Sunday, May 13, 2012

Medical Halachah: Obligation to Heal and Be Healed

This is a set of vignettes and sources for a Medical Halachah shiur I am to give Monday evening; your feedback on the vignettes would be appreciated:

Obligations to Heal and Be Healed

לע"נ רב יהודה ב"ר יצחק הלוי ור' אברהם ב"ר יצחק



· Susan, 89, has emphysema, cataracts and trigeminal neuralgia, and is diagnosed with Stage 2 breast cancer. Her doctor says the tumor is treatable with chemotherapy. Is Susan entitled to refuse the treatment?

· Alex, 74, has been diagnosed with pancreatic cancer, and is refusing to consider radiation, surgery, or chemotherapy. Alex's wife, Jill, suggests to the physician that she could hide oral doses of the chemotherapy drug fluorouracil in his food. Should the physician pursue this course?

· Dr. Schwartz has a patient, Jim, 45, who suffers from hypertension and whose family has a history of heart trouble. For years, Dr. Schwartz has been advising Jim to take on a regimen of cardiovascular exercise and to control his diet, but Jim has ignored his advice. May Dr. Schwartz refuse to see Jim as a patient?

Is there an obligation to seek healing?

1. Devarim 32:39

ראו עתה כי אני אני הוא ואין אלקים עמדי אני אמית ואחיה מחצתי ואני ארפא ואין מידי מציל

See, now - I am He, and there is no other power with Me. I will kill and I will bring to life, I will strike and I will heal, and there is no saving from My hand.

2. Talmud, Bava Kama 85a

בי ר' ישמעאל אומר +שמות כ"א+ ורפא ירפא מכאן שניתן רשות לרופא לרפאות

In the yeshiva of R' Yishmael they said: 'He shall heal' – From here we see that permission is given to doctors to heal.

3. Talmud, Sanhedrin 73a

מנין לרואה את חברו שהוא טובע בנהר או חיה גוררתו או לסטין באין עליו שהוא חייב להצילו תלמוד לומר לא תעמד על דם רעך והא מהכא נפקא מהתם נפקא אבדת גופו מניין תלמוד לומר והשבתו לו אי מהתם הוה אמינא הני מילי בנפשיה אבל מיטרח ומיגר אגורי אימא לא קא משמע לן

How do we know that one who sees another drowning in a river, being dragged by a beast or being attacked by bandits, is obligated to save him? It is written: "You shall not stand by the blood of your neighbour."

But is that law from this source? It is from that source: "How do we know one must restore a friend's physical loss? It is written: 'You shall restore it to him.'"! From there I would only have known personal restoration, not to hire someone.

4. Ramban to Vayyikra 26:11

והכלל כי בהיות ישראל שלמים והם רבים, לא יתנהג ענינם בטבע כלל... עד שלא יצטרכו לרופא ולהשתמר בדרך מדרכי הרפואות כלל, כמו שאמר כי אני ד' רופאך. וכן היו הצדיקים עושים בזמן הנבואה...

The principle is that when the Jews are complete, the laws of nature will not govern them at all… They will not need a doctor and will not need to be careful about therapeutic activities at all, as it is written, ‘For I am HaShem your healer.’ And so the righteous did in the prophetic era…

5. R' Eliezer Waldenberg, Tzitz Eliezer 5: Ramat Rachel 20

דבריו שם נאמרים ביסוד עיקרי הדברים בשרשן בזמן שאין שום גורמים חיצוניים מפריעים, אבל מכיון שלפי מציאות הדברים דכמעט רובא דרובא דבני אדם אינם זכאים לכך שתבוא רפואתם ע"י נס מן השמים והתורה בעצמה לא תסמוך דיני' על הנסים א"כ שוב כלול נתינת הרשות גם לחולה, ועוד יותר מזה דמצוה וחיובא נמי איכא בדבר כיון דלפי מעשה האדם חיותו תלוי בכך

His words there are stated regarding the foundation of things, at their root, when there are no external factors. However, since almost the great majority of people do not merit healing via miracles from Heaven, and the Torah itself says not to depend upon miracles, this permission applies to patients as well. Further, it is a mitzvah and obligation, since his life depends upon it.

