Rabbi Yossi SprungThe 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)”. This is discussed at great length in the Rishonim and Poskim, and we have reviewed the topic in the past.
The main issue that they grapple with is the Pasuk in Parshas Beshalach:
“If you will listen to the voice of Hashem your God and do what is right in His eyes, listening to His Mitzvos and guarding His laws, all [of] the disease that I placed in Mitzrayim I will not place upon you, for I am Hashem your healer.” (Shemos 15:26)
Most Mefarshim explain that this Pasuk promises that Hashem will heal B’nei Yisrael from natural illnesses. Rashi explains: “If I place [an illness] it is as if I have not placed it for I am Hashem your healer”. The Ramban understands the Pasuk differently:
This is a warning: He was urging them not to be rebellious like the Egyptians. If they listen to His voice, they will be spared from diseases. Those same diseases would afflict those who transgress His will, just as they afflicted the Egyptians who did not listen to Him. It is like when He said that He would “place upon you all the diseases of Egypt that you feared; they will cling to you” (Devarim 28:60). And it also states: “For I am Hashem your healer” – this is a promise that “I will remove any naturally occurring diseases from your midst just as I ‘healed’ the waters.”
What is the meaning of this promise? If we interpret the Pasuk as saying that only Hashem can heal us, what is the purpose of seeking medical assistance?
Similar questions arise from the Pasuk that accuses King Assa that “he did not seek out Hashem; only the doctors” (Divrei haYamim 2:16:12) and from the fact that the Chachamim approved when King Chizkiya hid the Sefer Refuos “so that people should beg for mercy [from Hashem]” (Brachos 10b, Rashi).
We have previously discussed this topic[1] and will outline three approaches of the Rishonim in this essay.
The Rambam’s approach
The Rambam states (Perush haMishnayos, Pesachim):
Just as I thank Hashem when eating for providing me with something to assuage my hunger and sustain me, so must I thank Him for providing Refua that heals my illness when I utilize it.
Sefer Refuos was a book of cures that are not naturally used for Refua, such as those that Ba’alei Talismas (charms) believe will cure a certain illness if they make the charm in a particular manner and other such forbidden matters. The author only wrote it for study, not to use any of its instructions. This is permissible, as will be explained, because the things that Hashem warned against doing may be taught and learned. For Hashem said “Do not learn to do”[2] and we have a tradition that interprets [the Posuk as indicating] that you may learn to understand and offer rulings. When peoples’ conduct deteriorated and they used it for healing, he (Chizkiya) hid it. Perhaps it was a book that contained harmful potions such as instructions as to how to make a specific potion, how to drink it, what illness it causes, and how to cure them. When a doctor would see these illnesses he would know that so-and-so was given a certain drink and he could give him a potion that would cure him. But when the people’s conduct deteriorated they would use it to kill and he hid it.
The same may have been the case with King Assa; perhaps he sought doctors who dealt in charms rather than regular Refua. According to the Rambam’s approach, when Hashem sends Refua through regular medical means it is akin to eating and drinking.
Rabbenu Bachya and the Rashba’s approach
Rabbenu Bachya discusses this subject in Chovos haLevavos, (Sha’ar haBitachon 4):
Regarding health and sickness, a person must trust in the Creator in this matter, while working on maintaining his health by natural means and fighting sickness according to the customary ways, as the Creator commanded: “He shall surely heal”. All of this [may be done] without believing that the [proposed] causes of Refua or illness can help or cause harm without the permission of the Creator. When he trusts in the Creator, He will heal him from his illness with or without a means, as it states: “He sends His word and heals them”.[3] He may heal him with a harmful remedy. You already know what happened with Assa – how he was rebuked and chastised for placing his trust in doctors rather than in Hashem during his illness.
