Who Pays the Costs?

  1. Is the Jewish medic supposed to offer his services for free?
  2. Is the person who called the ambulance responsible for all charges? (hereafter the helper)
  3. Perhaps the patient has to cover his own care?

Copper Snakes

In Parshos Chukas, Hashem asks Moshe Rabbeinu to save the lives of his fellow Jews after venomous snakes bit them. Hashem instructs him to fashion a replica of a snake and place it high up so that all the dying people can gaze at it and thereby survive. ((Might this be the source of the Rod of Asclepius as a symbol of medicine and healing? Sources I have seen refer back to Greek mythology and its symbols but no further. This symbol may have nothing to do with Greek mythology, but even if it does, perhaps this aspect of Greek mythology had its root in this scene from the Torah. If the rod and snake together were originally the symbol of medicine and healing, it might refer to the elevated rod on which the image of the venomous snake was lifted. According to the Midrash, however, there was no rod as the copper snake suspended miraculously in the air. The Torah does refer to the image of the snake to be placed by or on a ness (Bimidbar 21:8), which can be translated as a miracle or rod. )) Surely there were costs involved. Moshe even considered using gold as the appropriate material but reconsidered and decided to use copper. ((See Sforno. )) Should the beneficiaries—the bitten people who were healed—cover the cost of their own care? The Gemoro reads the text as saying that Moshe was to make the copper snake from his own assets. ((The Torah writes Aseh lecho sorof. In Avodoh Zoroh 44a, the Gemoro learns from the extra word lecho that Moshe should make it from assets that belong to him, mishelcho. The Malbim (Melochim II 18:4) explains that although Moshe’s copper snake was extant for generations and was worshipped as a healing idol, due to a halachic argument it was not destroyed as avodoh zoroh until the reign of Chizkiyohu. Jewish rulers up until Chizkiyohu’s reign figured that since Moshe had used his own material, the copper snake belonged to Moshe and therefore the idolatrous practices of others cannot alter the copper snake’s halachic status as non–avodoh zoroh. Chizkiyohu disagreed and ruled that the idolaters had done enough to the snake for it to be considered theirs. Since, at least with regard to the laws of avodah zoroh, the copper snake is considered belonging to them, therefore any subsequent worship done to what was later to be named Nechushtan, made it into an object of avodah zoroh and forbidden. )) Does this imply that the beneficiary need not pay?

The Victim (or Patient)

In Sanhedrin (73a), we learn that although one does not have to spend any money to return a lost item to its rightful owner, nevertheless when a person is in a position to save another Jew’s life he must lay out money to do so. ((Saving a life from danger (e.g., bandits or drowning; cases mentioned in the Gemoro) is also included in the mitzvoh of hashovas aveidoh since preventing the body from separating from its soul is considered equivalent to returning the body to its owner. The halachic distinction between saving a life and returning lost items is due to an extra verse in the Torah that requires us to take action and not stand by when a life is at risk. ))

The Gemoro seems to indicate that along with the responsibility to save lives comes financial liability to pay for the fulfillment of the mitzvoh. ((הנה לשון הגמרא אבדת גופו מנין ת”ל והשבותו לו אי מהתם ה”א ה”מ בנפשיה אבל מיטרח ומיגר אגורי אימא לא? קמ”ל. ונחלקו הראשונים בפירוש הגמרא. ביד רמ”ה מדייק לשון הגמרא דלא קאמר הגמרא סד”א דא”צ לקיים המצוה בממונו קמ”ל, דלישתמע דלענין הצלת נפשות חייב להוציא ממונו אלא קמ”ל דבעינן למיטרח ולהשכיר פועלים אחרים שיצילו, אבל באמת אין עליו חיוב להוציא ממונו, ואם יודע שהניצול לא יחזיר לו הוצאותיו פטור מלהציל. ונראה דס”ל דקרא דלא תעמד על דם רעך אינו ל”ת בפנ”ע שחייב להוציא ממונו לקיימו אלא הוא גילוי קרא להוסיף על מצות השבת אבידה דלענין אבידת גופו מחוייב לחזור על כל הצדדים להשיב גופו לנפשו לטרוח ולשלם לפועלים עבורו היכא דבטוח שיחזיר לו מעותיו. וכ”כ בשו”ת חו”י מסברא דנפשיה בסימן קמ”ו. אלא דסיים שם דכל הפוסקים חולקים ע”ז פה אחד וס”ל כדעת הרא”ש פ”ח דסנהדרין ס”ב דכשיש לניצול ממון חייב להחזירו למציל אבל כשאין לניצול ממון עדיין חייב להצילו מממונו הביאו המ”מ ספ”א מהלכות רוצח, וכ”ה במאירי שם וכ”פ הטור בח”מ סימן תכ”ו ובסמ”ע שם, וכ”ד הח”ח בספרו אהבת חסד בהערה ה’ בפתיחה ויותר מבואר בח”ב פרק כ’ ס”ב. ונראה דס”ל דאין מצות הצלת נפשות הנלמדת מקרא דלא תעמד על דם רעך סניף של השבת אבידה אלא ל”ת בפנ”ע ודינו כשאר מל”ת דצריך להוציא ממון לקיימם, וכבר פסק הח”ח דצריך להוציא כל ממונו להציל נפש מישראל (אלא דע”ע בחידושי רע”א ליו”ד סימן קנ”ז ס”א בהא דנחלקו החו”י וריב”ש לענין ל”ת שמקיים בשוא”ת אי חייב בחומש נכסיו או כל ממונו וע”ע במ”ב סימן תרנ”ו סק”ט). )) This might explain why the people dying in the desert were not responsible for the cost of the copper snake. Moshe, who was given the method and mitzvoh of saving them, was responsible to cover the costs.

