Originally delivered as the d’var Torah for Parashat Mishpatim 5782 on January 29, 2022 at Congregation Beth Shalom, Pittsburgh, PA. Portions of this talk originated or were adapted from lectures given at Ohev Shalom of Bucks County, Richboro, PA and for the Maimonides Society of the Jewish Federation of Richmond, VA in February, 2020, and from my post “My Stethoscope is Praying” from February 2019, but this is the first time all of this material came together as one.
I was on suicide watch for a patient a few years ago. After a long series of emails and text messages and phone calls, the psychiatrist, the therapist, the patient and I were all satisfied they were safe. After the dust settled, I mentioned to the therapist that I had recommended a book to the patient by Rabbi Naomi Levy. “Are you mixing religion and medicine?” she texted back.
“That’s my brand…” I replied.
So in early 2019, when #medtwitter began blowing up with the phrase, “Keep your religion out of medicine,” it hurt me. The Department of Health and Human Services had just released guidelines allowing healthcare providers to refuse to provide any services they found morally offensive. Purportedly, this was a rule needed to combat the epidemic of doctors, nurses, and pharmacists being bullied into performing abortions, dispensing contraception or gender-affirming hormones, or engaging in other care they felt to be reprehensible.
The people I usually see on that hashtag are mostly docs and other healthcare providers, deeply interested in the medical humanities, in stories and poetry and emotions and meaning. Large numbers of them are also fierce advocates for better gender equality in medicine, LGBTQ+ rights, reproductive freedom and a host of other issues. The new guidelines had them up in arms. In their rage, one by one, they shouted, “Medicine is no place for your religion.”
It’s well known that after Rabbi Abraham Joshua Heschel marched in Selma, Alabama, in 1965, he remarked afterward to his daughter, Susanna, “Legs are not lips and walking is not kneeling. And yet our legs uttered songs. Even without words, our march was worship. I felt my legs were praying.”
Less well known is that in 1964, Heschel spoke before a meeting of the American Medical Association, as part of a discussion entitled, “The Patient as Person.” At that conference, he spoke as reverently of medicine of his work in Selma the following year.
“The Mother of medicine is not human curiosity,” he declared, “but human compassion. What constitutes being human, personhood? The ability to be concerned for other human beings.”
Mutual concern was so important to Heschel that he felt that its absence might endanger the whole enterprise. “Without a sense of significant being, a sense of wonder and mystery, a sense of reverence for the sanctity of being alive, the doctor’s efforts and prescriptions may prove futile.” Heschel tells me that my stethoscope is praying.
And yet Heschel already saw the seeds of the crisis we are in today, as the unique trust and reverence medicine used to enjoy among the professions had already begun to erode. “While medical science is advancing,” he observed, “the doctor-patient relationship seems to be deteriorating.” He saw medicine suffering from what he termed a “spiritual malaria,” a disease in which the patient becomes nothing more than “a human machine in need of repair . . . an ingenious assembly of portable plumbing.” And if that’s the case, then the doctor becomes nothing more than a plumber.
Despite what my online community says, religion and conscience in medicine don’t begin and end with whether someone believes a fully human life begins at the moment of conception or the moment an infant’s head emerges from a mother’s body. I’ve mostly steered clear of Twitter since early in the pandemic, but I can guarantee that with the many abortion cases now before the Supreme Court, medtwitter is taking shots at religion again.
The abortion debate allows one hotly contested issue in medicine to obscure a greater truth – medicine is exactly the place for my religion. It says so right in this week’s parsha: rapo yirape, “he shall surely heal,” a phrase that forms the basis for the Jewish permission, and indeed obligation, to practice medicine to relieve suffering and restore health.
We need it to keep hospitals that still bear religious names focused on their religious mission of healing and compassion, instead of on the revenue that has become a false idol for the whole healthcare system. We need it to ensure that healthcare is a safe space for the homeless, the refugee, and the victim. We need it to prevent the progressive medicalization, dehumanization and objectification of people into patients (or worse, customers) caused by technology and medicalizing normal human experiences. And yes, we need it to inform our discussions about when life begins – and when and how it ends, like the discussion in which I was honored to participate last month, at Rabbi Perlman’s invitation, on physician-assisted suicide.
