Monday, April 22, 2013

Rav Moshe Feinstein: Can A Jewish Physician Work On Shabbos And Can He/She Violate Shabbos For A Non-Jew

I will be translating and discussing Rav Moshe Feinstein's Responsa found in Igros Moshe volume 6 (Orech Chaim, Chelek 4:79)

Question from my friend Menachem Dovid Zomba (?):
When a [medical student] finishes his training to become a Physician and G-D has made him successful to become His messenger. [The physician is given the opportunity] to heal the sick [people] that come to him, [at that point what would you (Rav Moshe) say to him] if he wants to know how to deal with all the things that are pertinent to the [Torah's] laws (halacha)? I am writing this in short, but [I also want to know] more than what I have asked because this is an integral subject.

Answer of Rav Moshe:
The Rambam writes in the beginning of the second chapter of Shabbos:
Shabbos is suspended in the face of a [situation] that causes a danger to life, just like all other commandments [are pushed off in the face of a life and death situation.]
The Kesef Mishna writes (there):
The [Rambam's] intention is that [Shabbos] is suspended but it is not made permitted.
This [opinion] seems puzzling because on Shabbos, with regards to [dealing with] a sick person, even if it is possible to do [forbidden actions] through a non-Jew in a permissible way, it is permitted [to violate Shabbos.] On the contrary [to the Kesef Mishna's opinion], the Rambam writes (Shabbos 2:3) that Even when there is a non-Jew in front of us [ready to deal with the sick person], we do not do these things (acts of healing that violate Shabbos) through a non-Jew or small children, [but rather through an adult Jewish male.] The Kesef Mishna explains [the reason the Rambam says this is] perhaps the onlookers will say that [violating Shabbos for saving a life]is only permitted with difficulty and it will be they won't want to desecrate Shabbos through a Jewish Adult male. Also, because they will not be so zealous [to save someone's life on Shabbos] as the Kesef Mishna brings over in the name of the Ramach [and this will be bad for the one whose life is in danger.]

If this is [what the Kesef Mishna believes] then in what way does it matter that Shabbos is suspended and not made permitted [with regards to saving a life?] This is not similar to the laws of impurity that are permitted for the congregation according to Rav Sheshes. [For he] only suspends [the laws of impurity by the entire congregation] therefore it is better to bring pure [Kohanim (priests)] from another family, like it says in Yoma 6b.

We need to say that even though this is practically irrelevant, [still we need to discuss this because of the principle of] putting in effort to go after the permitted track. We need to know if doing a [forbidden] act on Shabbos for saving a life is really [considered] a forbidden act, but nevertheless [Shabbos] is suspended and one is obligated to transgress the forbidden act of Shabbos, and the same goes for other forbidden acts, with regard to saving a life. On the other hand, [it could be] that this is not considered a forbidden act at all when it is for saving a life. Even though this is practically irrelevant once the sick person has already come to [the physician,] there is a relevant issue. This issue pertains to a physician that is in a place that has many physician, then he should not place himself in a situation where he is easily found [on Shabbos,] rather [the physician] needs to close his office [on Shabbos] and the number that is listed in the phone book to find him should be his office number and not his house number. This is in order that he should only be found by those who recognize him even if this physician deals with Jewish sick people. Also, this physician should not carry a telephone (beeper?) with him in order to hear anyone who calls him. For, after [we established] that there are more physicians [in the area,] he has no obligation except to those [sick people] who actually come to him. The reason for this is that not every man has the merit to be a healer (therefore, if people come specifically to this Jewish physician because of his unique skill it is permitted). [Still,] a physician has an obligation to make an effort that [sick people] should not come to him [on Shabbos] once he is in a place that has other physicians, especially if there are non-Jewish physicians, that sick people, even Jews, can go to.          
Even if [the physician] is in a place that a majority [of the city] are non-Jews and the minority are Jews and he is recognized by [the people of the city] and they know to come to him when they need to be healed in a dangerous situation, then for his dealings with the non-Jews, he should follow the laws of the country. For, it is certain that a physician gets a day off and since the physician is a Sabbath observer, he should designate his day off as Shabbos so that he can leave his house on [Shabbos.] This is what the physician must do, or he should find another way that he should not be found.

