Doctors - obligation to use

from my sefer on Parnossah

Akeidas Yitzchok (#26): The degree of effort that one must exert is to the full limit of his intelligence and ability against all obstacles. Only those things which are clearly beyond his control and that continue effort would constitute rebellion and foolishness against G d does he have to accept. This principle applies in every area where a man is faced with adversity - from any of G d’s agents. For example if a person sees that his city is afflicted by plague , the prudent reaction is to isolate himself in his house. Why should he stay outside where the angel of death is killing everyone. Furthermore if he see that the plague is getting worse in the city he should quickly flee the city to a safe and secure location. If the plague follows after him and strikes him down in his place of refuge he should not refrain from utilizing all possible medications which made has made and that G d allows to be taken. In most cases these efforts will succeed in saving him from harm. If these options are not available to him then he has fulfilled his obligation of effort by whatever means are available to him. He needs to realize that without doubt G d sent His angels to get him and he has nothing left but to accept the judgment of Heaven and to prepare his soul to return back to G d. This approach applies to every type of catastrophe that exists in the world in general and in particular. This is the enlightened way to deal with problems. The righteous will follow it in everything that they do. This approach removes depression and anxiety from all those who suffer from problems because they know for sure that their fate is not determined by accident or their own laziness. Rather he is aware that all is dependent upon G d’s will - and he realizes the importance of prayer. All of this is in strong opposition to the approach of the Ramban  who states that even though G d gave the doctor permission to cure he did not give the sick the right to be treated but rather they should rely totally on G d to be cured. The Ramban asserts that cure will be granted only when he repents fully from his sins which caused the illness in the first place.

Avnei Nezer (C.M. 193): [Written by the father of the Avnei Nezer] … According to the Ramban who says that the ideal is not to use doctors at all... he would also permit the sick person to refuse treatment.... However according to the Bach it would be prohibited for a person to refuse medical treatment. Nevertheless it would appear if the sick person is really a tzadik then he can rely on the Ibn Ezra and the Ramban since relative to them the Bach is the minority opinion.... Furthermore it would appear to me that in this matter everyone would be considered a tzadik since he wants to be strict with himself with prohibited food and he has trust in G d even in the face of death. Therefore even a person who is not considered a tzadik would be permitted to refuse the doctors’ orders to be cured by eating unkosher food. .....

Berachos (60a) He shall cause him to be thoroughly healed. From this we learn that permission has been given to the physician to heal. 

Berachos (60a) One who enters to let blood says: May it be Your will, O Lord my G-d, that this enterprise be for healing and that You should heal me. As You are a faithful G-d of healing and Your healing is truth. Because it is not the way of people to heal, but they have become accustomed.

Chochmas Adam (151:25): If the Torah hadn’t given permission to be cured through medicine then it would have been prohibited. That is because someone who follows in the path of the Torah will not be harmed by any event such as the change in air or unhealthy food... Tehilim(33:18) says: G d’s eye is on those who fear Him. He in His mercy constantly watches over them. Whoever is supervised by G d is obviously not going to harmed. This is the meaning of the expression of our Sages - that Jews are not influenced by the stars but by G d. However if a person does not conduct himself in this high spiritual path and is not attached to G d, then he is in fact determined by the stars. Thus when our sages say that a person who is born under a particular constellation... it is only referring to the situation when a person has chosen to conduct his life in the way of nature rather than by being attached to G d. The fact is that by having proper merit a person can overcome the influence of the constellations. G d knows the thoughts of man when he is not under the influence of constellations... G d has created herbs and trees and similar things which have the natural ability to cure and He has given us permission to be cured with this medicine i.e., the natural way.

