A Responsum for 17 Adar: R. Moshe Feinstein on Doctors on Shabbat

On the seventeenth of Adar 1979, R. Moshe Feinstein, Iggerot Moshe Orach Chayyim 4;79, responded to a newly graduated medical student’s question about treating non-Jews on Shabbat, when the Gemara seems to rule against it. R. Moshe will eventually strongly affirm Jewish doctors’ right and responsibility to save non-Jewish lives on Shabbat.

He prefaced that with a discussion of an issue the questioner hadn’t raised. From my minimal experience with Iggrot Moshe, this is uncommon for R. Moshe, suggesting he felt a pressing need to address what remains a continuing challenge for those who ply the medical trade.

A Meaningless Distinction?

He starts by noting Rambam’s use of the word דחויה, pushed aside, to describe the right to save lives on Shabbat, in the beginning of the second chapter of Laws of Shabbat. That implies that, as opposed to הותרה, is permitted, we are only allowed to set Shabbat aside as absolutely necessary. If we took that as a requirement, we would work to minimize Shabbat violations even while saving a life, such as by preferring that someone who isn’t obligated do it (such as a non-Jew or minor) or by transgressing “only” Rabbinic commands.

That doesn’t hold water, since Rambam himself, Laws of Shabbat 2;3, ruled out those kinds of calculations, for fear (as Kessef Mishnah explains) that those who see us act this way will be squeamish about violating Shabbat to save lives, leading to tragedy.

But if he’s not going to make use of the דחויה/ הותרה distinction, why mention it?

During or Before?

For R. Moshe, it was to tell us that we should do what we can to avoid being put into that situation. Once a life needs to be saved, we do not think of how to minimize Shabbat violations, but before we reach that point, we can and should. While a doctor in a small town or who stumbles on a medical emergency cannot avoid it, in large cities, it is often possible to avoid being called on Shabbat without worsening anyone’s medical care.

His examples are somewhat outdated, but his principle still applies: while one might have to take calls from his or her own patients—since halachah recognizes a personal element to successful treatment, so that a patient rightfully assumes that being treated by his/her own doctor carries a greater chance of healing—there is no need to make oneself broadly available. Especially in the United States, with mandated days off, a Jewish doctor could make Shabbat such a day.

He’ll get to residents and being “on call” in a moment, but I want to pause to consider the implications. In his view, observant doctors should do all they can to avoid having to violate Shabbat. That means if they are part of a practice, they agree to take Sundays (or other times the non-Jews in the practice do not want) in order to keep their Shabbatot free.

It also seems to me to mean, although he doesn’t bring it up, that Jewish doctors should do what they can to live near their hospital, if they are going to have to go in regularly on Shabbat. If Shabbat is only דחויה, pushed aside, and we are supposed to do what we can ahead of time to avoid violations, the choice of living place seems to me an important and often overlooked issue.

If the response is that there is no place to live close to that hospital, we get into questions of how we choose which hospital employs us, how we choose professions (if some other profession forced us to act in ways halachah didn’t approve, how would we handle it?).

Another issue raised by a doctor who heard me review these sources is that much of the Shabbat violation in hospitals (and that Jewish doctors necessarily join once they’re there on Shabbat) has no hint of saving lives (for example, discharge paperwork that could be filled out after Shabbat). This isn’t the forum to address it, but R. Moshe’s distinction between ahead of time and in the moment is a reminder that the goal should be—away from any actual medical treatment of those whose lives are at risk– minimum Shabbat violation.

Trading Call

One of the central ways to do so is to make sure not to be on call on Shabbat.  Since most non-Jews preferred to be off on Sunday (in 1979, anyway), R. Moshe didn’t think it would be too much of a problem switching one’s calls (it does mean a doctor in training would have very few Sundays off, which can put pressure on a family).

Trading with nonobservant Jews is more of an issue, since they, too, should ideally refrain from these activities on Shabbat. Nevertheless, R. Moshe thinks there are two ways to handle this: first, deal with whoever assigns the call rotations, convincing him or her to always assign oneself non-Shabbat calls (Thanksgiving, New Year’s, Sundays, more night call, etc.).

He permits this even if that means that an observant Jewish doctor will get some extra Shabbat calls, since that’s what’s called לפני דלפני. The Torah obligates us to avoid leading someone else to sin, Vayikra 19;14, ולפני עור לא תתן מכשל, before a blind person you shall not put a stumbling block (broadly speaking). That only goes as far as the actual person; to lead someone else to lead a third person to sin is not specifically prohibited (it’s not lauded, but here it’s being done in the name of securing one’s personal Shabbat observance; the other Jew can take care of him/herself).

