Question:

As life expectancy grows, many people are faced with the difficulties of caring for a parent with Alzheimer's disease.¹ According to Jewish law, is it permissible to institutionalize such a parent?

Responsum:

This question presents a difficult moral dilemma. On the one hand, the Torah commands us to "Honor your father and your mother" (Exodus 20:12, Deuteronomy 5:16) and again: "You shall each revere his mother and his father" (Leviticus 19:3), which seem to be absolute requirements regardless of their behavior. On the other hand, if the parent has deteriorated to such an extent that he or she requires being strapped into bed or being drugged or having a diaper changed, is it "honor" and "reverence" for a child to do this? Or is it greater honor for an outsider to do so? What about the emotional strains on the child? How much must he or she bear? 

This sounds like a new dilemma but, in fact, the problem of parents who have deteriorated mentally is mentioned in Jewish sources as early as the second century b.c.e., and the specific question raised above has been hotly debated by halakhic authorities for over 800 years.

 The apocryphal book of Ben Sira, dating to the second century b.c.e., tells us (3:12-13): 

My son, be strong in the honor of your father; and do not leave him all the days of your life. Even if he loses sense, let him do [all that he wishes] and do not shame him all the days of his life. 

A post-Talmudic midrash teaches much the same thing: 

Even if your father's spittle is running down his beard, obey him immediately. ²  

The Talmud does not explicitly deal with our issue, but it contains three passages which discuss the erratic behavior of parents. ³ Dama ben Netina, the gentile "Mayor" of first-century Ashkelon, was once chairing a meeting of the City Council. His mother entered, tore off his golden silk cloak, hit him on the head, and spat in his face - but he did nothing to shame her. ⁴  

Another Talmudic passage reads: 

They asked Rabbi Eliezer: "To what extent must one honor one's father and mother?" He replied: "To the extent that if he takes your wallet and throws it in the sea, you should not shame him" (Kiddushin 32a). 

These two Talmudic passages were codified by Maimonides (Mamrim 6:7) and Rabbi Joseph Karo (Shulhan Arukh, Yoreh Deah 240:3, 8) and they seem to agree with Ben Sira and Seder Eliyahu - no matter what you parent does, you must obey him and not shame him. 

But if this is the case, what can a child do if he can no longer bear his parent's strange or abnormal behavior? This dilemma is dealt with in a third Talmudic passage which became the basis for most subsequent halakhic discussion: 

Rav Assi [who lived in Babylon] had an aged mother. She said to him: "I want jewelry!" He made some for her. "I want a husband!" He replied: "I'll look for one for you." "I want a husband as handsome as you!" He left her and went to Israel. When he heard that she was coming after him, he asked Rabbi Yohanan: "Is it permissible to leave Israel for Hutz La'aretz [the Diaspora]?" He replied: "It is forbidden." [He asked:] "Towards his mother - what is the law?" He replied: "I don't know.".. . In the meantime, Rav Assi heard that her coffin was coming. He said: "Had I known, I would not have left Babylon!" [Or: "Had I known, I would not have asked permission to leave Israel!"] (Kiddushin 31b). 

This story is very problematic. Was Rav Assi's mother mentally disturbed (she seems to be interested in marrying her own son) or merely crotchety? Can a child run away when he can no longer tolerate a parent's erratic behavior? And what does the final ambiguous sentence mean? Did Rav Assi regret abandoning his mother or is he saying that not only did he act properly by leaving her, but he was not even required to meet her coffin? 

The halakhic authorities interpreted this story in two conflicting directions. Maimonides (1135-1204) and his followers used it to legitimate custodial care, while Ra'avad of Posquieres (1120-1198) and his followers came to the opposite conclusion. 

Maimonides codified the story as follows: 

If one's father or mother should become mentally disordered, he should try to treat them as their mental state demands, until God has pity on them. But if he finds he cannot endure the situation because of their extreme madness, let him leave them and go away, commanding others to care for them as befits them (Mamrim 6:10).

According to the last sentence, it is perfectly legitimate to institutionalize a parent with Alzheimer's disease, even though this is not explicitly stated in the story about Rav Assi.

Ra'avad of Posquieres (1120-1198), Maimonides' classic critic, disagrees (Hassagot, ad. loc.): 

This is not a correct ruling! If he goes and leaves him, who shall he command to watch him?! 

Apparently, in Ra'avad's time and place there was no option of custodial care and, indeed, the first Jewish old age home seems to have been founded in Amsterdam in 1749. ⁵  

All subsequent halakhic authorities aligned themselves with either Maimonides or Ra'avad. The Maimonidean camp, ⁶ replies that since Rav Assi's mother was brought to Israel in a coffin, he must have ordered others to take care of his mother. Regarding the practical issue raised by Ra'avad, they reply that the child can hire someone to take care of the parent. They further state that in cases of a parent who has deteriorated mentally, an outsider can do a better job than a child for two reasons: First of all, the parent will be embarrassed to misbehave in front of an outsider. Secondly, an outsider can raise his voice or physically restrain the parent if necessary, while a child would never be able to do such things and is not allowed to do so. 

