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Parashas Mishpatim

The Place of Medicine in Halachah

Excerpt from Trust Me! When men argue with one another and one hits the other with a rock or with a fist, and he does not die but takes to bed: If he rises and walks outside on his cane, then the assailant shall be absolved; he shall pay only compensation and provide for healing. (Shemos 21:18-19) Tanna d'vei R. Yishmael: "From here we derive that the doctor has permission to heal."?(Bava Kamma 85a)

The Chumash Torah Temimah comments:

By stating that the assailant must pay for his victim's medical expenses, the Torah implies that a doctor is permitted to apply medical treatment and does not thereby contradict the Divine will. This is because the Almighty endowed Creation with healing abilities, and by employing them, the doctor is merely fulfilling the Divine will.

* * *

The Gemara (Berachos 10b and Pesachim 56a) mentions that King Chizkiyahu had a book which contained the cure for every illness. He saw, however, that the book was being misused, as people would turn to it to find a cure without contemplating what brought on the disease in the first place. The purpose of illness - to cause a person to make a personal accounting of his deeds and turn to God - was being lost (see Rashi). Therefore, Chizkiyahu decided to conceal the book.

* * *

It is written in the Zohar (the end of parashas Ha'azinu) that sometimes a person becomes ill because he is being punished and must lose a certain amount of money. He will not be healed until he spends all the money that it has been decreed for him to pay. Once he has done so, Hashem will bring about a cure for him.

R. Eliezer Waldenberg in Tzitz Eliezer (vol. 5, in the section entitled Ramas Rachel, 1:4, based on the Ma'avar Yabok, Sifsei Tzaddik 21) derives from here that a person shouldn't scrimp on medical expenses. Moreover, by freely distributing money to tzedakah, a person will spare himself the need later on to spend that same money on medical expenses. "Just like a person's income is fixed on Rosh Hashanah for the upcoming year, so too are his expenses established" (Bava Basra 10a).

* * *

Commenting on Vayikra 26:11, the Ramban asks: "What place do doctors have in the lives of those who do Hashem's will? Didn't the Almighty promise us that He Himself would heal us? Asa was criticized for turning to doctors. When the people of Israel were 'pure and many' (cf. Nachum 1:12), their affairs were not conducted in any natural fashion whatsoever, not regarding their bodies nor their property, neither publicly nor privately. The Almighty's blessing was on their bread and water. He removed all illness from them and they had no need of doctors. Indeed, it wasn't even necessary for them to seek any type of preventative medicine, as it says: 'For I am Hashem who heals' (Shemos 15:26). We find that tzaddikim who lived in the time of the prophets did not seek medical attention, for they realized that their illnesses were brought on by transgression. Rather, they would seek out the prophets."

Despite this, Chazal inform us that a doctor has permission to heal, basing themselves on the phrase: "and [he will] provide for healing" (Shemos 21:19). Thus, Chazal tell us explicitly that we are in fact permitted to seek medical care! Based on this seeming contradiction, the Ramban derives a very important principle: there are two parallel paths of action for two different types of individuals. The majority of people do not attain an exalted level of emunah, and the path of medicine is open to them. However, when an individual reaches sublime heights of yiras Hashem and removes himself from the general scheme of nature, he should trust completely in Hashem and not rely upon doctors.

This discussion should not to be taken as the basis for a halachic decision. The Tzitz Eliezer, (vol. 17 section 2), discusses at length the subject of emunah and the obligation to seek medical attention. In subsection 3 he writes that the statement of the Ramban regarding a person with perfect emunah does not apply to our generation. In our time, everyone is obligated to seek medical attention and no one should rely purely on bitachon. If so, what role does bitachon play? The patient should have faith that it is Hashem who is healing him, and that the doctor or the medicine is only His agent.

* * *

Shomer Emunim (in Ma'amar Ha-Bitachon v'Hischazkus, ch. 5) contains a letter to his student:

My dear disciple - do not be frightened, for Hashem will certainly come to your aid. As for a specific course of action, if your intention is to go to a doctor, make sure you seek out the best one available. This is what our Rebbe, R. Ber, has told us to do - that if one wants to consult a doctor, he should make sure to go to the most renowned one there is. This is because the best doctor has Heavenly assistance, which is the cause of his success. The Rebbe also stressed the well-known idea that it is not the doctor who heals, but the angel who accompanies him - and the better the doctor, the more powerful the angel who accompanies him. Moreover, R. Ber is not alone in this approach. Moreinu, the holy Rebbe of Belz, always instructed his followers that if they go to a doctor they should specifically seek out the best one.

