CCAR RESPONSA COMMITTEE

 

5771.5

 

Reciting Blessings over Tube Feeding

 

 

Sh’elah.

 

Over the course of multiple life-threatening esophageal ruptures, I spent 6 months being fully sustained by feeding tubes – certain times only through a Jejunostomy tube (J-tube) and certain times through a combination of the J-tube and a Gastrostomy tube (G-tube).  Throughout most of that time period, I was torturously conscious and aware of my situation.  I asked an Orthodox friend of mine if there was a blessing I could say over my tube feedings, and she informed me that because tube feedings are not considered a form of eating, there was no blessing I could say.  At the time I already felt that almost everything had been taken from me, so when I learned of this facet of halakhah I felt that I was being isolated from Judaism as well.

 

I therefore ask this question of you: from the standpoint of our Reform responsa tradition, is it appropriate to recite a blessing over tube feeding? (Courtney L. M. Berman, Cincinnati, OH)

 

 

T’shuvah.

 

Your Orthodox friend is correct. By that, we mean that she is accurately representing the consensus view among contemporary Orthodox poskim (halakhic authorities) on the question you pose. At the same time, not all halakhic authorities follow that consensus, and an argument can be made that the consensus does not reflect the best interpretation of the sources upon which it is based. The majority of this Committee support the consensus view, namely that tube feedings are not to be defined as “eating” and that, therefore, it is inappropriate to recite the blessings for food over tube feedings. One member of the Committee dissents from this position.

 

Our t’shuvah will proceed in three stages. First, we will examine the discussion of this issue in the halakhic literature, so as to explain both the consensus and the minority opinions among traditional and Orthodox poskim. Second, we will present the viewpoint of the majority of this Committee. Finally, we will offer the dissenting opinion.

 

1. The Halakhic Discussion. The blessings we recite before eating food, as well as birkat hamazon (the “grace after meals”), are called birkhot hanehenin, literally “blessings over things that bring enjoyment.”[1] That term indicates the central importance of the concept of hana’ah, variously translated as “enjoyment,” “pleasure,” “benefit,” or “profit”: we recite blessings as an expression of gratitude to God for deriving benefit from God’s world. As the Rabbis teach, “it is forbidden to derive benefit/pleasure (hana’ah) from the world without reciting a b’rakhah.”[2] But precisely how do we derive this hana’ah? That question lies at the center of a Talmudic machloket (dispute) over the nature of the Torah’s prohibitions against the eating of various foods. Rabbi Yochanan holds that to be held culpable for violating these laws, a person must experience hana’at garon (literally, “enjoyment of the throat”): that is, one must orally ingest a minimum amount of the forbidden food within a prescribed limit of time. Resh Lakish, on the other hand, holds that the key is hana’at me`ayim, “satiation”: one transgresses the prohibition once the minimum quantity of the forbidden food collects in his stomach, no matter how slowly he or she consumes it.[3] The accepted halakhah follows Rabbi Yochanan.[4] From here, later authorities conclude that, for halakhic purposes, the act of akhilah (“eating”) is defined by the ingestion of food through the mouth.[5]

 

This definition serves as the basis for some important rules of law. For example, one may take a medication that contains prohibited ingredients provided that one consumes it in an unusual manner that does not bring “enjoyment” (she-lo k’derekh hana’atan), because even though the prohibited substance reaches the stomach, the patient has not technically “eaten” it.[6] Similarly, a patient may be fed through a stomach or intestinal tube on Yom Kippur, since artificial nutrition that bypasses the throat is not defined as “eating” and is therefore not prohibited on that day.[7] Critically for our question, Orthodox poskim apply this same standard to the issue of b’rakhah. One fed through a tube is exempt from the requirement of reciting a blessing, since, in the words of Rabbi Ya`akov Breisch, “the recitation of a blessing was established only over the act of eating, and ‘eating’ is defined exclusively as the oral ingestion of food.” [8] And since the blessing is not required, to recite it would violate the prohibition against b’rakhhah l’vatalah, reciting a blessing that is not “required” in that setting.[9]

 

The above summarizes what we have called the “consensus” position, the opinion of most contemporary Orthodox poskim.[10] On the other hand, some prominent halakhists hold the opposite view. They regard satiation, rather than taste or hana’at garon, as the factor that triggers the requirement to recite a b’rakhah.[11] If so, it would follow that one fed through a J-tube or a G-tube should say a benediction, for he or she is definitely gaining satisfaction from the artificial nourishment even though no “eating” is involved. While most Orthodox poskim, to repeat, do not draw this conclusion, the arguments supporting it lead some of them to suggest a compromise: it would be “a good thing” for the patient being fed in this way to hear the blessings recited by another person “who can thus enable (the patient) to fulfill his obligation (sheyotzi’o y’dei chovato).”[12] At first glance, of course, this compromise position seems self-contradictory. How can we speak of enabling a tube-fed patient to fulfill the “obligation” to recite a b’rakhah when, according to the law, no such obligation exists? Rabbi Eliezer Yehudah Waldenberg (d. 2006), the outstanding Orthodox medical-halakhic authority, hints at the thinking behind this notion:

