The Heart Knows Its Own Bitterness

The Heart Knows its Own Bitterness is a sugya (pericope) in the Babylonian Talmud's tractate Yoma, based on a Biblical verse, which has become important for Jewish ethics. The phrase may also refer to an ethical principle that is derived from the sugya. In particular, the sugya is relevant to deliberations about patient autonomy, in relation to expert medical opinion.

Context

The sugya of "The Heart Knows its Own Bitterness" is found at Yoma 83a of the Babylonian Talmud, which is foundational for Jewish ethics and rabbinic law. Yoma is the Talmudic tractate that focuses on the Jewish day of atonement, Yom Kippur. The sugya incorporates a Talmudic understanding of mishnah 8:5 in Yoma, which allows for exemptions from Yom Kippur fasting due to pregnancy or illness.

The mishnah states:

With regard to a pregnant woman who smelled food and was overcome by a craving to eat it, one feeds her until she recovers, as failure to do so could lead to a life-threatening situation. If a person is ill and requires food due to potential danger, one feeds him according to the advice of medical experts who determine that he indeed requires food. And if there are no experts there, one feeds him according to his own instructions, until he says that he has eaten enough and needs no more.

— Yoma 8:5

Law Professor Ayelet Hoffmann Libson traced the history of the "The Heart Knows its Own Bitterness " sugya in greater detail. She examined the mishnah as well as a more strict version in the Tosefta (Kippurim 4:2). The Tosefta includes stories of Shammai and Rabbi Akiva, thereby showing that exemptions to fasing "were used sparingly," in contrast to the Mishnah. Libson points out that "according to this passage it is not at all evident that the value of human life overrides all other considerations," such as the priority afforded to fasting on Yom Kippur. Moreover, Libson puts the mishnah's approach in the context of "veneration of expertise," given that the rabbis were themselves authorities who relied on their expertise over Jewish law.

According to Libson, for the fasting situation, both the Palestinian and Babylonian Talmud versions elevated the value of the preservation of human life (pikuach nefesh). On their use of the Proverb, "The Heart Knows its Own Bitterness," Libson see a dual purpose: "first, [the verse] anchors the argument that favours the individual’s own medical assessment of his condition over that of an external agent. Second, the verse relates the discussion of illness and self-knowledge to Yom Kippur in a more fundamental way," that is, a deeper religious meaning. As a further step, Libson deconstructs the sugya as having an early layer by amoraic rabbis and a edited layer of redaction that opens up another nuance that goes beyond patient self-knowledge into the spiritual grounds for fasting. She suggests that Hellenistic and Christian views, of the self and of suffering, may have influenced the redaction-era rabbis to treat Yom Kippur as an opportunity for self-regulated suffering: "Only the individual can correctly assess the bitterness for which she may be atoning on Yom Kippur, and therefore only the individual can engage in prohairesis, determining whether to risk pain and even life for the sake of purification and atonement." Along these lines, Libson mentions the case of a rabbi (a Tosafist, Isaac ben Asher) who fasted to death in the medieval period, earning some recognition for piety as well as pushback on the rabbinic acceptance of such conduct.

Application in Rabbinic Law

An authoritative source of rabbinic law, the Shulchan Aruch, uses the sugya of "The Hearts Knows its own Bitterness" to determine the behavior of a sick person on Yom Kippur. In Siman 618 of Orach Chayim, the Shulchan Aruch states that fasting would be waived based on the opinion of one expert, including a non-Jewish doctor, if the person's condition might worsen, even if the patient's life is not in danger. Yes if a person says they need food, their view outweighs even 100 doctors who say they should fast.

The sugya informs rabbinic understanding of the Biblical commandment to fast on Yom Kippur. Hence it is discussed in the 313rd mitzvah of Sefer Ha-Chinuch, a 13th C. rabbinic law book.

Medical ethics and health

In Jewish medical ethics, the sugya is at the heart of discussions about handling patient refusal to be fed. With several variables at play, Immanuel Jakobovits created a detailed chart for his seminal Jewish Medical Ethics.

The sugya also informs Jewish moral reasoning for situations where the patient want a specific medicine, even if not otherwise medically indicated. For example, David ben Solomon ibn Abi Zimra (16th C.) wrote that, thanks to the principle of "the heart knows its own bitterness," a patient's treatment decisions should be honored, even for the sake of "peace of mind."

For Yom Kippur specifically, the Encyclopedia of Jewish Medical Ethics gives a digest of contemporary rabbinic ethics grounded in Yoma 83a: "If the patient says that he needs to eat he must be fed even if 100 physicians say that he does not need to eat. The reason is that a person's heart knows its own bitterness. He must first be reminded, however, that it is Yom Kippur. Nonetheless, one should not frighten him by telling him that today is Yom Kippur...."

The sugya has also been invoked in discussions of eating disorders in the Jewish community.

