Yom Kippur Morning Sermon, September 23, 2015; 10 Tishrei 5776
Rabbi Thomas Alpert’s bio
Little Aaron and his father were entering the synagogue to pray on Yom Kippur. It was an old, large Temple, the type with lots of old, large plaques on the wall of the sanctuary. Aaron stopped at one and asked his father, “Daddy, who are all those people?”
His father answered, “Those are the names of all the members of this congregation who died in the service.”
Aaron was quiet for a moment, and then he asked, “The morning or the evening one?”
While I devoutly hope that no one will perish during this service, I do admit that there’s much about the experience of Yom Kippur that reminds us of death. The unetaneh tokef poem that we recited earlier raised the point explicitly: “Who will live and who will die?” it asks. Then, just to make sure that we don’t miss it, it continues with all the ways we could lose our lives: by fire, by water, by beast, by earthquake. And our minds conjure up our own lists: by cancer, by heart attack, by auto accident.
We’re ready to do this conjuring because the whole day functions as a kind of rehearsal for our deaths. I have on a white robe, but in traditional congregations, the married men normally wear a different white garment. It’s plain, with no pockets. It’s called a kittel. They know each Yom Kippur that they’ll wear this garment at least one more time. They’ll be buried in it.
During the long chanting of Kol Nidre last night, we stared into an open box, a reminder of the open box into which our bodies will one day be placed. As for those bodies, Rabbi David Wolpe has written, “Like corpses, we need no food, for we have no bodily discomforts or desires. While our spirits cry out, our physical being is as if dead.”
The New Yorker cartoonist Roz Chast has drawn and written a heartbreakingly funny memoir of her parents’ last years. Its title refers to her mother’s attitude toward conversations about death. That title is Can’t We Talk About Something More Pleasant?
The rabbis would have understood Mrs. Chast’s reaction. A story is told of Rava sitting by the bedside of his teacher, Rabbi Nachman. Rava said to the comatose man, “Show yourself to me in a dream,” and this being a story, his teacher does so. Rava asks him a question we all want to know the answer to: “Did you suffer when you were dying?”
Rabbi Nachman answered, “No more than taking a piece of hair out of milk. Yet, I have to tell you, if the Holy One said to me, ‘Now go back to the world as you were before [you were ill],’ I wouldn’t do it, because the fear of death is too much to take.”
The fear of death is too much to take. The rabbis understood it, Mrs. Chast expressed it, and I feel it. I do not want to think about this topic, and I would prefer not to ask you to think about it either. But we have to do so.
I know that some of you may feel that for whatever reason, you can’t hear about this now, or that someone you are with can’t hear about it. If so, I won’t be offended if you decide to leave while I’m talking.
If I feel compelled to say this, why am I discussing this topic at all? I do so because this is Yom Kippur. It’s the day that we confront our mortality. It’s the day that we acknowledge who we are, with no masks, no pretense. It’s the day when we’re compelled to speak the truth.
The Talmud tells the story of the final illness of the great sage Rabbi Judah the Prince, the legendary compiler of the Mishnah. The sages decreed a fast day and prayed continuously for him in his home. This was the equivalent of our doctors taking all possible measures to keep him alive. His maidservant went to the roof of his house, where she too prayed that he would live. But when she saw how much pain he was in every breath he took, she prayed that God would spare this good man any further suffering. And then she did more than pray. She dropped an earthen pot from the roof. For a split second, the noise distracted those who were praying, and that interruption allowed God to take Rabbi Judah the Prince.
Rabbi Judah died 1,800 years ago. Since then, our methods for keeping people alive have moved beyond prayer for the most revered of sages to routine medical care for a large segment of the population. But the insight of Rabbi Judah’s maidservant remains in short supply.
This summer, I read a book that I consider indispensable for every adult in this congregation. It’s called Being Mortal, and its author is a doctor at the Brigham and Women’s Hospital in Boston, Atul Gawande. Early in the book, Dr. Gawande has this to say:
Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals…. This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.