Chazon Ish (Emuna and Bitachon 5:5): … Sickness - [contrary to the Rambam] - is a punishment and should motivate a person to repent and to pray. Nevertheless a doctor has permission to cure because there are very few genuinely spiritual people who can follow this approach. The generation of Chezkiyahu was unique. Sanhedrin  states that they searched the entire land of Israel and could not find an ignorant person… Such spiritual giants needed to rely entirely on their faith and trust in G d and not utilize medicine. The Ramban: writes the minority who are totally sanctified to serving G d do not in fact utilize medicine. However this approach is reserved only for people on the level of the R’ Shimon bar Yochai. 

Chazon Ish (Letters 1:136): I personally consider natural efforts concerning health to be both a mitzva and obligation. The obligation being to complete the image of man that the Creator made in His world. We find that Amoraim went to non-Jewish doctors and even heretics for the sake of medical cures. Many plants, animals and matter were created for the sake of their curative powers. Also the gates of wisdom were created which are available to everyone in order to think, understand and know these matters. While it is true that there is an alternative in the spiritual realm to transcend nature and material effort, nevertheless it is necessary to balance this very carefully. That is because both deviations from the precise truth are improper - whether to trust more than the level of bitachon that I have actually reached or to rely too much on personal effort…

Chovas HaLevavos (4:37) We will say regarding health and sickness. A man is placed under a duty to trust in the Creator in this, while working on maintaining his health according to the means whose nature promotes this, and to fight sickness according to the customary ways, as the Creator commanded "and he shall surely heal him". All of this, without trusting in the means of health or illness that they could help or hurt without the permission of the Creator.

Chovas HaLevavos (4:4): … A person should have trust in G d regarding his health but at the same time he needs to strive by natural means to avoid sickness as Shemos says: The doctors will thoroughly heal him. However he is not to view these natural efforts for health as actually helping or harming him by themselves. In fact they only work according to G d will. When one has proper trust in G d, He will heal you from your illness whether with something which is healthy or with something which is harmful… That fact that G d can cure with something very harmful is known from  Elisha and the bad water which he modified with salt. We also see that in the Wilderness the bitter water was turned sweet with bitter wood ….

Derashos HaRan (#6): I have absolutely no doubt that spiritual sickness is the cause for physical sickness. In fact there is no cure of the body without cure of the soul. … spiritual illness is the cause of physical illness and that a totally healthy soul can ward off all deadly influences… 

Ibn Ezra (Shemos 21:19): The double language of healing is to give permission for the doctor to heal external wounds and sores. However internal illness is to be cured by G d…That this is prohibited can be seen from the criticism of King Asa  that he went to the doctors but did not turn to G d

Ibn Ezra (Shemos  23:25) G-d chose Israel and taught them His Torah. If Israel observes the Torah they become wise. Their wisdom guides them in a straight path to all things that will not harm them. The general rule is: the body must be subservient to the dictates of the soul (neshamah) rather than the soul being subservient to the dictates of the body. When the soul (neshamah) is strong, then the heavenly power known as nature, which preserves the body, grows in might. Now our verse tells us that G-d’s blessing shall be upon all our food and drink. For there is a curse that adversely effects the power of nature, as in Thou shalt eat, but not be satisfied 

Ibn Ezra (Shemos  23:25) Observe that all illnesses come from the food that enters the body. Now a person who observes the Torah will not fear them. This is the meaning of and He will bless thy bread. There are other diseases that come from outside the body due to a change in the air caused by a shift in the arrangement of the planets. It is concerning this that our verse states, and I will take sickness away from the midst of thee. Look, a person who observes the Torah has no need for a physician along with G-d the Revered. Scripture thus writes, yet in his disease he sought not to the Lord, but to the physicians. I have thus spoken on the science of medicine. I will now speak on the science dealing with the heavenly bodies. Note that what befalls human beings depends on the alignment of the planets and what their arrangement indicates at the time of a person’s birth. The aforementioned is extremely difficult to understand. If a woman is born under an arrangement that decrees she will not be able to carry her children to term, then it will be the nature of her womb to abort the children in it. The same is true if the woman is born under an arrangement that decrees that she be barren and not have children. 

