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  Chapter 15 from
Listen To Your Messages
And other observations on contemporary Jewish life

By Rabbi Yissocher Frand 


Other Available Chapters
4 


Quality Adjusted Life Years

Fist impressions can be misleading. Many isues may seem perfectly benign at first glance, posing no threat to our Torah way of life, but upon further reflection, they are revealed as fundamentally incompatible with the Torah view. And this creates a great problem for us, because by the time we identify a concept as alien to Judaism, it may already have insinuated itself into our consciousness, causing damage that may be difficult to repair.

Rashi in Parashas Vayechi observes that this parashah is a setumah, that there is no space separating it from the previous parashah. Why? It is meant to symbolize, Rashi tells us, that when Yaakov passed away “nistemu eineihem veliban shel Yisrael mitzoras hashibud,” the eyes and hearts of the Jewish people were beclouded by the difficulty of their oppression.

The commentators immediately ask: What oppression? We all know that the oppression of the Jewish people did not begin until all of Yaakov’s sons passed away many years later.

The Sfas Emes explains that, although the actual physical bondage did not begin until many years later, a profound change in the Jewish people occurred when Yaakov passed away, a change that affected their eyes and their hearts. What does this mean? It means that the sensitivity of their Jewish eyes and their Jewish hearts was diminished. A Jewish person views the world through Jewish eyes, with a particular Weltanschauung formed by Torah values and ideals. He reacts to the world with a Jewish heart, with specifically Jewish feelings and attitudes. But when Yaakov passed away, this special sensitivity was blunted, clouded, dulled. The absolute Jewishness of their perspective was compromised.

If that’s what our Sages tell us about the exalted children and grandchildren of Yaakov Avinu, what can we say about our own humble generation?

In the modern world, we suffer terribly from this blunted perspective. It is hard for us to distinguish between those ideas that are part of long-standing Jewish tradition and those ideas that are of recent vintage and foreign to the Torah.

Let me give you an example. It involves a recent news item from California, the greenhouse of innovative American thought. It seems that the state has established a new commission to study self-esteem.

Self-esteem. What an intriguing and beguiling concept. The media has labeled self-esteem as the elixir of the Nineties, the panacea for all ills, from poor grades to bad management. Who can be against self-esteem? What can be objectionable about the State of California seeking to promote self-esteem among its citizens?

Is there anything not Jewish about self-esteem?

On the contrary, self-esteem is a very Jewish concept.

Rabbeinu Yonah writes in his introduction to Shaar Avodah, “The gateway to becoming a true servant of Hashem is to know one’s own worth.” There you have it. Self-esteem! A person has to know who he is.

But upon further reflection, we discover a wide and gaping chasm between the Torah view of self-esteem and the contemporary version. Self-esteem derives from an appreciation of one’s own worthiness, but how is that worthiness measured? In modern society, which is so productivity oriented, worthiness is determined by one thing: the capacity to perform and to produce. A person who is no longer able to produce is no longer considered worthy. But according to the Torah view, worthiness is not determined by what you do but by who you are.

The Dubno Maggid makes this point very clearly with regard to the relationship of Yitzchak and Rivkah to their children. The Torah tells us (Bereishis 25:28): “And Yitzchak loved Eisav because he ate his trapped game, but Rivkah loves Yaakov.” The commentators are puzzled. Why is the relationship between Yitzchak and Eisav expressed in the past tense, “and Yitzchak loved Eisav,” while the relationship between Rivkah and Yaakov is expressed in the present tense, “and Rivkah loves Yaakov”?

With someone like an Eisav, the Dubno Maggid explains, his only worthiness derived from the trapped game he delivered rather than his personal qualities. And if a person’s worth is determined by what he does, it is always in the past tense, because what you’ve done is always in the past. As they say in America, “What have you done for me lately?” That’s the measuring rod. What have you done? What have you accomplished? On the other hand, “Rivkah loves Yaakov” because of who he is, and therefore, that love remains constant, always in the present tense.

Ask a kid in America, “What do you want to be when you grow up?” Do you know what he will invariably answer? That he wants to be a doctor, a lawyer, a captain of industry, a rabbi, a teacher and so on. But all these do not answer the question. You asked him what he wants to be, but he tells you what he wants to do. Do you know why? Because that’s America. Being is doing. Your whole essence of a person, his entire sense of self is determined by what he does. That’s why in America, when two strangers strike up a conversation, one of the first questions will be, “So what do you do for a living?” I read that someone was so annoyed by this question that he would respond, “I’m an undercover agent for the IRS.” End of conversation.

But that is the way things are. This is the order of the questions. What’s your name? What do you do? And the second question is more fundamental than the first. Because in America, what you do defines who you are.

But do these different conceptual approaches to personal worthiness affect us in a practical way?

