TFN no.5754.18 373-380


Physicians and Indigent Patients


Many of the Jews from the former Soviet Union who have settled in our community are now dependent upon

government assistance for their health care. Frequently when they call physicians in the community to secure

appointments, they are told that these physicians do not see patients who are without private insurance coverage.

While our local Jewish Family Service has had some success in making individual appeals to physicians active in

our congregations to provide care for these newcomers, a broader question remains. Under our tradition, may a

Jewish physician refuse to treat a patient because he or she lacks medical coverage? (Rabbi Melanie Aron, Los

Gatos, CA)

This question addresses the situation in the United States, where as of this writing health care is largely a private

matter rather than a right guaranteed by the community to all citizens or residents. Yet it also has application in

countries where health care is state-sponsored and where physicians and other medical professionals have been

known to go on strike against what they regard as inadequate funding, poor compensation, and the like. In both

cases, the issue is essentially the same: may physicians refuse for economic reasons to provide medical service?

The Mitzvah of Medical Practice.

We begin our discussion by noting that Jewish tradition regards the practice of medicine as a mitzvah, a

religious obligation which imposes duties upon doctor and patient alike.

This attitude was not unanimous; a number of texts express a highly negative stance toward medicine, physicians,

and those who resort to them. This critical viewpoint proceeds from the doctrine that God is the Source of both

illness and healing.1 If disease is understood as a sign of God’s displeasure, as punishment for our

misdeeds, it follows that the correct response to it is prayer and repentance. When one turns instead to the

practitioners of the medical arts, one betrays both a desire to frustrate the divine decree and a fundamental lack of

trust in God. Thus, King Asa of Judah is criticized in that “in his sickness he sought not God but rather

physicians,”2 while King Hezekiah wins praise for hiding away a medical book so that people would

learn to pray for healing rather than seek medical help.3 The Talmud declares that one who does

engage the services of a medical practitioner should pray: “May it be Your will…that this procedure restore my

health…You are a faithful and healing God, whose healing is true. As for human beings, they have no power to

heal; rather, it has become a habit with them.” The implication, says Rashi, is that human beings “should never

have become involved with medicine; instead, they should have learned to seek God’s mercy.”4 This

way of thinking finds its classic expression in the commentary of Nachmanides (Ramban) to Leviticus 26:11. He

writes that the blessings promised in that chapter as a reward for our obedience to God are all miracles,

suspensions of the natural order of the world. This teaches that when Israel is at one with God, it is exempted from

the normal workings of nature and merits special providence. Medicine is irrelevant to the community of the

righteous, for whom disease is a matter not of the body but of the spirit. Cures are effected by repentance and

prayer, for God “will bless your food and your water and remove all disease from your midst” (Ex.

23:25).5 Had Israel maintained its trust in God, it never would have needed physicians and

medicine; since, however, “it has become a habit with them,” the Torah grudgingly permits the physician to

practice his art.6 Yet this “habit” continues to separate us from God; were we to walk in God’s ways,

we should have nothing to do with physicians.

Despite these opinions, the tradition developed a positive and affirming conception of medicine. This fact is most

obvious in the large number of rabbinic scholars who were also physicians, as well as in the significant medical

literature produced by rabbinic writers, most notably Maimonides.7 The Talmud tells us that “one

who is in pain should go to the physician” and forbids a scholar from residing in a town that lacks a

doctor.8 The apparently negative statements on medicine receive different

explanations.9 Nachmanides himself argues that the “permit” to practice medicine is in fact a

mitzvah, falling under the rubric of pikuach nefesh, the saving of life.10 The

saving of life overrides the prohibitions connected with Shabbat and Yom Kippur,11 and Ramban

notes that we often set aside these prohibitions on the strength of a doctor’s diagnosis.12

Maimonides, meanwhile, derives the commandment to practice medicine from Deut 22:2, the obligation to restore

lost objects which, say the rabbis, extends to the saving of life.13 Whatever its Scriptural basis, the

Tur and the Shulchan Arukh formulate the obligation to practice medicine as

halakhah:14 the patient is required to resort to the physician, and the physician is required

to heal. Whoever delays or refrains from meeting this obligation is considered as having shed blood.

