Part 1: Difficult Diagnosis
Legal Challenges: Informed Consent
From a legal perspective of informed consent, since healthcare professionals are open to liability issues, malpractice, and losing their license if they don't inform patients about all relevant information that pertain to their treatment, they tend to err towards full disclosure as often as possible, regardless of the emotional or psychological impact it may have on the patient. This is framed as a patient's "right to know."
From a legal perspective of informed consent, since healthcare professionals are open to liability issues, malpractice, and losing their license if they don't inform patients about all relevant information that pertain to their treatment, they tend to err towards full disclosure as often as possible, regardless of the emotional or psychological impact it may have on the patient. This is framed as a patient's "right to know."
The History:
Jonathan F. Will, A Brief Historical and Theoretical Perspective, Chest 139:6 pg. 1493
While physicians did develop a more consistent practice of obtaining patient consent in the early 20th century, the medical literature indicates that the practice was fueled more by a desire to respond to lawsuits than by a moral imperative to respect patient autonomy. In a 1911 article, physician George W. Gay suggested that “careful and explicit explanations of the nature of serious cases, together with the complications liable to arise and their probable termination... be given to the patient ... for our own protection.”…
In Schloendorff v Society of New York Hospitals, Justice Cardozo planted the seed for what would become the informed consent doctrine when he wrote, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.”
Jonathan F. Will, A Brief Historical and Theoretical Perspective, Chest 139:6 pg. 1493
While physicians did develop a more consistent practice of obtaining patient consent in the early 20th century, the medical literature indicates that the practice was fueled more by a desire to respond to lawsuits than by a moral imperative to respect patient autonomy. In a 1911 article, physician George W. Gay suggested that “careful and explicit explanations of the nature of serious cases, together with the complications liable to arise and their probable termination... be given to the patient ... for our own protection.”…
In Schloendorff v Society of New York Hospitals, Justice Cardozo planted the seed for what would become the informed consent doctrine when he wrote, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.”
Exceptions:
1. https://journalofethics.ama-assn.org/article/informed-consent-what-must-physician-disclose-patient/2012-07
In Arato v. Avedon, however, physicians were not required to disclose particular statistical life expectancy rates to a patient suffering from pancreatic cancer, mainly on the grounds that statistics do not usefully relate to an individual’s future.
1. https://journalofethics.ama-assn.org/article/informed-consent-what-must-physician-disclose-patient/2012-07
In Arato v. Avedon, however, physicians were not required to disclose particular statistical life expectancy rates to a patient suffering from pancreatic cancer, mainly on the grounds that statistics do not usefully relate to an individual’s future.
If, for example, a patient has become so emotionally distraught that he or she would become incapable of making a rational decision, courts generally do not require disclosure. If disclosure is likely to cause psychological harm to the patient, a physician does not have a duty to disclose. However, a physician cannot use the exception to withhold information merely because he or she thinks the information may cause the patient to refuse a specific treatment. In other words, a physician must disclose information that a reasonable person would want to have for decision making, even though that information may cause the patient to refuse treatment that the physician believes is in the patient's best interest.
Given that requirements for informed consent are relatively vague and undefined and the exceptions are few, it is in the physician’s best interest to inform patients thoroughly about proposed treatment options, ascertain that they understand their choices, and secure their consent. Doing so will help provide quality patient care and avoid exposure to legal action.
Given that requirements for informed consent are relatively vague and undefined and the exceptions are few, it is in the physician’s best interest to inform patients thoroughly about proposed treatment options, ascertain that they understand their choices, and secure their consent. Doing so will help provide quality patient care and avoid exposure to legal action.
2. Clarence H. Braddock III, MD, MPH Assistant professor, Medicine Adjunct professor, Medical History and Ethics; https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/82
The second circumstance is if the patient him- or herself states an informed preference not to be told the truth. Some patients might ask that the physician instead consult family members, for instance. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.
The second circumstance is if the patient him- or herself states an informed preference not to be told the truth. Some patients might ask that the physician instead consult family members, for instance. In these cases, it is critical that the patient give thought to the implications of abdicating their role in decision making. If they chose to make an informed decision not to be informed, however, this preference should be respected.
The Ideal:
Clarence H. Braddock III, MD, MPH Assistant professor, Medicine Adjunct professor, Medical History and Ethics; Ibid.
There are many physicians who worry about the harmful effects of disclosing too much information to patients. Assuming that such disclosure is done with appropriate sensitivity and tact, there is little empirical evidence to support such a fear. If the physician has some compelling reason to think that disclosure would create a real and predictable harmful effect on the patient, it may be justified to withhold truthful information.
Clarence H. Braddock III, MD, MPH Assistant professor, Medicine Adjunct professor, Medical History and Ethics; Ibid.
There are many physicians who worry about the harmful effects of disclosing too much information to patients. Assuming that such disclosure is done with appropriate sensitivity and tact, there is little empirical evidence to support such a fear. If the physician has some compelling reason to think that disclosure would create a real and predictable harmful effect on the patient, it may be justified to withhold truthful information.