Even with regards to this law, and the majority of the laws, it is not practical whether the [laws] are suspended or permitted. Nevertheless, the physician should be zealous to know that [these acts of healing on Shabbos] are forbidden things, but they are permitted because of a danger to life so he should be careful to differentiate between what is permitted (that which is necessary to perform for the patient on Shabbos) and what is forbidden (that which is not necessary to perform for the patient on Shabbos).

Now, I have introduced what a physician needs to know and one need not worry that he will come to desecrate Shabbos. This is  from the aspect that sometimes [a physician] needs to do a forbidden act on Shabbos for a sick person. [Therefore,] I will return to the question of [a Jewish physician] dealing with a [sick] non-Jew [on Shabbos.] It is clear and simple that the answer that Abaye gives in [Tractate] Avoda Zara 26a that [a Jewish midwife] can tell [a non-Jew giving birth] that [the reason the Jewish midwife can not deliver the non-Jewish pregnant woman] is because "for us that guard the Shabbos we can desecrate the Shabbos [and deliver a Jewish woman's baby (the reason being that there is a danger to life),] but for you that do not keep the Shabbos we can not desecrate the Shabbos [and, therefore, can not deliver a non-Jewish baby (even though there is a danger to life).]" We do not accept this answer in our countries, not [to be given to] the sick person and their family, nor to the heads of the country. For, it is certain that if [a Jewish physician] were in a hospital and he said this answer [of Abaye], not only would it not help him (for the non-Jew would not accept this answer) when there are no other physicians there and he does not want to heal, we definitely do not pay attention to his words. Also, if there are no other physicians there we judge him like a negligent person and a murderer if, heaven forbid, there would be any reason (like the non-Jew dying or contracting some type of illness).

Therefore, with regards to working in a hospital, for there are definitely many physicians in a hospital and there are even more physicians looking for work, and the majority of these physicians do not want to be there on Sunday, it is possible for a physician that follows the Torah to switch his work duty hours that he should always work on Sundays instead of Saturdays and the non-Jewish physicians will work on Saturdays. I know many Torah observant physicians that do this.

Essentially, [one could switch Saturdays for Sundays] with a Jewish physician that is not Torah observant that also wants to be [in the hospital] on a Saturday rather than a Sunday. There is a real permissible way [to do this.] The Torah observant physician should request from the administration of the hospital that his duty hours should always include Sundays [instead of Shabbos.] This is ok even though because of this it will force other Jews to come in [on Shabbos] because there are not enough non-Jews to fill the duty hours for Shabbos. This is true even if the other Jews are Torah observant, but in private they are not careful about [all the Torah's laws.] And this is even [a better option] when there are enough non-Jewish physicians that [will allow] all the Torah observant Jews to not have to have duty hours on Shabbos, even if on account of this non- Torah observant Jews will have to work on Shabbos.

However, even if [one is] not able to [arrange this] and the Torah observant Jew is scheduled for duty hours on Shabbos, he should still try to switch his [Saturdays] for a non-Jewish physician's [Sundays.]  Also, there is a big reason to allow [a Torah observant Jew] to switch with a non-Torah observant Jew, because even when [non-Torah observant Jews] stay in their houses they desecrate Shabbos on purpose with any forbidden acts that they want to do, and this is no less than the forbidden acts that they would do in the hospital. This is not considered "Placing a stumbling block" because you are just switching forbidden acts with forbidden acts. In fact, [the non-Torah observant Jew] may be doing even less [forbidden acts in the hospital] because there are many sick people that [performing forbidden acts for them] is permitted. Also, many [of the forbidden acts in the hospital] are only Rabbinically forbidden and the majority of [the forbidden acts] that he does in his house are Biblically [prohibited.]

