Pain Relief and the Risk of Suicide: A Jewish Perspective

Pain Relief and the Risk of Suicide:  A Jewish Perspective

Rabbi Aaron L. Mackler, Ph.D.

July 6, 1999

Jewish ethics values healing and the preservation of life as important goods and as activities mandated by God. The case presented, involving a 29 year old male with AIDS who requests large doses of analgesics and sedatives, may involve some degree of tension between these values: actions taken to relieve pain, supported by a mandate to heal, might contribute to a patient's death by suicide, ending life and violating a traditional Jewish norm.

Upon closer examination, it appears that thoughtful provision of pain relief and supportive care has the potential both to relieve the patient's suffering and to lessen the likelihood that he would feel compelled to end his life.

As I understand the Jewish tradition, life is appreciated as a blessing and a gift from God. Each human being is esteemed as created in God's image. Whatever the level of one's physical and mental abilities, and whatever the extent of dependence on others, each person has intrinsic dignity and value in God's eyes.

Judaism respects our bodies and lives as God's creation, which have graciously been entrusted to our care. We have the responsibility to care for ourselves and seek beneficial medical treatment--we owe that to ourselves, to our loved ones, and to God. In accordance with the tradition's respect for the life given by God, it rejects homicide, suicide, and assisted suicide.

Medical treatment that contributes to a patient's recovery is clearly supported by Jewish ethics. So is treatment intended to improve the patient's functioning or relieve pain. Humans are to act as God's partners in improving the world and helping persons in need. Scriptural support for these positions is seen in passages specifically discussing healing and in the general admonition to "love your neighbor as yourself" (Leviticus 19).

In appropriate cases, interventions such as surgery or medications to relieve pain may be mandated despite risks entailed.1,2,3 In the words of Rabbi Immanuel Jakobovits: "Analgesics may be administered, even at the risk of possibly shortening the patient's life, so long as they are given solely for the purpose of rendering him insensitive to acute pain."4 The judicious provision of medications intended to benefit the patient, even with the risk of side effects, is part of the enterprise of health care.

I understand the case presented as involving the provision of beneficial medication that poses the risk of hastening the patient's death by contributing to a suicide. The risk seems relatively modest in the case as described, and should not prevent the provision of needed pain relief. Since my intention as physician would be to relieve pain, I would seek to take reasonable precautions to lessen the risk of precipitating death.

For example, if one sedative (such as a benzodiazepine) would be as effective as another (such as a barbiturate) but would be less likely to be used in a completed suicide, I would prescribe the less risky medication. In an unusual case, I might limit the prescription to only a few days' or a week's supply, if this limitation would effectively reduce the risk of suicide, and if it would not prevent the patient from obtaining needed medication.

Perhaps more importantly, I would try to clarify for the patient my intention in providing the medication: to relieve pain, and not to assist in the ending of life. The prescription should not be taken as a judgment that the patient's life is not worth living, or that I am tired of caring for this patient who will not get better, or that I am giving my approval or "permission" for actively ending life. Rather, it should be seen in the context of the therapeutic relationship, as a manifestation of my commitment to care for, and never to abandon, the patient.

My commitment to care for the patient has other implications as well. As the physician in this case, I would be troubled that the patient is "in constant pain." It would be important for me to increase my knowledge of palliative care for AIDS patients, and perhaps to arrange for a consult by those with greater expertise in pain relief and/or HIV disease.

Review articles and handbooks suggest that much can be done to alleviate pain and other symptoms of patients with AIDS.5,6,7 I am mindful of studies suggesting that only 20 to 60 percent of cancer pain is treated adequately, even though adequate treatment is possible in at least 90 percent of cases, and even patients whose palliation is not "adequate" generally do not experience the constant pain described.6

Both the patient's report of constant pain, and any suggestions that the patient might commit suicide, dramatically signal the need for careful attention to the patient's suffering and possible responses. Clinical depression is relatively common among patients who are terminally ill or in pain, and correlates highly with suicide.

Contrary to popular misconception, major clinical depression is distinct from the sadness that typical accompanies terminal illness, and generally responds to psychiatric treatment, even in the absence of improvement of the underlying disease.6 Other issues may include inadequate social support, spiritual despair, or a fear of abandonment. Together with family members, other health care professionals, and other individuals who may be of help, I would explore and seek to alleviate the patient's suffering.

