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Suppose a doctor recommends a patient receive a pacemaker, both improve the quality of life and extend the patients life. However, the patient has no interest in getting one. Does Halacha compel the patient to get a pacemaker?

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    what does the dr say about the odds of what will happen if he does not get the pacemaker – ray Jan 13 '15 at 19:38
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    Do you have any reason to think pacemakers are unique halachically? If not then i dont know why you havent mentioned survival statistics which would seem to be the only a priori relevant factor in every medical procedure. – Double AA Jan 13 '15 at 19:44
  • @Ray: I do not know the odds the Dr is giving, however he recommends it to both improve the quality of life and extend the patients life. Patient does not want one. He is uninterested in going through the procedure. Does Halacha require him to listen to the Doctor. – C. Ben Yosef Jan 13 '15 at 19:50
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    i didnt say it was too narrow. You have presented a narrow case but without hardly any useable details. So it is quite hard to answer definitivly – Double AA Jan 13 '15 at 19:58
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    @ray That's quite similar, but not a duplicate. For one thing, C. Ben Yosef reported that the doctor said that this treatment would "extend the patients life". – Fred Jan 14 '15 at 8:14
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The Kitzur Shulchan Aruch in סימן לב - שמירת הגוף על פי הטבע says:

סעיף א': הוֹאִיל וֶהֱיוֹת הַגוּף בָּרִיא וְֹשָלֵם מִדַּרְכֵי הַֹשֵם הוּא, שֶׁהֲרֵי אִי אֶפשַׁר שֶׁיָבִין אוֹ יֵדַע דָּבָר מִידִיעַת הַבּוֹרֵא וְהוּא חוֹלֶה, לְפִיכָךְ צָרִיךְ הָאָדָם לְהַרְחִיק אֶת עַצְמוֹ מִדְּבָרִים הַמְאַבְּדִין אֶת הַגוּף, וּלְהַנְהִיג אֶת עַצְמוֹ בִּדְבָרִים הַמַבְרִין וְהַמַחֲלִימִים אֶת הַגוּף. וְכֵן הוּא אוֹמֵר, וְנִֹשְמַרְתֶּם מְאִד לְנַפְשׁוֹתֵיכֶם. ‏

Based in the Pasuk וְנִֹשְמַרְתֶּם מְאִד לְנַפְשׁוֹתֵיכֶם one has an obligation to actively keep the body healthy and help it heal.

And again in סימן קצב - דין החולה והרופא ובמה מתרפאין we learn:

סעיף ג': הַתּוֹרָה נָתְנָה רְשׁוּת לָרוֹפֵא שֶׁיְרַפֵּא, שֶׁנֶּאֱמַר, וְרַפֹּא יְרַפֵּא. וְלָכֵן אֵין לוֹ לַחוֹלֶה לִסְמֹךְ עַל הַנֵּס, אֶלָּא חַיָב לְהִתְנַהֵג בְּדֶרֶךְ הָעוֹלָם לִקְרוֹא לְרוֹפֵא שֶׁיְרַפֵּהוּ. וּכְבָר כַּמָה חֲסִידֵי עוֹלָם נִתְרַפְּאוּ עַל יְדֵי רוֹפְאִים. וּמִי שֶׁמּוֹנֵעַ אֶת עַצְמוֹ מִלִּקְרוֹא לָרוֹפֵא, שְׁתַּיִם רָעוֹת הִנֵּהוּ עוֹשֶׂה, הָאַחַת, דְּאָסוּר לִסְמֹךְ עַל הַנֵּס בְּמָקוֹם שֶׁיֵּשׁ סַכָּנָה, וְדָבָר זֶה גּוֹרֵם שֶׁיִזָּכְרוּ עֲוֹנוֹתָיו בִּשְׁעַת חָלְיוֹ. וְעוֹד, דַּהֲוֵי יֻהֲרָא וְגֵאוֹת שֶׁסּוֹמֵךְ עַל צִדְקָתוֹ שֶׁיִתְרַפֵּא בְּדֶרֶךְ הַנֵּס. וְיֶשׁ לוֹ לִקְרוֹא לָרוֹפֵא הַיוֹתֵר מֻמְחֶה, וּבְכָל זֹאת לִבּוֹ יְהֵא לַשָׁמַיִם, וִיבַקֵּשׁ רַחֲמִים מֵאֵת הָרוֹפֵא הַנֶּאֱמָן יִתְבָּרַךְ שְׁמוֹ, וְאַךְ בּוֹ יִבְטַח לִבּוֹ (ברכי יוסף) (וְעַיֵּן לְעֵיל סִימָן סא סָעִיף ד). ‏

A person has an obligation to heal himself - and to do so with the best medical team available.

