Are we going to subscribe to an ageist and ableist medical model of decision-making driven by profit, and outmoded ideas about the infallibility of science? Or are we going to seek ethical alternatives that make life-and-death choices more equitable?
The Hebrew word “Pesakh” connotes “hovering in a protective way,” much as a mother bird might hover over her nest, protecting her offspring. The common translation of Pesakh as “Passover” comes from an erroneous rendering by the 16th-century English translator William Tyndall. Understanding the word as God hovering over the houses of the Israelites in a protective posture is more resonant. God guards the most vulnerable in that moment of danger.
Similarly, we are called upon to protect the most vulnerable in society. This is a Jewish value that extends from the biblical text, through the prophets (“plead the cause of the widow and orphan”), to the Talmud and beyond. Throughout history, Jewish communities have risen to this challenge.
Some of us reading this today are in at “elevated risk” should we contract the COVID-19 virus. Our own bodies may be on the line. The ethical considerations outlined below, as well as the medical dilemmas discussed and the values that inform life-and-death decisions, are an ever-present personal reality right now. A question before us as lives hang in the balance is: Are we going to subscribe to an ageist and ableist medical model of decision-making driven by profit, numbers and outmoded ideas about the infallibility of science, or are we going to seek ethical alternatives that make life-and-death choices more equitable?
During this pandemic, health-care professionals are weighing who gets protected and who gets passed over in the face of what should have been an avoidable resource crisis.[fn]The crisis could have been circumvented at numerous junctures if, for example, the federal government had invoked the Defense Production Act, if nurses unions’ calls were heeded sooner for compelling industry to produce ventilators, if hospitals and government agencies decided earlier on to buy more protective gear, and if laid-off GE and GM workers were listened to. The problem could have been prevented with no one being denied life-saving medical interventions and protections, yet we are now compelled to make previously avoidable choices.[/fn] The choice between who receives the benefits of limited medical resources, like a ventilator, is often based on the likelihood of recuperation. This, of course, favors the young and healthy — those who theoretically have longer to live and have better outcomes — leading to discrimination against the ill, the aged and the disabled.
By contrast, in our broader society, the value of our fellow human beings is not determined by illness, age or disability. Certainly not in Judaism. Yet when we enter a hospital, many of us have had the experience of being seen primarily as our condition or disease, and not for who we are. We are sometimes asked to put our faith in a system that combines a 19th-century scientific rationalism (which affirms the ultimate inerrancy of scientists) with a modern drive towards financial capital and quantitative output.
As an institution, the medical field has its own cultural perspectives, and sometimes they do not reflect those of its own patients. As my colleague, Rabbi Elliot Kukla, recently wrote in The New York Times:
Almost no one in my personal or professional world would ‘earn’ care if the United States were to come to a scenario like Italy. Not my 102-year-old client with brilliant blue eyes and ferocious curiosity who survived Auschwitz; not my friend who is a wickedly smart writer, activist, and wheelchair user currently recovering from major surgery; nor me, with my immune system that doesn’t work well, or works too hard, attacking my own tissues.
What are our values? Is denying treatment to anyone over 65 or denying life-saving interventions to those with mental disabilities (as proposed in Alabama) the routes we want to go? Is this the logical, inevitable road we have to take? If we think medicine stands as a solid, immutable beacon of reason and neutrality, let’s remember that in the not-so-distant past — under this same guise of scientific rationalism — medicine operated segregated hospitals, embraced eugenics, conducted unethical experiments on unwitting minorities, along with a host of other questionable practices. Current decision-making processes during this pandemic should be examined and questioned. Health-care professionals are not experts in medical ethics. Their decisions are not infallible.
What are the values on which health-care decisions ought to be based? We would do well to consult the teachings of the philosopher and ethicist Martin Buber and the British Jewish philosopher Isaiah Berlin.
Buber, in writing about the “I-Thou” relationship, emphasizes the subtlety and primacy of relations. The “I” should not objectify anyone as an “it,” as the elderly, ill and disabled are objectified during this pandemic. A person’s supposed usefulness, or assumed lack thereof, is weighted against relational considerations. We are seeing this now in Italy and Spain, and as an emerging proposition in certain American states. According to Buber, the “I” needs instead to acknowledge and integrate a living relationship. For Buber, an ethical and even sacred choice is to view our fellow human being first and foremost in relationship, and not through the lens of objectified categories. Yet medicine, as a form of scientific discipline, naturally categorizes. By at least considering, if not restoring, the Buberian model of relationship, we also reclaim a better qualitative discernment about how life-and-death decisions are made, particularly during this crisis.
But systemic problems and failures are often due to a chain of events or decisions that lead up to it. Multiple factors over time have brought us to this point in the pandemic in which mechanistic life-and-death decisions are made. By reducing each of us to codes to be entered into a database, by seeing us as means to profit, by demanding that medical professionals treat more and more patients for shorter periods of time, and by creating an inpatient assembly line system, the relational aspects have been surgically removed from the warp and woof of medical practice.
Many who go into medicine want to be of service to their patients. Yet doctors and nurses are increasingly confronted by administrative directives based on financial business models that compel them to increase their hourly patient count and to spend more time entering data into a computer. During the last 20 years, the medical field has shifted even more towards the “it” and away from the “I-Thou” by deploying hospitalists who are limited in their ability to know their patients beyond what is contained in medical profiles, as compared to primary-care physicians who often know more about the whole person. Relationships on multiple levels have been cast aside in favor of expediency and profit.
