4 4. Challenges in Accepting Palliative Care Cultural factors can pose diﬃculties in successfully suggest- ing palliative care to a patient and his family. Many Muslims believe that palliative care does not preserve life but delays death and postpones one’s fate. There are those who will feel discriminated against as a minority or as a result of inferior insurance, or because they believe that decisions were made to free up space for another patient [33]. Palliative care, and especially deescalation of care, is seen as “giving up” or shirking one’s duty to heal. Furthermore, immigrant or minority Muslims may feel that inferior care is being given because of their religion or ethnicity or level of insurance, or that the physician is lying to the family, exaggerating a poor prognosis to end care sooner and make way for other patients [33]. In Judaism, some patients or their families might refuse palliative care because they see it as a prohibited form of “giving up” on healing. In particular, they might feel that it demonstrates a less than perfect faith that God will heal. The husband of one of our patients refused palliative care for her because he was worried that doing so would show a deﬁciency of faith for which his wife would be punished by God. There are, of course, a great variety of approaches in Judaism, and it is never helpful to challenge or “correct” a patient or his/her spouse’s view, only to learn what their approach is and work within it. We would like to present one perspective within the Jewish tradition that may be helpful to those looking to ﬁnd a Jewish viewpoint more in keeping with the palliative approach. The son of one of our patients asked us, “Do you believe in the Maimonidean or the Nachmanidean approach to doing our part to bring about a miracle?” What he was asking, by referring to the positions of two illustrious rabbis of the Middle Ages, was whether or not it was acceptable for them to take a palliative approach in their father’s care while maintaining hope for his miraculous healing, or whether they needed to pursue curative oncology treatments as a way of partnering with God in bringing about the miraculous healing. The debate, in philosophical terms, is whether God simply does the miracles or whether we ﬁrst need to do our part, futile though we know our eﬀorts will be in bringing about the miracle without God’s help, and then God will meet us halfway. But the question, in human, pastoral terms, asks whether we must “do everything” or is it permissible, from the perspective of proper faith, to maintain hope for healing while at the same time focusing on palliation. An important Jewish source for this discussion is the commentary of Rabbi Shmuel ben Meir on the Babylonian Talmud. The Talmud states, “Rav Amram said in the name of Rav, From three sins a man has no escape every day: from sinful (lustful) thoughts, iyyun teﬁlla, and harmful speech” (Babylonian Talmud, Bava Batra 164b). What could be the meaning of the sin of iyyun teﬁla, literally “close examination of prayer,” that people violate every day? Rabbi Shmuel ben Meir explains as follows: “Some explain that after he prays he thinks in his heart that God will reward him and do what he needs and fulﬁll his request because he prayed with proper intent (kavana).” In other words, one must not be so arrogant Evidence-Based Complementary and Alternative Medicine as to think that God is somehow required to provide what one asks for. Even if we behave perfectly, or pray perfectly, God does not have to do what we say. We can extend this from prayer to faith. Maintaining perfect faith that He will heal will not necessarily lead God to heal our beloved. And not having perfect faith in their healing will not bring about someone’s death. We must preserve perfect faith that God can heal, but we need not act as if we are 100% conﬁdent that God will heal. Rather, we must do what is best for the moment, given a realistic understanding of the situation, and maintain hope that things will change for the better. Otherwise, we could end up causing a lot more pain and suﬀering to the patient, our beloved family member, and that is not what Judaism requires. To return to the philosophical question of whether or not there is a need to “do everything” in order to partner with God in bringing about a miracle, we would suggest that undergoing all the treatment options recommended by the medical team is already a suﬃcient means of partnership and that, when palliative care is indicated, it is ﬁne to focus on treating the pain and suﬀering. 5. Avoiding Unnecessary Treatments That Increase or Extend Suffering Another principle of palliative care is to avoid treatments that add to the amount of suﬀering without a medical expectation of curing the condition or improving quality of life. What do Islam and Judaism have to say? When death approaches and is unavoidable, Islam directs that the patient be allowed to die without heroic measures or supreme eﬀorts [37]. Medications and medical technology should be used to enhance the patient’s quality of life during his life. At the same time, Islam forbids acts that expedite death. Withdrawing care is permissible in two circumstances in Islam. The ﬁrst is when a diagnosis of brain death has been made. The second is when the current treatment, be it curative or palliative, is no longer curing or palliating suﬀering but merely prolonging a natural and inevitable death [33]. The Prophet is quoted as saying “None of you should wish for death because of a calamity befalling him; but if he has to wish for death he should say: O Allah! Keep me alive as long as life is better for me and let me die if death is better for me.” In Judaism, the belief cited earlier, that death is evil, dovetails with many Jews’ desire to “do everything” to try for a cure. Even if the goal is not a cure, one common approach is to do whatever is possible to extend life, since one moment of life in this world is more valuable than all the world to come. In contrast to those views, we will bring two recent voices from among the many great Jewish thinkers. Rabbi Moshe Feinstein, a leading American Jewish legal thinker of the 20th century, in response to a question regarding care of a patient for whom no cure is possible, wrote: “If physicians have no means of healing such a patient or of reducing his suﬀering, but do know a treatment to keep him alive for a limited time at the current level of suﬀering, then they should not give him this treatment . . .. Even great medical experts, if