I would investigate in particular the possibilities for hospice care. I understand the patient's wish not to "spend his last days in a hospice" to refer to a free-standing hospice or other health care facility. Provision of hospice services to outpatients and those cared for at home is often available, however, and in fact is the primary way in which such services are provided in the United States. For information on resources, I might turn to local colleagues, or to organizations such as the National Hospice Association (800-658-8898).

The same principles would guide a decision to prescribe medicine that the patient says may well be used for a deliberate overdose within the next few days. Here the details of the case and my conversation with the patient would be crucial. Especially if the patient volunteers this information, what is superficially a request for palliation may be in fact a thinly veiled request for assisted suicide, or at least an invitation to discuss the issue.

In this case, I would not supply the prescription, but would address the patient's suffering and perceived need to end his life. If the medication was in fact needed to relieve the patient's severe pain, and this seemed to be the patient's primary motivation in requesting the prescription, I might well prescribe the medication. I would take especially extensive precautions to minimize the risk of suicide; for example, in my choice of drug and amount prescribed. I would take special care as well to ensure that my actions were not seen as a signal of approval for suicide.

Most importantly, if told that a desired prescription might well be used for suicide, I would redouble my efforts to explore and respond to the patient's suffering. Health care professionals with the greatest experience in caring for terminally ill patients report that when patients' suffering is taken seriously and efforts are made to alleviate it, the need to end life is no longer seen as compelling.

By providing the medication that is needed to alleviate pain in the context of a treatment plan of supportive care, I would likely alleviate the patient's suffering and lessen the risk of hastening death, by suicide or other means. Such a course of action would be supported by Judaism, as it would be by other approaches to health care ethics. Based on the reports of experts in palliative care, it appears that this course of alleviating suffering without contributing to the active causing of death is possible in virtually all cases. It certainly appears to be possible in the case at hand.

References

1. Bleich JD: Judaism and Healing. New York: Ktav, 1981.
2. Dorff EN: A Jewish Approach to End-Stage Medical Care. Conservative Judaism 1991; 43: 3-51.
3. 0 Reisner AI: A Halakhic Ethic of Care for the Terminally Ill. Conservative Judaism 1991; 43:52-89.
5. O'Neill WM, Sherrard JS: Pain in Human Immunodeficiency Virus Disease: A Review. Pain 1993; 54: 3-14.
6. New York State Task Force on Life and the Law: When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context. New York: New York State Task Force on Life and the Law, 1994, pp 40-43.
7. Washington State Medical Association: Pain Management and Care of the Terminal Patient. Seattle: Washington State Medical Association, 1992.

Rabbi Aaron L. Mackler, Ph.D., is Associate Professor of Theology at Duquesne University in Pittsburgh. He serves as Vice President of the Society of Jewish Ethics. Rabbi Mackler is a member of the Rabbinical Assembly’s Committee on Jewish Law and Standards, for which he serves as Chair of the Subcommittee on Bioethics, and of hospital ethics committees in the Pittsburgh area.

Dr. Mackler served as ethicist for the New York State Task Force on Life and the Law, and taught as Visiting Assistant Professor at the Jewish Theological Seminary of America. He received a B.A. from Yale University, an M.A. and rabbinic ordination from the Jewish Theological Seminary of America, and a Ph.D. from Georgetown University. He has spoken on health care ethics and theology for numerous professional societies and other audiences.

Dr. Mackler's publications include Introduction to Jewish and Catholic Bioethics: A Comparative Analysis (Georgetown University Press, 2003), and an edited volume, Life and Death Responsibilities in Jewish Biomedical Ethics (New York: Finkelstein Institute, Jewish Theological Seminary of America, 2000). He also has written numerous articles in the fields of Jewish theology and bioethics.

Case of Sexual Harassment of Teenage Girl (1915)

Case of Sexual Harassment of Teenage Girl (1915)

New York, NY

After being sexually harassed Lydia Silverman attempted suicide.  The offenders in this case were not named.

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Table of Contents:

1. Teased over kiss, girl tries suicide (07/05/1916)

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Teased over kiss, girl tries suicide 
New York Times - July 5, 1916

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How Do You Spell Relief?

