Autopsies In Halacha

Since I am a pathology resident, I do a fair amount of autopsies (50 are required to graduate). Therefore, it was incumbent upon me as an orthodox Jew to look into the legal challenges with this subject. I have become accustomed to ask my questions to Rabbi Tendler, but since I was reading through the Nishmat Avraham and I found this paragraph I thought I would share:

and here are the sources:

The previous pages of the Nishmat Avraham go through why it is forbidden to perform an autopsy on a deceased Jew. He quotes one opinion that it is allowed for learning medicine, but firmly brushes that opinion aside and says it is irrelevant since most opinions say it is forbidden. He goes on to say how even if the person himself, let alone his family, requests an autopsy or donates the body to science since they do not have ownership over their body their words are meaningless and an autopsy may not be performed.

The only time an autopsy may be performed is when it will somehow save a life. (Most, if not all, autopsies are not done to save lives.)

The reason I find this specific paragraph intriguing is because the law in the Shulchan Orech (Yoreh Deah 349:1) which all of this is derived from equates a Jewish corpse and a non-Jewish corpse. Why then are there so many special rules by a Jewish corpse, but a non-Jewish corpse can so easily be used?

I have not looked through all of the sources since I am limited with my referencing materials. However, using Hebrewbooks.org I was able to find a good Shulchan Orech, Yoreh Deah that had many commentaries. There, I was able to find the Pischei Teshuva on this halacha (Yoreh Deah 349:1) which gives a foundation to the seemingly lenient opinion by non-Jews, but the much stricter opinion by Jews. It says that the prohibition that one may not benefit from a Jewish corpse is biblical, but not benefiting from a non-Jewish corpse is only rabbinically prohibited.

This actually helps explain HOW one could be allowed to perform an autopsy on a non-Jewish corpse when there is minimal reason and a Jewish corpse would need a maximal amount of reason, but I still need to understand WHY it should be that one is biblically prohibited and one is only rabbinically prohibited. I hope to translate one or both of Rav Moshe Feinstein's Responsa on this subject in the coming days.   

Rav Moshe Feinstein: Can A Jew Have Plastic Surgery

The Responsa of Rav Moshe Feinstein in Choshen Mishpat 2:66 (In Volume 7 of Igros Moshe) can be found in the original Hebrew version Here. The following is my translation with my comments.

66. Is a Young Woman Permitted To Beautify Herself Through The Use Of Surgery Which Causes a Wound To Her Body?

Rav Moshe's Responsa:
It was asked of me if, in order to get married, a young woman can beautify herself through a doctor using surgery which causes an injury to her body. Is it permitted with regards to the prohibition of "Injuring Oneself?"

It is [found] in Tosfos, Babba Kama 91b heading Rather [this Tanna], that there is a prohibition to injure oneself even in a necessary situation. For example, [the case in the Mishna on 90b (found here) of it being forbidden for] a woman to uncover her hair in order to place an isar (some amount) equivalent of oil on her head for a benefit (she was damaging herself, by uncovering her hair, for a benefit, but it was still deemed impermissible). If so, even here (by having plastic surgery in order to get married) which is considered a great need, apparently it would be forbidden because it is a stretch to [try] and separate between a small need (this case quoted from the Mishna) and a great need (our case of a woman wanting to get married) as long as we can not find an explanation [of the difference] (between a great need and a small need).

However, we can ask a question on this [understanding of Tosfos] from the conclusion that this Tanna is Rabbi Elazar Hakafar in the name of Rebbe. This Tanna holds that a Nazarite is a sinner because he causes himself grief [due to] wine and there is a fortiori argument (kal vichomer in the Gemara found here) for the one that causes grief to himself with an injury (that he is also a sinner). [However,] it is clear that logic dictates if he (the Nazarite) had a monetary benefit or another type of benefit when he is causing himself grief by not drinking wine, this would not be forbidden. If this is so, then it also holds true by one who injures himself, which we learn from a fortiori argument [from the Nazarite,] that it should not be forbidden when there is a need (to cause the injury) for monetary gain or some other need. [Therefore,] how can Tosfos write that even if it is necessary (for some benefit) it is forbidden to injure yourself?

[To understand Tosfos] we need to say that [the case of] holding back from drinking wine for any beneficial reason is not considered to be causing grief since the beneficial gain (from not drinking the wine) is greater than the grief it causes. For, [if he were to] drink then he would not gain [anything] and this would cause even more grief [than not drinking in the first place] because he would lose [whatever beneficial] gain he would have attained if he did not drink the wine. [This means] all of the grief that occurs from withholding from drinking wine is only from the aspect of his desire to [drink wine] (meaning, a person only experiences suffering from withholding wine because he desires to drink it). [However,] by us he has a [greater] desire to [attain this beneficial] gain [he gets from not drinking] (Therefore, we see this guy is actually not suffering at the end of the day). However, injuring himself causes actual grief (physical, materialized injury) that is not from the aspect of [one's personal] desires, it is not interchangeable with the grief of not [attaining a beneficial] gain that is only [considered grief] from the aspect of a person's desire to profit. [In a situation] that a person wants to injure himself in order to profit, that he has a great desire to attain monetary gain and therefore is willing to suffer grief, this is [still] forbidden.

Furthermore, according to the [final] law we do not hold like Rabbi Elazar Hakafar in the name of Rebbe and, nevertheless, the Rambam decides in the beginning of Chapter 5 of Injuries (Chovel) that it is forbidden to injure oneself, like it is stated in the GRA Yoreh De'ah Siman 236 Seif Katan 6. If this is so (that the GRA is right about the Rambam holding that injuring oneself is forbidden) he is learning it from somewhere else (and not Rabbi Elazar Hakafar in the name of Rebbe) that it is [forbidden] in every situation, even when there is a need.

