SARS and Self-Endangerment to Save Others.
To what extent must physicians risk their own lives to treat their patients?
Apr 25, 2003 TORONTO (Reuters) - Exhausted health workers on the front line of Toronto's battle against SARS must also cope with the frightening knowledge that they are most at risk, and there is no fail-proof way to protect them . . .
Physicians have been treating contagious diseases for millennia. As a result, the death toll in the medical profession has been high in times of epidemic. What does the Torah teach us about the obligation of the physician to treat weighed against the prohibition of endangering one's life?
This question has become particularly timely with the spread of Severe Acute Respiratory Syndrome (SARS). There was worldwide panic, with planes detained, medical meetings cancelled, and embassies reduced to skeleton crews. Even the physician who first recognized SARS died of it.
But we must separate the true risk from the hysteria. While as of the last World Health Organization update, SARS has killed an estimated 800 people and sickened more than 8400, with the number growing each day, influenza kills between 250,000 and 500,000 people each year around the world. Even in the United States, with a vaccine and modern medical care widely available, flu kills at least 36,000 people a year. The "Spanish flu" pandemic of 1918 killed between 40 million and 50 million worldwide, most of them young, healthy adults. The "Asian flu" and "Hong Kong flu" pandemics of 1956-1957 and 1967-1968 killed a combined 4.5 million people.
The AIDS epidemic
It is not common conduct for physicians to refuse to treat flu patients for fear of there becoming infected themselves. It is more common for paranoia and raw emotion to drive calls for patient quarantines and refusals of healthcare workers to treat infected patients. HIV is the most recent example of such behavior, where some healthcare workers refused to treat "AIDS" patients, despite the fact that the risk of becoming infected by casual contact was virtually nonexistent. The Centers for Disease Control reported in 2001 that they were "aware of 57 health care workers in the United States who have been documented as having a seroconverted to HIV following occupational exposures." There were "137 other cases of HIV infection or AIDS among health care workers who have not reported other risk factors for HIV infection" and reported occupational exposures, but did not have documented seroconversion after exposure. Overall, the total is still a very small number considering the prevalence of the disease, the frequency of needle sticks and other occupational exposures, and the almost 25 years that HIV has been recognized.
Nevertheless, early in the AIDS epidemic, before the mode of HIV transmission was clear, self-endangerment was a legitimate concern for healthcare workers treating AIDS patients. Why have physicians traditionally been willing to treat patients with communicable diseases and to what extent may they risk their own lives to treat their patients?
The basis of the physician's dedication to his patient should be the responsibility that the Torah places on the physician to heal. From as Torah perspective, barring mitigating circumstances, the physician (like anyone else in a position to save an endangered neighbor) must treat the sick. Therefore, we must ask how far the obligation extends. Does the physician have to endanger his own life to treat a patient with a dangerous contagious disease?
While mandated to heal, the Torah also commands the doctor to zealously guard his own health.
In such a case, the healthcare worker is caught between a rock and a hard place. While mandated to heal, the Torah also commands him to zealously guard his own health. The doctor must ask himself the question: May I expose myself to a questionable danger to save someone else from a definite danger? The answer to that question is the subject of dispute.
The Obligation to Save a Life
The Talmud derives the fundamental requirement to save another person from danger directly from the Torah. The Talmud1 explains: "From where do we know that if one sees his friend drowning in a river, or if he sees a wild animal attacking him, or bandits coming to attack him, that he is obligated to save [his friend]? The Torah teaches: "Do not stand over your neighbor's blood (but rather save him) [Leviticus 19:16]." According to Maimonides2, this translates into a positive obligation to use your time, money and even your body to save your fellow.
Nevertheless, there is a fundamental debate in Jewish legal sources whether this obligation extends to risking one's own life to save another. While the Jerusalem Talmud does require self-endangerment if there is only a questionable risk to the rescuer, no major code, including the Code of Jewish Law (Shulchan Aruch) brings this requirement as normative Jewish law.
Must I risk my life to save another?