Ibn Ezra (Shemos  23:25) Now if a person who is born under an arrangement of the planets that determines that he will have a physical makeup that is unable to beget children cleaves to G-d, then if he truly cleaves to G-d, the revered G-d will strengthen the power of this man’s kidneys and see to it that his sperm functions properly so that he will be able to have children. G-d therefore told Abraham, I am G-d Almighty; walk before Me, and be thou whole-hearted (Gen. 17:1). This is what the rabbis meant by “Cease thy planet gazing.” G-d told Abraham, “If you make a treaty to serve Me, I will greatly multiply you, as I will overcome what nature has decreed for you.” This is not a victory over the arrangements of the stars, for they were not created to do good or ill to the lowest world. On the contrary, they always go and do the service of G-d, as that is what they need to do. The inhabitants of the lowest world receive a thing and its opposite from them in accordance with their desire. Thus if we observe the Torah we will not receive evil from the heavenly bodies. 

Ibn Ezra (Shemos  21:19) Scripture tells us concerning King Asa, yet in his disease he sought not to the Lord, but to the physicians). Now Scripture distinguished between them. It does not state, and he shall surely heal. It rather reads, and shall cause him to be thoroughly healed. I will explain this very well later on in this portion

Ibn Ezra (Shemos 23:25) AND YE SHALL SERVE THE LORD…HE WILL BLESS THY BREAD AND THY WATER. Its meaning is, you shall serve only the Lord who took you out of the house of bondage and brought you to the land of nations which served other G-ds who were not able to save them from your hands. Serving G-d is defined as doing all that the Lord has commanded, namely, to love the Lord, to cleave unto Him, to swear by His name, to pray to Him, to sacrifice the daily and the additional offerings unto Him and to honor Him by giving tithes. One who does the above has his reward with him. The latter consists of the following four things which he will receive in this world. One, And He (G-d) will bless thy bread and thy water. Two, I (G-d) will take sickness away from the midst of thee. Three, None shall miscarry, nor be barren, in thy land. Four, The number of thy days I (G-d) will fulfill. Now all of these rewards pertain to the body. In addition, G-d will do the reverse of these blessings to your enemies.

Ibn Ezra (Shemos 23:25): G d in his kindness chose Israel and taught them His Torah. If they observe it they become wise. This wisdom guides them in the straight path so that they are not harmed by anything…. When the soul is strong then the special heavenly power known as nature gets stronger and preserves the body. Furthermore this verse says that there will be a special blessing on all our food and drink. That is necessary because there is a curse that comes diminish the power of nature as we find in Micha 6:14): You will eat but not be satisfied. All bodily infirmities come from food which enters the body. However a person who observes the Torah has no fear of them. That is what is meant by He will bless your bread. There are other illnesses that come for external reasons due to changes in the atmosphere because of changes in the Heavenly bodies…. Consequently a person who observes the Torah has no need for a doctor other than G d…

Ibn Ezra (Shemos 23:25) There are some great scholars who are very learned in the two laws but have not studied the sciences. I therefore cannot begin to explain the abovementioned blessings without first mentioning a bit of the sciences. Man’s body comes from the lowest world. However, man’s soul, which is tied to the body, comes from on high. There are two powers that are intermediate between the body and the soul. These two powers are referred to in the main in Hebrew as ru’ach (spirit) and nefesh (life force, appetite, desire), for the soul (neshamah) is the rational part of man and its place is in the brain of man. From it comes the power of all emotions and the desire to move. The ru’ach (spirit) is situated in the heart. Life depends on the ru’ach. The ru’ach desires to dominate; that is, it seeks to overcome all opposition. It is the source of anger. Solomon similarly said, Be not hasty in thy spirit (ruchakha) to be angry, and A fool spends all his spirit (rucho). The seat of the nefesh (life force, appetite, desire) is in the liver. It is the nefesh that desires to eat. It is thus written, because thy soul (nafshekha) desires. The nefesh is the source of sexual desire. Now some people are created in such a way that these three souls are strong. In others they are weak. In other instances one soul is strong, another weak, or neither weak nor strong. Now, people fall into twenty-seven categories. G-d gave the Torah to strengthen, to intensify, and to increase the power of man’s supernal soul. When this happens the body does not rule over it. However, if the Torah is not observed, then the body overpowers the neshamah.

