Recently, a physician I know asked me an intriguing question. Does making rounds fulfill the mitzvah of bikkur holim, the Jewish religious obligation to visit those who are sick? My “off the cuff” answer to him was that it depends upon how the physician makes rounds, that is, the way in which he or she visits the patient in the course of these professional responsibilities. As I promised him, this week’s essay develops my answer more fully.
In America, making rounds is generally done in two ways. A physician, whether working alone or in a group practice, checks in with his or her patients, usually in the mornings, to see how their medical treatment or recovery is progressing. In large teaching hospitals attached to medical schools, a senior or attending physician would check in with patients, with medical students or residents in tow. Their discussion of different patient histories and treatments gives the more experienced doctor an opportunity to teach the students how to practice medicine. The mitzvah of bikkur holim is a sub-category of the more general obligation of gemilut hasadim, performing acts of loving kindness. Gemilut hasadim is derived from the biblical commandment to love one’s neighbor as oneself, found in Leviticus 19:18.
Maimonides – who we should remember was a physician as well as a rabbi and philosopher – lists three components of how we should conduct ourselves during a visit to a sick person. First, there is the physical act of the visit itself, which should be done frequently throughout the day within the limits of the patient’s abilities. Second, bikkur holim must transcend all class divisions and be done in a state of humility, with the visitor sitting near the patient in a way that conveys a sense of empathy, intimacy and sensitivity. We are even duty bound to take into account when during the day we are visiting, so as not to distress the person who is sick. Third, we pray for and with the patient for God’s merciful healing.
Earlier Talmudic teachings and other sources explain that the primary purpose of visiting the sick is to insure that their physical needs are met. Implicit in this is the goal of meeting their emotional and spiritual needs. Our visiting reassures them that the community will not abandon them in the midst of their suffering, fear and personal dislocation. Finally, we the visitors have the task of reminding sick people that God will not abandon them and of emulating God, Who the tradition imagines is the ultimate model of compassionate attendance to those who fall ill.
Given these mandates of Jewish law, does a physician doing rounds fulfill his or her obligation to visit the sick? Again, it depends. Certainly, just the presence of a visiting physician, however briefly or early in the day, can be extremely comforting to a patient anxiously awaiting news of his or health. Therefore, in the most minimal sense, anytime a doctor visits a patient on rounds, he or she is engaging in bikkur holim.
However, while this might correctly explain the letter of the law concerning bikkur holim, it misses its spirit. Writing a little more than four hundred years after Maimonides in his massive legal compendium, the Shulhan Arukh, Rabbi Joseph Karo rules that if one visits a sick person and does not pray with him or her, the visitor has not fulfilled this obligation. Invoking God’s presence has to be part of the visit, because illness is not merely a physical disorder. It engenders deep existential crisis and loneliness that only God can embrace and soothe. Yet, I cannot blame any physician for not wanting to cross the boundaries of professionalism and objectivity by praying with patients. Someone who is sick does not expect his or her doctor to behave this way, and I suspect that many people would find it off putting. Thus, how could a doctor’s visit on rounds ever fulfill this commandment fully?
Let me suggest that God’s presence underlies every doctor’s visit, not because doctors are God, but because their role as God’s partners in the healing process is inherently sacred. This is the case, whether or not a specific physician is religious or is motivated to do the work for purely spiritual or humanitarian reasons. As the patient, I can still get a glimpse of God’s love through how well this human partner of God’s does the work of healing me.
Yet a doctor’s partnership with God is not only about technical ability. A doctor is a human being first, and human beings are commanded to visit the sick as part of the general mandate to love our fellow human beings through acts of kindness. Elsewhere, Maimonides delineates eight levels of giving tzedakah, philanthropy for the poor, from most to least ideal. The lowest level involves giving only after we are asked and in a begrudging, denigrating manner. This minimally fulfills the obligation to give tzedakah, but it is still strongly discouraged behavior. In like manner, a physician on rounds must engage a patient with kindness, a listening ear, and genuine reassurance that he or she cares. Only then can the physician say that he or she has truly fulfilled the obligation of bikkur holim. To paraphrase Rabbi Abraham Heschel, the great moral and spiritual challenge of all healing arts is to remember that the patient is a person first.