Stigma and Seeking Help for a Child
Our Gemara on Amud Aleph discusses the process by which we determine compensation for a debilitating injury inflicted upon a child. The Talmudic jurisprudential method for evaluating disabling loss and damages to a person is by considering the value of this person if he was sold as a slave, what was his prior market value versus his current value with his disability. Since such an appraisal is demeaning, the Gemara records an incident where the father of the child objected to submitting his child through this process. (In a culture that relies on testimony to establish lineage, it was a legitimate concern that years later an inaccurate recollection could lead to mistaken allegations about the child having been a slave.) The judges countered with an objection that this father’s fears of propriety and status would deprive his son of the financial compensation that he deserved from the damager since no assessment would be made. The father’s response was to reassure the court that when his child matures, he would make sure to personally provide his son with the deserved compensation.
This Gemara brings to mind the challenges parents face when deciding what kinds of help to seek for a disabled child. If a child has a mild disability, mental or physical, the parents may be reluctant to seek clinical treatments that could stigmatize the child, or even the extended family. When the danger or disability is so strong or obvious, it is less of a challenge, because the urgencies overcome the resistance. However, some scenarios are more murky when the condition is on the border between severe to moderate. Should a child with moderate to severe depression be treated inpatient? Should a child with moderate learning disabilities stay in a mainstream school, or in a more supportive environment? There are no easy answers, but our Gemara reminds us that a parent’s fears about stigma does not reduce the obligation to make sure the child receives his due. The judges only accepted the father’s objection because of his pledge to take responsibility for his disabled child’s compensation due to him upon maturity. We also must consider that in the Gemara’s case, this child could receive the compensation later on in life. However, regarding certain developmental aspects of human growth, such as academic and social functioning, opportunities and windows close for a child, and are much harder to restore later on in life.
Should a person inflict damages upon another person, he is also liable to also pay his medical bills, aside from the loss of productivity, pain and humiliation. Our Gemara on amud aleph discusses a number of scenarios where the damager might seek to minimize his losses by economizing, such as offering to heal the person himself if he has the medical skills, or to use a friend who would provide the service as a courtesy. These cost cutting suggestions are rejected out of fear that this more “haimish” form of service will be of reduced quality.
The Rosh (Hachovel, Siman Aleph) observes, “The person who is ill must feel a comforting presence from the healer.” In other words, the bedside manner of the physician is important to the healing process. According to researcher Debra Roter ( Debra Roter, The Patient-Physician Relationship and its Implications for Malpractice Litigation, 9 J. Health Care L. & Pol’y 304 (2006). Available at: http://digitalcommons.law.umaryland.edu/jhclp/vol9/iss2/7 ), there seems to be no correlation between malpractice claims and any retrospective measurement of clinical quality. Meaning to say, malpractice claims seem to have little to do with the actual number of errors or other indicators of quality medical care. It appears that most claims do not come from the patient’s anger over the failed procedure, but rather frustration with the level of communication with the doctor. Post facto analysis shows that litigants often complained about not being properly warned, not having their questions answered and not being treated with respect. Yet doctors who had better rapport and committed similar medical errors were not sued. The patient may be likely to forgive poor treatment outcomes so long as they felt good with the doctor. Selecting from a random group of physicians whose conversations with patients were recorded, researchers found common factors and correlations:
“The sued doctors had shorter visits by almost three minutes, used less partnership-type exchanges (i.e., asking for the patient’s opinion, understanding of what was said and expectations for the visit, showing interest in patient disclosures, and paraphrasing and interpreting what the patient said), engaged in less humor and laughter, and were less likely to orient the patients as to what to expect in regard to the flow of the visit than physicians who had never been sued.”
“Surgeons judged to have more dominant voice tone [in the recordings] were almost three times as likely to be in the sued group than others, while the surgeons whose voice tone was rated as conveying concern and anxiety were half as likely to be in the sued group.”
