- Do we have permission to heal?
The Torah gives permission to the doctor to heal from the following passuk: “…and he who caused the injury shall provide for his healing”(Shemos 21:19). The Hebrew words used in the pasuk for healing are commonly quoted as the source for providing medical care, referred to as “verapo yerapei/ ורפא ירפא“. This pasuk is brought down as the biblical source in Talmud Berachos (60a).
In Baba Kama (85b), Rashi comments, why do we need permission to heal G-d’s affliction? The answer is that we should not say that when G-d afflicts, how dare man intervene and heal. Therefore, it was necessary for the Torah to instruct us to heal. Tosfos comments that we may think that we can only heal injuries caused by man but not from G-d; this is not so.
The Rashba points out that the repetitive phrase used “heal to heal/verapo yerapei”, teaches us that we may treat injuries caused by man and we may treat illnesses sent by G-d.
The Midrash (Socher Tov Shmuel 4:1) quotes an incident where Rabbi Yishmael and Rabbi Akiva gave medical advice to a sick person. A farmer who observed this behavior of these famous Rabbis asked why they were permitted to heal, if G-d gave a man an illness? They answered, just as a tree will not grow if the earth surrounding it is not fertilized and plowed, so too, if a tree is not watered and fertilized it will not live but will die. Similarly, the body of man is like a tree; man’s fertilizer is medication and man’s farmer is the doctor.
In Sefer Devarim, the Zohar (Haazenu 299a) states, “one should not say since G-d imprisoned, one should not try and release him”. Even though G-d had imprisoned the sick man, nevertheless, one should try to free him. If the doctor can cure his physical illness, good. If not, the doctor should try to bring him to repent from his sins and cure his soul. The Zohar comments about this doctor – “G-d will bless this doctor in this world and the next”.
The commentary, Shoel u` Meshiv (Yoreh Deah 336), points out that the Halacha in Shulchan Aruch gives permission for a doctor to heal any illness. The Taz asks if it is a mitzvah for a doctor to heal the sick? He answers, in the affirmative, that it is a commandment (mitzvah) for a doctor to treat the sick. Had the Torah not give permission, it would seem the doctor interferes in the work of G-d.
This Halacha is clearly stated in the Shulchan Aruch (Yoreh Deah 336:1), “The Torah has given permission to the doctor to heal. It is a mitzvah to do so and part of pikuach nefesh (saving a life). If a doctor refuses to do so he is guilty of bloodshed”.
The Ramban (Perush Mishnayos, Nedarim 84) points out that the Torah commands the doctor to treat sick Jews. Similarly, the Nishmat Avraham states that it is an obligation of the doctor to prevent healthy Jews from becoming sick or injured.
How do we know who is a qualified physician, according to Halacha? The Chida (Shiyorei Beracha Ohr HaChaim 328:1) states that nowadays, the permission granted for a doctor to practice medicine is issued by a professional body (State/Government Medical License Board). Based upon the official medical license, diploma, board certification etc. one can assume the doctor is qualified. Similarly, the Shevet Halevi (She`alos v`Teshuvos 4:151) comments that doctors today practice with the permission of Beis Din. When a physician has qualifications from an accredited institution, the Beis Din accepts this as evidence of the doctor`s ability to practice medicine competently.
2. Why do we get sick?
One usually becomes ill through his own fault (Midrash Vayikra Rabba). Rebbe Acha states that we have a personal obligation not to get ill. This can apply to us being obligated to keep a proper diet, exercise, not smoking, getting a colonoscopy at age 50, preventive medicine etc. We learn this from the passuk “G-d will turn away every illness from you” (Devarim 7:15). The words “from you” tells us that not to become ill, depends on you.
The 8th blessing in the Shemoneh Esrei is Refaenu ( רפאנו). The Talmud (Megilla 17b) asks: “Why did the Great Rabbis establish the blessing for healing as the eighth one in the Amidah?” Because bris milah is performed on the eight day and it is an operation which requires healing; they therefore designated the eight blessing for healing.