However, in any case, if it is necessary according to Rabbi Elazar Hakafar in the name of Rebbe  to say that when it is needed [to injure yourself] it is permitted, that would be a proof that everyone holds [when it is needed then it is permitted] because we don't find anyone who argues [on Rabbi Elzarar Hakafar in the name of Rebbe.] Also, concerning the Mishna that is dealing even with [a case of] there being a need and Rabbi Akiva says it is still forbidden the Gemara brings it from Rabbi Elazar Hakafar in the name of Rebbe saying that even according to Rabbi Elazar Hakafar in the name of Rebbe it is forbidden to injure yourself even when there is a need (This reveals that, according to everyone, injuring yourself is forbidden even if there is a need). Therefore, it is necessary to say like I answered (Basically, that an actual injury to yourself is not allowed even if done for some type of gain, but a denial of a desire that causes you non-physical pain would be allowed).

Still, the Rambam writes in the beginning of chapter 5 of Injuries (Chovel) with regards to the prohibition of hitting an upright Jew, this [prohibition] is for hitting in the way of strife. According to another version it is referring to [hitting] in a derogatory fashion, see there (English, Hebrew). If so (that the injury is prohibited if it is done in the way of strife or degradation), with our situation (plastic surgery) that the injury is to beautify and there is no [injury] in the way of strife or degradation then the prohibition is not relevant. [Furhtermore,] if injuring a friend is only [prohibited] when done in the way of strife or a derogatory fashion then also with self inflicted injuries it is not forbidden when done to beautify because that [also] is not done in the way of strife or in a derogatory fashion.

This idea that my friend Rav Tuvia Goldstein SHLITA [learned] from the language of "And not just the injury itself, but all who injure upright Jews in the way of strife transgresses a negative commandment" that the condition of "the way of strife (that the Rambam says)" is only with regards to the blow and not the injury, does not make sense. For, whether it is [referring] to the injury or the blow, it is all learned from the one verse of (Devarim 25:3), "Do not add." This implies that, according to the Rambam, the adding of lashes is considered the way of strife and degradation and from this [verse] you are not able to learn about the blows that are not given in the way of strife or degradation. If so (that our logic is correct), then the injury is specifically included in the way of strife or degradation and this condition of "the way of strife" also applies to the injury (not just the blow) because it is irrelevant to try and separate a teaching in one verse (meaning, it is not the correct thing to do to separate the injury and the blow which are both learned from one verse).      
 
A proof to the Rambam's opinion can be brought from that which was said in Babba Kama there (91b, translation in Soncino), "R. Hisda, whenever he had to walk between thorns and thistles used to lift up his garments Saying that whereas for the body [if injured] nature will produce a healing, for garments [if torn] nature could bring up no cure." If every injury is liable (forbidden to be done) how was it permissible for him (Rav Chisda) to go between the thorns and thistles without clothing [protecting his feet]? This would [definitely] cause an injury to himself and would be a transgression of the prohibition of causing an injury to oneself even though it was not his intention, but it is a pesik Reisha (sure thing that it is going to injure him) since it is a stretch to say it was done in a way that it was not a pesik Reisha (not a sure thing to injure him). Therefore, we need to say that the prohibition of injuring only applies if it is done in the way of strife and since [Rav Chisda] needed to walk [through the thorns and thistles] this is not considered the way of strife and there is no prohibition [for what Rav Chisda did.]

We need to say that there are [situations] of need that are prohibited when they are done with the intention to cause grief. For example, someone who tears [their clothes] because of a dead person that it (this tearing) causes extra grief [in addition to] his grief over the deceased and he wants to destroy [something] (this is not allowed). However, according to this, with [regards to the issue of] injuring oneself,  it should also be prohibited for a person to scratch [themselves] because of the deceased. For, the desire and need is to cause [more] grief from this [scratching] and this is done in the way of strife and degradation which is prohibited even if there is a need, because the desire to have [added] grief is considered a need to him (the one mourning over the deceased). [The reason this is prohibited is because] the Torah prohibited injuring yourself in any way [that was done within the boundaries of strife and degradation.]

[However,] we can ask from this [law] of scratching because of the deceased that it required a different verse [to prohibit] it (Vayikra 19:28). [This seems to imply] that scratching because of another distressing factor, like a house that collapsed, or a boat that sank in the sea, there [seems to be] no prohibition, like that which is seen in the Gemara in Makkos 20b. It is difficult to suggest that [the verse that says you can not scratch yourself because of the deceased] is an extra prohibition and the exception to this prohibition is that of when the house collapses [and it is permissible to scratch yourself. However, this] is only an exception to that verse, but it is still prohibited because of the law of injuring yourself. [The reason it is difficult to claim this] is because Tosfos says in Sanhedrin 68a, with regards to the incident where Rabbi Akiva struck himself until blood flowed down upon the earth [after] the death of Rabbi Eliezer (See Gemara in English here) says, "There [is no prohibition of] scratching oneself [here] because he did it because of Torah [learning], like [Rabbi Akiva exclaimed, "I have a many coins] but no money changer to accept them" (Meaning, I have many questions on Torah, but no one to answer them). (Tosfos seems to be saying that one is allowed to scratch themselves if they are scratching themselves for a reason other than grieving specifically for the deceased. In Rabbi Akiva's case, he scratched himself because of all the Torah learning he would miss out on and that seems to be allowed without any prohibitions.)

However, we can still ask because of the [prohibition of] injuring oneself [it should be forbidden (to cause yourself extra grief through scratching). In fact,] Rabbi Akiva in the Mishna (Babba Kama 90b) holds that it is forbidden to injure yourself. And it is difficult to say (to give an answer to our question of it should still be prohibited under the law injuring yourself) that this (that one may scratch himself for any reason other than causing himself grief over the deceased) is like Rabbi Akiva of the Braisa (91a) and not like Rava that holds according to Rabbi Akiva of the Braisa it [really] is forbidden to injure [oneself (just like the Mishna),] because then we could ask from the Braisa in Sanhedrin (68a, where Rabbi Akiva actually injures himself).