© (1998) By Vicki Polin, MA, LCPC, ATR

Photograph by Vicki Polin

There are so many different things you can do when you feel stress. Many people jog, work out at the gym, scream under railroad tracks (so no one can hear them), or pound pillows. Here are two alternative to helping to elevate stress from your life.

There are a few things that you can do just about anywhere. One of the most important things is to breathe (inhale and exhale). Breathing is a natural way to reduce stress. When we breathe we allow oxygen to get to our brain. One thing I suggest to people is to carry a bottle of bubbles along with them. Instead of going outside and lighting up a cigarette, you can blow bubbles. Not only are you helping yourself to inhale and exhale slowly, you are also helping the people around you to relax. Everyone enjoys watching bubbles float through the air.  Ok, at first if you are out in public people may start staring, but before you know it, you started a new trend.  Just about everyone enjoys blowing bubbles. 

Another great stress reducer is playing with clay. Some times just squeezing the clay between your fingers can be soothing. Other times pounding it on a table will do the trick. Below is a recipe for making Play Dough. You can make several different colors just by dividing up the dough and adding different color food colorings. The play dough will last for several weeks by keeping it in a zip lock bag.

Play Dough

4 cups White Flour

2 cups Salt

2 tablespoons Cream of Tartar

2 teaspoons Food Coloring

1/4 cup Vegetable Oil

3 Cups Water

1 Large Pot

Mix dry ingredients in large pot, then add food coloring, oil, and water. Mix well. Turn stove on high, mixing with a wood spoon. Once dough becomes thick remove from pot on a plate. Wait a minute before kneading with your hands. Store play dough in zip lock bags.

When Men Are Victims

Reprinted by Permission. © (1996) Eric L.

Fraidy cat. Wussy. Cry baby. Don't be such a baby. You're acting like a girl. What are you afraid of? Don't be afraid. You have no right to be afraid. There is nothing to be afraid of. You shouldn't be afraid. What are you crying about. Big boys don't cry. Quit your crying. That doesn't hurt. Grow up and act your age. What's the matter? Can't you take care of yourself?

Ever hear comments like that? If you're like me you've probably heard them all your life, ever since you were a little boy. It was very early in childhood that we were taught to deal with our pain. Our mothers told us to stop crying, our teachers told us to be quiet, and our mentors told us to deal with it and buck up and be a Man. So we learned to say, I can handle it. I'm fine. It wasn't shameful to admit we were hurt, but admitting we couldn't handle it, oh boy that was a one way ticket to being a Loser. And being a victim, well geez, you might as well hang a note on your back that says, Kick Me. So what do you as a man when you've been victimized? There's not much help available, unless you're rich, well insured, and surrounded by a loving fully functioning family and an incredible support group. How many of us have that? What little help that is available for victims is usually directed towards women that have been victimized, and the staff often has a biased view of men and are ignorant of men's emotional needs. So what's a fella to do?

First of all, I would like to say to anyone who has suffered through some kind of trauma (whether that's a car accident or a sexual assault or a history of childhood abuse) and is experiencing extreme emotional reactions:

You are not sick. You are not crazy. You are not "mentally ill". There is nothing "wrong" with you. What is happening to you are normal, natural reactions to an extraordinary experience that you have survived. It was an experience that was beyond the capacity of any human being to handle, and it is going to take some time for your system to process it and integrate it. You are going to encounter a tremendous number of people who don't understand that, who are uncomfortable with that, and will want you to control yourself. Ignore them, and stay away from them. Find a safe place to attend to your own healing. Surround yourself with people who will let you process the experience at your own pace, in your own unique way, and will help you move forward with dignity, grace, and compassion. You are a survivor.

Having said that, I think the first thing you need to do as a man is to tell yourself, I need help. Asking for help is not something we have been socially conditioned to do. Not only is it often seen as a sign of weakness, but most of the social support systems in this country are geared towards taking care of women who have been victimized. There are no crisis hot lines or shelters for battered men, there are no hot lines for male victims of sexual assault, there are no halfway houses for men recovering from a life of prostitution, and there are very few resources for men or boys who are victims of childhood sexual abuse. The few resources that are dedicated to men are things like soup kitchens or shelters for men who have fallen so far they are homeless. They may be good places to start if you have an addiction problem and need help getting back on your feet, but they often times don't have a clue about the depth of pain and anguish that a trauma survivor has. And you will probably need a lot of help healing that.