According to Rabbenu Bachya, there is no contradiction between “I am Hashem your healer” and “He shall surely heal”. Doctors are permitted to heal, but the patient must know that it is Hashem who heals him. This was King Assa’s sin; he placed his trust solely in the doctors rather than Hashem. The Rashba elaborates (Shu”t 1:413):
If a person becomes ill, he may turn to medications as long as his heart is directed to Heaven and he knows that the true Refua is from Hashem and he seeks Him. He should not think that it depends on this medication or that doctor. This is what is stated about Assa, “Also in his illness he did not seek out Hashem; only the doctors”. Someone who has an illness should not rely on a miracle by not seeking doctors or turning to beneficial substances, be they natural or Segulos. Moreover, it is forbidden to go into dangerous situations and rely on a miracle, as is said, “A leaning wall recalls sin”.[4] And they said, “Anyone who relies on a miracle, it is not performed for him”. A person may trust in man as long as he does not turn his heart from Hashem. And it states, “Cursed is the man who trusts in man and turns his heart from Hashem”.[5] However, to trust in Hashem that He will bring salvation through this person is permissible and a Mitzva.
He further explains why Chizkiyahu hid the Sefer Refuos:
Shlomo who created the Sefer Refuos did not make it as a form of Darkei Emori. The fact that Chizkiyahu hid it and that the Chachamim approved was not because of Darkei Emori. Rather, in his wisdom, the Chacham authored his book about matters that are very beneficial, both in nature and Segula. So much so that people came to rely on them in their illnesses and they did not seek Hashem, therefore he hid it and [the Chachamim] approved… This is why they hid it but did not burn it, for there is no issue with Darkei Emori even though he also ground up the copper snake.
However, the Rambam (ibid.) vehemently rejects this explanation of Chizkiyahu’s disposal of the Sefer Refuos (though he certainly agrees with the fundamental idea that a Choleh must place his trust in Hashem):
Besides the fact that this is nonsense and delusional, they attributed to Chizkiya and his supporters who approved [of his move to hide the Sefer Refuos] extraordinary foolishness the likes of which one cannot attribute to the lowest of people. According to their confused and foolish thinking, if a person is hungry and turns to bread and eats it, thus certainly curing him from his great pain, shall we say that he has removed his trust from Hashem? We would call them fools… This [flawed perspective]would not require refutation were it not for its widespread acceptance.
The Chasam Sofer (Shemos 21:12) answers the Rambam’s question by differentiating between hunger and illness. Sickness is a result of sin, therefore, Teshuva is appropriate. Hashem will cure him of his illness and he will not need Refua. This is not the case with hunger. The Bach (336) cites the Chasam Sofer’s approach and concludes: “This is the Minhag in all Jewish communities.”
The Ramban’s approach
The Ramban (Vayikra 26:11) has a completely different approach. He contends that a Choleh may not turn to a doctor for a cure; the only permission given was for doctors to heal if a patient turns to them. This explains King Assa’s sin and why the Sefer Refuos was hidden:
…The rule is that when Yisrael are perfect and numerous, their affairs are not directed through nature – neither their physical selves nor their land, and neither the general public nor individuals – as God will bless their bread and their water and will remove disease from among them to the point that they will not need a doctor at all or any manner of Refua. [This is the meaning of] the Pasuk (Shemos 15:26) “For I am Hashem, your healer.”
This was the practice of righteous people in the era of prophecy – when they fell ill due to their sins, they would seek out prophets, not doctors. Thus was the conduct of Chizkiyahu (Melachim II 20:1-3). Furthermore, the Pasuk relates [regarding Assa] “Yet in his illness he did not seek out Hashem, but the doctors”. (Divrei haYamim II 16:12) If they had been accustomed to using doctors, why would the Pasuk refer to the fact that he used a doctor? Surely the sin was only that “he did not seek out Hashem”? Rather, the explanation must be that the Pasuk speaks like a person who says, “So-and-so did not eat Matzah on Pesach, but rather Chametz”.
But somebody who seeks Hashem through the prophet shall not seek out doctors. What role do doctors play in the home of those who do the will of Hashem? [Hashem] has promised “and He will bless your bread and your water and I will remove disease from your midst”[6] whereas doctors are concerned mostly with food and drink, warning against [eating] certain foods and commanding [to eat] others.