Ra'avad's followers reply that it is clear from the end of the story (see the first translation above) that Rav Assi regretted having left his mother and therefore the story proves that custodial care is prohibited. ⁷ Furthermore, if, as Maimonides claims, "others" can take care of the parent, then why can't the child do so himself since he has a better understanding of his parent's desires and idiosyncrasies? In addition, this camp seeks support from R. Jacob ben Asher (1270-1343) who in his code (Tur, Yoreh Deah 240) quotes Ra'avad after Maimonides, which seems to indicate his agreement with the former. Lastly, this camp asserts that Rav Assi's mother was not mentally disturbed but rather old and crotchety. Rav Assi left her because he knew he could not honor her requests properly. But a demented or senile parent needs extra physical care from the child while his demented requests can be ignored because he no longer has all of his faculties. 

What then are the halakhic options open to a child faced with the dilemma of caring for a parent with Alzheimer's disease? It appears from the above analysis that there are three legitimate halakhic options: 

1. A child with stamina and emotional fortitude can follow the line of thought expressed by Ben Sira and advocated by the Ra'avad and his camp. They view "honor thy father and thy mother" as an absolute value which cannot be absolved by the erratic behavior of the parent. Regardless of how the son feels, he must personally take care of his parents as commanded by the Torah and must not "leave [them] all the days of his life". 

2. Others may place their parent in a nursing home, following the example of Rav Assi as interpreted by Maimonides and his followers. According to this view, a child is not personally obligated to care for the parent, if he must sacrifice his own emotional health Responsa in a Moment 40.in the process. They further state that in cases of mental deterioration, the honor of the parent can be better served by an outsider who can do things the child cannot do and that the parent would not want him to do. 

3. Yet I believe the preferred halakhic solution is one implied by a number of the rabbis in the Maimonidean camp - to keep the parent at home ⁸ but pay an outsider to attend to the functions which are painful or inappropriate for the child to perform. This solution incorporates the concerns of both Ra'avad and Maimonides. On the one hand, the parent feels wanted and loved by his or her child, a feeling frequently lacking in an institutional setting. The parent functions better at home than in a new and strange environment. ⁹ By keeping the parent at home, the child fulfills the commandment to "honor your father and your mother" in a direct and personal fashion as demanded by Ra'avad. On the other hand, following Maimonides, the child protects the parent's honor and the child's own emotional health by ensuring that a professional is on hand who can perform functions not in keeping with the honor owed a parent by a child. ¹⁰  

NOTES 

1. Some four million Americans are now afflicted with Alzheimer's disease - see Newsweek, December 18, 1989, pp. 54-63 and March 20, 2000, pp. 48-56;
Muriel Gillick, Tangled Minds: Understanding Alzheimer's Disease, New York, 1998. 
2. Seder Eliyahu Rabbah, Chapter (27) 25, ed. Friedmann, p. 136.
3. Two of the three Talmudic passages cited here are aggadic or non-legal in nature. This is not unusual; halakhic authorities frequently rely on non-legal passages in the Talmud when there is a dearth of halakhic sources.
4. Kiddushin 31a and cf. Yerushalmi ibid., Chapter 1, fol. 61b. According to a parallel passage in Devarim Rabbah 14:1, she was hasrat da'at - mentally deficient in some way.
5. Encyclopaedia Judaica, Vol. 2, col. 346.
6. R. Shem Tov ibn Gaon (fourteenth century), in Migdal Oz ad. loc.; R. Nissim Gerondi (1300-1380), on Rif to Kiddushin, ed. Vilna, fol. 13a; R. David ibn Zimra (1479-1573) in Radbaz ad. loc.; R. Joseph Karo (1488-1575) in Shulkhan Arukh Yoreh Deah 240:10; R. Solomon of Chelm (eighteenth century) in Mirkevet Hamishneh to Maimonides ad. loc.; R. Yehiel Michal Epstein (1829-1908) in Arukh Hashulhan, Yoreh Deah 240:32; and R. Eliezer Waldenberg, Tzitz Eliezer, Vol. 12, no. 59.
7. R. Shlomo Luria (1510-1574), Yam Shel Shlomo to Kiddushin, chapter 1, par. 64; R. Joshua Falk (1555-1614) in Derishah to Tur Yoreh Deah 240; R. Joel Sirkes (1561-1640) in Bah ibid; R. David Halevi (1586-1667) to Shulkhan
Arukh Yoreh Deah 240:10, subparagraph 14; and R. Samuel Strashun (1794-1872) in Rashash to Kiddushin ad. loc.
8. The growing phenomenon of adult day care centers enables many children to keep parents with Alzheimer's at home - see Newsweek, July 2, 1990, pp. 56-58.
9. Midrash Hagadol to Genesis 35:6, p. 597 relates that in the ancient city of Luz "when a man became disgusted with his father and mother he would remove them to another city and immediately they would die".
10. For further reading, see Gerald Blidstein, Honor Thy Father and Thy Mother, New York, 1975, pp. 116-119; Levi Meier, "Filial Responsibility to the 'Senile' Parent" in Levi Meier, ed., Jewish Values in Bioethics, New York, 1986, pp. 75-84; Barry Freundel, "Halakhah and the Nursing Home Dilemma", Proceedings of the Association of Orthodox Jewish Scientists 10 (1990), pp. 85-106.