The Reality:
1. Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016 Jan;29(1):101-2.
When physicians lack proper training, breaking bad news can lead to negative consequences for patients, families, and physicians... Results revealed that 91% of respondents perceived delivering bad news as a very important skill, but only 40% felt they had the training to effectively deliver such news.
2. https://www.oncnursingnews.com/view/compassionate-care
Researchers at the The Schwartz Center for Compassionate Healthcare at Massachusetts General Hospital in Boston surveyed 800 hospitalized patients and 510 physicians and found broad agreement that compassionate care is considered very important to successful medical treatment. However, only 53% of the patients and 58% of the physicians indicated that they felt that compassionate care is being provided to patients.
1. Monden KR, Gentry L, Cox TR. Delivering bad news to patients. Proc (Bayl Univ Med Cent). 2016 Jan;29(1):101-2.
When physicians lack proper training, breaking bad news can lead to negative consequences for patients, families, and physicians... Results revealed that 91% of respondents perceived delivering bad news as a very important skill, but only 40% felt they had the training to effectively deliver such news.
2. https://www.oncnursingnews.com/view/compassionate-care
Researchers at the The Schwartz Center for Compassionate Healthcare at Massachusetts General Hospital in Boston surveyed 800 hospitalized patients and 510 physicians and found broad agreement that compassionate care is considered very important to successful medical treatment. However, only 53% of the patients and 58% of the physicians indicated that they felt that compassionate care is being provided to patients.
Alternative Models in Healthcare:
1. Family-Centered Patient: Care Lee H. Igel, PhD and Barron H. Lerner, MD, PhD; AMA J Ethics. 2016;18(1):56-62. doi: 10.1001/journalofethics.2017.18.1.msoc1-1601.
Over the past half-century, the central relationship in Western medicine—between patient and physician—has shifted from paternalism, in which the doctor decides what is in the patient’s best interest, to patient-centered care, in which decisions that support an individual patient’s needs, goals, and values are made in partnership. Now, a family-centered approach is contributing to the emergence of what might be called “post-autonomy” medicine. The goal here is not to restore decision-making power to clinicians; rather, it is to develop a more sophisticated version of self-determination—one that accounts for how autonomy occurs within specific social and cultural contexts.
1. Family-Centered Patient: Care Lee H. Igel, PhD and Barron H. Lerner, MD, PhD; AMA J Ethics. 2016;18(1):56-62. doi: 10.1001/journalofethics.2017.18.1.msoc1-1601.
Over the past half-century, the central relationship in Western medicine—between patient and physician—has shifted from paternalism, in which the doctor decides what is in the patient’s best interest, to patient-centered care, in which decisions that support an individual patient’s needs, goals, and values are made in partnership. Now, a family-centered approach is contributing to the emergence of what might be called “post-autonomy” medicine. The goal here is not to restore decision-making power to clinicians; rather, it is to develop a more sophisticated version of self-determination—one that accounts for how autonomy occurs within specific social and cultural contexts.
2. Selective Paternalism: Brian C. Drolet, MD and Candace L. White, MD, MA; Virtual Mentor. 2012;14(7):582-588. doi: 10.1001/virtualmentor.2012.14.7.oped2-1207.
There are critical implications to the loss of physician-driven decision making in medicine. In many fields (e.g., law, education, economics), it is generally accepted that decisions are best made by experts. Within their respective fields, experts are charged with understanding the nuances required for best practice of the profession. Physicians are obligated to ensure quality and value in health care through education, expertise, and ethical practice patterns. Despite the common political opinion, medicine is not a simple consumer-producer market, and physicians cannot be forced into a fully patient-autonomous system. Furthermore, a default overemphasis on autonomy hinders the upholding of other central values in medical ethics: respect for autonomy must be balanced with nonmaleficence, beneficence, justice, and the paternalistic obligation to uphold standards of care.Utilizing paternalism selectively in decision making is not only necessary but obligatory.
There are critical implications to the loss of physician-driven decision making in medicine. In many fields (e.g., law, education, economics), it is generally accepted that decisions are best made by experts. Within their respective fields, experts are charged with understanding the nuances required for best practice of the profession. Physicians are obligated to ensure quality and value in health care through education, expertise, and ethical practice patterns. Despite the common political opinion, medicine is not a simple consumer-producer market, and physicians cannot be forced into a fully patient-autonomous system. Furthermore, a default overemphasis on autonomy hinders the upholding of other central values in medical ethics: respect for autonomy must be balanced with nonmaleficence, beneficence, justice, and the paternalistic obligation to uphold standards of care.Utilizing paternalism selectively in decision making is not only necessary but obligatory.
