Judaism Contribution to Creating a more Humane Medical Science

The Bible describes three different worlds, three successive experiments of a sort, each of them acknowledging greater imperfection in human behavior.  In Eden, humans are immortal, vegetarian, and at peace.  Outside Eden, where Cain Kills Abel, they are mortal and violent.  After the Flood, they are no less violent, and, beginning with Noah himself, they are in the sway of uncontrollable sexual urges as well.  Abraham emerges from this troubled world, and so do the three faiths that bear his name. The tribes who become the people Israel, living in this world, became the progenitors of a people for whom sickness and health were matters of God's dispensation.  What is the place of medicine in such a world?

By way of an answer, here is a prayer I say every morning.  The prayer was composed about 1600 years ago by the Babylonian rabbi Abayei.  For all that time its explicit purpose has been to make a blessing - that is, to give thanks to God - for one's physical integrity, immediately after having relieved oneself.  It is even posted outside the bathrooms of many restaurants catering to observant Jews.  I will use Dr. Ken Prager's translation of the earliest version we have in writing, from Talmud Brachot 60b:

"Abayei said when one comes out of the privy he should say 'Blessed is He who had formed man in wisdom and created in him many orifices and many cavities.  It is obvious and known before Your throne of glory that if one of them were to be ruptured or one of them were to be blocked, it would be impossible for a man to survive and stand before you.  Blessed are You that heals all flesh and does wonders.'"

In the context of this prayer, doctors and medicines are a redundancy at best and a blasphemy at worst.  Why should anyone conversant with this universe of belief wish for another person to take the risk of arrogating God's power to heal flesh?

The first textual reference to what we would call a medical condition is after the Flood, in Genesis 8:21, where God acknowledges the inescapable presence of repressed memories which motivate self-destructive and aggressive behavior in later years: " Never again will I doom the Earth because of man, since the devising of man's mind are evil from his youth."  But when medicine itself first appears in Exodus 15:25-26, the context is unexpected and troubling to the modern eye: medicine should never be necessary except to compensate for moral failure, as disease is the result of a failure to follow God's commandments. Right after the Jews escape from Egypt - at the cost of a God-sent plague that selectively kills all Egyptian firstborn, followed by a God-sent drowning of all their fathers - they find themselves in a waterless desert.  After fixing the problem in a temporary fashion, God

"put them to the test.  He said 'If you will heed the Lord your God diligently, doing what is upright in his sight, giving ear to His commandments and keeping all His laws, I will not bring upon you any of the diseases that I brought upon the Egyptians, for I the Lord am your healer.'"

Three thousand years later, it is safe to say that most religious people, Jews and non-Jews alike, do not see medicine this way, but rather that they see it as an aspect of our willingness and ability to assume a role our ancestors were commanded to leave to God.  Just as we take on the capacity to change other aspects of the natural world through science - think of the seeding of clouds for rain - we assume permission to act in imitation of God by curing illness and enhancing fertility through medical interventions.

This is a new notion, not wholeheartedly endorsed by the judgements of traditional Judaism.  The arrogation of an unknowable God's prerogatives of life and death brings with it the requirement that the patient surrender free will and the right to choose a future. To greatly oversimplify, Talmud counsels differently: the patient must be the one to choose to be treated, and ought not choose to give away that free-will choice, even to a doctor. The Talmud argues in many places that medicine, and by extension certainly the science that provides medicine with many tools, ought not to be given full authority over a sick person.  Rather, the patient should be allowed to follow his or her intuition on the matter.  A doctor's intervention is justified only insofar as a sick person seeks it out.

As Rabbi Yaakov Neuberger points out, this view is articulated most dramatically by the ruling in Talmud, Yoma 83a, that allows a patient to eat on the fast of Yom Kippur if he feels his life would be endangered by fasting, despite a doctor's certain assurances to the contrary. Doctors do receive the encouragement and approval of the Talmud, but this biblical dispensation is given precisely because it is understood that medicine will always be imperfect.  The point is explicitly made that if medicine were certain of its cures, it would not need the dispensation in the first place.