The Maharal (Ner Mitzvah) points out that the number eight stands for all that is above nature ( למעלה מן הטבע ). This emphasizes that physical healing is a supernatural occurrence above the plane of nature. Similarly, the Chanukah miracle is celebrated for 8 days to symbolize that the Jewish victory was miraculous.
The Talmud (Shabbos 32b) teaches: “A healthy person should always pray that he does not get sick, because once sickness strikes he must have great merit to regain his health.”
The Refaenu tefillah states: “Save us – then we will be saved \הושיענו ונושעה “. When a person lives a holy life he is insulated from sickness. When one is afflicted by a physical ailment it is often a symptom of a spiritual failure. A sick person is called a “choleh – חולה” , which is from root word “chol – חול “, unholy. The word “chol -חול “ is from word “חלל,” emptiness, implying that there is a void of sanctity. We therefore ask G-d to save us, “הושיענו” from spiritual failure and then “נושעה” we will be saved from medical sickness (Tefillah L’Dovid). We also beseech G-d not only to cure us, but to save us from the adverse side effects of surgical procedures and medications (Noviminsker Rebbe).
Refaenu continues: “for you are our praise כי תהלתנו אתה- .” What does praising G-d have to do with good health? We learn from a verse in Mishlei (27:21) that a person who prays with fervor and passion is aflame with love and praise for G-d. This spiritual fire cleanses the body of all its physical ailments. Thus we pray for G-d to heal us because we are aflame with His praises which should cure us. The Midrash (Shir HaShirim Rabbah 2:14) states that the sicknesses that G-d afflicts us with are only meant to bring us closer to Him – כל חולת אהבה אני (שיר השירים ב:ה) . So three times a day we pray “Heal us Hashem. You need not make us sick in order for us to love and praise You – You are our praise already and we promise to continue praising You in good health. You afflict only those who are indifferent to you – we promise not to forget You (G-d) !”.
The Zohar (Parshas Shelach) teaches that sickness results when the accusing angels denounce a person for his sins and he is condemned to suffer. But when the sick person repents and accepts G-d as his King, all is forgiven. G-d himself participates in every successful healing procedure. The Almighty holds the doctors hand and guides him – ה יסעדנו על ערש דוי (תהילים מא:ד)”
- Must one practice preventive medicine and protecting oneself from disease?
Yes, this includes not smoking, observing a proper diet, exercise etc. Ramabam (laws of murder/Rotzeach 11:4) states that it is a positive mitzvah to remove obstacles that may lead to a danger to one’s life; “It is a positive mitzva to remove any impediment that might pose a danger to life, and to be extremely cautious in this regard”.
We must also guard our health based on the Torah commandment to guard our bodies, “shmor nafshecha”. The Torah says “…guard your life very carefully… (Hishamer Lecha U’shmor Nafshecha Me’od).” This means a person should do the utmost to preserve his health and prolong his life (Devarim – 4:9).
- Is one allowed to use the alternative medicine mentioned in the Talmud?
No. (Tosfos Moed Katan 11a, Chazan Ish Nashim 27:3) nishtaneh hatevah, the natural order of the world has changed since the times of Chazal, so that the treatments offered in the Talmud are not effective nowadays. The cures in the Talmud are written in code and are now not understood. Since we don’t understand the Talmud the treatments will not work, and this will disrespect the words of Chazal (Rav Akiva Eger Yoreh Deah 336:1). Rav Shrira Gaon (Gitin 68b) has a different approach. He points out that when Chazal discuss medicine and nature, they discuss the topics based upon the contemporary knowledge of their time, not to be confused with the holy words of the Torah. Thus we can only accept their words in these matters if current medicine has the same understandings nowadays.
Rav Shlomo Kluger writes (shailos v’teshuvos uvacharta bachayim 87) that one may set aside Shabbos laws to save a life. However, this is only if the cure is conventional and only if it has been tried and proven. One may not violate Shabbos laws with supernatural cures or prayers.