 Igros Moshe (Yoreh Deah IV #8): Since the Torah has permitted a person to be cured by a doctor and according to the Rambam(Hilchos De’os 4:23) and the majority of Rishonim (Tur and Shulchan Aruch Yoreh Deah 336) it is a Torah obligation - it is absolutely certain that a person must go to an expert doctor even if the doctor is a heretic. This obligation exists even if the doctor is a non-Jew who worships idols because there is no concern today that they might intentional kill (Yoreh Deah 155). One should not be bothered by the issue of how G d sends his cures through heretics. The existence of medicine means that we are commanded not to rely on miracles as long as it is possible to be cured with drugs which were created by G d to cure the sick. The doctor knows about the sickness and he knows which drugs cure the best. However since it is possible for a doctor to err on occasion - it is necessary to pray to G d that the doctor not err and succeed in treating him. Furthermore we find in the gemora that our Sages went to non-Jewish doctors and heretics - in circumstances where there was no concern that the doctor would try to kill them (Avoda Zara 28a). However if the doctor is a missionary, it is prohibited to utilize him even if there is no other doctor. In reality the overwhelming majority of doctors - whether non Jews or sinful Jews - do their work and don’t get involved in missionary activity. Thus one need not be concerned with this unless it is known that the doctor is in fact a missionary. (See Igros Moshe Yoreh Deah 2:57 concerning psychologists and psychiatrists who are heretics that it is prohibited to utilize them).

Kitzur Shulchan Aruch (192:1–2): A person should always pray that they don’t become ill. If he becomes sick he needs to have proper merit in order to be cured… We also find in the gemora that if a person has a headache, he should view that he was locked in irons. If he becomes ill enough that he needs to go to lay in bed he should view that he has been taken to be judged for capital punishment. Someone who is on trial for his life - if he has a good pleader he will be saved and if not he will be lost. Who are in fact the pleaders for a man’s life? They are repentance and good deeds. Therefore even if 999 are against him and one speaks in his favor - he will be saved… Whoever has a sick person in his house, he should go to a sage to pray for him… It is also customary to give charity for the sake of the sick person. That is because repentance, prayer and charity remove the bad decree. It is also customary to offer a blessing for the sick person in the synagogue. If he is critically ill it is customary to do this even on Shabbos and Yom Tov. Sometimes the name of the sick person is changed because even a name chance can nullify the bad decree.

Kitzur Shulchan Aruch (192:3): The Torah has given permission for the doctor to cure the sick...Therefore a sick person should not rely on a miracle but he is obligated to conduct himself according to normal procedure and call a doctor to cure him. Many spiritual giants have been cured by doctors. A person who refuses to call a doctor he has done two evil things. The first is that it is prohibited to rely on a miracle to save him from danger. This causes that his sins be recalled. The second is that it is a manifestation of boastful pride that he insists are relying on his own righteousness that he should be saved by a miracle. Furthermore not only should he call for a doctor but that he should use the greatest expert. In spite of this his heart should be directed at Heaven and he should pray to G d and to trust him. 

Maharal (Netzach Yisroel): Even though the Sages said (Bava Kama 85a) that doctors are permitted to cure illness, nevertheless the main thing is to have trust in G d and want that He be his doctor in nature. However in the time of Chezkiyahu they only wanted a cure from nature and they paid no attention at all to the cure that comes from G d in a manner which transcends nature. Therefore he concealed the Book of Cures which is itself totally in nature and it was good that he removed this exclusive focus on the material aspects of cure.