[Furthermore,] we can't say that scratching is considered giving honor to the deceased by [showing that one is] especially grief stricken because of him (or her) to the point that a person scratches and causes groups [of scratches] in their flesh and, therefore, this [would not be] considered the way of strife (thereby it would not be forbidden). [The reason is,] even for honoring the deceased [in this way,] this is considered the way of strife and degradation since the honor of the grief and degradation is because of [the deceased.]

We need to say [the reason this scratching is not prohibited under the law of injuring yourself is] that he is silencing his grief with this [scratching and it] is like that which is said in Gemara Shabbos 105b. Rashi explains the phrase in the Mishna (there) about he who tears in anger according to Rav Avin who says it is a reparation, for it calms him down because he forgets his anger (this guy that is angry and tears something is soothed because the ripping makes him forget his anger). So too, when someone injures themselves it [helps] him forget and silences his grief and anger that he has from the deceased. Therefore, this is not considered the way of strife and degradation, [therefore,] the aspect of the prohibition of injuring himself is not present. Only because of another prohibition, that of scratching because of the deceased [is present. However, scratching oneself] because of his collapsed house or boat that sank is not prohibited and, therefore, Rabbi Akiva's [case] was permitted because his grief was over the Torah [learning and the scratching was] to quiet his grief.

I saw in the Orech La'ner in Yevamos at the bottom of 13b this question (about Rabbi Akiva saying it is prohibited to injure yourself, yet we see Rabbi Akiva injured himself) and his answer was [if you scratch yourself] because of honoring the Torah it is permitted, just like there is no [prohibition of] waste when mutilating [an animal] for a royal funeral (This is a transgression of wasting the animal, but since it is for the honor of royalty it is allowed because of the honor given).  [However,] this does not appear to be correct at all because there is no honor for the Torah with this (scratching yourself). [In fact,] the Torah despises this kind of "honor." [Also,] in Tosfos it does not mention the word honor, rather [Tosfos explains that] he was grief stricken over the Torah [that he would miss out on] when it says "I do not have a money changer." Furthermore, this is found in the Shach in Yoreh De'ah Siman 180 Seif katan 10.

Additionally, the answer that [Rabbi Akiva scratched himself] unintentionally and did not expect blood to come out with his blow, just like the [story] of Rava in Gemara Shabbos 88a, "While the finger[s] of his hand were under his feet [and he ground them down, so that his fingers spurted blood,]" this is [also] not right at all. Over there[, by Rava,] his fingers were placed in a way that it was not a blow. Also, the grief (or pain) was minimal because the legs just happened to be [in a position] that crushed [the fingers] and he did not [even] think about it, that is why it is relevant to say that it was unintentional. However, where [Rabbi Akiva] hit himself with the intention to cause himself grief (pain) it should definitely enter his mind that [the blow could cause] blood to come out, so how is it relevant to consider that [Rabbi Akiva hit himself] without intention?

Also, we can not answer like that which the Bais Yosef holds in Yoreh De'ah there (Siman 180) that if it is a different grief (other than a deceased person) it is permitted [to scratch yourself] (The reason this answer can not be accepted, in my opinion, is because it does not answer the question. First of all, why is a scratching other than for a deceased person allowed from the aspect of injuring yourself? Second, why is injuring yourself on account of the deceased not prohibited under the laws of injuring yourself? Why does it need a separate verse?). So too, the Ramah holds this there (Siman 180 Seif Katan 6). Rather, we need to say as I have explained.

See the Shita Mikubetzet in Babba Kama 91b in the name of the Ramah that says that this [case] of Rav Chisda teaches us that a man is allowed to injure himself and we rule like him since he is a later [authority.] However, he asks on the Rambam why he says [injuring himself] is prohibited. But, [the Rambam] is as I have written that he only holds [injuring yourself] is prohibited if it is done in the way of strife.

However, it appears that we can ask from Sanhedrin 84b that Rav would not permit his son to extract a thorn [from his flesh, since in drawing it out he would make a slight wound. And the Gemara] asks, if so (that this is prohibited because it makes a wound) then it applies by other [people] as well (even if they are not a son). However, this injury is not done in the way of strife and degradation since his intention is to extract the thorn and there is no prohibition of "do not add" (Devarim 25:3, with regard to lashes). Also, this is not similar to a son [causing an injury to] his father which [the son is then liable] to [die by] strangling even if the wound is not in the way of strife or degradation, where the only exception is for healing (the son is not put to death if he causes an injury to the father while trying to heal, but he is put to death in other situations even if the injury was not caused in the way of strife or degradation).

And we need to say that there is a fear (in the case of Rav and there is a good question from this Gemara) that perhaps [the son] will injure [the father] more than what is considered the way of healing, like is found in the Nimukei Yosef in the name of the Ramban (19a on the pages of the Rif). The intention is that this (act of healing by the son for the father) should be done in a way that [the son] is able to be careful that he does not injure [the father] more than necessary. But, if he can not be appropriately careful because of the bother and this injury is larger [than necessary] it is considered [to be done] in the way of strife and degradation since it (the injury) was not needed for healing. [Also,] this warning, for a man is always considered forewarned, is like he did not think about the prohibition (for a son to injure a father) due to his laziness to [heed] the warning. Therefore, we find that he transgressed the prohibition of injuring through negligence. [Hence,] this is a good question (what we originally asked, that it should apply by other people as well) and it should be prohibited [for everyone] if there is this concern with a son to his father (that the son pulling out the thorn may damage his father more than necessary).        

In fact, from the [idea] that the Gemara explains, that it is permitted to let blood from a friend, and we ask if it is permitted for a son to [let blood] from his father, this is a proof that the prohibition to injure, that we learn from (Devarim 25:3, with regard to lashes) "do not add," is specifically in the way of strife and degradation and not when an injury occurs during healing. However, with regard to injuring your father, that it simply says (Exodus 21:15) "Strike," there is room to say that even in the case of healing [the son] will be liable [for punishment] when there is no danger, for the law of saving a life pushes off [this law (but when there is no danger, healing does not push off any laws).] If so (that you are allowed to let blood from anyone and there is no prohibition of injuring because it is not in the way of strife and degradation), you can learn from this that also in a case that is not for healing, if the injury is in a way that is for his (the person receiving the injury's) good and it is not in the way of strife and degradation it is permitted, like the Rambam holds.

