Introduction
My most recently published book on bioethics was an attempt to suggest that human dignity was the foundational principle in bioethics – the principle on which all other principles were parasitic.
‘Dignity’ has not had a good reputation in the Academy. It is commonly dismissed as hopelessly amorphous, incurably theological, or parasitic on more hard-edged notions such as autonomy. One of the challenges in the book was to give dignity a meaning, concordant with the literature, which dealt with those criticisms. In order to do so I had to propose a meaning and an origin which did not depend on the Imago Dei. I expressly reserved the possibility that the Imago Dei, properly understood, could generate the same conclusion. In fact I believe it can. This post explores that contention.
The account of dignity for which I contend in the book is based upon human thriving – for which ‘humanization’ is a near synonym. There is no contradiction between the book’s contention and this essay’s contention. This essay is about Jewish answers to problems in medical ethics. Judaism’s business is human thriving. Judaism asserts that humans are, inalienably, made in the Image of God, and that they thrive best when they consciously acknowledge that likeness in themselves and others, and seek to live in the light of the knowledge.
Christian philosophers have mishandled the notion of the Imago Dei. There are two related reasons.
First: at least since the Middle Ages, Gnosticism has (despite the church’s loud anti-Gnostic rhetoric) permeated Christian thought and, crucially, affected Christian exegesis of the Creation narratives in Genesis. It manifested itself in a suspicion of embodiment. Sex was dirty: celibacy was optimal: food was a soul-endangering trap.
The Creation narratives were read through this distorting lens. Gnosticism both generated the misexegesis and was reinforced by it. If ideal humans were purely spiritual animals, then how should one read the insistence of Genesis that humans were made in God’s image? Answer: by concluding not only that God is spirit (which is true), but that he is wholly uninterested in anything material – which is neither an exegetically correct nor a logical corollary.
Second: Christian theologians over-analysed the hermeneutically ascertainable attributes of God in the Creation narratives in an effort to decide how Man should be. God spoke, for example: therefore language was an essential human attribute. More repercussively, God reasoned: he has Mind. Therefore the ability to reason is an essential attribute of properly constituted humans.
This idea found glorious expression in the Renaissance, and malignant expression in the philosophy of Kant. Kant has metastasized throughout western thought. His ideas of the primacy of reason and autonomy have coalesced into the ruling autonomistic paradigm of modern bioethics.
Kant shares the Gnostics’ suspicion of bodies. He has nothing to say to anyone whose ability to reason is truncated. He is, therefore, almost uniquely unqualified to comment on the major problems of bioethics which is concerned with embodied creatures, many of whose minds are seriously truncated by disease or trauma.
Judaism avoided these pitfalls. It was always more concerned with bodies than Christianity – perhaps because it had a mistier idea of the afterlife. And the rabbis, who understood the nuances of the Genesis passages better than Christian interpreters, resisted the temptation to say: ‘This is a revealed characteristic of God. A proper human being must in some way reflect it.’ They were broad brush and pragmatic. It paid dividends. Judaism continued to have something to say about medical ethics when Christianity, hamstrung by Gnosticism, reason-worship and body-hatred, did not.
Ethics and medical ethics
Of course there’s a mass of learning on Jewish medical ethics. I know some of the literature, although I’m not an expert in it. The key modern books are collections and attempted codifications of masses of responsa.
I have intellectual and ideological problems with some aspects of the halachic project. But I share some of its ultimate objectives (human thriving, perceived broadly, I think, as I’ve characterised it, and the incremental creep towards some sort of messianic age) and its core values.
It’s those core values with which I’m concerned now. Often in halachic discourse they’re so encrusted by precedent that they’re invisible, or occupy so small a space within the protectively ring-fenced arena of permissibility that you can easily miss them.
The core values that I think can be identified are not applicable only to medical ethics. If they were, that would be a sure sign that I’d got them wrong. Medical ethics deals with humans rather than specific problems about humans. If it doesn’t – if it pretends instead that it is the sovereign of an independent territory to which its own esoteric rules apply – it loses all its authority. The rules governing proper behaviour towards a sick human are those governing proper behaviour towards any human. If that’s not the case, it must mean that the sick human is in some sense dehumanized by the very morality that is designed to protect his humanity. Accordingly medical ethics is simply ethics. Which means that this essay is both ridiculously ambitious and embarrassingly trite. Ambitious, because the business of ethics is arguably the whole business of being human. And trite, because in the space I’ve got I can utter only a few platitudes about how to be a mensch.
The values won’t usually compel a particular answer. The essay has the right title: ‘Framework….’ The values form a skeleton which can move in a particular direction only when muscled up by discussion.
What is man?
Since ethics (I’m contending) is about how to be a human being well, it needs to know something about what humans are – to hazard an answer to the Psalmist’s question: ‘What is man, that thou art mindful of him?’
