Pikuach Nefesh: the Primacy of Saving a Life

Pikuach Nefesh:

the Primacy of Saving a Life

Elana Stein Hain

Where does the idea of Pikuach Nefesh (פיקוח נפש), the primacy of saving a life, come from in Jewish tradition? Why are we commanded to break Shabbat in order to save a life? What exceptions did the rabbis make to the principle of pikuach nefesh? The primacy of saving a life is an overriding value in Jewish law, and in a moment when our normal lives are disrupted, the ideas behind pikuach nefesh take on a new relevance.

Dr. Elana Stein Hain is Scholar-in-Residence and Director of Faculty at the Shalom Hartman Institute of North America, where she serves as lead faculty and oversees the content of lay and professional leadership programs. Elana also co-leads the Created Equal research team with Joshua Ladon.

Elana earned her doctorate in religion from Columbia University with a dissertation on the topic of legal loopholes in rabbinic law. She is an alumna of the Yeshiva University Graduate Program in Advanced Talmudic Studies (GPATS) and the Consortium in Jewish Studies and Legal Theory Graduate Fellowship. Elana served for eight years as a clergy member on the Upper West Side of Manhattan, at both Lincoln Square Synagogue and the Jewish Center, and taught at the Wagner School at NYU. She lives on the Upper West Side of Manhattan with her family.

א"ר יוסי מנין לפקוח נפש שדוחה [את השבת] שנא' (שמות לא) את שבתותי תשמרו יכול במילה ועבודה ופיקוח נפש ת"ל אך חלק פעמים שאתה שובת פעמים שאי אתה שובת ר"א אומר מילה דוחין עליה השבת מפני מה מפני שחייבין עליה כרת לאחר זמן והרי דברים ק"ו ומה אם על אבר אחד ממנו דוחה את השבת דין הוא שידחה השבת על כולו אמרו לו ממקום שבאת מה להלן ודאי ולא ספק אף כאן ודאי ולא ספק א"ר עקיבה וכי במה החמירה תורה בעבודה או בשבת החמירה בעבודה יתר משבת שהעבודה דוחה את השבת ואין שבת דוחה אותה והרי דברים ק"ו ומה עבודה שדוחה את השבת ספק נפשות דוחה אותה שבת שעבודה דוחה אותה אינו דין שספק נפשות דוחה אותה הא למדת שספק נפשות דוחה את השבת.
R. Yose said: Whence do we know that saving a life takes precedence over the Sabbath? As it is written. “…you shall observe my Sabbaths.” Is it possible that circumcision and the temple service and saving a life [do not take precedence over the Sabbath]? The Torah teaches “But” - a portion. There are times when you observe the Sabbath and times when you do not observe the Sabbath. R. Elazar says: Circumcision takes precedence over the Sabbath because one is punished for it by karet (excision) after time. And the matter is a kal va’homer. If for one limb of him the Sabbath can be superseded, it is logical that the Sabbath should be superseded for all of him. They said to him: according to your reasoning just as in that case it is certain and not uncertain, so too here it must be certain and not uncertain. R. Akiva said: And with respect to which was the Torah more stringent? With the temple service or with the Sabbath? [The Torah was more stringent] with the temple service than with the Sabbath, for the temple service takes precedence over the Sabbath and the Sabbath does not take precedence over the temple service. And the matter is a kal va’homer - if the temple service takes precedence over the Sabbath and a risk to life takes precedence over it, with regard to the Sabbath, which the temple takes precedence over - is it not logical that a risk to human life should supersede it? Behold, you have learned that a risk to life takes precedence over the Sabbath.
ר' אחא אמר משום ר"ע הרי הוא אומר (שמות כב) אם במחתרת ימצא הגנב וגו' בעל הבית מהו ודאי או ספק הוי אומר ספק אם הורגין נפש להחיות נפש בספק דין הוא שידחו את השבת להחיות נפש בספק הא לא נתנו מצות לישראל אלא לחיות בהן שנאמר (ויקרא יח) אשר יעשה אותם האדם וחי בהן וחי בהן ולא שימות בהן אין לך דבר עומד בפני פיקוח נפש חוץ מע"ז וגילוי עריות ושפיכות דמים בד"א שלא בשעת הגזירה אבל בשעת הגזירה אפילו [מצוה] קלה שבקלות אדם נותן נפשו עליה שנא' (ויקרא כב) ולא תחללו את שם קדשי [וגו'] ואומר (משלי טז) כל פעל ה' למענהו.
R. Aha said in the name of R. Akiva. Behold, it says: “If a thief is found tunneling in…” Is the house’s owner certain or uncertain? You must say he is uncertain. If they kill a person to save a life in a case of uncertainty, it is logical that they should push off the Sabbath, in order to save a life in a case of uncertainty. Behold, the commandments were only given to Israel that they might live by them, as it is written “Which a man shall perform and live by them” - he shall live by them, and not die by them. Nothing takes precedence over saving a life, save idolatry, sexual sins, and murder. In which circumstances are these things said? When it is not a time of persecution. But, when it is a time of persecution, even when it comes to the smallest of small commandments, a person should die for it, as it is written: “Do not profane my holy name” (Leviticus 22) and “the Lord made everything for his own sake” (Proverbs 16).