[Therefore,] we are forced to say that this question of it should also be forbidden for another (not just a son to a father) when removing a thorn is because there is a warning from injuring more than what is necessary [and if an injury does occur then it] is considered the way of strife and degradation, like I have answered.         
Additionally, there is a proof from the story in Sanhedrin 89b of where Micah says to his friend, "Please, smite me," that the one who refused to smite [Micah] was punished by being stricken by a lion. The Gemara asks, "From where did he (the one who refused to smite Micah) know he should be punished?" The Gemara answers, "Where  [the prophet is] well established (as a prophet) it is different" (Even though Micah did not give a sign that he was a prophet, since he was an established prophet, this "friend" should have listened to him. See the Gemara there for a better understanding). [The Gemara] needs to prove this [idea] from Avraham at Mount Moriah and Eliyahu at Mount Carmel (that they were listened to even though they had not performed signs because they were established prophets) and [the Gemara] does not prove [its point] from this [case of Micah] itself. If you don't say this (that Micah is an established prophet and, therefore, you believe he is speaking the word of G-D) it would be forbidden to listen to him (Micah) because of the prohibition of (Devarim 25:3, with regard to lashes) "Do not add." We see that from the aspect of the prohibition of "do not add" it was permitted [for the "friend" to hit Micah] since [Micah] said to him that it was the word of G-D that he should be hit and that [makes it] not the way of strife and degradation.

[Furthermore,] even if [Micah] was not yet established as a prophet and it was not permitted to trust him to transgress a prohibition, nevertheless, since he did not say that he should be hit because he wanted to injure himself, but rather because it was the word of G-D, and he believed this was [the word of G-D], in no way is this considered the way of strife and degradation. Also, [this friend of Micah was] permitted to believe [Micah] since he is a great and wise man and it would be appropriate for him to receive prophecy. [This is true since] even if there is no obligation to believe [a prophet] until he performs a sign and wonder, like the Rambam says at the end of Chapter 7 of Yisodei HaTorah. Nevertheless, [the Rambam holds] it is permitted to believe him when he is fit for prophecy since if the truth is like his words, then there is no prohibition at all. (Therefore, since the injury would not be in the way of strife or degradation it is allowed)

[Plus,] you can not push off the prohibition (of injuring) from the aspect that it is a command of a prophet because he is only permitted to be believed [to give a command] if he gives a sign or is an established prophet. However, if the prohibition of injuring applied in every situation (even if the injury would not be in the way of strife and degradation) and it was only because of the commandment of the prophet (that Micah was telling the friend to hit him), he would be obligated to transgress the prohibition of injuring and [the Gemara] would have proved this idea that a prophet who is established is different and does not need a sign from this case [of Micah] itself (and it would not have needed to bring Avraham or Eliyahu to prove this idea). If this is so (this explanation of the Gemara in 89b), then it would be a proof to the Rambam (that the prohibition of injuring only applies when it is done in the way of strife and degradation).

Accordingly, it appears from this [reasoning] that it is permitted for a young girl to beautify herself even if it is through causing an injury [to herself] since [the injury] is not done in the way of strife and degradation, but rather the opposite, [it is done] for her benefit.

See Sanhedrin 84b that Rav Masna says a son is allowed to let blood for his father because of the verse (Vayikra 19:18), " Love your neighbor like yourself," and Rashi explains Jews are warned not to do things to their friends that they do not want done to themselves. It is obvious that the intention is not for a person who does not care to do something to himself that he can then do that [action] to his friend, rather anything that is not for his [neighbors] benefit [is no allowed.] For example, a person who wants to cause himself affliction or injuries, this is definitely forbidden to do to your friend even according to the one that holds injuring yourself is permitted. Not only with regards to injuries [does this idea apply,] but even by a man that does not care about his shame. [This is] not only to uphold the Mishna in Avos Chapter 4 Mishna 4 that says, "Rabbi Levitas, a man of Yavneh, said be extremely humble," see over there the Rambam's commentary on the Mishna with the occurrence with "that" righteous [person.]

Rather, even if it is a person's nature not to care that it is forbidden for him to mock his friend, on the contrary he is obligated to honor his friend, and [he does not care that] it is a great sin to whiten the face of your friend (embarrass your friend) from the prohibition of "you shall not bear a sin on his account" (Rashi says this means "[in the course of your rebuking your fellow,] do not embarrass him in public"). [and] if [the embarrassment] occurs in public the punishment is [the one who embarrasses] loses his share in the World-to-Come, like is explained in the Rambam in Chapter 6 of De'ot halacha 8 (Hebrew here) that the prohibition to embarrass a [fellow] Jew is even in private and [the Rambam] does not mention a difference to say that a humble person (who does not mind being embarrassed) is permitted to embarrass other people. If this [reasoning is correct then] also a man that wants to torture himself with afflictions and injuries, it is forbidden for him to afflict and injure his friend.

However, the intention of Rashi (in Sanhedrin 84b) that an injury like this, that is for benefit, like blood letting, that every man wants and desires to do this to themselves from the aspect of a person's love for themselves, it is not relevant to forbid him from doing this [beneficial] action to his friend and you do not need a verse to allow this [action.] Consequently, even for his father that the explanation does not say the liability for striking him is specifically when it is done in the way of strife and degradation and there is no verse to exempt healing, still it is impossible to forbid [this beneficial action of causing an injury] when it is for the good of the father, like the [case of] blood letting to heal even if there is no fear of danger or loss of life.