They most certainly do. If worthiness is productivity, then modern society must rethink what makes life itself important. And the inevitable conclusion is that what makes life important is its active participation in society. This, in turn, spawns a new term called quality of life. What does this mean? It means that life is only valuable when it has a certain measurable quality, a very disturbing thought.

In the lexicon of the Torah, however, there is no such word, no such terminology. The Torah does not speak of the quality of life but the sanctity of life, because by its eternal standards, all human life has value. Every single human life is a spark of the Divine.

The Torah demands that we desecrate the Shabbos to rescue even the most tenuous of lives, but that flies in the face of the modern attitude towards life. In modern society, where worthiness depends on productivity, the unborn, the infirm, the terminally ill are all viewed as intolerable and very expendable burdens that interfere with our quality of life.

That explains why American society declares, in diverse and subtle ways, that certain lives are just not worth living. That may explain why 23 million unborn infants have been aborted in America since 1973.

That explains why Richard Lamm, the former governor of Colorado, can declare explicitly what others imply with subtlety, “The elderly have a duty to die and get out of the way.”

Self-esteem based on productivity. Quality of life. Get out of the way and die. That’s the modern perspective.

Modern attitudes toward life have so indoctrinated our society with the concept of the quality of life that a life of suffering is automatically considered meaningless and worthless. A dying patient in a hospital, helpless and suffering, how can this life possibly have meaning? And if it doesn’t, why bother to preserve it?

According to our eternal Torah, however, life always has intrinsic value. Every soul was sent down to this world for a specific amount of time. That is its purpose. And therefore, every additional moment that the soul spends in this world is infinitely precious.

In one of his books, Rabbi Abraham J. Twerski, M.D. describes how he visited a young woman, the mother of two little children, who suffered from multiple sclerosis. She was deteriorating, blind and helpless, a total burden to her family, and not surprisingly, she was deeply depressed.

What could you to say to such a woman? Dr. Twerski related to her the following Gemara (Sanhedrin 101a):

The rabbis taught: When Rabbi Eliezer fell ill, four sages came to visit him, Rabbi Tarfon, Rabbi Yehoshua, Rabbi Elazar ben Azariah and Rabbi Akiva.

Rabbi Tarfon spoke up and said: “You are more precious to the Jewish people than the raindrops, because raindrops only bring benefit in this world while you bring benefit in this world and the next.”

Rabbi Yehoshua spoke up and said: “You are more precious to the Jewish people than the sun, because the sun only brings benefit in this world while you bring benefit in this world and the next.”

Rabbi Elazar ben Azariah spoke up and said: “You are more precious to the Jewish people than parents, because parents only bring benefit in this world while you bring benefit in this world and the next.”

Rabbi Akiva spoke up and said: “Suffering is precious.”

[Rabbi Eliezer] said to them: “Prop me up so that I can hear the words of my disciple Akiva.”

The question immediately arises: Why did Rabbi Akiva’s words bring greater consolation to Rabbi Eliezer than the words of the other sages?

Let us think about Rabbi Eliezer’s situation. He is lying on his deathbed, completely helpless. He knows that his days of teaching Torah are over, that he will never again open the eyes of a new talmid to the wonders of the Torah. He knows that it is all over. So what do the other sages say to him? That he is as precious as raindrops, the sun, parents? But that is all in the past. Never again will he bring anyone benefit in this world or in the next. And so, there is little consolation in these words.

But Rabbi Akiva tells him something else entirely. Rabbi Akiva tells him that there is still something great he can do right now, even as he lies stretched out on his deathbed. What is that? He can accept the suffering he has been allotted with faith and love, and therefore, even in his diminished state, his life still has a purpose.

Indeed, that is all the Almighty ever asks of a person. That is all He ever expects of us. A person does not have to make a so-called “productive” contribution to society. All he needs to do is fulfill to the best of his ability his role as a servant of the Almighty. And if that entails merely lying in a bed and suffering, then that is more than sufficient.

This is what Dr. Twerski told the young mother dying of multiple sclerosis. More than anything else he could have said, these words brought her consolation and peace.

In a similar vein, I would like to relate an amazing story that happened to a talmid of mine. This young man had once attended Columbia University, and from time to time, he would return to participate in outreach programs on the campus. Last year, he went back to Columbia University for a Shabbaton.

On Friday night, he was sitting at the table with some of the best and brightest students of Columbia University. There were also a number of mentally retarded children in attendance, brought there by an organization called Yachad, an organization for the developmentally disabled.

“Every Jew has a role in life,” the young man was telling his rapt audience. “Just as no two letters in the Torah may touch each other, no Jew can infringe on the purpose and mission of another Jew. Everyone has his role.”

Just then a 17 year-old Yachad boy raised his hand. “I have a question,” he said. “What is my role? I’m mentally disabled. I can’t do anything. So what is my role in life?”

