Pain medications for terminal patients

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 of the medication for pain control. The physician knew that increasing the dose of the medication would mean the patient would stop breathing, and die. Yet, not increasing the medication would result in the continuation of severe pain, with the patient’s death in a few weeks, anyway. Essentially, administering the higher dose of pain medication would kill the patient; is this allowed?
Yuri, M.D.
Dear Dr. Yuri,
Your question is a very difficult one to decide on a purely moral, or philosophical basis, but 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 that will only allow him to live temporarily. Jewish law defines this as 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 to potentially save a patient’s life.
The authorities apply this reasoning, albeit with a caveat, to a question similar to yours: A patient is terminally ill, has no hope for recovery and is suffering great pain. To administer more pain killer will certainly relieve his pain, but could 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 ruled that not only can the doctor administer the medicine but is obliged to administer the pain medication despite the risk (Igros Moshe Ch. M. 2:73). 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 a condition in its own right. The suffering and despair it can cause could render the pain, itself, as a lethal condition. Every doctor knows how profoundly the mental state and emotional well-being of a patient can affect the overall medical condition and the mortality of his sickness, especially as it pertains to intense pain.
We also 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 to perform actions that will calm the patient or make him/her more comfortable. This is true if they improve the patient’s mental state, even when those actions do not directly affect his/her condition. The Talmud considers the mental state to be directly related to the mortality of the condition.
Rabbi Feinstein concludes that a patient should never be allowed to suffer uncontrollably, even when treating that suffering means a risk of mortality. This ruling, however, carries two important stipulations:
• The medication is given to control the pain, 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.
• The medication must be administered by an expert, who will know how to manage the therapy in a way that 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, 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.
Although watching the suffering of another is a profoundly difficult thing to endure, it is an area where we need to entrust the suffering of the patient to the just judgment of God, whose ways we do not always understand. We well know we cannot switch roles with Him.

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