Deprived of protective life-saving resources and in battlefield conditions, medical professionals are now making life-and-death decisions. Further, because of the nature of this pandemic, older, more experienced physicians and nurses are encouraged to stay home due to the higher risk, while younger professionals are essentially “thrown under the bus” as a sacrifice to a faulty, profit-driven system in the midst of an unprecedented crisis. Under these circumstances, how could the patient not be treated as what Martin Buber describes as an “it”? Where is the time for the relational?
With so many forces arrayed against the relational, what is the path forward? The British Jewish philosopher Isaiah Berlin wrote that:
To force people into the neat uniforms demanded by dogmatically believed in schemes is almost always the road to inhumanity.[fn]Henry Hardy, and Roger Hausheer, eds., The Proper Study of Mankind: An Anthology of Essays, Isaiah Berlin (New York: Farrar, Straus, and Giroux, 1998), 16.[/fn]
When elderly, disabled and ill people are categorized as less important, that potentially leads us down that same road of inhumanity and bad choices. Berlin further notes that the precondition for decent societies and morally acceptable behavior, and the reconciling of conflicting values, is based on constant and continual evaluation and repair.[fn]Ibid.[/fn] He wrote that this may be a somewhat dull solution and not necessarily the stuff of heroic action, yet if there is some truth in this view, then perhaps that is sufficient.
There is no a priori reason for supposing that the truth, when it is discovered, will necessarily prove interesting. It may be enough if it is truth, or even an approximation to it.[fn]Ibid.[/fn]
Constant and continual evaluation and repair is critical because values change over time, place and circumstance. It allows for cultural shifts and new insights to enter into the calculation. It might be hoped that hospitals, particularly their ethics committees, will integrate the process Berlin recommends of “constant and continual evaluation and repair” when it comes to ethical considerations both during this crisis and moving forward.
Berlin’s theory echoes an essential refining and repairing aspect of Talmudic discourse. Rabbi Yohanan and Resh Lakish engaged in exactly in this kind of process in which for every halakhic (Jewish legal) answer that Rabbi Yohanan gave, Resh Lakish could come up with multiple countervailing responses. When Resh Lakish died, Rabbi Yohanan deeply mourned the loss of a partner with whom he could hone answers.[fn]Bava Metzia 84a.[/fn] Menachem Fisch in his book Rational Rabbis closely mirrors Berlin when he writes:
In the realm of Torah-study, confirmation is useless. Finding that one’s views happen to fare well with those of former generations can teach nothing from which the halakhic system can be said to profit. Keen, prudent relentless troubleshooting is the only way to improve the system. And this can be adequately achieved only by group effort, and only by groups sufficiently heterogeneous and sufficiently divided in their opinions to allow real debate. It is not truth that one can ever hope to achieve — only progress, improvement, amelioration.[fn]Menachem Fisch, Rational Rabbis: Science and Talmudic Culture (Bloomington and Indianapolis: Indiana University Press, 1997), 1908[/fn]
In this way, ethics operates much in the same way as science — always questioning, always looking at new circumstances. As medical research seeks new ways to address a new virus, so should medical ethics avoid older, inherited values that no longer apply in this particular crisis.
Continual evaluation and repair in the midst of a crisis may seem like a luxury. To take the time to develop an “I-Thou” relationship may strike us as so far outside the bounds of the urgent realities on the ground that it’s not worth considering. Yet we’ve come this point precisely because over a prolonged period of time, we have put our faith in a system that sees itself as serving, first and foremost, expediency, physical needs and institutional financial interests, while viewing the field of ethics and spiritual concerns as secondary at best or extraneous at worst.
There are hospitals that, in the midst of this COVID-19 emergency, are seeking to turn the tide. They are calling upon and gathering representatives of various humane disciplines in order to avoid going down the path of inhumanity. It may be a stop-gap measure, but they recognize the problematic factors that go into decision-making, particularly in the face of a global emergency. They are considering ways to integrate more of the “I-Thou” relationship. They are making the conscious choice not to discount the sick and disabled when it comes to allocating medical supplies and demands for an increase in billable patient hours. If a few hospitals can do this, then it’s likely many more can as well. Decisions that are made today may be models for the future.
It is incumbent upon each of us during this crisis to continue to support the medical field in making moral choices — not mechanistic and “cost-effective” ones — when it comes to saving lives. We do not want to invest in an ageist and ableist model of decision-making motivated by profit, numbers and presumed infallibility.
The prophet Isaiah proclaimed that our rituals and sacrifices mean nothing without good works and without defending the oppressed. During Pesakh this year, we can take up Isaiah’s baton and truly focus on a central message of the occasion: protecting, and advocating for, the lives of those of us who are most vulnerable. That is what God did in the central part of the Exodus narrative. That epic act of protection — hovering over and guarding those at risk — is precisely what gives the holiday its very name: Pesakh.
Let this Pesakh holiday season be one in which the best of our tradition informs the moment and converts our rituals into action in support of protecting the lives of those of us who might otherwise be discounted.