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THE MANDATE TO HEAL

By: Dr. Daniel Eisenberg



We take it for granted that Judaism allows us to go to the doctor when we are ill. We pride ourselves on being a “rational” religion whose dictates usually mesh with common sense. When someone is seriously ill, we emphatically desecrate Shabbat to save his life because the Torah (Vayikra 18:5) clearly states, “and you shall live by them [the mitzvot],” which the sages of the Talmud explain to mean, “to live by them, and not die by them.” Indeed, medical issues occupy a great deal of space in the Talmud and throughout Jewish literature, dating back to the Torah. The long tradition of great physicians throughout Jewish history – many of whom  were also great rabbis, the most famous being the Rambam – would appear to firmly establish the Torah’s positive attitude towards medicine and physicians.

IS THERE A MANDATE TO HEAL?

In truth, there is a great deal of controversy in Jewish halachic literature as to the nature and parameters of the physician’s mandate to heal. While most authorities recognize a very broad mandate, there is a minority opinion that severely limits the scope of the authorization granted by the Torah to provide medical care.

The clearest source for the right to heal is the Torah’s discussion of a case of a person who strikes his fellow, requiring the assailant to compensate the victim for his medical expenses:

 “If one man strikes another and the victim does not die [which might make it a capital crime]…then [the aggressor] shall pay for his [lost] time [from work] and he shall cause [the victim] to be thoroughly healed.” (Shemot 21:18-19)

Rashi interprets this passage as instructing us that “he shall pay the fee of the physician.” Clearly, if the aggressor is commanded to pay the doctor’s bills, then seeking medical treatment and providing medical treatment must be not only permissible, but also obligatory.

WHAT RIGHT DO WE HAVE TO HEAL?

Ibn Ezra, however, in his commentary to this verse, draws an intriguing distinction. He writes that the command to heal “is a sign that permission has been granted to physicians to heal blows and wounds that are externally visible. All internal illnesses, however, are in Gd’s hand to heal.”

Why does Ibn Ezra take a limited view of the mandate to heal?

Ibn Ezra’s case is not a hard one to make. The Torah itself instructs that if we obey the Torah’s commands, “then any of the diseases that I placed upon Egypt, I will not bring upon you, for I am Gd, your Healer” (Shemot 15:26). This verse implies that Gd does not need man to cure the afflictions that He creates. Ibn Ezra argues that the meaning of this Torah passage is that because Gd acts as the (sole) healer of all illness, we will not need physicians.

Ibn Ezra’s perspective forces us to ask the question, is it not a lack of faith that would lead us to seek medical care? What right does one have to “short circuit” Gd’s will and attempt his own meager cures? Does man have any right to heal at all, and if he does, are there any limitations on how it may be accomplished? Is every action done in the name of therapy justified, solely because a physician performs it?

WHY DO WE GO TO DOCTORS?

Because Judaism recognizes the enormity of these questions, Gd’s explicit permission is necessary to allow us to practice medicine, and the limits of medical practice are carefully circumscribed. Both the duty to save one’s fellowman and the restrictions that apply thereto are well-grounded in the Torah and discussed at length in our codes of Jewish law.

“The Torah gives permission to the physician to heal; moreover, this is a mitzvah.”

The complexity of the philosophical tension between Gd’s control of health and the role of the human healer is encapsulated by the enigmatic words with which the Shulhan Aruch, the authoritative code of Jewish law, opens its discussion of the laws applying to physicians: “The Torah gives permission to the physician to heal; moreover, this is a mitzvah and it is included in the mitzvah of saving a life; and, if he withholds his services, he is considered a shedder of blood.”

This sentence is rather puzzling. We do not find the Shulhan Aruch informing us that the Torah gives permission to keep kosher, observe Shabbat, or perform any of the other mitzvot presented in the Torah. Why is permission specifically granted here?