Beit Lechem Yehuda (on Yorei Deah) forbids taking medication for any illness unless prescribed by an expert physician. One who disregards this is like one who commits suicide. Similarly, the Nishmat Avraham comments that it is prohibited for a layman to advise a patient to take medication based on the fact a doctor gave medication for the “same condition”.
Midrash (Tanchuma Yisro 8) states “G-d says there is no illness which cannot be healed. The medication and cure for each and every disease is known.” The Talmud in Berachos (10b) states that King Chizkiyahu concealed the book of cures so that the sick would pray to G-d for mercy. People at that time placed their trust in doctors not in G-d. The Ramban points out (Yayikra 26:11) that when the majority of the Jews are free of sin they will not need the services of a doctor. This is based on the pasuk “…For I am Hashem your Healer” (Shemos 15:26). This is how the tzadikim acted during the era of the Neviim. The Navi would tell them how they had sinned so they could do teshuva and regain their health. Rav Ovadia Yosef ((שו”ת יחוה דעת ח”א סי’ סא writes that according to the Ramban nowadays times are different and prophesy has ceased to exist, therefore, we must act in accordance with medical advice.
- Who are the best doctors? Does one need to consult his rabbi to get a referral to the “best” doctor?
Tzitz Eliezer (Shaylos Teshuvos 5, Ramat Rachel 22) states that even a doctor with minimal experience is also obligated to treat patients, as long as he is competent. However, the doctor should not be embarrassed to ask for advice when he has a doubt about the diagnosis or treatment.
There is a famous misquoted Mishna in meseches Kiddushin (82a), “the best of doctors go to Gehenom(hell)”. This refers to doctors who are guilty of harm from willful and negligent actions. The Tiferet Yisrael explains – the doctor who considers himself the “best”, according to the words of the Mishnah, is one who prides himself on his knowledge and therefore refuses to consult with other physicians and does not consult the textbooks [medical literature]. The greater the danger that the doctor may be sent to Gehenom, the greater the reward if he conquers this faulty character trait.
We have in the 8th blessing of the Amida:כי קל מלך רופא” – For you are G-d, King , the healer”. The King of all healers is G-d himself. The blessing of רפאנו designates G-d as the ultimate healer, not a haughty doctor. Such a doctor deletes the prayer of רפאנו or recites it without the proper intent. Now for this doctor he has 17 blessings in the Amida not 18. This is another explanation of the Talmud, טוב שברופאים לגיהנם (קידושין פב:). Since (Tov)טוב means the best and the gematria of “Tov” is 17, the arrogant “best doctor” “הרופא הכי טוב” recites only 17 blessings with kavanoh (proper intention) in the Shomeh Esrei prayer, not 18.
Nowadays, one should daven for G-d to send the right doctor to be His agent for healing. In Talmud Avodah Zarah (55a) Rabbi Akiva explains how sickness is healed – G-d Himself dispatches the angels of suffering and sickness. G-d makes each angel swear that they will enter this man only at a specified time and the angel will only leave him on a certain hour, but only if he is treated by the particular doctor who administers a specific medicine (treatment) and none other. When the angels depart at the pre-ordained time G-d is aרופא נאמן ; whereas when the patient does a full teshuva, G-d immediately acts a רופא רחמן and sends an instant cure.
- Is one allowed to study medicine?
Rambam (Chapter 5 Shemoneh Perakim) the practice of medicine is a good introduction to acquiring intellectual and moral values and truly succeed in attaining knowledge of G-d. The Chovos Halevavos (Shaar Habechina 5) suggest that it is our obligation to study the creation of a human being, his early development, the formation of the body, the structuring of its organs, the basic functions of each one, and why it was necessary to make him in the form in which he is fashioned. In this way we can recognize the greatness of G-d as it says in Iyov (19:26) “from my own flesh I will see G-d”.
According to the Levushei Mordechai (Shaylos vTeshuvos 29) Chelkat Yaakov (Shaylos vTeshuvos 84) it is a mitzvah to study medicine. Whereas, Rav Moshe Feinstein in Iggros Moshe (Shaylos vTeshuvos Yorei Deah 151) states that there is no obligation to study medicine. Similarly, Rav Auerbach clarifies that there is a mitzvah to study Torah. However, if one is to choose a profession, and not learn Torah full time, it is better to study medicine, if one is capable.