Vignette 1 – May a patient refuse treatment?

6. R' Yosef Karo, Shulchan Aruch Orach Chaim 618:1

חולה שצריך לאכול, אם יש שם רופא בקי אפילו הוא עובד כוכבים שאומר: אם לא יאכילו אותו אפשר שיכבד עליו החולי ויסתכן, מאכילין אותו על פיו... אפילו אם החולה אומר: אינו צריך, שומעים לרופא

If a patient needs to eat, and an expert doctor – Jewish or not Jewish – says that without eating his illness may worsen and he may be endangered, we feed him… Even if the patient denies needing it, we listen to the doctor.

7. R' Moshe Feinstein, Igrot Moshe Choshen Mishpat 2:73:5

אם הוא מחמת שאינו מאמין לרופאים אלו צריכין למצא רופא שמאמין בו, ואם ליכא רופא כזה ואי אפשר לפניו מצד המחלה לחכות עד שיבין שהוא לטובתו וגם לא לשלחו כשרוצה בבית חולים וברופאים שהם בעיר אחרת מוכרחין הרופאים שבכאן לעשות בעל כורחיה אם כל הרופאים שבבית חולים זה סוברים שזהו רפואתו, וגם יהיה באופן שלא יתבעת מזה שאם יתבעת מזה אפילו שהוא ענין שטות אין לעשות כי הביעתותא אפשר שיזיקהו וגם ימיתהו ויהיה זה כהמיתוהו בידים... וגם בעצם נתינת רפואה כזו שיש בה סכנה שנוהגין הרופאים ליתן כשמחלתו דהחולה מסוכנת יותר ממדת סכנה דהרפואה עצמה יש לדון...

If a patient’s refusal is because he does not trust the doctors, then they must find a doctor he trusts.

If there is no such doctor, and the disease is such that we cannot wait for him to understand that this is for his own good, and we cannot send him to another hospital and doctors in another town, then the doctors here must treat him against his will if all of the doctors in this hospital believe that this is the way to cure him.

This should be done in such a way that he is not frightened, even if his fright is foolish, for the fright could harm him, even fatally, and that would be like actively killing him…

And if the medicine itself is dangerous, and the doctors give it only to a patient whose illness is so dangerous that the danger involved in the therapy is less than that of the illness, then there is room to debate.

8. R’ Yitzchak Weiss, Minchat Yitzchak 4:120:2

מה מהני רצונה בזה, אם דינא הכי

What does the patient’s desire have to do with this?

9. Talmud, Sanhedrin 84b

בן מהו שיקיז דם לאביו רב מתנא אמר ואהבת לרעך כמוך

May a son let blood to treat his father? Rav Matna said: "Love your neighbour as yourself."

10. R' Yaakov Emden, Mor uKetziah Orach Chaim 328

נ"ל דווקא כשרוצה למנוע מהשתמש ברפואה הוודאית (אף הסתמית ע"י רופא מומחה כוודאית חשיבא)... אבל אם נמנע מפני שאינו מחזיקה לרפואה בדוקה אפילו מדעת עצמו בלבד, כ"ש אם מסייעו רופא אחד... אין כופין, וכ"ש אם חושש הוא שמזקת לו אותה טרופה שסידר לו הרופא האומר צריך... רק בחולי ומכה שבגלוי שיש לרופא ידיעה ודאית והכרה ברורה בהם ועוסק בתרופה בדוקה וגמורה

It appears to me that [we compel] only where he wishes to refrain from a definite treatment – and the default assumption regarding an expert doctor is that his treatments are 'definite'… But if he refuses because he doesn't think the cure is tested, even on his own say-so and certainly if another doctor agrees, then we do not compel him. This is certainly true if the patient is concerned that the treatment may harm him… And [we compel] only for a revealed illness or wound, where the doctor has definite knowledge and clear comprehension and is using a tested treatment…

11. R' Yaakov Emden, Mor uKetziah Orach Chaim 328

אבל יש שבוחרין בספק נפשות כדי להציל עצמן מיסורין קשין כאותן שמוסרין עצמן לחיתוך מפני אבן שבכיס ובגיד וחצץ הכליות הכואב אותן מאד בצער קשה כמוות ר"ל. ולאלה מניחין אותן לעשות כחפצם בלי מוחה, מחמת שכמה פעמים נושעים ונרפאים.