From this, it would follow that a Jewish physician is not entitled to refuse treatment to a patient for financial

reasons. A religious obligation does not cease being a religious obligation on account of its expense. And since the

practice of medicine is an enterprise of pikuach nefesh, a duty which outweighs virtually all others, we

would conclude that the physician must surely provide life-sustaining treatment to patients regardless of their

ability to pay. Indeed, are we not taught that the physician who refuses to treat the indigent is deserving of

everlasting punishment?15 While doctors may press their reasonable financial demands, therefore,

they cannot shirk the duty imposed upon them by the Torah.16

The Physician and Economic Freedom.

The matter, however, is not so simple. Like all human beings, the physician is possessed of an essential dignity

which the community cannot ignore. Fundamental to this dignity is what we moderns might term economic

freedom. The traditional basis for this principle is the verse (Lev. 25:55): “for the people of Israel are My servants,”

to which the rabbis add: “and not the servants of servants.”17 The free man or woman ought not to

be a slave to the economic demands of others.18 From this, we learn that the worker is entitled to

quit his or her job, even after beginning it.19 We read too that workers, whether laborers,

professionals, or the owners of businesses, may organize and adopt trade policies that determine the prices they

charge the public.20 This “right to strike” does not include the right to inflict damages upon the

employer. A worker dealing with perishable goods, for example, may not quit before completing the

job.21 We might argue on this basis that a physician, who has charge of the most perishable of

“goods,” may not refuse to treat a patient. This limitation, however, seems to apply only to a worker who has

already begun the job. Should a doctor refuse to begin treatment in the absence of assured compensation, this law

would not force him or her to provide it.

Yet surely, we might respond, the physician is not like other laborers. The physician performs a mitzvah,

and one can hardly go on strike against a commandment. Moreover, the physician’s mitsvah is that of

pikuach nefesh, a duty which must be performed whenever the opportunity presents itself. As Maimonides

writes, “whoever is able to save a life but does not save it violates the commandment: `do not stand idly by the

blood of your neighbor’ (Lev. 19:16).”22 Thus, once an individual seeks the services of a physician,

the physician is obliged to treat that person. He or she may not turn away indigent patients on the grounds that

other physicians can treat them, for perhaps the treatment offered by others will not succeed. As the rabbis remind

us, it just may be the destiny of this indigent patient to be healed by this doctor.23

Thus, we could argue, the physician does not have the same right enjoyed by other workers to withhold his or her

services. The saving of life must take precedence over the physician’s economic freedom.

Still, the duty to save life does not necessarily fall upon the physician as an individual. The commandment of

pikuach nefesh is addressed to all of us, not just to a particular class of persons; the physician has no

greater obligation than does anyone else to save life. This is a key element in the Jewish legal theory which permits

physicians to be paid for their work:24 when a positive commandment is incumbent upon all

members of the community, no one person can be required to perform it for free.25 Physicians are

entitled to reasonable compensation because, though they render a service that only trained professionals are

allowed to administer,26 they are the agents of the community. The mitzvah they perform is

our mitzvah, not just theirs. Like others who provide vital public services, they are the means by which

each of us fulfills the individual responsibility to save life. Thus, if it costs money to perform the mitsvah,

that expense ought to be borne by the community, by all of us together, and not by doctors alone.27

It is arguably unfair to require that physicians treat indigent patients without adequate compensation.

Conclusion. The case before us therefore is a complex one, in moral as well as halakhic terms. It

involves a conflict between two traditional values–the mitzvah of medical care and the economic freedom

of the individual–which resonate with us as liberal Jews. It follows that any proper solution will also be complex,

its specific details determined by the circumstances of the community in which it is adopted. Still, our

understanding of Torah and moral imperative from within the context of Reform tradition convinces us that such a

solution ought to incorporate four fundamental principles.

