Halachic Guidelines for Physicians in Intensive Care Units*
Avraham Steinberg, M.D.
The following guidelines were formulated in consultation with the late Rabbi Shlomo Zalman Auerbach æö"ì and Rabbi Shemuel ha- Levi Wosner ùìéè"à, who reviewed the original Hebrew and gave their approval.
A. The guidelines below apply to intensive care unit (ICU) patients only when all of the following conditions apply:
1. The patient was admitted to the ICU with the assumption that his life might be saved.
2. The patient received complete intensive care treatment for his medical condition, including ventilation, treatment of infection, blood pressure control, blood clot and hemorrhage prevention, blood transfusion, intravenous feeding, and constant monitoring of blood pressure, pulse, respiration, and oxygenation.
3. At least three of the patient’s vital systems have unquestionably and irreversibly failed and all treating physicians – that is, all physicians in the ICU and all assisting specialists – have decided that all possibilities of saving his life have been exhausted and death from his illness or injury is imminent.
4. All of the above have been met, the physicians believe that the patient is suffering greatly, and it can be assumed that if there is no hope for recovery, the patient would not wish to continue suffering.
B. The guidelines below apply to ICU patients of all ages: adults, children, and infants.
C. The halachic principle pertaining to such a patient is based on the balance between the obligation to save life and the pro- hibition against actively shortening life on one hand, and not prolonging unnecessary suffering when there is no hope for recovery on the other.
1. One should avoid introducing any new treatment that will only prolong the suffering of such a patient.
2. One should cease performing diagnostic tests, such as blood tests to determine the patient’s condition, since they only add to the patient’s suffering and have no benefit whatsoever.
3. There is no need to continue monitoring a patient in this con- dition – that is, to continue checking his blood pressure, pulse, and oxygen saturation (even if the automatic monitors were already connected to the patient) – or to alter treatment as a result of the data on the screen since such examinations and treatments have no benefit whatsoever for the suffering patient.
4. One should continue analgesic treatment in order to reduce the patient’s pain and suffering as much as possible.
5. It is forbidden to do anything that will lead to the patient’s immediate death; even if there is only a suspicion that the action will lead to his death, it is forbidden.
5a. It is therefore forbidden to disconnect the patient from a respirator if the physicians believe that there is a possibility that his breathing ability is entirely dependent on the machine, and it is forbidden to abruptly withhold medications such as dopamine, which regulates blood pressure, if the physicians believe that doing so will cause the patient’s blood pressure to suddenly drop and, therefore, result in his immediate death.
6. One may alter or cease treatments when the physicians do not believe that doing so will cause the patient to immediately die – even though, as a result, he will die from his illness or injury within a number of hours – provided that the physicians believe that the patient is suffering, the changes in treatment are gradual and controlled, and the patient is monitored following the changes.
6a. It is therefore permitted to lower the rate of the artificial respirator to the point where the patient is still breathing; to lower the respirator’s oxygen concentration to the level of regular air normally breathed; to gradually lower dopamine dosage if no significant change is expected in the patient’s blood pressure – and even if a change is seen in his blood pressure, as long as it will not lead to his immediate death; to cease total parenteral infusion – that is, the concentrated nutrition the patient is fed through the vein – and to feed him orally through a feeding tube or even to feed him sugar and water solution intravenously; to discontinue medications given to prevent blood clots and hemorrhages, such as heparin and H2 blockers; and to discontinue insulin given to lower high blood sugar levels. All this is on strict condition that the patient is terminal and suffering greatly.
6b. It is therefore permitted not to renew medications or treat- ments given periodically rather than continuously. For example, one need not restart dopamine or antibiotic treatment after the IV bag has been emptied. All this is on strict condition that the patient is terminal and suffering greatly.
E. These guidelines pertain only to patients as described above (A, B). For all other cases an halachic authority should be consulted.
Source: ASSIA – Jewish Medical Ethics,
Vol. IV, No. 1, February 2001, pp. 5-6
* Originally published in Hebrew as “Klalim Hilchatiyyim le-Hitnahagut Rofeh be-Yehida le-Tippul Nimrats” in Ha-Kinus ha-Beinleumi ha-Sheini: Refua, Etika ve-Halacha: Asufat Ma’amarim (Jerusalem: The Schlesinger Institute, 1996). More recently published in ASSIA 63-64 (vol. 16, nos. 3-4) (1998): 18-19.