The question of providing artificial nutrition and hydration (ANH) to a patient toward the end of his life raises many emotional, medical, and halachic dilemmas.
Food is not only a natural necessity but is also an important part of our individual and ethnic identity. Withholding food feels to many like depriving someone of his personhood. For Jews, it may also invoke memories of Nazi and Hamas tactics.
However, many medical professionals warn that artificial feeding can sometimes be useless or even harmful. This article will provide the basic contours of the discussion. As always, each patient’s case should be examined individually.
How Halacha views artificial feeding
Generally, it is strictly forbidden to starve a person to death by denying him access to food. A person who ties someone up and leaves him to the elements, for example, is considered a killer. The fact that the killer did not directly strangle the victim doesn’t change the fact that his actions caused someone to die.
In the case of ill patients, however, the cause of their potential starvation is their underlying medical condition. At times, the patient has swallowing difficulties (dysphagia), leading to risks of aspiration pneumonia, malnutrition, and dehydration.
At other times, patient will have minimal appetite due to their disease or from symptoms like nausea, abdominal pain, or gastrointestinal obstructions. At times, a patient will nonetheless insist on eating a food that poses risks.
For example, I was recently consulted on cases in which patients craved chocolate and Diet Coke. As Rav Asher Weiss has argued, so-called “risk feeding” is permissible if it is done in a careful manner because we want to preserve the patient’s oral intake of food for both medical and emotional reasons. Frequently, we can also provide items with varying textures like ice chips or nutritional shakes (e.g., Ensure) while using speech pathology to improve swallowing capabilities.
Many times, caregivers can even spoon-feed patients. While sometimes emotionally draining, this may be sufficient to provide essential nutrients, particularly toward the end of life when bodies require fewer calories.
When such steps are insufficient, options of medical nutritional therapy are explored.
Sometimes we can provide sufficient nutrients intravenously (IV); at other times, however, this is not possible due to lack of vascular access (i.e., no accessible veins) or fluid overload (i.e., the body can’t tolerate more liquids).
Other times, we may administer enteral nutrition through an NG (nasogastric) tube that’s inserted through the nose into the stomach; or a PEG (percutaneous endoscopic gastrostomy) tube, which inserts nutrition directly into the stomach.
These interventions, sometimes temporary but other times permanent, can frequently provide effective nutritional alternatives and meaningfully extend people’s lives. Patients with neck cancer, ALS, and other ailments regularly benefit from these mechanisms.
When it is not medically contraindicated, most decisors contend that one should provide some form of oxygen, nutrition, and hydration. These are seen as natural needs that also ensure the patient’s comfort.
Indeed, Israeli law mandates these interventions be provided, even when a patient is terminally ill.
We should allow the underlying illness to take its course and not deprive a patient of a natural need that will cause him to die sooner. This is the default position shared by my organization, Ematai, which regularly advises patients and families around the world regarding end-of-life care.
Sometimes, patients who are suffering and are terminally ill will resist ANH interventions, asserting that they prefer death to life under this circumstance. Rabbi Shlomo Zalman Auerbach felt that we should nonetheless compel ANH.
He agreed, however, that we can sometimes reduce the amount given to basic water and sugar in cases when there was no chance of survival or if more invasive measures like a PEG tube could cause harm or will not be accepted by the patient.
Rabbi Moshe Feinstein, however, ruled that we should encourage patients to accept this intervention, but we cannot compel them. Many doctors also note that it can be physically difficult to force a patient to accept such interventions and might further cause more harm if the patient pulls out the tube or violently responds to his hands being tied.
Interestingly, this entire approach regarding ANH was challenged by one of Jerusalem’s greatest scholars, Rabbi Zalman Nechemia Goldberg. He argued that in cases when a patient has a terminal illness and is suffering to the point at which he prefers death over such a life, then there is no obligation to apply interventions to save someone. Of course, the prohibition of mercy killing (retzicha) remains, but there is no obligation to proactively extend such a life (chiyuv hatzalah). Accordingly, one can forgo all new medical interventions, including ANH, in such circumstances.
As Rabbi Goldberg conceded, most decisors rejected this position. However, this perspective is shared by Rabbi Hershel Schachter and Rabbi Mordechai Willig. They assert that ANH is a form of medical intervention that is fundamentally no different than surgery, dialysis, or other medical treatments. It is forbidden to starve a person who can otherwise swallow food.
This is distinctly different from artificial interventions that only prolong the dying process and extend an excruciating experience. In their minds, this includes patients with advanced dementia. Notably, some doctors believe that there is limited medical benefit to PEG tubes and other devices in actually extending the lives of dementia patients.
Ultimately, each patient must be assessed individually on a medical level and in consultation with his chosen rabbinic adviser. Ematai’s Robert M. Beren Medical Halacha Helpline is available to help families with these complex dilemmas.
The writer is the executive director of Ematai and author of Ethics of Our Fighters. www.Ematai.org