If that doesn’t work, R. Moshe allows direct trading with non-Jews and even with nonobservant Jews. That second one is more surprising, since that Jew is also obligated to observe Shabbat. First, R. Moshe points out that this Jew will likely violate Shabbat wherever he is; when a person can easily commit the sin we are putatively leading them to, that’s not an issue of לפני עור (there might be other issues, but those don’t arise here). If she would drive her car anyway, it’s less of a problem for an observant Jew to encourage her to do so.

Better to Be Non-Shabbat Observant On Call

More so, (and rather cleverly, I think) R. Moshe says that if this nonobservant Jew is in the hospital, that likely reduces his or her level of Shabbat violation, since much of the time in the hospital, s/he will be saving lives. Trading call with a nonobservant Jew might be a win-win.

He does not mention direct trading with another observant Jew, I think because there he’s worried about לפני עור. Where I might wonder is if two observant Jews both already have a Shabbat call, if they can trade them. I’m not sure R. Moshe would allow it, since the one with the earlier call is still having the other one violate Shabbat before he or she would have had to.

However we handle that instance, the overall picture is clear, important, and too often left unmentioned: being a doctor is not a blanket pass to ignoring Shabbat. It allows Shabbat violation to save lives, without pausing to check niceties of how to do so. But the best option is to put oneself in a situation where others can take care of Shabbat emergencies.

Saving Non-Jews: The Quandary

The actual question, though, was about non-Jews, and here the discussion needs to be properly framed. It is easy to assume that if we value peoples lives, we would save them. If we would not save that life, it must mean we don’t value it.

That’s not the whole picture. Our question isn’t whose lives we think are worth saving on Shabbat, it’s whose lives Hashem allowed us to save on Shabbat? The phrasing reminds us that our conduct on Shabbat is ordained by Hashem, and Hashem understands all these issues. After all, the Gemara also derives the permissibility of practicing medicine at all: theoretically, Hashem could have said to leave it all to Him.

We save lives on Shabbat because we have sources that allow it. וחי בהם ולא שימות בהם, the verse says that Hashem gave us the Torah to live by, not to have to die over (although the obligation of kiddush Hashem sometimes does require dying; different conversation). That source, though, doesn’t seem to include permission for us, as Jews, to save those not part of that system.  When Hashem gave us Shabbat, it seems, the exception carved out was that observance of Shabbat (and most other halachot) shouldn’t lead to death, but says nothing about others.

Abbaye argued exactly that, and said we should explain that to non-Jews who ask us to save their lives on Shabbat.  In Avodah Zarah 26a, he says we can tell them we are only allowed to violate Shabbat for those upon whom Shabbat is obligatory.

Today, it’s clear that no one would accept that (and would insist that it showed we don’t value non-Jewish lives). Indeed, when I reviewed these sources orally, listeners were certain no one would ever have accepted that claim. Abbaye seemed to disagree, in his time and place.

Saving Non-Jews Today

The theory aside, we are all agreed that that would never pass for anything other than terrible prejudice today, and therefore R. Moshe is clear that we save all lives on Shabbat, Jewish or not, without a second thought.  (Mishnah Berurah disagreed, but R. Moshe rejects it forcefully, surprised that Mishnah Berurah could have said that).

He adds one last point, that our concern with building positive relationships with those around us means that we have to be even more careful today, in a time of telephones and newspapers, than in times gone by.  There may have been a time when the conduct of a particular Jew in a particular town would remain in that town; today—and the Internet has heightened this– word will get around, and cause problems for other Jews. So even if, today, a certain Jew thought that he could get away with saying he didn’t save non-Jewish lives on Shabbat, R. Moshe would think that he could not say it, because he’d be hurting other Jews’ relationships with non-Jews.

Save Lives, Whenever Needed

Sum total, R. Moshe is clear that whenever a doctor is confronted with a danger to life (Jewish or not), s/he must save that life by all means necessary, without concern for halachic niceties of how to avoid greater violations. But it is preferable to avoid being put into that situation, as long as there are others who can effectively take up the slack.

The definition of “avoid” isn’t completely clear, but it raises questions for Jewish doctors who care about Shabbat. The problem isn’t saving non-Jewish lives when necessary—that’s fine, good, and required—it’s what’s considered necessary, and whether the common definition of when we have to be on medical duty is the same as the halachic one.