It is easy to hypothesize that subjective feelings of satisfaction stemming from a positive bedside manner, lead to improved medical outcomes. The element of hope that comes from another person’s concern and commitment, aside from a greater receptivity to the treatment, thus increasing compliance with various recommendations, is as significant a part of the treatment as the medicine itself.
The Importance of Transition
Our Gemara on Amud Aleph discusses a case where a person inflicts damage upon a person by pouring a caustic agent on the person’s head that causes permanent baldness. Each category of damage is evaluated, loss of livelihood, pain, medical bills, actual loss of physical feature, and humiliation.
How does loss of hair interfere with livelihood and/or cause pain? The Gemara explains that this person was a dancer or performance artist, and relied on gestures of his head and hair as part of his performance. The pain was caused by the presence of fissures in his scalp, so that the applied agent burned. And, in relation to the humiliation, the Gemara reflects, “What can be a greater humiliation than this?”
What is the “this” that our Gemara is referring to? How can the Gemara call baldness a humiliation that none can be greater than, when there are billions of people in the world who are balding or already have no hair? Rav Steinsaltz’s commentary, following his practice of giving the simplest explanation, assumes that the humiliation is the exposure of the fissures or sores on his scalp that were previously hidden by his hair. This is an original and creative peshat that solves this question, but the other commentaries do not seem to learn that way. Shulchan Aruch (CM 420:12) codifies this rule as applying to any case where the damager caused permanent baldness, and does not make payment for humiliation contingent upon having sores on the now exposed scalp. Rather, it would seem, the baldness itself is a humiliation. Our original question then returns: Why is baldness, a natural condition almost inevitable for most, considered such an embarrassment ?
We must conclude that a sudden loss of hair, especially when inflicted by another, is subjectively humiliating. This is most likely due to the lack of time to prepare or cope with this sudden unexpected change in appearance. This idea is also supported by an incident described later on daf 90b, where a woman claimed compensation for public embarrassment from a man who pulled her head covering off. The defendant set up his own sting operation, and set up witnesses who observed her voluntarily uncovering her hair in public. Despite this, Rabbi Akiva still awarded her the damages. One way to understand that ruling is along the lines of above. If she uncovers her hair voluntarily, that is one thing. But to have it suddenly done against her will is far more humiliating.
Humans do not do well with unexpected changes and the idea of needing time to transition and adjust has been extensively researched, especially in educational literature. Schlossberg and Goodman (1995. Counseling Adults in Transition: Linking Practice with Theory. New York: Springer. 2nd ed.) conducted research on how people cope with change. Some key points that he described are:
There are various types of transition:
- Anticipated transitions (Graduation)
- Unanticipated transitions: (such as divorce, sudden death of a loved one, loss of a job or social status)
- Non-events: transitions that are expected but do not occur
Schlossberg identified four major sets of factors that influence a person’s ability to cope with a transition (known as the 4 S’s):
- Trigger: What precipitated the transition?
- Timing: Is the transition considered “on time” or “off time” in terms of one’s social clock?
- Control: What aspect of the transition does the individual perceive as being within his/her control?
- Role change: Is a role change involved and, if so, is it viewed as a gain or a loss?
- Duration: Is it seen as permanent, temporary, or uncertain?
- Previous experience with a similar transition: How effectively did the person cope then, and what are implications for the current transition?
- Concurrent stress: Are other sources of stress present?
- Assessment: Who or what is seen as responsible for the transition, and how is the individual’s behavior affected by this person?
- Personal and demographic characteristics affect how an individual views life, such as socioeconomic status, gender, age, stage of life, state of health, and ethnicity.
- Psychological resources include ego development, outlook, and commitment and values.