Halacha: Doctor Responsibility & Patient Obligation
Healthcare professionals have an obligation to do everything in their power for the wellbeing of the patient. This depends on individual context and the situation, but certainly includes their psychological and emotional health, as this will significantly effect their recovery and quality of life. Doctors are viewed as sources of information, but are not assumed to be the ultimate arbiter of what is best for the patient, as there could be larger conflicts with Torah and also questions of bias, questions of integrity, and prioritizing the patient above all else. Patients don't have a right to know, rather they have an obligation to seek the best treatment available to them.
Healthcare professionals have an obligation to do everything in their power for the wellbeing of the patient. This depends on individual context and the situation, but certainly includes their psychological and emotional health, as this will significantly effect their recovery and quality of life. Doctors are viewed as sources of information, but are not assumed to be the ultimate arbiter of what is best for the patient, as there could be larger conflicts with Torah and also questions of bias, questions of integrity, and prioritizing the patient above all else. Patients don't have a right to know, rather they have an obligation to seek the best treatment available to them.
See also: https://www.aamc.org/news/delivering-grave-news-empathy-and-honesty#:~:text=When%20Cox%20co,introduce%20this%20training%20to%20students & https://www.clinicalcorrelations.org/2016/12/02/balancing-patient-information-with-our-professional-and-relational-duties-to-patients-and-families-without-appealing-to-paternalism/
The Mind/Body Connection in Healthcare & Halacha:Rabbi Chaim Jachter (https://www.koltorah.org/halachah/revealing-painful-medical-truths-to-patients-by-rabbi-chaim-jachter)
The Gemara (Moed Katan 26b) teaches that one must not inform a very sick person of the death of a relative lest he become depressed and his condition deteriorate. The Shulchan Aruch (Yoreh Deah 337) codifies this rule as normative. The Shach (ibid subsection 1) adds that even if the patient is aware of the death of the relative, we do not instruct him to perform Keriah (tearing of his garments) lest it “increase his level of anxiety.”Rav Shlomo Zalman Auerbach (cited in the Nishmat Avraham Y.D. 337:2) goes even further. He rules that if a mourner during Shiva must visit a gravely ill patient, the mourner may remove any sign of mourning such as ripped clothes and non-leather shoes in order to hide the fact that he is in mourning.
The Shulchan Aruch codifies these attitudes. We must make every effort to avoid discouraging a very sick individual. We must not cry before the sick person, nor may we eulogize the deathly ill person in his presence lest this break his heart (Y.D. 337). No talk of funeral preparations may take place while the person is yet living (Y.D. 339:1). Dr. Abraham S. Abraham adds (Nishmat Avraham Y.D. 337:4) that both visitors and medical personnel must exercise discretion when talking in the presence of a patient who appears to be unconscious. In reality, the patient may be conscious and the patient may hear discouraging words that have the potential to break his spirit.
We must take great care to avoid discouraging a patient when instructing him to recite the Vidui (confessional) that is to be recited prior to dying (Y.D.338: 1). The Shulchan Aruch states that we approach the gravely ill person in the following manner: “We say to him, ‘Many have recited the Vidui and did not subsequently die and many who have not recited the Vidui and have died, and all who confess have a share in the world to come.’”
Concern for the psychological impact of the instruction to recite the Vidui is so great that an interesting practice developed in Berlin and some other communities more than two hundred years ago to accommodate it. The Chochmat Adam (151:11) records that in these communities, leaders would go to anyone who was sick for three days to instruct him to execute a will and recite the Vidui. The Chochmat Adam notes that since this was the standard practice for all ill patients, the patient did not perceive this instruction as an indication that they were in imminent danger of dying. He recommends that all communities adopt this practice.
The Gemara (Moed Katan 26b) teaches that one must not inform a very sick person of the death of a relative lest he become depressed and his condition deteriorate. The Shulchan Aruch (Yoreh Deah 337) codifies this rule as normative. The Shach (ibid subsection 1) adds that even if the patient is aware of the death of the relative, we do not instruct him to perform Keriah (tearing of his garments) lest it “increase his level of anxiety.”Rav Shlomo Zalman Auerbach (cited in the Nishmat Avraham Y.D. 337:2) goes even further. He rules that if a mourner during Shiva must visit a gravely ill patient, the mourner may remove any sign of mourning such as ripped clothes and non-leather shoes in order to hide the fact that he is in mourning.
The Shulchan Aruch codifies these attitudes. We must make every effort to avoid discouraging a very sick individual. We must not cry before the sick person, nor may we eulogize the deathly ill person in his presence lest this break his heart (Y.D. 337). No talk of funeral preparations may take place while the person is yet living (Y.D. 339:1). Dr. Abraham S. Abraham adds (Nishmat Avraham Y.D. 337:4) that both visitors and medical personnel must exercise discretion when talking in the presence of a patient who appears to be unconscious. In reality, the patient may be conscious and the patient may hear discouraging words that have the potential to break his spirit.
