Medical Assistance in Dying
Physician-assisted death is now legal in Canada under the name MAiD: Medical Assistance in Dying; it is also legal in some other countries and some US states. The Canadian guidelines mandate that the patient be fully aware when giving consent to this decision, and that their suffering has become unbearable with no hope for recovery. May a Jew choose this option for themselves? May a Jewish medical practitioner assist a patient in dying? (Rabbi Lawrence A. Englander, Mississauga, Ontario)
“Law that lacks tzedakah, that does not draw from the wellsprings of feelings and tenderness, of heartfelt ways of pleasantness and inner kindliness, that is confined by its boundaries and does not break through its borders to go beyond what the law requires—such law is absolute wickedness.”
CAVEAT: Although some form of medical assistance in dying is currently legal in California, Colorado, Hawai’i, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, Washington, and the District of Columbia, this responsum addresses ONLY the Canadian law. The absence of guaranteed access to affordable health care in the US, as well as significant regional differences in access to care even for those with insurance, means that we cannot be certain that an individual in the US considering medical assistance in dying is not being affected by their own or their family’s financial situation, or by obstacles to obtaining necessary and appropriate treatment.
We are aware that this question raises powerful fears. Some people hear in it echoes of some twentieth century nightmares, as epitomized in the phrase “life unworthy of living,” and believe passionately that “euthanasia” is a “treacherous first step on a slippery slope to genocide.” We are convinced, however, that the narrow and carefully defined window opened in Canada’s Medical Assistance in Dying law is none of those things. We will argue that we are in accord with the realistic and life-affirming perspective of our tradition in responding in the affirmative for that small number of patients for whom it is the only treatment available for what clinicians refer to as “total pain.” (See below for a discussion of this concept.) We undertake to answer this question in light of this reality.
I. Medical Assistance in Dying (MAiD)
Canada’s Medical Assistance in Dying law, which came into force on November 1, 2018, allows physicians, nurses, and pharmacists to provide lethal doses of medication, either by administering it directly or giving it to the patient to administer themselves. The original law limited eligibility for MAiD to individuals meeting all of these criteria:
- making the request oneself
- at least 18 years old
- capable of making one’s own health care decisions
- able to provide informed consent to the procedure
- eligible for publicly funded health care services in Canada
- having a diagnosis of a “grievous and irremediable medical condition,” including all these criteria:
- having a “serious and incurable illness, disease, or disability”
- being in an “‘advanced state of irreversible decline’ in capability”
- experiencing “intolerable physical or psychological suffering”
- “natural death” having become “reasonably foreseeable”
The law also mandated the following safeguards:
- The request must be made in writing by the individual themselves after being informed of their condition.
- The written request must be witnessed, signed, and dated by two independent witnesses. Specifically, this disqualifies the patient’s health care facility operator, any unpaid caregivers, and anyone who benefits from the patient’s death.
- Two medical practitioners who are independent of each other must both provide written opinions confirming that the eligibility criteria are met.
- The patient must be made aware of all treatment options for their medical condition, including palliative care, before providing their informed consent for MAiD.
- The medical practitioners must confirm that the request has been made freely, without undue influence.
- There must be a 10-day reflection period between approval of the request and carrying out the procedure, unless death or loss of capacity to give consent is imminent.
- The patient may withdraw their consent at any point, and must again give explicit consent to proceed immediately before administration of the drug. If at that point the patient can no longer give or waive consent, any movements or gestures they make will be understood as waiving the procedure.
The law was amended subsequent to a legal challenge upheld by Canada’s Supreme Court. As of March 17, 2021, it no longer requires that natural death be “reasonably foreseeable.” It also allows individuals to request MAiD if they “experience unbearable physical or mental suffering from [their] illness…that cannot be relieved under conditions that [they] consider acceptable.” That expansion of eligibility was accompanied by these provisions, in addition to the ones enumerated above:
- One of the two practitioners must be an expert in the patient’s particular condition. If neither is an expert, they must bring one in.
- The patient must be informed of all palliative and other support and care opportunities available for their condition, and given consultations with providers.
- The patient and their practitioners must have seriously considered all these options.
- The process of determining this patient’s eligibility for MAiD must take at least 90 days, unless there is a chance that the person will lose the ability to give consent before the 90-day waiting period is up.
Finally, the law as written excludes individuals whose only illness is a mental illness, at least until March 17, 2023. The Canadian government and health care professional associations are currently working to develop guidelines for these individuals, and have a deadline of March 17, 2022, to present those guidelines.
Health Canada published extensive reports on the law’s results for 2019 and 2020, the first two full years for which it was in effect. Available statistics, therefore, do not include any instances of individuals whose death was not “reasonably foreseeable.” In 2020 there were 7,595 reported instances of MAiD, a 34% increase over 2019—an increase the Minister of Health attributes to increased awareness of, and openness to, this option. The average age of those opting for MAiD was 75.3 years. The report documented that 5,248 of the Year 2020 MAiD patients were suffering from some form of cancer; 1,048 from cardiovascular conditions; 858 from chronic respiratory conditions; and 775 from neurological conditions (273 ALS; 140 Parkinson’s Disease; 75 multiple sclerosis; 287 other). Of the 7,595 patients, 6,289 were receiving palliative care prior to choosing MAiD. Of the 1,306 patients who were not receiving palliative care, 1,156 would have been able to access it if they had wanted.
Canadians submitted a total of 9,375 requests for MAiD in 2020. Of these, 1,193 died before receiving MAiD; 232 withdrew their requests (154 because they changed their minds and 78 because they found palliative measures sufficient); 566 requests were denied after being judged ineligible (210 because medical practitioners judged them not competent to make health care decisions, 157 because medical practitioners judged that their deaths were not reasonably foreseeable, 98 because they were unable to provide informed consent, and the remainder for other unnamed reasons).