 

It is common in a hospital setting that the patient being fed by a tube shares a room with another patient who eats in the usual manner and who can fulfill the patient’s obligation (v’sheyukhal l’hotzi’o) by reciting birkat hamazon (grace after meals) on his behalf. This can be a very reassuring thing for the tube-fed patient who is passionate about fulfilling the mitzvot and who is distressed (mitzta`er) when he is unable to do so.[13]

 

Waldenberg knows that the consensus Orthodox position – a view he shares[14] – can impose a severe spiritual toll upon the religious patient. To exempt such a person from the requirement of b’rakhah is to separate him or her, at least for that moment, from the community that expresses its identity through the performance of mitzvot. He and other poskim, it seems, are sensitive to the concern you raise: they do not want observant Jews to feel “isolated” from their Judaism. For that reason, they recommend a solution that, by extending the “obligation” of b’rakhah to individuals in this situation, stands at odds with the consensus position.

 

2. The View of This Committee. The majority of us side with the consensus position: it is inappropriate to recite the benedictions for food over tube feeding. We say this, first and foremost, because of the very real distinction between food and medicine. We recite a blessing over the hana’ah we receive from food because eating is an act that we consciously choose to do. Our b’rakhah expresses our thanks for God’s bounty at the very moment we decide with intention (kavanah) to benefit from it. By contrast, we do not recite benedictions over actions that we do not choose consciously to perform, even though we derive benefit from them. We do not say a blessing, for example, over breathing or enjoying the sunshine, because those are actions that we cannot intentionally choose not to do. The sustenance one receives from a feeding tube is comparable to these examples. Although a patient may consciously choose to allow the procedure, once the device is inserted it delivers medical treatments in the same way a saline IV delivers a nutritionally necessary solution. The body takes in the liquid without conscious intent, just as it breathes or absorbs sunlight. Thus it forms part of a medical regimen, a course of treatment undertaken in fulfillment of our tradition’s commandment to preserve life.[15] In this sense it is not an act of “eating,” and it ought not to be described as such.

 

It is critical for another reason, too, that we maintain the distinction between food and medicine. Consider the case of a terminally ill, end-stage patient who is being kept alive by way of a feeding tube. Is it permissible to remove the tube, to discontinue the artificial nutrition and hydration and to allow the patient to die when all hope for a satisfactory medical outcome has disappeared? In our 1994 responsum on that question,[16] we have written that the answer depends in large part upon whether we define artificial nutrition as “food” or as “medicine.” To the extent that the feeding tube is a medical procedure, introduced as a response to the patient’s illness, it is arguable that we are permitted to discontinue that procedure in a situation of therapeutic futility.[17] Should we in the present t’shuvah unequivocally define nutrition through a feeding tube as an act of “eating,” we would raise serious doubt as to the morality of the decision to discontinue artificial nutrition in end-stage cases. Since we do believe that such a decision is morally justifiable under Jewish tradition, we do not wish to engender unwarranted confusion in the minds of patients and family members who confront such fateful choices.

 

Conclusion. For the reasons we have outlined, we think that it is inappropriate to recite a benediction for food over a tube feeding.

 

We are sensitive to the feelings that you bring to this sh’elah. You raise a powerful concern: no Jew should be made to feel “isolated” from Judaism at a time of illness. We think, however, that there are other prayers that you could recite, words more appropriate to the situation than the blessings over food. The Rabbis long ago composed such a prayer to be recited at the time of medical treatment: “May it be Your will, Adonai my God, that this treatment be a source of healing to me, for You are a gracious healer. Praised are You, Adonai, who heals the sick.”[18] We would suggest that prayer, along with any personal supplications that the patient may wish to add, as the best, most fitting Jewish liturgical response to illness.

 

A Dissenting View. One member of the Committee takes offers the following dissent.

 

I differ with the majority for two reasons.