We must take great care to avoid discouraging a patient when instructing him to recite the Vidui (confessional) that is to be recited prior to dying (Y.D.338: 1). The Shulchan Aruch states that we approach the gravely ill person in the following manner: “We say to him, ‘Many have recited the Vidui and did not subsequently die and many who have not recited the Vidui and have died, and all who confess have a share in the world to come.’”
Concern for the psychological impact of the instruction to recite the Vidui is so great that an interesting practice developed in Berlin and some other communities more than two hundred years ago to accommodate it. The Chochmat Adam (151:11) records that in these communities, leaders would go to anyone who was sick for three days to instruct him to execute a will and recite the Vidui. The Chochmat Adam notes that since this was the standard practice for all ill patients, the patient did not perceive this instruction as an indication that they were in imminent danger of dying. He recommends that all communities adopt this practice.
Changing Times and Cultures/Systemic Challenges:Rabbi Dr. Avraham S. Abraham (Nishmat Avraham Yoreh Deah 338:4)
But today it is very hard to hide from a cancer patient the nature of his illness, and especially as most of them are treated via radiation and chemotherapy, or in an oncology unit or clinic. Further, thank God the success rate for treating these patients is increasing, and in many cases they can not only extend the patient’s life, but actually completely cure his illness. And if they don’t directly inform the patient of the nature of his illness, along with the hope of his treatment, he will certainly think the worst of his situation. Just the opposite, lack of knowledge, and worse, wrong and deluded knowledge, will bring him to despair and depression. On the other hand, when they tell him of his illness he will be able to reveal to the doctor his thoughts and fears, and in open conversation it will be possible to encourage him and give him the emotional support which is so important and necessary.
But today it is very hard to hide from a cancer patient the nature of his illness, and especially as most of them are treated via radiation and chemotherapy, or in an oncology unit or clinic. Further, thank God the success rate for treating these patients is increasing, and in many cases they can not only extend the patient’s life, but actually completely cure his illness. And if they don’t directly inform the patient of the nature of his illness, along with the hope of his treatment, he will certainly think the worst of his situation. Just the opposite, lack of knowledge, and worse, wrong and deluded knowledge, will bring him to despair and depression. On the other hand, when they tell him of his illness he will be able to reveal to the doctor his thoughts and fears, and in open conversation it will be possible to encourage him and give him the emotional support which is so important and necessary.
The Conflict:
How are we to balance informing a patient of all the factors necessary for them to make an informed decision, versus the overwhelming difficulty that confronts a patient during such circumstances, to increase the likelihood of recovery or quality of life?
How are we to balance informing a patient of all the factors necessary for them to make an informed decision, versus the overwhelming difficulty that confronts a patient during such circumstances, to increase the likelihood of recovery or quality of life?
Approach 1: Context Sensitive Disclosure Rabbi Dr. Avraham S. Avraham (Nishmas Avraham Y.D. 338:3)
1. Patients with serious illnesses but their lives can be extended by treatment and potentially may even be cured should be told the truth if the assessment is that it will help them deal with their situation and cooperate with their treatment. In such cases, one should first reveal it to their closest family members and only then, together with the family, reveal it to the patient himself while encouraging him and giving him hope.
2. Patients with terminal conditions that are no longer amenable to treatment (all that is available to them is pain relief and amelioration of other symptoms) should not be informed of their condition. Only their close family should be told.
3. Patients who have exhausted all treatment options and are likely to die any minute should be instructed to recite Viduy. However, it appears that this is not the custom.
1. Patients with serious illnesses but their lives can be extended by treatment and potentially may even be cured should be told the truth if the assessment is that it will help them deal with their situation and cooperate with their treatment. In such cases, one should first reveal it to their closest family members and only then, together with the family, reveal it to the patient himself while encouraging him and giving him hope.
2. Patients with terminal conditions that are no longer amenable to treatment (all that is available to them is pain relief and amelioration of other symptoms) should not be informed of their condition. Only their close family should be told.
3. Patients who have exhausted all treatment options and are likely to die any minute should be instructed to recite Viduy. However, it appears that this is not the custom.
Approach 2: Concealing the WorstRav Moshe Shternbuch (Teshuvos v’Hanhagos 1:870)
[Regarding a cancer patient who had pain in his stomach but was not aware of his disease. He asked the doctor to swear to him that it wasn’t cancer. The question was whether it was permitted for the doctor to swear falsely that it wasn’t.]
Doctors in today’s day and age have different opinions as to the degree that one should conceal the existence of cancer from a patient. I personally have experienced that when it becomes known to a patient that he has cancer, his condition worsens. For example, there was a certain relative of ours who was told that he was critically ill with cancer. He replied that “he believed in Hashem’s salvation” but from that moment on his condition drastically deteriorated and he no longer had the strength to tolerate the pain as he thought that he was nearing the end of his life in any case. I am familiar with many such cases (my esteemed brother in law Rav Yitzchak Shechter z”l worked tirelessly on behalf of the sick and he worked to prevent doctors from revealing diseases to patients, believing that it was Pikuach Nefesh to do so. There are today different opinions amongst doctors in this regard but it appears that certainly, when the patient’s disease is in its initial stages one who reveals to him that he has an incurable disease is “spilling blood” without reason).