* * *

The following are excerpts from the Tzitz Eliezer (vol. 10, section 30; vol. 11, section 41), by R. Eliezer Waldenberg.

Regarding medical care, the principles of strict bitachon would seem to dictate that we trust solely in Hashem and not turn to doctors. Indeed, we find this concept among Christian Scientists. In reality, however, this idea is foreign to Judaism. Our greatest gedolim routinely send people not only to doctors, but to the most renowned specialists. And the gedolim themselves don't rely on miracles, but seek the best medical care available. What is the source for this attitude in Torah literature?

We know from the phrase: "and [he will] provide for healing" (Shemos 21:19) that doctors are allowed to heal. From where, however, do we know that it is permissible for a patient to seek out a physician's help? The Rashba (Teshuvos, vol. 1, section 4, 413) writes that once the Torah allowed doctors to heal illness, the practice of medicine became a permitted art; however, a person's heart should be focused on Heaven, and he must understand that the cure really stems from Hashem. We can seek medical help as long as we don't rely entirely on the medicine or on a specific doctor. One who is sick should not rely on miracles nor refrain from pursuing natural channels for a cure. Medical help is not contrary to the Torah's command that we believe in the Almighty's direct supervision over us and His concern and care for our needs.

Concerning this issue, the Shulchan Aruch (Yoreh De'ah 336:1) rules: "The Torah gave permission to a doctor to heal, and this is a mitzvah that is included in the commandment to save lives. If a doctor refrains from healing patients, it is as if he has shed blood. This is true even if there is someone else available who is qualified to care for the patient, for the merit to be healed does not come from just anybody." Perhaps this is the doctor Heaven designated to effect the cure.

As a source for the above Halachah, the Be'er Ha-Golah cites the Ramban (Sefer Toras Ha-Adam, Sha'ar Ha-Sakanah), who states that if necessary we may desecrate Shabbos to attend to a person's medical needs. This proves that the Torah requires us to seek medical attention, for if not, why is it permissible to perform medical procedures that require one to violate Shabbos? The Ramban also states (in his commentary on the Torah, Devarim 11:13) that miracles are performed only for the perfectly righteous. However, Heaven relates to average individuals according to the normal workings of the world, whether for good or for bad.

The Akeidas Yitzchak (parashas Vayishlach, Sha'ar 26) develops this theme of the Ramban even further. In the course of his commentary, he rails against people who take bitachon literally and refuse to seek medical aid. These individuals reason that Hashem beset them with illness because of their sins, and He will cure them when their sins have been forgiven. The Akeidas Yitzchak writes that we are not allowed to consider ourselves as being so righteous that God will perform miracles on our behalf. Rather, we must consider ourselves as ordinary individuals who are obligated to exert effort in order to achieve our goals.

We find this idea echoed by the Taz in his commentary on the Shulchan Aruch (Yoreh De'ah 336:1), where he discusses Chazal's dictum that "the doctor has permission to heal" (Bava Kamma 85a). But this statement is contradicted by the Shulchan Aruch, which says that seeking medical attention and practicing medicine are mitzvos. How, then, can the practice of medicine be termed a mitzvah when the Gemara merely allows one permission to seek a physician's aid?

The Taz explains that ideally a person should turn to God to heal him, and within this framework it is merely permissible to turn to a doctor. In our lowly state, however, we cannot depend on the Almighty's unambiguous aid. Therefore, we must work within the confines of nature, and it is an obligation and a mitzvah to seek medical attention. Yet despite this, it is important to point out that, according to the Ramban (Vayikra 26:11) and the Ein Ya'akov (the end of tractate Horayos), it is still possible to find exalted tzaddikim who are permitted to rely totally upon Hashem and not seek out medical assistance.

It thus emerges that the Almighty relates to us on two levels: On the level we call nature, which is existence after the sin of the first man; and in accordance with the original state that existed before Adam's sin. This is the intent of the Taz when he writes: "the real cure comes from Heaven."

This opinion is borne out by the Gemara (Sanhedrin 17b), which states that it is forbidden for a talmid chacham to reside in any city that does not have a doctor living there.

