Rabbi Jachter's Halacha Files
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Parshat Shemot & Va'eira          18-25 Tevet 5766             January 21, 2006             Vol.15 No.18


Revealing Painful Medical Truths to Patients
by Rabbi Chaim Jachter

Families and doctors are regrettably faced all too often with a painful decision as to whether or not one should reveal the truth to a patient about his illness. On the one hand, one would think that adults should be entitled to know the truth about what is happening to them. On the other hand, sometimes knowing certain information is to one’s detriment. Indeed, Kohelet states that adding knowledge adds pain (1:18). Knowledge is not always in our best-interest and sometimes ignorance is bliss.

Balancing Halachic Values
When dealing with the issue of informing a patient of a serious illness, caregivers and family must delicately balance the Halachic values of stating the truth and preserving the well-being of the patient. Truth is a paramount Torah value. Chazal state that the seal of Hashem is Emet (truth). Nevertheless, the Torah records that Hashem inaccurately reported to Avraham the comments that Sarah had made about him, in order to preserve marital harmony (see Breishit 18:12-13 and the commentary of Rashi ad. loc.). Similarly, one should not always present an accurate assessment to the patient if it will adversely affect his health.
This point is expressed in a number of classical sources. 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 Midrash (Kohelet Rabbah 5:6) describes a conversation between Yeshaya the prophet and King Chizkiyahu (see Melachim II 20:1-11). Hashem sent Yeshaya to inform Chizkiyahu that the latter’s illness was fatal. The Midrash describes Chizkiyahu’s criticism of Yeshaya for delivering such a depressing message as follows: “Customarily, when one visits the sick, the visitor says to the patient, ‘May Heaven have mercy on you.’ When a physician visits a sick individual he tells him, ‘This you may eat and this you may not eat. This you may drink and this you may not drink.’ Even if the doctor sees that the patient is near death he does not say to him, ‘Write a will for your family,’ lest this weaken the patient’s resolve.’” We see that it is insufficient to tend to the patient’s physical needs without paying attention to his psychological needs. Incidentally, we see the same approach regarding the Mitzvah of honoring one’s parents (Kiddushin 31) and giving Tzedakah (Rambam Hilchot Matanot Aniyim 10:4).
Furthermore, a well-known Midrash (cited by Rashi to Breishit 23:3 s.v. Lispod and see Siftei Chachamim ad. loc.) relates that Sarah Imeinu died when she was told about Akeidat Yitzchak and about how Yitzchak was almost slaughtered. This Midrash teaches that one must be extremely careful in how one delivers sensitive information, emphasizing that delivering traumatic news to someone in a very delicate medical condition (such as Sarah Imeinu, who was 127 years old at the time) can potentially have lethal consequences (also see Rashi to Pesachim 3b s.v. Ahadrei LeKarei). The Ramban (Bereishit 45:26) explains that the same applies to delivering surprisingly happy news to weak individuals, such as when Yaakov Avinu was informed that Yosef was alive in Egypt. For further discussion regarding the appropriate manner to present devastating information, see Rav Itamar Warhaftig’s article in Techumin 1:537-539.

Shulchan Aruch
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.

Practical Advice- Rav J. David Bleich and Dr. Abraham S. Abraham
Rav J. David Bleich (Judaism and Healing, page 33) offers the following helpful suggestions for implementing these Halachot in the contemporary setting: “There is no need to convey a precise diagnosis to the patient, when such information can reasonably be withheld, if the patient will identify the diagnosed condition with a terminal malady. When the patient is aware of the gravity of his situation, the physician should always be encouraging and positive in his approach. He should stress the positive aspects of available modes of therapy and, by word and action, encourage the patient not to abandon hope. This is not to say that the doctor should guarantee either recovery or longevity. He should rather endeavor to bolster the spirits of his patients without denying the possibility of serious developments. Above all, the physician’s tone and demeanor should at all times be hopeful and supportive.”
Dr. Abraham (Nishmat Avraham Y.D. 338:1) adds that doctors should never state that there is absolutely no chance for recovery, nor should they state with certainty the amount of time that they expect a patient to live. Physicians must realize the limitations of medical knowledge and accept that Hashem makes these sorts of determinations. Indeed, Dr. Abraham cites Rav Kook’s opinion (Teshuvot Daat Kohen, number 140) that medical assertions made by physicians are not regarded as absolute truth but merely as Safeik, possibly true.
Rav Betzalel Stern – a twentieth century authority – rules that doctors should not reveal to a patient that he is afflicted with cancer (Teshuvot BeTzeil Hachochma 2:55). Dr. Abraham S. Abraham (ibid.), however, notes that nowadays this can sometimes be impossible and/or counterproductive. Ignorance in some situations is not bliss and may cause the patient to panic more than knowledge of his illness would have. Dr. Abraham recommends that the doctor should first reveal the information to very close relatives and only then, together with these relatives, present the bad news to the patient. The conversation must be as encouraging as possible and coupled with the point that the physician and the therapy will serve as Hashem’s messenger together with the prayers of the patient and his family in facilitating a full recovery. Indeed, it is well-known that the patient’s attitude plays a dramatic role in determining the result of serious disease. Hence, medical personnel, family, rabbis, and friends are obligated to provide the patient with the most psychological support possible.
Dr. Abraham notes that if the patient is suffering in an advanced stage of cancer to the extent that there is no hope of curing the cancer (and the patient will therefore receive only palliative care to make him more comfortable), then he should not be told that he is suffering from cancer. (He does add, though, that close family members should be informed.) One may add that if the patient knows that he is suffering from cancer, but does not know that his condition has worsened, it is possible that the doctor should not reveal the updated information to the patient. Indeed, my family made a decision not to inform my father Z”L that his lung cancer had spread to other parts of his body. In retrospect, this was a sound decision that was suited to my father’s personality. I believe that my father’s quality of life during his last six months was enhanced by his ignorance of the details of his condition. In particular, I recall helping my father purchase some new clothes a few months before his death, which I believe encouraged him and helped him live somewhat longer.
Generally speaking, if one is (God forbid) faced with this sort of question regarding a patient or family member, he should consult with his Rav and a team of competent professionals to devise an appropriate course of action. It is important to customize the approach to the patient’s personality and circumstances, as there is no “cookie cutter” approach to such a difficult situation. If family and caregivers handle the situation properly, experience teaches that it can serve to increase both the quality and the length of life of the patient.

Conclusion
It should be noted that the Halachic approach to telling patients the truth runs very counter to the prevailing secular culture. Western culture today emphasizes the right of patients to know the details of the malady they are suffering from. On the other hand, it is fair to say that the Halacha does not recognize a patient’s “right to know.” Rather, we are obligated to act in a manner that promotes our own health and the health of others and withhold certain information if that is determined to be in the best interest of the patient.
If one has not executed a living will with provisions that caregivers follow Halachah regarding this issue, it is quite possible that one’s caregivers will not follow the Halachah in this regard. Thus, it is crucial to execute a living will with provisions that family and caregivers consult a Rav regarding how to observe the Halachah concerning truth telling to patients. Furthermore, by designating a specific Rav to make a decision, it helps avoid a potential fight among family members regarding which Rav to consult and what information should be revealed.
May Hashem bless us that we should not experience any more illness and that we never need to implement any of these ideas and approaches in practice.

 

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