Physicians are required under the law to report how the person requesting MAiD described their suffering. Thus we are able to see what constituted, for these individuals, “intolerable physical or psychological suffering…caused by their medical condition or their state of decline…that [could] not be relieved in a manner that [they found] to be acceptable.” Here is what they reported:
|Nature of suffering as reported by patient||Percent of patients who cited it as a reason|
|Loss of ability to engage in meaningful activities||84.9%|
|Loss of ability to perform activities of daily living||81.7%|
|Inadequate control of pain (or concern for future)||57.4%|
|Loss of dignity||53.9%|
|Inadequate control of symptoms other than pain (or concern for future)||50.6%|
|Perceived burden on family, friends, or caregivers||35.9%|
|Loss of control of bodily functions||33.1%|
|Isolation or loneliness||18.6%|
|Emotional distress / anxiety / fear / existential suffering||5.6%|
|No / poor / loss of quality of life||3.1%|
|Loss of control / autonomy / independence||1.9%|
Significantly, one might think that “loss of ability to engage in meaningful activities/perform activities of daily living” and “loss of control/autonomy/independence” are one and the same. Both, after all, describe a severe restriction of an individual’s ability to act. Clearly, however, the sufferers do not see it that way. Rather, it appears that most of them find even a circumscribed life valuable as long as they can still engage in “meaningful” activities, in “daily” activities—that is, activities that render them included in the world of the living, even if in a limited fashion.
II. Reading our sources
All halachic precedents have rejected providing a person with medical assistance in dying. This committee’s fullest statement on this question is from 1994 and states as follows:
Jewish tradition, as is well known, prohibits suicide, if by “suicide” we mean a rational, premeditated act of self-killing. The prohibition flows from the tradition’s affirmation of the sanctity, the inviolability of human life. This affirmation, in turn, assumes the doctrine that life belongs to God, Who has the final say in its disposal. This implies that the individual has no right of “ownership” over his/her life, no authority to bring that life to an illegitimately premature end. For this reason, the court may not execute a criminal on the strength of his own confession, “for the human life is not the property of man but of God…one’s confession cannot be accepted with respect to a matter that does not lie within his power…(for) one is not entitled to commit suicide.” Similarly, Jewish law prohibits euthanasia, or mercy killing. Inasmuch as human life remains sacred and inviolable until the final moment of its existence, the sources uniformly reject any distinction in this regard between the dying person (the goses) and any other. “The dying person is like a living person in all respects” (S’machot 1:1). Though he or she lies in a moribund state in which death is imminent, a person is still a person, a human being created in the image of God. This life is to be treasured and protected; even though the prognosis is hopeless, he or she deserves all appropriate care. Just as the laws prohibiting work on Shabbat may be violated in order to save life (pikuach nefesh), so do we violate them on behalf of the goses. We set aside the Shabbat in order to treat this person, despite the fact that this is a life we cannot “save.” The one who kills the goses is guilty of murder. The dying person is compared to a flickering flame: the slightest touch will extinguish his life. It is forbidden to take any action that hastens the death of the goses; “whoever touches him commits bloodshed,” even though this act is taken out of compassion, in order to relieve him of terrible pain and suffering.
Given this clear statement of prohibitions, why are we revisiting this issue?
A. New knowledge
Obviously, medical practice has progressed dramatically since the Talmudic period and since the 16th century, when the Shulchan Aruch was written. We regularly adjust our perspective, and consequently change our practices, in light of new information and novel medical technologies. For example, Rabbi Esriel Hildesheimer ruled that deaf persons, categorized halachically in the Mishnah (second century CE) with children and mentally incompetent persons as exempt from the mitzvot due to lack of understanding, could take their place as full members of the community because in Hildesheimer’s day experts had long since shown conclusively—as a result of the advent of sign language—that deaf persons were capable of functioning as full, competent human beings. He wrote:
“…[I]t is close to certain that in the time of the Gemara, and even in the days of the Rambam, there was no knowledge of the possibility of teaching someone how to speak if they were born deaf….The sages of the Talmud addressed the reality of their day, and they spoke only of their present….Such [that the deaf were uneducable idiots] was the world’s attitude in those days [i.e., the early nineteenth century]…and thus it was explained in the medical texts of that era; only after that did [doctors’] thinking change, until they reached the conclusion that deaf people do possess the power of reason….”
This same principle, that new evidence is grounds for a change in the law, also applies to the concept of “total pain,” a condition identified in 1967 by Dame Cicely Saunders, the founder of the modern hospice movement. Saunders “coined the term ‘total pain’ to characterize the multidimensional nature of the palliative patient’s pain experience to include the physical, psychological, social, and spiritual domains [emphasis added]….[O]ptimal pain relief is not possible if all dimensions of ‘total pain’ are not addressed. Dame Saunders also pointed out that, as total pain increases, the patient experiences a severe loss of control over their life; this in turn, leads to further pain and despair.”
A corollary of the concept of total pain is the recognition that there is a difference between biological existence and living. The modern hospice movement seeks to mitigate total pain by addressing all of these dimensions—physical, psychological, social, and spiritual—in ways that enable the patient to preserve their sense that they are living rather than merely existing to the greatest possible extent. We are convinced that the idea of “total pain,” including both the role it plays in palliative care and the ways in which it has revolutionized how the medical profession regards debilitating and terminal illnesses, is an example of the medical and scientific advances to which our tradition has always been open.
Medical knowledge and scientific knowledge are not the only types of knowledge that change, leading to changes in how we discern the correct course of action. The study of history reminds us that what we might call “social knowledge” also changes. By “social knowledge” we mean the tacit assumptions that underlie social and legal norms and behavioral expectations. For example, consider how attitudes toward women and their role in public life have altered since the Mishnah was written. We have rejected the limitations placed on women’s roles in our religious community because we have rejected the assumptions on which those limitations rested.
There are also aspects of human life that constitute realities so fundamental (e.g., climate and the ways in which it facilitates or circumscribes human existence) that they rarely even rise to the level of consciousness until some problem forces us to take notice of them. Life expectancy and the relationship between health, disease, and medicine is one such reality. Demographers and medical geographers now commonly refer to an “epidemiological transition” to account for the ballooning of the planet’s human population in the last century. One of the foundational articles in this field explains: “During the [epidemiological] transition, a long-term shift occurs in mortality and disease patterns whereby pandemics of infection are gradually displaced by degenerative and man-made diseases as the chief form of morbidity and primary cause of death.” The author identifies a three-stage process: 1) the stage of “pestilence and famine” when average life expectancy at birth is only 20–40 years; 2) the stage of “receding pandemics” when average life expectancy increases to 30–50 years and populations begin to grow; and 3) the stage of “degenerative and [lifestyle-related] diseases,” when mortality rates decline sharply and average life expectancy reaches beyond 50 years.