The Tzitz Eliezer (vol. 11, section 41:7) concludes:

It is unconscionable to allow one who is critically ill to forgo medical help even if this will result in chillul Shabbos. Indeed, we are even obligated to force him to violate the prohibitions of Shabbos in order to receive medical attention (refer to Mishnah Berurah, section 328:42, subsection 6). This is the case even if there are two doctors involved, one claiming that there is no danger to life and the other claiming that there is. In such a case, we force the patient to submit himself to treatment, even if he does not wish to violate the laws of Shabbos.

We Must Seek Medical Attention

The Tzitz Eliezer continues:

The Kitzur Shulchan Aruch (192:3; see also Birkei Yosef on Yoreh De'ah 336:2) writes that a person who refrains from calling a doctor commits two grave offenses. First of all, it is forbidden to rely on a miracle in a time of danger, and doing so when one is ill will cause one's sins to be recalled in Heaven. Secondly, it is considered conceited and arrogant for a person to regard himself as being so pious that he can rely on a miracle for his healing.

The Shevet Yehudah (Yoreh De'ah 636) writes that it's true that we find tzaddikim who become sick and pray for Heavenly mercy and are answered without having to seek medical treatment. However, we are forbidden to learn from their behavior in this realm. These people are different, for through their pious actions and their many merits, they have risen above the rule of nature. These exalted people are few, and one should not trust that he has reached such a level. Moreover, even these individuals do not rely on miracles for their salvation; rather, they always begin with the intent to seek a natural cure. Heaven, however, miraculously sends them relief and thus obviates the need for them to pursue medical treatment.

Seek the Best

The Tzitz Eliezer ends by citing the conclusion of the Shevet Yehudah:

It is a Torah obligation for a sick person to seek medical help, and one is even required to seek the most accomplished doctor and the best possible medical treatment. One who ignores the Torah's injunction in this area, and instead relies on the Almighty to miraculously cure him, is nothing more than a fool. Such a person is considered negligent regarding his health, and eventually, he will be forced to answer for his behavior before the Heavenly court.

To Consult the Top Doctor

An interesting question arises: if a family of limited means is covered by a health plan that delivers a professional, albeit mediocre level of service, should they nevertheless seek expensive medical treatment from leading doctors? Indeed, this question applies even if the family can afford the superior care: should they spend an exorbitant sum to receive the best medical treatment available, or receive standard medical attention and use the extra money for other, perhaps better, purposes?

In truth, this question has no easy answer. It seems that many people pursue a course based on false bitachon. Convincing themselves that they are ba'alei bitachon (people who have perfect trust in Hashem), they behave in a manner that is not in consonance with their true spiritual level. These people feel that their spiritual stature is such that they can spend a minimum amount of money and rely on Hashem to bless the doctor's work. In reality, however, they are far from living on such an exalted plane of bitachon. Of course, it is very admirable that a person wants to strive for the very highest level of spiritual perfection; however, it is vital that he be aware of his shortcomings. From what we have seen until this point, it seems that only those few tzaddikim who truly live a life consistent with the highest spiritual standards can turn to Hashem exclusively regarding their health. The rest of us must pray to Hashem and at the same time turn to the medical profession for help.

When it comes to common colds and ordinary medical procedures, a conservative approach is certainly valid. Common and simple procedures can be performed by the regular medical staff available. (Although even here one is advised to proceed with open eyes. I am sure the readers of this work who belong to the medical profession are justifiably proud of the high standard of service they provide. However, it is an unfortunate fact that many people have had negative experiences with mediocre members of the medical establishment. These people provide less than professional service - e.g., the doctor who prescribed or the nurse who administered the wrong medication, or the patient who suffered unnecessarily after being treated by an inexperienced intern.)

Concerning more complex medical procedures, one should be much more prudent. Gedolim generally advise people to seek the top specialist in the field. Indeed, this is the express opinion of the Tzitz Eliezer (vol. 11, section 42), who quotes the Shevet Yehudah (Yoreh De'ah 336) on this matter. In summary, this is a complex area, and the person desiring to develop his bitachon should seek the advice of a competent halachic authority to achieve the proper balance between bitachon and pragmatism. Moreover, each case is different, and it is dangerous to give a general ruling that is meant to apply to all cases. By no means should one base his course of action on what he reads here. The purpose of this essay is merely to provide a framework within which the issues may be discussed. Concerning a practical decision in these very complicated and important matters, one should turn to our gedolim and poskim for direction.