The cornerstone authorities are of course the creation narratives in Genesis. The distinctively Jewish interpretations of these are in the famous passage from Mishna Sanhedrin. (1) ‘Adam was created alone to teach you that if anyone destroys one life, Scripture reckons it as if he had destroyed a whole world; conversely, if anyone preserves one life, Scripture reckons it as if he had preserved a whole world.’ (2) [The creation of one common ancestor] also leads to peace among people, for no many can say, My ancestor was greater than yours.’ ‘….when the Holy One, blessed be He, formed all men in the mould of Adam, none [exactly] resembled another. Therefore a man should say, The world was created for me!….’ The numbering is my own. When I return to these passages I will refer to the two elements as ‘Sanhedrin (1)’ or ‘Sanhedrin (2)’. One or other of the elements comes into most of the principles.
The principles
(a) Human beings are hugely valuable
This is a constant and dominant Jewish theme. In many ways the other principles are footnotes to it. Sanhedrin (1) and (2) make the point. So do both the Lex talionis, which prescribes death for the death of a man , and the Talmudic reluctance to put the death penalty into effect. You can call this the notion of the sanctity of life if you please, but that formulation seems to me to beg more questions than it answers.
This principle doesn’t imply the vitalism of conservative Catholicism – which, because of the scarcity of resources, has the effect of killing salvageable humans in order to keep permanently insensate humans biologically alive. There is a time for living and a time for dying. But it does imply, at the least, a presumption in favour of the maintenance of life. Such a presumption has long been embedded in the English law , and is eminently workable, even given the exigencies of modern medical life.
There’s a danger, in trying to extract general principles, that the force of the original laws is forgotten. That’s a particular danger with the Lex talionis. Yes, it’s authority for the proposition that human life is valuable, but both it and many related text say much more than that. There’s an inescapable and inescapably stern prohibition on the taking of life. I suggest that this translates into an endorsement of a moral distinction between acts and omissions. That distinction is much criticised. The difficulty of the distinction is highlighted by powerful thought experiments such as the Trolley Problem. But to demonstrate difficulty in extreme situations is not to render the distinction practically worthless, or to drain it of moral content. Its utility has been demonstrated in the homicide laws of most jurisdictions. Its concordance with our intuitions suggests that its origins are old and deep.
This doesn’t, of course, mean that passive killing is fine, and that one can blithely withhold or withdraw life-sustaining treatment. The presumption in favour of the maintenance of life will often mandate aggressive and sustained medical efforts. This conclusion can be drawn from many parts of Jewish thought, including the obligation of hospitality. Abraham felt joyfully obliged to offer the traditional hospitality of the Bedouin to parched wanderers : so too there is an obligation to offer sustenance (which might include ventilation and antibiotics, for instance). This is an obligation that’s particularly onerous when the potential recipient is downtrodden by disease or age: the bias to the weak is prominent in (especially), Amos and Hosea.
Sanhedrin (1) and (2) are often misquoted as referring only to Jewish lives. There are some late scribal additions which buttress the misreading. But both Genesis and the Mishna are clear: we’re all sons of Adam and daughters of Eve.
(b) Humans are embodied creatures
I’ve said about enough about this already. It’s a wise religion, and one that’s likely to have something very meaningful to say about medical ethics, which has a specific blessing for the opening of the bowels and the emptying of the bladder.
(c) Humans are stories
History is one of the great Jewish discoveries. Jews taught the world that time moves in a straight line rather than cyclically, and added the gloss that history has a point – that it’s moving from creation to some sort of Messianic consummation. The Creation narratives had insisted that the universe had a purpose. Judaism, in other words, tells of a metanarrative.
This, wedded to the idea that humans are significant and unique (see especially Sanhedrin (2)), created the powerful and pervasive principle (perhaps already implicit in, or a necessary consequence of, the fact of consciousness) that humans are narratives themselves. The great metanarrative is the stage on which the individual performances are played out. Without that stage our performances wouldn’t be insignificant, but they’d be isolated street acts: they’d lack context and coherence.
There’s an extent to which, by divine condescension and daring, gracious delegation, the metanarrative of this planet is the sum of the individual human narratives. The Bible is full of human stories.
Stories have a beginning, a middle and an end. In a satisfactory story each of these elements bears some coherent relation to the others.
So what?
Well, many things, but four points for now.
We’re (at least in part) the authors of our own stories. Respect for authorial integrity (which is essential to the integrity of the narrative), will mean that we respect patient autonomy. There are other sources of that notion. We’ll come to them in a moment.
We’ll be slow to lop off the end of the story. If I don’t tell my children the end of their bedtime story they’re rightly outraged. It spoils the whole thing for them. Translated to the wards, this will make us look critically at suggestions that life is prematurely ended, or that a chance to write a good ending is frustrated.
Each part of the story is as essential as every other. If you rip a couple of pages out of the middle of the book, what’s gone before and what comes after will be affected, and may be drained of some important context. Medical ethics tends to focus on the dramatic problems at the beginning and the end of life, but what happens in the middle is important too.
The best stories aren’t monologues: they have a cast of characters. Which brings me to the next point.