It is logical to say that even Rav Dimi bar Chinina (Sanhedrin 84b) that requires a verse to permit blood letting to heal his father and he makes a connection between injuring a man to injuring an animal, he is only referring to injuring his father [that requires a verse] that perhaps there is a loss of fear that comes with the injury and this levity occurs even when blood letting for healing purposes (but no verse is necessary to allow a person to heal a friend). Also, perhaps a verse is necessary if the father does not want an injury, even though it is for healing purposes, that [the son] is also exempt and permitted to do this like the law states in the Minchas Chinuch commandment 48 (the son is exempt from injuring his father against his will if it is for the purpose of healing). [Over there,] he holds that this is not known from "Love your neighbor as yourself" because we find a minority of people that do not want to be caused pain with an injury, even if they know this will heal them, in a case that there is no danger. Therefore, there is room [to claim] that we need to go according to the will of this [type] of person, even though he is from the minority, and we need a verse that connects [injuring a man] to injuring an animal that it is exempt when it is for the sake of healing even if it is against the will of the owners. Since [the healer] did not cause damage in [the animal], on the contrary he increased its worth, and it is not relevant to be liable to give anything for increasing value to a man even if it was against the will [of the owner,] so too it writes by injuring a man, dealing with his father, if it is to heal him [the healer] is exempt even if it is against [the] will [of the father. However,] Rav Masna holds (Sanhedrin 84b) that the verse is not needed because it is logical to follow after the majority of people [and not worry about the minority.] 

[On the other hand] perhaps Rav Masna argues on this and holds that letting blood for the father against his will is forbidden when there is no danger and [Rav Masna] is not like the Minchas Chinuch. So too, it is possible that the Rambam decides [this way], according to what he writes in the 5th chapter of the laws of Mamrim halacha 7 (Hebrew here), that "If, however, there is no one else there capable of doing this but him and they are suffering, he may let blood or amputate according to the license that they grant him." This language implies that without the "license" of the father it would be forbidden for the son to let blood for [his father] for healing purposes because he (Rambam) decides [the law is] in accordance with Rav Masna.

The Minchas Chinuch takes this language of the Rambam and learns that  his language is not specific. However, it is possible that it is specific and [Rambam holds] that it is forbidden to [heal your father] by force because he (the Rambam) is holding there is an argument with this between Rav Masna and Rav Dimi bar Chanina and [the Rambam] decides like Rav Masna. In any situation, the verse that Rav Dimi bar Chanina requires [is only for] one injuring his father [for healing,] but blood letting for a friend [in order] to heal him, that it is permitted even when it is not necessary, does not require a verse according to the Rambam. For, when [the injury is done] not in the way of strife and degradation (like an injury to heal) there is no prohibition. [Therefore,] even if we do not hold like the Rambam in this case since it (the injury inflicted for healing) is for his benefit, it is permitted in its simple understanding without a separate verse, [because it is included in] "Love your neighbor like you love yourself" that Rav Masna says.

But, perhaps what I wrote in the second explanation that Rav Dimi bar Chanina needs a verse for [a situation of] injuring his father against his will, perhaps he also needs a verse for injuring a friend for healing against his will. And, we know this from an "all the more so" [situation] that since injuring his father is permitted through a connection (to another verse), all the more so [injuring] his friend should be permitted. If we say that Rav Masna argues and [holds] that it is forbidden [to injure] his father against his will [in order to heal him,] perhaps he also holds that it is forbidden [to injure] his friend against his will [in order to heal him.] This requires further looking into. According to the law of the Minchas Chinuch it is obvious to him that it is permitted to [injure] his father [against his will for the purpose of healing him] and all the more so with [regards to] his friend.

However, if it is the will of his friend [to be injured in order to be healed] then everyone holds that it is permitted even without a verse. Also, even if we do not hold like the Rambam and we say that it is forbidden to injure in any way (not just specifically in the way of strife or degradation) since [this injuring] is for his benefit and according to his will [it is permitted] from the verse of "Love your neighbor as yourself."

If this is so, then by a young woman that wants to beautify herself, that it is for her benefit and according to her will, we can simply permit it even if we do not hold like the Rambam in his innovation that [injuring someone is only forbidden if done] in the way of strife and degradation.

There is a further slight proof that can be brought from Bechoros 45a that we learned if [the kohain] had something extra [on his body] and he cut it off, if it was forbidden to cut it off then the Mishna should have added in [the phrase] even though it is not permitted, like we learn in the first Mishna of the first (found here) and second chapter (found here) over there (in Bechoros) by someone who sells the [embryo of ] his donkey and [the embryo of] his cow to a non-Jew that we learn [the phrase] even though it is not permitted. [However,] here we do not say this, which implies that it is permitted [for the kohain to cut off extra parts of the body.] It is a stretch to say that these Mishnas argue on Rabbi Akiva of the Mishna in Babba Kama (90b) and hold that [really] a man can injure himself, for the Mishna does not bring this [case from Bechoros] according to the Tanna that argues [on Rabbi Akiva.] Rather, we need to say that since it (this cutting off an extra appendage) is for beautification [of the kohain] and is, therefore, for his benefit and he wants this, there is no prohibition of injuring involved.

From this there is a real proof for our case, that even more so by a young girl that good looks are very necessary and good for her, much more so than a man, for it is seen in Kesubos 59b, Rav Chiyya taught, "A wife [should be taken] mainly for the sake of her beauty." That it is certainly considered for her benefit [to have surgery to improve her looks] and it is permitted to be injured in order to beautify herself.  
End of Rav Moshe's Responsa

I would just like to add that, for a man, this Responsa seems to say that he is allowed to have plastic surgery as well. The main reason I believe this is because of his last point with the Kohanim cutting off extra appendages. For a further look into this idea, see Rav Moshe's Responsa on a man caring about his appearance (found here).

