer. One can conclude from this that there are situations in which prevention of suffering is more important than conserving temporary life. Rav Moshe Feinstein adapted this rationale “in situations where there is suffering and medicine does not have a method for even alleviating this pain, because in these cases people would rather die than live such lives of suffering”7.
3.4 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 harm8. 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?
3.5 Using Painkillers That May Shorten Life
The generally accepted halachic position is that one may give a terminally ill patient painkillers, even if there is a concern that they will shorten his life9. The poskim have determined a number of qualifying factors:
- The pain is a component of the illness, and the treatment is within the protocols of what a physician may perform. This permit includes assuming a low risk that the patient will die from the treatment, as the Ramban explains10.
- It is the generally accepted treatment method for patients in distress and since this is the practice, it falls under the guidelines of “God protects the simple”11.
- The treatment of the pain itself will cause the patient to feel better and enable him to eat and drink in a better fashion, thereby extending his life in the process. 12
- The obligation to extend the patient’s life is limited and would be non-existent in cases where there is no chance for recovery and significant distress. A patient like this who is suffering tremendously does not need to struggle to breathe in order to live13.
- One injection itself will not shorten life, and only repeated administration is life-threatening14.
Morphine at its core is not a form of euthanasia that interferes with cardiac functioning. It can lead to coma, and only leads to respiratory insufficiency indirectly15.
- One is permitted to give painkillers (such as morphine) to a patient in extreme distress even if there is a risk that the medication will shorten his life. This is on condition that the medicine is administered for the purpose of alleviating the pain and not for the purpose of shortening the patient’s life16 and it is known that one dose will not cause harm to the patient.17
- When a patient is conscious, it is proper to include him in the discussion and enable him to choose whether to prolong his life even in a state of suffering or whether to mitigate suffering despite the risk to his life.
- When a patient cannot express their opinion and consent, one should consider what the patient would want and what they would request from their physicians in this state.
- Despite this, it is worthwhile to note that proper usage of morphine is not life-threatening. See The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill’, pages 104-105.
- Elsewhere we have expanded on the fundamental issue of halacha’s relationship to suffering. There we deal with the tension between the inherent value of life and the value of quality of life, and the issue of whether one may forgo life-prolonging treatments when in a state of severe distress. See position paper ‘The Impact of Suffering on Medical and Halachic Considerations’. Here we will discuss a different aspect of the tension between the sanctity and quality of life, and therefore we have summarized the main issue and expanded on the practical aspect of morphine administration. We also do not cite all our sources here, for the extended discussion see the aforementioned paper. For additional halachic perspectives of using painkillers, see position paper ‘Painkillers and Consciousness’.
- See: The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill ’, pages 171-176; volume 2, entry ‘Consent’, pages 633-717; position paper of the Israeli Medical Association, ‘Medical Ethics, the Treatment of Terminal Illnesses, and Ineffective Treatments’, October 2019 (https://bit.ly/3gigj8k), and see later endnote 10.
- This is the ruling of the Shulchan Aruch, Orach Chayim, 339:4.
- Shulchan Aruch, Yoreh Deah, 336:1. See position paper ‘The Obligation to Be Healed’.
- Mishneh Torah, Hilchot Rotzeach Ve’Shmirat Hanefesh, chapter 2, halacha 5.
- See Igrot Moshe Responsa, Choshen Mishpat, volume 2, article 74:2. His ruling there applies in cases where there is no ability to heal the person and continued treatment is accompanied by suffering. In these cases, there is no obligation to heal them, and even if we do not know the patient’s wishes, we assume that his death would be preferred over his life.
- According to Rabbi Shlomo Yosef Zevin (In Light of Halacha, pages 318 onwards; ibid., Halacha and Medicine, 2 , 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 ‘Informed 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.
