Buber, Berlin, and Pesach: Ethics in an age of Pandemic

The Hebrew word “Pesach” connotes hovering in a protective way, much as a mother bird might hover over her nest protecting her offspring. The common translation of Pesach as “Passover” comes from an erroneous rendering by the 16th century English translator William Tyndall. The former translation, as we read the haggadah, which implies God hovering over the houses of the Israelites in a protective posture, makes more sense. It is a gesture meant to guard the most vulnerable in that moment of danger and precariousness. It is also a theme which is carried throughout our tradition. We, as Jews, are called upon to act as an aegis for the most vulnerable in society. This is a Jewish value which runs from the biblical text, through the prophets (“plead the cause of the widow and orphan”), to the Talmud and beyond.

These were not theoretical considerations, but were meant to instill into the community as part of its own cohesion and survival a high degree of ethics. In fact, this is not theoretical for some people reading this today, as they themselves are at elevated risk. Our own bodies may be on the line, so the ethical considerations which are outlined, the medical dilemmas discussed, and the values which inform life and death decisions are not just a passive implication for many of us. They 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 which make life and death choices more equitable?

The idea of “protecting” versus “passing over” are apropos of this pandemic as we weigh who gets protected and who gets passed over in the face of what should have been an avoidable resource crisis, one which could have been circumvented at numerous junctures if, for example, the federal government 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.

The choice between who receives the benefits of limited medical resources, like a ventilator, is often based on likelihood of recuperation and overall success. This, of course, favors the young and healthy– those who theoretically have longer to live and have better outcomes, assuming protocols themselves do not devolve into outright discrimination against the ill, the aged, and the disabled. Yet, in our broader society who we are as individuals and the value of our fellow human being 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, or even judged, as our condition or disease, and not for who we are. Whatever our personal or cultural values, we are sometimes asked to put our faith in a system which combines a scientific rationalism developed in the 19th century (which states that the ultimate truths of science will harmoniously unify all of us through unassailable logic and precise mathematical terms) with a modern drive toward financial capital and quantitative output. It is here that values can come into conflict. Every society, religion, culture, and nationality has its own center of gravity. The medical field, as an institution, also has its own cultural perspectives, and sometimes they are scarcely similar to those of its own patients. As my colleague, Rabbi Elliot Kukla, recently wrote as an op-ed 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 not treating 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 the inevitable but logical road we have to take?  If you think medicine stands as a solid immutable beacon of reason and neutrality, then I remind you that under this same guise of scientific rationalism medicine in the not too distant past, and within the lifetime of some alive today, also operated segregated hospitals, embraced eugenics, conducted unethical experiments on unwitting minorities, along with a host of other questionable practices. Don’t think current decision making processes during this pandemic are also unassailable, especially when the ethical implications of those decisions touch on fields which are not the exclusive domain of medicine. If questioning of those medical choices is not given consideration, or even permitted, then medicine has arrogated unto itself the role cardinals and popes held not long ago. It would be inadvisable for medicine to claim for itself an infallibility as an article of faith similar to that of fundamentalist religions.

In considering this multiplicity of sometimes conflicting values we might initially look to the philosopher and ethicist Martin Buber and then, secondly, to 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, for example, those over 65 and those who are ill or disabled who may be medically objectified and categorized as essentially “its” during this pandemic. This person’s supposed usefulness, or assumed lack thereof, is weighted against relational considerations. We are seeing this now in Italy, Spain, and as an emerging proposition in certain American states. According to Buber the “I” needs to instead 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 to the field in how life and death decisions are made, particularly during this crisis

But systemic problems and failures are often not due to one single cause, but to a chain of events or decisions which 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 considered and even made. By reducing us to codes to be entered into a database, by seeing us as means to profit, by demanding 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 DNA 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 which compel them to increase their hourly patient count, to spend more time entering alphanumerics into a computer, and then with the extraordinarily limited time they have left, and deprived of protective life-saving resources, in battlefield conditions, 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 higher risk, while it is the younger professionals who 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? Moreover, 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 sometimes know more about the whole person. Relationship on multiple levels has been cast aside in favor of expediency and profit.

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.”1 By implication, the dogma of medicine when it comes to how it neatly categorizes patients, life and death decisions, and elderly and disabled individuals, 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.2 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, 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.”3 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 is, at its core, an ongoing mediation process, much as the Talmud itself is a refinement of ideas which bridge centuries, generations, societies, the rise and fall of rulers and nations, and evolving principles. All of these factors themselves could similarly be seen as potentially arrayed against the bulwark of ethics contained within Talmud itself. Through constant honing and refining a resilient system of ethics was maintained. 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 Lekish engaged in exactly in this kind of process in which for every halakhic (Jewish legal) answer that Rabbi Yohanan gave, Resh Lekish could come up with multiple countervailing responses, When Resh Lekish died, Rabbi Yohanan deeply mourned the loss of a partner with whom he could hone answers. (Bava Metzia, 84). Menachem Fisch in his book Rational Rabbis closely mirrors Berlin at each step when Fisch 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.”4 In this way ethics operates much in the same way as science. It is ironic, therefore, that sometime the medical field will assume a dogmatic approach to ethical issues around patient care and life and death decisions, almost seeming to claim an infallibility about the criteria they choose. This has become especially evident during this crisis.

But finding “truth”, or an approximation thereof, through 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 which 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.

Yet, there are hospitals which, 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 which go into decision making, particularly in the face of a global emergency. They are considering ways to integrate more of the “I-Thou” relationship, and are making the conscious choice to not discount the sick and disabled when it comes to the unconscionable limitation of medical supplies and demands for an increase in billable patient hours. If a few hospitals can do this, it’s likely many more can as well. Decisions that are made today may be models for the future. Do we want successive generations to see the choices we made during this historic epidemic as grounded in profits or ethics, in expediency or in relationship, in categories or through compassion?

It is incumbent upon each of us during this crisis to continue to support the medical field in making moral, not mechanistic and “cost effective” choices 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. Isaiah the prophet exhorted that our rituals and sacrifices mean nothing without good works and without defending the oppressed. During this year’s Pesach when many are unable to observe the normal rituals, we can — in this singularly unique historical confluence of holiday and plague– 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 haggadic narrative. That singular epic act of protection– hovering over and guarding those at risk– is precisely what gives the holiday its very name: Pesach. Let this Pesach holiday season be one in which the best of our tradition informs the moment and converts our temporarily suspended or modified holiday rituals into action in support of protecting the lives of those of us who might be otherwise discounted.

1. Henry Hardy, and Roger Hausheer, eds. ,The Proper Study of Mankind: An Anthology of Essays, Isaiah Berlin (New York: Farrat, Straus, and Giroux, 1998), 16.
2. Ibid.
3. Ibid.
4. Menachem Fisch, Rational Rabbis: Science and Talmudic Culture (Bloomington and Indianapolis: Indiana University Press, 1997), 190.