Therefore, I would say that concealing the information is a matter of Pikuach Nefesh and it would be permitted for a doctor to swear (falsely) to the patient in order to convince him that he does not have a malignant disease. However, since there are those who rule differently, it is difficult for me to rely on my own judgment and permit a prohibition in the Torah, particularly in the realm of false oaths that are a grave sin.
Therefore, my advice to the doctor in question is to tell the patient that he has a policy never to take an oath, even to tell the truth. However, he is willing to affirm (which does not carry the prohibition of an oath) that the patient does not have cancer. However, there are cases where it is clearly Pikuach Nefesh to reveal the truth and then it would even be permitted to violate the prohibition of false oaths. Each case requires consultation with a Rav.
If the patient adjures the doctor to take an oath that he is only telling the truth he shall not swear falsely unless he is certain that without taking the oath the patient will be endangered.
[Regarding a cancer patient who had pain in his stomach but was not aware of his disease. He asked the doctor to swear to him that it wasn’t cancer. The question was whether it was permitted for the doctor to swear falsely that it wasn’t.]
Doctors in today’s day and age have different opinions as to the degree that one should conceal the existence of cancer from a patient. I personally have experienced that when it becomes known to a patient that he has cancer, his condition worsens. For example, there was a certain relative of ours who was told that he was critically ill with cancer. He replied that “he believed in Hashem’s salvation” but from that moment on his condition drastically deteriorated and he no longer had the strength to tolerate the pain as he thought that he was nearing the end of his life in any case. I am familiar with many such cases (my esteemed brother in law Rav Yitzchak Shechter z”l worked tirelessly on behalf of the sick and he worked to prevent doctors from revealing diseases to patients, believing that it was Pikuach Nefesh to do so. There are today different opinions amongst doctors in this regard but it appears that certainly, when the patient’s disease is in its initial stages one who reveals to him that he has an incurable disease is “spilling blood” without reason).
Therefore, I would say that concealing the information is a matter of Pikuach Nefesh and it would be permitted for a doctor to swear (falsely) to the patient in order to convince him that he does not have a malignant disease. However, since there are those who rule differently, it is difficult for me to rely on my own judgment and permit a prohibition in the Torah, particularly in the realm of false oaths that are a grave sin.
Therefore, my advice to the doctor in question is to tell the patient that he has a policy never to take an oath, even to tell the truth. However, he is willing to affirm (which does not carry the prohibition of an oath) that the patient does not have cancer. However, there are cases where it is clearly Pikuach Nefesh to reveal the truth and then it would even be permitted to violate the prohibition of false oaths. Each case requires consultation with a Rav.
If the patient adjures the doctor to take an oath that he is only telling the truth he shall not swear falsely unless he is certain that without taking the oath the patient will be endangered.
Other Poskim who concur: Rabbi Betzalel Stern (Responsa Betzeil Hachochmah 2:55), who rules that a cancer patient should not be informed of his diagnosis, since prayer can always be effective, but a patient who is hopeless may not believe this and so will fail to pray properly for his recovery. . This position is endorsed by Rabbi Shlomo Aviner and Rabbi Shilo Refael, Sefer Assia vol. 3 pp. 335-37.
Approach 3: Full Disclosure Rabbi Prof. Yigal Shafran (https://www.medethics.org.il/article/r0071023a/)
Advocates full disclosure, inasmuch as it gives the patient clarity about their situation, awareness about the efforts doctors are making for their recovery and wellbeing, and that lack of disclosure creates doubt about the honesty of medical professionals, which could lead to anxiety and doubt about the treatment being provided, and that, in turn, could hamper treatment and lessen efficacy (because of negative psychological impact). He adds that, halachically, if it is clearly evident someone is on the brink of death, we help them prepare for it spiritually (with vidui and teshuva), as well as emotionally.
However, he elaborates elsewhere (Assia 42-43, 5747, p16-23, as summarized by the Encyclopedia Hilchatit, Hilchos Refua, Erech “Giluy Meida l’Choleh”):
Since, from the Halachic perspective, the question as to whether to tell a patient the truth or not is dependent on what is best for him, it follows that we cannot give a clear-cut rule. Rather, each case should be judged for itself – what will be the correct thing for each patient?...Today, it is generally accepted to evaluate a patient at the time of initial diagnosis and to determine how much to tell him in the course of his treatment. Each decision is thoroughly unique to each individual patient, his feelings, his mind, and his
cultural background. Therefore, one should not make general rules such as creating a policy to “always inform the patient” (as is the case in America for various reasons) or “never to inform him” (as would appear to be the conclusion of various Teshuvos on the subject).