רבי שמעון בן מנסיא אומר, הרי הוא אומר ושמרתם את השבת כי קדש היא לכם. לכם שבת מסורה, ואי אתם מסורין לשבת. רבי נתן אומר, ושמרו בני ישראל את השבת לעשות את השבת לדורותם, חלל שבת אחת כדי שתשמור שבתות הרבה.

R. Shimon b. Menassia says (Ibid. 14) "And you shall keep the Sabbath, for it is holy to you" — Sabbath is given to you and you are not given (i.e., "surrendered") to the Sabbath. R. Nathan says (Ibid. 16) "And the children of Israel shall keep the Sabbath to observe the Sabbath for their generations": Desecrate one Sabbath in order to keep many Sabbaths.

א"ר יהודה אמר שמואל אי הואי התם הוה אמינא דידי עדיפא מדידהו (ויקרא יח, ה) וחי בהם ולא שימות בהם אמר רבא לכולהו אית להו פירכא בר מדשמואל דלית ליה פירכא

Rav Yehuda said that Shmuel said: If I would have been there among those Sages who debated this question, I would have said that my proof is preferable to theirs, as it states: “You shall keep My statutes and My ordinances, which a person shall do and live by them” (Leviticus 18:5), and not that he should die by them. In all circumstances, one must take care not to die as a result of fulfilling the mitzvot. Rava commented on this: All of these arguments have refutations except for that of Shmuel, which has no refutation.

וּשְׁמַרְתֶּ֤ם אֶת־חֻקֹּתַי֙ וְאֶת־מִשְׁפָּטַ֔י אֲשֶׁ֨ר יַעֲשֶׂ֥ה אֹתָ֛ם הָאָדָ֖ם וָחַ֣י בָּהֶ֑ם אֲנִ֖י יְהוָֽה׃ (ס)
You shall keep My laws and My rules, by the pursuit of which man shall live: I am the LORD.

"וחי בהם" – לעולם הבא. ואם תאמר בעולם הזה, והלא סופו מת הוא! הא מה אני מקיים "וחי בהם"? לעולם הבא. "אני ה' " – נאמן לשלם שכר.

(Vayikra 18:5) "and he shall live in them": in the world to come. If you would say, in this world, is it not one's end to die? How, then, is "and he shall live in them" to be understood? In the world to come. (Vayikra 18:5) "I am the L–rd" — trusted to reward.

תוספת הילקוט:[יג] "וחי בהם" – לא שימות בהם. היה ר' ישמעאל אומר, מנין אתה אומר שאם אמרו לו לאדם בינו לבין עצמו עבוד עכו"ם ואל תֵהָרֵג!, יעבור ואל יֵהרג? תלמוד לומר "וחי בהם" – ולא שימות בהם. או אפילו ברבים ישמע להם?... תלמוד לומר (ויקרא כב, לב) "ולא תחללו את שם קדשי ונקדשתי" –

13) (Vayikra 18:5) "and he shall live in them": and not die in them. R. Yishmael was wont to say: Whence is it derived that if one is told in private to serve idolatry or be killed, he should transgress and not be killed? From "and he shall live in them," and not die in them. — But perhaps even in public he should accede. It is, therefore, written (Vayikra 22:32) "And you shall not desecrate My holy name, and I shall be sanctified in the midst of the children of Israel."

