Pain medication and suffering

By Rabbi Yerachmiel D. Fried

Dear Rabbi Fried,

I recently came across an interesting moral dilemma. A terminal cancer patient in severe pain was on a very high dosage of opioids. He requested more medication for pain control. The physician knew that increasing the dose of the medication could cause the cessation of breathing and the patient could die. On the other hand, not increasing the medication will result in the continuation of severe pain and the patient could die several weeks later with great suffering. Essentially, administering the higher dose of pain medication will probably kill the patient; is this allowed?

Thanks, Yuri, M.D.

Dear Dr. Yuri,

Your question is a very difficult one to decide on a purely moral or philosophical basis. It is, however, one for which we have clear guidelines from our rabbinical leadership based upon principles taught in the Talmud.

We’ll start with a different situation: A patient has a condition which will only allow him to live temporarily (generally defined by Jewish law as surely dying within a year). A treatment is available that, if successful, will enable him to live for many more years; if not successful, it could kill him immediately. Jewish law teaches that the doctor may ethically and morally administer that treatment and even should do so, although it runs the risk of killing the patient. One can and should run a lethal risk for one whose time is very limited to potentially save the life of a patient for the long term.

The authorities apply this reasoning, albeit with a caveat, to a similar question to yours: if a patient is terminally ill, has no hope for recovery and is suffering great pain. To administer more painkiller will certainly relieve his pain, but may stop his breathing, causing him to die. In this case, the risk we are taking is not to potentially cure the patient, but to relieve his pain and suffering. Would the above reasoning apply even in this situation? 

Rabbi M. Feinstein ob”m ruled1 that not only can the doctor administer the medicine, he or she is obliged to administer the pain medication despite the risk.

Rabbi Feinstein’s ruling is predicated upon the understanding that pain is not innocuous; it is not only a symptom of another condition. Pain is considered to be a condition on its own right; the suffering and despair it can cause could render it as a lethal condition. Every doctor knows how profoundly the mental state and emotional well-being of a patient affect his overall medical condition and the mortality of his sickness, especially that of intense pain.

We find a precedent for this in the laws of Shabbos, which require us to desecrate the holiness of Shabbos to save Jewish life. When a patient is deathly ill, one is allowed to desecrate Shabbos in order to perform actions which will only calm down the patient or make them more comfortable. This is true even when those actions do not directly affect or contribute to the cure of the patient’s medical condition as long as they will improve his or her mental state. The Talmud considers the mental state to be directly related to the mortality of the condition, hence that supersedes the all-important laws of Shabbos.

Rabbi Feinstein concludes that a patient should never be allowed to suffer uncontrollably, even when treating that suffering there is a risk of mortality. This ruling, however, carries two important stipulations: 

The medication is given to control the pain and not to kill the patient. 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.

Secondly, it must be administered by an expert in this area who will know how to manage and titrate the medication in a way which will minimize the risk of the suppression of breathing; this is not an area to be trusted to a student or amateur.

Your situation would, then, not be permitted if the physician knows the dose will be lethal, as we never have the license to take the life of a patient.

Although observing the suffering of another is a profoundly difficult thing to endure, it is an area where we need to, as much as it pains us, entrust the suffering of the patient to the just judgment of G-d, Whose ways we do not always understand. We well know we cannot switch roles with Him!

Rabbi Yerachmiel D. Fried is dean of DATA-Dallas Area Torah Association.

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