Rambam's (Maimonides') View of Medical Care (Rationalistic Approach)

The rationalistic approach to medical care, in Jewish thought, is best represented by Rambam (Maimonides). The reason for this, I believe, has to do with his view on G-D's role in the world. Where Ramban (Nachmanides) believes that G-D intervenes in every aspect of life, the Rambam believes "nature" is the dominant force in a person's life. G-D only intervenes for the extremely righteous and only on occasion. Rambam says (The Guide For The Perplexed 3:51):

But those who, perfect in their knowledge of God, turn their mind sometimes away from God, enjoy the presence of Divine Providence only when they meditate on God; when their thoughts are engaged in other matters, divine Providence departs from them...Hence it appears to me that it is only in times of such neglect that some of the ordinary evils befall a prophet or a perfect and pious man: and the intensity of the evil is proportional to the duration of those moments, or to the character of the things that thus occupy their mind... Hence it may occur that the perfect man is at times not happy, whilst no evil befalls those who are imperfect; in these cases what happens to them is due to chance (nature). This principle I find also expressed in the Law. Comp. "And I will hide my face from them, and they shall be devoured, and many evils and troubles shall befall them: so that they will say in that day, Are not these evils come upon us, because our God is not among us?" (Deut. xxxi. 17).

The Rambam believes that a normal person does not experience divine providence for the majority of their lives. It is only an extremely righteous and knowledgeable individual that experiences divine providence. Therefore, most occurrences are not due to G-D's direct intervention, but through chance (nature). This approach leads the Rambam to take a much more proactive approach to medical care. Medical care is necessary, in fact obligatory, because G-D did not cause this illness. Chance (nature) is what causes most illness and that is why a Jew needs to take care of himself by staying healthy and going to the doctor. Also, this is why a doctor has an obligation to heal and not just permission.

The Rambam's obligation for a person to seek out a doctor can be inferred from his introduction to Mishna Avos (Ethics of Our Fathers, Chapter 3)

Likewise, just as when people, unacquainted with the science of medicine, realize that they are sick, and consult a physician, who tells them what they must do, forbidding them to partake of that which they imagine beneficial, and prescribing for them things which are unpleasant and bitter, in order that their bodies may become healthy, and that they may again choose the good and spurn the bad

Rabbi H. Norman Strickman explains this excerpt to mean that the Rambam believes a person should consult a physician in times of illness. This idea is also seen in the Rambam's Mishna Torah (De'os 2:1, translation found here)

To those who are physically sick, the bitter tastes sweet and the sweet bitter. Some of the sick even desire and crave that which is not fit to eat, such as earth and charcoal, and hate healthful foods, such as bread and meat - all depending on how serious the sickness is. Similarly, those who are morally ill desire and love bad traits, hate the good path, and are lazy to follow it. Depending on how sick they are, they find it exceedingly burdensome...What is the remedy for the morally ill? They should go to the wise, for they are the healers of souls. They will heal them by teaching them how to acquire proper traits, until they return them to the good path.

It seems like the Rambam believes that the remedy for someone who has bad character traits is the same as for someone who is sick, consult a wise healer. By the morally ill, the healer is someone who can help them with their lack in morality. For a physically ill person, the healer is a physician. This can best be illustrated later on in this section of the Mishna Torah (De'os 4:1 translation found here)

Since maintaining a healthy and sound body is among the ways of God - for one cannot understand or have any knowledge of the Creator, if he is ill - therefore, he must avoid that which harms the body and accustom himself to that which is healthful and helps the body become stronger.

The Rambam clearly states that one must maintain a healthy body in order to properly serve G-D. He then goes on to list advice, as a physician, as to how people should maintain their health. So, it appears to be that the Rambam believes that there is an obligation, if not a necessity, for an ill person to consult a physician. (This allows us to contrast the Rambam with Ramban. The Ramban believes a person SHOULD NOT consult a physician as seen here.)

The Rambam's obligation for a Jewish Physician to heal is, actually, somewhat innovative. As pointed out by Benjamin Gesundheit (In Rambam Maimonides Medical Journal),

Maimonides did not accept this well known apologetic attitude of the Talmud towards medicine based on his philosophy of life (Weltanschauung), and he was the first Rabbinic author to understand medicine as a fundamental and a-priori religious duty anchored in a well known Biblical source and further supported by its Talmudic interpretation.

The reason for the Rambam's innovation is, as Gesundheit says, because of his philosophy of life. This also led him to a very interesting source for a physician's obligation to heal. Most commentators bring the verse from Shemos (21:19), "And he shall surely be healed." This is talked about in the Gemara (Babba Kama 85a)

The School of R. Ishmael taught: [The words] "And to heal he shall heal’’[is the source] whence it can be derived that authorization was granted [by God] to the medical man to heal.

However, this verse only creates permission for a physician to heal. Therefore, many commentators conclude that a physician has no obligation, only permission. That is why the Rambam learned a physician's obligation to heal from a completely different verse. This is seen in the Rambam's commentary on the Mishna (Nedarim 4:4),

There is a Biblical obligation for the physician to heal a sick Jew. This is included in what is explained about the verse (Devarim 22:2) "And you shall return it to him." [This includes] healing his body, for this is like when you see him in danger and you are able to save him with your body, your money, or your knowledge.

Ingeniously, the Rambam takes the obligation to return a lost object to mean anything that is "lost" must be returned. In this case, if a person has "lost" his health and a physician has the ability to "return" it to him, then the physician is obligated to do so. (See also Mishna Torah Hilchos Nedarim 6:8)

Rambam's unique source that leads to the physician's obligation to heal also leads to another innovation. A Jewish physician is obligated to heal even a sick non-Jew in a case where it will create a sanctification of G-D's name, a desecration of G-D's name if he does not, or simply because it is "the way of peace" (Laws of Theft and Lost Objects 11:3). We also see that the Rambam "practiced what he preached" from his letter to Rabbi Samuel Ibn Tibbon (found in Freidlander introduction to The Guide),

I reside in Egypt (or Fostat); the king resides in Cairo, which lies about two Sabbath-day journeys from the first-named place. My duties to the king are very heavy. I am obliged to visit him every day, early in the morning; and when he or any of his children or the inmates of his harem are indisposed, I dare not quit Cairo, but must stay during the greater part of the day in the palace. It also frequently happens that one or two of the royal officers fall sick, and then I have to attend them. As a rule, I go to Cairo very early in the day, and even if nothing unusual happens I do not return before the afternoon, when I am almost dying with hunger; but I find the antechambers filled with Jews and Gentiles, with nobles and common people, awaiting my return.