So when I went looking for a cure for malaria, I went all the way back to the beginning – and by that I mean Beginning, with a capital B. Bereishit, Chapter 1, verses 26 and 27: (26) And God said, “Let us make man in our image, after our likeness. They shall rule the fish of the sea, the birds of the sky, the cattle, the whole earth, and all the creeping things that creep on earth.” (27) And God created man in God’s image, in the image of God, God created him; male and female God created them.
And what are we to do with this information? “Walk in God’s ways,” taught the prophets, and after them the rabbis of the Talmud: do the acts of kindness that God does in the Bible, like clothing the naked, burying the dead, visiting the sick – and yes, healing them. In a world where God does not come face to face with us, the closest we will ever get is face to face with another human being.
Mishpatim focuses on exactly this expression of our relationship to God. After realizing in last week’s parsha that direct experience of God’s presence at Sinai is more than they can handle, Mishpatim focuses on the details of how individual human beings, and larger groups of us, can live in relationship. Long time Beth Shalom veteran Adam Shear wistfully lamented in a Library Minyan d’rash years ago that in becoming Bar Mitzvah on Shabbat Mishpatim, he had a little bit of “Yitro envy.” Instead of giving his Bar Mitzvah d’var Torah about the dramatic event of Revelation, Adam got stuck with a laundry list of commandments that to a 13-year-old boy may have felt “obvious.” But it is in that laundry list that the rubber of good intentions hits the road of real life.
True, one of the mitzvoth in the list is the crucial Jewish text in the discussion around abortion (Exodus 21:22). Instead, let’s look at two passages that express a fundamental truth of Judaism: Exodus 22:20 and 23:9 are both versions of the commandment not to wrong the stranger that appears at least 36 times in the Torah (according to an accounting in Bava Metzia 59b).
A while back a person I was caring for lashed out in frustration, “You doctors all come from such perfect lives, you don’t understand broken people like me.” That person, and many others I’ve cared for over the years, sometimes literally don’t recognize themselves in the mirror. It was an insight first shared with me by a woman who had undergone gastric bypass surgery for weight loss; she looked in the mirror one day and just didn’t see herself. Similarly, people with skin diseases, amputations, or sudden loss of mobility can look at their reflections and wonder, “Who is that?”
In their illnesses, they have become strangers to themselves, unknowable, unrecognizable. How much stranger must they feel in the land of medicine, eerily separate from their Lifeworlds, with its foreign language, strange rules, and upside-down priorities?
Sadly, the land of medicine treats strangers much the way the people of Sodom and Gomorrah did: it abuses them. Our parsha commands us not to take a poor person’s garment in pledge for a debt; the podcast An Arm and a Leg recently documented a health system (Methodist Hospital in Memphis) that was so aggressive in collecting debts it would garnish the wages of its own employees. Medical debt is the single largest cause of personal bankruptcy in the US and has been for at least my entire career in medicine.
Were that not enough, the land of medicine holds grudges against strangers. I care for a lot of people who have been labeled “difficult” elsewhere, because of raising complaints, failing to follow medical advice, or insisting on doing things in an unconventional way. Often, they are people whose diagnosis is unclear or who are failing to respond to standard treatment. Rather than labeling them as patients with difficult illnesses, they are labeled as difficult patients. Why “difficult” is such a negative term for doctors, of all people, is hard for me to fathom; as Jimmy Dugan (Tom Hanks’ character in A League of Their Own) put it, “It’s supposed to be hard! If it were easy everyone would do it.”
The “difficult” label spreads through the system, too. Put in the medical chart, it never leaves a person; one specialist after another sees it, forms an opinion before even meeting the person, and closes ranks with their colleagues. I have seen the effect it has on people, effectively shutting them out of care anywhere, gaslighting them to the point that they appear paranoid, and may indeed believe that they are losing their minds. Exodus 23:1 admonishes us, “Lo tisa shema shav” – do not carry false rumors, or in another meaning of the word, do not “elevate” false rumors, meaning do not raise them to the level of truth – “al tashet yadecha im rasha l’hiyot ed hamas” – do not join hands with the wicked to become a malicious witness.