We cannot read our foundational halachic texts without being aware that they were written by men who lived in the first of these three stages. Their views of health and disease, life and death, were shaped by their reality. Most people died of wars, famines, plagues, infectious diseases (e.g., pneumonia, tuberculosis, flu, cholera, diphtheria, typhoid), food poisoning, infected wounds, or some internal problem undiagnosable and untreatable by the physicians of the day, such as a ruptured appendix or an ectopic pregnancy. Children died in large percentages; childbearing led to death for many women. Death generally followed closely upon falling ill. Very few people lived long enough to die of the various diseases that accompany aging in a prosperous society (heart disease, stroke, cancer, Type 2 Diabetes, Parkinson’s Disease), and when they did, they died without the benefit of modern medical treatments that prolong life and enable one to live with those conditions for additional months or even years. In the context of that reality, pronouncements about the preciousness of even a few moments of life read quite differently than they do in our time.
Consider, in this regard, the very fact that the Shulchan Aruch (following the Tur, which in turn followed the Torat HaAdam of Naḥmanides [Ramban, R. Moses b. Nachman, 1190–1273]) combines visiting the sick, the practice of medicine, and dying into a single section. This editorial decision reflects the reality that prior to the modern era, physicians knew very little about diagnosing or treating most serious illnesses, and had very few means of treating life-threatening illnesses. Our ancestors did not presume that a medical practitioner would be able to accurately diagnose or effectively treat illness. Illness was not something they expected to manage successfully. A physician might or might not actually be effective; God might or might not show mercy and intervene. The reality was that people who became seriously ill usually died, and death usually occurred within a short span of time.
The Ramban, himself a physician, included these Talmudic passages in Torat HaAdam:
Our Sages taught in Mo-eid Katan: One who dies immediately—this is being stolen [from life]. One who fell ill for a day and died—this is a rushed death….Two days and then they died—this is a hasty death. Three days and they died—this is a death of [divine] rebuke. Four days and they died—this is a death of [divine] anger. Five days and they died—this is the ordinary death of most people. Another version in Evel Rabati says this: [Death after] four or five days is a rushed death; after six days is as decreed in the Torah; after seven days is a loving death; more than that is [a death of] suffering….R. Judah says: The saintly ones of old used to suffer before their deaths with internal illnesses for ten or even twenty days, in order to scour themselves out thoroughly, so that they could enter the world-to-come fully purified, as it is written, He shall act like a smelter and purger of silver; and he shall purify the descendants of Levi and refine them like gold and silver, so that they shall present offerings in righteousness (Malachi 3:3).
In other words, the time between being afflicted with a mortal illness and dying could be too short, too long, or just right, but rarely extended beyond three weeks. The best interval between terminal diagnosis and death was approximately one week—presumably because it allowed time to come to terms with reality, make one’s final arrangements, and gather the family. Less time, affording insufficient time to prepare for death, indicated divine displeasure with the individual. But what is especially noteworthy here is the view that a dying process of more than a week is deemed “suffering”—and that a dying process of ten or twenty days of internal illness was something so extreme and rare that our predecessors saw it as an example of yisurin shel ahavah (“chastisements of love”), i.e., suffering ordained by God as a “gift” so that upon death, the one who experienced the yisurin shel ahavah will be entitled to a greater reward in the world-to-come. In our age, however, people more and more frequently continue in this state of degeneration and dying for many months or even years—and we know that this is happening because of the help of modern medicine, not as a divine gift.
C. A holistic tradition
The popular understanding of Responsa literature is that in determining halachah it relies on halachic precedents, supplemented by informed knowledge of whatever matter is at hand, and that it generally does not rely on aggadah, non-halachic discussions or stories, and does not view them as precedents for legal rulings. It is worth noting that recent scholarship analyzes the interplay of halachic and aggadic material in the Talmud and considers the ways in which aggadic material might influence our reading of halakhic material. In this instance, we believe it is essential to recognize that our Sages chose to preserve and transmit various narratives in classical Jewish texts that discuss suicide or interventions intended to end an ill person’s suffering by bringing about their death, because they have profound relevance, as other authorities have noted.
Torat HaAdam is a particularly apt touchpoint for us, precisely because it is a halachic guide to illness and death that includes a great deal of aggadah. We are firmly persuaded that a holistic reading of our tradition—seeing halachah and aggadah as integrated elements of a single world view—is essential if our tradition is to remain relevant and viable for us and for future generations. As Rabbi Gordon Tucker wrote in his dissent from the CJLS responsum on homosexuality:
…[T]he Torah (and a fortiori subsequent expressions of religious law) is not a record of commanding utterances from God, but rather a record of the religious quests of a people, and of their understanding of how God’s will commands them. The long-standing —and understandable—tendency to divide up religious literature into halachah (law) and aggadah (narrative) has thus always been a mistake. The law is given cogency and support by the ongoing story of the community that seeks to live by the law….The ongoing, developing religious life of a community includes not only the work of its legalists, but also its experiences, its intuitions, and the ways in which its stories move it. This ongoing religious life must therefore have a role in the development of its norms, else the legal obligations of the community will become dangerously detached from its theological commitments….So we would do well to speak of Halachah, written with a capital “H”, when we wish to denote not only collections of rules and precedents, but rather a more expansive repertoire of legally relevant materials, which include the accretions over time of theological and moral underpinnings of the community of faith. And a vision of a Halachic methodology would then be one that would include the more conventional halachic methods, but would also appeal to aggadic (narrative) texts that have withstood the tests of time to become normative Jewish theology and ethics.
The medical advances of the last century have revolutionized the age-old relationship between sickness and health, life and death. We have the ability to extend the lives, and thereby draw out the deaths, of many people with terminal diseases. We also have among us, thanks to advances in medical technology, some number of people who are not terminally ill, but who live under permanent conditions in limited health or well-being (e.g., individuals with ALS; quadriplegia; Locked-in Syndrome; and those whose pain is not medically manageable). Medical intervention enables many such individuals to live for many years, but offers no possibility of improvement and may not alleviate the pain the individual experiences. A small number of these individuals assert that living under such circumstances is not acceptable, and that they have reached the point where they wish to end their lives through a medical procedure. Other individuals who face a long-term degenerative condition anticipate that they may reach the point at which death is preferable to living. We believe that the halachic prohibitions against hastening or causing death live side by side with extensive recognition of the just cause of the person who loves life, but finds that life is no longer a blessing under the conditions in which they must live it. Our predecessors did, in fact, acknowledge this dilemma and indirectly admitted its justification. The same tradition that opposes murder and suicide does recognize that life is sometimes more burdensome and less desirable than death, and preserves multiple stories that affirm both ending one’s own life and assistance in dying. We turn, therefore, to those narratives.