 

First, the “consensus” Orthodox opinion, with which the majority agrees, rests upon a highly questionable interpretation of the relevant Talmudic source. In that passage,[19] Rabbi Yochanan and Resh Lakish dispute the precise point at which one becomes culpable for eating forbidden foods. The technical definition of “eating” is therefore entirely germane to the discussion.[20] Our subject, however, is b’rakhah, which the Talmudic passage never mentions. The later authorities, those identified with the “consensus” position, connect the two issues and deduce that we recite a blessing specifically over the act of eating. Yet we need not accept that connection. As we have seen, our sources[21] teach that we recite a b’rakhah as a statement of thanks to God for the hana’ah that our food provides. The patient who receives her sustenance from a feeding tube certainly derives hana’ah from it. She may therefore be obligated – and is at least entitled – to recite a blessing over that sustenance, even if she does not “eat” it.

 

Second, I think that the majority overstates the fear of “unwarranted confusion.” Put differently, we can allow persons in this condition to recite a blessing over tube feeding and still justify the discontinuation of artificial nutrition for end-stage patients. The question, as our 1994 responsum frames it,[22] is not whether the mechanism delivers “food” or “medicine” but whether it can be deemed a medical procedure, an action undertaken by medical personnel as part of the indicated course of treatment. Once that treatment loses its therapeutic rationale, we have moral grounds upon which to discontinue it. It does not matter that the tube delivers “food” if, as a medical procedure, it serves no legitimate therapeutic function; it may be disconnected, as any futile medical procedure may be discontinued. In the case of our sho’elet, by contrast, the artificial nutrition is hardly “futile” but serves an entirely legitimate therapeutic rationale. It is, in other words, her sustenance, over which she may rightfully recite a blessing.

 

The sho’elet wishes to recite such a blessing, and I see no sufficient reason, based either in traditional halakhah or contemporary concerns, to deny her that opportunity.

 

NOTES

1.         Birkat hamazon is often classified in a category by itself, since it is considered to be required directly by the Torah (Deuteronomy 8:10; B. B’rakhot 21a; Yad, B’rakhot 1:3). By contrast, the blessings recited before eating food or before benefiting from other things are considered Rabbinic in origin. See B. B’rakhot 35a; Tosafot ad loc., s.v. ela s’vara hu; Yad, B’rakhot 1:2; Chidushei haRashba, B’rakhot 35a; Meiri, Beit Hab’chirah, B’rakhot 35a.

2.         A baraita in B. B’rakhot 35a. The text continues: “one who benefits from the world without reciting a blessing is guilty of m`ilah,” the misappropriation of God’s property. The Amoraim explain that, prior to the recitation of a b’rakhah, “the earth and its fullness belong to Adonai” (Psalms 24:1), i.e., we are not authorized to draw benefit from the physical universe. Once a person recites the appropriate blessing, however, we say that “the heavens belong to Adonai, but the earth has been given to human beings” (Psalms 115:16) and we are permitted to derive hana’ah from the world.

3.         B. Chulin 103b. The terms hana’at garon and hana’at me`ayim, which figure prominently in all subsequent discussions of this topic, are found in Rashi ad loc., s.v. harei neheneh g’rono.

4.         Yad, Ma’akhalot Asurot 14:3.

5.         See R. Yosef Babad (19^th-century Poland), Minchat Chinukh, mitzvah 313, no. 2: “there is no such thing as ‘eating’ in the absence of ‘enjoyment of the throat’” (b’lo hana’at garon la havei akhilah k’lal). See also R. Ovadyah Yosef (20^th-21^st century Israel), Resp. Yabi`a Omer, v. 5, Orach Chayim, no. 18: the word ve`akhalta (“you shall eat”) in Deuteronomy 8:10 “comes to tell us that what is required is ‘the enjoyment of eating’ (hana’at akhilah), that is, ‘enjoyment of the throat’ (hana’at garon).”

6.         B. Pesachim 25b; Yad, Y’sodei Hatorah 5:8 and Ma’akhalot Asurot 14:10-11; Shulchan Arukh Yoreh De`ah 155:3. The person described here is one who does not suffer from a serious (life-threatening) illness. In the event of a serious illness, the rules of pikuach nefesh apply, and the patient is permitted to take the medication even if that act involves normal eating. See Reform Responsa for the Twenty-First Century, v. 1 (New York: CCAR, 2010), no. 5758.8, pp. 139-146, http://www.ccarnet.org/responsa/rr21-no-5758-8/, at notes 5-10.

7.         R. Shalom Schwadron (19^th-century Galicia) Resp. Maharsham 1:123-124; R. Chaim Ozer Grodzinski (20^th-century Vilna), Resp. Achiezer 3:61; R. Avraham Steinberg (20^th-century Poland), Resp. Machazeh Avraham 1:129. The distinction between patients suffering from serious and non-serious illnesses (see preceding note) apply here as well.