The Rosh, however, rules that in the cases mentioned in the Gemoro (i.e., seeing someone in the process of drowning, being dragged by wild animals or about to be attacked by bandits), should the victim have the funds to pay for the costs of the rescuer’s expenses, the rescuee must reimburse the rescuer. ((בפסקים בסנהדרין פ”ח סימן ב’ ומובא בסמ”ע ריש סימן תכ”ו. וכעי”ז אפשר לפרש הא דמצאנו בשו”ת הרא”ש סימן פ”ה ס”ב, הובא ברמ”א בסימן ק”ח ס”א בקרובי משפחה ששלמו הוצאות רפואיות עבור חולה, ובתוך הדברים הוסיף הרא”ש דה”ה כל אדם שהוציא הוצאות עבורו מפני פיקו”נ, דלאחר שנתברר שהוציאו סכום מסוים ולא נפרעו יכולים לגבותו מהיורשים מאחר דהחולה היה חייב בהם. וצ”ב מדוע חייב החולה שמת לשלם עבור הוצאות רפואיות שלא בקש מהם שיעשו ולא הועילו, ולכאורה דמי לירד שלא ברשות ולא השביח דאין לו אלא הוצאות שיעור שבח, וכשמת ואין שבח אין מגיע לו שום הוצאות. וי”ל דעכ”פ הועילו הרפואות להאריך חייו, וכיון שנהנה מהטיפול הוי כיורד שלא ברשות והשביח דמשלם הוצאות שיעור שבח, ולכן החולה חייב לשלם לקרובים, וממילא גובין מנכסיו שירשו יורשיו. אולם בהמשך כתבתי דרך אחרת לבאר דברי שו”ת הרא”ש דחייב אף שלא הועיל התרופות והטיפול משום דחשיב כשדה עשויה ליטע דחייב כשתלי העיר אף בלא השביח, עיין ציון 23.

I heard my rebbi, Horav Zalman Nechemiah Goldberg, apply this law to a case brought to him in which a person driving down the road saw a young man (about 15-years-old) run into the street right in front of his car. In order to avoid running him over he swerved the car and crashed it into a wall destroying the car but saving the boy’s life and luckily his own as well. The question presented was whether or not the young man is responsible to pay for the damage to the car? Upon hearing the case, Rebbi recounted this Rosh and drew a comparison. The driver was halachically required to damage his car to save the boy’s life. However, the driver is entitled to be reimbursed for his loss expended on behalf of saving the boy’s life. When the young man has assets to pay the value of the damage to the car, he must do so. )) If so, the question returns: would people in the same situation as those healed in the desert be required to cover the expenses involved?

Although the Rosh does prove his point, he does not offer an explanation as to which halachic process he is employing that obligates the rescuee to reimburse the rescuer. ((הרא”ש מוכיח דינו מהא דנרדף ששיבר כלים של אחרים בברחו מפני רודפו חייב, ואם ממון של כל אדם מחוייב להציל אחרים, היה הנרדף צריך להיות פטור משבירת כלים כשנעשה לצורך הצלתו כיון שנעשה ברשות, אלא ע”כ שאין ממונו מחוייב להצלת נפשות.

