Thank you for your interest in my High Holy Day sermon. I hope you enjoy reading it. Please note that this material is under my copyright. You have my permission to forward it in its entirety, but not excerpted, as long as you include this disclaimer. I am sorry for these conditions, but they save me a lot of explaining on the other end! Jack Moline
Yom Kippur 2011/5772 - Dying - ©Rabbi Jack Moline
Before I say anything else, I want to say that I am healthy. There is no surprise about my well-being waiting for the end of this sermon. At 59 years old, I have some of the dubious blessings of aging and the detritus of my swim in the genetic pools of my forebears, but I am just fine. My cardiologist and my urologist are here today, and if you need confirmation, I hereby waive all HIPAA restrictions so that Arnie and Iver can confirm what I am saying.
I begin that way because I am going to be talking about my death. More specifically, I guess, I am going to be talking about my dying. We are all going to cry, especially the members of my family who already know what is in this sermon. But if I can do this in front of all of you, emotional coward that I mostly am, then you can do this privately with the people you love. And you must.
Two things compel me to have this conversation today. The immediate motivation is an article that appeared in The New Yorker in August of 2010. It is entitled "Letting Go: What should medicine do when it can't save your life?" The author is Dr. Atul Gawande, a surgeon from Boston who is also a MacArthur fellow and a terrific writer. I commend the 24 pages of his prose to you, but only if you have a long time to think about them. I had about a year.
The other motivation is my age. Twenty-five years ago and two months, I arrived here to be your rabbi. I was 34 years old, the father of two little girls. Before the year was out, my father had received the diagnosis that eventually became his death sentence. He was 63. Two of his grandsons are named for him, as I am named for my grandfather. At 63 my father had survived two major heart attacks, multiple bypasses, a bout with melanoma and surgery to remove a cancerous testicle. He had been controlling his diabetes with a very strict diet for five years. When he came to visit me here the one and only time, a then-member looked at him and said to me, "It's hard when our parents become elderly, isn't it." He died of brain cancer at age 65, shortly after his fortieth wedding anniversary and just before Chanukkah.
I do not expect to succumb to anything in the next six years, and Ann and I intend to compete for the family record of length of marriage which stands in the mid-sixties at the moment. If I say I am looking forward to meeting all of my grandchildren, it is not to put pressure on own children, but to say that I am determined not to have any of them named for me.
But who knows? When Disney made the movie "Pollyanna" in 1960, the local pastor was played by a young Karl Malden. Before Pollyanna changed his heart, he would thunder from his pulpit, "Death comes unexpectedly!" That performance was cause for great hilarity among some friends we had in our early twenties. There are too many of you in this room who see nothing comic in that monologue.
And you might make the argument that the liturgy of the day gives me cause to say what I have to say. Within a few minutes of the conclusion of these remarks, we will sing together mournfully, "b'rosh hashanah yikateivun, uv'yom tzom kippur yeikhateimun," "On the New Year it is written and on the fast day of atonement it is sealed: who shall live and who shall die." But listen to the list: who will pass on and who will be born, who shall live and who shall die, who will live a full life and who will die young, who by fire, who by water, who by sword and who by beast, who by hunger, who by thirst, who by earthquake and who by plague. They are, most of them, sudden deaths without warning. Death that comes unexpectedly.
That's what death was, mostly, for a lot of human history. Some people died slowly, but most people died quickly. A wild beast, a war, a collapsing building. Illnesses we shrug off today - strep throat, urinary tract infections, a cut from a household knife - could take the life of a young and otherwise healthy person. Diseases we barely know thanks to vaccines and inoculations claimed hundreds of lives at a time. T'shuvah, t'filah and tz'dakah were not so much talismans against death as a way to give life meaning for the frightened worshippers of dozens of generations.
Our tradition is pretty good at dealing with such deaths. This holy congregation has shown support to friend and stranger alike when the angel of death has paid a visit - washing and dressing the body with gentleness, sitting with the body through long and lonely nights, accompanying the family to secure the grave, nurturing the bereaved with food and prayer and companionship. I commend all of you who practice any part of these mitzvot and I invite the rest of you to follow the example of your fellow congregants.