Sforno, commenting on that verse, takes it to be a prohibition on co-signing documents with one who is maliciously spreading rumors. As I add my insights to a person’s medical charts, I think what it must mean to “join hands” with those who are propagating labels, maligning a person in a record that now lives forever and can be instantly duplicated. One person I cared for over 8 years found themselves waiting hours for supplemental oxygen when they had pneumonia – because their chart documented a history of prescription drug abuse years before. I’ve become very careful how I describe my interactions with people, how I refer to them and how I interpret even their bad behavior – always “al kaf z’chut”, with the benefit of the doubt in mind, so as not to add fuel to the fire of these false rumors, and where possible to set the record straight.
When you’re difficult, the land of medicine treats you like Marvin K. Mooney in the Dr. Seuss book: “Would you please go now?” A far cry from Exodus 23:5, which commands us to raise up our enemy’s donkey if it collapses under its load. Rashi looks at that verse and poses the rhetorical question, “Who could see that animal suffering under its burden and not be moved to help?” Kal va’chomer, who could see a human being, even a “difficult” one, suffering and choose to dismiss them rather than set aside their dispute and try to heal them?
The events of the last two years have highlighted what these “difficult” folks are going through. On the purely clinical front, the discovery of a “long COVID” syndrome, which by some estimates affects 10-40% of COVID survivors for months after “recovery,” if not longer, with sleep disturbances, brain fog, breathing and cardiac impairment, and crushing fatigue. It marks the first time we have seen massive numbers of people simultaneously develop a “functional illness” that bears a strong resemblance to disorders like chronic fatigue syndrome, post-treatment Lyme disease syndrome, functional neurologic disorders and other frequently stigmatized illnesses. My hope is that the massive amount of research being done on this phenomenon with bear fruit for people with those other misunderstood, mistreated illnesses. Yet some researchers are already questioning the existence of this condition, despite literally millions of people who are experiencing it, and suggesting that the condition is caused by believing that one had COVID more than by actually having it. In other words, it’s all in their heads. All ten million heads.
At the same time, we’ve learned a lot about illnesses of a different sort – societal, systemic illnesses. Being sick while Black has long carried a risk of poor access to care, lower likelihood of receiving all evidence-based treatment, and much higher risk of spending more time with hospital security, CYF or some other punitive treatment than with one’s own doctor or nurse. Speaking up about these risks carried a risk of having the patient labeled as paranoid, and their belief that the system or the treatment they received was racist weaponized against them.
I have patients so traumatized by the care they received at our flagship health system in this city that seeing the telltale emblem on a badge, even in my unaffiliated clinic, has caused them to berate the student wearing the badge and storm out of my office. Black faculty members at medical schools around the country have spoken up about systemic racism and found themselves out of work, accused of various kinds of misconduct that took place “before” they spoke out and yet somehow was never brought to their attention.
So if Mishpatim calls out the bad behavior in the healthcare system, what does it say about how we should behave? Let’s go back to the patient who castigated me about us healers with the perfect lives.
Now, it’s true that as a group, people entering medicine (and here I mean becoming doctors, not healthcare as a whole) are privileged. As overt and hidden costs of applying to medical school, paying tuition, and achieving licensure continue to rise, that privileged status has only gotten worse. Let’s assume that this person meant we were privileged, not perfect.
Because perfect, we’re not. The process of training for a career in medicine, nursing, or rehabilitation science almost certainly involves some kind of trauma. Aside from the obvious trauma of witnessing extreme suffering, there is the sleep deprivation, the strain on family and social relationships, the ever-present impostor syndrome, and sadly, the ubiquitous abuses of power throughout the hierarchy in the form of discrimination, sexual harassment, assault, and hazing that persist to this very moment.
Twitter may make me angry, but the #medtwitter community also provides a window into what is motivating, troubling and occupying my fellow healers in other corners of the world. So I offer, as evidence of the trauma of training, the resident who posted that her male cardiology attending had offered the group an opportunity to do some additional learning about echocardiography (ultrasound of the heart), provided she would act the part of the patient – unclothed from the waist up. Dateline? January 2020.