- Can a layman or pharmacist give patients medical advice? Can a paramedic give medical treatment when a qualified doctor is present?
One should not treat a patient unless he is qualified and there is no other doctor who is more competent then he who can treat the patient; otherwise he is guilty of bloodshed. (Shulchan Aruch, Yorei Deah 336:1)
If one treated a patient without the permission from Beis Din, he is obligated to pay damages, even if he is qualified.
- Can a pharmacist prescribe medications?
Tzitz Eliezer warns pharmacists not to prescribe medication on the basis of their superficial knowledge of medicine. They do not know how to examine a patient properly. They do not examine patients as part of their profession to fill prescriptions. In addition, they are not trained how to diagnose illnesses. Thus a pharmacist may only prescribe well known medications (like over the counter medications).
Similarly, a patient must be careful not to take medication on his own initiative ( or from a medication gemach) without the instructions of a physician. However one may take over the counter (OTC), well known medications, when clearly indicated.
- Who is liable for unintentional harm to a patient ?
If one has permission from Beis Din to treat and he harmed the patient unintentionally, he is exempt from judgment by man but will be judged by Heaven (Yoreh Deah 336:1). If the patient dies and he realized that this was due to error on his part he goes into exile (needs to repent/do teshuva) on his own.
Tashbetz (Shaylos vTeshuvos 3:82) explains that if doctors would be liable for damages because of inadvertent mistakes, no one would practice medicine. The Torah gave permission to heal knowing the risks of the practice of medicine.
A medical doctor is a “Rofeh”, he is not liable for unintentional harm since he can only treat what he can see. This is assuming one is treating according to the accepted practice and standard of care !
Yad Avraham comments that if a patient dies, the doctor has not performed the mitzvah of healing, however, one is not liable for damages while in the act of attempting to perform a mitzvah.
Tashbetz points out that physicians are always involved throughout their work day as being involved in a mitzvah.
- What is the difference between the liability of a surgeon and a physician ?
According to Rav Auerbach if a surgeon operated on a part of the body that he should not have or the patient dies; then that surgeon goes into the galus(exile)/do teshuva.
When a patient agrees to surgery he is aware the success rate is not 100%. Therefore the surgeon is not liable for a mishap if it is not the result of negligence.
It is permitted to operate even if there is doubt an operation will succeed; especially if the situation is where the patient may die immediately if an operation is not done.
- Is a doctor allowed to take payment for treatment?
The Shulchan Aruch states in Yoreh Deah (336:2) that it is forbidden for a doctor to take payment from a patient for his knowledge and advice. However, he may take payment for his trouble (sechar batalah) and from refraining from other employment. The Talmud is more clear on this topic, (Baba Kama 85a) “a doctor who charges nothing is worth nothing”. In other words, you get what you pay for. Targum Yonasan quotes the pasuk (Shemos 21:19) “verapo yerapei” – he must pay the doctor’s fees until he is cured.
Aruch Hashulchan Halacha 3 allows the doctors to charge for travel, writing prescriptions and all overhead expenses. The Torah Shelaima also quotes the pasuk (Shemos 21:19) “verapo yerapei” “and he should provide for his healing” gives the doctor right to charge for his services, otherwise without the pasuk one might think it is forbidden.
Only G-d is free. The Birkei Yosef (Yoreh Deah 336) points out the gematriah of shechina (שכינה) is 385, which equals the phrase רופא חנם (He Who heals for free).
- Is a doctor allowed to refuse treatment to one who cannot afford to pay?
A doctors payment is for S’char batalah, for choosing the medical profession as a job. According to Rav Auerbach a doctor is entitled to a higher salary if he chooses to work at another hospital. He is also entitled to charge a USA salary if he chooses to live in Israel.
