Permission and Obligation: A Jewish Paradigm for Care
Sara Labaton
Credit: Shutterstock
Sara Labaton is Director of Teaching and Learning at the Shalom Hartman Institute of North America.
In memory of Dr. Warren Enker
During fifteen years of living with cancer, my father accessed the best that modern medicine had to offer. Multiple surgeries, long courses of chemotherapies, and radiation lengthened his life and gave us hope. Throughout his illness, my father developed relationships with remarkable physicians whose care, in the sense of social and interpersonal ministration, went beyond the confines of researching and treating his cancer. Over these years, however, my family also witnessed a medical system that paid scant attention to care. It was painfully hard to find people who could communicate honestly but compassionately about the impact of disease and eventually about death.
There were doctors who offered short-term fixes, without consideration of my father’s pain and quality of life, and other doctors whose casual references to his dying hit like blunt force trauma. Similarly, even those of us intimately connected to my father as family members and friends said things and did things that were at best, awkward, and at worst, profoundly insensitive. It turns out that it is not simple to care for those who are sick, whether you are in the profession of providing medical care or you are someone whose care is motivated by personal love and concern.
Illness is a stark reminder of the frailty and unpredictability of our bodies, our mortality, and the lack of control we exercise over our lives. This naturally elicits a range of emotions including discomfort, disgust, sadness, and anger from those who encounter the patient clinically or personally. It bears mentioning that because the contemporary medical landscape allows for the siloing of those who are sick in sterile and out of the way environs like hospitals, sickness itself is alien to those of us who do not encounter it regularly. The reality of sickness and what it represents, therefore, triggers complicated emotional reactions that can interfere with caring for those who are sick.
Likewise, although we live at a time that has brought forth awesome and lifesaving medical interventions, illness and care are both subject to limiting phenomena, including the corporatization of medicine, the byzantine and punishing bureaucracy of health insurance, the larger epidemic of loneliness, and the ways in which medicine has become politicized. The result is widespread mistrust or confusion for those personally connected with the patient, and fatigue or even callousness among medical professionals.
I wrote this piece to acknowledge how complicated it is to care for sick people, and, simultaneously, to push those of us within the medical community and without to think more deeply about caring for them. I believe that the classical Jewish tradition, when read and applied in a particular way, is a provocative resource for considering our moral obligations in the face of illness. I’m especially interested in how the medieval Jewish scholars Maimonides and Nahmanides reimagined what they likely regarded as obsolete rabbinic traditions about healing while embracing the rabbis’ view of the obligation to visit the sick. In doing so, I believe that they created compelling models of caring for the sick that still hold today, even though our medical knowledge and technology have advanced far beyond what was available when they were writing.
Permission to Heal
Several rabbinic texts grapple with the tension between the idea, found in various biblical texts, that God is responsible for inflicting illness, and the reality that people go to doctors for healing. If God is the source of bodily malfunction, it follows that the power of healing belongs to God and not to humans. Within that model, it would seem that because medical care inappropriately intervenes with divine will, people should not seek out doctors, and doctors should not practice their craft. But the rabbis also recognize that medical care exists, and the rabbinic tradition mediates the tension between these ideas in different ways. One well-known rabbinic teaching does so by deploying the language of permission in formulating an approach towards healing.
The Torah outlines what should happen when a victim recovers from an assailant’s assault: “if he then gets up and walks outdoors upon his staff, the assailant shall go unpunished, except that he must pay for the loss of his time and heal, he shall heal” (Ex. 21:19, emphasis added). The rabbis of the Talmud read this verse as mandating that an assailant must pay for both the victim’s lost wages and for their medical care (bBava Kamma 85a). The school of Rabbi Yishmael infers from the double language of healing (“heal, he shall heal”) that doctors have permission to perform acts of healing.
The idea of permission to heal returns in bBerakhot 60a, where the Talmud debates the question of whether bloodletting requires a blessing:
As Rav Aha said: One who enters to let blood says: “May it be Your will, O Lord my God, that this enterprise be for healing and that You should heal me. As You are a faithful God of healing and Your healing is truth.” Because it is not the way of people to heal [i.e., healing is a divine and not a human enterprise], but they have become accustomed [to trying to heal through medical interventions].