It appears that the Rambam believed treating non-Jews was just as important, in most situations, as treating Jews.

In conclusion, we see the approach of the most rationalistic Rabbi, Rambam (Maimonides). My personal belief (in congruence with the belief of other, more knowledgeable people) is that his approach to the medical profession stems from his philosophical outlook on life. He believes that G-D does not cause most illnesses directly, therefore, he believes that if man has the capabilities to cure those illnesses, he should. This is why, I think, he finds the acts of preventing one's own illness, seeking out a physician, and a physician healing not to just be permissible acts, but obligations. Many Rabbis before and after the Rambam would not even say it is permissible to seek out a physician and they barely even allow a physician to heal. In response to these Rabbis the Rambam would say, "But the Gemara is CLEAR!!! Return it to him, return his lost health. It's a Mitzva (commandment)!" 

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.

Ramban's (Nahmanides') View of Medical Care (Mystical View)

I think we should start with the Ramban's opinion about medical care since it is probably the most widely held stance in Orthodox Jewish circles (Either consciously or subconsciously). The first source that we can delve into is what he says in Parshas Bechukosai (Vayikra 26:11). In the middle of his commentary on this verse, the Ramban goes on to explain his Views of medical care. I will translate his words and then discuss them.

והכלל כי בהיות ישראל שלמים והם רבים, לא יתנהג עניינם בטבע כלל, לא בגופם, ולא בארצם, לא בכללם, ולא ביחיד מהם, כי יברך השם לחמם ומימם, ויסיר מחלה מקרבם, עד שלא יצטרכו לרופא ולהשתמר בדרך מדרכי הרפואות כלל, כמו שאמר (שמות טו כו): כי אני ה' רופאך. וכן היו הצדיקים עושים בזמן הנבואה, גם כי יקרם עוון שיחלו לא ידרשו ברופאים רק בנביאים, כעניין חזקיהו בחלותו (מ"ב כ ב ג). ואמר הכתוב (דהי"ב טז יב): גם בחליו לא דרש את ה' כי ברופאים, ואילו היה דבר הרופאים נהוג בהם, מה טעם שיזכיר הרופאים, אין האשם רק בעבור שלא דרש השם. אבל הוא כאשר יאמר אדם, לא אכל פלוני מצה בחג המצוות כי אם חמץ.

The General rule is that when the children of Israel are complete and numerous then nature does not effect them at all. Not their bodies, not their land, not as a nation and not as individuals because G-D blesses their bread and their water. He removes sickness from their midst to the point that they don't need a doctor and they are guarded in their path (of life) from (even needing to follow) the ways of medicine. For example, it says (Shemos 15:26) "Because I am G-D your healer." So too, that is what the righteous people did in the days of prophecy. When the important people would sin and become ill they would not seek out doctors, but only prophets like the story of Hezekiah (Chizkiyahu) when he became sick (Kings 2 20:2,3) Also, the verse says (Chronicles 2 16:12) "Also in his sickness he did not seek out G-D, only doctors" and if going to doctors was the path to follow what was the reason [the verse] mentions physicians (the verse should just say he did not seek out G-D)? The only sin here should be that he (King Asa) did not seek out G-D (to heal him and there should be no mention of doctors). However, (this was a case where) a man (the doctor) says so and so should not eat Matza (unleavened bread) on Pesach (passover) only Chametz (leavened bread) (and that apparently was the sin or increased the sin).      

אבל הדורש השם בנביא לא ידרוש ברופאים. ומה חלק לרופאים בבית עושי רצון השם, אחר שהבטיח וברך את לחמך ואת מימיך והסירותי מחלה מקרבך, והרופאים אין מעשיהם רק על המאכל והמשקה להזהיר ממנו ולצוות עליו.

However, the one who seeks out G-D through a prophet does not inquire of doctors. What is the purpose (lit. portion) of a doctor in a house that does the will of G-D? After we are assured (by G-D) that He will bless our bread, our water, and remove sickness from our midst (what is the point of a doctor?!?!). By doctors, their actions only involve warning us which food and drink we should stay away from and they make demands of us. 

וכך אמרו (ברכות סד א :

כל עשרין ותרתין שנין דמלך רבה רב יוסף אפילו אומנא לביתיה לא קרא, והמשל להם (במדב"ר ט ג): תרעא דלא פתיח למצותא פתיח לאסיא.

והוא מאמרם (ברכות ס א): שאין דרכם של בני אדם ברפואות אלא שנהגו, אילו לא היה דרכם ברפואות יחלה האדם כפי אשר יהיה עליו עונש חטאו ויתרפא ברצון ה', אבל הם נהגו ברפואות והשם הניחם למקרי הטבעים.

So it says [in the Gemara] (Tractate Brachos 64a):

During the entire 22 years that Rabbah reigned (as Rosh Yeshiva), Rav Yosef did not even call upon a cupper (some form of doctor) to come to his house (Showing that righteous people do not need doctors). Also, there is a parable for this [idea that a righteous person does not need doctors and a sinner does] (Bamidbar Rabba 9:3): A door that doesn't open for mitzvos (Jastrow translates as charity) opens for the physician (meaning you will be punished with sickness for not performing the mitzvos).   

This is a saying [in the Gemara] (Brachos 60a): It is not the [intended] path of man to deal with medicine, rather it is what they are accustom to doing. If it was not man's custom to deal with medicine then a man would become sick when he did a misdeed. (Meaning), he would sin and be healed by the will of G-D. However, they (man) are accustomed to deal with medicine so G-D leaves them to the occurrences of nature.
 

וזו היא כוונתם באמרם(שם:

ורפא ירפא מכאן שנתנה רשות לרופא לרפאות.