Some choose to endanger their lives in order to avoid great pain, like those who undergo surgery for a kidneystone… which pains them like death. They may do so without protest, for they are often saved and healed.

12. R' Shlomo Zalman Auerbach, cited in Nishmat Avraham 2 pg. 47-48

אין לבצע ניתוח כזה נגד רצונו של החולה (או אפילו לנסות לשכנע אותו להסכים לניתוח) כיון שמדובר כאן בניתוח גדול ומסוכן שרק יוסיף לסבלו של החולה בלי סיכוי כל שהוא לחיי עולם.

One may not conduct such a surgery against the patient's will, or even try to convince him to agree, since this is a great and dangerous surgery which will only add to his suffering without any chance of restoring 'eternal' life.

Vignette 2 – Deceiving a patient

Vignette 3 – Refusing to care for a patient

13. Vayyikra 19:16

לא תלך רכיל בעמך לא תעמוד על דם רעך אני ד'

Do not travel as a peddler [of tales] in your nation; do not stand by the blood of your neighbour; I am Gd.

14. Talmud, Nedarim

לח: - המודר הנאה מחבירו... ומרפאו רפואת נפש אבל לא רפואת ממון

מא: - רפואת נפש גופו רפואת ממון בהמתו

38b - One who has vowed not to benefit someone else… may provide refuat nefesh but not refuat mammon.

41b - Refuat nefesh means healing his body, refuat mammon means healing his animal.

15. Shulchan Aruch Yoreh Deah 336:1

נתנה התורה רשות לרופא לרפאות. ומצוה היא. ובכלל פיקוח נפש הוא. ואם מונע עצמו, הרי זה שופך דמים ואפילו יש לו מי שירפאנו, שלא מן הכל אדם זוכה להתרפאות

The Torah gave permission to the doctor to heal, and this is a mitzvah and included in the general mitzvah of saving lives. One who restrains himself is spilling blood even if he has someone to heal him, for one may not merit to be healed by just anyone.

16. Shulchan Aruch Choshen Mishpat 261:4

המאבד ממונו לדעת אין נזקקין לו

One need not aid a person who destroys his own property knowingly.

17. Talmud, Ketuvot 68a

האומר אם מת הוא לא תקברוהו מנכסיו אין שומעין לו לאו כל הימנו שיעשיר את בניו ויפיל עצמו על הציבור

If one says they should not bury him from his assets, we do not listen; he cannot enrich his children and make the community responsible.

18. R' Chaim Yosef Dovid Azulai, Birkei Yosef Orach Chaim 301:6

ויהי היום ליל ש"ק אירע שנערה ישראלית שתתה סם המות והתחילו לה דבקי מיתה ובאו אצל האיש הלז בליל שבת וקם וכתב הקמיעא לנערה ותכף הקיאה ועמדה על בוריה. וביום השבת נודע בעיר כל אשר נעשה ולעזה עליו המדינה שחילל שבת בשאט נפש וכתב ונתן בידה. והוא השיב דפקוח נפש דוחה שבת. והיו מגמגין בדבר. אי לזאת שאל שאל האיש אם חטא בזה ואם תמצא לומר שחטא אי עבר אדאוריתא או אדרבנן.

One Friday night, a Jewish girl drank poison and signs of death began. They came to a certain man on Friday night, and he rose and wrote an amulet for the girl; she vomited, and returned to health. This event became known in the city on Shabbat, and people gossiped that he had violated Shabbat wantonly, writing and giving this to her. He replied that saving lives overrides Shabbat. They were uncertain, and so the man has inquired as to whether he had sinned, and if it was a sin then whether it was biblical or rabbinic.


  1. And what about the health policies that deny people of certain age and income medical care?

  2. A doctor's Hippocratic oath states in part "First, do no harm." In case #1, treatment may very likely either shorten the patient's remaining lifespan and/or reduce its quality significantly, and if the patient would view either of those as harmful then she is entitled to have her doctor respect that decision. In case #2, deceiving the patient would certainly harm his relationships with both doctor and spouse and therefore the doctor should refuse to participate. In case #3, the doctor should not dismiss an uncooperative patient if no other physician is available, but if there is another doctor then the first is not doing harm by declining to provide further treatment; he's merely allowing the patient to experience the consequences of his own choices.

