One of the most frequent questions that Ematai receives relates to the use of pain medications toward the end of life.

For many patients dying from a terminal illness, the suffering can be excruciating. Pain can cause shortness of breath and fatigue, which in turn can spur fear, anxiety, or depression. These psychological responses reduce mobility and increase the work of breathing. Studies show that patients undertreated for pain die faster.

As such, it is crucial to provide proper palliative treatments especially toward the end of life, including the use of medicines like morphine.

Addressing Common Misconceptions:

Unfortunately, some patients are sometimes not offered sufficient pain relief. Family advocates should always be asking for assessments by palliative experts. However, other families may be hesitant to receive palliative therapy because they are under the misconception that such medicines may hasten death, a risk they think is forbidden under Jewish law.

1. Medically, carefully administered pain medications do not hasten a patient’s death. 

2. Even if there was such a potential side effect, Jewish law would allow for such treatment. 

Part of the misconception is created by the fact that opioids can be used for the intentional death of a patient. Euthanasia is prohibited under Jewish law. The attempts to legalize it around the world (sometimes under the banner of “medical assistance in dying”) should be opposed by concerned Jewish citizens.

However, carefully administered opioids are essential to treating a patient. It is true that pain medicines may initially have a respiratory depressant effect. Like all medications, there are potential side effects. However, the body can adjust quickly and tolerate the impact of this medicine. Without pain medications, patients frequently suffer from heavy breathing. With opioids, they can breathe with less stress. It is essential for patients and families to not hesitate to request treatment that will provide comfort and may even extend the life of the patient. Because such therapy is lifesaving, one may even violate Shabbat if necessary.

Halachic Approaches to Justifying Pain Management

If opioids would indeed carry a risk of hastening a person’s death, would it be permissible under Jewish law?

The answer, once again, is yes: Even if pain medications would incur a risk of hastening death, Jewish law permits – and even mandates – administering the therapies necessary to address the pain, providing that the intent is solely to alleviate suffering.

Rabbi Shlomo Zalman Auerbach made a number of arguments: 

• Rabbi Auerbach adds that he believes providing pain relief is a fulfillment of the mitzvah “Love your neighbor as you love thyself.” Act to prevent your loved one from having a terrible painful experience that you would dread undergoing.
• Untreated pain is likely to cause greater harm than any side effects from pain medications. 
• There is no guarantee that any given dose will cause the person to die or hasten his or her demise. As such, he concludes, “If each dose on its own will not certainly curtail a person’s life, then although many repeated doses will do so, he/she should be treated.” 

Rabbi Yitzchak Zilberstein compared this situation to a famous ethical dilemma (known, in some variations, as the “trolley problem”). If a person sees an arrow heading toward a group of people and he is able to deflect it so that it will kill only one person, thus saving many others, it is permissible for him to do so. The act of deflecting the arrow – although it causes a death – is intrinsically an act of rescue of the others in the arrow’s path. Therefore, the person should try to save as many people as possible.

The same is true in our case. Providing morphine is essentially a therapeutic act for the purpose of easing pain. Therefore, even though it may result in the shortening of life, it is still not considered an act of killing, since the intent is solely to treat therapeutically.

Rabbi Eliezer Waldenberg contends that pain is no different than any other form of physical ailment. We treat it under the rubric of medical care, following the biblical commandment “You shall surely heal.” Perhaps there will be side effects to this intervention and perhaps not. Either way, we must address the ailment.

In Summary:

When necessary and requested, doctors can provide pain medications that will make the person be less alert. People may choose this option to prevent suffering as nature takes its course.

Significantly, part of providing palliative care is choosing wisely which medications and therapies are no longer beneficial, given the current goals of care. It is not necessary to start interventions that prevent people from dying and that needlessly prolong the suffering that becomes harder to control. Judaism regards extending living as a great mitzvah. Prolonging a painful dying process is not our goal.

Each case, of course, needs to be examined for both medical and halachic considerations. Judaism believes in the sanctity of life while also recognizing that we must alleviate suffering to the extent possible. Allowing a person to die in pain that could be relieved is not an option. 

Reach out to our helpline for specific questions about pain management at the end-of-life.