לא אמרו שנתנה רשות לחולה להתרפאות, אלא כיון שחלה החולה ובא להתרפאות כי נהג ברפואות והוא לא היה מעדת השם שחלקם בחיים, אין לרופא לאסור עצמו מרפואתו, לא מפני חשש שמא ימות בידו, אחרי שהוא בקי במלאכה ההיא, ולא בעבור שיאמר כי השם לבדו הוא רופא כל בשר, שכבר נהגו. ועל כן האנשים הנצים שהכו זה את זה באבן או באגרוף (שמות כא יח): יש על המכה תשלומי הרפואה, כי התורה לא תסמוך דיניה על הנסים, כאשר אמרה (דברים טו יא): כי לא יחדל אביון מקרב הארץ, מדעתו שכן יהיה. אבל ברצות השם דרכי איש אין לו עסק ברופאים.

This is the intention of the saying [in the Gemara] (Berachos 60a):

(It says in Shemos 21:19) "He shall cause him to be healed," from here [we see] that [G-D] gave permission to physicians to heal.

It does not say that [G-D] gave permission to the sick person to seek out healing. However, since the sick person became ill and [instead of seeking out G-D] came to be healed, for [the sick person] is accustomed to use medicine. Furthermore, [this man] is not from the congregation of G-D that their portion is while living (and G-D will cure this man Himself). Therefore, the physician should not inhibit himself from his healing. Not because he is worried that perhaps [the patient] may die by his hands, because he is an expert in his work. Also, [the physician should not be worried] because [of the idea that] is said that G-D alone is the healer of all flesh, because it is already the custom [of people to seek out a physician.] Therefore,  by the men who are fighting and hit each other with a stone or fist (Shemos 21:18) there is a payment needed for the healing of the wound, because the Torah (Bible) does not rely its laws on miracles. When the [Torah] says (Devarim 15:11) "For the poor shall not cease from in the midst of the land (this is in reference to the commandment of charity),"  this was because He knew [and wanted] it to be this way. However, [this is opposite to healing] because G-D wanted the path of man to be that he [or she] should not deal with medicine or physicians.  

I want to sum up the Ramban's view and then I will discuss it in more detail. The Ramban goes through great length to explain that, simply put, a sick person seeking out a doctor or medicine is a Bidieved (not optimal) situation. The way the world is supposed to work is man sins, he is afflicted with sickness, he prays to G-D and is healed. However, because man has perverted the original path of the world and has accustom himself with seeking medicine and doctors, now those avenues are the natural way to be healed.

This opinion really fits well with the Ramban's whole philosophy of life. This philosophy can be found most clearly and succinctly in the Ramban's commentary on Shemos 13:16 in the last paragraph.

 From the great open miracles man will admit to the hidden miracles that are the foundation of the entire Torah. For a man does not have a portion in the Torah of Moshe, our teacher, until he believes that all our dealings and occurrences are miracles that are not nature or the custom of the world whether it be on a general or on an individual scale. [One must believe] if he does the mitzvos (commandments) our success is his reward. However, if he transgresses [the mitzvos] our destruction is his punishment. Everything is according to heavenly decree, as I have mentioned already. (Breishis 17:1, Shemos 6:2)

The Ramban believes that there is no such thing as nature, at least by the Jewish people. Everything that happens to us, rain or shine, is directly from G-D. This philosophy obviates the need for the Ramban to explain why medicine appears to be the healer and not prayer to G-D. According to the Ramban, G-D really does directly heal. In fact, back in the good old days, that was the only way to be healed, pray and be healed. However, somehow man became reliant on medicine, because that became the custom. This led to G-D changing the healing process from an open miracle (pray and thou shalt be healed) to a hidden miracle (you must go to doctors). Still, it is not the medicine that heals the person, but G-D (through a hidden miracle that APPEARS to be nature).

My explanation of the Ramban comes down to a few details. The Ramban believes that nature (at least with regards to Jews) is an illusion. Everything is directly from G-D either in the form of an open miracle (10 plagues of Egypt) or a hidden miracle ("natural" occurrences). This leads the Ramban to explain that a patient should NOT seek out a doctor, because prayer to G-D SHOULD help in and of itself. In fact, the Ramban points out that this used to be the only way to be cured from illness. However, once man became accustom to seeking medicine and medical care that was ALLOWED to be given by a doctor. There was no obligation created to give medical care, because people should NOT be seeking medical care.

That is how I will end my opening explanation and thoughts on the mystical view of medical care as seen through the Ramban's eyes. Really, medical care is part of the illusion of "nature" according to this view.   

DIfferent Approaches To Medical Care In Judaism

Judaism, as many of you are aware, has many different approaches to a wide variety of topics. Being that I am shortly going to be officially joining the medical profession, I thought it would be appropriate to discuss the two main philosophies in Judaism behind a doctors role as caretaker. The two main figures I will be discussing are the Rambam (Maimonides) and the Ramban (Nachmanides). They seem like the best two approaches because they are polar opposites, yet they were both physicians. 

Rambam, based on his rationalistic approach to Judaism, believes that a doctor has a biblical obligation to use his or her knowledge to heal anyone with an illness. He also conveys that a patient has the obligation to seek out the best possible treatment that can be attained. In contrast, Ramban, based on his mystical approach to Judaism, argues that G-D is the healer of illness, not man. According to him, even when a physician is involved with treating a disease, it is really G-D that cures the patient. To the Ramban a physician’s role within medicine is very minimalistic and he argues that a physician is permitted, rather than biblically obligated, to heal. Ramban goes so far as to say that a devout person should not seek out a physician but rather rely on prayer. 

These two views represent, I believe, the paradigms of rationalist vs mystical Judaism. Both were physicians, but Ramban clearly believed that G-D's involvement is absolute, controlling every little detail of human existence. However, the Rambam was much more of a minimalist. G-D's involvement only went so far, but man has to be the master of his own physical world. 

I plan on going through the sources in the Rambam and the Ramban and show how they tease out their different understandings. However, I also want to delve into their personal backgrounds. How could it be that two physicians, born and raised as Jews under Muslim rule, in approximately the same era come to such radically different conclusions about their own profession?

It's going to be a fun journey.