The answer is that only with regard to this mitzvah might we have thought that the action should be forbidden. Left to our own logic, we would have no choice but to assume that Gd makes people sick and Gd alone heals.

However, once the Torah clearly stated that healing is permitted, it immediately becomes a mitzvah – a religious obligation – like all other mitzvot. Therefore, the Shulhan Aruch quite appropriately states that “the Torah gives permission to the physician to heal; moreover, this is a mitzvah.”

THE JEWISH VIEW OF THE PHYSICIAN

What is the Jewish approach to the physician?

The Tanach tells a fascinating account of Asa, King of the Judean Kingdom, who, when he fell ill, “did not seek out Gd, but only doctors” (Divre Hayamim II 16:12), for which he was criticized.

If healing and guarding health are mitzvot, what did King Asa do wrong?

His error was that he only sought out the doctors. Healing is a partnership between Gd and man. While Gd is the ultimate healer, He delegates part of His role to mankind and asks the physician to practice medicine. Gd makes a person ill, and He then finds him the right doctor to heal him. We might say that part of the “punishment” of illness is the fear that one will not find the right physician capable of healing him.

This is why the Shulhan Aruch states: “if he withholds his services, he is considered a shedder of blood. And even if there is someone else (available) capable of healing, not every physician is destined to heal every patient.” Medicine is an art, and therefore one must pray that he finds the right doctor who is destined to cure him. Similarly, no physician may excuse himself from a case merely because there is another physician present, for he may be the one destined to cure this patient; he may be the one who will make the right diagnosis and prescribe appropriate treatment, when all others are baffled or incorrect. This approach must obviously exist within the reality of the physical limitations of each physician and the special divine inspiration necessary to make correct decisions.

The Jewish approach to illness and medicine requires us to recognize the preeminent role of Gd in healing, while seeking appropriate medical care. Asa’s sin was turning exclusively to doctors, without the recognition of Gd as the ultimate healer.

THE PHYSICIAN’S RESPONSIBILITY

The Talmud, in a baffling passage, states: “Tov sh’brofim l’gehenom,” which literally means, “The best of the doctors are bound for gehinom” How do we reconcile this astonishing statement with the positive view Judaism promulgates regarding physicians?

One traditional explanation is that the physician must recognize the awesome responsibility that he holds in treating illness, as even a small error could possibly cause a patient’s death. Constant vigilance is required to avoid making a preventable error that would be bordering on criminal negligence.

A second understanding of this mysterious passage focuses on one of the great risks of medical practice – arrogance. The statement can be understood to mean that specifically those doctors who consider themselves the best are bound for gehinom. The humble physician will recognize his limitations and consult with colleagues to ensure his patients are receiving the best possible care. One who considers himself the “best” doctor will see no need to consult with those less qualified than himself, eventually causing unnecessary harm to a patient for which he will be culpable.

Like the patient, the physician, too, must recognize his role as an intermediary in healing, not its source. When the physician begins seeing himself as the source of healing, he is destined for gehinom.

LIMITS TO MEDICAL PRACTICE

On this basis, we can easily understand why, despite the normative Jewish attitude that considers healing to be a mitzvah, even in the most expansive Jewish approach to medicine there are limits to the authorization to heal. Physicians are granted a mandate to heal. However, it is unequivocally clear from halacha that permission is granted to a physician to treat a patient only when he can offer that patient therapy that can be reasonably expected to be efficacious. This, at times, may include even experimental treatments that could potentially be beneficial. But when a physician cannot offer effective therapy, cannot alleviate pain, and cannot cure the patient, he or she ceases to function as a physician. In such a case, he or she has no more of a license than anyone else to cause harm to another person.

Judaism believes that physicians are given both a great opportunity and an awesome responsibility. The mandate to heal is, essentially, a command to rise to the challenge and do Gd’s work effectively, honestly, and responsibly.

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. Dr. Eisenberg writes extensively on topics of Judaism and medicine and lectures internationally on topics in Jewish medical ethics.