1. Every member of the community enjoys a right to adequate medical care. As we read the tradition, this demand

is paramount. Medicine is a mitzvah, the duty of pikuach nefesh which we owe to all whose lives

are in danger. To deny medical treatment to human beings because they cannot afford to pay for it is repugnant to

any decent conception of what Torah requires of us. One may debate, legitimately, both the precise definition of

“adequate medical care” and the means by which it is delivered. That it must be delivered, however, cannot be

doubted, as the CCAR has repeatedly made clear.28 Our primary moral task is not to decide whether

the poor shall receive treatment; it is rather to determine the fairest and most efficient way of getting it to


2. The ultimate responsibility for providing medical care to the indigent rests upon society as a

whole.29 Tradition teaches us that, inasmuch as each of us is commanded to save life, each of us

shoulders equally the burden which this duty imposes.30 And our Reform tradition holds that justice

is a social matter. Our commitment to social justice and social action requires the conclusion that no just society

can fail to meet this duty.

3. In the present case, we Jews have a special responsibility above and beyond our obligations as members of the

wider community. For many years, we struggled to liberate the oppressed Jews of the former Soviet Union. We

organized and lobbied to secure their right to emigrate to lands which would allow them to live as Jews in peace

and freedom. We did this in fulfillment of the mitzvah of pidyon shevuyim, the redemption of

captives, a duty which in our tradition takes precedence over all other forms of tzedakah.31

Thus, although the obligation to aid the poor rests upon the entire community, we have an added measure of

obligation toward these, our brothers and sisters. It would be a moral failure if, having exerted great efforts to bring

them out of bondage, we were to ignore their pressing human needs once they arrive in our midst. Our ethical

responsibility is not discharged until we have helped them secure housing, employment, medical care, and the

other tools necessary to build lives of independence and dignity. This implies, we think, that Jewish physicians

have a special and vital contribution to make.

4. Even though the provision of medical care is the responsibility of society as a whole, physicians cannot on this

ground shirk the moral responsibility to render medical care to those who call upon their services. When a person

seeks medical care from a physician, the physician is bound under the rubric of pikuach nefesh to provide

it, either personally or by making arrangements for the patient to see another doctor. We are not unmindful of the

just monetary demands of medical professionals. Physicians are entitled to seek compensation from the community

for their services; in the event that community assistance is insufficient to meet the need, they may make other

financial arrangements as they see fit. Yet we cannot help but note that physicians, even when they treat the

indigent for free, still earn incomes which compare quite favorably to those of police officers, fire fighters,

educators, and all others who devote their professional lives to the performance of mitzvot. We conclude

that the health and lives of the poor must in principle take precedence over the economic requirements of the


We do not pretend to have the “right” solution to the intricately complex problem of health-care access in the

United States. Again, we presume that the particular arrangements for providing medical care to the indigent will

vary from place to place. As we see it, however, one truth is and must remain constant: under no circumstances

may physicians, Jewish or otherwise, simply refuse to provide that care on the grounds that the patients lack

insurance. Jewish tradition and moral decency demand no less.


  • Exo. 15:26. See BT Sanhedrin 101a for a hint that sickness

    and health depend largely upon faithfulness to God’s commandments

    and not upon medicine.

  • II Chr. 16:12.
  • This rabbinic tradition, recounted in BT Berakhot 10b and

    BT. Pesachim 56a, is derived aggadically from Isaiah 38:3. See

    Rashi to the Berakhot passage, s.v. she-ganaz sefer refu’ot.

  • BT. Berakhot 60a and Rashi, s.v. she’ein darkan shel benei

    adam. See also Rashi’s explanation of the statement in the

    Mishnah (M. Kiddushin 4:14): “the best physician is deserving of

    hell.” One of the reasons for this condemnation, he writes, is

    that the physician arrogantly regards himself, rather than God,

    as the healer (BT Kiddushin 82a, s.v. tov she-barof’im). See

    also notes 9 and 15, below.

  • Ramban also cites Exo. 15:26 in this regard; see at note 1.
  • BT. Baba Kamma 85a, from Exo. 21:19. This, says Ramban, is

    not a grant of permission to the patient, who in any event ought

    not to resort to medicine. As he has chosen the “habit” of

    medicine, however, separating himself from “the congregation of

    God,” the physician may treat him without incurring divine


  • R. Natan Zvi Friedman, Otzar Ha-Rabbanim, Tel Aviv, 1975,

    identifies about 80 significant rabbinic personalities as


  • BT. Baba Kama 46b and Sanhedrin 17b.
  • Thus, King Asa’s sin is not that he consulted physicians