ואפשר דהיד רמ”ה החולק על הרא”ש היה דוחה הראיה, דכשהאדם לא ראה ולא שמע שחבירו בסכנה לא נתחייב כלל בהצלתו ואין ממונו משועבד בקיום המצוה כיון שבעליו עדיין לא נתחייב. רק היכא דכבר נתחייב האדם להציל, א”כ מוטל עליו כל טצדקי בכדי שינצל חבירו ואפילו להוציא מממונו.

אמנם לא נתברר לדעת הרא”ש, איך נתחייב הניצול לשלם למציל עבור דבר שלא בקש שיעשה עבורו. וע”ז כתבתי למעלה באנגלית מדין יורד שלא ברשות בשדה שאינה עשויה ליטע שהשביח. )) The rescuee may not have requested the intervention, and although surely afterwards he is grateful, on what legal grounds can the rescuer demand compensation for his expenses? ((נראה דכל עוד שלא שילם המציל ההוצאות יש מקום לחייב הניצול על התשלום מדין כופין אותו להציל את נפשו מממונו, וכעין מה שפסק הרא”ש בפ”ד מכתובות סי”ב אם אמר אדם כשאמות על תקבורני מנכסי אין שומעין לו דלאו כל הימנו שיעשיר את בניו ויפיל את עצמו על הציבור, וכעי”ז בהג”א שם מכאן פסק מהר”ם מי שנתפס ויש לו דיו משלו וצוה שלא לפדותו משל עצמו שפודין אותו בע”כ, ועיין במרדכי שהביא פסק מהר”ם שם סימן קנ”ו. ובהגהת מרדכי שם אות קנ”ו (בפ”ד מכתובות) נשאל לר’ חיים וכו’ אם שומעין לאלמנה שלא לקבור בעלה מנכסים שאין בהם כדי כתובה וכו’ יקבור מנכסים שהם משועבדים לקוברו ומפקיעים ירושה דאורייתא (וע”ע בש”ך סימן ק”ז סק”ו). ועכ”פ נראה דיש מקום לומר דהאדם מחוייב להציל א”ע וממונו משועבד לכך, ואפשר לכופו להשתמש בממונו לשלם להצלת נפשו, אמנם נראה דבד”א כל עוד שעדיין לא ניצול, אבל לאחר שחברו כבר הוציא הוצאותיו וניצול או מת, מנין שנכסי הניצול בין בידו בין ביד יורשיו, משועבדים למציל. והרי השתא לא שייך לכפותו ולכאורה אין נכסיו משועבדים. והרא”ש בסנהדרין מיירי להדיא דהמציל כבר הוציא הוצאות, ומ”מ יכול לגבותם מהניצול, וע”ז אנו דנין איך נוצר חוב זה. ))

Perhaps the Rosh can be understood in light of the laws of yored (found in C.M. 375). In many areas of halochoh we find that when Reuven provides an unsolicited, and unanticipated service, or improvement to the value of Shimon’s assets (at a cost to himself), Reuven is entitled to some payment provided that Shimon benefits. ((The amount he is paid depends on a number of factors. If the added value not only was unsolicited but Reuven was justifiably able to assume that Shimon was not planning to do that which Reuven ultimately did, then Reuven deserves to receive either his expenses or the benefit to the recipient, whichever is less. If Reuven could have justifiably assumed that Shimon was interested in doing the type of service or added value that Reuven ended up doing, he is entitled to the going rate for the service he provided despite the fact that he was not asked to do what he did (See C.M. 375:1). ))

However, if the unsolicited and unanticipated action is ineffective, Reuven receives nothing for his expenses or opportunity costs since Shimon did not benefit. See note for examples. ((There are numerous examples in halochoh in which a person spent money for another person or because of another person and he is unable to claim any of it back unless the other person benefited.

