In this article, Rabbi Johnny Solomon grapples with the question: ‘Is it better to tell a dying person that the end is near or is it better that he is unaware of his imminent death?’

Few of us consider a final illness before death to be a blessing. However, according to the Jewish tradition, getting ill before dying is actually a gift that was requested by the patriarch Jacob [1].

According to the Midrash [2], Jacob was afraid of dying suddenly without settling his affairs or making peace within his family. He therefore asked G-d to make him ill before his death so that he would not die without warning. G-d did so, as evident from the fact that a messenger came to Joseph to inform him ‘behold, your father is ill’ [3].

But what type of ‘gift’ is the knowledge that you are soon to die?

According to Rabbi Benjamin Blech in his outstanding book ‘If God is Good Why is the World So Bad?’, the gift of a final illness is the gift of ‘awareness’ [4] which is beneficial not only to the dying person, but also, to their survivors. In the case of the dying person, they are given the opportunity to use their last days and hours to ‘rectify many things that might have gone uncorrected’ [5], and in terms of their survivors, we find that they are more receptive to the guidance and instructions of their dying relative whose words ‘are considered to carry much more power’ [6].

Of course, there is no fixed script for those near death. Some, like the patriarch Jacob, use their final hours to convey blessings to their children [7] as described in Parshat Vayechi, while others like King David use their final hours to give advice about succession [8]. However, according to Dr. Ira Byock – a leading palliative care physician and author of ‘The Four Things That Matter Most’ – those who are dying can find great solace in saying four short sentences to their nearest and dearest before they die [9]. They are:

• Please forgive me
• I forgive you
• Thank you
• I love you

In ‘The Four Things That Matter Most’ Dr. Byock explains the significance of each of these four sentences and provides many examples of how they have brought comfort to those on their death bed. For example, one of his patients called Steve had the opportunity to say these four sentences before passing, and ‘as he faced life’s end, Steve was transformed and so was everyone around him… Paradoxically, in the process of dying, he was healing and becoming well within himself. And in healing his own emotions, he helped his children heal their – for the rest of their lives’ [10].

Given all this, we must consider what is the right course of action in a situation where a patient is not aware of their prognosis. Is it better for them to be told that their end is near, or is it better that they remain unaware of their imminent death?

In examining this issue from a Jewish Medical Ethics perspective, Dr. Judah L. Goldberg writes that ‘deciding whether to disclose or conceal medical information boils down to a consideration of the potential risks and benefits of each option’ [11]. In support of full disclosure, some Rabbinic authorities refer to the Shulchan Aruch [12] which ‘enjoins a companion to instruct a perilously ill patient to confess’ [13], while numerous halakhic sources indicate that ‘psychological distress can cause biologic harm’ [14] and suggest that non-disclosure is preferred.

Currently, many medical practitioners adopt the view proffered by Dr. Abraham S. Abraham who explains that in cases of untreatable patients, the physician should not inform the patient of their condition ‘in the vast majority of cases’ [15].

However, Dr. Alan Jotkowitz and Dr. Shimon Glick have recently challenged this approach by claiming that ‘modern clinical investigations have not substantiated the supposed medical risk of truth-telling’ [16] and that ‘patients should ultimately be in charge of their own medical care’ [17]. As Judah Goldberg explains, ‘Jotkowitz and Glick’s position presents a challenge… to rethink the mind-body relationship in halakha, and with significant potential consequences’ [18]. But the question remains, ‘who should hold ultimate authority in sifting through all this uncertainty and making concrete choices?’ [19]. To this, Judah Goldberg responds, ‘certainly not the physician, for the simple reason that many of the unknowns lie in areas to which the physician cannot claim any special expertise. The physician may know the pathophysiology of terminal cancer, but whether this dying patient belongs in a hospital, a skilled nursing facility, or at home with loved ones and hospice nurses is as much an existential question as a medical one. Moreover, it is a deeply personal question, filled with nuance and laden with emotion, and belongs to no one but the patient’ [20].

Until recently classic Jewish Medical Ethics literature has taken the view that knowing that death is near quickens the death process which is why numerous halachic authorities have discouraged full disclosure out of concern for ‘biologic harm’. But what we learn from the above-mentioned Midrash concerning Jacob is that awareness is a gift, and that knowing that you are about to die can, at least in some instances, provide the greatest opportunity for the ultimate healing.

NOTES
[1] Much of my initial remarks originate from Rabbi Benjamin Blech’s outstanding If God is Good Why is the World So Bad? (Simcha Press, 2003) pp. 111-118
[2] Midrash Bereishit Rabbah 65:9
[3] Bereishit (Genesis) 24:1
[4] Benjamin Blech, If God is Good Why is the World So Bad? p. 117
[5] Ibid. p. 118
[6] Ibid. p. 119
[7] see Bereishit (Genesis) Ch. 49
[8] see Melachim I (Kings I) Ch. 2
[9] see Ira Byock, The Four Things that Matter Most (Atria Books, 2014) p. 3
[10] Ibid. p. 30
[11] Judah L. Goldberg, ‘Towards a Jewish Bioethic: The Case of Truth-Telling’, Tradition 43:2 (2010) p. 10
[12] Shulchan Aruch, Yoreh Deah 338
[13] Judah L. Goldberg, ‘Towards a Jewish Bioethic: The Case of Truth-Telling’ p. 11
[14] Ibid. p. 10
[15] Abraham S. Abraham, Nishmat Avraham: Yoreh Deah 338:3
[16] Judah L. Goldberg, ‘Towards a Jewish Bioethic: The Case of Truth-Telling’ p. 13, based on Alan B. Jotkowitz and Shimon Glick, “The Physician Charter on Medical Professionalism: A Jewish Ethical Perspective,” Journal of Medical Ethics 31(2005), 404-405
[17] Judah L. Goldberg, ‘Towards a Jewish Bioethic: The Case of Truth-Telling’ Ibid.
[18] Ibid. p. 16
[19] Ibid. p. 19
[20] Ibid.