Categorized | Columnists, D'var Torah

Another perspective on palliative pain control

Posted on 11 April 2019 by admin

By Cantor Sheri Allen

I read with great interest Rabbi Fried’s response to “Yuri, M.D.” regarding whether or not pain medication could be administered to a dying patient (in intractable pain) in a dose that would essentially lead to the patient’s immediate death (TJP, March 28, 2019). Rabbi Fried responded that the mitigation of pain is of the highest priority, and as long as the intent was to control pain and not kill the patient, and was administered by a medical professional, then the obligation to not let the patient suffer would take precedence over the risk that the patient might die, or his/her death might be hastened, as a result of the increased dosage. He reasons, “We are only allowed to take a risk to take the patient out of his or her suffering, not to administer a medication that would clearly kill the patient or with the intention of hastening his or her death.”
But that was not the scenario that the reader described, so Rabbi Fried concluded, “Your situation would, then, not be permitted, as we never have the license to take the life of a patient, and you said that the physician knows the dose requested by the patient will take his life.” So the answer hinges on intent. And if, in fact, the doctor knew for a fact that the dosage he was about to give would kill the patient, then I would have to concur with Rabbi Fried — he/she is forbidden by halacha and most state laws (with the exception of seven U.S. states and the District of Columbia) to administer the increased dosage.
But it’s a bit more complicated than that. Dr. Robert Fine, clinical director of the Office of Clinical Ethics and Palliative Care for Baylor Scott and White Health in Dallas, states that it is very difficult to determine with certainty how much pain medication will cause a patient’s death. In fact, he sites research that challenges the assumption that administering opioids in the setting of serious illness hastens death, stating, “When administered properly, there is no evidence such medicine kills the patient, and there is some evidence that failure to treat pain hastens death because pain is stressful and stress is harmful. Sure, there is a dose that one can argue one knows is inherently fatal — however it is not clear to me what the dose is in an absolute sense — it will vary from patient to patient. Furthermore, opioids as a means of causing death are so unpredictable that states who execute persons on death row don’t use opioids to carry out the execution. Opioids just aren’t very good drugs for killing people.”
Assuming there is no clear-cut formula for “dosing a patient to death” (unless a doctor was completely negligent and knowingly administered the medication improperly), we can therefore assume that his/her only intent would be to mitigate pain and suffering. After studying this issue, in a teshuvah (ruling) for the Conservative Movement’s Committee on Jewish Law and Standards, Rabbi Elliot Dorff concludes, “In an attempt to alleviate the severe pain of a person in the last stages of dying, morphine and other pain medications may be administered in doses sufficient to dull the pain, even if this simultaneously hastens the person’s death. The intent to treat is the crucial factor.”
I wholeheartedly agree with Rabbi Fried that “watching the suffering of another is a profoundly difficult thing to endure.” But I don’t necessarily believe that “we need to entrust the suffering of the patient to the just judgment of God.” That’s why humans (with God’s help!) created hospice (full disclosure: I’m a hospice chaplain). The intent of hospice is to provide comfort at the end of life – emotional, social, spiritual and of course physical comfort, the latter of which requires a variety of appropriately dosed medications, including opioids in many cases. If administered correctly, patients will be relieved of their suffering, and family will be spared the pain of witnessing it, and can concentrate on simply being a caring, loving presence for their loved ones.
Sheri Allen is the part-time Cantor for Congregation Beth Shalom, and a chaplain for the Jewish patients at Vitas Healthcare Fort Worth.

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