Michtav M’Eliyahu (3:170): At first glance it would seem that there is a major dispute concerning curing the sick. The view of the Ramban is that the truly pious do not need doctors. The view of the Rambam is that it is a major error and stupidity not to use doctors. Rambam says that using doctors for illness is no different than using food to cure hunger - neither shows a lack of faith. Thus the Rambam says one should use doctors and give thanks to G d for cure just as one eats and gives thanks to G d for the food…. However upon more careful examination it is apparent that there is no disagreement between the Rambam and the Ramban but they are talking about people on different spiritual levels. At the highest spiritual level the person perceives in all events the hand of Providence. Thus he deals directly with G d in all matters. Therefore if such a person gets sick he will go to the prophet to determine the spiritual cause for his illness and what G d wants from him in order to correct the problem. If such a tzadik went to a doctor in the normal manner he would be considered as turning away from G d and that he believes now that there are causes other than spiritual ones. Thus use of doctors is degrading for a highly spiritual person and he is thus sinning - even the Rambam would agree to this. At the lower level of spirituality, people view that everything is caused by natural forces. Thus for these people G d hides from them and conducts their world through the intermediary factors of natural forces. This is what the Ramban referred to as those “who are left to the random forces of nature.” So while these people have an obligation to pray to G d for cure, they are required to utilize medicine and natural procedures and to give thinks to G d when they get cured. This is the way to acknowledge G d’s conduct and kindness with them and learn about His ways. The Ramban would also agree that for such people that they need to go to doctors….A person on this lower level who refuses medical treatment is properly described by the Rambam as a fool. That is because a person’s serving of G d has to be according to his spiritual level… 

Moreh Nevuchim (03:37) "whatever is used as medicine" does not come under the law of "the ways of the Amorite"; for they hold that only such cures as are recommended by reason are permitted, and other cures are prohibited. When, therefore, the dictum was quoted: a tree that casts off its fruit may be laden with stone or dyed with red color, the following objection was raised: The loading of the tree with stones may be justified on the plea that it serves to weaken the strength of the tree, but why should it be permitted to dye the tree with red color? This question shows that the dyeing of the tree with red color, and all similar things which are not explained by analogy from nature, are prohibited as "ways of the Amorite." 

Nefesh HaChaim (2:11): Even though it is a clear halacha in the gemora that an individual can add requests in prayer for his personal needs and suffering in each beracha according to the subject, it still should not be done because of his concern for his personal suffering. That is not the correct approach for those who are truly righteous. It is truly puzzling how it is possible to ask anything at all from G d so that his suffering should be removed. The issue is analogous to being cured from sickness. The doctor gives him strong medicine or in extreme cases amputates a limb in order to prevent the spread of the poison causing the illness. Does a person beg the doctor not to give the medicine or not to amputate the limb? The sick person is in fact paying to give him these unpleasant treatments. Therefore one who not pray to have suffering removed. They are in fact the ointments and medicines that revitalize to atone for sin. Our sages  stated: “There is no suffering unless caused by sin” - because the sinful person cannot obtain atonement without suffering

Or HaChaim (Shemos  23:25) And I will remove illness from amongst you. There are certain sicknesses which result from the intake of certain foods, illnesses not visible on the surface of one’s body. There are other external illnesses which are due to changes in climate, etc. This is why the Torah assures the Jewish people that when they serve the Lord G-d will bless their food and water so that their bodies will be able to resist the sickness which may normally result from the consumption of food and drink containing invisible but harmful ingredients. This means that the righteous person will not have to have recourse to a physician. 

Or HaChaim (Shemos  23:25) And I will remove sickness from your midst. G-d characterized the blessing as composed of three components. 1) Man (the Israelites) will be healthy in order to enjoy G-d's bounty. The Torah speaks about: "I will remove sickness," i.e. G-d will do this as an act of providence. Unless there is physical health and wellbeing all food will become repulsive instead of enjoyable. 2) There will not be a woman who miscarries, i.e. nature will co-operate; 3) people will live out their allotted years. In all these matters G-d demonstrated His blessing; without these conditions G-d's usual gifts, i.e. health, food, etc., His blessings would not be recognizable as true blessings.