Chaza”l also said (Brachos 64a) “all twenty-two years that Rabbah bar Yosef ruled, he did not even summon a blood-letter to his house (for Refua).” They also coined the expression “a gate that is not opened for Mitzvos is opened for the doctor” (Bamidbar Rabbah 9:13). This is also the meaning of their saying “it is not the way of people (to search for) Refuos, but it has become the custom” (Brachos 60a). Were it not customary for people to search for Refuos, a person would only fall ill when he was deserving of punishment for a sin, and would be cured when G-d so desired. But the people have become accustomed to Refuos, and therefore G-d leaves them to the happenstance of the natural world.
This was the intent of Chaza”l when they said “and he shall surely heal – from this verse we learn that a doctor has permission to heal”. They did not say “a sick person has permission to be healed” but rather, if a person becomes sick and comes to be healed (because he is so accustomed and is not from the congregation of Hashem whose lot is for life), then the doctor does not need to forbid himself from healing him – whether because of fear that the patient might die under his hand, since he is competent in his practice, or because he says that God alone is the healer of all people – for people have already accustomed themselves [to seeking Refua].
However, the Ramban appears to contradict his comments elsewhere. In Toras haAdam (Inyan haSakana), he explains the notion that the Torah gave permission to heal: “This Reshus means a Mitzva, for it is a Mitzva to heal and included in Pikuach Nefesh, as it is taught: “We feed him by the word of experts.”[7] We see that any doctor who understands this wisdom and trade must heal; if he refrains he is considered a murderer.”
In his sefer Birkei Yosef (Y.D. 336), the Chida addresses this contradiction and explains: “A person who looks at [the Ramban’s] words in Toras haAdam will see that everything he wrote about a Mitzva and Pikuach Nefesh refers to the doctor. In his comments on the Torah, he revealed his intent that the custom of the doctors is incorrect.”
This needs further explanation. If the doctors’ custom is incorrect, why did the Ramban state that a doctor who refrains from healing is a murderer?
We could suggest that when people only trusted in Hashem it was incorrect for doctors to play a part. However, since it has now become the custom to seek out doctors as Hashem’s Shelichim, a doctor who refrains is held culpable. In any case, the Ramban’s approach remains that the Heter only pertains to the doctor; the patient himself must always turn to Hashem.
However, the Chida argues:
It would seem that nowadays one should not rely on a miracle. A Choleh must behave like the custom of the world which is to call a doctor to heal him. It is not in his power to change the ways of old and to say that he is greater than many pious men of old who were healed by doctors. There is almost an Issur in this matter, whether it is due to arrogance or relying on a miracle at a time of danger and causing his sins to be recalled at a time of illness. He should instead act like regular people who are healed by a doctor. But he should cling to his Creator to beg for mercy with all his heart and should trust specifically in Him.
R’ Yitzchak Arama[8] also disagrees with the Ramban (Akedas Yitzchak, Vayishlach 26):
Who will listen to him in such a matter? Must every person not show himself to be among the average whose efforts benefit them…? Aside from the fact that it is unthinkable that a doctor is permitted to heal yet the Choleh may not go to him for treatment. He must already have permission [as this should otherwise be forbidden due to] Lifnei Iver (Vayikra 19:14).
We can pose another question on the Ramban. When he mentions those who seek doctors are “left to the happenstance of the natural world”, is he implying that this applies to individuals who are not on the Madreiga to be healed by Hashem? If that is the case, the Issur to seek medical treatment would only apply to Tzadikim, who are not subject to happenstance; everyone else would be permitted to seek medical treatment Alternatively, is there a general Issur that applies universally but the Ramban intends to convey that by placing trust in human beings he is left to happenstance?