Like any other Torah obligation, one does not have a dispensation simply because one is depressed.

Furthermore we learn in סימן קצד - דיני גוסס ושמירת המת that:

סעיף א': הַגּוֹסֵס (פֵּרוּשׁ, הַמַּעַלֶה לֵחָה בִּגְרוֹנוֹ מִפְּנֵי צָרוּת הֶחָזֶה, וְזֶה יִקְרֶה סָמוּךְ לַמִּיתָה, וּלְשׁוֹן גוֹסֵס הוּא מִלְּשׁוֹן מֵגִיס בִּקְדֵרָה, שֶׁהַלֵּחָה מִתְהַפֶּכֶת בִּגְרוֹנוֹ, כְּמוֹ הַמֵּגִיס בִּקְדֵרָה תוספת יום טוב, פרק א דערכין) הֲרֵי הוּא כְּחַי לְכָל דְבָרָיו. וְלָכֵן אָסוּר לִגַּע בּוֹ, שֶׁכָּל הַנּוֹגֵעַ בּוֹ, הֲרֵי זֶה שׁוֹפֵךְ דָמִים. לְמָה הַדָּבָר דּוֹמֶה. לְנֵּר מְטַפְטֵף, שֶׁכֵּיוָן שֶׁנּוֹגֵעַ בּוֹ אָדָם, מִיָד נִכְבֶּה. וְאַף עַל פִּי שֶׁהוּא גוֹסֵס זְמַן אָרֹךְ וְיֵשׁ צַעַר גָדוֹל לוֹ וְלִקְרוֹבָיו, מִכָּל מָקוֹם אָסוּר לִגְרֹם שֶׁיָמוּת מְהֵרָה, כְּגוֹן לְהַשְׁמִיט הַכַּר וְהַכֶּסֶת מִתַּחְתָּיו, מֵחֲמַת שֶׁאוֹמְרִים, שֶׁיֵשׁ נוֹצוֹת מִקְּצָת עוֹפוֹת שֶׁגּוֹרְמִים לְעַכֵּב אֶת הַמִּיתָה, אוֹ לָשׂוּם מַפְתְּחוֹת בֵּית הַכְּנֶסֶת תַּחַת רֹאשׁוֹ, כָּל זֶה אָסוּר. אֲבָל אִם יֵשׁ שָׁם דָּבָר שֶׁגּוֹרֵם עִכּוב יְצִיאַת הַנֶּפֶשׁ, כְּגוֹן קוֹל דוֹפֵק וְכַיּוֹצֵא בָזֶה, מֻתָּר לַהֲסִירוֹ, דְּאֵין בָּזֶה מַעֲשֶׂה, אֶלָּא שֶׁמֵּסִיר אֶת הַמּוֹנֵעַ וְאֵינוֹ נוֹגֵעַ בּוֹ. ‏

Even somebody in his death throes - who is clearly in pain - even if it's taking a long time for them to expire - is considered fully alive and one commits murder if one hastens his demise.

The קיצור ש''ע ילקוט יוסף is even more explicit about the absolute obligation to heal oneself. In סימן ב' - דיני הרופא והחיוב להתרפאות he writes:

א: חיוב גדול על החולה להתרפאות כדרך כל הארץ, ואסור לו להמנע מלהתרפא בדרך טבעית. וכל המתעצל בזה וסומך על הנס אינו אלא מן המתמיהים, ודעת שוטים היא זאת, וקרוב להיות פושע בעצמו, ועתיד ליתן את הדין על כך, וגם אם מכוין בשביל מצוה, עליו לידע דהוי מצוה הבאה בעבירה. וגם מי שנחלה בחולי פנימי, חייב להתנהג על פי דרך הטבע, וללכת אל הרופא, ולהתנהג כפי הוראת הרופאים, אלא שיתלה בטחונו בה' יתברך, והחונן לאדם דעת ומלמד לאנוש בינה, שיתן בלב הרופאים להבין ולהשכיל ולדעת שרשי המחלה ודרך רפואתה, והמונע עצמו מללכת לרופא, הרי זה מתחייב בנפשו. [ילקו''י אבלות מהדורת שנת תשמ''ט עמוד כט, ובמהדורת תשס''ד סימן ב' סעיף א עמוד סו] ‏

It's forbidden not to heal oneself, and one will be held responsible [if one dies] for not haven taken care of one's health.