וכל האנשים אשר נגעה תורת ה' בלבבם הלכו אחריהם וינוסו המדברה. וישבו שם הם ונשיהם וטפם ומקניהם, כי גבר הקצף מאוד מאוד. וישמעו אנשי המלך בעיר דוד אשר בירושלים כי רבים הכבידו את לבם לבלתי עשות את מצות המלך. וכי גם עזבו את הערים להסתתר במדבר ונקבצו אליהם עם רב. ויקומו פתאום להתגולל עליהם ביום השבת. ויאמר להם: עד אנה מיאנתם לשמוע בקול המלך, קומו נא וצאו מזה ועשו את מצוותיו וישבתם בטח. ויענו ויאמרו, לא נצא, כי את דבר המלך לא נעשה, ואת השבת לא נחלל. וייגשו אל המערה ויערכו כלי מלחמה לקראתה. והאנשים אשר בקרבה לא הרימו את ידיהם לירות אבן או לסכור את פיה. ויאמרו אליהם: נמותה הפעם בניקיון כפנו, והשמים והארץ עדים בנו כי בזדון תהרגונו. ויפלו עליהם ביום השבת, ויהרגו כל אשר במערה. וימותו הם ונשיהם וטפם ומקניהם. ויהיו המתים כאלף נפש. ומתתיהו ורעיו שמעו את הדבר וייצר להם מאוד. ויאמרו איש אל אחיו: אם עשה נעשה כאשר עשו אחינו, לבלתי התייצב לפני הגויים בעד נפשנו ותורתנו, עוד מעט והשמידונו. ויוועצו כולם ביום ההוא לאמור אם הילחם ילחמו אויבינו בנו ביום השבת, ויצאנו לקראתם ועמדנו על נפשנו, ולא נמות כמות אחינו במערות.

Then many that sought after justice and judgment went down into the wilderness, to dwell there: Both they, and their children, and their wives; and their cattle; because afflictions increased sore upon them. Now when it was told the king’s servants, and the host that was at Jerusalem, in the city of David, that certain men, who had broken the king’s commandment, were gone down into the secret places in the wilderness, They pursued after them a great number, and having overtaken them, they camped against them, and made war against them on the sabbath day. And they said unto them, Let that which ye have done hitherto suffice; come forth, and do according to the commandment of the king, and ye shall live. But they said, We will not come forth, neither will we do the king’s commandment, to profane the sabbath day So then they gave them the battle with all speed. Howbeit they answered them not, neither cast they a stone at them, nor stopped the places where they lay hid; But said, Let us die all in our innocency: heaven and earth will testify for us, that ye put us to death wrongfully. So they rose up against them in battle on the sabbath, and they slew them, with their wives and children and their cattle, to the number of a thousand people. Now when Mattathias and his friends understood hereof, they mourned for them right sore. And one of them said to another, If we all do as our brethren have done, and fight not for our lives and laws against the heathen, they will now quickly root us out of the earth. At that time therefore they decreed, saying, Whosoever shall come to make battle with us on the sabbath day, we will fight against him; neither will we die all, as our brethren that were murdered in the secret places.
מתני׳ עוברה שהריחה מאכילין אותה עד שתשיב נפשה חולה מאכילין אותו ע"פ בקיאין ואם אין שם בקיאין מאכילין אותו על פי עצמו עד שיאמר די
MISHNA: With regard to a pregnant woman who smelled food and was overcome by a craving to eat it, one feeds her until she recovers, as failure to do so could lead to a life-threatening situation. If a person is ill and requires food due to potential danger, one feeds him according to the advice of medical experts who determine that he indeed requires food. And if there are no experts there, one feeds him according to his own instructions, until he says that he has eaten enough and needs no more.