Dr. Gawande tells the story of Sara Monopoli. At thirty-four years old and within days of delivering her first child, she was diagnosed with lung cancer. The doctors induced labor, and soon “Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was in perfect health.”
Sara and her husband Rich met with their oncologist, a good and respected clinician. The cancer had metastasized. The doctor told them that it was inoperable. But, he said, there were chemotherapy options, and he told them that “some of these responses can be long-term.”
As Gawande continues:
Words like “respond” and “long-term” provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless for him to confront Sara and Rich with that now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on “aggressively managing” this diagnosis.
She tried the treatment. It failed. She tried another. It failed, too. She tried a third. Soon, the cancer had spread. She was “running out of options.”
Dr. Gawande asked the doctor treating Sara Monopoli “what he hopes to accomplish for terminal lung cancer patients when they first come to see him. ‘I’m thinking, can I get them a pretty good year or two out of this?’ he said. ‘Those are my expectations. For me, the long tail for a patient like her is three or four years.’” The problem is that, as the doctor noted, this isn’t what people want to hear. As he says, “They’re thinking ten to twenty years. You hear that time and again. And I’d be the same way if I were in their shoes.”
The other problem is, as Gawande puts it, “when you have a patient like Sara Monopoli, the last thing you want to do is to grapple with the truth.” Not only did her treating oncologist fall into this trap, but so did Dr. Gawande himself when he was called in on the case. He didn’t know what to say, so he said nothing other than to talk about medical options.
Part of the reason for this hesitancy is that statistics are only statistics. Gawande recalls reading a story many years ago that had a profound effect on him. I can understand that. I read the same story back then, and it had a profound effect on me. It was told by the paleontologist and writer Stephen Jay Gould. He was given a diagnosis of “a rare and lethal cancer.” Being a scientist himself, he went to the medical library and read up on it. The statistics were both clear and frightening: the median survival rate was eight months after the cancer was discovered. But being particularly trained in statistics, Gould delved into the numbers behind the numbers, and he discovered what statisticians call a “long tail,” a slender graph of patients who lived for many years. And he did. He lived for twenty years before dying at age sixty of an unrelated cancer.
Of this, Gawande writes:
I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means that we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets – and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.
Sara’s husband Rich recalled, “I always wanted to respect her request to die peacefully at home. But I didn’t believe we could make it happen. I didn’t know how.” One morning, she woke up short of breath. She was taken to the hospital. She had pneumonia. As Gawande writes, “The medical team had only one option left: to put her on a ventilator. Sara was a fighter, right? And the next step for fighters is to escalate to intensive care.” The last few hours of her life were spent on that ventilator instead of at home.
And he continues:
This is a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run – and when we imagine ourselves to have much more time than we do – our every impulse is to fight…. The fact that we might be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do…. We want … choices. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Fix Something.
It might seem in telling you the story of Sara Monopoli that I’m arguing in favor of fatalism and in opposition to fighting against the odds. But I’m not. I remember the story of Stephen Jay Gould. What I am saying is that we need to be thoughtful, that we have the obligation as human beings to decide how we want to live our lives in good times and bad.
La Crosse, Wisconsin, is an ordinary mid-sized Midwestern city with one unusual distinction. Its elderly residents spend far less time in the hospital than the national average and live longer than the national average by about a year, despite not being healthier than most other Americans. The reason seems to date back to 1991, when “local medical leaders headed a systematic campaign to get medical people and patients to discuss end-of-life issues.” I don’t mean filling out advance health directives, although that was part of the process. I mean talking about these questions, and doing it not just once. Conversations take place when people are healthy, when they start to get sick, when the illness progresses. As Gawande observes, “The discussion, not the list, was what mattered most.” Let me repeat that. “The discussion, not the list, was what mattered most….”
We need the discussion because, as Dr. Gawande also notes, we have “a society that faces the final phase of the human life cycle by trying not to think about it.” Yom Kippur serves as a corrective for this tendency. It forces us to confront our own mortality, and it forces us to think about it. It tells us to decide how to make life worth living.