This cautious, modest approach to the task of healing a sick person seems jarring and out of place in a scientific context.  Seen from the world of basic research, where patients are submitted by lottery to double-blinded, randomized studies - let alone from the cost-effective world of for-profit managed care - the notion that the patient must remain the arbiter of his or her fate seems quaint, even a bit perverse.  The issue raised by the Jewish tradition here is not a matter of the data, that is, of medical science itself, but of its presentation to a patient, refracted through the lens of medicine. The modern physician's manner of presenting a diagnosis or taking a history often tends to carry with it a level of certainty and authority quite incompatible with the medical modesty recommended by Jewish tradition.

This is not solely a matter of overstepping by  science, nor of bad manners among scientists, nor even of bad manners among doctors, nor of their failure to think deeply enough about the dignity, self-determination and insight of a patient.  There is as well a deep wish on the part on many people to surrender control of their situation to some authority, and illness can only add to any person's baseline of innate passivity. Without accepting its moral obligation to be concerned for the individual intentions of each patient, intentions which can be learned only by attention to each person's idiosyncratic past as well as their objective signs and subjective symptoms, a doctor will continue to be at risk of defaulting on her responsibility to a patient, regardless of treatment outcome.

The requirement that free will be preserved places a paradoxical limitation not just on the application of science to medicine, but on all human interventions. In his essay "Catharsis," Rabbi Joseph Soloveitchik describes the paradox in a way familiar to secular scholars of the absurd: the essential element of heroism in Jewish terms is retreat. The paradigm of the hero who retreats is the patriarch Jacob, who wrestles an angel to the ground and then, instead of consummating his victory, lets him go.  From such a withholding of final victory Jacob's descendants - the Jews of today - draw their continued existence:

"The Torah wants man, who is bold and adventurous in his quest for opportunities, to act heroically, and at the final moment, when it appears to him that victory is within reach, to stop short, turn around, and retreat.  At the most exalted moment of triumph and fulfillment man must forego the ecstasy of victory and take defeat at his own hands. ... By freeing the defeated enemy Jacob defeated himself.  He withdrew from a position he had won through courage and fortitude.  He engaged in the movement of recoil."

To a person guided by Torah as the revelation of an unknowable but caring God, successful medical intervention need not confer any moral grandeur, nor need medical failure imply moral decay. From this Jewish tradition, medicine can perhaps learn to recoil at the moment of victory, to pull back from the opportunity to take on the inappropriate role of judge of another person's fate.

It will be difficult to change the habits of the day, because for anyone - Jewish or not - who doubts there is an unknowable deity concerned for the moral content of their individual actions, medicine does have a way of filling the gap, sapping a patient's freedom to choose how to live his or her life. The enormous capacity of science to create tools for the manipulation of the natural world has helped confer moral authority on medicine by default.  The lesson to be drawn from the Jewish tradition is that doctors and scientists have a moral obligation not to fill this gap with their own certainty, if for no other reason than to avoid losing their own God-given free will in turn.

How might this lesson from Judaism play out in more general, operational terms in today's medicine? In the most general terms, Judaism instructs us to redefine medical practice in the following ways.  The profession - from basic researcher to primary-care physician - would accept the full autonomy of the patient at all times; the profession would see this autonomy of the patient as a critical aspect of the patient's identity as a unique and complete human being regardless of physical or mental condition; and these obligations would not be less compelling in the last moments before a patient's inevitable death.

The mind/body dichotomy, and the current separation of mental and physical ailments, would have to be seen as senseless and damaging to the integrity of patient and doctor alike: the body is all.  Indeed it is curious that any serious scientist still holds on to the notion of the mental as anything but physical; 150 years ago Darwin correctly called the mind an excretion of the brain, and today we can see it at work in the switching on and off of connections among the cells of the central nervous system.

Treatment of mental illness would be seen as medicine, pure and simple, and it would be possible to revisit aspects of medical care now suppressed because they fall at the boundary of mind and body, a boundary that we now know to be crossed at every instant, in both directions. In the same way, certain aspects of genetic medicine now emphasized as the wave of the future would be hedged about with precautions, as it would be understood that they risk the integrity of the patient, even as they reveal a great deal of prognostic information.

On the other hand, rogue aspects of medicine now suppressed because they are not easily reduced to testable models - psychosomatics and the placebo effect, for instance - might emerge as powerful tools for medicine. The notion of a psychosomatic effect should not be controversial, as we have all experienced one or more: they are the changes in the objective symptoms of an illness as a result of an induced change in self-image or mood.  They can go in either direction; there are psychosomatic illnesses, and there are psychosomatic cures.  For myself, I know that calling my doctor with a set of symptoms makes those symptoms less troublesome, just as I know that imagining what these symptoms might imply instead of calling to find out makes them immediately worse.

