Dr. Arnold Relman, former editor-in chief of the New England Journal of Medicine, professor emeritus at Harvard, and one of the world’s most venerated physicians, fell down stairs and broke his neck last June 27. He was rushed to Massachusetts General Hospital, where he immediately told them who he was. As he recounts in the current issue of The New York Review of Books, “Within a few minutes, it seemed, my cubicle filled with physicians, nurses, and other members of the staff.”
X-rays and a CT scan showed fractures of three vertebrae in Relman’s neck and multiple fractures of bones in his face and skull, with massive hemorrhage around the injuries. The medical team plunged into action. They gave him large doses of adrenal steroids, intravenous fluids, and vitamin K, carefully calibrated to take into account the dosages of regular medication he had been taking.
Suddenly Relman began to choke due to the massive hemorrhage compressing his windpipe. An anesthesiologist tried, but failed, to get a breathing tube into his trachea. A doctor from the surgical trauma team was summoned. He did an emergency tracheotomy, which enabled Relman to breathe.
Then his heart stopped. The medical team immediately did cardiopulmonary resuscitation and administered injections of drugs to stimulate his heart. Within two minutes his heartbeat resumed, but during the next 15 minutes his heart stopped twice more. As Relman writes, “My cardiologist, a senior and much-respected clinician, arrived in the ER just in time to advise the team on their management of the cardiac arrests and the treatment of my rapidly changing heart rhythms and blood pressure. … The resuscitation saved my life.”
Relman was hooked up to a respirator, a catheter was inserted, and more tests were performed, as well as three bronchoscopies to suck blood clots out of his bronchi.
The total cost of his medical care came to $478,000. Was it worth it?
Then he was taken to the surgical Intensive Care Unit. “My wife and our children” he writes, “all gathered at the ICU very late that first night – three physicians and three lawyers, a company that in other hospitals might have bothered the hospital staff. But not here.
“The doctors and nurses kept my family informed and were receptive to their questions and suggestions. … The nursing staff did everything they could to relieve my discomfort. They were always available day and night, and all of them were competent and kind.”
After 11 days in the ICU, Dr. Relman was transferred to the Spaulding Rehabilitation Hospital where he continued his recovery for another month. The total cost of his medical care, almost all of which was covered by his insurance through Harvard’s faculty plan, came to $478,000.
One more detail I have not yet mentioned: When he broke his neck, Dr. Arnold Relman was 90 years old.
If Joe Shmoe, a 90-year-old retired plumber, had arrived at the ER of Mass General after having broken his neck, one wonders what kind of care he would have received. Would the medical staff have mobilized so aggressively to try to save his life? When his heart stopped, would they have resuscitated him three times or, given his age and the possibility that his broken neck might leave him a quadriplegic, would they have hung a “Do Not Resuscitate” sign on his bed? Would his cardiologist have dropped everything and rushed to the ER to supervise his treatment?
I’m sure Mass General is a shrine of compassion for all sick and suffering souls, but would they have suspended the universal rule of no more than two family members in the ICU if those relatives had not been “three physicians and three lawyers”? Would they have been “receptive to [the family’s] questions and suggestions” and “always available day and night, and all of them competent and kind” for a ninety-year-old retired plumber?
Let’s face it: Our society considers some lives more valuable than others. The value we attribute to a particular life reveals the values we ourselves live by.
Two Contrasting Views
In the simplest terms, the ultimate value of Western society is productivity. People’s lives are considered valuable as long as they are producing, regardless of what they are producing in terms of its benefit to society. He could be the plant manager of a factory that produces 42 shades of lipstick. She could be an academician researching the mating customs of the Aztecs. As long as a person produces, his or her life is valuable.
The value of a person’s productivity has a shelf life. No one would hesitate to resuscitate a 69-year-old retiree who broke his neck, for his productive life is still “fresh.” But 15 years later, we already hear terms such as a “burden to society.”
A person in a coma is the ultimate non-producer. This explains the growing consensus that comatose patients should not be fed, so that they can “be allowed” to die.
Of course, the exception is “important people,” those who have attained prominence in some field, such as Dr. Arnold Relman. The instinctive response of the Mass General staff to do everything possible to save the life of this 90-year-old patient was based on his considerable accomplishments of the past, not on the expectation that he would continue to produce. Similarly, during the eight years that former Prime Minister of Israel Ariel Sharon spent in a coma, none of his doctors suggested disconnecting his feeding tube. You might do that to an ordinary citizen, but not to a former head of state.
The Jewish view of the value of life is drastically different. According to Judaism, a soul descends into this world and dons a physical body in order to accomplish a unique mission and to effect a particular tikkun [rectification].
It matters not whether one is 20 or 200 meters high, but only how many rungs one has scaled.