But what our tradition is not so good at dealing with is death that does not come so unexpectedly. It is not the fault of Judaism. It is the by-product of the remarkable changes in medicine in our lifetimes. For example, doctors are apparently required to be much younger than they used to be. And they have at hand resources that make the outpouring of care my beloved father received in the last six months of his life seem primitive. It takes longer to die than it used to. And we have no piyyut, no devotional poem that warns us that last week it was written and today it is sealed who by cancer and who by stroke, who by heart failure and who by emphysema, who by degenerative muscular disease and who by dementia.
Too many of you know: t'shuvah, t'fila and tz'dakah do very little to mitigate the harshness of those decrees.
Dr. Gawande's article tells a number of stories about people with terminal conditions. The longest description is of Sara, who discovered she had cancer when she was in the thirty-ninth week of her first pregnancy. Her baby was delivered early so that she could begin immediate treatment. All the stops were pulled out and no expense was spared. Here, after all, was the very person for whom medical science strives - a young woman, a brand-new first-time mother. The first drug protocol was ineffective, as was the second, as was the third. In a matter of months, she had gone from robust to frail, unable even to walk from her car to the doctor's waiting room. It was clear to the doctor, who is named and interviewed in the article, that hope for a cure was gone and that Sara had at most a year or two of life ahead. An experimental therapy was available, but to qualify for it, she had to take a fourth round of chemotherapy with a great likelihood of causing further debilitating side effects.
The doctor did not discuss with Sara what was inevitable. Instead, he became complicit in a normal and understandable phenomenon: the patient and her family were not ready to confront the reality of her disease. In his interview, he acknowledges that he would be the same way on the other side of the table. Sara embarked on a series of treatments in hope of a miracle cure that robbed her of any meaningful improvement and, in the end, did not prolong her life except for a short time and in the most technical sense. Sara had put into place all the necessary preparations we know about - instructions for raising her children, expressions of love for her family, the right phrases about quality of life. But she and her family were so deeply in denial that they never had the most important conversation.
It is unfair to expect that doctors will bear the burden of guiding their patients through the hazardous existential waters of facing the inevitability of death. I suspect that you are like me in this regard: I want compassion from a doctor, but not distraction. I want my physician focused on what he or she knows, which is my medical care, not the deeply personal issues that require reflection and introspection. Dr. Gawande makes the argument for preparing doctors to practice an expanded kind of medicine. I want to make a different argument.
I want to make the argument that each of you must be braver than you think you can possibly be and have a devastating conversation with the people you love.
I am not talking about preparing a living will. That you should do in any event. Having advance medical directives will guide your caregivers in the kind of interventions and procedures to pursue when you are what our tradition calls a gosseis, a person facing death. The conversation I mean ix not about death. It is about dying.
The living will you have is of no value if the people charged with making decisions with you or for you do not know what the words mean to you. My cousin, Rabbi Arnold Goodman, recalls visiting a congregant in the hospital and seeing tubes and wires connected all over her body. "I thought you had declared you did not want extraordinary means used to keep you alive," he said. She replied, "It's amazing of how your definition of `extraordinary means' can change."
Dr. Gawande tells the story of a colleague of his, Dr. Susan Block, who is a nationally-recognized pioneer in the field of palliative care. She trains other doctors how to have difficult conversations with their patients. She insists they cultivate compassion and empathy, and she makes it clear that the conversations take time that may not fit neatly into the model of office hours that are necessary in the modern practice.
Some eleven years ago, her father, who was 74 at the time, was diagnosed with a mass growing in the spinal cord of his neck. The neurosurgeon said that if he had surgery to remove it, he stood a 20% chance of being paralyzed from the neck down. Without the surgery, he had a 100% chance of that paralysis. She was her father's health-care proxy.
The evening before the surgery Dr. Block and her father talked about friends and family to keep their minds off the next day. She left for the night. Halfway home she said to herself, "Oh my God, I don't know what he really wants." She turned around and went back to her father. Expert though she was in end-of-life discussions, she felt horrendous going through her list of questions with him. She eventually said these words: I need to understand how much you are willing to go through to have a shot at being alive, and what level of being alive is tolerable to you. In the ensuing conversation, he eventually said, "Well, if I am able to eat chocolate ice cream and watch football on TV, then I'm willing to stay alive. I'm willing to go through a lot of pain if I have a shot at that."
There is a lot more to this story, but here is the end. When an emergency presented itself during the procedure and more surgery was necessary, Dr. Block asked the surgeons if her father would be able to eat chocolate ice cream and watch football on TV. They said he would, and she authorized the surgery. He survived ten more years, even with two years of difficult rehabilitation. When the complications of aging and partial disability made swallowing too difficult for him, he stopped fighting and came home to hospice care. He died peacefully.