- Intervening to bring about a death
Our tradition assumes that prayer is efficacious, and therefore regards it as an essential complement to the physician’s skill in bringing healing. It follows that when the medical tool kit is empty, prayer is the only remaining option. When our classical sources use the phrase “visit the sick,” they presume that the visitor will contribute to the sick person’s cure by praying for their welfare during the visit. This is made clear in the Talmud, which brings a statement by R. Akiva that “[e]veryone who does not visit a sick person is like one who sheds their blood.” Rav Dimi understands this to mean that “[e]veryone who visits a sick person causes him to live, and everyone who does not visit a sick person causes him to die,” which the Gemara then explains: “[It means that] everyone who does not visit the sick neither prays for them to live nor prays for them to die.”
Commenting on this passage, the Spanish halachist R. Nissim Gerondi (1310?–1375) acknowledged the reality that there are times when the better course of action is to help bring about a person’s death.
Neither prays for them to live nor prays for them to die—It seems to me that this passage means that there are times when one should pray for the sick person to die, such as when they are suffering severely from their illness and there is no possibility that they will live…But even in a case where death would be a benefit, the prayer [of one who does not visit] will not help, even a bit, to bring that benefit.
Two widely cited Talmudic stories demonstrate clearly not only that the rabbis believed prayer could keep a person alive or could cause their death, but also that there are times when it is appropriate to stop praying for someone to live, and even to pray for someone’s death. The first of these is about the death of R. Judah the Patriarch, known simply as “Rabbi.” He fell gravely ill with some disease of his “innards.”
On the day that Rabbi died, the Sages decreed a public fast and prayed for divine mercy [to let him live]. They said: Anyone who says that Rabbi has died will be run through with a sword. Rabbi’s maidservant ascended to the roof and said, “The upper realms [i.e., the angels] want Rabbi and the lower realms [i.e., humans] want him. May it be Your will that the lower ones will defeat the upper ones.” But when she saw how many times he had to go out to the privy, removing his t’fillin and putting them back on [each time], and how this caused him to suffer, she said, “May it be Your will that the upper realms defeat the lower ones.” But the rabbis would not stop praying for mercy for him [i.e., keeping him alive], so she took a pitcher and threw it from the roof to the ground. They fell silent and interrupted their prayer, and Rabbi died.
In other words, the rabbis’ efficacious prayer keeps R. Judah alive, thereby prolonging his suffering. His maid, recognizing the extent of his suffering, interferes with his care to reduce its duration. Furthermore, the context for this story makes clear that R. Judah himself is ready to die. He has spoken with his sons, appointed Shimon to be a scholar and Gamliel to succeed him as Nasi, given instructions concerning Yosef Cheifani and Shimon Efrati who serve him, spoken with the Sages concerning how they are to mourn him after his death, and appointed Chanina bar Chama to head the academy after his death. Under these circumstances— Rabbi has concluded his final arrangements and his remaining time alive consists of intolerable suffering—the maidservant acts out of love and respect and is honored for her act.
The second story is about the deep friendship between R. Yochanan and Resh Lakish, and the grief of the former after the latter died.
Resh Lakish died, and R. Yochanan mourned deeply for him. The rabbis said: Who shall go to restore his equilibrium? Let R. Eleazar ben Pedat go, for he is a sharp student. [R. Eleazar ben Pedat] went and sat before R. Yochanan. Every time Rabbi Yochanan recited a teaching, Eleazar cited a textual support. R. Yochanan cried out: “Are you like the son of Lakish? When I said something, he would ask twenty-four questions. I would provide twenty-four answers, and in that way, Torah would increase. But you simply offer support! Do you think I don’t know that my teachings are good?”
R. Yochanan tore his clothes and wept, saying, “Where are you, son of Lakish?” He grieved so much that he lost his mind. The rabbis prayed on his behalf, and he died.
Observing that R. Yochanan’s life was one of unremitting suffering, his colleagues intervened to bring about his death through prayer. Their prayer that he might die is considered prayer “on his behalf.” Ultimately, the sages of the Talmud would hold, God determines whether R. Yochanan lives or dies, but human effort on the side of compassion is deemed moral.
- Deciding to take one’s own life
The Tanach narrates how King Saul took his own life after the Israelites’ disastrous defeat at the hands of the Philistines.
The Philistines attacked Israel, and the men of Israel fled before the Philistines and [many] fell on Mount Gilboa. The Philistines pursued Saul and his sons, and the Philistines struck down Jonathan, Abinadab, and Malchi-Shua, sons of Saul. The battle raged around Saul, and some of the archers hit him, and he was severely wounded by the archers. Saul said to his arms-bearer, “Draw your sword and run me through, so that the uncircumcised may not run me through and make sport of me.” But his arms-bearer, in his great awe, refused; whereupon Saul grasped the sword, and fell upon it. When his arms-bearer saw that Saul was dead, he too fell on his sword and died with him.
Later commentators justified Saul’s decision by ascribing it to his desire not to be tortured, shamed, or humiliated by the Philistines—a desire that they regarded as logical and well-founded. R. Isaac Abravanel, for example, wrote:
After his three sons died, and Saul was left alive alone, the battle raged around Saul, and some of the archers hit him, meaning that the archers found his location and began pursuing him, and then Saul became afraid of the archers. And it is appropriate to note that Saul was not afraid that they might kill him…; rather, he was afraid that they would wound him in such a way that he would not die immediately, but would not be able to resist, and they would take him alive and abuse him, by putting his eyes out or cutting him up limb by limb; for the Philistines hated him for what he had done to them. So he chose to die at the hands of those who loved him, rather than at the hands of those who hated him.
In other words, Saul’s suicide was justified by his fear of what might happen to him if he remained alive.
R. Chanina ben Teradyon was martyred by the Romans in the Hadrianic persecutions following the Bar Kochba revolt. According to the story in the Talmud, he was caught teaching Torah in public and sentenced to be burned with the Torah scroll wrapped around his body.
