License to Heal – Part 1

As opposed to most other professions, the very nature of the physician’s career seems to interfere with Hashem’s Hashgacha of the world. We believe in Hashgacha Pratis: “No man bangs his finger below (in this world) unless it was announced above (in Heaven)” (Chulin 7b). Thus, if it was decreed upon a patient to be cured, this would presumably occur without the physician’s efforts, and if he is destined to die, how can the physician reverse that? Don’t medical interventions contradict our belief in Hashem? There are religious sects, including the Karaites, who forbid human intervention in illness or injury, even if that will lead to a patient’s death.^[1]

The Chachmei haTorah address this dilemmaand discuss two separate questions: Is a physician permitted to heal? And if so, is it obligatory to do so?

These questions not only pertain to physicians but to patients as well. Is turning to medicine an expression of inadequate or complete lack of faith in Hashem?

1 – Permission to Heal

The Heter for a physician to heal is derived from the Pasuk: “He need only give [compensation] for his loss of work and he shall surely heal (v’Rapo Y’rapei)” (Shemos 21:19). Chazal elaborate in Maseches Brachos (60a):

R’ Acha said: One who is about to undergo bloodletting should say: May it be Your will, Hashem, my God, that this endeavor be a cure for me, and may You heal me. For You are a faithful God and healer and Your healing is true. For it is not the way of people to [seek a] cure, but this is their custom.

Abaye said: A person should not say this! For it was taught in the Beis haMidrash of R’ Yishmael: “He shall surely heal” – from here we see that a physician is granted [Divine] permission to heal.

It is clear from this Gemara that without that a doctor requires the Torah’s permission, a doctor would not be allowed to engage in his profession.

Several explanations are suggested for this:

Rashi and Tosfos

Rashi explains the phrase “For it is not the way of people to [seek a] cure”: “They should not have sought cures, but [instead] asked for mercy”. Similarly, in his comments to Bava Kama 85a: “A physician is granted Divine permission to practice medicine – we do not say that Hashem caused the illness and he (the doctor) cures it!”

Tosfos ask (ibid. s.v. “sheNitna”):

Why can we not derive it from the word “Rapo” alone? The answer is that we would have thought that this [only] applies when one person is injured by another [and hence the physician has permission to treat him]. But an illness that comes from Heaven – if he would treat him, he would appear to be opposing the King’s decree. It therefore states [“Y’rapei”] to teach that it is nevertheless permissible.

Like Rashi, Tosfos explain that without the Pasuk, a physician’s intervention would have seemed to oppose the divine will. However, Tosfos add that, unlike an illness from Heaven (such as a heart attack or stroke), an injury caused by a fellow man is not considered a Heavenly decree – it could occur even without a Gezeira. Accordingly, the Pasuk specifically permits a physician to treat illnesses that come b’Y’dei Shamayim.

At any rate, the question remains: if illness and suffering are Hashem’s decree, why is a physician permitted to “oppose” it and, in fact, how can his efforts possibly prove effective?

 “Man, his days are like those of grass” (Tehillim 103:15)

Chazal give a beautiful explanation (Midrash Temura 2):

R’ Yishmael and R’ Akiva were once walking in the courtyards of Jerusalem accompanied by another man. They met a sick person who said to them, “Rabbosai, tell me how I will be healed?” They replied, “Do such and such until you recover.” He asked, “And who struck me (with illness)?” They answered, “haKadosh Baruch Hu.” He replied, “[If so] you are intervening in a realm that is not your own. He struck [me with illness] and you are healing me! Are you not countering His will?” They asked, “And what work do you do?” He answered, “I work the land, indeed, here is a sickle in my hand.” They asked, “And who created the vineyard?” He answered, “haKadosh Baruch Hu”. They exclaimed, “You are intervening in a realm that is not your own. He created it and you are cutting it down!” He replied, “Do you not see that sickle in my hand? If I wouldn’t have plowed the land, weeded it, fertilized it and hoed it, it wouldn’t have produced anything!” They answered, “Foolish one! From your work, do you not hear what is stated “Man, his days are like those of grass.” Just as a tree will not grow if one doesn’t hoe and fertilize and plow, and if it grows but isn’t watered or fertilized, it will not live but will die, so too is the human body – the fertilizer is the [equivalent of the] medicines or the types of Refua and the man who works the land is [equivalent to] the doctor.

Certainly, illness comes from Hashem but is also part of nature. Just as a person must tend to his field for it to produce fruit, he must also protect his body from harm and obtain medical treatment in case of illness. In short, a physician does not work against the will of Hashem; he is considered Hashem’s emissary when saving the lives of his patients.

The Position of the Zohar

We find a similar statement in the Zohar (Devarim 299:1):

Lest you claim, “Since Hashem decreed a person should be sick, nobody should make an effort for him” – it is not so, for King David said (Tehillim 41): “Fortunate is the person who acts wisely with the destitute” – “the destitute” is a person lying in the hospital, and if the doctor acts wisely with him, Hashem will bless him.

It further states (ibid. 304:2):

All Refuos in the world are in the hand of Hashem, but some are effected through a messenger.

In other words, indeed, a patient will not survive if Hashem has decreed his death. However, if the illness is a form of punishment or warning, a physician can effect a cure. An illness may come upon a person with the intent that he will be cured via medications, as Chaza”l state in Avoda Zara (55a): “[Illnesses are called “faithful”] for they are faithful in carrying out their purpose. When they are dispatched to a person they are made to swear that they will not leave him until such-and-such day, through a particular doctor, and a particular medication.”

Clearly, the concept of healing does not negate Hashem’s will; a physician is merely the emissary of the cure.

The Zohar (Zohar Chadash 3, Ha’azinu) asks why Hashem inflicts illness on a person if he will simply go to a doctor to be cured. It answers that the purpose of illness is to cause a person pain and financial loss to serve as atonement.

Additional Approaches of the Rishonim

The Ramban (Toras haAdam, Sha’ar haSakana) mentions another  issue that arises when one engages in Refua:

A physician should not say: “Why do I need this trouble? Perhaps I will err and kill someone by mistake.” The Torah, therefore, permitted him to practice medicine.

Although permission has been granted, he must exercise extreme caution; namely, a physician “must be exceedingly careful as one would be regarding capital cases” (Tur, Y.D. 336).

The Ramban offers an alternate approach to understanding the need for the Torah to permit the practice of medicine (which accords with Rashi’s view, above): “Alternatively, lest one say: Hashem causes illness and He heals! For it is not the way of people to [seek a] cure, but this is their custom, as it states (Divrei haYamim 2:16:12): “Even in his illness, [King Asa] did not seek out Hashem, but the doctors.”

Rabbenu Yaakov of Orleans (cited by Tosfos haRosh ibid.) explains that the Torah grants permission so that a physician may charge for his work.

The Moshav Zekeinim (Shemos 21:19) suggests that the Torah permits a person to go to a physician even after another physician has failed to heal him. In those circumstances, despite reason to believe that it is Hashem’s will that he remain ill, the Torah permits him to seek out another physician.

To be continued…