Rather, each patient should be judged separately...Therefore, it seems reasonable to say, that the Halachic approach should also be
tailored to the time and place. In cases where knowing the truth will be helpful to a patient, he should be informed of his condition. Where the knowledge will only increase his fear, he should not be informed. Each case should be judged separately and individually. Similarly, while there may be times where one needs to inform a patient that his state is critical, one should never bring him to despair and to a state of hopelessness. It has been proven scientifically that depression and hopelessness weaken the body’s immune response.
Advocates full disclosure, inasmuch as it gives the patient clarity about their situation, awareness about the efforts doctors are making for their recovery and wellbeing, and that lack of disclosure creates doubt about the honesty of medical professionals, which could lead to anxiety and doubt about the treatment being provided, and that, in turn, could hamper treatment and lessen efficacy (because of negative psychological impact). He adds that, halachically, if it is clearly evident someone is on the brink of death, we help them prepare for it spiritually (with vidui and teshuva), as well as emotionally.
However, he elaborates elsewhere (Assia 42-43, 5747, p16-23, as summarized by the Encyclopedia Hilchatit, Hilchos Refua, Erech “Giluy Meida l’Choleh”):
Since, from the Halachic perspective, the question as to whether to tell a patient the truth or not is dependent on what is best for him, it follows that we cannot give a clear-cut rule. Rather, each case should be judged for itself – what will be the correct thing for each patient?...Today, it is generally accepted to evaluate a patient at the time of initial diagnosis and to determine how much to tell him in the course of his treatment. Each decision is thoroughly unique to each individual patient, his feelings, his mind, and his
cultural background. Therefore, one should not make general rules such as creating a policy to “always inform the patient” (as is the case in America for various reasons) or “never to inform him” (as would appear to be the conclusion of various Teshuvos on the subject).
Rather, each patient should be judged separately...Therefore, it seems reasonable to say, that the Halachic approach should also be
tailored to the time and place. In cases where knowing the truth will be helpful to a patient, he should be informed of his condition. Where the knowledge will only increase his fear, he should not be informed. Each case should be judged separately and individually. Similarly, while there may be times where one needs to inform a patient that his state is critical, one should never bring him to despair and to a state of hopelessness. It has been proven scientifically that depression and hopelessness weaken the body’s immune response.
Other Poskim: Rabbi Elazar Schach (HaRav Schach–Conversations, pp. 235-36) was asked about disclosing a terminal diagnosis to a patient, he responded by noting the evolution of medical opinion toward disclosure. He also added that the point of all suffering is to inspire a person to examine their life and engage in the process of teshuva. Therefore, if their condition is kept unknown by doctors and family, they are thus preventing this opportunity.
See also: https://e8b7a5f9-e27e-4732-8c9b-1f83787ae640.filesusr.com/ugd/9c4394_525d0815a9a545a38b65fe2178f35de2.pdf & https://baishavaad.org/diagnostic-disclosure-dilemmas-therapeutic-privilege-in-halacha/
Part 2: Death in the Family
Rabbi Moshe Tzuriel (https://www.daat.ac.il/daat/kitveyet/shana/minhagey-4.htm)
Today, it is common to inform the public of a person’s death through wall posters or loudspeakers. However, there is an explicit Talmudic source: “One who spreads bad news is a fool” (Pesachim 3a). Similarly, the Shulchan Aruch (Y"D 402:12) writes: “If someone lost a relative and has not yet been informed, it is not obligatory to tell him—even for his father or mother.” The Rama adds: “Nevertheless, regarding male children, the custom is to inform them so that they may say Kaddish, but for daughters there is no custom at all to inform them.” This is in direct contrast to those who rush in our times to make such announcements.
The Chida (in Avodat HaKodesh, Tziporen Shamir, section 171) explains: “For you cause great harm, as the one who hears will become distressed and his service of God will be diminished—and the sin is upon you.” In Responsa Chavos Yair, he ruled leniently not to inform the mourner if doing so would nullify his Purim joy. See also Sefer Chassidim section 403.
Today, it is common to inform the public of a person’s death through wall posters or loudspeakers. However, there is an explicit Talmudic source: “One who spreads bad news is a fool” (Pesachim 3a). Similarly, the Shulchan Aruch (Y"D 402:12) writes: “If someone lost a relative and has not yet been informed, it is not obligatory to tell him—even for his father or mother.” The Rama adds: “Nevertheless, regarding male children, the custom is to inform them so that they may say Kaddish, but for daughters there is no custom at all to inform them.” This is in direct contrast to those who rush in our times to make such announcements.
The Chida (in Avodat HaKodesh, Tziporen Shamir, section 171) explains: “For you cause great harm, as the one who hears will become distressed and his service of God will be diminished—and the sin is upon you.” In Responsa Chavos Yair, he ruled leniently not to inform the mourner if doing so would nullify his Purim joy. See also Sefer Chassidim section 403.