They brought him and wrapped him in the Torah scroll and surrounded him with bunches of branches and set them on fire. Then they brought tufts of wool soaked in water and placed them over his heart so that he would not die quickly….His students said to him, “Rabbi,…open your mouth and let the flames enter through it [so that you die more quickly].” He said, “It is better that the One Who gave me my life should take it, than that I should harm myself.” The executioner said to him, “Rabbi, if I increase the flame and remove the wool tufts from over your heart, [so that you suffer less and die more quickly], will you bring me into the World-to-Come?” He said, “Yes,” and [the executioner] said, “Swear to me,” and he swore. Immediately [the executioner] built up the flames and removed the tufts of wool from over his heart, and his life quickly left him. And [the executioner] then jumped into the pyre. A divine voice then proclaimed, “R. Chanina ben Teradyon and the executioner are summoned to the life of the World-to-Come!” Rabbi [Judah the Patriarch] wept [over this] and said, “There are those who attain eternal life in a moment, and those who attain it only after years [of striving].”
Initially R. Chanina rejects his students’ suggestion that he hasten his death, asserting that God should determine the precise moment of his (impending) death. However, he reaches a point where he can no longer endure the suffering, and accepts the executioner’s offer to hasten his death. Furthermore, the executioner also then kills himself, either to take advantage of R. Chanina’s promise to bring him to the next life or, perhaps, out of fear of retribution for his dereliction of duty. There is not a hint in this story that either man has done wrong.
Finally, there is the startling story of a woman who was tired of living.
It happened that an extremely elderly woman came before R. Yose ben Chalafta, and said to him: “Rabbi, I am too old, and my life is distasteful to me. I can taste neither food nor drink, and I would like to depart from this world.” He said to her, “What accounts for your long life?” She said, ‟I am accustomed, even if there is something very dear to me, to set it aside and go early to the synagogue each day.” He said, “Refrain from going to the synagogue for three consecutive days.” She did so, and on the third day she fell ill and died.
R. Yose apparently finds nothing strange about this woman’s attitude, and makes absolutely no effort to dissuade her. He acknowledges and validates her sense that because she is incapable of doing the things that make life an act of living, she is merely existing, and he actively tells her how to bring an end to her existence.
These stories depict individuals in very different circumstances. King Saul is physically well, but terrified because he is trapped in a situation where all he can expect is pain, suffering, and humiliation. R. Chanina has apparently reached the limit of how much suffering he can endure. The old woman is not imminently dying, but finds no satisfaction in life R. Yochanan’s emotional suffering had extinguished the quality of his life. Nevertheless, what these stories have in common is that they depict individuals who have reached a point where life is no longer a divine gift, but has become instead a form of torture. In other words, they depict individuals who are experiencing “total pain.” For each, the decision to die enables them to regain control over an uncontrollable situation.
III. Toward a Halachic View of MAiD
Adopting Rabbi Tucker’s framework, we may say that our Halachah values life, and values the practice of medicine to preserve life—but many traditional halachot are rooted in the pre-modern reality when life spans were mostly short, medical knowledge and treatments extremely limited, and the dying processes usually of limited duration. Our obligation to our people is to provide guidance that values life and values the practice of medicine to preserve life in a way that fully acknowledges the circumstances of our own times. When we acknowledge the current reality, far different from that of the ancient or medieval world, and engage with it appropriately, we continue the tradition of those who came before, who also couched their understanding of halachah in terms of their contemporary reality, including the science and technologies of their day in balance with the lived experience of people. If we do not acknowledge the new reality and discern a way to engage with it appropriately, we will simply become irrelevant. We also risk causing severe pain and harm in the world by holding to outdated modes of thought and behavior.
The narratives we have seen are interwoven with the halachot on the very same Talmudic pages. We see that loving life, valuing individual life, and valuing the ability of the physician to preserve life were not our Rabbis’ only considerations. They recognized that life is more than existence. These narratives demonstrate that they knew that a person in extremis may rationally and justifiably choose death over life; that a reasonable person may reach the point where they see that their life, as opposed to their existence, has ended; and that sometimes the greatest compassion one can receive is to be assisted in dying.
A. Ending one’s life can be a rational decision for one whose death is “reasonably foreseeable.”
The general halachic view of suicide now is that the person who kills themself must have been incapable of making a rational decision in that moment. This originates in the locus classicus for discussions of suicide, the minor Talmudic tractate S’machot. There it states that the rituals of mourning are truncated for one who intentionally does away with themselves (m’abed et atzmo b’daat). “The general principle is that we do everything which is for the honor of the living, but we do not do what is not for the honor of the living.” The text goes on to define one who “intentionally does away with themselves”—for example, one who declares to onlookers their intent to throw themselves off the roof, and then does so in sight of the onlookers. However, it continues, one who is found hanged or impaled on a sword is presumed to have killed themselves unintentionally, and no mourning rituals are withheld. It then goes on to relate two anecdotes of children who were so afraid of parental punishment for some infraction that they killed themselves; the Sages conclude that in such cases no mourning rituals are to be withheld (and that parents should never be such severe disciplinarians to cause such fear). This brief set of five paragraphs establishes the parameters for all subsequent halachah regarding taking one’s own life. All authorities weigh the prohibition against intentionally doing away with oneself against the mitigating factor of emotional distress. Maimonides takes the most stringent stance against taking one’s own life, defining it as an act of bloodshed just like taking the life of another. By contrast, the Shulchan Aruch takes a generous stance toward individuals’ emotional distress: “A minor who intentionally does away with themselves is considered to have done it unintentionally, and likewise an adult who intentionally does away with themselves while they are under compulsion, like King Saul. We do not withhold any [mourning rituals] from them.”
As the Aruch HaShulchan sums it up:
The general principle with regard to one who intentionally does away with themselves is that we attribute it to whatever possible cause we can—for example, out of fear, or out of pain, or that they lost their reason, or that they thought that this was a mitzvah in order not to stumble by committing other transgressions, or for other similar reasons. For the truth is that it really is far-fetched that a person would commit a desecration like this with an absolutely clear mind.
And yet halachah recognizes that refusing medical treatment can be a rational decision under certain circumstances. A large number of authorities, including this committee, recognize that a person who is suffering need not subject themselves to every possible treatment to extend life. Rabbi Mark Washofsky wrote for this committee that a patient with terminal cancer need not subject herself to a painful treatment: “One is obligated to accept treatment that offers a reasonable prospect of therapeutic effectiveness, the attainment of an accepted medical purpose. The purchase of an additional three months of life in a pain-filled and dying condition does not, in our judgment, meet that standard. If such was the best that this patient could reasonably have hoped for, [the patient] was not morally obligated to accept the treatment.”