- See: Minchat Shlomo Responsa, Tinyana, article 86 (the opinion of Rabbi Shlomo Zalman Auerbach is also brought in the Nishmat Avraham, Yoreh Deah, article 339:4); Tzitz Eliezer Responsa, volume 13, article 87; Teshuvot Ve’Hanhagot Responsa, volume 3, article 361; Be’Mareh Habazak Responsa, volume 6, article 78; Rabbi Yitzchok Zilberstein ‘Morphine for a Terminally Ill Patient Suffering from Aspiration’, Assia, 59-60 (5757), pages 52-57. Rav Feinstein’s position is unclear. In a responsum that does not deal with the subject directly (Igrot Moshe Responsa, Choshen Mishpat, volume 2, article 73:1) he writes: “but if there is a medication that will alleviate the suffering and not shorten even a moment of his life, we must administer it as long as he is not actively dying”. It thus seems that he prohibits this method, but there are those who explain from here that he indeed permits it. According to Rabbi Avigdor Nebenzahl, ‘Administering Psychoactive Substances to Terminal Patients’, Assia, 25-26 (5740), pages 39-41, drug administration in this fashion does not just have an aspect of murder but are murderous in nature. However, he ultimately accepts the opinion of his rabbi Rabbi Shlomo Zalman Auerbach in practice. See also: The Medical Halachic Encyclopedia, volume 5, entry ‘Terminally Ill’, pages 161-162; Nishmat Avraham, Orach Chayum, article 328:17.
- Tzitz Eliezer Responsa (earlier endnote 9), according to the Ramban’s opinion in the Torat Adam, Sha’ar Hameichush, the Matter of Sakanah [Rabbi Chavel Edition, Jerusalem 5724], pages 41-43, and Teshuvot VeHanhagot Responsa (earlier endnote 9). Published alongside the responsum in the Tzitz Eliezer is the response of Professor David M. Meir, CEO of Sha’arei Tzedek Hospital at the time, who writes that the modern medical stance also states that pain is part of the disorder that the physician is required to treat, and there is an obligation to treat the patient even if this treatment is accompanied by risks, just like any other drug or medical procedure.
- See Minchat Shlomo Responsa, (earlier endnote 9).
- See: Tzitz Eliezer Responsa (earlier endnote 9); Minchat Shlomo Responsa (earlier endnote 9.
- See what we wrote in position paper ‘The Impact of Suffering on Medical and Halachic Considerations’, alongside endnote 12; See the Minchat Shlomo Responsa (earlier endnote 9) as well. Even Rav Waldenberg, whose opinion is that even in a case of suffering one should not withhold life-prolonging treatments, justifies the heter in the aforementioned responsum (earlier endnote 9), stating that since there is no chance of recovery there is preference for treating the pain. He relies on the opinion of the Ya’avetz, Mor VeKetziah, article 328, 101a.
- This is the opinion of Rabbi Shlomo Zalman Auerbach in the Nishmat Avraham, Yoreh Deah (earlier endnote 9); Rav Nebenzahl (earlier endnote 9) writes this in his name as well. In Teshuvot VeHanhagot (earlier endnote 10) Rav Sternbuch writes that he would be more lenient than Rabbi Shlomo Zalman Auerbach, and even in a case where a patient could potentially die from one injection may one administer the medication, as long as the goal is to treat the pain. He does not expand on this topic, since practically one cannot determine if one injection will certainly cause damage.
- See the words of Rabbi Yitzchok Zilberstein (earlier endnote 10). This stance is not independent, but juxtaposed to the claim that a patient is not obligated to extend his life in such a situation.
- Tzitz Eliezer Responsa (earlier endnote 9); the opinion of Rabbi Shlomo Zalman Auerbach in the Nishmat Avraham, Yoreh Deah (earlier endnote 9).
- This is the opinion of Rabbi Shlomo Zalman Auerbach in the Nishmat Avraham, Yoreh Deah (earlier endnote 9); Rav Nebenzahl (earlier endnote 9) writes this in his name as well.