Then the boy started to cry. Within moments, tears were streaming down the faces of most of the Columbia college boys as well.

This very powerful question faced the young man. What is my role?

Thinking quickly, he came up with an excellent answer. “You want to know what your role is?” he said. “I’ll tell you. You asked a question. You made people think. You made people cry. You touched people. That’s your role. You asked an important question.”

A week later, just one week later, the young man received a telephone call. The 17 year-old boy from Yachad had gotten up one morning and told his mother he wasn’t feeling well. A few hours later, he died.

The young man went to pay a shivah call, wondering what he could say to the parents. But before he had a chance to say anything, his father said, “You know, my son fulfilled his role. He asked his question. Maybe that was why he was sent down to this world.”

This is a true story.

So this is the Torah perspective on life. A person’s life is precious even if he is not being “productive.” Maybe all he has to do is ask a question. Maybe all he has to do is lie on his bed and suffer in silence. There may not be much quality of life as we understand it, but there is plenty of sanctity of life.

But let us take a look at where the contemporary obsession with quality of life is leading society. Let us take the issue of health care reform. If universal health care is going to happen, costs will have to be controlled. In other words, using the term which is on everyone’s mind but no one wants to utter, there will be rationing. Health care reform equals health care rationing.

And where do you think those cuts are going to be? The first people who will be denied health care are those whose quality of life is deemed inferior. According to studies, 40 percent of a person’s health care costs are incurred during the last few months of his life. Think about it. 40 percent of a lifetime’s worth of health care expenses is incurred in the last few months. So won’t this be the perfect place to make some deep cuts?

There are professional people today whose job it is to make these assessments. They categorize treatment costs in terms of QALYs. Quality adjusted life years. This is how they try to make a determination on these cost issues. Is it cost-effective to spend $40,000 on a cardiac defibrillator for an old person with bad lungs and bad kidneys? How many QALYs (quality adjusted life years) can he have? These are the questions that will be considered by the bureaucrat in Washington before he makes his life-and-death decision.

But let us take a look at what the Meiri says in Yoma 83a. The Mishnah tells us a pile of bricks may be moved on Shabbos if there is a possibility of rescuing a person trapped underneath. But what if after they start to excavate they discover that the person trapped underneath is on the verge of death, that he cannot live for even another hour? Nonetheless, rules the Meiri, the excavation must go forward to preserve the last few minutes of the trapped person’s life. Why? Because maybe in those few minutes he “may repent and confess his sins.” Maybe he will have a hirhur teshuvah. This little but transcendent moment makes life worthwhile and necessitates the desecration of the Shabbos to preserve it.

But how would the bureaucrat in Washington see it? How does modern society look at it? When they see a comatose person, do you think they would make an effort to give him a few lucid moments so that he might still have a hirhur teshuvah? Not a chance. He has no QALYs left. There is no quality of life.

There are, of course, many halachic issues that must be addressed by a qualified posek when a patient is in extremis, and it is not my intention to imply that there is no limit to the heroic measures that must be taken to preserve that final moment of life. But the well-meaning doctor may come and say to the family, “I’m sorry, but there’s no quality of life.” Remember, this doctor doesn’t know about hirhurei teshuvah. He doesn’t know about Divine sparks and the time allotted to a neshamah in this world.

Rabbi J. D. Bleich writes about his maternal grandmother who suffered kidney failure and was comatose for 36 hours. He came into the hospital, looked at the chart and saw that there was nothing being done for his grandmother.

He called the doctor to complain. “Why aren’t you doing anything for her?”

“Listen,” said the doctor, “she’s an old lady. Let her go in peace and dignity.”

Rabbi Bleich considered the doctor’s words. Intellectually, he knew what his decision had to be, but emotionally, it was difficult.

“Treat her,” he said. “Try to keep her alive as long as you can.”

And so they started treating her.

On Shabbos, Rabbi Bleich came into the hospital room. “Good Shabbos,” he said to his grandmother.

Then this old woman, who had been comatose for 36 hours, opened half an eye and responded, “Good Shabbos.”

A few hours later, she passed away.

Do you realize what just happened here? Rabbi Akiva Eiger writes in his commentary to the Shulchan Aruch that when a person says “Good Shabbos” he fulfills a mitzvas
asei d’oraisa
, a positive Torah commandment. On the last Shabbos of her life, that grandmother fulfilled a great mitzvah, and for all eternity, she will reap the merits of this mitzvah of which the doctors almost deprived her because of her minuscule quality of life.

Yafeh sha’ah achas b’teshuvah umaasim tovim b’olam hazeh mikol chayei olam haba. One hour of repentance and good deeds in this world is more precious than the entire world to come. That is how the value of life is measured according to our holy Torah.

 
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