Autonomy

In a 2016 article on contemporary patient autonomy, Berger and Cahan state that Jewish medical ethicists tend to assume there is a correct medical decision to be made, so that patient autonomy is honored only in cases of medical uncertainty. Against this assumption, they argue that Jewish law can achieve a more robust version of patient autonomy with the sugya of The Hearth Knows its Own Bitterness. For their argument, first they show that the Palestinian Talmud gives patients a choice whenever there is some minimal or doubtful risk to life. Second, they say that the sugya "introduces a major shift in [The Talmud's] understanding of how and why we defer to the patient or physician." Their point hinges on an interpretation of the final voice in the Talmudic passage, Mar Bar Rav Ashi. In this rabbi's view, the biblical phrase "The Heart Knows its Own Bitterness" conveys that the patient possesses knowledge about his own condition that is of a totally different nature than any expert’s knowledge about it." In other words, there is a kind of medical self-knowledge that should be taken into account, thereby opening the scope of patient autonomy. Berger and Cahan conclude that patient self-knowledge should form a more nuanced conception of medical halakhah and that secular medical ethics would benefit from giving patients not only the right of decision but also some credit for knowledge of their experience of disease.

In 2022 law review article, Laynie Soloman and Russell G. Pearce deploy The Heart Knows its Own Bitterness as one of two principles for their constructive development of progressive approach to halakhic decision-making for heterodox (i.e., non-Orthodox) Jews.

Text

The Talmudic sugya elaborate on latter part of the mishna, which considers the needs of a sick person (bold added):

It was taught in the mishna: If a person is ill and requires food due to potential danger, one feeds him according to the advice of medical experts.

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.

However, in the opposite case, if a doctor says that the ill person needs food, but the ill person himself says he does not need to eat, one listens to the doctor. What is the reason for this halakha? It is because confusion [tunba] has taken hold of the ill person on account of his illness, and his judgment is impaired. Consequently, he himself does not know how much he needs food.

— Yoma 83a, Babylonian Talmud

The sugya continues:

We learned in the mishna: If a person is ill, one feeds him according to the advice of medical experts. This implies that if there are experts present, then according to the advice of experts, yes, one feeds the ill person; but at his own instructions, no, one does not feed him, contrary to Rabbi Yannai’s opinion. It further implies that according to the advice of several experts, yes, one feeds an ill person; however, according to the advice of only one expert, no, one does not feed him.

There appears to be a requirement for at least two doctors, which also contradicts Rabbi Yannai’s opinion that the opinion of one expert is sufficient to override the opinion of the ill person. The Gemara rejects this: With what are we dealing here? We are dealing with a unique circumstance: The ill person says I do not need food, and the consultation of experts is required. The Gemara suggests: But let them feed him according to the advice of one expert, as Rabbi Yannai said that in such a circumstance one feeds the ill person based on the advice of one doctor. The Gemara answers: No, the requirement of two experts is necessary in a case where there is another, third expert with him who says that the ill person does not need to eat. In such a case, one feeds the ill person according to the advice of two experts who agree that he requires it. The Gemara asks: If so, this is obvious, since it is a case of uncertainty concerning a life-threatening situation, and in all cases of uncertainty concerning a life-threatening situation, the halakha is lenient.

The Gemara answers: No, this halakha is necessary in a case where there are two other doctors who, along with the ill person, say that he does not need food. And although Rav Safra said that two witnesses are like one hundred witnesses, and one hundred witnesses are like two witnesses, that rule applies specifically to the matter of testimony; however, in the matter of assessing a situation, we follow the majority of opinions. Therefore, one might think in this case that the ill person should not be fed because the opinion of two doctors plus the ill person should override the opposing opinion of two other doctors. Generally speaking, two or more witnesses constitute complete testimony, and there is no difference between the testimony of two and the testimony of a large number of people. However, this principle of following the majority applies specifically to assessing monetary issues, but here it is a case of uncertainty concerning a life-threatening situation. Therefore, although it is the opinion of two doctors against the opinion of two doctors and the ill person, the ill person must eat.

The Gemara asks: But from the fact that it is taught in the latter clause of the mishna that if there are no experts present one feeds him according to his own opinion, by inference, the first clause of the mishna is referring to a case where the ill person said he needs to eat. In that case, the mishna states that one follows the experts’ opinion, not his own, and feeds him. The Gemara answers: The mishna is incomplete and is teaching the following: In what case is this statement that he may eat only based on the advice of experts said? It is when the ill person said: I do not need to eat. But if he said: I do need to eat, and instead of two experts there is only one who says that he does not need to eat, one feeds him according to his own opinion. Mar bar Rav Ashi said: Any instance where an ill person says: I need to eat, even if there are one hundred expert doctors who say that he does not need to eat, we listen to his own opinion and feed him, as it is stated: “The heart knows the bitterness of its soul” (Proverbs 14:10). We learned in the mishna: If an ill person himself says he needs to eat and there are no experts present, one feeds him according to his own opinion. This implies that the reason one feeds him is because there are no experts present. One may infer from this that if there were experts present, no, one would not feed the ill person based on his own opinion but would instead listen to the advice of the experts.

The Gemara rejects this: This is what the mishna is saying: In what case is this statement that one follows the opinion of the experts said? It is when the ill person said: I do not need to eat. However, if he said: I do need to eat, it is considered as if there were no experts there at all; we feed him based on his opinion, as it is stated: “The heart knows the bitterness of its soul” (Proverbs 14:10). All the experts are ignored in the face of the ill person’s own sensitivities.

— Babylonian Talmud