Even further, we find in the Responsa of Rabbi Yedidya Tiah Weil (18th c., section 111) that if the deceased's son is a yeshiva student, and the mourning would cause him to stop learning, then one should not inform him until after thirty days, so that he would fulfill the mourning only as a “distant report,” lasting only one hour. This was the practice with the renowned gaon Rabbi Yaakov Yitzchak Ruderman (a member of the Moetzes Gedolei HaTorah in the United States), who in his youth was learning in the Slabodka Yeshiva in Lithuania, far from his home. When his father (also a famous rabbi) passed away, and the head of the yeshiva (Rabbi Mordechai Shlomo Epstein, known as the “Levush ei Mordechai”) was informed, he ruled not to notify the son until thirty days had passed, so as not to interrupt his Torah study.
Moreover, if the deceased left behind several sons, it is sufficient for one to say Kaddish, and there is no need to inform the other sons. So ruled Responsa Maharsh Engel (part 6, section 10) in the name of the author of Baruch Taam (18th c.), and this was also the practice of the Rebbe Rabbi Yechezkel of Shinova (19th c.), author of Divrei Yechezkel. They brought proof from the language of the Rema, who began speaking of “sons” in plural, but concluded, regarding Kaddish, in singular: “that he should say Kaddish”—implying only one needs to.
In Responsa Mishneh Sachir (by Rabbi Yissachar Shlomo Teichtal, may God avenge his blood, author of Eim HaBanim Semeichah, section 234), he builds on this and says that there is no need to inform even the brother of the deceased, because in Masechet Kallah (chapter 4) it is stated that only the son provides benefit through saying Kaddish—not other relatives. This explanation is cited in Sdei Chemed, collection of laws, section on mourning, paragraph 152. It is also written in Responsa Rama MiPano (section 89, end).
The sefer Nishmas Yisrael (page 102) concludes that refraining from informing close relatives is even appropriate when the deceased himself requested before dying that they be notified—since he does not have ownership to cause them pain and to prevent them from their work for seven days, and from Torah study for seven days, etc. This approach stands in direct contrast to today’s common practice of publicizing deaths.
Let us return to our question: is it permitted to inform the public of a death through posters or loudspeakers?
In Mo’ed Katan 27a it is stated that one heard the sound of a shofar, and likewise in Ketubot 17a it speaks of 6,000 shofar blasts. From here it appears that they publicized the death of a person!
This can be answered:
A. The shofar did not notify the townspeople of the death per se, but rather to come and escort the deceased—and that is a matter of mitzvah. In the question “Is Aibu still alive?” (Pesachim 4a), it referred to a report not for the purpose of a mitzvah, because it was after burial.
B. It may be that the honor of a great rabbi differs from that of an ordinary deceased person, because it relates to the honor of the community.
C. The prohibition is to reveal directly, but through indirect means it is permitted.
D. One must take care not to alarm others. When the shofar is sounded, people know someone has died in the city, but they do not know who it is, and therefore the listener is not struck with fear.
In Mo’ed Katan 27a it is stated that one heard the sound of a shofar, and likewise in Ketubot 17a it speaks of 6,000 shofar blasts. From here it appears that they publicized the death of a person!
This can be answered:
A. The shofar did not notify the townspeople of the death per se, but rather to come and escort the deceased—and that is a matter of mitzvah. In the question “Is Aibu still alive?” (Pesachim 4a), it referred to a report not for the purpose of a mitzvah, because it was after burial.
B. It may be that the honor of a great rabbi differs from that of an ordinary deceased person, because it relates to the honor of the community.
C. The prohibition is to reveal directly, but through indirect means it is permitted.
D. One must take care not to alarm others. When the shofar is sounded, people know someone has died in the city, but they do not know who it is, and therefore the listener is not struck with fear.
Conflict: Common practice is to inform relatives, perhaps this is because it will cause more distress subsequently. Alternatively, there are many customs (both Kabbalistic and normative) that are cathartic for many people, and provide a sense of meaning and direction. Contemporary culture does significantly influence people's feelings about being informed.It is an open question whether the benefits of immediate disclosure nowadays outweighs the costs.
Part 3: Tragedy on Shabbos
The Conflict: Rambam (Responsa Pear HaDor 130)
And these supplications and requests and prayers which were copied from the books of the Geonim—it does not appear appropriate to me to say them, neither as an individual nor as a congregation, not on Shabbat and not on Festivals. Because the Sages, of blessed memory, when they instituted something to be said on Shabbat for the sick and the like, they said (Shabbos 12a): “Shabbat is not a time for crying out, and healing is soon to come, and His mercies are abundant.”
And this is merely a statement of information alone.