However, once it is set that [the physician] must be in the hospital on Shabbos or that he is already the established physician that even if his office is closed on Shabbos sick non-Jews will specifically come to him with their dangerous matters, he is forced to deal [with the sick non-Jew] even if he has to desecrate Shabbos through something that is Biblically prohibited. Even more so, if a disaster happens close to [the physician's] house that they call all the nearby physicians more so than the distant physicians, since in our countries they do not accept the excuse of Abaye, it is a real and present danger for [the physician] to his physical body from the family members of the sick person. Also, if [the physician] is not worried that there is any personal danger to him, he should still be worried that this will create a great hatred [for Jews] from the people of the country and their leaders. For, he should be worried of the danger that can result from this.

Even according to Tosfos there (Avoda Zara 26a) heading Savar, where he is in bewilderment of how is it possible to permit Biblically prohibited acts because of "hatred," [it should be allowed in our case. The reason for this is because] according to the situation in our countries in our day and age there is a great danger from "hatred." Even in the countries that permit every Jew to follow in the laws of the Torah, nevertheless it should not be on account of this (that they let us follow our laws) that [the physician] should not want to save lives [of non-Jews on Shabbos.]

I am in wonderment over what the Chafetz Chaim (Mishna Berurah 330 Seif Katan 5) [says.] He writes:
Physicians, even the righteous ones, travel great distances to heal non-Jews, squeeze out (Sochtim) medicines themselves, and pick fruits (Masik) that [these actions are all] completely desecration of Shabbos with intention. (Saying that one is not allowed to do this)
[The Chafetz Chaim is talking about a situation] even if [not performing these actions] will cause hatred. However, in Russia with regards to small cities that only have one physician for [the city] and all surrounding areas, then it is certain and clear that if he did not go to heal the non-Jew they (the non-Jews) would clearly kill him with their claims that he caused the death of their sons, their daughters, etc. Also, the judges of the country would not punish (the non-Jews who killed the Jewish physician) so severely or they would completely let the non-Jews off for killing him, not even [to punish the non-Jews] in the way that the judges punish small felonies by making them worry, in private, if they will be killed. Also, we see that really we are worried about "Lest he create hatred," for later on in the [Mishna Berurah it is revealed] that his intention (that physicians can not violate Shabbos for a non-Jew) is only with regards to the country of India (?) and if there is no worry about [hatred] then he would not have to [specify] this (therefore we see that there really is a worry for hatred). So, since there is a doubt (of danger) in every situation, even if it is a small doubt, we are lenient by a life in danger (and allow a Jewish physician to treat a non-Jew on Shabbos).

Looking at the Chasam Sofer found in Yoreh De'ah 131 where he writes in his commentary:
If there is "hatred," this is a worry of danger to life, then we can permit even a Biblically forbidden act.
[According to] the language of the Divrei Chaim (Volume 2 Orech Chaim Siman 25) after he writes that because of "hatred" we can not desecrate Shabbos with a Biblically forbidden act of picking fruit (Masik), [he continues and says:]
But the custom of physicians is to be lenient by this and I heard that there was a decree of the land that permitted them [to do so.]
It appears to be [that he says this because] he does not understand which decree deals with this. We need to say that his intention is that even though he himself holds that we should not worry about the danger because of "hatred." Nevertheless, he does not say to protest the physicians that are lenient because he is not sure that there is no worry of danger for the reason of his assessment that there is no danger. [It is possible] that [his assessment] only pertains to where he lives, that perhaps in his place and the surrounding areas there are many physicians and they (the non-Jews) do not care so much. For, even if it was certain that it would add hatred because of [not treating non-Jews on Shabbos,] this is just generalized hatred that a non-Jew has toward a Jew (in the days and area of the Divrei Chaim), for there is a great deal of hatred, and there is no [added] danger. However, know that there are definitely places where a physician can not be found and there is a worry of danger [if the Jewish physician refuses to heal a non-Jew and it would then be allowed. Therefore,] the Divrei Chaim writes that this is the custom of the physicians (that they treat non-Jews on Shabbos even by desecrating Biblically forbidden acts) even where he lives and they do not protest because he heard there was a decree to permit them [to do so] in every place. The reason for this is so that [the physician] should not err and be stringent even in a place where the "hatred" will cause a danger [to life.]

