Palliative care and hastening of death

[Michael Merdinger]

If one gives morphine to a dying patient to relieve pain, I understand
there might be two possible ways in which this might hasten death:

1) the morphine might stop the breathing process, or

2) the morphine might relieve pain, enabling the person to relax and
let go.

Clearly, option one is active and would be prohibited. But is option
two (assuming it could be isolated) the permissible removal of an
impediment to death (the pain itself being the impediment) similar to
removing the wood chopping discussed by the Rema?

[RabbiM]

This is a much more complicated question. Let us break it down into several segments.
1.      Can one do something which relieves pain, and is thus for the needs of the patient, even if it shortens the patient's life. Are we required to consider long-term negative consequences according to halacha?
2.      How direct does the life-shortening effect of the medication have to be for there to be a חשש of שפיכת דמים? As Rabbi Merdinger correctly points out Chazal forbid even the touching of a goses in case it shortens his life. Morphone always suppresses respiration, but this will only be immediately fatal in a very few cases. (Not that it is relevant to halacha directly, but I remind the group of the story of Lord Dawson, physician to King George V of England who confessed in his diary -Ramsay, J. H. R. A king, a doctor, and a convenient death at British Medical Journal, May 1994,308:1445---"At about 11 o'clock it was evident that the last stage might endure for many hours, unknown to the patient but little comporting with the dignity and serenity which he so richly merited and which demanded a brief final scene. Hours of waiting just for the mechanical end when all that is really life has departed only exhausts the onlookers and keeps them so strained that they cannot avail themselves of the solace of thought, communion or prayer. I therefore decided to determine the end and injected (myself) morphia gr. 3/4 and shortly afterwards cocaine gr. 1 into the distended jugular vein."... The reason  was to ensure that the announcement of the king's death should appear first in the morning edition of The Times and not in some lesser publication later in the day. To make doubly sure that this would happen Dawson telephoned his wife in London asking her to let The Times know when the announcement was imminent. Would that be considered רציחה he certainly considered it to be קירוב מיתתוand it created a bit of a storm when the article was published in 1994.) But for it to be considered מקרב מיתתו we would need to have intention to shorten life, (as Dawson did) and not intention to make the patient more comfortable.

וע' בשו"ת אגרות משה יו"ד ח"ב סימן קע"ד ענף ד` וע' שו"ת ציץ אליעזר חלק י' סי' כ"ה: וע' רמב"ם הל' מלכים פרק ט' הל' ד' וע' שו"ת אחיעזר ח"ג סי' לז וע' ש"ך חו"מ סי' שפו ס"ק ה'
וע' שו"ת משנה הלכות ובמה שכתבתי נלפענ"ד לישב פסק ידידי הרה"ג הצדיק אבד"ק פאפא שליט"א שנשאל בצדיק אחד שחלה את חליו אשר בו מת והיה גוסס ב"מ והיה נותנין לו מים עם סוכר הנקרא (אינטערוינעס בלע"ז) ונשאל כדת מה לעשות אם להמשיך בזה וכפי ששמעתי פסק שלא ליטול המחט מידו התחובה בו אלא יפסיקו למעלה בהקנה מקום שנכנס על ידו המים המתוק וח"א הקשה לי עליו דכה"ג הט"ז אוסר ולא התירו אלא כשאינו עושה כלום אבל למנוע מהחולה דבר אסור אמנם לפי הנ"ל אתי שפיר פסקו של הרה"ג הנ"ל דהט"ז נמי לא פליג להסיר המלח אלא שמזיז הגוסס אבל הכא הרי לא מזיז החולה כלל אלא מסיר האינטערוינעס ע"י שמונע מלהכנס בהשפופרת שע"י נכנס להמחט שבבשרו וכה"ג מודה הט"ז דשרי. וע' חוברת אסיא נט-ס
Now there is another concern which needs to be addressed.
because orthodox Jews do not believe one may shorten life in order to avoid suffering, many people are afraid to have any involvement with a palliative care service. This does not seem to be warranted. Studies have shown that on balance patients who receive palliative care when it is appropriate actually live longer than those who receive routine care. It is important to emphasize the beliefs of the patient and family to the palliative care team, but we do believe in relieving pain as long as it is not in the interest of ending life earlier. This deserves a much longer discussion and we will try to address it further very soon.