מספר מזהה: 6328

- מכון שלזינגר - https://www.medethics.org.il -

end of life management

שאלה:

I would appreciate communication with you regarding what is the latest in the Halacha regarding terminal patients.
I was previously the Head of the Radiation Oncology Dept  at the University of the Witwatersrand and the Johannesburg group of Hospitals. After retirement I became involved in Palliative Care and started The Palliative Medical Institute. We trained doctors,nurses and community care workers in the Ethos and skills of Palliative Care.
Our mission differed from the usual definition of Palliative Care. We realized that there is an enormous amount of unnecessary suffering in the hospital of patients who are curable, and that it does not make sense to teach Palliative Care only for those who have life threatening or terminal illness. (and in private practice, in homes, in clinics  etc)  
We therefore expanded the WHO definition to the following: 
 Palliative Medicine is the active management to relieve suffering , physical, emotional, psychsocial and spiritual of the patient and the family. ( This is the first part of the WHO definition)
It starts at the moment of first contact with the patient and continues for the duration of the illness. If and when the illness becomes incurable, palliative care plays the major or total role.  ( The blue is our change from the WHO definition )
I discussed this abut 6 or 7 years ago with Prof Neil McDonald of McGill University in Montreal who was with the WHO in a senior capacity. In fact he told me that he had written their definition. He said our approach was logical and makes sense and encouraged us to continue with it. He said World Health would come to that approach in time but that they move slowly. 
It is important therefore that all doctors and nurses are taught the Ethos and Skills of  Palliative Care and that Palliative Care teams or specialists should be available for difficult problems. 
I was asked in 2001 to put a team into the Johannesburg Academic Hospital by the Professor of Medicine who found tremendous suffering in all wards, compounded by the AIDS epidemic . 
This team has been operating for 10 years, and we also teach some groups of medical students , who have found it of great value when they do their internships and in practice, because their role models during their training have indicated that with some patients  "There is nothing more we can do" as they have never been taught those skills. Of course there is always something one can do!
I am writing to you at the moment because I have had, and heard of, very distressing situations with orthodox doctors, who I believe misinterpret the Halacha. I contacted Rabbi Kurstag of the Beth Din and he advised me to contact you as its not his area of expertise.
I will give you two examples of many.    The first is of a patient who had an advanced carcinoma of the oesophagus. He was sent for radiation to try and palliate his symptoms of shortness of breath etc.  Suddenly the terminal event occurred in the ward in  that the tumor broke through into the trachea causing total obstruction of the airway. The patient was in unbearable suffering unable to breathe. I  told the intern to  immediately give the patient intravenous sedation so that he should not die a tortured death. He refused. He was an orthodox Jewish young man and told me that his religion did not allow it as he would be killing the patient. I was horrified as I did not believe that the Jewish religion forbade the relief of suffering in a terminal patient. I explained that it was not a lethal dose of sedation, only enough to make him unaware of the dreadful experience of not being able to breathe, and that he was actually dying ( of his cancer.) He still was not convinced.  I met that young doctor again many years later,. He was now a radiologist. I asked him if he had changed his mind. he said no, and that he had had a most distressing time with his own father who was dying and unable to breathe and he could not help him.
The second patient was not mine, but I was visiting a friend who was being looked after by Hospice. While I was there the Hospice Nurse arrived and when I met her at the door she was crying. She told me that she had just come from a house where the (Jewish) patient was dying of lung cancer.  He had pleural effusions. There was fluid in both lungs. Around his bed were three orthodox Jewish doctors, one a pulmonologist.  They had inserted a drip, and the nurse asked them if they would discontinue it as it would increase the fluid in his lungs. Their reaction was extraordinary. They told her to leave the house and never come back.  She was crying because she said the poor man was drowning in his own fluid, and she found it unbearable. I looked at the death columns and he only died two days later which must have been an unbearable death.
I have asked Rabbi Kurstag to have sessions with the orthodox Jewish doctors to explain that the Jewish religion does not teach that one must allow patients a tortured death. That is why he referred to you.
I am anxiously awaiting your reply.
A second question is regarding the Living Will so that patients can give Advanced Directives as to whether they wish to be kept artificially alive or not,
Only 60-70 years ago doctors could not cure most conditions and certainly could not prolong life. Now that they can, unfortunately the prolongation of life often means prolongation of suffering or actually causing suffering. The teaching of medicine has become disease orientated and no longer patient orientated. It is time the pendulum shifted back to the middle. We, of the Hospital Palliative Care Team are trying to achieve the integration of Palliative Medicine into Curative Medicine so that its is part of the main stream training for all doctors and nurses and that all patients will be treated humanely.  
Yours sincerely,
S B

תשובה:

1.       Pain treatment: Alleviating terminal pain is not only permissible according to Jewish law but actually required. Jewish law views terminal pain as a disease by itself and hence the same way that we are obligated to treat cancer or heart failure we are obligated to treat unbearable pain. This approach holds true also concerning complications: when a person has a disease and requires medication or surgery, there are side effects and complications to the treatment. One is permitted to take reasonable risks of complications in order to benefit in curing or reducing the danger of the disease. One is allowed to be treated with chemotherapy whether it is intended to cure the cancer or to alleviate it even if there are known and expected complications. However, if the complications include a very high risk of mortality it is forbidden. The same rules apply in the treating the disease called terminal pain. One is permitted to give morphin or other beneficial treatments to alleviate pain even if in a small percentage it may hasten death. However, if the situation is such that the treatment will cause death in a very high probability or if the dosage is so high that it is expected to cause death – it is fo0rbidden. Obviously if the intent is to kill the patient it is absolutely forbidden. Hence, good palliative care never intents to kill the patient and the type and dosage of the medication is almost always such that does not hasten death. In fact there are studies that show prolongation of life when pain is appropriately controlled.

2.       Living Will: in well-defined circumstances and conditions living wills are acceptable according to Jewish law.

3.       See The Dying Patient Law, 2005 , JME 6,2 pp.13-29 (2008) [Translated by V. Ravitsky and M. Prawer], and the article in Hebrew on the Halachick basis of the law: הבסיס ההלכתי להצעת חוק "החולה הנוטה למות"רפואה והלכה: הלכה למעשה, עמ' 476-488 (2006) ; אסיא עא-עב, עמ' 25-39 (2003)