Nor is recognition of a patient’s right to refuse life-extending treatment is limited to such extreme situations. Rabbi Moshe Feinstein, for example, ruled that if a person does not trust their doctor, every effort must be made to persuade them to accept treatment, but if they ultimately choose to reject the treatment, they cannot be coerced. He also acknowledged that a person suffering with a grave illness might choose to reject life-prolonging treatment. Thus we see that while preserving life is a mitzvah, and that the physician’s obligation to heal is also a mitzvah, these mitzvot do not necessarily lead us to ignore the wishes of a person suffering from a grave illness with respect to their own care.
Contemporary Orthodox authorities are drawing the conclusion from Rabbi Feinstein’s and Rabbi Shlomo Zalman Auerbach’s responsa that “quality of life” considerations are not irrelevant, and that a patient may make their treatment decisions by weighing treatment outcomes against suffering. “[W]hat risks critically ill patients are willing to assume may depend not only on the pure odds of survival, but also on what kind of survival.” Furthermore, there is no halachic definition of “unbearable suffering;” Rabbi Auerbach regards even “severe emotional distress (seivel nefesh)” as a factor in refusing treatment. Rabbi Judah Goldberg, MD, concludes:
One can perhaps adduce further support for this approach from the Talmudic narrative that lies at the heart of R. Feinstein’s rulings [, i.e., the story of R. Judah’s maid enabling him to die]…In other words, the best arbiters of suffering and its consequences may be patients, along with their caretakers, who can interpret ever-changing medical assessments in light of their deep, nuanced understanding of the overall situation and consider their options accordingly….
To be sure, this does not mean that, halachically speaking, patients can choose any course of action they wish….
However, if after thoughtful reflection, a patient wishes to decline critical care interventions because the risk of suffering seems to outweigh the possible benefits of treatment, I believe that halakha grants him or her the right to do so. Moreover, a patient who is frail and/or chronically ill, though not technically terminal, and for whom critical care interventions are likely to be more burdensome than helpful may decide before critical illness develops to decline such treatments.
As Rabbi Washofsky pointed out, modern medicine’s ability to offer seriously ill people more and more treatments with fewer and fewer benefits has led us to reconceptualize the very nature of “medical treatment.” He wrote:
We begin with the definition of the mitzvah of refuah, the duty to heal (i.e., to practice medicine) as understood by Jewish tradition. That duty holds only when it is possible to accomplish it, that is, when the measures to be applied to the patient serve some accepted therapeutic purpose. It follows that if the drugs, surgeries, and other procedures do not serve such a purpose—if they lack…“therapeutic effectiveness”— they are not (or are no longer) regarded as “medicine,” as measures defined as obligatory under our duty to heal. Those procedures, to be sure, are not forbidden; the patient and the patient’s family may wish to accept them on the slim chance that they will do some good. But they are not obligatory because they are not “medicine.” The patient is entitled to refuse them or to discontinue them once they are deemed to have lost their therapeutic effectiveness.
… [T]he standard of “therapeutic effectiveness” is by no means simple to apply to specific cases, since “(t)erms such as ‘therapeutic’ and ‘successful treatment’ are inherently vague and impossible to define with precision. In many situations it will be problematic if not impossible to determine when or even if the prescribed regime [sic] of therapy has lost its medical value.” Some decisions concerning the non-application or discontinuation of treatment will indeed be difficult to make. On the other hand, “(t)he standard of therapeutic effectiveness, as a tool by which to make judgments concerning medical treatment, allows us to draw some conclusions with moral confidence.” [Emphasis added]
It was recognition of this reality that led to the emergence of palliative care as a medical specialty. However, we are now facing the reality that palliative care does not address every individual sufferer’s experience of total pain. If we accept that we are obligated to heed the patient when their experience of their own illness leads them to reject treatment, we believe that we are also obligated to heed them when their experience of their own illness is that their pain is so complete—such a combination of physical, psychological, social, and spiritual pain —that even palliative care no longer provides adequate therapeutic effectiveness, and they can no longer bear to live in such pain.
This conclusion raises fears that people who are depressed over their illness will opt for suicide rather than address their depression and, hopefully, find a way to continue living. The phenomenon of “suicide tourism” is a real one— but the Canadian law prevents this with carefully framed limits that exclude non-Canadians, exclude those whose only illness is mental, and mandate careful evaluations and waiting periods. Indeed, the evidence provided by Canadian doctors demonstrates that MAiD patients are not unbalanced or depressed. They are mostly people who have undergone treatment for their illnesses for as long as it was providing benefit. At the point when it no longer provided benefit, they wanted to be able to decide— like R. Chanina—how much they were willing to endure.
We recognize and respect the rationality of an individual with a terminal diagnosis who chooses to try every possible medical treatment. Similarly, we recognize and respect the rationality of an individual with the same diagnosis who, upon consideration, chooses to forgo all medical treatment other than palliative care. Surely, then, we can and must also recognize the rationality of an individual who moves incrementally on a continuum, from whatever treatment they begin with, to the point where no treatment addresses their total pain, and they want only —as did the elderly woman whom R. Yose helped to die—the opportunity to end having to exist in that state.
B. Ending one’s life can be a rational decision for one whose death is “not reasonably foreseeable.”
Our responsum 5768.1 addresses the case of an elderly woman confined to a wheelchair whose condition is stable, but who doesn’t want to live anymore, and has decided to stop eating and starve to death. Writing for this committee, R. Washofsky said: “The fact that a person does not wish to live with a certain permanent disability does not render that disability a ‘terminal illness,’ and it most certainly does not justify the self-destructive measures that this person contemplates.” He recommended counseling, and further advised that “as a last resort,” force-feeding might be necessary—though he notes that the very nature of that sort of procedure could well rob it of its therapeutic value.
This case closely parallels the Talmudic story of the old woman who no longer wanted to live, but reaches the opposite conclusion. We now revisit that conclusion. We are compelled to ask: How much physical and mental suffering would force-feeding have to cause this woman before one could say that it was of no therapeutic value, and she could choose to discontinue it? The answer, of course, is that we cannot say in advance—but we hope that we would recognize it if we saw it.