ב: יש בריפוי משום מצות השבת אבידת גופו, וגם משום מצות ואהבת לרעך כמוך, והחיוב לרפא הוא בין אם החולי הוא של סכנה או צער ואיבוד אבר. ואף אם הרופא הוא מכובד וזקן חייב לטפל בכל חולה, גם כאשר הדבר כרוך בבזיון או בטירחא לרופא הזקן. וצריך הרופא לטפל בחולה אפילו אם הוא חולה סופני, הנוטה למות, בכל התרופות והטיפולים הרפואיים. וחלילה לקרב את קיצו של חולה סופני, כדי להקל על סבלו על ידי ניתוקו מהמכשירים. ועל קרובי המשפחה לוודות שהרופאים מזינים את החולה על ידי זונדה וכדומה, ומטפלים בו כיאות, ויש לעקוב אחר פעילות הרופאים כיון שיש בהם המזלזלים בטיפול בחולים סופניים כאלה. [ילקו''י אבלות מהדורת תשס''ד סימן ב' סעיף ב עמו' סט]‏

Even elderly people require the best medical treatment - even though he has no chance of living very long. Shortening his life is forbidden, even if the sick person will suffer indignities as a result.

More so, relatives have an obligation to ensure the medical treatement is being done properly.

  • If we have an obligation to take extraordinary actions to extend our lives, such as getting a pacemaker, we should be starting such actions early in life by eating a healthy diet and exercising. I know of no rabbis today who require that (whether or not they should is beyond my pay grade). – Bruce James Jan 21 '15 at 19:25
  • @BruceJames - No need for them to say this, as it's clearly documented in Halacha that you have to eat healthy. May I suggest you look in the Kitzur in סימן לב - שמירת הגוף על פי הטבע - toratemetfreeware.com/online/f_00561.html#HtmpReportNum0031_L2 – Danny Schoemann Jan 22 '15 at 8:15
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There is a responsum from Rav Moshe about a patient refusing medical care, in the fifth volume of Tzomet's halachic journal, תחומין. Here is a very loose translation/summary of what he writes there.

When a patient refuses to take (life-saving) medicine, it depends on why he is refusing. If he still believes that he could be healed by this doctor, but is reluctant to do something which is painful for him, which is a מעשה שטות ומעשה תינוקות, a juvenile/stupid thing to do, then we force the patient to take the medicine, as much as we are able to.
However, if he does not think that this doctor will be successful at healing him, then we have to find doctors that he believes will be effective at healing him. But if there are no doctors who the patient thinks will be effective, or if it is impossible to make the patient understand that what we are doing is for his benefit, then we force him to take the medicine, so long as all the present doctors feel that this is beneficial for him.

However, the only cases where we force a patient to pursue healing are those where the patient will not become upset (שלא יתבעת מזה); for if the patient should get upset, this can be be harmful, even life-threatening. Thus, in those cases, it is better to do nothing.
Therefore, in every case where there is a patient that is unwilling to undergo treatment, all of these variables need to be weighed carefully, before forcing treatment on a patient; the only time doctors should force treatment on a patient is when they do so לשם שמים, with good intent.

Additionally, if there is any amount of סכנה, danger, in the pursuit of this treatment, even if the doctors usually administer this treatment, because the illness is more dangerous, the patient cannot be forced into treatment.

With regards to administering a treatment that is dangerous, but the danger of the illness is still greater (i.e., in general, and not in a case where the patient is refusing treatment) -- one should not always administer this treatment, because even if the treatment was proven to be safe for healthy people, there isn't necessarily proof that it's safe for a very ill patient. A potentially dangerous treatment should never be administered, unless there is proof that more than half of the people who are sick with this illness, to the degree to which this patient is sick, have recovered from their illness.
This calculation must be done carefully, because it is hard, even for very great doctors, to calculate.

So the halacha in this case, according to Rav Moshe, is dependent on many factors -- the mindset of the patient, the chance of recovery, and the danger of the illness and the treatment. As with all halacha questions on Mi Yodeya, it's best to ask a knowledgeable rabbi for a final ruling.