    but rather that he placed his reliance totally upon them,

    forgetting that the physician is God’s agent in the healing of

    disease. See Bayit Hadash to Tur, YD 336 and Metsudat David to II

    Chr. 16:12. Maimonides, Commentary to M. Pesachim 4:9, interprets

    the case of King Hezekiah so as to avoid its anti-medical

    implications, and he sharply rejects the suggestion that reliance

    upon medicine is evidence of a lack of trust in God. As for “the

    best physician is deserving of hell” (see note 4), R. Shmuel

    Edels explains that this refers to the arrogant physician who,

    thinking he is the best, injures or even kills his patient out of

    a refusal to consult other doctors (Maharsha, BT. Kiddushin 82a).

    See also Sirach 38:1-8 on the physician and the pharmacist as the

    instruments of God’s healing.

  • Nachmanides, Torat Ha-Adam, ed. H.D. Chavel, Jerusalem,

    1964, pp. 41-42. Rabbis through the ages have sought to resolve

    this position with that of Ramban on Lev. 26:11. Their general

    approach is to declare that, while in an ideal past we were able

    to rely upon spiritual healing, we no longer merit that status.

    On the contrary: today we are forbidden to abandon the workings

    of the natural world and to rely instead upon miracles. See Turey

    Zahav, SA, YD 336, # 1, and R. Chaim Y.D. Azulai, Birkei Yosef,

    YD 336, n. 2. See also R. Yitschak Arama, Akedat Yitschak,

    Vayishlach, who rather than resolving the contradiction rejects

    Ramban’s position in Leviticus on the basis of Biblical evidence.

  • BT. Yoma 85b, from Lev. 18:5.
  • Ramban cites M. Yoma 8:5-6. The physician’s role in

    deciding when the laws of Shabbat and Yom Kippur must be set

    aside is discussed in SA, OC 328 and 618.

  • BT. Sanhedrin 73a; Rambam, Commentary to M. Nedarim 4:4.
  • Tur and SA, YD 336:1.
  • Rashi to M. Kiddushin 4:14 (82a).
  • See R. Meir Steinberg, Assya, vol. 3, 1983, pp. 341-342,

    who forbids physicians’ strikes on this basis.

  • BT. Baba Kamma 116b.
  • Commenting upon Exodus 21:6, Rabban Yochanan ben Zakai

    condemns the Hebrew slave who chooses continued slavery over the

    freedom to serve his true Master; BT Kiddushin 22b.

  • Yad, Hilkhot Sekhirut 9:4; SA, CM 333:3.
  • BT. Baba Batra 8b; Yad, Hilkhot Mekhirah 14:9; SA, CM


  • SA, CM 333:5.
  • Yad, Hilkhot Rotseah 1:14, from BT. Sanh. 73a.
  • YT Nedarim 4:2; SA, YD 336:1.
  • Can one be paid for performing a mitzvah? Not precisely,

    say the rabbis; but one may be compensated for the expense

    incurred in doing that mitsvah as well as for the time which one

    might otherwise have spent in gainful employment. See SA, YD


  • Ramban, Torat Ha-Adam, p. 45; Isserles, SA, YD 336:3.
  • SA, YD 336:1.
  • See R. Eliezer Waldenberg, Resp. Tzitz Eliezer, v. 5,

    Ramat Rachel, ch. 24, # 6. On this reasoning, R. Shelomo Goren

    permits doctors to strike. So long as they provide medical

    treatment at a reasonable cost, the responsibility for meeting

    that cost rests upon the government. See Sefer Assya, v. 5, 1986,

    pp. 41-54.

  • See the resolution in support of a national health care

    system that would provide comprehensive medical benefits to all

    residents of the United States; “National Health Care,” CCAR

    Yearbook, v. ci, 1991, pp. 32-34.

  • See M. Sotah 9:6 on Deut. 21:7.
  • As is the case with tsedakah, an “equal share” will differ

    depending upon an individual’s financial means; see SA, YD 248:1.

    The point is that we must all contribute and not leave the

    responsibility with the physicians alone.

  • BT. Baba Batra 8a-b; Yad, Hilkhot Matanot Aniyim 8:10. And

    see our responsum 5753.5.

    If needed, please consult Abbreviations used in CCAR Responsa.