Family Matters

The treatment of patients with terminal illnesses

The treatment of patients with terminal illnesses is one of the most sensitive topics in medical Halacha. Numerous Teshuvos of the Gedolei haPoskim discuss in discontinuation or non-renewal of life-sustaining treatment of patients who are suffering greatly, including those who are sedated and/or dependent upon mechanical ventilation.

In this essay,  we will assume the position of the majority of the Poskim that there are conditions under which medical treatment may be passively withheld from a patient, though it would prolong his life. For example, if a patient will not return to consciousness or if he is suffering greatly and further treatment would exacerbate his pain and prolong his suffering, one may refrain from administering medication vasoactive medications, cardiopulmonary resuscitation, or dialysis.

Withholding medical treatment is not an act of murder. The obligation to treat an ailing patient stems from the precept of “Lo Sa’amod Al Dam Rei’echa” and the Poskim maintain that if a patient will not recover from his illness, his life is being artificially prolonged, and he is suffering greatly, the Torah does not command us to rescue him. This is all the more true if he is unconscious.

Clearly, in all such cases a person should consult a Halachic authority who is knowledgeable in the field. There are many details pertaining to each case that impact Halacha and it is crucial to supply all relevant information, especially considering the gravity of the issue.

If a competent Halachic authority permits the discontinuation of treatment, the patient should be consulted, if possible. If he is conscious and lucid, he should be asked whether he wishes to continue treatment and, if he replies in the affirmative, despite of his dim prognosis and terrible suffering, it is forbidden to discontinue it.

Rav Shlomo Zalman Auerbach zt”l (Minchas Shlomo 1:91) maintains that a patient should actually be encouraged to continue treatment:

Many debate the question of treating a patient who is a Goses.  Some Poskim maintain that just as we desecrate Shabbos for Chayei Sha’ah, so should every patient be compelled to save himself for the sake of Chayei Sha’ah because he does not “own his body” to forego even a minute of life. 

However, logic would dictate that if the patient is suffering severe physical pain or mental anguish, he should be provided with food and oxygen even against his will, but medications that will cause him pain or suffering may be withheld at his request. 

If the patient is God-fearing and of sound mind, it is appropriate to explain to him that it is better to experience “one hour of repentance in this world than all of the life in the World to Come”. This is evident in the Gemara in Maseches Sotah (20a) which states that it is a merit to suffer for seven years rather than dying immediately. 

In other words, aside from the Halachic question of whether it is permissible to withhold palliative care, a patient and his caregivers should bear in mind that life in this world – even if it is replete with suffering – is of inestimable value. Additionally, as suffering atones for a person’s sins, it is spiritually beneficial to extend a patient’s life.

(We should add that if a patient asks for his treatment to continue yet his caregivers do not cooperate, the agitation itself may hasten his death.)

In summary, even when it is permissible to discontinue medical treatment, the final decision is left to the patient (if he is in a state to make the decision). If he asks for treatment to be discontinued, we may acquiesce. If he does not ask for it to be discontinued, and certainly if explicitly asks for continued treatment, it is absolutely forbidden to disobey his wishes.[1]

If a patient is unresponsive or unable to communicate his wishes, and has not previously expressed his desires, his caregivers must adhere to Halacha. A Halachic authority should be consulted and physicians should make their decision accordingly. Under certain conditions, such as multisystem organ failure or permanent loss of consciousness, a Rav can authorize the passive discontinuation of treatment.

This leads us to our question: If the relatives of a patient in this condition wish to make this decision on his behalf, do they have any Halachic standing to do so?[2] On one hand, they know the patient well and should be able to predict what his position would be if he were able to express it. However, there is no additional reason that they should have any authority to determine his medical treatment. (In fact, the patient himself is not considered the “owner” of his body such that he can make decisions that violate Halacha.)

However, the notion that family members can accurately assess a patient’s wishes is not entirely clear. Studies have shown that there is often a wide difference between a patient’s wishes and his relatives’ perception. Additionally, in many cases a patient’s relatives may be swayed by self-interests, such as the desire to be rid of the responsibility and burden of caring for him, or even the potential inheritance of his estate. Therefore, they cannot necessarily be trusted to have his best interests at heart or to be capable of objective assessment of his wishes.

Furthermore, there are often disagreements withing the family as to whether treatment should be continued. For example, if a patient’s sons express opposing opinions, we would certainly be unable to decide one way or another, and a third party (i.e., a Halachic authority) would need to make a decision on the matter.

What would happen if a patient’s wife expresses one opinion and his son disagrees? Would we give greater standing to the wife or the son?

In Halachic literature, contrary to the law and ethical norms that have developed over the years, this question is not discussed explicitly. We asked HaGaon Rav Asher Weiss Shlit”a for his thoughts and this was his reply:

The basis for granting relatives standing [to determine a patient’s course of treatment] stems from their ability to better appraise the patient’s wishes. There is no other reason to grant them unique status. For example, the fact that they are suffering greatly due to the patient’s treatment does not impact the fate of the patient at all.

In principle, it is reasonable to take the relatives’ opinion into account. We can assume that they are able to assess what the wishes of the patient would be in these circumstances. Obviously, we should clarify whether the patient had previously addressed the issue and revealed his opinion(s) on how to act in these situations.

It must be made clear to the relatives that their only consideration should be their assessment of the patient’s wishes, and they must be urged not to take any other considerations into account in such a grave matter.

The best approach is for the relatives to approach an expert Posek who should familiarize himself with the patient’s medical state and the assessments of his physicians. He should also hear the relatives’ position on the matter and weigh the merits of their arguments.

When there is disagreement among family members, it seems logical to give greater weight to the opinion of the person who was closest to the patient. For example, his wife’s opinion should be preferred to his children’s opinions. If there is a dispute among the children, but one of them took care of the parent during his illness and understood his viewpoint in general, he has the tools to better assess what the patient’s position would be in such a situation.

However, there are no definite rules in this regard. A Posek’s determination can change depending on the facts at hand. He must clarify the situation to the greatest possible extent and take into account all of the possible considerations in order to reach the correct decision. However, as stated, the family’s opinion does carry weight.

[1] This is the accepted approach among the Poskim. See for example the Igros Moshe (C.M. 2:74:1 & 75:1) who states: “It is necessary to inform the patient and ask him if he wishes to receive treatment with these medications. If he prefers a life of suffering over death, we must administer them. If the patient does not want to live a life of suffering, these medications should not be administered.”

[2] Certainly, if the patient has signed a power of attorney or appointed a healthcare proxy, authorizing a designated relative, friend, or Rabbi to make decisions on his behalf, it should be honored (according to the ruling(s) of the Halachic authority who has been consulted). Our question is whether to take the family members’ position into account when the patient did not appoint them as his guardian(s).