And they omitted the recital of the middle blessings of the Amidah (the 18 blessings) because they are comprised of mercy and supplication. And the reason is: For prayer is a directed service in honor of Hashem, and one must mention each day the matter appropriate to that day. And when Shabbat and Yom Tov arrive, one must be joyful and delighted, and give thanks to God who gave rest to His people Israel—Shabbatot and festivals for joy. Not that it should be a day of fasting and crying out and mourning. And nothing should be mentioned on them except words that are desirable/beautiful and joyful, and to mention His wonders which He performed for our forefathers and for us.
And these supplications and requests and prayers which were copied from the books of the Geonim—it does not appear appropriate to me to say them, neither as an individual nor as a congregation, not on Shabbat and not on Festivals. Because the Sages, of blessed memory, when they instituted something to be said on Shabbat for the sick and the like, they said (Shabbos 12a): “Shabbat is not a time for crying out, and healing is soon to come, and His mercies are abundant.”
And this is merely a statement of information alone.
And they omitted the recital of the middle blessings of the Amidah (the 18 blessings) because they are comprised of mercy and supplication. And the reason is: For prayer is a directed service in honor of Hashem, and one must mention each day the matter appropriate to that day. And when Shabbat and Yom Tov arrive, one must be joyful and delighted, and give thanks to God who gave rest to His people Israel—Shabbatot and festivals for joy. Not that it should be a day of fasting and crying out and mourning. And nothing should be mentioned on them except words that are desirable/beautiful and joyful, and to mention His wonders which He performed for our forefathers and for us.
דיני שבת התלויים בדיבור. ובו כב סעיפים:ודבר דבר שלא יהא דבורך של שבת כדבורך של חול הילכך אסור לומר דבר פלוני אעשה למחר או סחורה פלונית אקנה למחר ואפי' בשיחת דברים בטלים אסור להרבות: הגה וב"א שסיפור שמועות ודברי חדושים הוא עונג להם מותר לספרם בשבת כמו בחול אבל מי שאינו מתענג אסור לאומרם כדי שיתענג בהם חבירו: (ת"ה סי' ס"א):
“Ve’daber davar” (teaches us) that one’s manner of speech on Shabbos must not be the same as one’s manner of speech on a weekday. Therefore, it is prohibited to say 'I will do such and such tomorrow' or 'I will purchase this and this merchandise tomorrow'. It is even prohibited to engage in idle talk excessively. RAMA: People who have pleasure from hearing stories or the latest news may speak these things on Shabbos, but one who does not enjoy them may not speak them for the sake of giving pleasure to someone else.
(ג) עונג להם - ואסור לספר בשבת איזה דבר שמצטער בו:
It is a pleasure for them - and it is prohibited to discuss matters on Shabbos that cause a person distress or anguish.
ז) לספר בשבת מאוהביו שמתו או שהן בצער אסור. ס"ח סי' ק"י. כנה"ג בהגה"ט. מ"א א"ר או' א':
To discuss on Shabbos regarding someone dear to him who died (recently) or is in distress/pain is prohibited. Sefer Chassidim §110. Knesses HaGadolah, glosses on Tur. Magen Avraham, Eliyah Rabbah §Aleph.
Rabbi Eliezer Melamed (https://www.yeshiva.org.il/ask/3651)
Question:
Is it permissible to tell a person on Shabbat that his relative was injured in a terror attack like the one that occurred in Hebron?
Answer:
It is appropriate not to tell bad news on Shabbat. The Sages told (Yalkut Shimoni, Mishlei 964) about the wife of Rabbi Meir, Beruriah, who was a woman of valor, and she did not tell him on Shabbat about the death of their two sons. Only after the conclusion of Shabbat did she comfort him...
Shabbat Kodesh is a taste of the World to Come, a day that is entirely good, in which we contemplate reality with a positive perspective. Therefore, one should not recount sorrowful matters on it. And from the delight of the sanctity of Shabbat, we will have the strength to cope with the difficulties of this world. From the eternal perspective of Shabbat, we are able to overcome the tragedies of this world, which is a hallway before the banquet hall. May Hashem merit us to keep Shabbatot, and may He comfort the widows and orphans with the rebuilding of Jerusalem and Hebron.
Question:
Is it permissible to tell a person on Shabbat that his relative was injured in a terror attack like the one that occurred in Hebron?
Answer:
It is appropriate not to tell bad news on Shabbat. The Sages told (Yalkut Shimoni, Mishlei 964) about the wife of Rabbi Meir, Beruriah, who was a woman of valor, and she did not tell him on Shabbat about the death of their two sons. Only after the conclusion of Shabbat did she comfort him...
Shabbat Kodesh is a taste of the World to Come, a day that is entirely good, in which we contemplate reality with a positive perspective. Therefore, one should not recount sorrowful matters on it. And from the delight of the sanctity of Shabbat, we will have the strength to cope with the difficulties of this world. From the eternal perspective of Shabbat, we are able to overcome the tragedies of this world, which is a hallway before the banquet hall. May Hashem merit us to keep Shabbatot, and may He comfort the widows and orphans with the rebuilding of Jerusalem and Hebron.