- Intimate relationships
- Networks of friends
- Institutions and communities
- Those that modify the situation
- Those that control the meaning of the problem
- Those that aid in managing the stress in the aftermath
It is a human need to have stability and sudden changes, even for the better, can cause stress reactions, let alone traumatic and painful changes. However, humans are resilient and self-healing. Knowing and planning for transitions are most helpful, and if they occur suddenly, understanding and acknowledging the losses and the changes are important in the recovery process. Seeking ways to restore a sense of stability and control also help, and this does not necessarily mean fighting the change, but also finding new meaning and purpose to come to accept the change. This is a personal process that should not be rushed by others. Loved ones and family should be patient and supportive allowing the person time and space to grieve the loss.
Our Gemara on Amud Aleph shares Rav Yosef’s musings about his status as a blind person:
At first, I would say: If I hear one who says that the halacha is in accordance with the opinion of Rabbi Yehuda, who says: A blind person is exempt from the mitzvos, then I will host a festive day for the Sages. What is the reason? It is that I am not commanded and nevertheless I perform mitzvos. But now that I heard this statement of Rabbi Ḥanina, as Rabbi Ḥanina says: One who is commanded and performs a mitzvah is greater than one who is not commanded and performs it, I say: If I hear one who says to me that the halacha is not in accordance with the opinion of Rabbi Yehuda, then I will host a festive day for the Sages. What is the reason? It is that as I am commanded, I have more reward.
Sefer Daf al Daf quotes Eyn Eliyahu who asks on this from the teaching in Avos (1:3):
Do not be like servants who serve the master in the expectation of receiving a reward, but be like servants who serve the master without the expectation of receiving a reward.
If so, why should it matter to Rav Yosef whether or not he receives a reward?
Similarly, one might ask regarding the blessing in the Amidah for the righteous, where we ask that “Hashem give good reward to those that have true faith in him.” Why is this a point of interest to the righteous? Although, we might answer that here we are praying for them – they are not praying for themselves, so perhaps it is the right thing to pray that they receive reward, even if they serve God without expectation.
Regardless of the question about the Amidah, Eyn Eliyahu answers, that in fact Rav Yosef operated without any expectation of reward. It was merely out of humility that he framed his behavior as somewhat expectant of reward, because it is presumptuous to project such pure motivations. Ben Yehoyada answers that Rav Yosef was not referring to rewards in this world, or even the next. He was referring to the concept discussed in Avos (4:2):
בֶּן עַזַּאי אוֹמֵר, הֱוֵי רָץ לְמִצְוָה קַלָּה כְבַחֲמוּרָה, וּבוֹרֵחַ מִן הָעֲבֵרָה. שֶׁמִּצְוָה גּוֹרֶרֶת מִצְוָה, וַעֲבֵרָה גוֹרֶרֶת עֲבֵרָה. שֶׁשְּׂכַר מִצְוָה, מִצְוָה. וּשְׂכַר עֲבֵרָה, עֲבֵרָה:
Ben Azzai said: Be quick in performing a minor commandment as in the case of a major one, and flee from transgression; For one commandment leads to another commandment, and transgression leads to another transgression; For the reward for performing a commandment is another commandment and the reward for committing a transgression is a transgression.
In other words, Rav Yosef was happy to receive the reward of being inspired or receiving divine assistance to do more mitzvos, that comes from doing mitzvos. Psychologically speaking, this is known as Behavioral Momentum, which means once you are engaged in something you deem important or positive, it gives you strength and encouragement to do more and similar activities.
Despite the answers given, I believe there is a simpler answer. Rav Yosef indeed did not have concern for the reward in terms of receiving any benefit, but he did use the reward as a yardstick to determine the importance of the activity. He figured if there is more reward for the mitzvos that one does because he is obligated, that must mean they have greater impact. While the commentaries offer different reasons for why there is greater reward for a mitzvah that one is obligated to perform, once again, there is a basic logical reason. Imagine one person who is talking a vitamin because his doctor says he has a nutritional deficiency. Another person can take this vitamin too, but obviously, it will have less impact because he does not need it. So too, it is logical to assume that if a person is obligated in a mitzvah, that mitzvah is more impactful and beneficial to his soul. This is what Rav Yosef was celebrating.