Among the earliest responsa on the topic of risking life to save others were those of Rabbi David ben Solomon ibn Avi Zimra, known as the Radbaz. He lived along with Rabbi Karo, the author of the Shulchan Aruch, in Safed in the 16th century. The Radbaz3 was asked a chilling question. What should one do if a government officer tells a Jew: "Let me cut off one of your limbs in a way that you will not die, or I will kill your friend!" After bringing several proofs, he concludes that if there were even a questionable risk of death (safek sakana), then one who agrees to lose his limb would be a pious fool (chasid shoteh) -- the Talmudic description of one who goes way beyond the call of duty based on a perverted religious ideal.
In a second responsa, the Radbaz further fleshes out the issues involved in entering danger to save others. The Radbaz explains that one is required to save his neighbor when the rescuer undergoes no danger to himself whatsoever, such as warning a person asleep beneath a shaky wall to get up or to share life-saving information with someone else. He then adds that: "he must save his friend even if there is a small possibility of danger (safek sakana) to the rescuer. For example, if he sees his friend drowning in the sea or bandits coming to assault him or [sees him] being attacked by a wild animal -- all of which entail a possibility of danger -- nevertheless, he still must rescue [his friend]."
These apparently contradictory rulings of the Radbaz are reconciled by Rabbi Ovadia Yosef, 4former Sefardi Chief Rabbi of Israel, by explaining that the Radbaz's first responsa, where he says that one who risks himself to save another is a pious fool refers to when the odds of danger to the rescuer are 50% or greater. When the odds are lower, the second responsa applies.
The Balancing Act
One is not obligated to risk one's own life to save others if there is definite danger to the rescuer.
Rabbi Yisroel Meyer Kagan (known as the Chofetz Chaim), in his seminal commentary to the Shulchan Aruch entitled Mishnah Brurah,5 conclusively rules that one is not obligated to risk one's own life to save others if there is definite danger to the rescuer. He writes that even a question of danger to the rescuer outweighs the definite danger to the endangered party. Nevertheless, he mirrors earlier rulings that state that if there is only a question of danger, the would-be rescuer should evaluate the situation to make a judgement about the actual risk involved in saving the endangered party and not be too overly cautious with the risk to his own life.
It is possible that from a Jewish ethical perspective, there is an intrinsic distinction between questionable risk and actual danger. An actual danger may represent a known threat to life, such as certain diseases or dangerous situations. A questionable risk may mean that there is merely a possibility that there is a danger to life (versus a known extent danger which is considered a true danger). In the case of the sinking ship mentioned above, a definite risk may be sharks in the water, while a questionable risk may be the possibility that there are sharks in the water. In such a case, one should honestly evaluate the probability of sharks in the water and choose to attempt rescue (if he can swim) if the probability of sharks is small. Jewish law stresses that one should not use a far-fetched risk as an excuse to withhold treatment.
The practical implication of these rulings is that a physician must be intellectually honest in every case of treating a patient with a communicable disease. If the risk to the physician is very great, then he is foolish to risk his life. On the other hand, if the risk to himself is very small, then he has no justification to refuse treating the very sick patient. The risk to the endangered person and the risk to oneself must be weighed. If one wishes to "save" someone who is in minimal danger, then he is permitted to take virtually no risk himself. On the other hand, if a boat with passengers who cannot swim is sinking and one is a qualified lifeguard, then one is required to take the very small risk inherent in saving the drowning victims.
Obviously, when calculating the risk to the physician, we assume that the physician will be taking all reasonable precautions in treating the sick patient. In the case of AIDS, where we now know that the risk to the treating physician is minimal, particularly when no invasive procedure is performed, there is little basis for refusing to treat. The obligation to treat when there is a very small danger is based on the concept of shomer pasaim Hashem6, that God watches over the simple in their activities of daily life (see Risk in Halacha). One must not allow prejudice and paranoia to influence this issue. The physician must evaluate whether the risk of treating the contagious patient exceeds the level of risk that he is usually and habitually willing to take.
Until the healthcare professional can be assured that there is a relatively safe way to treat patients with SARS, there is a justification to refuse to treat the patient.
