Treatment Decisions
Hastening Death vs. Removing Impediments
ההוא יומא דנח נפשיה דרבי גזרו רבנן תעניתא ובעו רחמי ואמרי כל מאן דאמר נח נפשיה דר' ידקר בחרבסליקא אמתיה דרבי לאיגרא אמרה עליוני' מבקשין את רבי והתחתוני' מבקשין את רבי יהי רצון שיכופו תחתונים את העליונים כיון דחזאי כמה זימני דעייל לבית הכסא וחלץ תפילין ומנח להו וקמצטער אמרה יהי רצון שיכופו עליונים את התחתוניםולא הוו שתקי רבנן מלמיבעי רחמי שקלה כוזא שדייא מאיגרא [לארעא] אישתיקו מרחמי ונח נפשיה דרבי
§ It is related that on the day that Rabbi Yehuda HaNasi died, the Sages decreed a fast, and begged for divine mercy so that he would not die. And they said: Anyone who says that Rabbi Yehuda HaNasi has died will be stabbed with a sword. The maidservant of Rabbi Yehuda HaNasi ascended to the roof and said: The upper realms are requesting the presence of Rabbi Yehuda HaNasi, and the lower realms are requesting the presence of Rabbi Yehuda HaNasi. May it be the will of God that the lower worlds should impose their will upon the upper worlds. However, when she saw how many times he would enter the bathroom and remove his phylacteries, and then exit and put them back on, and how he was suffering with his intestinal disease, she said: May it be the will of God that the upper worlds should impose their will upon the lower worlds.And the Sages, meanwhile, would not be silent, i.e., they would not refrain, from begging for mercy so that Rabbi Yehuda HaNasi would not die. So she took a jug [kuza] and threw it from the roof to the ground. Due to the sudden noise, the Sages were momentarily silent and refrained from begging for mercy, and Rabbi Yehuda HaNasi died.
הביאוהו וכרכוהו בס"ת והקיפוהו בחבילי זמורות והציתו בהן את האור והביאו ספוגין של צמר ושראום במים והניחום על לבו כדי שלא תצא נשמתו מהרה אמרה לו בתו אבא אראך בכך אמר לה אילמלי אני נשרפתי לבדי היה הדבר קשה לי עכשיו שאני נשרף וס"ת עמי מי שמבקש עלבונה של ס"ת הוא יבקש עלבוני
אמרו לו תלמידיו רבי מה אתה רואה אמר להן גליון נשרפין ואותיות פורחות אף אתה פתח פיך ותכנס בך האש אמר להן מוטב שיטלנה מי שנתנה ואל יחבל הוא בעצמו
אמר לו קלצטונירי רבי אם אני מרבה בשלהבת ונוטל ספוגין של צמר מעל לבך אתה מביאני לחיי העולם הבא אמר לו הן השבע לי נשבע לו מיד הרבה בשלהבת ונטל ספוגין של צמר מעל לבו יצאה נשמתו במהרה אף הוא קפץ ונפל לתוך האור
They brought him to be sentenced, and wrapped him in the Torah scroll, and encircled him with bundles of branches, and they set fire to it. And they brought tufts of wool and soaked them in water, and placed them on his heart, so that his soul should not leave his body quickly, but he would die slowly and painfully. His daughter said to him: Father, must I see you like this? Rabbi Ḥanina ben Teradyon said to her: If I alone were being burned, it would be difficult for me, but now that I am burning along with a Torah scroll, He who will seek retribution for the insult accorded to the Torah scroll will also seek retribution for the insult accorded to me.
His students said to him: Our teacher, what do you see? Rabbi Ḥanina ben Teradyon said to them: I see the parchment burning, but its letters are flying to the heavens. They said to him: You too should open your mouth and the fire will enter you, and you will die quickly. Rabbi Ḥanina ben Teradyon said to them: It is preferable that He who gave me my soul should take it away, and one should not harm oneself to speed his death.
The executioner [kaltzatoniri] said to him: My teacher, if I increase the flame and take off the tufts of wool from your heart, so that you will die sooner and suffer less, will you bring me to the life of the World-to-Come? Rabbi Ḥanina ben Teradyon said to the executioner: Yes. The executioner said: Take an oath for me, that what you say is true. Rabbi Ḥanina ben Teradyon took the oath for him, and the executioner immediately increased the flame and took off the tufts of wool from his heart, causing his soul to leave his body quickly. The executioner too leaped and fell into the fire and died.