Ramban (Vayikra 26:11): In general when most Jews existed on a high spiritual level they did not conduct their lives based on natural rules - either for their personal health or the running of society. G d gave special bounty in their bread and water and preserved them from sickness so that they did not need doctors or medical science at all. … That is how the tzadikim conducted themselves in the time of the prophets. So even when they were harmed as the result of sin they did not go to doctors for treatment. They only went for help to the prophets as we see in the case of Chezkiyahu s. Berachos says: It is not inherent that people take medicines but they have accustomed themselves to do it. In other words if people hadn’t accustomed themselves to go to doctors then people would get sick according to their sins and be cured by the will of G d. But since they have chosen to act according to Nature, G d leaves them to the random forces of Nature. This is the intent of: “He shall cause them to be thoroughly healed. From there we learn the principle that doctors are permitted to heal.”

Ramban (Vayikra 26:11):  Our sages did not say that the Torah permits the sick to be cured by a doctor. Rather they said that concerning a sick person who is accustomed to go to doctors and is clearly not one of the very spiritual people - the doctor should not refuse to heal him. He should not refuse to heal because of fear that he might kill the sick person with his treatment - because obviously he is well trained. He should also not refuse saying that only G d heals because people have already adopted the practice of being cured by medicines. Consequently if two people fight and they hit each other with a stone or fist the assailant must pay for medical treatment since the laws of the Torah are not based on miraculous events….However when a man pleases G d there is no need for doctors.

Rav Yaakov Kaminetsky(Emes L’Yaakov Bechukosai): The typical understanding of the Ramban is that in truth it is prohibited for a person to utilize doctors and medical treatment but should rely totally on G d to cure him… In contrast the typical understanding of the Chovas HaLevavos (4:4) is that man needs to act as if he is helping G d provide him with his sustenance. Thus it is understood that the Ramban takes a more stringent position that eschews personal effort while the Chovas HaLevavos requires a person to exert himself and not rely on his spiritual merit. However a closer look at the Chovas HaLevavos reveals that he is in fact more stringent in the matter of personal effort. His actual position is that the sole reason for the effort is to be involved in building society [which G d requires to keep him busy and away from sin]. Thus the effort is a mitzva like any other mitzva of the Torah and does not cause him to reach the goal but is only a perquisite for G d to give him what one wants.

Shevet HaLevi (8:251): Question: Concerning the refusal of a sick person to allow medical treatment - can he be forced to accept treatment which is a mitzva for both the sick person and for the doctor? If in fact he can be forced to accept treatment , is it the doctor’s or the court’s obligation? What is the halacha today when it is a violation of the law of the land to force medical treatment on someone who is capable of making decisions. Answer: If the person refuses treatment because of his strong bitachon (trust) in G d then his refusal does not constitute a nullification of a mitzva as we see in the Ramban (Vayikra 26:11). However if he refuses treatment because of suicidal motivation or because of nonsense, then it would seem that the forced treatment should be done through the beis din (court) according to the advice of the doctor. Furthermore it seems from the Taz (Y.D. 336) that the obligation and mitzva to use medical treatment applies only to the ordinary person but not a complete tzadik. In addition the view of the Tzitz Eliezer - that there is an obligation to persuade someone who refuses treatment because of bitachon - is the correct halacha when we see that the sick person’s life is possibly in danger. That is because we can’t be sure that his bitachon is strong enough that it allows him to avoid medical treatment - which has been permitted by the Torah. While I am well aware that the Ktzos HaChoshen and the Nesivos (Choshen Mishpat 3) discuss whether the obligation to force is for beis din or it applies to every individual… However, in my humble opinion, the decision as to whether to force treatment on the sick person is given only to those with true understanding of the Torah. That is what I meant by the term beis din. …