Abaye said: One should not say this, as the school of Rabbi Yishmael taught: “And heal, he shall heal” (Ex. 21:19), from here, permission is granted to a doctor to heal.
In this passage, the Talmud evinces two perspectives: Rav Aha suggests that ideally, people should refrain from seeking and administering medical care. But given that they do so anyway, it is proper to recite a prayer asking God to heal the patient through the operation that follows. Abaye, alternatively, cites the school of Rabbi Yishmael’s interpretation of Exodus 21:19 to argue that God permits healing and that Rav Aha’s ambivalence and prayer are consequently unwarranted. Even Abaye, though, who views healing as a legitimate practice, assumes that it is necessary to get permission to heal and locates that permission in a technical piece of biblical exegesis.
In the medieval period, rabbinic discomfort with medicine finds expression in thinkers like Abraham ibn Ezra, the twelfth century Spanish biblical commentator, who also characterizes Exodus 21:19 as a sign that God gave doctors permission to heal. Distinctively, he limits this permission to the healing of external, visible injuries. He considers internal injuries, those with no discernible cause, to be for God, and not doctors, to heal. Ibn Ezra’s resistance towards medical healing also manifests in his comment on Exodus 15:26, where God identifies as rofekhah, “your doctor,” and promises not to inflict Israel with the diseases of Egypt if they observe the divine commandments. As ibn Ezra explains, God can accomplish supernatural feats that defy medicine, a phenomenon the Israelites themselves have already witnessed.
Maimonides, the celebrated 12th century philosopher, codifier of Jewish law, community leader, and doctor, diverges sharply from this traditional ambivalence towards medical care. In his Commentary to the Mishnah, Maimonides insists “it is an obligation from the Torah for the doctor to heal the sick of Israel and behold this is in the category of what they [the rabbis] say in [their] explanation of the biblical phrase ‘you shall return to him,’ (Deut. 22:2) to include his body” (Nedarim 4:4). Here, Maimonides draws on the rabbinic notion, found in the Talmud, that saving someone who is drowning or under attack falls under the legal requirement to return a lost object, as it is akin to returning to them their life or wellbeing, which was almost lost. In extending this requirement to include medical care, Maimonides turns healing into an obligation.
Nahmanides, the 13th century Spanish exegete, mystic, halakhist, and doctor, adopts Maimonides’s stance, but with a significant twist. He writes in Torat Ha’Adam (“The Torah of the Human”), a treatise on mourning, that healing is a reshut demitzvah, a “permission-for-obligation”—a seemingly paradoxical legal category of his own creation. Nahmanides explains that the permission to heal is necessary to alleviate doctors’ anxieties that their attempts to heal might actually be harmful, while the obligation to heal is justified by verses like “love your neighbor as yourself” (Lev. 19:18) and rabbinic categories such as pikuach nefesh, the notion that saving a life supersedes nearly every other commandment. Indeed, he casts doctors who refuse to heal as guilty of shedding blood.
Thus, Nahmanides diverges from prior traditions in three ways: First, he assigns the practice of healing to a new legal category, permission-for-obligation, combining the Talmudic notion that doctors require permission with the Maimonidean notion that doctors are obligated to heal. Second, he provides a different reason why divine permission is necessary for healing, namely, that it serves as theological insurance for medical malpractice. This is far from the notion that the domain of sickness and health belongs to God alone. Finally, he affirms that healing is obligatory because of the moral principles of loving one’s neighbor as oneself, the ultimate value of saving human life, and the injunction against taking a life.
Permission, obligation, and permission-for-obligation constitute three different paradigms for understanding healing that continue to influence Jewish thinking about medical care. When it comes to the paradigm of permission, human healing is not presented as an obvious or automatic response to illness, and no singular moral force attaches to it. One position in bBerakhot 60a permits bloodletting because it has become a social convention and only with the incorporation of a blessing, while the other position permits such medical care only because of a redundant term for healing in the Torah.