One’s mission and one’s tikkun are as individual as one’s fingerprint. And just as different fingerprints cannot be rated hierarchically by standards of beauty, so human beings cannot be judged hierarchically or compared. Each person is climbing his or her own spiritual ladder. And since everyone starts on a different level, it matters not whether one is 20 or 200 meters high, but only how many rungs one has scaled.
The growth of a soul takes place within. As the Vilna Gaon, one of the greatest sages of the last millennium, wrote, the only purpose of life in this world is to fix one’s character traits. Thus, a stingy person may have the challenge to become generous. However, his success does not lie in how many hospital wings he donates, but rather in his victory over his own parsimony every time he writes a check. Another person’s tikkun could be to overcome a tendency toward anger or jealousy, or to grow in the traits of gratitude or humility.
Thus, from a Jewish perspective, the lipstick plant manager’s life is valuable not because of the 42 shades of lipstick he is producing, but because of the self-discipline he is developing by getting up every morning to go to work and by the kindness he is choosing in the way he treats his workers. As our sages say, “According to the effort is the reward,” (Ethics of the Fathers, 5:26). The academician’s life is valuable not because of the research papers she produces, but because of the perseverance she is developing in pursuing her goal and the egotism she is overcoming when she gives proper credit to her research assistants.
I have always considered the most Jewish place in Israel to be not the Kotel [the Western Wall], but Alyn Hospital for severely handicapped children and adults. Most of the patients there can barely move a single limb, are incontinent, and cannot talk. Yet huge resources are expended for their care, and a large, devoted staff works round the clock to lovingly tend to these patients. These are the people whom Hitler would have gassed, considering them worthless. The Jewish view is adamant: Every human life is valuable. Even in the most disabled body, the soul can still accomplish its work.
Every human life is valuable, and even in the most disabled body, the soul can still accomplish its work.
As long as the soul is in the body (which is the very definition of life), a human being can be effecting his or her rectification. Ninety-year-old people may not be able to do productive work, but they can grow in the trait of gratitude as they accept the services that others render them and can grow in the trait of humility as they suffer the inevitable physical and mental limitations of aging. This inner work is not an epilogue to life; it is the very purpose of life.
The soul is always conscious, regardless of the state of the body. This explains the many documented cases of surgical patients under general anesthesia who later quote comments (and jokes!) made by the medical staff during the surgery. Thus, even a comatose person may be accomplishing much inner “soul work.” Can there be a greater lesson in humility than to be trapped in a body that cannot move or speak? In addition, even a comatose patient accrues spiritual merit by inspiring family members to perform acts of loving kindness for the patient’s care. *
Man, Animal, Tree
Rabbi Akiva Tatz, who is also a physician, poses an intriguing question: The majority of medications for human beings are based on plant matter. For example, aspirin is based on white willow bark; digitalis comes from foxglove. Since human DNA is closer to animal DNA, why don’t most of our medications derive from animal tissue?
The Torah makes the baffling statement: “A person is a tree of the field.” Rabbi Tatz, quoting earlier Jewish sources, explains that both a person and a tree are vertical, while an animal is horizontal (think lions and cows). He goes on to elucidate that an animal, once it reaches adulthood, stops growing. A tree, on the other hand, as long as it lives, continues to grow, reaching up toward the heavens, as it were.
In this definitive way, a human being is more like a tree than an animal. As long as a human being lives, he or she has the potential to grow, to reach up toward the heavens.
We all know “horizontal humans,” who do not idealize growth and who cling to complacency. But God does not give up on such people. He sends them challenges – in health, finances, or family – where not changing is no longer an option. Of course, humans differ from trees in that trees have no free choice; they always grow upward. Humans can choose to go up or down. A person can respond to challenges by becoming better or bitter. A human being is “vertical,” but the elevator can go up or down.
Where inner growth is recognized as the purpose of life, no life is more valuable than another, for each individual has the potential to learn, grow, and accomplish one’s particular rectification.
This core principle is embodied in the following Jewish law. If a 90-year-old comatose patient was the only perfect match to donate a life-saving organ to the world’s most celebrated person, but by removing that organ the nonagenarian’s life would end one minute sooner than otherwise, it would be forbidden to remove the organ, because every minute of life is valuable and no one’s life is considered more important than another’s.
The ability of a 90-year-old to grow and to change is attested to by Dr. Relman, who writes: “Fortunately, my mental functions seem to have remained intact. My ability to read, think, speak, and write is essentially unchanged, so far as I can tell. Not so for my emotional state, which has clearly changed.… I certainly have been sobered by the realization of the fragility of my existence and my limited future.”
No matter how much a person has accomplished, when it comes to inner growth, the sky’s – or should I say heaven’s – the limit.
*(The halachic position on end-of-life issues is beyond the scope of this article. Jews facing such issues for themselves or their relatives should consult a rabbi who is expert in the halacha of medical ethics.)