The Taz (ibid.) takes the first approach:
The Torah approved of Refua through natural means for it understood that mankind would not be worthy enough to merit being healed by miracles. Therefore, it is not relevant to say that “he shall surely heal” teaches that it is a Mitzva and if he is worthy he would not require it; on the contrary, he would need a miraculous Refua. Rather, according to the nature of man, it is permissible for him and hence it is an obligation and a Mitzva since man’s life is dependent upon this as demonstrated by his actions. This seems correct to me.
It seems that the Taz bases his explanation on the Ramban’s concluding words: “But since Hashem desires the ways of man, he has no business with doctors” – i.e., the Issur only applies to someone whom Hashem desires, namely, a Tzaddik.
The Tzitz Eliezer (Shu”t 5 – Ramat Rachel 20) proposes an alternative approach to understanding the Ramban in line with other Rishonim:
To resolve the words of the Ramban in Chumash, we must say that he refers there to the root of the matter, specifically, when there are no external causes. However, since in reality the vast majority of people do not merit miraculous Refua and the Torah itself does not rely on miracles regarding its laws (see the end of Ramban ibid.), the permission given thus includes the Choleh. There is even a Mitzva and obligation since a man’s life depends upon his actions … Or, once people began to be healed [by doctors] Hashem left them to nature, as the Ramban states. Hence, there is now a Mitzva to seek medical treatment due to Sakana.
R’ Waldenberg zt”l elaborates in another Teshuva (11:41):
Since the Giver of the Torah desired that His people would be on the highest level of “Mamleches Kohanim v’Goy Kadosh”, and every person can become a Tzaddik like Moshe Rabbenu (see Rambam, Hilchos Teshuva 5:2), the Torah did not state the matter of healing in terms of giving Reshus to the Choleh. The desire was for Yisrael to be wholesome such that matters would not be determined by nature whatsoever and they would not require doctors or medications (as the Ramban states ibid.)… Rather, the Torah stated this permission from the perspective of the doctor (i.e., that he may heal) for a time when Yisrael are not on the highest desired level before Hashem in which case Hashem leaves them to nature. Or for when an individual separates himself [from others] when [Klal] Yisrael are on the level of “Adas Hashem”, yet he acts differently and seeks doctors. This elevated level existed when there was prophecy, hence at that time even if a Tzaddik happened to sin and fall ill he would not seek the doctors; only the Nevi’im (as the Ramban states). But once prophecy was no longer available due to our great sins, this exalted state ceased and Hashem left Yisrael to natural causes. Consequently, similar to a situation when two men engage in a fight and strike each other with stones or their fists, the one responsible for the injury must pay the medical costs. The Torah does not rely on miraculous events in its legal rulings, as noted by the Ramban. Thus, even though Hashem would prefer that humans not seek the help of doctors, one may not rely on miracles, and it is imperative to pursue medical assistance and treatment as permitted by the Torah. Failing to do so is viewed as an act of murder, as per the Ramban in Toras haAdam.
In conclusion, the dispute is not only about whether a Choleh may seek medical assistance but whether he may be stringent and refrain from doing so. The Rambam and Rabbenu Bachya permit one to seek medical treatment; in their view, it is forbidden for a person to be stringent.[9]
There are three approaches to understanding the Ramban: according to the Chida’s interpretation, it is forbidden to seek medical help and every Choleh must be stringent. However, according to the Taz, only a Tzaddik may be stringent, but according to the Tzitz Eliezer, in contemporary times, one is permitted to consult doctors and may not be stringent.
[1] See Tzav and Shemini 5784.
[2] Devarim 18:9
[3] Tehillim 107:20
[4] Berachos 55a
[5] Yirmiyahu 17:5
[6] Shemos 23:25
[7] Yoma 82b
[8] R’ Yitzchak ben Moshe Arama (c. 1420-1494) was from the Chachmei Sefard in the era of the expulsion of Jews from Spain.
[9] The Ibn Ezra asserts that a person may not turn to a doctor in the case of an internal illness, but neither may he be stringent to refrain from doing so in the case of an external injury.
Rabbi Yossi Sprung
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