The language of permission appears in some Haredi Jewish communities today, where it is common for patients to seek a rabbinic imprimatur for various medical procedures. More commonly, the belief that doctors and medicine function as divine instruments fits this paradigm as well. In this context, some argue that, while it is certainly permitted to consult with doctors and engage with medicine, it is God’s will (and God’s will alone) that is decisive when it comes to the healing of the patient. Further, for certain segments of society, the notion that the medical establishment infringes on people’s freedom entails a belief that their own permission (not God’s) is necessary for doctors to practice. The paradigm of permission assumes that doctors are somewhat hubristic in interrupting the divinely or naturally dictated course of events.
In transforming healing from something permitted to something obligatory, Maimonides changes the moral and theological stakes of medicine in accordance with his broader philosophical outlook. For Maimonides, doctors are potential lifesavers and their obligation to provide medical care stems from a greater obligation to help someone whose life is in danger. Because Maimonides treats illness as part of the natural cycle of life in the world and advances a more naturalistic conception of divine providence, it stands to reason that he views doctors as operating independently of God. Even when Maimonides expresses the position that virtuous people can avoid misfortune through their knowledge of God, many scholars read this non-literally and non-miraculously, arguing that Maimonides’s God does not manipulate a person’s cellular makeup and inflict them with disease because of their misdeeds or lack of virtue.
This approach to both illness and healing is one that resonates for many liberal Jews today, and indeed, it resonated most strongly for me over the course of my father’s illness. I never blamed God for his cancer, but I also never thanked God for successful surgeries or beseeched God to save my father. As a pulpit rabbi, my father would get questions from his dismayed congregants of “Why you? Why is God making you endure this?” In response, he would say, “Why not me?” His cancer originated not with a divine choice but with an errant cell. This does not mean that he was stoic or fatalistic, but that his emotional and intellectual efforts were directed not entirely to God, but to getting the most effective medical treatment available.
Nahmanides’s paradigm of permission-for-obligation subtly opens new dimensions when it comes to healing. First, it takes the anxieties of doctors seriously, a position that is consistent with Nahmanides’s understanding of how medicine emerged as a divinely sanctioned enterprise. In his Commentary to the Torah, Nahmanides presents the ideal state as one where a relationship between Israel and the divine precludes a need for doctors (Leviticus 26:11). In this utopia, God inflicts and heals according to Israel’s conformity with the divine will. However, once Israel accustoms itself to going to doctors and following medical regimens, God retracts from actively intervening in Israel’s affairs, and lets nature, rather than sin or virtue, take its course. In this vision, therefore, it is not just the case that doctors cure and save in a godlike fashion, but also that they assume the role previously occupied by God. This highlights the awesome consequences of their work and why they require (or feel they require) permission to heal. The permission in Nahmanides’s permission-for-obligation, therefore, is a function of social convention and divine retraction. Once patients opt into medical care, doctors are permitted to treat them without concerns about either accidentally killing them or arrogating to themselves divine powers impeding their work. Nahmanides combines this understanding of the doctor’s position with the reality that once a patient steps through their door, they are morally obligated to treat them. It is here that Nahmanides takes the needs of the patient seriously. In couching healing not only as saving a life (pikuach nefesh), but as loving one’s neighbor as oneself, Nahmanides centers the social, emotional, and physical needs and preferences of the patient.
Integrating the permission to heal with the obligation to heal reminds doctors that their ability and mandate to heal are not absolute, but rather, require some type of limitation, whether it derives from God or from the patient. In both Torat Ha’adam and his biblical commentary, Nahmanides profoundly humanizes both the doctor and the patient. While ideally, an intimate relationship with God might preclude the need for doctors, Nahmanides seems to understand that in the normative world, when confronted with sickness, bodily dysfunction, and pain, some people (perhaps most) would prefer to engage with the concrete ministrations of doctors and not with God.
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Bikur Holim
While medical healing has elicited a range of attitudes among Jewish thinkers, the requirement to offer material and social support to those who are ill has remained fixed. The mitzvah of bikur holim, visiting the sick, has laid the groundwork for cadres of volunteers and robust Jewish charitable organizations, all devoted to caring for the sick. Moreover, in a 2002 piece, “The ‘Sick Visit’ (Bikkur Holim): A Model for Medical Humanism,” Dr. Rachel Katz-Sidlow, an expert in medical education, demonstrates how the practice of bikur holim can help cultivate stronger care and more of a patient-centered approach among doctors, whose training and experiences sometimes lead to diminished compassion in their relationships with patients.
