Truth-Telling to Patients
TraditionOnline.org features open archives dating back to the journal’s founding in 1958 and I would like to highlight one article exemplifying how helpful and insightful this material can be. As people live longer, questions about the decision-making process regarding care for the infirm and elderly have grown more prominent. A 2010 essay by Rabbi Dr. Judah Goldberg makes an invaluable contribution to our thinking on these matters.
Had Goldberg’s essay been purely and narrowly halakhic, analyzing the classic legal sources, he would not have needed the TRADITION forum to articulate his ideas. However, his analysis touches on the nature of medical knowledge, the relationship between doctor and patient, the value of autonomy, and how formalistic halakha is. These items would less naturally appear in a halakha sefer even though they could impact on a rabbinic response.
Conventional rabbinic wisdom held that one should not inform a patient about a terminal illness because the news might upset the patient and lead to further deterioration of health. Obviously, pikuah nefesh is an overpowering halakhic consideration. Dr. Alan Jotkowitz and Dr. Shimon Glick, among others, have challenged the standard approach and their argumentation raises important larger issues. If scientific reason once worked off logic and intuition, it now focuses much more on empirical studies and such studies indicate that knowledge of approaching mortality does not actually increase the death rate. Goldberg also relates this conclusion to a modern bifurcation between the mind and the body but this is not crucial to the point.
Another change in understanding relates to the nature of medical evaluations. Some view doctors as experts who arrive at a definitive diagnosis and then offer the optimum treatment. However, medical reality is much more complicated. Diagnosis involves guess work and varying doctors often arrive at different conclusions. Perhaps the surgeons recommend surgery while the radiologists suggest radiation treatment. This dynamic makes it much harder to view the doctor as the definitive deciding authority. Different treatments will bring varying side effects and only the patient can guess how he or she will react to those effects. This shift reflects a modern trend towards greater valuing of autonomy.
Furthermore, we understand the potential abuses of power inherent in granting doctors too much control. We are reluctant to set a precedent where doctors feel that they can make crucial decisions without the consent of the patient. History includes horror stories of arrogant medical practitioners.
Goldberg also wonders whether concealing information will work since a relative may reveal the truth or the patient may discover it by himself. He does not say this but I believe the latter scenario far more likely in our age of Google. After the truth emerges, subsequent loss of trust in the doctors can impact negatively.
The essay includes some discussion of rabbinic sources. R. Moshe Feinstein ruled that a patient needs to make an informed choice in the case of a surgery with a degree of risk where the doctor thinks the procedure improves the overall chances (Iggerot Moshe, Hoshen Mishpat 2:73). Apparently, halakha does not always demand following the path with the best numerical chance of prolonging life and does value some degree of patient autonomy.
R. J. David Bleich cites support for the conventional position from a midrash in which King Hezekiah faults Isaiah for saying to him “Give last instructions to your family as you will die and not live.” Such discourse causes the ill to lose hope (Kohelet Rabba 5:6). Goldberg makes three important points in response. We are reluctant to derive halakha from aggadic sources. The midrash talks of “the way of the world” which sounds more like a societal assumption and less like a universal truth. The criticism may relate more to the harshness of tone and less to the actual content. Even those who favor disclosure call for tact in place of brutal honesty.
The point about aggadic source material leads to a larger idea. While halakhic thinking inclines towards definitive answers, particular areas of life do not lend themselves to such certainty. The facts are too uncertain and the dilemmas are too personal for a one-size-fits-all all response. Some end-of-life conundrums belong in this ambiguous category.
Anyone advising others about such sensitive matters would do well to read Goldberg’s essay. It combines halakhic knowledge with an awareness of changes in our understanding, such as that gained through empirical studies, and a greater awareness about the uncertainties of diagnosis and treatment that impact rabbinic rulings. My summary does not do full justice to the essay and analyzing the arguments means reading with care in its entirety (all 22 pages). It is precisely these factors that make TRADITION and its content valuable. We feature authors who realize the relevance of broader wisdom and who pen essays about serious topics longer than sound bites.
Note: For more on treating those in their final years, see Atul Gawande’s Being Mortal: Medicine and What Matters in the End (Picador); and on medical decision-making, see Jerome Groopman’s How Doctors Think (Harper Collins).
Yitzchak Blau, Rosh Yeshivat Orayta in Jerusalem’s Old City, is an Associate Editor of TRADITION.
2 Comments
At 92-years-of-age, these articles are important to me. I might note one benefit of keeping an elderly patient informed: If he or she knows of impending death after a period of months or a few years, an heretofore-independent person may choose the option of spending the final period in a hospice environment devoted to make life as pleasant as possible for limited-remaining-life people or possibly a friendly regular retirement home. Without knowledge, the options might not occur to the person. David Klepper
Further thoughts. 1. What I posted earlier is covered in one of the articles with a URL above. 2. Halacha tells us to use the best medical-scientific treatment availalable today, regardless of what the Torah relates as applicable to a specifoic disease. As, indeed, the RAMBAM did in his day. Truthfulness is TORAH, in any case, and lieing for medicasl reasons is only Rabbinic, so, doesn’t Halacha demand truthfulness except when medical advice very clearly stetes the opposite, as for one in a mental institution oir with Alzheimer’s Disease, and doctors advise this?