In terms of the biology of the body, such psychosomatic effects are evidence that the mind and body are one, or more precisely, that mental states are states of the body, occurring as the tissues of consciousness in the brain and the perceiving organs draw information from the body's physical condition and change that condition in turn. That much is safe to say on the basis of all we have learned about the brain in the past few decades.

Our medicine is nevertheless still imbedded in a prior assumption, one that has remained unchanged since Aristotle.  That is the notion that mental states are ineffable, existing somehow independent of the physical body, floating free in the matrix of the brain, unable to interact with any material part of the body.  By holding on to that classic Greek presumption, modern medical practice falls unwittingly into a dogma wholly at odds with its own data.

The failure of modern medical practice to examine the consequences of holding on to this position continues to reduce all psychosomatic effects to self-deceptions, since they cannot be real: if the mind is immaterial, it cannot have material effects.  This prior dismissal of psychosomatic events has cost the medical profession a good deal of opportunity to meet its Hippocratic Oath, as these effects do no harm, cost no money, and often bring about precisely the healing that medicine is sworn to seek.

Of the many psychosomatic effects now in the shadows, I will highlight only one, the so-called Placebo Effect.  "Placebo" means "I will please."  A placebo is any objectively inert thing - a sugar pill, a word, a gesture - that has the effect of making someone feel better. A placebo's inertness makes it uninteresting to anyone for whom medicine is restricted to the intervention by active compounds and procedures which produce measurable and reproducible changes in the body.  That same inertness makes a placebo interesting to anyone for whom the mind's workings are an example of the body at work, and important to anyone for whom the sole justifiable reason for any treatment is the improvement of the patient's condition.

A model of the mind as separate in substance from the body is not so different from the data-free religious notion of an implanted, ineffable soul.  The placebo effect is problematic in religious terms only for people who mistakenly conflate the ineffability and immateriality of an immortal soul with the material reality of mental states as expressions of the body's nervous tissues.  Setting that confusion aside, certainly from a Jewish perspective and hopefully from a Christian one as well, clinical placebo effects should be welcomed, studied, and used.

The placebo effect is a natural subject for collaborative study among physicians and religious figures. When prayer works, it may well be a real placebo effect. Prayer as a placebo effect may not be a wholly welcome notion to someone who sees answered prayer as evidence for direct communication between an unknowable God and an ineffable soul. The Center for the study of Science and Religion hopes to initiate a series of meetings among physicians and religious figures to engage the difficult task of building mutual understanding and cooperation between those who apprehend the existence of their immaterial soul, and those for whom the existence of the soul is not so important as the reality of the placebo effect.

Taking a careful look at the placebo effect will also mean taking a careful look at the most important aspect of medical care, the relationships between doctor and patient.  The integration of psychosomatic phenomena like the placebo effect into medical practice could serve as a basis for overcoming the current uses of medical language to set doctor and patient apart.  As Dr. Rita Charon has written, "Doctors differ from patients in the ways they use language and the purposes to which they put words.  Doctors use words to contain, to control, to enclose.  ... Patients use language to express the sensations of things being amiss." Acknowledging the reality of psychosomatic effects would help a doctor to hear a patients' use of language, obliging them to speak in that language in order to be effective.  This could dramatically relieve the pain caused by missed communication, especially if the physician finds she is able to help the patient fix a part of what is amiss, when he is made to feel understood and appreciated as well as examined. The current secular relationship, which encourages the doctor to allow the data of her tests to justify her becoming the sole arbiter of the patient's situation, is unsuitable for any serious study of the placebo effect.

As the German historian of medical ethics Nikola Billar wrote, "The placebo effect is inherent in medical practice, but it is medicine's choice to neglect or employ its power. ... If we do not reject the placebo effect as mockery, it can serve as a mirror, a chance for reflecting medicine's means as well as its goals.  The ability to integrate the placebo effect in an ethically and medically adequate way could be a major achievement of modern medicine, which would benefit not only patients, but physicians as well, serving as a reminder of what lies at the heart of medicine: 'one person treating another.'"

Robert Pollack, Ph.D.
Professor of Biological Sciences
Director, Center for the Study of Science and Religion
Columbia University New York, NY 1002

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