Rabbinic literature is preoccupied with bikur holim, going so far as to include it in the short list of activities (now recited in the daily liturgy) that merit reward in this world and the next (bShabbat 127a). Rabbinic laws and narratives about bikur holim express three broad values that should guide such visits: humility, empathy, and the inherent dignity of those who are ill.
According to the Talmud, “visiting the sick has no fixed measure” (bNedarim 39b). While the phrase “no fixed measure” is understood by the rabbis in a few different ways, I am particularly compelled by explanations that emphasize the need for humility in the context of visiting the sick. For example, one interpretation is that “even the older or greater should visit the younger or lesser,” requiring visits to sick people with no regard for age or social status, even when that involves a seeming demotion of one’s status or the awkwardness of interacting with those outside one’s natural social circles. It recalls the midrash of God visiting Abraham after the latter’s circumcision (bSotah 14a), and in doing so, leaves no question as to the limitlessness of this requirement. An alternative explanation is that the limitlessness of bikur holim might require a person to make as many as one hundred visits in a day. This not only exemplifies the extreme devotion the rabbis want people to demonstrate to those who are ill, but also demands this devotion at the expense of one’s own comfort and convenience. Visitors must subjugate themselves to sick people.
When Maimonides codifies bikur holim, he integrates these two explanations and includes the provision that “whoever adds to this is to be praised, only that they should not be a burden,” highlighting the importance of placing the emotional and physical sensitivities of the patient front and center. Maimonides includes this obligation with other acts of lovingkindness (gemilut hasadim), all of which, he notes, are done with one’s body. The insistence on physically showing up to do this work and be present is another means of cultivating humility in the visitor. A corollary to the idea of humility is that of empathy, or treating the sick as one would want to be treated. Indeed, Maimonides locates the biblical source for bikur holim (along with the other delineated acts of loving kindness) in the verse “love your neighbor as yourself” (Lev.19:18), which he interprets as “all things that you would like others to do for you, you should do for your fellow.”
More pointedly, in a midrash found in Ecclesiastes Rabbah, the rabbis rewrite a story from the book of Isaiah to offer a lesson in empathy to none other than God and God’s prophet. In the biblical version, the prophet Isaiah brings the stricken King Hezekiah news of his impending death, along with instructions to get his affairs in order, to which the latter prays and cries in response (Is. 38:1-2). In the midrash, however, Hezekiah retorts:
Isaiah, customarily a man who goes to visit the sick, says to him: “From Heaven should compassion be upon you” and a doctor comes to his side and says to him, “this thing eat, but that thing do not eat, drink this but do not drink that.” But even if he [the doctor] sees that the patient is near death, he does not say: “Set your affairs in order,” lest this weaken his resolve. And you are telling me, “Set your affairs in order for you are dying and will not live.” (5:6)
If we remember that it was God who sent Isaiah with this message, the midrash is not only subverting the message of the Bible, but critiquing divine communication, asking God that bad news be delivered more gently. God’s bedside manner, it would seem, leaves something to be desired, and doctors should learn from this episode how not to tell their patients that they are dying.
Finally, the texts of bikur holim illuminate the inherent dignity of the ill. In bShabbat 12b, Rabbi Elazar is described as sometimes blessing the sick in Hebrew and sometimes blessing them in Aramaic. The latter is surprising, as it contravenes the rabbinic dictate not to petition for one’s needs in Aramaic because the ministering angels do not understand the language. But the Talmud justifies Rabbi Elazar’s practice by noting that the Divine Presence itself dwells with the sick and does understand Aramaic.
In the same passage and for the same reason, the Talmud prohibits visitors from sitting on the sickbed, but rather explains, they “must wrap [themselves] about and sit in front of [the sick person], for the Divine Presence is above an invalid’s pillow, as it is said, ‘The LORD supports him upon the couch of languishing’ (Ps. 41:3).”
