Mishpatim: Permission for a doctor to heal

An anonymous commenter ("Anonymous") points out some interesting Rabbenu Bachyas this week. He writes:

Just a few Points of interest and questions from the Rabbenu Bachya for you.
1) First in כא, יט in his discussion on doctors he says only healing external wounds. Is that literal or does it mean Physical versus Psychological?

Literal. And this is clear from the parallel Ibn Ezra. But a fascinating Rabbenu Bachya and Ibn Ezra, so let us explore it.

The pasuk states:

יט אִם-יָקוּם וְהִתְהַלֵּךְ בַּחוּץ, עַל-מִשְׁעַנְתּוֹ--וְנִקָּה הַמַּכֶּה: רַק שִׁבְתּוֹ יִתֵּן, וְרַפֹּא יְרַפֵּא. {ס}

19 if he rise again, and walk abroad upon his staff, then shall he that smote him be quit; only he shall pay for the loss of his time, and shall cause him to be thoroughly healed. {S}

Rabbenu Bachya writes upon this:

'ורפא ירפא' - כל רפואה בבשר ודם לא מצאנוהו בכל הכתובים כי אם בדגש וכו', אבל בהקב"ה מצינו ברפה וכו', והטעם בזה כי הרפואה בבשר ודם אינה אלא על ידי צער וטורח והוא שיסבול הסם או המשקה המר, אבל רפואה של הקב"ה בנחת אין שם צער כלל כי ברכת ה' היא תעשיר ולא יוסיף עצב עמה. ומה שאמרו חז"ל 'ורפא ירפא' מכאן שנתנה רשות לרופא לרפאות לא אמרו אלא במכה שבחוץ שהכתוב מדבר בה, אבל חולי מבפנים אין זה תלוי ביד הרופא אלא ביד הרופא כל בשר אשר בידו נפש כל חי.

To explain this, and expand upon it. He first points out that when people heal, there is always a dagesh (chazak) in the word רפא. For example, the above pasuk. Or also in Yirmeyahu 51:

ט רִפִּאנוּ אֶת-בָּבֶל, וְלֹא נִרְפָּתָה--עִזְבוּהָ, וְנֵלֵךְ אִישׁ לְאַרְצוֹ: כִּי-נָגַע אֶל-הַשָּׁמַיִם מִשְׁפָּטָהּ, וְנִשָּׂא עַד-שְׁחָקִים.

9 We would have healed Babylon, but she is not healed; forsake her, and let us go every one into his own country; for her judgment reacheth unto heaven, and is lifted up even to the skies.

But when Hashem heals, the peh won't have a dagesh in it. This is because when people heal, there is an element of tzaar, but Hashem heals without this. Thus, for example:

יד רְפָאֵנִי יְהוָה וְאֵרָפֵא, הוֹשִׁיעֵנִי וְאִוָּשֵׁעָה: כִּי תְהִלָּתִי, אָתָּה.

14 Heal me, O LORD, and I shall be healed; save me, and I shall be saved; for Thou art my praise.

Now, people object to this Rabbenu Bachya with examples of Hashem healing and there being a dagesh. For example, by Avimelech, in Bereshit 20:17:

יז וַיִּתְפַּלֵּל אַבְרָהָם, אֶל-הָאֱלֹהִים; וַיִּרְפָּא אֱלֹהִים אֶת-אֲבִימֶלֶךְ וְאֶת-אִשְׁתּוֹ, וְאַמְהֹתָיו--וַיֵּלֵדוּ.

17 And Abraham prayed unto God; and God healed Abimelech, and his wife, and his maid-servants; and they bore children.

One answer is that this is a dagesh kal, after the shva nach, and so this is not what Rabbenu Bachya means. However, here is a counter-example, with a dagesh chazak. In II Melachim 2:21:

כא וַיֵּצֵא אֶל-מוֹצָא הַמַּיִם, וַיַּשְׁלֶךְ-שָׁם מֶלַח; וַיֹּאמֶר כֹּה-אָמַר יְהוָה, רִפִּאתִי לַמַּיִם הָאֵלֶּה--לֹא-יִהְיֶה מִשָּׁם עוֹד, מָוֶת וּמְשַׁכָּלֶת.