...אמר ר' ינאי חולה אומר צריך ורופא אומר אינו צריך שומעין לחולה מ"ט (משלי יד, י) לב יודע מרת נפשו פשיטא מהו דתימא רופא קים ליה טפי קמ"ל

...Rabbi Yannai said: If an ill person says he needs to eat, and a doctor says he does not need to eat, one listens to the ill person.What is the reason for this halakha? It is because the verse states: “The heart knows the bitterness of its soul” (Proverbs 14:10), meaning an ill person knows the intensity of his pain and weakness, and doctors cannot say otherwise. The Gemara asks: It is obvious that a person knows himself better than anyone else does. Why does this need to be stated explicitly? The Gemara answers: It is lest you say that the doctor is more certain because he has had more experience with this condition. Therefore, the verse teaches us that even so, it is the ill person who knows his own suffering better than anyone else.

רופא אומר צריך וחולה אומר אינו צריך שומעין לרופא מ"ט תונבא הוא דנקיט ליה
However, in the opposite case, if a doctor says that the ill person needs food, but the ill person himself says he does not need to eat, one listens to the doctor. What is the reason for this halakha? It is because confusion [tunba] has taken hold of the ill person on account of his illness, and his judgment is impaired. Consequently, he himself does not know how much he needs food.
תנן חולה מאכילין אותו ע"פ בקיאין ע"פ בקיאין אין ע"פ עצמו לא ע"פ בקיאין אין על פי בקי אחד לא
§ We learned in the mishna: If a person is ill, one feeds him according to the advice of medical experts. This implies that if there are experts present, then according to the advice of experts, yes, one feeds the ill person; but at his own instructions, no, one does not feed him, contrary to Rabbi Yannai’s opinion. It further implies that according to the advice of several experts, yes, one feeds an ill person; however, according to the advice of only one expert, no, one does not feed him. There appears to be a requirement for at least two doctors, which also contradicts Rabbi Yannai’s opinion that the opinion of one expert is sufficient to override the opinion of the ill person.
הכא במאי עסקינן דאמר לא צריכנא וליספו ליה ע"פ בקי לא צריכא דאיכא אחרינא בהדיה דאמר לא צריך מאכילין אותו ע"פ בקיאין
The Gemara rejects this: With what are we dealing here? We are dealing with a unique circumstance: The ill person says I do not need food, and the consultation of experts is required. The Gemara suggests: But let them feed him according to the advice of one expert, as Rabbi Yannai said that in such a circumstance one feeds the ill person based on the advice of one doctor. The Gemara answers: No, the requirement of two experts is necessary in a case where there is another, third expert with him who says that the ill person does not need to eat. In such a case, one feeds the ill person according to the advice of two experts who agree that he requires it.
ספק נפשות הוא וספק נפשות להקל לא צריכא דאיכא תרי אחריני בהדיה דאמרי לא צריך ואע"ג דאמר רב ספרא תרי כמאה ומאה כתרי ה"מ לענין עדות אבל לענין אומדנא בתר דעות אזלינן
The Gemara asks: If so, this is obvious, since it is a case of uncertainty concerning a life-threatening situation, and in all cases of uncertainty concerning a life-threatening situation, the halakha is lenient. The Gemara answers: No, this halakha is necessary in a case where there are two other doctors who, along with the ill person, say that he does not need food. And although Rav Safra said that two witnesses are like one hundred witnesses, and one hundred witnesses are like two witnesses, that rule applies specifically to the matter of testimony; however, in the matter of assessing a situation, we follow the majority of opinions. Therefore, one might think in this case that the ill person should not be fed because the opinion of two doctors plus the ill person should override the opposing opinion of two other doctors.
וה"מ לענין אומדנא דממונא אבל הכא ספק נפשות הוא
Generally speaking, two or more witnesses constitute complete testimony, and there is no difference between the testimony of two and the testimony of a large number of people. However, this principle of following the majority applies specifically to assessing monetary issues, but here it is a case of uncertainty concerning a life-threatening situation. Therefore, although it is the opinion of two doctors against the opinion of two doctors and the ill person, the ill person must eat.
והא מדקתני סיפא ואם אין שם בקיאין מאכילין אותו על פי עצמו מכלל דרישא דאמר צריך חסורי מיחסרא והכי קתני בד"א דאמר לא צריך אני אבל אמר צריך אני אין שם בקיאין תרי אלא חד דאמר לא צריך מאכילין אותו על פי עצמו
The Gemara asks: But from the fact that it is taught in the latter clause of the mishna that if there are no experts present one feeds him according to his own opinion, by inference, the first clause of the mishna is referring to a case where the ill person said he needs to eat. In that case, the mishna states that one follows the experts’ opinion, not his own, and feeds him. The Gemara answers: The mishna is incomplete and is teaching the following: In what case is this statement that he may eat only based on the advice of experts said? It is when the ill person said: I do not need to eat. But if he said: I do need to eat, and instead of two experts there is only one who says that he does not need to eat, one feeds him according to his own opinion.
מר בר רב אשי אמר כל היכא דאמר צריך אני אפי' איכא מאה דאמרי לא צריך לדידיה שמעינן שנאמר לב יודע מרת נפשו
Mar bar Rav Ashi said: Any instance where an ill person says: I need to eat, even if there are one hundred expert doctors who say that he does not need to eat, we listen to his own opinion and feed him, as it is stated: “The heart knows the bitterness of its soul” (Proverbs 14:10).
תנן אם אין שם בקיאין מאכילין אותו ע"פ עצמו טעמא דליכא בקיאין הא איכא בקיאין לא ה"ק בד"א דאמר לא צריך אני אבל אמר צריך אני אין שם בקיאין כלל מאכילין אותו ע"פ עצמו שנאמר לב יודע מרת נפשו
We learned in the mishna: If an ill person himself says he needs to eat and there are no experts present, one feeds him according to his own opinion. This implies that the reason one feeds him is because there are no experts present. One may infer from this that if there were experts present, no, one would not feed the ill person based on his own opinion but would instead listen to the advice of the experts. The Gemara rejects this: This is what the mishna is saying: In what case is this statement that one follows the opinion of the experts said? It is when the ill person said: I do not need to eat. However, if he said: I do need to eat, it is considered as if there were no experts there at all; we feed him based on his opinion, as it is stated: “The heart knows the bitterness of its soul” (Proverbs 14:10). All the experts are ignored in the face of the ill person’s own sensitivities.