  1. Reuven and Shimon both had donkeys by the river. Reuven’s donkey is worth 200 and Shimon’s is worth 100. Shimon can only save one donkey. Should Reuven accept an offer by Shimon that Shimon will save Reuven’s donkey if Reuven will agree to pay Shimon 100 for the loss of Shimon’s donkey, then if Shimon is successful and is able to retrieve Reuven’s donkey, Reuven owes Shimon 100. If, however, Shimon is unsuccessful, Reuven only owes him the amount he would pay to hire a worker to rescue his donkey. Yet, if Shimon never made an offer to Reuven and instead of going after his own donkey, he went after Reuven’s donkey, should Shimon return empty-handed, he cannot claim anything from Reuven despite the fact that he could have retrieved his own donkey and instead went after Reuven’s (Ramo C.M. 264:4).
  2. Reuven owns property all around Shimon’s property and fences three sides leaving the fourth side open, Shimon does not owe anything to Reuven towards the cost of the fence. In this case, Reuven felt compelled to fence his property because of Shimon; nevertheless, since Shimon did not benefit from Reuven at all, Reuven owes Shimon nothing (Gro 264:7).
  3. Reuven enters Shimon’s abandoned home, buys black paint, and paints Shimon’s house without his permission. Reuven is not entitled to be reimbursed for the cost of the paint. Since there was no benefit to Shimon, Shimon does not need to pay the expenses (based on Nesivos 264:7). ))

There are poskim (Maharashdam and Rav Waldenberg, see note) who explain the Rosh based on this principle. Expenses laid out to fulfill the mitzvoh to save another Jew should be no different than other cases of benefiting others where there is no mitzvoh to act. The rescuee is responsible to reimburse the rescuer because the operation was successful and the rescuee benefited. Accordingly, should the rescue operation fail, the rescuer would not be entitled to any reimbursement for losses or money spent. ((The Maharashdam (Y.D. 204) responded to case where a young man joined a group of misdirected people and left religion. Some righteous people devised a plan to retrieve him from the cult he fell in and spent money implementing their strategy. Although they captured the young man, ultimately, their plan proved fruitless and they were required to release the person to his own inclinations. Still, they approached the young man’s father claiming reimbursement for their expenses. The Maharashdam ruled that since they were ineffective, the father is not obligated to reimburse them since he did not benefit from them. The Maharashdam concludes by differentiating between his case and that of the Rosh who requires the victim to reimburse by assuming that in the case of the Rosh the rescuer was successful in his mission.

Rav Waldenberg (Tzitz Eliezer vol. 10, 25:29) uses this approach to reject the claim of a good person (Reuven) who heard that a young boy was dying in a nearby village and needed medical attention. The tzaddik Reuven, called for an ambulance and doctor on Yom Kippur to treat the sick boy. The doctor came and tried to help but was unsuccessful and the boy died. Reuven sued the father of the young boy for his costs. Rav Waldenberg argued that since the boy did not recover, the father did not benefit from the attempt to save his son’s life and he is not obligated to pay. The Rosh that requires one to pay for a rescue is only because the mission was successful. ))

If this analysis were correct, it would have interesting ramifications. Imagine Yehudis tried to save Esther’s life (e.g., Esther was choking) by calling an ambulance, and the medics came as fast as they could but could not be of service (Esther either died or did not need assistance e.g., someone dislodged the obstruction before the ambulance arrived). Since medics generally charge a fee for the call itself even if they do not provide any service to the patient, would Yehudis need to pay and be unable to reclaim anything from Esther?

Another example actually took place in Israel. A person with vascular problems went to a hot mikve and a blood vessel burst. Some of the other people in the mikve, frightened by the enormous amount of blood, wanted to call Hatzoloh but the man protested and said he was accustomed to the problem and could deal with it himself. He proceeded to take out bandages from his bag and bandaged himself. The other people were concerned that he might be unaware of the danger he was in and called an ambulance, which arrived to do absolutely nothing. ((Should medics arrive and perform an exam to ascertain that there is no cause for concern, it appears to this writer that such care should be considered medical care from which the patient benefited (provided that the patient is relieved to have had the confirmation of his good health). Even though no treatment was given, ruling out danger is part of medical care and would consequently obligate the victim to pay the relevant costs, even according to Maharashdam’s interpretation of the Rosh. Similarly, if Reuven harms Shimon and Shimon is taken to the hospital for tests and evaluations, it stands to reason that the attacker should cover such expenses despite the fact that no medication or treatment was administered at the hospital. ))

Who should pay? Should the patient pay since the call was made on his behalf? Alternatively, perhaps the caller obligated himself by making the call? Is it possible that neither has to pay and the medic must suffer the lost income?

In the aforementioned scenarios in which the victim did not benefit from the medics, according to the Maharashdam and Rav Waldenberg, the victim would not have to pay. Would the helper be required to pay because they made the call for the ambulance?

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