  • I don't know if that article is quoting from the Igros Moshe or not, but in choshen mishpat 2 siman 74.5 & 75.4 discuss this with similar language. – user6591 Feb 4 '15 at 1:02
  • They didn't say if they were quoting from Igros Moshe....I guess I kinda assumed that since they did that, it wasn't published there....but it might have just been a scrape. Odd, though, that they didn't say (or I don't remember that they said) where they were taking it from, if that's the case. – Shokhet Feb 4 '15 at 1:13
  • Well congrats on 9k! And feel free to stick these maareh makomos in your answer in case anyone wants to check things up inside. First double check to make sure im not mixed up though, this is after all your answer, your achrayos:) – user6591 Feb 4 '15 at 14:36
  • Thanks :) ...I think I will try to find it inside before editing that in...I'm no Igros Moshe expert, but CM doesn't feel like the right place for this. – Shokhet Feb 4 '15 at 22:28
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    that's one of the things that are most fun about the Igros! Its like a box of chocolates. You never know what you're gonna get. – user6591 Feb 5 '15 at 0:08
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Rabbi Hershel Schachter's reading of the Rambam is that in some cases where treatment is painful and the outcome uncertain, this may be the patient's choice -- within reasonable limits. (He wrote a fascinating article in the Journal of Halacha & Contemporary Society many years ago in which he compared this decision to Israel's decision of land-for-peace.) But if the prognosis is so good that any reasonable person would go with it, the patient is obligated to go with treatment.

He clarified on a yutorah shiur that an otherwise healthy seventeen-year-old who needs a diseased limb amputated and can live into his 70s with a prosthetic is obligated to do so, rather than say "no I'd rather die at 17 than have an amputation!" His student, Rabbi Kenneth Brander, describes (also in a yutorah shiur) the tale of a fellow who'd always been a powerful and influential figure who developed a host of serious medical problems around age 60 or so. He wanted to leave the earth now, rather than live on for many years as a shadow of his former self, always on the receiving end of others' kindness and treatment. Rabbi Brander wasn't sure if this passed the reasonable-person test; Rabbi Schachter came down to Florida, met with the patient, examined the details of this situation, and concluded that it did -- i.e. this was the patient's choice.

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This is a straightforward question of v'Rapo yi'Rapeh and "v'Nishmartem Me'od Lenafshoteichem". What haveh amina is there not to listen to the doctor?

  • Do you have a source for your contention? – C. Ben Yosef Jan 13 '15 at 20:08
  • The surgery to install it is dangerous. – Double AA Jan 13 '15 at 21:08
  • @DoubleAA I don't think that parameter was specified in the OP, though this may be true on a case-by-case basis. In general, though, it isn't considered particularly dangerous. NIH website: "Pacemaker surgery generally is safe." Mayo Clinic website: "Life-threatening complications of pacemaker implantation are rare." – Fred Jan 13 '15 at 23:39
  • @Fred I was responding to the answer's rhetorical question. Someone could easily imagine Shev ve'Al Taaseh playing a role here. – Double AA Jan 14 '15 at 0:30
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Two considerations. First, if the person is suffering in their present condition and is choosing to passively not alleviate the situation, I would point to Igros Moshe Choshen Mishpat 2 #65 where he says the suffering caused by dieting is assur because the person is חובל בגופו. Unless it is for health reasons. To compare to this case, if we are discussing a routine procedure which can alleviate the suffering I would think it is easily compared to eating. Obviously if it is not a simple procedure and or the person is not in physical discomfort from their condition, this does not apply.

Point number two. If this is a quality of life question where the person will continue to suffer after the procedure, I will quote a gemara in Sota 46b which I don't think I've seen quoted in discussions of this issue. Please correct me if I'm wrong. וילך האיש ארץ החתים ויבן עיר ויקרא שמה לוז היא שמה עד היום הזה תניא היא לוז שצובעין בה תכלת היא לוז שבא סנחריב ולא בלבלה נבוכדנצר ולא החריבה ואף מלאך המות אין לו רשות לעבור בה אלא זקנים שבה בזמן שדעתן קצה עליהן יוצאין חוץ לחומה והן מתים. Apparantly we have nothing against people putting themselves in a situation whereby they are passively allowing the end of their own life once the quality of that life had degraded to such a degree. Whether or not a person can actively end their own life to spare themselves from suffering is a completely different subject.

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