Thus, until the healthcare professional can be assured that there is a relatively safe way to treat patients with SARS, there is a justification to refuse to treat the patient. There are precedents for such a position. For example, an actual case7 came before a prominent Israeli halachic authority. Rabbi Yitzchak Zilberstein was asked whether a physician in her first trimester of pregnancy is obligated to treat a patient with rubella (German measles). Contact with the patient posed a 50% risk of physician developing the disease with an associated high risk of birth defects, miscarriage, or stillbirth. Rabbi Zilberstein ruled that the possibility of miscarriage represented a potential threat to the physician's life and she was therefore not obligated to treat the patient.
A similar question arises in retrospect with respect to September 11 attacks. Hundreds of police and firefighters lost their lives attempting to rescue the people trapped in the towers. Due to the extraordinary circumstances, they probably did not recognize the tremendous risk in which they were placing themselves when they entered the buildings. Had they known that there was a high likelihood that the towers might collapse, Jewish law would almost certainly have barred them from entering. As we will discuss below, this is true despite the increased latitude that fire-fighters are granted by Jewish law to risk their lives, due to the intrinsically dangerous nature of their life-saving work.
The issue of whether one may donate a kidney is dealt with in a similar way, with opinions ranging from calling the action a midas chasidus (extraordinarily selfless) to calling the donor a chasid shoteh (a pious fool). Most halachic authorities take the former position, because the risk to the donor is considered small8. Nevertheless, one is definitely not required to donate a kidney even to save the life of someone else, since there is a small risk of death from anesthesia, the surgery itself, and due to the small risks associated with having only one kidney. Of interest, Rabbi Yosef Shalom Eliashuv, arguably the greatest living halachic authority in Israel, rules that one must undergo pain and suffering to save the life of someone else.9
The special case of epidemics
The question of entering a dangerous situation is dealt with at length in the Talmud and commentaries10 The Talmud explains that when one enters a situation of danger, God examines his deeds to see if he deserves to be saved from harm. For this reason, one should not enter into a dangerous situation without a valid reason. A distinction may be drawn between pre-existing danger (swimming in shark-infested water) and danger that may develop (such as the risk of driving a car). For example, there is a concept that someone who is on a mission to do a mitzvah, will not be harmed,11 however this may not be the case if the danger is preexisting.12
One leniency permitting entering a dangerous situation is to earn a livelihood (see: Risk in Halacha). Another leniency is the permission granted by the Torah to undergo risk for communal benefit. The Talmud13 states that " if there is a plague in the city, remain there (i.e. do not flee to another city). Rabbi Shlomo Luria, the author of the commentary Yam Shel Shlomo14, a 16th century commentary on the Talmud, notes that:
"from here, there are those who wish to learn that during a plague it is forbidden to flee [the city]… However, I found it written15 in the name of great authorities that it is permitted [to leave]… But nevertheless, if it is within his power to save others either physically or with money, heaven forbid that he should refrain from doing so and remove himself from the suffering of the people. [But,] if heaven forbid there is no difference (i.e. he cannot help the others), then we act according to what was written [in Tractate Shabbos 55A] that a person should not remain in the place of danger. And we see great people that went and fled to another place [in time of plague]… Regarding the gemara which states that one should remain in his place [during a plague], this is after the plague has begun and has already become strong (perhaps he has already been infected and his traveling to another place would neither help him nor help others, because he may spread the disease to another place). However, early [in the outbreak], it is wise to escape… therefore, it appears that if a plague has infected a city one is obligated to flee if he has the ability. This does not apply to people who previously contracted the disease and recovered, for the world recognizes that there is no fear of recurrence."
This line of reasoning would imply that in the case of an epidemic, one may (and possibly should) risk his life to treat the community. One source16 even states that one may choose to sacrifice himself to save others. Nevertheless, it is almost unanimous that one is not required to do so.
The rationale behind the possible obligation to risk one's life for the community in time of epidemic must be understood in light of our understanding of the Babylonian Talmud's assertion that one is not required to enter a questionable danger to save someone else from a definite danger. In that case, there is only one endangered person and one rescuer. In such a case we might ask why the endangered person's life is more valuable than the rescuer. But in the case of epidemic, where there are many endangered people, and the risk of many more becoming sick, even the Babylonian Talmud might concur that one may risk his life to safe the community. The parameters of such an approach are beyond this essay.