The notion that the presence of God is with the sick and must shape our interactions with them is remarkable when we consider the relative lack of hygiene or sterility in the ancient world. In bNedarim 41a, the Talmud prohibits visiting people with certain types of infirmities, including those with intestinal diseases who might have to relieve themselves in front of the visitor, which would cause them embarrassment. Not visiting people with such illnesses is thus considered, by the rabbis, to be more respectful of their dignity than visiting. The Divine Presence does not, however, stay away from those who are frail, soiled, or undressed. Rather than divesting the patient of dignity, the fact of illness invites the Divine Presence itself into the room and onto the bed with the sick person, reinforcing their intrinsic dignity and worth.
In prioritizing bikur holim, the rabbis recognize that illness brings loneliness and stigma in its wake. It is easy to forget about those who are isolated at home or in hospitals, and it is also easy to pretend that the potential awkwardness of the visit is reason not to undertake it. The detailed guidelines of bikur holim are tools meant to bring those who are sick from the margins and into the community. On the day my parents received the news of my father’s diagnosis, one of his friends tracked him down and said, both lovingly and humorously, “This is a fine mess you’ve gotten us into.” With the first-person plural pronoun “us,” this friend signaled that he would be physically and emotionally present for my father in his illness, which he was, showing up not only to our house, but to nearly every surgery and chemotherapy appointment until the day my father died.
Two Types of Caring
Studying the historical development of Jewish teachings about illness offers us a vocabulary to talk about ethics and care in the context of medicine. The language of permission, obligation, and permission-for-obligation lets us consider the nuances of providing and receiving medical care, even though medicine has changed so much since these texts were written.
I want to close with one last consideration: can a doctor’s care for a patient itself be an act of bikur holim? Maimonides draws a line between the obligation to medically heal and the obligation to emotionally support the patient, indicating that they are similar but not the same.
Nahmanides, however, links his idea of permission-for-obligation to loving one’s neighbor, which is the prooftext Maimonides deploys for bikur holim. To my mind, this connection creates a model of medical care that more fully integrates the values of bikur holim in its instantiation. We might say that once we choose to participate in the medical enterprise, doctors are not simply obligated to heal but must undertake healing with the additional moral and interpersonal dimensions reflected in the texts of bikur holim.
When healing and bikur holim are closely linked, the values of humility, empathy, and the dignity of those who are ill become as relevant to the medical providers as they are to the visitors in their interactions with the person who is sick. In this model of healing, medicine must be integrated with social and emotional support for it to be permitted.
My reading of Nahmanides is in line with the writings of contemporary care ethicist Nel Noddings, who notes in her book, Caring, “It is the recognition of and longing for relatedness that form the foundation of our ethic, and the joy that accompanies fulfillment of our caring enhances our commitment to the ethical ideal that sustains us as the one-caring.” For a doctor to not only discharge their obligation to heal, but to do so with care, they need to establish and acknowledge a relationship with the patient.
Nahmanides’s view is also echoed by Dr. Atul Gawande in his book, Being Mortal:
If to be human is to be limited, then the role of caring professions and institutions—from surgeons to nursing homes—ought to be aiding people in their struggle with those limits. Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.
I want to close by sharing a story from my father’s illness that illustrates the significance of Nahmanides’s view. From the beginning of my father’s diagnosis, Dr. Warren Enker, his surgeon, served as my parents’ guide through multiple procedures and treatments, both because of his medical expertise and because of the care he consistently manifested. When my father’s cancer spread to a part of the body outside Dr. Enker’s area of expertise, he referred my parents to a surgeon-friend of his at a different hospital. In the early morning of the ensuing surgery, Dr. Enker unexpectedly strode into the operating room dressed in his scrubs, with permission in hand to be present throughout the surgery, to literally and proverbially hold my father’s hands. My father said afterward that he had felt bereft upon arriving at the hospital, knowing that Dr. Enker would not be performing the surgery, and when he then saw Dr. Enker, it almost felt miraculous. Dr. Enker’s presence exemplified Nahmanides’s paradigm of care, a doctor simultaneously engaged in both healing and bikur holim. May his memory inspire us towards deeper care for those who are sick, vulnerable, or lonely.
