September 22, 2018

How the Bible plays out in hospital intensive care units

In this week's parsha, V'zot ha-Brakhah, we read about the farewell blessing of Moses to the Israelites.  At 120 years of age, Moses views the land that God promised to Abraham and his descendents.  The Israelites will proceed to inhabit this land of milk and honey, but Moses will not.  Moses must die in the land of Moab just short of leading his people into the promised land.  Moses died “al pi adonai,” meaning that Moses died “at the command of the Lord.”

The Rabbis examined why Moses required the Lord's command to die.  In the words of Elie Wesel, retelling the Rabbis' analysis, “When Moses learned that his hour had come, he refused to accept it.  He wanted to go in living — though he was old and tired of wandering and fighting and being constantly tormented by this unhappy and flighty people he was leading across the desert.”  According to the Rabbis, Moses then haggled with God to continue to live, composing prayers, putting on sackcloth, calling on others for support and arguing “Don't you trust me?….Have I not proven my worth?”  God would not back down.  Wesel notes that after being advised by an angel to accept God's decree, Moses should have graciously heeded the sage advice.  But Moses would not and began to bargain according to Wesel:

We went on refusing to die, pleading, crying for another day, another hour, as would any common mortal….So great was his despair that he  declared himself ready to renounce his human condition in exchange for a few more days of life:  'Master of the Universe, he implored, let me live like an animal who feeds on grass, who drinks spring water and is content to watch the days come and go.  God refused.  Man is not an animal; he must live as a human or not at all. 

The Rabbis understood humans' unwillingness to give up life.  But they also understood that all humans must die.  The struggle to survive is innate in each of us, yet we need to learn that this strong impulse must be accede to a greater force.  The Rabbis recognized that humans would be willing to trade one's most precious attribute, humanity, to prolong life, if even for a brief time.  They projected that even Moses, the powerful and great leader of the Israelites, would be willing to give up cognizance of the nature of the world, recognizing others and being part of the human race just to eek out another day.

The Rabbis never could have imagined, but this battle plays itself out daily in intensive care units around the globe.  Man, imbued with the divine spirit, has developed medical advancements that rescue those with failing hearts, lungs, bowels and livers.  People who have experienced “sudden death” are hurriedly hooked up to blood-pumping, oxygenating, continuously detoxifying remarkable machines by amazing clinicians.  Some of these people miraculously walk out of the hospital to continue a renewed life.  But for many, these ventilators, artificial hearts and kidney machines cannot restore humanity. Instead, these machines and feeding tubes and medications yield broken bodies that cannot interact, cannot carry swallow or taste, cannot recognize loved ones.  Many suffer while maintained alive.

A study of critical care physicians at one Southern California hospital system found that more than one in ten patients receiving treatment in their hospitals' intensive care units were receiving treatments that would not benefit the patient in a meaningful way.  These treatments usually would keep a patient alive, albeit briefly for most, but not in a fashion befitting a human.  Many of these patients were comatose with no chance of improving, others could never survive outside of an intensive care unit, but medical technology with tubes and drips and endless effort could keep them precariously balanced between life and death in a room full of machines.  The physicians surveyed in this study, many deeply wounded by the experience, indicated that they should not be providing these critical care treatments.  But they were compelled to do so by families who could not let go, families who were willing to preserve life for an extra day or perhaps several despite the state of their loved one, the suffering and the cost.

The Rabbis, nearly two millennia ago, when herbs and leaches constituted the best medical care had to offer, recognized that man was not served by succumbing to the basic instinct to preserve life at any cost.  We can learn today that it is humanity that we must strive to preserve at all times.  And that there is sometimes a need to say “no, it is time to die.”


Dr. Neil S. Wenger is professor of medicine in the Division of General Internal Medicine at UCLA and a consulting researcher at RAND. He is director of the UCLA Healthcare Ethics Center and is chair of the Ethics Committee at the UCLA Medical Center.