8.         R. Ya`akov Breish (20<sup>th</sup>-century Switzerland), Resp. Chelkat Ya`akov, Orach Chayim, no. 52: “b’rakhah nitkenet rak al akhilah, v’akhilah la mikarei rak derekh hapeh l’me`av”.

9.         The recitation of a b’rakhah l’vatala, according to some authorities, violates the prohibition against taking God’s name in vain (Exodus 20:7); Yad, B’rakhot 1:15, on the basis of B. B’rakhot 33a. Others regard the Exodus verse as an asmakhta, a textual indication of the law but not the law’s actual source. In their view, unnecessary b’rakhot are prohibited by Rabbinic decree (see R. Yitzchak bar Sheshet [14^th-century Spain], Resp. Rivash, no. 384, end).

10.       See Resp. Machazeh Avraham (note 7, above); R. Eliezer Yehudah Waldenberg (20^th-century Israel), Resp. Tzitz Eliezer 12:1; and R. Ovadyah Yosef (note 5, above): no blessings are required in the absence of hana’at garon.

11.       R. Ya`akov Emden (18<sup>th</sup>-century Germany), Mor Uk’tzi`ah, ch. 196 (82d) and Siddur Beit Ya`akov, Hanhagat Has`udah (“In my opinion, even if one received no pleasure [hana’ah] from the act of eating – for example, if he swallowed the food whole, without tasting it – if he was satiated by it, he recites the appropriate blessing”); R. Yosef Teomim (18^th-century Germany), P’ri M’gadim, Eshel Avraham, 210:1; R. Meir Eisenstadt (18^th-century Austria), R. Panim Meirot 2:27.

12.       Resp. Machazeh Avraham (note 7, above). See also R. Mordekhai (Leopold) Winkler (19^th-century Hungary), Resp. L’vushei Mordekhai 1:32 and R. Eliezer Waldenberg (20^th-century Israel), Resp. Tzitz Eliezer 13:35, sec. 3.

13.       See preceding note.

14.       See note 10, above.

15.       That is, the practice of medicine is the fulfillment of the mitzvah of pikuach nefesh, the obligation to preserve human life. For sources and discussion, see Teshuvot for the Nineties, no. 5754.18, at pp. 373-375 (http://www.ccarnet.org/responsa/tfn-no-5754-18-373-380), and Responsa for the Twenty-First Century, v. 2, no. 5761.7, at pp. 123-124 (http://www.ccarnet.org/responsa/nyp-no-5761-7).

16.       “Treatment of the Terminally Ill,” Teshuvot for the Nineties, no. 5754.14, section V, at pp. 353-355 (http://www.ccarnet.org/responsa/tfn-no-5754-14-337-364).

17.       We say “arguable” because each case must be judged on its own; as the responsum (see previous note) makes clear, the determination of “therapeutic futility” can be made only on the basis of a careful and prayerful decision with respect to this patient’s condition.

18.       The original form of this blessing, recommended for those who engage the services of a blood-letter, declares that we invoke God’s protection because “it was not intended for mankind to engage in medicine”  (B. Berakhot 60a). As Rashi (ad loc.) explains the passage, “that is, mankind was intended to pray for healing” rather than call upon the physician in times of illness. Maimonides omits that passage, presumably because he did not share the Talmud’s ambivalence about the propriety of medical practice; see Yad, Berakhot 10:21. Shulchan Arukh Orach Chayim 230:4 follows Maimonides on this point, and the commentators to that work note that the blessing is appropriate for all medical procedures. On the theological struggle over the propriety of medical practice in the classical sources, see our responsum no. 5754.18 (note 15, above).

19.       See note 3, above.

20.       The definition is similarly relevant to the question of how one fulfills the positive obligation to eat certain foods, such as matzah and maror on the night of the fifteenth of Nisan. See B. Pesachim 115b and Yad, Chametz umatzah 6:2: one who swallows matzah has fulfilled the obligation, while one who swallows the maror has not fulfilled the obligation, since one must taste the bitterness of the maror (Rashi, B. Pesachim 115b, s.v. bala maror lo yatzah). No such “taste” requirement applies to matzah; so long as the unleavened bread comes into contact with a person’s mouth, that person has “eaten” it and fulfilled the commandment. See Magid Mishneh to Yad ad loc. The point is that one is required to eat the matzah and the maror; hence, we need to define precisely just what “eating” entails. Our argument here is that the blessing over food has to do with the hana’ah the food provides and not with the manner in which one consumes it.

21.       See at note 2, above.

22.       See note 16, above.