21 And he went forth unto the spring of the waters, and cast salt therein, and said: 'Thus saith the LORD: I have healed these waters; there shall not be from thence any more death or miscarrying.'

where even though it was via an agent, it was the miracle of Hashem, and yet there is a dagesh chazak in the peh. Yes, you can say that this is waters rather than humans, but still, how is it going to be harsher (read on for what I mean) for the water? I did not have the time to look through every example with a concordance, so perhaps this is true in general, except for this particular case. It would be worthwhile to accumulate such a list.

My impression was that Rabbenu Bachya did not necessarily mean that it could never have a dagesh when Hashem is involved. Rather, that specifically by basar vadam, it will always be with the dagesh.

How does Rabbenu Bachya divine the meaning of this dagesh? I would suggest that his midrashic motivation is:

1. In general, with the dagesh it is with a more intensive form. Compare שבר with and without a dagesh chazak -- break vs. shatter.
   
   
2. And even the רפה form (namely, without a dagesh chazak) means relaxed.
   
   
3. Also, the root רפא means to loosen, relax. Indeed, this is true for other languages as well. See disease as dis+ease. Without the dagesh, it more closely resembles רפא as relaxed. Add the dagesh, and perhaps sever that connection somewhat.

Not that I necessarily agree with this distinction. After all, there are some roots in Hebrew for which the intensive form has more or less the same meaning as the non-intensive form -- the intensive form is not really more intense. And sometimes, it is perhaps being used as a causative. And Tanach is a fairly limited corpus. Perhaps if there were more seforim in Tanach, we might have encountered an exception to the rule.

In the pasuk in Mishpatim, see how וְרַפֹּא יְרַפֵּא is translated by JPS: and shall cause him to be thoroughly healed. The duplication is what sparked the word "thoroughly," but the context plus the dagesh sparked the "cause him to be," rather that "and shall heal him."

Now, about this:

מה שאמרו חז"ל 'ורפא ירפא' מכאן שנתנה רשות לרופא לרפאות לא אמרו אלא במכה שבחוץ שהכתוב מדבר בה, אבל חולי מבפנים אין זה תלוי ביד הרופא אלא ביד הרופא כל בשר אשר בידו נפש כל חי

Thus, Chazal in Bava Kamma give permission to heal, or rather say that Hashem has given permission to heal. But Rabbenu Bachya restricts this to external rather than internal maladies. He is not assuring psychologists.

How do I know? Compare with Ibn Ezra, who says the same thing:

ורפא ירפא -
לאות שנתן רשות לרופאים לרפא המכות והפצעים שיראו בחוץ, רק כל חלי שהוא בפנים בגוף ביד השם לרפאתו.
וכן כתוב: כי הוא יכאיב ויחבש.
וכתוב באסא: וגם בחליו לא דרש את ה' כי אם ברופאים.
והנה הכתוב הפריש, כי לא אמר ורָפוֹא יִרְפָּא מן הבנין הקל. רק ורַפֹּא יְרַפֵא שהוא מהבנין הכבד.
ועוד אפרש זה היטב בפרשה הזאת.
וחכמינו קבלו דברים אחרים עם אלה שניהם. כאשר קבלו בשמים עם קטורת סמים. ואינם כתובים.

His examples are {Yirmiyahu 5:18}:

יח כִּי הוּא יַכְאִיב וְיֶחְבָּשׁ; יִמְחַץ, וְיָדָו תִּרְפֶּינָה.

18 For He maketh sore, and bindeth up; He woundeth, and His hands make whole.

But I would say based on context that this is not meant literally: הִנֵּה אַשְׁרֵי אֱנוֹשׁ, יוֹכִחֶנּוּ אֱלוֹהַּ; וּמוּסַר שַׁדַּי, אַל-תִּמְאָס. This could well refer to troubles in general, and the healing is metaphorical.

King Asa it indeed criticized for consulting with doctors and not turning towards Hashem. In II Divrei Hayamim 16:2:

יב וַיֶּחֱלֶא אָסָא בִּשְׁנַת שְׁלוֹשִׁים וָתֵשַׁע לְמַלְכוּתוֹ בְּרַגְלָיו, עַד-לְמַעְלָה חָלְיוֹ; וְגַם-בְּחָלְיוֹ לֹא-דָרַשׁ אֶת-יְהוָה, כִּי בָּרֹפְאִים.