Can You Trust Any Doctor?

Chazal tell us that unfortunately not every doctor is totally trustworthy. As a matter of fact, they make a very extreme statement: "The best of doctors are destined for Gehinom" (Kiddushin 82a)! Of course, many of us have had very positive relationships with very wonderful and competent medical staff, so this statement, I'm sure, strikes quite a few of the readers as quite severe. Therefore I wish to present a partial compilation of what some of the commentaries have to say about this matter.

Rashi comments on this Gemara that doctors who consistently attend to the ill lose their fear of contagious illnesses and fail to heed the Torah's obligation that they take care of themselves. Furthermore, their constant attendance to the sick causes them to become numb to the sight of illness. Moreover, the suffering they encounter daily does not teach them any lesson that could have brought them to teshuvah.

Rashi also writes that sometimes a doctor will refuse to attend to a poor person who cannot afford to pay for treatment. Rashi adds a fifth reason: doctors are sometimes lax in their work and may cause their patients' death. R. Moshe Feinstein, (Igros Moshe, Yoreh De'ah vol. 3, section 36) comments that this refers to negligence. We also find this reason in the Ramban (Toras Ha-Adam, Sha'ar Ha-Sakanah), who writes that this refers to doctors who practice with inexcusable negligence and maliciousness. As a physician gains experience and successfully treats more and more difficult cases, he very well might become complacent and over-confident. As a result, he will become careless in his practice and make ill-considered judgments.

The Tiferes Yisrael (Mishnayos Kiddushin 4:14) has a similar view. He writes that Chazal's statement in the Gemara does not refer to just any doctor. Rather, it refers to one who is overly confident and considers himself the best in his field. His arrogance leads him to overrate his judgment and his powers of evaluation. Therefore, he relies solely on himself even in complex cases where room for doubt exists, refusing to consult with his colleagues. Moreover, he doesn't research the case thoroughly in medical literature to determine whether a medication might have any potential ill effects. Such a high-handed attitude will inevitably lead to mistakes that could have been prevented. As a result, the doctor is destined to go to Gehinom.

The Machaneh Chaim (Kol Sofer Al Ha-Mishnayos) writes that the way a doctor becomes the best is his field is by experimenting on many people who have different types of illnesses. He became an expert only after he saw many people die under his care, and thus he was able to asses how one treatment worked while another didn't. His real-life tests were what helped him become the most effective physician. Thus, he spilled much blood until he became the best of doctors. But his students, those who come after him and rely on his experiments, don't become the most proficient doctors like their teacher did. Therefore, if he became the best doctor in his field, obviously he killed many people in order to make his tests and he deserves to be consigned to Gehinom.

The Tzitz Eliezer (vol. 11, section 42) writes that although we are obligated to seek professional medical help, there is a real danger that the doctor, in the process of trying to heal, may in fact inflict damage on the patient. The K'reisi U'P'leisi (section 168:5) writes that despite the copious amount of medical research that has been done, nothing is truly clear without a doubt to even the most competent of doctors. Ultimately, everything is based upon their judgment and how they interpret the symptoms. It is for this reason that Chazal tell us that the best of doctors will go to Gehinom. Even though the Torah gave permission to the doctor to heal, this refers to external injuries or fractures that are clearly definable. Concerning internal injuries, everything is based upon guesswork and surrounded by doubts. Throughout the ages, there have been countless unnecessary deaths simply because the attending physician made a mistake. In these matters, a doctor needs to take the utmost care to make well-considered decisions as to a course of treatment. Every detail and action must be thoroughly thought out. (For further discussion on this point, see Tzitz Eliezer, vol. 17, section 2.)

Wishing everyone a Gut Shabbos!

________________________________________
Rabbi Eliezer Parkoff
Rabbi Eliezer Parkoff
Rosh Yeshiva
Yeshiva Shaare Chaim.

Rabbi Parkoff is author of "Chizuk!" and "Trust Me!" (Feldheim Publishers), and "Mission Possible!" (Israel Book Shop ? Lakewood).

If you would like to correspond with Rabbi Parkoff please contact him:
shaare.chaim@gmail.com or 732-325-1257

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