Evidence-Based Complementary and Alternative Medicine they do not know how to heal the patient, then they should not give treatments that do not cure, relieve suﬀering, or give him the strength to endure his suﬀering, but if it will calm the patient’s soul by giving him something, then it must be given” [38] (2 : 74.1). Rabbi Feinstein grounds his ruling in the Talmudic story (Ketubot 104a) of the death of Rabbi Yehuda the Prince, the leader of the Jewish people. Rabbi Yehuda the Prince was very ill and in a lot of pain and the prayers of all his students and the greatest leaders of the age were only eﬀective enough to preserve his life, but not to reduce his suﬀering. When his handmaid saw how much pain he was in every time he went to the bathroom, she went up to the roof of the building where the rabbis were praying and threw down a jar. When it shattered, they were momentarily distracted from their prayers and Rabbi Yehuda passed away. The handmaid’s action is praised—this was a situation where nothing more could be done for him, neither to cure him of illness nor to relieve his suﬀering, and she stopped the treatment from being given. Rabbi Shlomo Zalman Auerbach, a leading Israeli Jewish legal thinker of the 20th century, in discussing the case of a dying patient at the end of his life, wrote: “Some are of the opinion that just as the Sabbath must be violated to preserve even temporary life, so it is similarly obligatory to force the patient [to be treated], because he does not own himself so that he [has the right to] relinquish even a moment of life. However, it is reasonable that if the patient is suﬀering a lot of physical pain, or even if he is in great psychological pain, (although) I believe it is mandatory give him food and oxygen for breathing even against his will, it is permissible to withhold treatment that causes suﬀering if he requests it. However, if the patient is God fearing and is not mentally confused, it is extremely desirable to explain to him that a single hour of repentance in this world is more valuable than all of the world-to-come, as (it is written) that it is a “privilege” to suﬀer seven years rather than to die immediately [39] (1 : 91.24)”. Thus, we see that very signiﬁcant rabbinic writers do not automatically endorse continuing with treatments, and either indicate that it would be better not to give the treatment unless the patient speciﬁcally requests it or at least conclude that it is up to the patient to decide (see Bleich’s alternative application of these rulings [40] and Brody’s rebuttal [41]). At the same time, elsewhere, they rule that treatments to reduce pain and suﬀering must be obtained wherever possible [42]. What conceptual analysis underlies their rulings? For Rabbi Feinstein, at least, it seems that the duty to seek and provide healing only applies to treatments that actually help, either by potentially leading to a cure or by improving the patient’s condition [25]. If pain and suﬀering cannot be reduced, and attempts to cure have failed, then these treatments are not in fact helpful. However, if the patient actively wants the treatment, or if it helps him psychologically or spiritually, then an otherwise unhelpful treatment turns into a beneﬁcial one, and as such it should be pursued. In the cases generally addressed by palliative care, we can consider a second approach, even though it would not have pertained to the cases that Rabbis Feinstein and 5 Auerbach were discussing. They ruled regarding a situation where additional treatment could extend life slightly, but could not reduce suﬀering. Even in such a case, they said that Jewish ethics did not mandate such treatment. In palliative care cases, however, palliative care can actually reduce suﬀering. Furthermore, it is important to note that we have no medical reason to expect that continuing treatments will actually extend life as opposed to a purely palliative approach. Treatments given against doctors’ advice in the hope of extending life just as often lead to complications that shorten life. In addition, pain and suﬀering themselves can shorten life (as noted by Jewish thinkers, as well. See Rabbi Waldenberg citing the statement in the Babylonian Talmud, Tractate Ketuvot 62b, “A groan breaks half a person’s body” [43]). In one recent study among several showing this same result, patients with nonsmall-cell lung cancer who received early palliative care lived longer than patients receiving standard care, even though fewer patients in the palliative care group received aggressive end-of-life care [44]. Not all studies have shown such a beneﬁt from palliative care, but many have, so at best the question of which approach extends life more is, at this point, a factual tossup. In addition to a longer life, the palliative care group also enjoyed more productive time at a higher quality of life. Thus, in applying the “extending life” approach, we cannot be sure which approach is better, and the decision can then be left to the patient (Jotkowitz and Zivotovsky [25] cite the opinion of Rabbi Waldenberg, mandating treatment in the same case discussed by Rabbis Feinstein and Auerbach above. However, their position is predicated on the assumption that we are discussing a case where additional treatment will extend life. In our cases, where that assumption may well not be valid, he might not disagree). In addition to these two conceptual approaches, we would like to suggest and endorse a third possibility [45]. In Judaism, Jews have an obligation to make the most of their lives in terms of serving God, fulﬁlling the commandments, and growing religiously and spiritually. We have to maximize our ability to achieve in these areas, and not only maximize the amount of time that we live. Once we refocus the conversation on the religious goals of life, we realize that palliative care can sometimes be more conducive to fulﬁlling these tasks than continued treatments that involve diﬃcult side eﬀects. For example, the palliative approach can leave the patient with more strength for doing good deeds, while the aggressive approach might mean that all one’s energy is devoted just to getting through the treatment. As Rabbi Auerbach noted, the conversation with patients should revolve around how best to fulﬁll one’s religious duties during the life that remains. With that guiding principle, the decision regarding undergoing aggressive treatment can be left to the patient because he is often best placed to know for himself which approach will best enable him to serve God. 6. Psychological and Spiritual Care Palliative care also mandates caring for the psychological and spiritual needs of the patient. As we have noted, in Judaism, the command to heal implied in the verse, “and you shall