  3. Batya-
    Definitely an issue. I gave the shiur last night, and it was noted, re: the third vignette, that doctors drop patients or decline to see them all the time, for many reasons.

    Bratschegirl -
    Thanks for your comments. Re: #2 - What do you mean by "relationship" here? Willingness to accept treatment in the future, or something else?

    1. A patient needs to trust that his doctor is telling him the truth; about his diagnosis, about the benefits and risks of treatment, etc. To discover that, in the situation you gave above, that the doctor was colluding with his wife in treating him against his will, would make it difficult if not impossible to have such trust in the future. This would certainly affect his willingness to accept further treatment, potentially not only from this doctor but from others as well. I think it would be the worst sort of betrayal on the doctor's part.

  4. Bratschegirl-
    I thought that might be what you meant. But:
    1. It is extremely unlikely that there will be any future treatment, without this treatment now. And:
    2. Would you say the same for a doctor who physically forced his patient off a bridge when he was trying to jump?

    1. I think you're wrong about #1, unless his remaining lifespan is measured in minutes, in which case the question of further treatment is moot. If he lives more than mere minutes, there will be many other decisions to make regarding comfort medication, whether and when to pull the plug, etc. etc. etc. How could this patient ever again trust that his decisions were being honored and his instructions followed?

      I also recall you saying, in addressing a question of kashrut some time back, that part of paskening is taking into account the effect of one's answer on shalom bayit. Grave damage could done here by treatment behind patient's back, in my view.

      As for 2, of course not. But in that event, as you describe it, it would be the physician making the actual life-ending decision, even if the patient had been heading in that direction to begin with. A better analogy would be to ask if a physician who stood by and watched a patient jump off a bridge had an obligation to do otherwise.

      Actually, even that's not truly comparable. What's more comparable is the physician seeing his patient standing in the middle of the traffic lanes on the bridge, knowing that the odds were that at some point he would be struck and probably killed by an oncoming vehicle. If the physician believes that his patient has made this decision in full possession of his faculties, must he try to save the patient over the patient's objections?

      The poor fellow in #2 is going to die, probably sooner than anyone would prefer, including himself. There is no option (as there is not, indeed, for any of us) that does not end in death. As long as the physician believes the patient to be mentally competent to make this decision, why should he be required to override the patient's desire to live out his remaining time in peace, with no tubes, needles, deleterious side effects?

    2. I should have added to the first paragraph of my comment above the questions of whether and how to treat any related or unrelated health issues that will undoubtedly arise in the time remaining to him. How will he know, for example, that the antibiotics for his sinus infection are really what they are claimed to be?

  5. Bratschegirl-
    #1 - Why do those later decisions have greater significance than the current one?

    #2 - Matter of language; to me, forcing him "off the bridge" means away from jumping.

    On your last question - "As long as the physician believes the patient to be mentally competent to make this decision, why should he be required to override the patient's desire to live out his remaining time in peace, with no tubes, needles, deleterious side effects?" - I return to the bridge case. Couldn't patient who desires to avoid tubes, needles, etc, decide with full competence to jump off a bridge? And wouldn't one who saw him be obligated to try to prevent it?

  6. Later decisions don't have greater significance per se, but I thought it needed to be clarified that there would in fact be many, and that the doctor needs to realize that he won't be trusted to be a part of making them if he colludes with the wife in treating Alex against his wishes and is discovered. Nor will the wife. To leave Alex facing both death and this level of deceit and abandonment, when the latter could and should have been avoided, is to me precisely the sort of harm a physician should not be a party to causing.

    This doctor should advocate as vigorously as he can for the course of treatment he recommends (this would also constitute "trying to prevent" the jump from the bridge in your final sentence above) but respect the patient's autonomy to make the final decision.

    This is a most thought-provoking conversation, Rabbi. Thank you for letting me hijack the comment thread and having it with me!

  7. Bratschegirl-
    True, later decisions do exist. And yes, hurt feelings would be devastating. This is not a great set of choices.
    And thank you!