(א) הַגּוֹסֵס, הֲרֵי הוּא כְּחַי לְכָל דְּבָרָיו. אֵין קוֹשְׁרִין לְחָיָיו, וְאֵין סָכִין אוֹתוֹ, וְאֵין מְדִיחִין אוֹתוֹ, וְאֵין פּוֹקְקִין אֶת נְקָבָיו, וְאֵין שׁוֹמְטִין הַכַּר מִתַּחְתָּיו, וְאֵין נוֹתְנִין אוֹתוֹ עַל גַּבֵּי חוֹל, וְלֹא עַל גַּבֵּי חַרְסִית וְלֹא עַל גַּבֵּי אֲדָמָה, וְאֵין נוֹתְנִין עַל כְּרֵסוֹ, לֹא קְעָרָה, וְלֹא מַגְרֵפָה, וְלֹא צְלוֹחִית שֶׁל מַיִם, וְלֹא גַּרְגִּיר שֶׁל מֶלַח, וְאֵין מַשְׁמִיעִין עָלָיו עֲיָרוֹת, וְאֵין שׂוֹכְרִין חֲלִילִין וּמְקוֹנְנוֹת, וְאֵין מְעַמְּצִין עֵינָיו עַד שֶׁתֵּצֵא נַפְשׁוֹ. וְכָל הַמְּעַמֵּץ עִם יְצִיאַת הַנֶּפֶשׁ, הֲרֵי זֶה שׁוֹפֵךְ דָּמִים. וְאֵין קוֹרְעִין, וְלֹא חוֹלְצִין, וְלֹא מַסְפִּידִין עָלָיו, וְלֹא מַכְנִיסִין עִמּוֹ אָרוֹן לַבַּיִת, עַד שֶׁיָּמוּת. וְאֵין פּוֹתְחִין עָלָיו בְּצִדּוּק הדִּין, עַד שֶׁתֵּצֵא נַפְשׁוֹ. הַגָּה: וְיֵשׁ אוֹמְרִים דְּאֵין חוֹצְבִין לוֹ קֶבֶר אַף עַל פִּי שֶׁאֵינוֹ עִמּוֹ בַּבַּיִת, עַד אַחַר שֶׁיָּמוּת (ריב''ש סִימָן קי''ד). אָסוּר לַחֲצֹב שׁוּם קֶבֶר לִהְיוֹת פָּתוּחַ עַד לְמָחָר שֶׁלֹּא יִקְבְּרוּ בּוֹ הַמֵּת בְּאוֹתוֹ הַיּוֹם, וְיֵשׁ סַכָּנָה בַּדָּבָר (רַבֵּנוּ יְרוּחָם בְּשֵׁם הר''י הֶחָסִיד זַ''ל). וְכֵן אָסוּר לִגְרֹם לַמֵּת שֶׁיָּמוּת מְהֵרָה, כְּגוֹן מִי שֶׁהוּא גּוֹסֵס זְמַן אָרֹךְ וְלֹא יוּכַל לְהִפָּרֵד, אָסוּר לְהִשָּׁמֵט הַכַּר וְהַכֶּסֶת מִתַּחְתָּיו, מִכֹּחַ שֶׁאוֹמְרִין שֶׁיֵּשׁ נוֹצוֹת מִקְצָת עוֹפוֹת שֶׁגּוֹרְמִים זֶה וְכֵן לֹא יְזִיזֶנּוּ מִמְּקוֹמוֹ. וְכֵן אָסוּר לָשׂוּם מַפְתְּחוֹת ב''ה תַּחַת רֹאשׁוֹ, כְּדֵי שֶׁיִּפָּרֵד. אֲבָל אִם יֵשׁ שָׁם דָּבָר שֶׁגּוֹרֵם עִכּוּב יְצִיאַת הַנֶּפֶשׁ, כְּגוֹן שֶׁיֵּשׁ סָמוּךְ לְאוֹתוֹ בַּיִת קוֹל דּוֹפֵק, כְּגוֹן חוֹטֵב עֵצִים, אוֹ שֶׁיֵּשׁ מֶלַח עַל לְשׁוֹנוֹ וְאֵלּוּ מְעַכְּבִים יְצִיאַת הַנֶּפֶשׁ, מֻתָּר לַהֲסִירוֹ מִשָּׁם, דְּאֵין בָּזֶה מַעֲשֶׂה כְּלָל, אֶלָּא שֶׁמֵּסִיר הַמּוֹנֵעַ (הַכֹּל בְּהַגָּהַת אַלְפָסִי פֶּרֶק אֵלּוּ מְגַלְּחִין).
(1) One who is dying is like a living person for all his affairs. They do not dye his cheeks, and they do not anoint him, and they do not wash him, and they do not stuff up his orifices, and they do not remove the pillow from under him, and they do not place him on sand nor on clay nor on earth, and they do not place a pot or a trowel or a pitcher of water or a grain of salt on his stomach, and they do not announce about him to the cities, and they do not hire flautists and lamenters, and they do not close his eyes, until his soul departs. And anyone who closes his eyes while the soul is [still] departing, behold this one spills blood. And they do not tear [their clothing] over him and they do not remove their shoes and they do not eulogize over him and they do not bring a coffin into the house with him until he dies. And they do not open about him with [the post-death blessing of] justifying the judgment until his soul departs. Ra"mah Gloss: and some say that they do not dig a grave, even though it is not with him in the house, until after he dies. (Rivash 114) It is forbidden to dig any grave to be open until the next day, that they not bury him in it on that day, and there is danger in the matter. (Rabbenu Yeruham in the name of R. Yehudah he-Hassid, ob"n) And so it is forbidden to cause the dead person to die quickly. Such as one who was dying for a long time and he could not separate, it is forbidden to remove the pillow or the mattress from underneath him, because they say that there are feathers of some birds that cause this, and similarly they should not move him from his place. And similarly it is forbidden to place the keys of the synagogue under his head, in order that he take leave. But if there is something there that is causing delay in the departure of the soul, such as if there is a banging noise next to that house, such as a wood chopper, or there is salt on his tongue, and these are preventing the departure of the soul, it is permitted to remove it from there. There is no affirmative act in these examples at all - rather it is removing the barrier....