Are physicians different?
The last issue to consider is whether physicians, by virtue of their role in society, have a different responsibility to risk their lives to save others. Rabbi Eliezer Yehuda Waldenberg (known as the Tzitz Eliezer, after his multivolume halachic work) deals with this exact question. Dr. Avraham Steinberg of Shaarei Tzedek hospital in Jerusalem published a book17 compiling the medical halachic rulings of Rabbi Waldenberg in which he has a chapter entitled "On the treatment which exposes the physician to danger." He writes:
"In principle, a person may not place himself in possibly life-threatening danger in order to save his neighbor' s life. However, when discussing physicians, this law is somewhat modified. It is permitted for a physician to assume the risk of treating patients with any type of contagious disease. Indeed, he is credited with the fulfillment of an important religious duty. When preparing to treat a patient with a contagious disease, the physician should pray to God for special guidance and protection since he is endangering his own life. A military physician is permitted to render medical care to a wounded soldier in a combat zone although he is endangering his own life. This applies even if it is doubtful whether the wounded soldier will live, die, or be killed. Similarly, another soldier is allowed to place his own life in danger in order to rescue a wounded comrade from the combat zone."
Rabbi Waldenberg clearly rules that physicians do have an extra obligation to heal the sick. They must recognize the danger into which they enter and pray for divine protection. This fits well with the traditional role of the physician throughout history who risked his life for the sake of his patients. It is also clear that this obligation extends to other people whose task it is to enter dangerous situations to save others, such as soldiers and probably fire fighters.
Physicians have treated the sick for millennia, often at the cost of their health or their lives. For an equally long time, Jewish law has debated the parameters by which Jewish law allows one to risk his/her life to save others. SARS only presents the most recent occasion to consider this question. While a small degree of risk need not preclude a physician from treating contagious patients (or anyone else with expertise from saving others in dangerous situations), intellectual honesty and accurate information regarding risks and benefits is required. Unfortunately, all information is not always available when the need for treatment arises. While one should not be overly cautious at the expense of the lives of others, there is limit to how much risk one may take. Physicians are expected to undergo a greater degree of risk than others, due to their training and the crucial nature of their work, but still must be prudent in protecting their lives.
1. Sanhedrin 73a
2. Mishneh Torah, Laws of Murder and Guarding Life 1:14
3. Responsa Radbaz, Volume 3:627 (Elef 52)
4. Nishmat Avraham, Orach Chaim, 329:6
5. Mishnah Brurah, 329:19
6. Psalms 116:6
7. Medicine and Jewish Law, edited by Fred Rosner, Vol. I, chapter 4 sites the case as being in Assia, vol. 11 (1986), pp. 5-11.
8. Rabbi Ovadia Yosef (Halacha U'Refuah, vol. 3, pp.61-63), Rabbi Yaakov Yosef Weiss (Minchas Yitzchak, 6:103, p.2), Rabbi Eliezer Yehuda Waldenberg (Tzitz Eliezer 10:25), Rabbi Moshe Meiselman (Halacha U'Refuah, vol. 2, pp.114-121), Rabbi Moshe Hershler (Halacha U'Refuah, vol. 2, pp.122-127).
9. Kovetz Tshuvos, Siman 124
10. This section relies heavily on the treatise by Rabbi Yaakov Weiner, “Treatment of Contagious Diseases,” available from the Jerusalem Center for Research, P. O. Box 57058, Jerusalem, Israel (
11. Pesachim 8a
12. Yuma 11a, Kiddushin 39b
13. Bava Kama 60b
14. Yam Shel Shlomo, 6:26
15. Responsa Maharil 50
16. Migdal Oz, Even Bochan, 85
17. Jewish Medical Law: A Concise Response; Compiled and Edited by Avraham Steinberg, M.D. Translated by David Simons M.D.; Beit Shammai Publications, 1989, Part 10, Chapter 11