One of the main sources of help I have found in my own healing has been the support I have gotten within 12-step recovery community. The 12 step movement began when Alcoholics Anonymous was founded in 1935. Dr. Bob and Bill W. put together a program that addressed the physical, psychological, and spiritual aspects of the disease called alcoholism. For perhaps the first time in the history of the western world there was an organization with a mechanism to heal wounds of the spirit. That program gave birth to hundreds of different 12-step programs, which in my mind are all dedicated to healing wounds to the spirit. Through these programs thousands of people have found the courage, strength, and hope to heal from the insanity of what they have lived through. In my experience Alcoholics Anonymous is not just a bunch of people who have problems with alcohol. Most of the people I have met through AA have survived one or more horrendous traumas, and they were abandoned or neglected or abused by their family of origin. You don't know how powerful it is to walk into a room filled with people who have lived through the insanity that you have faced, and have them tell you that you are welcome, and that your story is real, and that you are not making everything up, and that what you did in order to survive was normal. Unfortunately that's not something our medical - psychotherapeutic community understands. Each group is different, and it is helpful to remember that everyone is in a different stage of healing and recovery, and that some people haven't been able to escape the painful reality of their own situation. AA and other 12-step groups are designed to help people help themselves, and to provide a structure for personal growth. Part of the healing process involves telling your story, and hearing other people's stories as well, and I know of few forums that are better than a 12 step meeting. By the way, most of the people I've met in 12-step groups were abused in some way, shape, or form in their family of origin.

There are many ways to ask for help: private and group therapy, workshops, 12-step recovery programs, books, and even videos. I suggest you experiment with different approaches and find what works for you. Some approaches can be confronting, others warm and gentle. You may need different approaches and techniques at different phases of your healing. Sometimes what may seem most confronting is actually a lesson needing to be learned. Don't concern yourself with being efficient and timely. Time may not heal all wounds, but all wounds heal at their own pace. But no matter what route you take, I think the most important step is finding people who can provide you support as you work through the emotional repercussions. There will be plenty of people who will simply not understand what you are going through. You may want to change them, to make them understand, or to act differently than the way they do. You may want people to act compassionate, or to be outraged, or to get excited, or to cry with you. Give it up. You can't control how other people will respond, and you can't change them. All you can change is yourself. Let people respond to you as they will, and seek out those people who respond positively and can support you. But be aware of the charlatans who talk about providing support, but don't walk the walk. There may be times when you feel alone and isolated and that nobody understands or cares. That is the most important time to reach out. Call suicide hot lines. Go to 12-step meetings. Find support groups. But get support.

I've also found a great deal of healing in the men's movement, although just like the feminist movement, there are many different factions and interests. Check out some publications and groups and keep your eyes and ears open and you can find some kindred spirits. One great thing I have found in the men's movement is the freedom to do things in my own way, to not have to do something in a way that is Nice, or Gentle, or Quiet, or Feminine and Pretty. I can be as ugly and as loud and as unexplainable as I need to be. I can let it all hang out so to speak. But beware, when you let it all hang out, things might happen to and within your body that can only be described as . . . unusual. Normal body functions may seize up and fail, strange tremors or numbness might happen in certain areas, unexplainable aches and pains might appear. Most "trained" medical professionals will look at those symptoms and dismiss them as psychosomatic (and tell you to get over it because it's all in your head), or they may want treat it as a physical disorder and medicate or operate or who knows what. But sometimes all that is really happening is that your system is trying to process an overwhelming experience and your body is reacting. So take care of your body. Get good nutrition. Get plenty of rest. Drink LOTS of water. Take long baths. Do healthy things that make you feel good. Get a massage. Get plenty of hugs. Play with puppies and kittens and teddy bears. And lastly, find a safe place to let whatever is happening in your body run its course. Find a place where you can cry and let your body tremble. Shake your head and mutter, "bugga, bugga, bugga, bugga, bugga." Hit pillows and rage. Throw rocks. Spit into the wind. Swear out loud. Walk. Dance. Do jumping jacks. Rock yourself to sleep. Move your body in whatever way you can. And remember to BREATHE.

P.S. Give yourself some credit. After all, you're a survivor. And one hell of a man to boot.