Monday, February 24, 2014

The Ethics of Palliative Sedation

Recently, I was asked about the ethics of palliative sedation (also known as "terminal sedation").

This is separate from palliative care, and the problems of hospice. For the purpose of this question, we are talking about sedating someone to the point of unconsciousness for the duration of their lives, because of great pain. Death is still weeks away, but doctors are not able to alleviate suffering without inducing unconsciousness.

On the one hand, one is fulfilling the mandate of relieving a person's pain; for more on that mandate, see Rabbi J. David Bleich's 2002 Tradition article, Palliation of Pain. 

On the other hand, the idea of putting someone into a permanent unconscious state seems a lot like killing them.

I haven't been able to find much in halachic literature, but I did find an interesting response from Rabbi Dr. Mordechai Halperin, one of the leading authorities in Medical Halachah in Israel. The original Hebrew is here; my translation is below:


I wish to receive counsel and guidance regarding my 91-year old mother, who has fractures all along her spine due to osteoporosis. Recently she fell and was bounced around, and since then she has experienced great pains.

The advice of the doctors is to sedate her, to prevent pain. According to the doctors she will not return to walking, or to moving her lower body. She can move her arms lightly. However, she is still lucid.

The question: May one go along with the doctor's advice and introduce her into sedation to prevent pain? I understand that this sedation would become a permanent state for the rest of her life.

I would appreciate it if you could respond by telephone. Thank you in advance.


The discussion is of a lucid woman. Therefore, this depends exclusively upon her desire, and one should ask her directly.

What do you think? And can you provide supporting sources?


  1. Whence the assumption that causing unconsciousness has any likeness to causing death? On the contrary; the controversy about halachic brain death would seem to indicate that unconsciousness and death have nothing to do with each other.

  2. I do not think the cases are similar. Palliative sedation is a case in which a patient suffering from extreme pain is sedated to the point of unconsciousness (is propofol, high dose midazolam, remifentanyl etc..). It is extremely rare for patient's to receive palliative sedation. It is only given in cases of terminal illnesses (not as you wrote above).
    The sedation referred to in the letter is one of very light sedation with narcotics which help alleviate the pain but do not make the patient unconscious.

    Regarding the ethics: see the doctrine of double effect. Is it applicable in Halacha?

  3. Yitz-
    Agreed on a practical level and vis-a-vis the brain death debate. But the person who asked me about this was concerned because of the induced level of non-function.

    1. Terminal illness - A fair point. I should have written "imminent", since this can be done for someone who has weeks to live. I will edit.

    2. I believe the case in the letter is of unconsciousness; the term הרדמה, used in the Hebrew, seems to make that clear. Also, I would not think they would be asking Rabbi Dr. Halperin about use of light sedation.

    3. Double effect is another issue, but one that is generally resolved as non-problematic in halachah. You might take a look at my shiur on the topic here.

  4. If I recall correctly, this YUTorah shiur from Rabbi Brand on medical marijuana quotes R' Zylbershtein asking R' Elyashiv about someone terminally ill and in pain who would rather spend their remaining time "out of it", even with something like LSD! R' Elyashiv replied that we do whatever to alleviate pain. "But what about having them conscious to say the final shma yisrael?" "Not our problem, we alleviate pain." "But how do we control the supply of these drugs so they don't get into the wrong hands, and isn't there the danger the hospital may be tempted to drug patients who would otherwise need more-involved care?" "Not our concern, we alleviate pain."

  5. I think the previous comment regarding double effect is on point. The goal is pain management. If it is achieved with an awake patient then good. If it cannot be achieved and also keep the patient awake, then the patient gets to decide what to do. Obviously only in the situations similar to those where a patient can choose pain medications even if it could cause respiratory depression and hasten death. It is not necessary and in fact wrong to change the goal from pain management to being unconscious. You don't need new halachic sourced because in truth it is not a novel halachic situation. It would be a novel situation if the goal is unconsciousness.

  6. Noam-
    I hear, and it's an interesting point. On the other hand, this is not as clear-cut as the normal double effect split, in which the two effects are not as close (kill the person blocking the tunnel in order to escape the cave, or divert the train in order to avoid having someone run over). Here, the two effects are very close - rendering the person unconscious and removing her sensation of pain.