The unetaneh tokef says that there is a “book … which speaks for itself, for our own hands have signed the page.” We write our own book. We make our own choices. But we do not write it alone. We make our confessions in the plural because each of us needs the other.
In America, we value autonomy. We want to make our own decisions, live our own lives, without needing any help from anybody. As we age, that ideal starts to become impossible to achieve. We do need help. But the ideal was false. We always needed help.
But that doesn’t mean that autonomy itself is false. The philosopher Ronald Dworkin explained that autonomy really means that “whatever the limits and travails we face, we want to retain … the freedom … to be the authors of our lives.” We want to write on the book of our lives, and our own hands have to sign the page. For most of us, as we age, our choices become more limited, but we want to exercise them within those limits.
The unetaneh tokef tells us that “repentance, prayer, and charity temper the severity of the [Divine] decree.” Age, frailty, illness: these may come. Death will come. We cannot alter the decree, but we can determine how we deal with it, and in that way temper its severity. As Dr. Gawande puts it, “This is what it means to have autonomy – you may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.”
Dr. Gawande’s daughter Hunter studied piano with a woman named Peg Bachelder. One day he got a call from her husband that Peg was in the hospital. She had a malignancy that developed from treatment for a previous cancer. She didn’t have much time left, and she was in great pain. Dr. Gawande and Peg’s husband persuaded her to try hospice. As the doctor explained to her, “hospice’s aim, at least in theory, was to give people their best possible day, however they might define it under the circumstances.”
Dr. Gawande broke the news to Hunter and also told her that her piano lessons with Peg were over. Yet, a few days later, they got a call from Peg. She was offering Hunter the opportunity to have a few more lessons. It seemed that hospice had made this possible, hospice and Peg herself. She and her husband had no children; “her students filled that place for her.” She had a few things left to tell them.
Peg lived for six weeks after going on hospice. “Hunter had lessons for four of them, and then the final two concerts were played. One featured Peg’s current students, all children in grade school; the other, her former students from around the country. Gathered together in her living room, they played Brahms, Dvořák, Chopin, and Beethoven for their beloved teacher.”
After the last recital for the children, she took each student away to give them a personal gift. She gave Hunter a book of music. Then she put her arms around the child and said, “You’re special.” That was her other gift.
Most of us would like to give these gifts, but its hard to do so if we’re hooked up to tubes in a hospital bed. Maybe we want that hospital bed. But we have to accept the opportunity and the obligation to decide.
This year, this Yom Kippur, we can start thinking in a mature way about how to take responsibility for aging and for crises, both in our lives and in the lives of those we love and have responsibility for. We can think today, and we can begin to act in the months to come. On a Wednesday night in late January, Dr. Andrea Schwartz will join us. Dr. Schwartz is a geriatrician with a degree in Jewish studies. She will help all those who attend to develop our own practical steps for dealing with aging and dying.
The gates will close this evening, and they will close for each of us some day. But we have the power to write the book of our own lives, to change its pages each day that we are here. That is our great gift, and our great responsibility. Yom Kippur reminds us of that. As we share in this holy day, so may we heed its lessons.
Kein y’hi ratzon, be this God’s will.
 David Wolpe, “Death Rehearsal,” in Who by Fire, Who by Water: Un’taneh Tokef, ed. Lawrence A. Hoffman (Woodstock, VT: Jewish Lights, 2010), p. 183.
 Roz Chast, Can’t we talk about something more PLEASANT? (New York: Bloomsbury, 2014).
 BT Mo’ed Katan 28a.
 BT Ketubot 104a.
 Atul Gawande, Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books, 2014), pp. 6, 9.
 Being Mortal, ch. 6.
 Translation from Mahzor Lev Shalem (New York: Rabbinical Assembly, 2010), p. 315.
 Being Mortal, pp. 76-77, 146-47, 210.
 Ibid. pp. 245-49.