Thinking back to her initial decision, Dr. Block said, "If I had not had that conversation with him, my instinct would have been to let him go at that moment because it just seemed so awful. And I would have beaten myself up. Did I let him go too soon?" If he had become thoroughly disabled by the emergency surgery, she said, "I would have felt so guilty that I condemned him to that."
I took a piece out of this sermon that I had originally included at this point. I will condense it into four sentences. There is no price that can be put on human life. The cost of curative treatments should not determine the use of those treatments for anyone, rich or poor. Just because a treatment is available does not mean its outcome is worth its cost in suffering or in dollars. We can argue that another time.
So with that, let me try to show you what that conversation might look like. I am not certain I will succeed. I cried uncontrollably when I thought about it. I cried as I watched my family cry when we talked about it. I cried as I prepared these words. But I feel compelled to encourage you to give a gift to the people you love to spare them the legacy of guilt that an uninformed decision leaves behind. It is a conversation, not a monologue, though this context does not allow for the give and take, the touching, the hugs. Please have this conversation while you are healthy and of sound mind. And if you change your mind, have the conversation again. Take your time. Think it through. And do not be concerned that you are tempting the evil eye or the Angel of Death. Then take a deep breath and speak honestly.
Some people look back at high school or college as the best time of their lives. For me, being a part of this family of ours is better than anything I ever imagined. My love for each of you reaches places so deep inside I didn't even know they existed. Seeing each of you grow into the person you have become, finding purpose in life, blossoming into a unique personality - these have been my greatest pleasures. In return, you have made me a better person than I ever would have been without your love. I want to be better than I am because I think you deserve it from me.
But the fact is, everybody has to die and I am no exception. It may be that my death will come suddenly, in which case I hope you will see to my burial according to Jewish law and take the full week to acknowledge my absence from your life. But if my death comes incrementally, if I am facing an ebbing away of what makes me me so that you have to make decisions about how to proceed with my care, I do not want to leave you guessing about what I want.
I don't have a sort of pithy wish, like chocolate ice cream and football, to use as a measure for you. My instructions may be too vague, but they are the best I can do. I want to be able to enjoy your company. And I want you to be able to enjoy mine. I would not mind becoming something of a burden on you - each of you has been a burden I have carried at some point in my life, and they were the happiest burdens I can remember. But if I am afflicted with an illness that will so decimate me that your lasting memory of me will be in my final misery, please spare me the misery and you the memory. Without your love and presence in my life, I have very little to live for. And my heart would break if, because of a decision you make, you cannot be at peace with my life or my death. Act on my instructions on my behalf and be confident that you have shown me all the love and respect a husband or father could want.
I hope that when I die you will not feel like you have already grieved my loss.
My father told me near the end of his life that he was not afraid to die. I don't share his courage, though I want to. But I am not afraid at all about being dead. I am entirely confident that the life my body surrenders will return to its source, and with or without my knowing it, I will live forever as we all will. In the meantime, if I have to look back at what I have accomplished in this world, I only have to look at you and know that I am leaving a better place than I found.
I love you, and I know you love me.
My friends, my dear friends. I cannot tell you that energy it takes for me to stand before you and perform what feel likes acts of emotional exhibitionism at this time of the year. My career has saved me thousands of hours of psychotherapy, but has made my life in many ways a book opened to Talmudic style scrutiny. I beg your forgiveness for the upset I know I caused you, and I beg your indulgence for the arrows I aimed at your hearts.
Enough of you have shared your agony with me at moments of decision making that I could not abandon the rest of you to uncertainty. And as I approach the age at which my father, who was no less certain than I that he would live out his 120 years, at which my father reached the Rubicon of his life, I could not abandon my family to that uncertainty. I love you all too much, and I love them more.
My words are not your words. In six months or six years, my words may not even be my words. By then, I hope that at least in this small corner of the community these conversations will be more common and easier to pursue.
T'shuvah, t'fillah and tz'dakah are not the tools we need when we consider who shall live and who shall die outside this room. But chessed, gilu'i lev v'sichat nefesh ma'avirin et ro'a hag'zeirah, lovingkindness, honesty and a heart to heart talk can indeed lessen the harshness of the dread decrees.
May you be inscribed and sealed for a good year.