Ayelet Hoffman Libson, Law and Self-Knowledge in the Talmud, p. 147

In sum, tracing the development of the rabbinic debate over fasting suggests that it is possible to identify three distinct models of how the rabbis related to the intersection of the sanctity of Yom Kippur and the risk to life. The mishnaic model relied on the experts’ authoritative decision, even when it contradicted the patient’s opinion that he was in need of food. The amoraicposition, by contrast, focused on the threat to life and emphasized that any doubt – raised by either patient or physician – is sufficient to be cautious and permit the patient to eat. The post-amoraic redactors diverged from this position, emphasizing instead the importance of the patient’s own knowledge in determining whether she should eat. I propose that there are two separate but interrelated transitions throughout this rabbinic conversation. First, there is a shift from the authority of experts to the autonomy of individuals. However, I believe we can also point to a second, subtler shift, occurring between the amoraic and post-amoraic periods. In contrast to the opinions of the earlier sages who understood the Mishnah as referring to medical knowledge alone, I offer a reading of a new perception in the post-amoraic layer, reinterpreting earlier sources so as to transition the discussion to a conversation about the religious-spiritual conception of fasting.

The correlation between fasting and atonement was not, of course, limited to one day per year. Rather, for both Jews and non-Jews in late antiquity, suffering constituted one of the central paradigms of religious understanding and conceptualization of the self. By delving deeper into the religious significance rabbinic Jews accorded to the connection between suffering, death and atonement, we will shed further light on the Talmudic dispute at hand, exploring the context in which suffering, knowledge and choice became inextricably intertwined.

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