Teshuva Meahava (Shaylos vTeshuvos 408,336) states that the doctor who refuses to treat a patient who truly cannot afford fees is guilty of “the best doctors go to Gehinom”. In this scenario, the Beis Din can force a doctor to treat without charge. If more than one physician is available the community must pay from public funds (government health care).
- Can one charge a high fee?
If the doctor demands a high fee as a precondition for treatment, the patient is obligated to pay him since he is in fact paying for his knowledge and experience, and that has no particular price tag (Yoreh Deah 336:3).
- Is the patient obligated to pay the doctor?
Must one pay for medical care or get free care? Zohar (Haazinu 299b) explains that sometimes illness is a result of a punishment decreed on one’s property and the patient will not recover until he has spent all the money he was decreed to lose. Only then will G-d send the cure. Ramban (Vayikra 26:11) The door to healing may not open through doing mitzvos, but the door to healing will open to the doctor.
Although it is a mitzvah for the doctor to treat the patient, he is not required to do so for free and is entitled to receive his fee. The patient must pay the doctor since it is a mitzvah required of everyone (the patient) to seek medical care. This obligation does not fall on a particular doctor and different doctors have different fees.
A doctor has no obligation to learn medicine in the first place. The mitzvah of treating patients is not one particular doctors obligation, since others can also learn medicine. The Taz (Yoreh Deah 336) explains that there is an understanding that the doctor and patient have agreed to payment terms, thus the patient must pay. Rav Waldenberg (Tzitz Eliezer 25) clarifies that if only one doctor is available the patient is not obligated to pay any higher fee than he agreed upon. However, the Rama (Choshen Mishpat 264:7) and Yam Shel Shlomo write that a patient must pay the doctor bill if it is usual to pay for this type of service.
Tosafot (Moshav Zekainim Shemos 21:19) comments on the double phrase “verapo yerapei” in the Torah – which means that if one is not helped by one physician he must go to another physician to search for a cure of his illness.
- May one depend on miracles and not seek medical assistance?
Rashba (Shailos v’Teshuvos 413) states that it is forbidden to depend on a miracle. Everything that may heal is permitted. Birkei Yosef also states one cannot depend on miracles and is obligated to go to a medical doctor. If a patient does not go to a physician then he is guilty of an aveira (sin). The reasons a person may not go to doctor is based on pride or one is depending on a miracle and both are aveiros.
One who is sick is obligated to seek out a physician to heal him. The patient needs to search for the most qualified physician and the most appropriate medications. One who is lazy or negligent and does not do so is a fool “shoteh”. He is acting with criminal negligence regarding his health and will ultimately have to stand judgment for this (Shevet Yehuda 336).
The Ramban’s opinion (Vayikra 26:11) is that during the era of the prophets, if one became ill because of some sin, he did not seek the help of a doctor but rather a Navi (Prophet). Rav Ovadia Yoseph (Sheailot Teshuvot) states that nowadays we have no prophets, therefore, we must act according to proper modern medical advice.
Chazon Ish (Kovetz Iggros) writes that the need to stay healthy is a mitzvah and obligation. G-d created the world to act in this fashion. If one could save a life by one’s efforts and instead prays to G-d, he will have violated the negative commandment of “do not stand idly by while your fellow’s blood is shed” (Vayikra 19:16) “לא תעמד על דם רעך”, (Chazon ish zichron Yaakov 5739).
The doctor is a “Shaliach”, a messenger of G-d. Everything comes from G-d. Every cure can only come from Him. He decides one’s medical fate not the doctor or the particular treatment. When sickness befalls a person, it is sworn to only come on a certain day and only leave on a certain day and time and only through a certain medication/[treatment] (Tzitz Eliezer). One must listen to the doctors instructions just like any law in the Shulchan Aruch (Gesher Hachayim).
Shulchan Aruch Yoreh Deah, Siman #336 (של”ו – יורה דעה שולחן ערוך)
Nishmat Avraham. Dr. Avraham S. Avraham.
Shemoneh Esrei. Rabbi Avrohom Chaim Feuer. Artscroll Mesorah Series.