שו"ת עשה לך רב חלק ה סימן כט
ברור שלא כתבנו כל הנ"ל כדי לברר דין נוצות שבכר וגרגיר מלח, אלא שדין הגרגיר שמותר להוציאו מלשון הגוסס, הוא הדמיון השלם למכונת הנשמה מלאכותית.
Responsa Aseh Lech Rav 5:29
It is clear that we have not written all of this to clarify the rule of feathers in a pillow, or a grain of salt. Rather, the rule of the grain, which one may remove from the tongue of the goses, is entirely comparable to a respirator...
שו"ת ציץ אליעזר חלק יג סימן פזחולה מסוכן שהרופאים התיאשו מלרפאו, וסובל יסורים קשים ממחלתו אם מותר להגדיל לתת לו זריקות הארגעה כמו מורפיום הגם שאינן מרפאות את המחלה והגם שעלולות מאידך לקרב מיתתו.
והנה לפענ"ד נראה דכל היכא שתכשירי הרפואה הניתנים הן בצורת כדורים והן בצורת זריקות, נתנים המה ע"י הרופא במטרה כדי להקל מעליו יסוריו הקשים מותר לו לתת לחולה, הגם שמאידך המה מזיקים לו ועלולים גם לקרב יותר את מיתתו, כי נראה שזהו ג"כ בכלל נתינת הרשות שנתנה התורה לרופא לרפאות...
Responsa Tzitz Eliezer 13:87
A dangerously-ill person of whose healing the doctors have given up hope, and suffers tremendously from his illness, may one increase the amount of pain reduction medicine, such as morphine, despite despite the fact that they do not heal the illness and might even hasten his death.
It appears to me that anywhere the medicines are given by the doctor, whether in pill form or intravenously, in order to lessen the pain, one may give it to the patient. Even though they might hasten his death, this too is included in the category of permission that was given to doctors to heal...
שלטי גיבורים מועד קטן טז: באלפס
ומכאן היה נראה לאסור מה שנוהגים קצת אנשים כשהמת גוסס ואין הנשמה יכולה לצאת ששומטין הכר מתחתיו כדי שימות מהרה, שאומרים כי יש במטה נוצות של עופות שגורמין לנפש שלא תצא. וכמה פעמים צעקתי ככרוכיא ולא עלה בידי, ורבותי חלקו עלי, והר"ר נתן איש איגרא ז"ל כתב על זה להתיר.
Shiltei Gibborim Moed Katan 16b
From here it would seem fit to prohibit that which some have the custom to do, namely that when the person is on the cusp of dying but the soul is not able to leave, they remove the pillow from beneath him so he dies quickly, for they say that the bed contains bird feathers that cause the soul not to depart. On multiple occasions I protested this but was not successful in effecting change]. But my teachers disagreed with me, and Rabbi Natan of Igra wrote that this is permissible.
Rabbi Yitzchak Breitowitz, “The Right to Die: A Halachic Approach,” www.jlaw.com (Orthodox)
To be a candidate for passive euthanasia, a patient must be terminally ill, suffering, and wanting to die. Most rabbinical authorities (Rabbi Moshe Feinstein, for one) have sanctioned the patient’s right to decline treatment provided a number of very specific conditions were met. First, the patient must be in a terminal condition – that is, whether the treatment is employed or not, the patient is not expected to live beyond a year. Second, the patient suffers excruciating pain and suffering.
Third, the patient has indicated that he or she desires not to be treated. In the event the patient is incompetent or unable to communicate his decision, next-of-kin may make such a decision based exclusively on what they feel the patient would have wanted. (Note: This is not based on what they would have wanted if they would have been the patient but rather what this particular patient would actually desire). Fourth, assuming the above three conditions are met, the patient may decline surgery, chemotherapy, and painful invasive treatments but may not decline food, water, or oxygen (which are the normal sustainers of life, the withdrawal of which may be tantamount to murder or suicide).
Antibiotics may also fall under the “food” category because they are generally a noninvasive, non-painful procedure. There is also some question whether tube feeding falls in the category of “food” or in the category of “surgery.” Most decisors would place it in the former but emphasize that even if the patient is halachically-obligated to take artificial nutrition, he should not be force-fed or physically-restrained. In no event may the patient or the physician take any affirmative step that would hasten death. Active euthanasia, regardless of motive, is morally and halachically equivalent to murder. On the other hand, halachah views both the goals and methods of hospice in a sympathetic light.