
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.
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.
"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.
...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.
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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