We agree that a person with a non-terminal, but debilitating, condition must be carefully screened for depression; the health care system must also ascertain that this individual has all the support necessary to enable them to lead the fullest possible life. But depression may not be the reason for the person’s unhappiness, and even the most generous support may not suffice. The reality of modern medicine is that some individuals are afflicted with severe physical illnesses or injuries that leave them alive and conscious—but in such limited circumstances that life is not a blessing to them, but rather a curse. For us to tell such an individual that their only option is to change their mental attitude so that they can experience joy in life and gratitude to God for keeping them alive, seems a cruelty beyond measure. Therefore, while we hope that a person even in a seriously compromised condition would find a way to value living, we conclude with sadness that this is not always possible, and that for some few individuals, the model of R. Chanina must remain an option.
C. May a Jewish physician administer MAiD?
A physician, by all understanding, uses their skill to heal. Can intentionally administering a lethal dose of drugs be construed as an act of healing?
Our Sages regarded the practice of medicine as authorized by the Torah: When men quarrel and one strikes the other with stone or fist, and he does not die but has to take to his bed—if he then gets up and walks outdoors upon his staff, the assailant shall go unpunished, except that he must pay for his idleness and cause him to be healed (ורפא ירפא v‘rapo’ y’rape). The Sages read this as both permission and obligation to use medical expertise. In their context, however, as we have seen, curing disease was difficult, as physicians had very few tools at their disposal. Even if a physician was unable to effect a complete cure, however, they could still apply their skills to restoring, to the greatest extent possible, the patient’s health and well-being, and also, crucially, to relieving the patient’s pain. Thus we allow a physician to administer painkillers as needed even if doing so will shorten the patient’s life. The result is death, but the intention was to alleviate pain. This is allowed even if the dosage is so high that the physician knows that they are causing this person’s death.
When R. Chanina could no longer bear his pain, he asked the executioner to help him die. According to this reasoning, just as a Jew might feel that they can no longer abide their suffering and ask for death, a Jewish physician might be so moved by the extreme suffering of an individual patient that they might feel compelled to help them end their life. In this instance the physician is acting like R. Yose with the old woman, or like the Sages with R. Yochanan—actively evaluating the patient’s condition and either furnishing them with the means to end their life, or ending it for them. (We note that under Canadian law a physician who prefers not to participate in MAiD may simply request that the patient be referred to another physician.)
We find that the Canadian law allowing MAiD adequately narrows its applicability to eligible Canadian residents capable of making this decision for themselves. There is virtually no possibility that one suffering from depression or otherwise not capable of making a rational and responsible decision would be able to use the system to take their own life. The health care system provides for all medical needs sufficiently that we are not worried that financial pressures might lead an individual to use the system to do away with themselves. We see no evidence that individuals with terminal or grave chronic illnesses are choosing to abandon lives they find meaningful.
Rather, in an era in which medical technology can prolong life to the point where a person’s existence becomes torture to them, when refuat haguf is no longer possible, we can, at least, support the choices of those individuals for whom death is refuat hanefesh. We therefore conclude:
- A Jew suffering from a terminal illness whose death is “reasonably foreseeable” may avail themselves of MAiD.
- A Jew suffering from a chronic illness whose death is not “reasonably foreseeable” may also choose to avail themselves of MAiD as a last resort, if living with the degree of suffering they must endure is intolerable.
- A Jewish physician who recognizes that a suffering individual has a terminal or incurable condition that has placed them in a state of total pain may respond to the sufferer’s desire to end their suffering by administering or making available drugs that will terminate the individual’s life.
Joan S. Friedman, Chair
Howard L. Apothaker
Lawrence A. Englander
Audrey R. Korotkin
David Z. Vaisberg
Dvora E. Weisberg
 Joseph Dov Soloveitchik, Halakhic Morality: Essays on Ethics and Masorah, ed. Joel B. Wolowelsky and Reuven Ziegler (New Milford, CT: Maggid Books, 2017), 135.
 https://compassionandchoices.org/resource/states-or-territories-where-medical-aid-in-dying-is-authorized/. Accessed 9 Nov 2021.
 The phrase has its origin in the title of a 1920 pamphlet on euthanasia published in Germany, Die Freigabe der Vernichtung lebensunwerten Lebens (Karl Binding and Alfred Hoche, 1920;
http://www.gutenberg.org/ebooks/44565. Accessed 9 Nov 2021). While the Nazis appropriated the phrase and used it as the justification for the “T-4 Program” (mass murder of physically and mentally handicapped individuals), the pamphlet itself offered a far more nuanced discussion of medical assistance in dying than what the genocidal regime took from it. See Howard Brody and M. Wayne Cooper, “Binding and Hoche’s “Life Unworthy of Life”: A Historical and Ethical Analysis,” Perspectives in Biology and Medicine 57, no. 4 (2014): 500–511. doi:10.1353/pbm.2014.0042. Accessed 9 Nov 2021.
 Thomas F. Tierney, “Euthanasia, Biopolitics, and Care of the Self,” in Sue Westwood, ed., Regulating the End of Life: Death Rights (London and New York: Routledge, 2022), 164.
 This summary is based on the information at https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html and its sub-pages, especially https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2020.html#1_0. (Accessed 5 November 2021.)
 The Quebec courts struck down the restriction to terminal illnesses as unconstitutional on March 12, 2020. Between then and the end of the calendar year, a total of 15 individuals nationwide not suffering from a terminal disease qualified and opted for MAiD in 2020. Health Canada, Second Annual Report on Medical Assistance in Dying in Canada, 2020, 13. PDF file. https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2020.html#8_0.
 Report, 5–6, 13. The report provides these figures as percentages; we have converted them into numbers to focus on the individuals behind the statistics.
 The numbers of 2020 requests and procedures carried out in 2020 do not correspond exactly because requests and procedures do not necessarily fall in the same calendar year, and because not everyone who requests MAiD opts to use it.
 Report, 19.
 Report, 20.
 5754.14: “On the Treatment of the Terminally Ill,” Teshuvot for the Nineties. https://www.ccarnet.org/ ccar-responsa/tfn-no-5754-14-337-364/.
