Background: The Jewish population worldwide totals around 15.7 million, with 5.8 million Americans identifying as Jewish (1). American Jews align with a spectrum of observances to Jewish law or Halacha, and many do not espouse a denominational preference or consider themselves religious at all. Orthodox Jews comprise around 20% of the American Jewish community and are most observant of biblically derived commandments for every aspect of life – from daily rituals such as food choice to healthcare decisions at the end-of-life (EOL) (2). Patients who identify with denominations such as the Reform, Conservative, and Reconstructionist movements consider but usually do not strictly adhere to the Jewish legal implications of healthcare choices. Rabbis, who are Jewish scholars, teach and interpret Jewish law and there is wide variation in practice. For Orthodox families, community rabbis serve a critical role in the interpretation of Halacha and will often be approached when difficult medical scenarios arise. This Fast Fact will focus on the beliefs and rituals of the Orthodox Jewish patient, although it is important to emphasize that individuals may apply Jewish religious observance in diverse ways, whether Orthodox or not. As always, clinicians should not assume a fixed set of EOL beliefs attributed to any religious or cultural identity and should approach discussions with cultural humility (see Fast Fact #216) (3).

Philosophy of illness: Two guiding principles in Halacha inform EOL decisions and practices (4): 

1. Every moment of life is of utmost value, and life should be prolonged when possible.
2. Death is a natural part of life and should be treated with dignity and respect.

Pain management: Generally, rabbis and religious scholars advocate pain control as acceptable (5,6). Jewish patients will typically allow pain medications to be used proportionately to symptoms acknowledging the potential consequence of decreased lucidity, analogous to the practice of the doctrine of double effect (7). Clinicians should discuss the potential of decreased alertness seen with medications which palliate symptoms (e.g., opioids, benzodiazepines), as individual preferences may vary.

Discontinuation of potentially life-sustaining treatment: In Orthodox Judaism, there is a distinction between acts of commission and omission. Orthodox Jewish patients typically may not de-escalate life-extending interventions that are continuous (such as a ventilator or pacemaker). Once a continuous intervention is begun, Orthodox patients may consider discontinuation an act of commission which may hasten death, which is forbidden under Halacha (5,6). Considering this, clear prognostic expectations should be shared with prior to beginning any life-sustaining intervention, if possible. When appropriate, clinicians should make it clear when a continuous intervention like a ventilator is no longer actually prolonging life. Discontinuation of cyclical treatments (such as dialysis or chemotherapy) may be considered omission and are more likely to be permitted under Halacha. If available, a Halakhic Living Will can help guide EOL treatment in a cultural concordant manner.

Medically administered nutrition, hydration (MANH) and oxygen: Most rabbis will encourage the use of oxygen and MANH when it is necessary to prolong life (e.g., a patient would be expected to die of starvation otherwise) and will rarely sanction they be stopped (5,8). If these interventions are detrimental to sustaining life (ie; the patient will likely aspirate if continued), the focus of communication should be on what will be done to provide comfort (ie; ice chips, mouth swabs, handfeeding).

Death by neurologic criteria: Orthodox Jews generally do not accept that the neurologic criteria for death (e.g. “brain death”—see Fast Fact #479) constitutes death and acknowledge cardiac cessation as true death (4). Orthodox families may not agree with discontinuation of “life-support” technologies, as they do not consider the patient to have died. Involvement of the community rabbi will be imperative in these situations. Other methods of organ donation, such as utilizing a living donor, are generally encouraged.

Suicide / Assisted dying: Suicide, including physician-assisted suicide, is generally considered an act of commission which hastens death and is forbidden according to Jewish Law (4).

Practices around death: In the last 72 hours of life, only medically essential movement of the body should be done to minimize any risk of hastening death (4,8). Orthodox patients may prefer to be surrounded by a “minyan”, or quorum of ten Jewish adults (typically men) at the time of their death, if possible (9,10). After death, a burial within 24 hours is preferred; death certificates should be done quickly to accommodate this. Families may request to perform a ritual washing of the body after death called “taharah”, and the deceased may be dressed in a white shroud called a “kittel”. Often a 7-day period of mourning called “shiva” is observed by close family members (9,10). These rituals are typically performed outside of the hospital. Resources and support for appropriate treatment of a deceased Jewish patient can be found through Jewish funeral homes or community burial societies called “Chevra Kadisha”.

Other considerations: Many Orthodox Jews follow a commandment of modesty and prefer to be assigned nurses of their own sex. It is customary not to touch individuals of the opposite gender outside of one’s family, although medically appropriate examinations are acceptable (10) – always respectfully ask. Men may wear head coverings such as a “Kippah” or hat, married women may cover their hair with a headscarf or wig. The Jewish sabbath (“Shabbat”) begins every Friday at sundown and ends Saturday after nightfall. Many common activities are prohibited during this time. Families may seek lodging near the hospital to accommodate restrictions on driving, carrying, and other prohibited actions during the sabbath. Orthodox families may not be available to answer the phone on Shabbat, and clinicians should discuss with them methods of emergency contact. Jewish dietary laws include eating kosher food, which some hospitals offer, and others provide through Bikur Cholim (visiting the sick) committees.

References  

1. Dashefsky A, Sheskin IM. American Jewish Year Book 2022: The Annual Record of the North American Jewish Communities Since 1899. 2023. Springer Cham. doi:10.1007/978-3-031-33406-1 .
2. Pew Research Center. Jewish Americans in 2020. May 4, 2021. Accessed April 4, 2024. Available at: https://www.pewresearch.org/religion/2021/05/11/jewish-americans-in-2020/pf_05-11-21_jewish-americans-00-7/.
3. Lum H,  Arnold RM.  Asking about cultural beliefs in palliative care #216. Journal of Palliative Med. 2012; 15(6), 714–715. doi:10.1089/jpm.2012.9583.
4. Weiner J. The End of Life. In: Jewish Guide to Practical Medical Decision-Making. 2017, pp 113-178. Urim Publications. 
5. Weiner, J. How Much Treatment? Jewish Guide to Practical Medical Decision-Making. (2017). (pp 69-86). Urim Publications. 
6. Loike J, Gillick M, Mayer S, et al. The critical role of religion: caring for the dying patient from an Orthodox Jewish perspective. J Palliat Med. 2010; 13(10):1267-1271. doi:10.1089/jpm.2010.0088.
7. Rinderle T, Willett J. Bioethical Distinctions of End-of-Life Care Practices #422. Journal of Palliat Med. 2021;  24(9): 1400–1402. doi:10.1089/jpm.2021.0320.
8. Steinberg, A. Jewish Medical Ethics. Schlesinger Institute. The Encyclopedia of Jewish Medical Ethics, Vol 6, 1998, pp. 624-645.
9. Weiner, J. After Death. In: Jewish Guide to Practical Medical Decision-Making. 2017, pp 185-266, Urim Publications.
10. Rabbi Naftoli Rabinowitz. Caring for the Orthodox Jewish Patient. Johns Hopkins Hospital. (Pamphlet). Pub 2022.

Institutional Affiliations:  Johns Hopkins University, Baltimore, MD (JE, NR); Gilchrist Hospice, Baltimore, MD (JE, CG); Massachusetts General Hospital, Boston, MA (LR).
Conflicts of Interest: None to report.
Version History: originally edited by Drew A Rosielle MD; first electronically published in October 2024.