This [opinion of the Divrei Chaim] is like that which we see in the Taz (Orech Chaim) 328 Seif Katan 5:
Even if a non-Jew is prepared [to do the act that is forbidden on Shabbos and heal] we have an adult male Jew do it. [The reason for this is because if we always relied on a non-Jew] we see from the Gemara that it will be a stumbling block for the future (because when a non-Jew is not available an adult male Jew will not want to do it). 
This [idea] is even more so by our case (that a Jew will not want to violate Shabbos for a non-Jew) for there will always be a stumbling block because every place has dangerously sick non-Jews. This is the reason for the decree of the land (that physicians can be lenient even by Biblically forbidden acts on Shabbos even for non-Jews). This ["decree"] is not actually a decree, rather it is the actual law (halacha) and the reason we have the language of decree is just so it will be publicized (See Tractate Munachos 68b where it uses decree in this way).

The Divrei Chaim, himself, perhaps he was holding that we do not want to teach things in one place and have them carry it to another and therefore even in his area where there is no danger they do not protest (the custom of the physicians to be lenient).

However, in our times we should be worried about the danger that we have illustrated in every place. Also, from the aspect that the news is made known through the newspapers what is done in the entire world, therefore, there is the stumbling block of people will learn from one place to another (if they do not treat a non-Jew on Shabbos in one place, some other place might not treat a non-Jew on Shabbos even if they should). Furthermore, it will instigate an increase in hatred to the extent that there will be many killings on account of this. Therefore, it is obvious that in our times we should judge this like an actual danger and that is why it is permitted. 

End of Igros Moshe
That is where I will end my translation. Rav Moshe goes on to talk about accepting money for treating on Shabbos, but this is enough for now. I would like to sum up the opinion of Rav Moshe. Simply put, an Orthodox Jewish physician should try his hardest to not work on Shabbos. However, if he must then he can even treat non-Jews on Shabbos. He can even violate Biblically forbidden acts in order to take care of his patients. 

In my opinion, I can't see why a resident physician would be different than a physician that has finished his or her residency. Both can write orders that take care of critically ill patients. The only caveat is that an attending physician will, EVENTUALLY, have to sign off on your orders. In some situations, the resident is the ONLY physician in the hospital that is able to take care of certain patients. That is why, based on this Rav Moshe, I think that a Shomer Torah and Mitzvos Jew needs to pursue a Shomer Shabbos residency. However, if you are unable to get one, then you can go to a non-Shomer Shabbos residency. However, you also need to try your hardest at the non-Shomer Shabbos residency to get out of working on Shabbos and Jewish holidays. In the end, if you are unable to not work on Shabbos then you would have the same laws apply to you, as a resident, as an attending Orthodox Jewish physician has.

I am very confused by Rav Schechter's (Rosh Yeshiva at YU) psak (ruling) that a resident is not allowed to attend a non-Shomer Shabbos residency even if he or she has pursued the Shomer Shabbos route. I can understand that a medical student is not allowed to do any forbidden acts on Shabbos, even Rabbinicaly decreed, but not a resident. The reality of the situation is that a resident is just as involved as a regular practicing physician. As a resident, you offer just as much care as an attending, but the attending signs off on your work, sometimes, hours later. This being the case, I have no idea why you would not be able to attend non-Shomer Shabbos residency if that is your only option. Rav Moshe seems to say that if your only option, as a physician, is to work on Shabbos then it is allowed.   

On another note, I am really confused by the Chafetz Chaim's statement, just like Rav Moshe. How can he be so disparaging about Torah Observant Jews when there are CLEARLY opinions that contradict him? I like how Rav Moshe explains him, but his statement allows for so many uninformed people to say that a physician is not allowed to work on Shabbos even to perform forbidden acts that are Rabbinical in nature. I have heard and seen this in so many places and reading Rav Moshe leads me to believe these people are fools. Especially if Rav Moshe is right and the Chafetz Chaim is only talking about a place where no danger exists, which that situation does not exist anymore as Rav Moshe points out due to newspapers and television.

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