 The locus classicus for this law is Mishnah Rosh HaShanah 3:8: חֵרֵשׁ, שׁוֹטֶה, וְקָטָן, אֵין מוֹצִיאִין אֶת הָרַבִּים יְדֵי חוֹבָתָן
 Although individual examples of teaching deaf persons to communicate were documented earlier, the modern development of standard sign language and the methods to teach it originated with the educational institution established by Charles Michel de L’Epee in Paris in 1755 and his invention of French sign language. Educators in other countries soon followed his example, and by 1830 there were schools for the deaf in a number of European countries and several US states, all teaching a variety of sign language. “Charles Michel de l’ Epee.” In Encyclopedia of World Biography, 2nd ed., 120–122. Vol. 21. Detroit, MI: Gale, 2004. Gale eBooks (accessed February 13, 2022). https://link.gale.com/apps/doc/CX3404707780/GVRL?u=ohlnk162&sid=bookmark-GVRL&xid=9fe58ad3.
 R. Esriel Hildesheimer, ShU”T Rabbi Azriel, EH #58.
 Cicely Saunders, The Management of Terminal Illness (London: Hospital Medicine Publications, 1967).
 Anita Mehta, RN, MSc(A) and Lisa S. Chan, RN, MSc(A), “Understanding of the Concept of ‘Total Pain’: A Prerequisite for Pain Control, Journal of Hospice and Palliative Nursing vol. 10, no. 1 (January/February 2008): 26.
 Abdel R. Omran, “The Epidemiologic Transition: A Theory of the Epidemiology of Population Change.” The Milbank Memorial Fund Quarterly 49, no. 4 (1971): 516–517 (emphasis in original). https://doi.org/10.2307/3349375.
 ShA YD “Laws of Visiting the Sick, Medicine, Dying, and Imminently Dying.” This is further subdivided into sections 335, “When the Visit the Sick, and for Which Illnesses, and How to Pray for Them;” 336, “Laws Concerning the Physician;” 337, “An Ill Person Who Has a Close Relative Die;” 338, “The Ill Person’s Confession and How to Broach It;” and 339, “Laws of the Imminently Dying (and Reciting the ‘Acceptance of Divine Judgment’) and What Are the Criteria [for Imminently Dying].”
 Torat HaAdam, Section “The Gate of the End,” Subsection “The Matter of Departure,” quoting BT Mo-eid Katan 28a and Tractate S’machot (also known as Evel Rabati) 3:9–11. It is also worth noting that S’machot 3:8 states: “One who dies before the age of fifty has died by karet. One who dies at age fifty-two dies the death of Samuel of Ramah. One who dies at sixty dies the death of which the Torah speaks [i.e., ordinary death]. One who dies at seventy dies a death of [divine] love. One who dies at eighty dies a death of special strength, as it is written, The span of our life is seventy years, / or, given the strength, eighty years (Psalms 90:10)….More than this is a life of pain [tzaar].”
 Barry Wimpfheimer, Narrating the Law (Philadelphia: University of Pennsylvania Press, 2011). We acknowledge that Wimpfheimer himself focuses on literary analysis and does not argue for applying this type of reading to halachic decision-making.
 For a striking example of applying the very aggadot we are considering here to questions of quality of life and end-of-life decisions, see Moshe D. Tendler and Fred Rosner, “Quality and Sanctity of Life in the Talmud and the Midrash,” Tradition: A Journal of Orthodox Jewish Thought, vol. 28, no. 1 (Fall 1993):18–27. https://www.jstor.org/stable/23260951.
 Gordon Tucker, “דרוש וקבל שכר: Halakhic and Metahalakhic Arguments Concerning Judaism and Homosexuality,” 19-20. https://www.rabbinicalassembly.org/sites/default/files/public/halakhah/teshuvot/
20052010/tucker_homosexuality.pdf. Accessed 14 July 2021.
 BT N’darim 40a. In context, R. Akiva appears to refer to physically taking care of the sick. The tradition, however, accepts the anonymous Gemara’s interpretation of his words as a reference to praying on behalf of the sick.
 R. Nissim ad loc.
 BT K’tubot 104a.
 BT Bava M-tzi-a 84a.
 I Samuel 31:1–5.
 Abravanel, Commentary on I Samuel, section 15, ad loc. In a discussion of pain medication, the Tzitz Eliezer (Part XIII, #87) goes out of his way to mention a reference in the Bet Yosef (Tur YD 157 ad loc.) to the example of Saul, as a model for committing suicide in a time of persecution out of fear that one will not be able to withstand torture.
 BT Avodah Zarah 18a.
 Yalkut Shimoni II, §943.
 S’machot 2:1–5.
 MT Hichot. Rotzeach 2:1–3.
 ShA YD 345:3.
 Aruch HaShulchan 345:5.
 5768.1: “Two Questions Concerning Medical Treatment for End-of-Life Patients.” https://www.ccarnet.org/ccar-responsa/nyp-no-5768-1/.
 Igrot Moshe HM Part II, #73 and #74. In a case where a diabetic, already an amputee, had either to accept a second leg amputation, or refuse and face almost certain death, R. Shlomo Zalman Auerbach ruled that the patient should not be forced to undergo the procedure against their will, nor should we attempt to persuade them to change their mind. Cited in A.S. Avraham, Sefer Nishmat Avraham: Hilkhot Holim, Rof’im, U-Refuah, (Jerusalem: 1984?), 2:47–48. In ShU”T Minchat Shlomo I:91:24 R. Auerbach also ruled that a person need not choose to undergo a life-saving operation that would leave them permanently paralyzed.
 Judah Goldberg, “A Halachic Framework for Decision-Making in Acute Critical Illness,” Tradition vol. 53, no. 1 (Winter 2021): 89–90.
 Goldberg, “A Halachic Framework for Decision-Making in Acute Critical Illness,”, 91.
 “Suicide tourism” refers to the growing global phenomenon of individuals from jurisdictions where MAiD is not available who choose to travel to a jurisdiction where it is available, in order to end their lives legally. Some jurisdictions, notably Switzerland, have very few restrictions on the procedure, meaning that there is no way to screen out and address the needs of individuals whose desire to end their lives may be a function of some combination of depression, financial concerns, family pressure, or other non-medical reasons. See Daniel Sperling, Suicide Tourism: Understanding the Legal, Philosophical, and Socio-Political Dimensions (Oxford: Oxford University Press, 2019; Oxford Scholarship Online, 2019). doi: 10.1093/oso/9780198825456.001.0001.
 Exodus. 21:18–19.
 BT Bava Kama 85a; Tur & Shulchan Aruch YD 336.
 ShU”T Tzitz Eliezer XIII #87.