12 And in the thirty and ninth year of his reign Asa was diseased in his feet; his disease was exceeding great; yet in his disease he sought not to the LORD, but to the physicians.

How this is internal, I don't know. But perhaps we are speaking of disease as opposed to injury. So we are not discussing psychological ailments here.

How to deal with this pasuk in Neviim, and this world-view, may indeed be troubling. Though one might give a teretz that he only saw them as his hope, instead of also turning to Hashem.

One way to resolve these two contrasting ideas is to say that the one permitted is for external injuries, while the one forbidden is for internal injuries and sickness. Indeed, the pasuk in Mishpatim is where one person smote the other, such that there was an external injury. So this might have been the motivation for making this particular distinction.

(A digression: giving reshut for the physician to heal I would consider to be pashut peshat. Hashem would not instruct one to heal another, or pay for him to be healed (note the causative form) is healing another person is forbidden.)

As is mentioned in the critical edition of Rabbenu Bachya from Mossad Harav Kook, the sefer Mateh Moshe takes this to task, pointing out cases in the gemara of Tannaim and Amoraim healing. Thus, in Bava Metzia 85b:

Samuel Yarhina'ah 20{=the Babylonian Amora Shmuel} was Rabbi's physician. Now, Rabbi having contracted an eye disease, Samuel offered to bathe it with a lotion, but he said, 'I cannot bear it.' 'Then I will apply an ointment to it,' he said. 'This too I cannot bear,' he objected. So he placed a phial of chemicals under his pillow, and he was healed.21 Rabbi was most anxious22 to ordain him, but the opportunity was lacking.

This {eye disease} would seem to be considered an internal disease, and yet the Tanna went to a physician, which should be prohibited as to Assa, if were indeed a problem, and the Amora actually healed him. And the Talmud actually records many remedies to internal diseases. Even if they are nonsense, and not to be trusted, as per Rambam, they still intended them to be used. So, as Mateh Moshe says, chas veshalom to say this and malign our great rabbis!

It is a good question, and I wonder at this -- whether they intended it as halacha, or simply to solve some internal Biblical contradiction. I would guess more about Rabbenu Bachya that he intended it as halacha. But then, they are offering it as a clarification of this statement of Chazal, so perhaps it is clarification rather than contradiction. How would they resolve it with these other gemaras? I don't know. And I suspect it is not lehalacha.

While on the topic, since the suggestion was raised that this prohibits psychology, I will note a troubling guest-post on the Daas Torah blog. An excerpt:

There are two parts to your question, one is halakhic and the other is haskafic. However, the hashkafa has to be settled before we move on to the halacha.

For instance you want a guilty party to have to make some kind of reparations for mental health care. You are assuming that mental health care is a valid form of healing and that it is in line with Torah values. Take for instance this:
http://www.youtube.com/watch?v=QS2G4_CeMCY

I post that because I know the Rosh Yeshiva he learned that from.

Then there is the perspective of others such as R' Mordechai Goldstein Shlit"a, who claims that psychology/psychiatry can diagnose accurate problems but is useless to resolve or heal them. He claims that is the shitta of the Yeshiva where he learned(Chafetz Haim), and has passed that on to each of his students at his own Yeshiva. Furthermore each of his former students that have started their own Yeshivas(at least each of the one's I have spent any time at) hold the same opinion. They have passed this on to their students, some of whom are Dayyanim that will hear cases.

It is troubling that such determinations of metzius, which belong in the realm of those capable of assessing the metzius, are being made on hashkafic bases by people who likely do not know the science and the data. Certainly people have been treated successfully by drugs proscribed by psychiatrists. And psychologists have also been successful. There are ways of measuring this. Half of psak is knowledge of halacha. The other half is an accurate understanding of metzius. And if ideological concerns get in the way, then the result is terribly flawed psak. As the famous saying by George Fuechsel goes, "Garbage in, garbage out."

Here, by the way, is the ignorant video linked to above. I could debunk it if need be -- but don't have the patience. (For starters, Freud is not the same as modern psychology/psychology, which rejects him; and he had oral cancer causing him much pain.) This is scary and sad: