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Congregation Netivot Shalom | 1316 University Avenue | Berkeley | CA | 94702 |
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Congregation Netivot Shalom | 1316 University Avenue | Berkeley | CA | 94702 |
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August 26, 2009 Why We Must Support Universal Health Care
by Rabbi Elliot N. Dorff |
Whether or not we are believers in the Obama plan, or any of the particular plans for universal health care currently winding their way through Congress, support for universal health care is an imperative in Jewish law. Although what is available in medicine and its cost have changed radically, particularly over the past century, the fundamental right to receive good care — and to be compensated for giving it — goes very far back in our heritage, though perhaps, ironically, not all the way to the Torah or even the Mishnah. When physicians could not do much to heal a sick patient, their services were easily attainable, relatively cheap, and, frankly, not much sought after. "The best of physicians should go to hell," the Mishnah says, reflecting people's frustration in the second century C.E. with doctors' inability to cure. With the advent of antibiotics in 1938, as well as other new drug therapies, and, especially, new diagnostic and surgical techniques, however, there has been an immense increase in the demand for medical care, precisely as it has become much more expensive. This raises not only the "micro" questions of how physicians should treat a given person's disease, but also the "macro" questions of how we, as a society, should arrange for medical care to be distributed. It is precisely this argument that is taking place in town halls and in the halls of Congress these days, sometimes in rational arguments but all too often in shouting matches that are clouding the real issues. Jewish tradition imposes a clear duty to try to heal, and this duty devolves upon both the physician and the society. Jewish sources on distributing and paying for health care are understandably sparse, however, because before the 20th century, medical care was largely ineffective and inexpensive. The classical sources that describe distribution of scarce resources and apportioning the financial burden for communal services deal instead with questions like providing for the needy or rescuing someone from captivity, from highway robbers or from drowning. Still, those discussions raise moral problems and suggest solutions that are often similar to those associated with scarcity and cost in modern medical care. One set of issues is this: Who should get what when medical interventions are scarce and/or expensive? The other set of questions is this: Who should pay for health care? I discuss at some length the answers that emerge from the Jewish tradition to both of these questions in Chapter 12 of my book, "Matters of Life and Death: A Jewish Approach to Modern Medical Ethics" (Jewish Publication Society, 1998). I will share here a general sense of how the Jewish tradition responds to these questions, which are at once so ancient and so contemporary. (For specific source references, visit this article at jewishjournal.com.)
If particular forms of medical treatment are scarce or expensive, who should get them? Although this question of triage is most dramatic when the decision is one of life or death, it affects the quality of people's lives in less threatening situations as well. Who, for example, should get a hip replacement when society cannot afford to provide one for everyone who needs one? Who should have the benefit of a heart bypass operation or transplant, and who shall be denied that? Which AIDS patients should get the regimen of drugs now available to lengthen their lives, and for whom is that just too expensive? In the High Holy Days liturgy, "who shall live and who shall die" is God's decision; but with the benefit and responsibility of today's technology, we find ourselves all too often in the uncomfortable position of having the responsibility to decide that ourselves. The rabbinic passages that might give us some guidance about triage go in five different directions: Social hierarchy. One passage in the Mishnah determines priorities on the basis of the victim's position in the hierarchy of society — with knowledge of Torah trumping all other social stations. Close relationship. Jewish laws on charity provide a second reservoir of precedents that may guide the provision of health care. In concentric circles, you are most responsible for yourself first, then for those closest in relationship to you, then for the rest of your local Jewish community, then for all other Jews, and then for all other people. A hierarchy of social needs. A third set of sources we might use as the basis for a Jewish ethic of the distribution of health care concerns the prioritizing of the community's duties to fund specific needs. The Shulchan Arukh specifies the order of preferences as follows: "There are those who say that the commandment to [build and support] a synagogue takes precedence over the commandment to give charity [tzedakah, to the poor], but the commandment to give money to the youth to learn Torah or to the sick among the poor takes precedence over the commandment to build and support a synagogue. One must feed the hungry before one clothes the naked [since starvation is taken to be a more direct threat to the person's life than exposure]. If a man and a woman came to ask for food, we [Jews acting in accordance with Jewish law] put the woman before the man [because the man can beg with less danger to himself]; similarly, if a man and a woman came to ask for clothing, and similarly, if a male orphan and a female orphan came to ask for funds to be married, we put the woman before the man. Redeeming captives takes precedence over sustaining the poor and clothing them [since the captive's life is always in direct and immediate danger], and there is no commandment more important than redeeming captives…. Every moment that one delays redeeming captives where it is possible to do so quickly, one is like a person who sheds blood." The Shulchan Arukh recognizes the varying needs of the community — physical, educational, religious and social. Each can be easily justified in terms of broader Jewish commitments to life, human dignity, worship and other religious expression, education, economic solvency and close social ties. Consequently, if one were to create a contemporary list based on these Jewish values for funding communal projects in the United States, it would probably closely resemble the Shulchan Arukh's list. Saving people who are threatened by human attackers would clearly come first, followed by providing food and clothing to prevent disease, followed by some order of curative health care, defense, education, culture and economic infrastructure. A hierarchy of need. Yet a fourth possible criterion in Jewish sources is that health care should be provided to the ones who need it most. Thus the Shulchan Arukh includes the following: "We redeem a woman before a man. If, however, the captors are used to engaging in sodomy, we redeem a man before a woman." This ruling is clearly based on the author's judgment of the relative needs of women and men in captivity. Since male captors would be more likely to rape female captives than to sodomize males, we must redeem women first, for they need to be saved not only from slave labor, but from sexual violation. If, on the other hand, the captors are known to sodomize male captives, we must redeem men first, for sodomy is, in this author's estimation at any rate, an even greater threat to the captive's life and dignity than rape is. Whether one agrees with that assessment or not, it is clear that the attempt of this ruling is to base the priority of recipients on who needs help most. Equality: First come, first serve. Finally, a fifth strain in Jewish thought and law objects to any hierarchy, whether governed by social position, family ties, communal duties, or even relative needs of the specific individuals involved in the choice; instead, it emphasizes the equality of everyone, as each of us is created in the image of God. Although this guideline for the distribution of health care evokes warm, universalistic feelings and stems from deep theological roots in our common origins as the creations of God, it suffers from the hard, pragmatic realities that prevent societies from giving all things to all people. These egalitarian principles, though, must have a call on all Jews who take their Jewish identity seriously.
Who should pay for medical care? The Jewish tradition divides that responsibility among the physician, the individual, family members and the community. Normally, Jewish law permits physicians to charge a fee for their services. Indeed, the Talmud opines that "A physician who charges nothing is worth nothing!" At the same time, there is great concern that the poor should have access to medical services. The Talmud thus approvingly sets forth the example of Abba, the bleeder, who "placed a box outside his office where his fees were to be deposited. Whoever had money put it in, but those who had none could come in without feeling embarrassed. When he saw a person who was in no position to pay, he would offer him some money, saying to him, "Go, strengthen yourself [after the bleeding operation]." There are similar examples among medieval Jewish physicians, and the ethic must have been quite powerful because it is not until the 19th century that a rabbi rules that the communal court should force physicians to give free services to the poor if they do not do so voluntarily. Today, not just the poor, but most people simply cannot pay for some of the new procedures, no matter how much money they have or can borrow. The size of the problem makes even conscientious and morally sensitive physicians think that any individual effort on their part to resolve this issue is useless. Moreover, the enormous costs of gaining a modern medical education must somehow be compensated for — to say nothing of ongoing malpractice insurance, overhead for their offices and for the hospitals in which they practice, staff, etc. Indeed, like everyone, doctors have a right to earn a living, and Jewish law imposes a limit on them no less than on other Jews as to the percent of their income that they may donate to charity — specifically, 20 percent of their income. So although physicians have some responsibility to care for others gratis or at reduced rates, they alone cannot be expected to bear the burden of financing health care. Individuals also bear some of the responsibility for paying for their own medical care, as they do for their ransom: "If someone is taken captive and he has property but does not want to redeem himself, we redeem him [with the money his property will bring] against his will." Although this source speaks of redemption from captivity and not health care, the duty to redeem captives is based on the danger to their lives in captivity, and thus this is a reasonable source for determining that an individual has a financial responsibility for his or her own health care. Moreover, one must pay for one's own health care before one pays for anyone else's, for saving one's own life takes precedence over saving anyone else's. In addition to paying for his own health care, a man assumes an explicit obligation in marriage, according to Jewish law, to pay for the medical care of his wife, children and other relatives if they cannot care for themselves. Once again, the precedent for this comes from the laws of redemption from captivity: A father must redeem his son if the father has money but the son does not. A gloss, by Rabbi Moses Isserles: "And the same is true for one relative redeeming another, the closer relative comes first, for all of them may not enrich themselves and thrust the [redemption of] their relatives on the community." In today's more egalitarian society, this would presumably mean that spouses of either gender have responsibility for the health care of each other and of their children. The immediate implication of these teachings is that one may not preserve the family fortune and make the Jewish community or the government pay for one's health care, except to the extent that the government itself makes provision for all sick, elderly citizens in programs like Medicare without restrictions as to a person's income or estate. Options can include using one's own assets or buying a health insurance policy, either privately or through one's employer. Public aid, though, is limited to when and if one qualifies for aid to the poor through programs like Medicaid, or for the elderly, like Medicare. The individual also has a duty to contribute to the medical care of others besides one's family. Although this is never spelled out in just those words, the Rabbis, as we have seen, see the absence of health care as shedding blood. Since the physician alone cannot be expected to bear the costs of health care for those who cannot afford it, this duty devolves upon the community, and the costs of health care for the poor become part of the charity one must give. Maimonides asserts: "If a person wants to give no charity at all, or less than is fitting for him, the court compels him and flogs him for disobedience until he gives as much as the court estimates is proper. The court may even seize his property in his presence and take from him what it is proper for that person to give. It may pawn possessions for purposes of charity, even on the eve of the Sabbath." Thus, with donations from, or taxes on, its members, the community as a whole has the duty to pay for the health care of those who cannot afford it themselves. In medieval Spain, for example, Jews played a prominent role in the state's program of socialized medicine, while in other places, Jewish communities, on their own, hired surgeons, physicians, nurses and midwives among their staff of salaried servants. Whatever the arrangement, the community as well as individual doctors were under the obligation to heal, and that was taken very seriously. In turn, the community must use its resources wisely, a demand that can serve as the moral basis within the Jewish tradition for some system of triage. The community must balance its commitments to afford health care with the provision of other services. The Talmud lists 10 such services: "It has been taught: A scholar should not reside in a city where the following 10 things are not found: (1) A court of justice that can impose flagellation and monetary penalties; (2) a charity fund, collected by two people and distributed by three [to ensure honesty and wise policies of distribution]; (3) a synagogue; (4) public baths; (5) toilet facilities; (6) a circumciser (mohel); (7) a surgeon; (8) a notary [for writing official documents]; (9) a slaughterer (shohet); and (10) a school-master. Rabbi Akiba is quoted [as including] also several kinds of fruit [in the list] because they are beneficial for eyesight." Several items here are relevant to health care. Since there was no indoor plumbing then — actually until the 19th or even 20th century in many places — it was important for purposes of public health to have public baths and toilet facilities. The "surgeon" mentioned in the list was the person who could perform the most important form of curative care known at the time — letting blood. Finally, Rabbi Akiba's addendum concerns one's ability to procure healthy foods in the town, recognition that our choice of food is important on a preventive basis in assuring health. Because no community's resources are limitless, and because social needs other than health care must also be met, the community must ensure that those who receive public assistance for health care deserve it. Thus, if a person repeatedly endangers his or her health through practices known to constitute major risks, such as smoking, drug or alcohol abuse, or overeating, the community may decide to impose a limit on the public resources that such a person can call upon to finance the curative procedures she or he needs as a consequence of these unhealthful habits. The legitimacy of the community enforcing such limits is established in Jewish sources with regard to captivity, the case that has served as the paradigm for many of the rules of assessment of cost throughout this essay: "He who sold himself to a non-Jew or borrowed money from them, and they took him captive for his debt, if it happens once or twice, we redeem him, but the third time we do not redeem him…. But if they sought to kill him, we redeem him even if it is after many times." Everyone is assisted in overcoming the consequences of the first and perhaps even the second indiscretion that endangers the person's life, but beyond that the community no longer has the duty to act. Even when the person will definitely die unless something drastic is done, the community has the right to assess the chances of success before deciding to expend the resources. The Shulchan Arukh assumes that a high enough ransom will surely redeem the captive, even after many times, but some medical procedures do not carry that certainty. So, for example, smokers cannot rightfully expect the community to pay for repeated lung transplants, and alcoholics may not call upon the community to pay for repeated liver transplants. Indeed, in light of the shortage of organs for transplant, the cost of the procedure, and the bad prognosis for smokers and alcoholics to benefit significantly from such transplants, current medical practice denies them even one transplant. This policy is warranted from the standpoint of Jewish law: Individuals must take responsibility for the consequences of their behavior, especially after being duly warned through captivity, sickness, or, in our time, education. Of course, those who have no resources to pay for health care may accept public assistance to procure it. In fact, they must do so, for to refuse needed care is to endanger their lives, which is, for Jewish law, tantamount to committing suicide. Still, the Shulchan Arukh strongly condemns those who use public funds for their health care when they do not need to do so, and it appreciates those who postpone calling upon the public purse for as long as possible: "Whoever cannot live unless he takes charity — for example, an elderly person or a sick person or a suffering person — but he forces himself not to take [communal funds] is like one who sheds blood [namely, his own] and he is liable for his own life, and his pain is only the product of sin and transgression. But anyone who needs to take [charity] but puts himself instead into a position of pain and pushes off the time [when he takes charity] and lives a life of pain so that he will not burden the community will not die until he sustains others, and about him Scripture says, 'Blessed is the man who trusts in God.'" Conversely, unless a given drug or medical procedure is so scarce that the government has put limits on who may obtain it even with their own money, individual patients who have the money to afford something that the government or their private plan does not provide may decide to pay for the drug or procedure privately. Individuals are free to spend as much of their own funds as they wish to redeem themselves or their relatives: "We do not redeem captives for more than their worth out of considerations of fixing the world, so that the enemies will not dedicate themselves to take them [Jews] captive. An individual, however, may redeem himself for as much as he would like…." This could seem unfair, but it is only the unfairness built into any capitalist system. Jewish sources do not require that Jews use socialism as their form of government or their rule for distributing and charging goods.
On the basis of these Jewish sources, the entire community is responsible to ensure that all its members receive the health care they need. This does not mean that everyone should get every possible treatment, no matter how remote its possibility of benefit or how high its cost. The community has both the right and the duty to make considered decisions about how it will allocate its resources among its various responsibilities. Those who can benefit most from the procedure must come first, and then first-come, first-served, regardless of social position, wealth, or relationships to the health care personnel involved. Jewish principles justify concern for the people of one's own nation first in such procedures as the supply of organs for transplant and of rare, new drugs, unless international agreements can be reached to provide medical services, for example, to the citizens of any nation visiting another or in the organ transplant supply based on need, not nationality. It is only absent such agreements that concern for one's own can legitimately come first. The Jewish demand that everyone have access to health care does not necessarily mandate a particular form of delivery, such as socialized medicine or government-sponsored health insurance for those who cannot afford private plans. Any delivery system that provides basic needs will meet these Jewish standards. Thus, while President Obama's original proposal for government-sponsored health insurance for those who cannot obtain or afford private insurance would surely fit Jewish criteria for meeting communal responsibility, so too would any other mechanism that provides basic minimum health care to everyone. The fact, however, that more than 40 million Americans have no health insurance is, from a Jewish point of view, an intolerable dereliction of society's moral duty. The Torah, the Prophets, and the Rabbis of our tradition all loudly proclaim that God commands us to take care of the poor, the starving and the sick. Given the current costs of health care, almost all of us fall into that category. On both moral and religious grounds, then, we simply cannot let the present condition continue; we are duty-bound to find a way to afford health care for all American citizens. A pragmatic concern also requires that we act now. The fact that some of those people will ultimately get health care in the most expensive way possible — namely, in the emergency room, usually when they are sickest — means that the United States is currently neglecting its fiduciary responsibility to spend its communal resources wisely. We Americans spend about 15 percent of the gross national product on health care; our Canadian, Western European and Israeli friends spend about half that — 8 percent. Yet their morbidity and mortality rates are much lower than ours. Yes, they give up some of their autonomy in their health care, but the vast majority of Americans have very little choice now. We get what our employer provides — no more, no less. It is time that we carry out our Jewish duty to manage our resources wisely as well as our obligation to provide health care for everyone. How we do that is a legitimate topic for debate, but we simply must do it.
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© Copyright 2009 The Jewish Journal and JewishJournal.com |
We think of ourselves in the form of an unfolding story. When we want to recover something from the past, we rewind the film that is our life to see the narrative there. When we think of the present, we do so in a narrative. As we're having breakfast we consider what lies ahead and what happened just a few minutes ago. Thinking about the future is done on the scaffolding of a narrative. Story holds it all together, gives it structure. All of this is an inner narrative that we couldn't possibly tell, and if we could, few would have the patience to listen to all of it. The stories we do tell are culled from the narrative within us.
If we were asked to tell our inner story, that ongoing narrative about our life, most likely we'd be stumped. That story isn't something we generally think about, nor is it easy to pin down. It is so close, so intimate, so much a part of flesh and bone, that we can't see it. Yet it very much patterns how we live and what we believe about ourselves.
We have worked with clergy groups to help them become better acquainted with their inner stories, using several strategies to take them back to the cutting room floor to look for a "this is my story" plot down there. Perhaps the most striking strategy is inviting them to tell us their earliest childhood memory. Alfred Adler first developed this strategy with his therapy clients. When asked to recall an early memory, Adler said, out of the incalculable number of possibilities, people select those that have a bearing on their present life situation. These early recollections are laden with clues about their "Story of My Life." Although they may not be aware of their life narrative, they are using it to understand the present and to anticipate the future with "an already tested style of action" (What Life Should Mean to You, Boston: Little, Brown and Co., 1931, 73-74).
Jesus lifted up the narrative of a small peasant village and challenged the dominant stories that supported the ruling classes in first-century Palestine. These wealthy rulers—including the Romans and the cooperating Jewish religious authorities—made up ten percent of the population. The other ninety percent were peasants, who produced all the wealth through agriculture. The ruling ten percent took two-thirds of all that the peasants produced, leaving them always living from hand to mouth and never far from starvation and death. The peasants were kept in their place by the dominant narrative of the authorities, which told them they deserved no better than what they had and that if they knew what was good for them they wouldn't question this setup. Jesus challenged this system, and he often used parables to do so, as he does here.
Jesus said to them, "Suppose you have a friend who comes to you in the middle of the night and says to you, 'Friend, lend me three loaves, for a friend of mine on a trip has just shown up and I have nothing to offer him.' And suppose you reply, 'Stop bothering me. The door is already locked and my children and I are in bed. I can't get up to give you anything'—I tell you, even though you won't get up and give the friend anything out of friendship, yet you will get up and give the other whatever is needed because you'd be ashamed not to. (Luke 11:5–8)
In this parable Jesus paints a picture of a remarkable peasant commitment to hospitality. Villagers faithfully welcomed traveling strangers, fed them, and gave them a place to stay. The village was so poor that each act of hospitality stretched it to the limit. They scarcely had enough to feed their own families, let alone strangers. Jesus discloses the power of this hospitality when he says that even though you won't get up and give your neighbor bread to serve the traveler out of friendship, you will do it "because you'd be ashamed not to." To refuse would be to break the village honor code of hospitality.
The story told by the elite was that because the peasants lived in such dire circumstances they should fight with one another for survival. Hospitality was a silly and extravagant practice for people in their position. The ruling class had an investment in peasants treating each other inhospitably, because it served to demoralize them. A demoralized peasantry was much easier to manipulate and exploit. To his hearers' surprise, Jesus told a parable that said their simple practice of hospitality was no small thing. It revealed the sharp contrast between their humanity and the ruthless inhumanity of the ruling class. The village practice of hospitality was a taste of the messianic banquet.
Jesus was not exhorting the villagers to do something more or something different. Rather, he was telling them that their inner story already expressed the dream of God. If they wanted to understand God's dream, they needed to look no further than their own hospitality. Jesus paid attention to a piece of the peasant story that the elite had cut out and thrown away and that the peasants themselves hardly realized was part of the dream of God. This striking account expresses a major theological theme undergirding our work: God is constantly at work in each person's story to realize God's dream. A person may or may not discern this activity. We have seen, however, that when people have the opportunity to thoughtfully explore their inner story within a supportive community, the possibility of finding evidence of God's work in that story is substantially increased. In a contemporary culture where the dominant theology depicts God as breaking into the world from outside, it is difficult to appreciate how the divine may be discovered within our stories.
It isn't easy for clergy in particular to discern and hold on to their story, because they are subjected to many forces that try to impose narratives that don't belong to them. As clergy enter into a safe, hospitable peer group, they begin telling things they can't tell anywhere else—accounts of dysfunctional staff members, a bishop they didn't trust, a humiliating encounter with a finance committee about their salary, their doubts about staying in ministry, their state of chronic fatigue, and their journey into spiritual wilderness. They also tell stories of success—figuring out how to deal with a thorny problem in the congregation, being excited by taking a different tack in preaching, experiencing transcendence as they offered pastoral care to a dying person. As they tell these stories they hear the sound of their own story.
We've used the metaphor of the cutting room floor to describe how people put together a story of an event. Most of the film of the actual event ends up on the cutting room floor. What remains is our particular construction of the event, crafted by us and a host of others to fit our particular way of looking at things. The gap between what actually happened and what we can tell about it is where narrative theory does its work. In this gap stories can be changed by going back to the cutting room floor and picking up discarded film. With this additional film, our participants could often find an alternative narrative with a different, more helpful plot.
On the second day of Rosh haShanah, the Torah reading tells the story of the binding of Isaac, in which a ram is sacrificed. The ram's horn or shofar is also a central part of the ritual: the sounds of the shofar are said to call one to repentance. It is also appropriate to meditate on the ram at the beginning of Elul because the new moon of Elul is the new year of the animals according to Mishnah Rosh haShanah 1:1.
"Ten things were created on the eve of the [first] Sabbath at twilight. They are: the mouth of the earth, the mouth of the well, the mouth of the donkey, the rainbow, the manna, Moses' staff, the shamir, the writing {of the tablets of the Ten Commandments), the writing instrument, and the tablets. Some say: the demons, the grave of Moses, and the ram [sacrificed in place of Isaac on Mount Moriah]. (Pirkei Avot 5:6)
Abraham grabs the ram hidden in the thicket and heaves it onto the altar in place of his son. This is the innate instinct of a life form to devour other things to survive. The binding of Isaac is not the lesson; it's the sacrifice of the ram that is the lesson. The ram is life, and we have to kill and eat other lives; we sacrifice them in place of ourselves. Our contemplation of this is the beginning of our knowledge of tragedy. This is why the Greeks mourned Persephone with her pomegranate and why the Sumerians wept for Dumuzi, and it is also why we sound the ram's horn on Rosh haShanah: to remind us of this innate tragedy, which God for some reason wrote into the DNA of animal life. In the face of this truth, we try to make our lives valuable; how else can we deserve the countless sheep, plants, ecosystems sacrificed for our needs? We are all Isaac staring into the eyes of the dying ram. To deserve this gift, we must become... what? This is the new year's question.
Another lesson of the ram: the ram encodes the hidden spiral of all things. The ram's horn we sound represents the double fallopian tubes; also the power of the male; also the space-time continuum with its startling curves and hollows. Also it represents the tzimtzum, the empty space at the beginning of creation; the space that allows creatures to come into being. Or, the ram's horn is the winding serpent of everything, the life-leviathan, the universe-umblicus. It dances in space and in song, filled with our voices, yet alien, vast, gorgeously terrible. This is why we blow the spiral horn during Elul: to teach us that everything is connected. Every action reverberates through the web; no string is plucked in isolation. The sound vibrations of the shofar lap against our ears like the great mother sea, murmuring: Thou art not alone.
The ram's horn is the demons, the spirits who came into the world without bodies, and the grave of Moses, whose spirit did not want to leave his body. Its voice teaches us of the unexpected, the wrench in the works, the separation without farewell, the never-made promise of safety. The ram's horn is the voice of the tangled thicket in which we all find ourselves, the unsorted pile of circumstance. The dark space inside the ram's horn is the dark of the moon, the labyrinth, the empty hours when we have to feel our way at night, unsure of the path.
The mouth of the ram's horn is the mystery of the mouth of the earth and the mouth of the well. The mouth of the earth swallows (as Korach and eventually even Moses were swallowed), and the mouth of the well heals and saves (as Hagar and Ishmael were saved). These two mouths of earth and water exist side by side inside the shofar. The ram's horn speaks of birth and death. The Talmud says that the sound of birth and the sound of death resound through the world and no one hears. At the season of the new year, we cause ourselves to hear these sounds, and meditate on living and dying and living and dying and living....
The mouth of the ram's horn is the mouth of the donkey who once spoke to its master. This mouth represents the speech of us animals, the words of prayer. The ram's horn speaks our eloquent hearts, and also our articulate finite bodies. The body's language is blood-rhythm and bone-growth, nerve-pulse and vocal cord, power and decay. The body is the rainbow of thought and feeling: all the colors of the moods and subtleties of the mind. And it is Noah's rainbow: the promise that flood will not come again to destroy the world, that nature's mysteries will never cease. The body is the manna of simple air, gathered in as large or small an amount as the body needs, not too much or too little, just as the manna was once gathered in the wilderness.
The ram's horn also contains the shamir: the magical worm that cuts stone. The shamir, it is said, once cut all the building blocks for the Temple so that no blade needed to be raised against the rock. The ram's horn cuts us apart and uses our wounded parts to build a new temple, a new beginning. The ram's horn is not a blade: it is not violent, but rather finds all the secret fracture points that long to be broken open.
There are two horns that come from the primordial ram: one that was sounded at Sinai, and one to be sounded at the time of the Messiah. We never know which one we are hearing: the wisdom of the past, or the truths of the future. We stand listening, trying to hear a sound so multiple it is like the waves of the ocean. We, the present, stand listening for past and future. For a moment, the ancestors whisper; ova and spermatozoa sing; words we have woven from our memories slip between these two books of life to write our names.
Millennia ago in ancient Sumer, the scribe-goddess Nanshe presided over the writing of the harvest accounts, at autumn when grains and deeds were gathered in. In a later age, the Holy One became the scribe of the seeds: seeds of the earth, seeds of the soul. The book of the Holy One is opened on Rosh haShanah and closed on Yom Kippur. The curves of the shofar are the curves of the letters, and the sound of the shofar is the ink: the shofar itself is the book of life, written with breath at every moment.
The shofar is the crying child entering the world. The shofar is the cry of the one who leaves the world. The shofar is the breath, running and returning while life lasts. We who know we are all this: we are the ram, emerging from the hairy thicket onto the altar, voicing the long ache of the soul-sound.
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Rabbi Jill Hammer, PhD, is an author, educator, midrashist, myth-weaver, and ritualist. She is the director of Tel Shemesh, a website and community celebrating and creating Jewish earth-based traditions, and the co-founder of Kohenet: The Hebrew Priestess Institute. She is the author of two books: Sisters at Sinai: New Tales of Biblical Women (Jewish Publication Society, 2001) and The Jewish Book of Days (Jewish Publication Society, forthcoming 2006). She is a poet and essayist whose work has been published in many journals and anthologies such as Lilith, Bridges, Response, Natural Bridge, Zeek, The Journal of Feminist Studies in Religion, The Jewish Spectator, Biblical Women in the Midrash, and The Women's Torah Commentary.
Being a flag-waver for Conservative Judaism nationwide these days breathes new life into the old expression, "If things are so good, how come I feel so bad?"
Except in Baltimore, which is experiencing a reverse of the country's trend of Reform Judaism passing Conservative Judaism in adherents. Membership units for Conservative shuls here are about 4,800 while the four Reform temples come in at about 3,000.
As Rabbi Avram Reisner of Congregation Chevrei Tzedek noted, "You don't sense crisis in the Conservative congregations here."
But the panoramic view of the U.S.-based Conservative movement and projections for its future have been perceived as so troubled that even Jack Wertheimer, a noted professor at the movement's Jewish Theological Seminary, wrote a much-circulated 2007 essay for Commentary magazine that bluntly asked, "Has the Conservative movement fulfilled its historical role, and should it call it quits?"
As Conservative partisans are quick to point out, that gives short shrift to some 700 synagogues that are the spiritual home of about 1.5 million American Jews and hundreds of religious schools, not to mention the 76 private schools — including Krieger Schechter Day School, 10 Ramah summer sleepaway camps and various youth and adult Israel trips.
Yet there is no denying the nationwide drop in Conservative affiliation these past few decades; the 2000-2001 National Jewish Population Study found that Reform for the first time had surpassed Conservative as the denomination of choice among American Jews.
Compounding the picture, the lower numbers combined with the nation's economic crisis have brought serious fund-raising shortfalls. Just ask the folks at Dr. Wertheimer's JTS, which now competes for movement-wide intellectual hegemony and dollars with the Los Angeles-based Ziegler School for Rabbinic Studies.
Then there are the lamentations that JTS, the flagship academic institution, no longer carries the clout it did when faculty included the spiritual guru/social activist Abraham Joshua Heschel and the colorful/intellectual Mordecai Kaplan, or when it boasted of graduates who were best-selling novelists shaping the national conversation — think of Harold Kushner ("When Bad Things Happen To Good People") and the late Chaim Potok ("The Chosen").
Beyond that, there is talk of rebellion in the ranks at the congregational arm, the United Synagogue of Conservative Judaism. Large synagogues are balking at the longtime perceived weakness of the national umbrella group and some smaller ones cannot pay dues.
Still, those headlines of controversy leave Rabbi Jay Goldstein of Beth Israel Congregation in Owings Mills wondering if he and some others sit in an alternative Conservative universe. Three years ago, he went to New York to meet with then-JTS Chancellor Dr. Ismar Schorsch. The titular head of the movement periodically met with rabbis from successful congregations of various sizes for text study and candid conversation.
"When we were presented with the national statistics, it didn't jive with what was happening in our congregations," he said. "We were rabbis who had created programs and ideas that were considered successful."
That led him to add, "The Conservative movement, without question when you look at the national statistics, is doing better in Baltimore and there's a complex of reasons."
That's not to say that the heavens are smiling incessantly on the immediate area's seven Conservative operations — Adat Chaim, Beth Am, Beth El, Beth Israel, Beth Shalom of Carroll County, Chizuk Amuno and Chevrei Tzedek. (Beth Shalom of Columbia, like that area itself, is not formally part of the Baltimore community, even though some of its members gravitate toward Jewish schools and institutions here.)
There are challenges, to be sure. More than one operation is concerned about lower Hebrew school affiliations and increased budget woes. (A few years ago, Adat Chaim dropped out of the United Synagogue of Conservative Judaism, in part because fewer members meant less money to pay national dues.) Still, when played out against the national scene, things are good here indeed.
Why is that? Is there something different at a Conservative shul's Shabbat morning Kiddush that keeps the faithful coming back for more? Is it persuasive rabbinic power? Is it creative educational offerings? Is it a combination of all that and plain old luck? Or is it that Baltimore, for all its Jewish and other quirkiness, simply stamps a different imprint on the mold of American Jewish living?
When put to the question, area rabbis and congregants come up with a panoply of responses that defy simple categorization, yet capture the strands that weave the fabric of a traditional, multi-generational community that bucks — or at least delays — national trends of assimilation among the masses, which in turn enables them to nurture the vibrancy of a slower growing core.
The differences start with the physical proximity, noted Jo-Anne Tucker Zemlak, an Owings Mills resident and assistant executive director of the UCJS Seaboard Region, which includes Maryland.
"I'll be talking to people in other communities about how we have two shuls across the street from one another that have 1,500 [Chizuk Amuno] and 1,700 families [Beth El]," she said. "People say to me, 'That's Baltimore. That doesn't happen anywhere else.'"
Making the case even further is that the 900-unit Beth Israel is less than eight miles from Beth El.
"Baltimore," Mrs. Tucker Zemlak said, "has learned to live together. Not that they are not all looking for the unaffiliated Jews. But they know that he or she might not be for them, but for the other shul down the street and that's OK. You can't take the flavor of Baltimore Conservative Judaism and put that anyplace else. It just doesn't work."
Rabbi Jan Kaufman agreed. After a 1960s childhood filled with B'nai B'rith Youth Organization activities, Beth Tfiloh school and then Baltimore Hebrew College, today she is director of special projects for the movement's New York-based Rabbinical Assembly. Her efforts have included helping to publish the Siddur Sim Shalom prayer book.
"Baltimore is a sui generi community," she explained. "Because people live close together, it adds for greater continuity and a stronger community … People in Baltimore listen to the rabbi. People read the synagogue bulletins. You see it in people's houses and that's not necessarily the case in other communities.
"People don't leave Baltimore," she added, "or they come back and, because of those strong connections, they really are invested and willing to pay for it in services."
Another factor, said Rabbi Steve Schwartz of Beth El Congregation, is the broad spectrum of Conservative congregations here. His congregation is not Chevrei Tzedek, which is not Chizuk Amuno, which is not Adat Chaim and so on.
"They are strong and there's good energy. Membership is stable or growing. Why is that?" Rabbi Schwartz asked rhetorically, throwing open his arms while leaning back on his office chair. "I don't know."
But he goes on to talk about leadership development, those multi-generational families and the courage to innovate. Take, for example, his congregation's annual "steel drums Shabbat." Then there was the "sushi in the Sukkah" Friday night a few years ago that saw about 500 people turn up on an evening marked by pouring rain.
Further, Baltimore's legendary parochial nature, which can feature people buying houses on streets where they rode bicycles as kids, might be a paradoxical strength.
"We're one synagogue affiliation generation behind [national trends]," Rabbi Goldstein observed. "Our affiliation is high. We had the time to correct the mistakes [made elsewhere] and come up with our own programmatic and directional response."
Take his congregation's Shleimut program, which brings to the building a social worker and a nurse to counsel and educate congregants on mental and physical health needs.
"It's a holistic triage bringing together the disciplines of religion and spirituality and social and health aspects," Rabbi Goldstein said. "It's what people need on all levels. It's a wholeness. It's become a whole new part of my rabbinate."
That fits what Rabbi Dana Saroken, Beth El's assistant spiritual leader, has to say about the way Conservative rabbis are being trained these days.
"In rabbinical school today there's a greater focus on pastoral care," she said. "Much of the shift has been generated by the students who are eager to learn how to be there for people and how to provide comfort, support and strength to people in their most difficult moments. Everyone is in agreement: The better we train our rabbis in human relationships, and the better we are at helping people connect with God and one another in their times of need, the healthier our Jewish community will be.
"While Talmud study and the study of Jewish law is important," she added, "most of what we are called upon to do, as rabbis, falls into the realm of pastoral work."
As such, for many it's not the heady philosophical questions that resonate, but issues of personal behavior. Recent movement-wide debates have focused on homosexuality, intermarriage and keeping kosher. In each, Baltimore rabbis and congregations have played a role.
Interfaith Marriages: Beth Israel was a pioneer in the Kiruv project, spearheaded by the movement's Federation of Jewish Men's Clubs. It strives to make congregations more welcoming for interfaith families. It has organized several training sessions for rabbis and volunteer leaders, one of which was hosted by the Pearlstone Conference and Retreat Center.
With that topic, just as with the national movement, local congregations struggle to adhere to Halachah (Jewish law) while being as open as possible.
"If you are intermarried, you can still live an integrated life and your family can still have a family membership, and the truth is there are many b'nai mitzvah meetings with families where I know the non-Jewish spouse better than the Jewish one," Rabbi Goldstein said.
At Beth Israel, the non-Jewish spouse is allowed on the bimah during the ceremony and to give a child's prayer, but cannot gain ritual honors.
There also is an unexpected positive impact of intermarriage, which can lead to conversion, Rabbi Goldstein said.
"One of the effects is that non-Jewish spouses are more comfortable with and receptive to the language of spirituality," he said. "So if 13 years ago I would have announced an initiative of reinvigorating a sense of spirituality and tefillah in the service, I would have been met with the concern of 'Can't we just have our davening?' I don't think I would have had the receptivity a generation ago that I have now."
At Adat Chaim in Reisterstown, while a non-Jewish mother is not required to convert to become a member, a non-Jewish spouse cannot formally participate in the Torah service. Yet, he or she can come up to the bimah and bless the children.
"Some of those non-Jewish parents are the most supportive in having their kids educated here and shlepping them to lessons," said Cantor Sharon Wallach, the congregation's spiritual leader since the retirement of Rabbi Michael Meyerstein last year.
It's not enough, added Rabbi Schwartz. The movement needs a more in-depth discussion about intermarriage. "Do we need to revisit patrilineal descent?" he asked. "What direction it will go I don't know, but these conversations have to take place."
Pushing Kashrut: Rabbi Reisner of Chevrei Tzedek is a leader in the Hekhsher Tzedek kashrut initiative. It seeks to ensure that kosher foods are prepared ethically, which includes the treatment of workers. Scandals such as last year's at Agriprocessors — a massive Orthodox-sanctioned kosher operation that faced 900 counts of employment and other workplace violations — thrust Hekhsher Tzedek into the national spotlight.
"It's one of those things that was not on the radar 10 years ago," said Rabbi Reisner, a member of the Rabbinical Assembly's Committee on Jewish Law and Standards, which develops Conservative Judaism's response to halachic matters. "It's catching a moment in American awareness that is hopefully going to push it forward."
Rabbi Reisner is hoping that Hekhsher Tzedek morphs into broader conversations about Jewish ethics — "the kind of thing that's happening with [disgraced investor Bernie Madoff] regarding personal ethics with your own involvement in the world."
Meanwhile, his wife and fellow Conservative Rabbi Nina Beth Cardin is a national pioneer in promoting Jewish communal awareness in environmentalism.
Over at Chizuk Amuno Congregation, Hekhsher Tzedek is striking a chord, said Rabbi Ron Shulman.
"It's the best thing that's re-energized people," he said. "All of the sudden you have a movement headed by people talking about how to keep kosher and what's sacred about it and how it relates us to Jewish tradition and the market."
One way his congregation sought to capitalize on that focus was last year's "cow project," which featured educational projects around kashrut, including the sale of organic kosher beef and lamb — which quickly sold out.
Same Sex Unions: A few years ago, the R.A. voted to allow members to perform same sex commitment ceremonies. Some of its members, including Beth El's Rabbi Schwartz and now-Rabbi Emeritus Mark G. Loeb, had already conducted such events; the R.A. had no formal prohibition against them.
Beth Am was one of six congregations to write to the R.A. as it debated the issue, saying that the time had come to fully recognize gays and lesbians in leadership, according to its spiritual leader, Rabbi Jon Konheim.
Meanwhile, despite the Torah's unambiguous prohibition against male homosexuality, and the Talmud's similar decision regarding women, many Conservative rabbis report a generational divide in the pews. When discussing the matter with teens a few years ago, Rabbi Goldstein found quizzical looks. "They looked at me and said, 'Are you teaching this to us, Rabbi? This is a no-brainer here,'" regarding the need to welcome gay Jews.
Other changes being discussed are the need to increase social action — long a hallmark of Reform Judaism and something that surveys repeatedly show energizes younger Jews. There's even talk of more music in the form of non-electric instruments and popular singing, the latter irking traditionalists weaned on the reverberations of chazzanut. More than one congregation has had fights over what role their choirs should or should not play in Shabbat services.
Adult education, too, has been substantially upgraded in the past decades. Sitting one afternoon in the shul's combined social hall/sanctuary, Cantor Wallach explained that Adat Chaim's members are "all along the spectrum" of Jewish belief and practice. Yet many active members are united in their desire for more education. "There continues to be a hunger for learning, maybe more so," she said. "We certainly have tried to keep up with that."
That's part of the new push to delve into the meaning of liturgy. After all, most prayers have seen little change in recent decades other than the push toward egalitarianism by adding references to the matriarchs in the Amidah, or silent devotion.
Beth Am, for example, has reshaped its religious school curriculum to gear everything toward understanding the siddur. "That is the one book we know that Jews will encounter as adults," Rabbi Konheim said. "It can and must have meaning on ethical, philosophical and social levels. It is all there, but it must be brought out."
Beth El is re-evaluating its Hebrew school curriculum to ensure that children gain the "bare bones tools" to make them competent in basic prayers.
"In going out to the minyan or at graveside, I'm seeing that when it comes time for Kaddish some of them can't say it," Rabbi Schwartz said. "I know that I learned things in Hebrew school. If you learn something in fourth grade or fifth grade — even by rote — you remember it."
Such efforts at creating meaningful Jewish prayer have been a major theme of Rabbi Shulman's rabbinate. He wants more changes, particularly the development of liturgy reflecting the modern Jewish experience when it comes to the State of Israel, the Holocaust and life in America.
He knows there is interest. Last year he was stunned that about 60 people showed up for his R.A. workshop on the matter in Washington, D.C. He had prepared 12 handouts. "It's not because I was teaching," he said. "It's because worship is not engaging most synagogues. In my experience, if you can't have an emotionally engaging prayer experience, then ultimately everything else wanes."
Such local focus does not push aside the importance of being part of a movement — although identifying with the United Synagogue of Conservative Judaism often is not an overriding factor for members, congregational leaders here agree. In part, that's because Conservative Judaism, with its "big tent" philosophy, has an easier time at defining what it's not than what it is.
"The movement is trying to figure out what to do. What does it mean?" Rabbi Schwartz said. "Some of the old answers are not compelling enough for today and the movement needs to make some shifts to re-evaluate and reorient."
For him, that might include a shorter service. Beth El's Saturday morning one starts at 10 and ends around noon. The standard at Conservative shuls is at least an hour longer. "That's three hours and all in Hebrew," Rabbi Schwartz said. "That was fine two or three generations ago."
For some congregants, such as Don Akchin, a longtime member of Beth Am Synagogue in Reservoir Hill, identifying as a Conservative Jew is not that important. Rather, it's the characteristics of the congregation that matter. He recalled the congregational debate nine years ago over what national organization with which to affiliate.
"We had been independent for 30 years or so and we were having difficulty getting rabbis and cantors because we were not part of a movement," he said. So the choice of affiliating Conservative was as practical as anything else for him, he said.
So does he consider himself a Conservative Jew?
"I grew up in a Reform temple in Shreveport, La.," he answered. "But my wife and I said when we got married that Reform is very, very difficult if you are a child … It's too intellectual until you're much older. So we migrated to Conservative because it was more traditional and it gives you something to touch and feel. Reform has since become more traditional, so they sensed it, too."
His congregation, he said, sits on the far left of what he called a "stodgy" movement. He proudly noted Beth Am was ahead of most in openness to homosexuals.
With such focus on welcoming interfaith families and homosexuals — long a hallmark of Reform Judaism — is the barrier between the two camps weakening?
Not necessarily, Rabbi Schwartz quickly responded, because some differences are not about to change. "We keep a certain service structure that's traditional. We keep kashrut and observe Shabbat" until sundown, he said.
For him, the movement's Etz Chaim Chumash (Five Books of Moses) is an excellent window into the world of Conservative Judaism.
"On a given page," he said, "you can find Talmud and Midrash cited, something from one of the Chasidic masters and also the newest archaeological scholarship — in a way that is quintessentially the Conservative movement. … The movement tries to maintain a traditional sense of practice, ritual, observance, while at the same time fully and completely interacting with the modern world."
Meanwhile, Rabbi Shulman is candid about the struggle he and his colleagues face in helping Conservative Jews to embrace the "tradition" part of the movement's amorphous slogan of "tradition and change."
"Our challenge has always been, and remains, the levels of religious commitment of those who participate in our synagogues and schools, and the poor quality of our national synagogue umbrella organization," he said. "Religious practice is not the choice of most Jews in our community, whether affiliated with Conservative synagogues or not, which leads to our educational and inspirational challenge."
And then there's this: "If the Conservative movement were to disappear tomorrow," he said, "many, many of us would want to build this movement from scratch because this way of living and teaching Torah is precious to us and we want to pass it on to the next generation.
"I would argue as well," he added, "in response to the demographics and challenges the entire American Jewish community faces, that the intellectual and spiritual approach of Conservative Judaism has the potential to reach a large number of Jews who seek to honor anew the traditions of our people's covenant with God. The Conservative movement is important as a means to that holy end."
Many insiders in Conservative Judaism are hoping that a rare wholesale change at the top in the past few years will bring new emphasis and energy to the faltering national movement arms.
"What's not healthy, and I say this politely and respectfully, are the national organizations that are charged with caring for and tending to the movement. That's what belies the bad publicity [regarding the movement being moribund]," said Rabbi Ron Shulman, spiritual leader at Chizuk Amuno.
Yet, change is not just on the horizon — it has arrived.
• Dr. Arnold "Arnie" Eisen became head of the Jewish Theological Seminary of America two years ago. His deep background in Jewish academia and philosophy has centered on contemporary Jewish practice. As such, Dr. Eisen hopes to effectively be able to speak both to professionals as well as laypeople.
• Rabbi Julie Schonfeld came on board in July as head of the Rabbinical Assembly. She is the first woman to hold the top professional position in the three movements that ordain women — Conservative, Reconstructionist and Reform.
• Also this year, Rabbi Steven Wernick became the new head of the United Synagogue of Conservative Judaism.
The challenge is clear, Rabbi Shulman said. "The United Synagogue is, with due respect to my friends there, completely broken," he said. "It does not earn the respect of the congregations it serves and it is figuring out what it wants to become next. They're going through the process of figuring out what's next. It will emerge either healthy and changed or morph into something else."
For his part, Rabbi Avram Reisner of Congregation Chevrei Tzedek would like to see the movement develop a long-discussed presence in Washington, D.C., enabling it to have a voice on national matters the way the Reform movement does through its Religious Action Center and modern Orthodoxy does through its Institute for Public Affairs.
The movement has taken steps in the past year to beef up its Israel and social action advocacy in Washington, appointing two popular and experienced congregation rabbis in the area, Baltimore native Rabbi Stuart Weinblatt and Rabbi Jack Moline, respectively, to focus such efforts.
Rabbi Reisner also would like to see a deeper effort to publish Jewish books, mirroring the success of the Orthodox ArtScroll series.
For his part, Beth Am Rabbi Jon Konheim sees a need to further develop educational curriculum and resources, similar to the way the Reform movement has done for its congregations.
There's talk of changing the name Conservative Judaism. Rabbi David Wolpe of Sinai Temple in Los Angeles, a well-known author and speaker in Conservative circles, has suggested Covenantal Judaism.
The late Daniel J. Elazar and former Baltimore Hebrew University President Rela Mintz Geffen suggested Masorti Judaism (Hebrew for "traditional Judaism"), in their 2000 book "The Conservative Movement in Judaism: Dilemmas and Opportunities."
After all, say those who want a different label, the monikers of other streams — Orthodox, Reform, Reconstructionist — instantly transmit a desired message. But Conservative?
"Conservative Judaism just doesn't really describe what the movement is all about, especially given the nuance of that word conservative in our society today," noted Rabbi Steve Schwartz of Beth El Congregation.
He pointed out that his congregation has basically already given itself a new definition. Synagogue newsletters now declare that Beth El is "a progressive synagogue affiliated with United Synagogue."
Indeed, one wonders if the label Conservative Jew even matters to some people. A few years ago, Rabbi Jay Goldstein of Beth Israel tried an experiment. He started talking to b'nai mitzvah students about being a Conservative Jew instead of just a "Jew."
"The average response was, 'Why do you have to use the word Conservative and not just Jewish?'" he said. "I doubt that feedback comes in a Reform or Orthodox shul."
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