If you survive the trauma in training, there’s trauma in practice, in the past two years more than most. Professional healers found themselves simultaneously celebrated as heroes with impromptu clanging of pots and pans, like some sort of medical Bastille Day, and hunted as villains, receiving death threats for their support of COVID mitigation measures and losing longtime patients who preferred to believe anti-vaccine conspiracy theorists over a trusted family physician. Theologian Kate Bowler likes to use the word “shiny” to describe how she felt about herself and her life before she was diagnosed with advanced cancer in her thirties. In 2022, I don’t think there’s a physician left in the world who still feels shiny.
Mekhilta d’Rabbi Yishmael sees this non-shiny stuff as the equalizer. That text understands the words of Exodus 22:20, “lo toneh,” do not wrong or afflict, a stranger, as meaning not to afflict them with words, meaning not to throw their past (as an idolater, a sinner, or what have you) in their face. It even gives them permission to taunt you in return if you do so: “Hey, weren’t you also a stranger? A slave? Aren’t you supposed to be kind to me?” MdRY understands that if we allow ourselves to remember who we are, beneath the shiny, we’re better able to understand them.
This admonition is sorely needed today. More disturbing to me than the “keep your religion out of medicine” line is a the suggestion that people who have chosen not to be vaccinated for COVID shouldn’t be offered treatment when they (nearly inevitably) get sick with the disease. Coming from committed healers, it suggests to me that they have kept their own religion as far away from medicine as they could get it. I completely understand that the anti-vaccine movement (by which I mean those for whom being unvaccinated is not a private choice but an ideology) feels to us like the enemy, endangering themselves, our other patients, and our whole society by pretending the virus doesn’t exist and the vaccines are the real threat. The parsha has an answer here, too: “When you encounter your enemy’s ox or ass wandering, you must take it back to him. When you see the ass of your enemy lying under its burden and would refrain from raising it, you must nevertheless raise it with him.”
Do I disagree with them? Sure. Do they frustrate and anger me? Absolutely. Are they human? You bet, and that is all the reason I need never to withhold care from them. We treat lung cancer in smokers, head injuries in people who ride motorcycles without helmets, and hepatitis C in people who use injection drugs. For that matter, given that the World Heart Foundation now says any amount of alcohol increases the risk of death from heart disease, most of us will someday need saving from something that we “self-inflicted” by raising a shot of Crown Royal in a l’chaim in the Samuel and Minnie Hyman Ballroom. Is that how we want our doctors to treat us?
A different frequent flier on #medtwitter, Dr. Londyn Robinson, who used to go by the name “rheuminate” when she was a third-year med student, provided a very different take on so-called “self-inflicted” illness. Robinson grew up in a town rural enough that the land of medicine really did seem like a foreign country, one she and her neighbors almost never visited, and for sure none of them did or would ever live there. In February 2020, she posted a story about having a conversation with a homeless patient about the joys and fond memories of McDonalds, and about how one of her urban-born, well-off classmates chided her for seeming to endorse the fast-food giant that has become synonymous in modern medicine with all that is unhealthy about our society.
What Robinson realized, and her classmate did not, is that McDonalds can be a lifeline for a homeless person: clean bathrooms, cheap, hot food, and a warm place to sit that is not in much of a hurry to kick you out. They spoke a common language, and part of that language for Robinson included Rabbi Nathan’s admonishment, “Do not attribute a blemish of your own to a stranger.” When both of you have suffered the same indignities, you bond over what you have in common. The encounter ended with Robinson showing the patient how to use the McDonalds ordering app, including how to maximize funds to actually get the healthier options for just as cheaply as the burger and fries.
There will be times, whether at the very beginning (or very end) of life, when the mixture of religion and medicine will lead us to conflicting conclusions – and when it does, hopefully that same religion will help the people in the debate to remember to treat each other with as much humanity as they do the people they care for professionally. But get rid of it altogether? Careful what you wish for – you might get it. And we’ve already seen what that looks like. It isn’t pretty.