(d) Humans are relational creatures
It was not good for Adam to be alone, God decided. And the companionship of non-human animals wasn’t enough. Adam found what he really was in his relationship with Eve. And its the same with us. Self-realization demands more than Self. To live in and for the Self is dangerous and miserable. It’s impossible to define ourselves without reference to the nexus of relationships in which we exist and of which, to a large extent, we consist. Yes, the Bible’s full of individual stories, but they are stories about relational creatures, and the stories, taken together, are the biography of a nation.
Traditional medical ethics has focussed narrowly on the interests of individual patients. The law has tended to define a doctor’s duty by reference to the relationship of one doctor to one patient. This perspective is slowly being eroded and replaced by a more communitarian ethic. My own work contends that in deciding what to do in a particular clinical situation one needs to conduct an audit of the way that the proposed act or omission will affect the dignity rights of all the stakeholders – who will include but will not be restricted to the patient.
One can derive the same conclusion from (inter alia) the Biblical stewardship obligations, from the idea that we are indeed our brothers’ keepers, and from the fact that many of the laws of Leviticus prescribe punishments for individuals which are wholly disproportionate to the individual’s fault, but are perceived as necessary for the good of the community.
Judaism will applaud the shift towards communitarianism.
(e) Humans are ends, not means
This follows from Sanhedrin (1) and (2). Jews will join Kant for the purpose of opposing instrumentalization, while being careful to avoid being tarred with his Gnostic brush.
(f) Humans are choosers
In the Jewish world view (as opposed to the Greek view, at least until Plato), humans have the dignity of causation. They can make real choices which affect both them and the rest of the world. Adam named the animals: Eve was permitted to reach out for the forbidden fruit: the mechanism by which Tikkun olam is effected is a matter for us: The Talmudic process (exemplified by the story of Rabbi Eliezer and God being out-voted) acknowledges that human brains have a real part to play in ascertaining truths about God and the world. We’re not just ‘tennis balls of the stars, to be knocked and bandied about’.
Human decisions, then, need to be respected. Autonomy will have a crucial place in Jewish medical ethics.
All civilized people agree that autonomy’s important. The difficult thing is working out what respect for autonomy means. But at the least it will mean a suspicion of medical (and, for that matter, rabbinic) paternalism, a concern for upholding good standards of informed medical consent and confidentiality, and sympathy for advance directives.
Now all that is trite. But to say any more than that one has to have recourse to other principles.
Respect for autonomy doesn’t in itself suggest that euthanasia’s unobjectionable, for instance. There are lots of autonomy-based reasons for objecting to euthanasia, and there are many other principles whose voices need to be heard in discussion with autonomy in the euthanasia debate. Autonomy by itself can’t come to a useful conclusion about abortion: there you have several competing autonomy claims, and you need other criteria to adjudicate between them.
So: autonomy’s vital. If it’s given absolute rule it becomes tyrannous.
(g) Humans sometimes have to have choices made for them
While Judaism puts a very high premium on human choice, it also recognises that good choices are better than bad choices. We think of Jews as those who voluntarily adopt the Torah, and acknowledge that the yoke of the Torah, while sometimes it might chafe, is a guarantee of ultimate fulfilment – a route to the Good Life. We’re used to saying things like: ‘God woos, but never rapes.’ ‘He’s given us the privilege of being able to reject him.’ But Talmud Shabbat 88a: 16 has a fascinating observation. It’s dealing with Exodus 19:17 – the seemingly uninteresting words: ‘…and they took their places at the foot of the mountain.’ The Talmud observes: ‘R. Abdimi b. Hama b. Hasa said: This teaches that the Holy One, blessed be he, overturned the mountain upon them like an [inverted] cask, and said to them: ‘If ye accept the Torah, ‘tis well; if not, there shall be your burial.’’
So according to R. Abdimi b. Hama b. Hasa, the Torah, which facilitates freedom and fulfilment, was accepted because the consequences of not accepting it would be death.
This can’t be adopted as a general principle. It goes against the grain of much other mainstream Jewish thinking. You’d have thought it came from one of the Inquisition’s sermons rather than from a rabbi. But perhaps it illustrates that in order to be free and fulfilled it may sometimes be necessary to be compelled.
That’s certainly the experience of many in clinical practice. The classic examples are the cases (there have been several) of pregnant women who have needle phobia. A Caesarean section is needed to save both them and the child. They refuse consent, out of fear of the anaesthetist’s needle. The courts typically order them to be held down by burly nurses while anaesthesia is induced. Many of the women write letters to the judge afterwards, saying how grateful they are to have been compelled. Other examples include the compulsory sterilisation of mentally incapacitous women for whom childbirth would be psychologically damaging.
Of course this principle has to be deployed very restrictively and cautiously. Compulsion is generally an abomination. But the exercise of autonomy or semi-autonomy is sometimes even more abdominable.
Summary
Decent medical ethics will involve a respectful conversation between these principles. The sound of that conversation is the murmur of dignity, or humanization, or thriving, with which Judaism is passionately concerned.
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