A Midrashic Model for Death and Dying, Rabbi Miriam C. Berkowitz, M.A. and Dr. Lawrence Knight, M.D. F.R.C.P.C. © The Mount Sinai Journal of Medicine, November 2001, Vol. 68 No. 6.

Abstract

This paper elucidates and explains an ancient midrash (rabbinic interpretation of a biblical text) through the lens of modern psychological theory. The midrash describes Moses’ reactions to his approaching death. The paper points out that these reactions anticipate the five classic stages, described by Elizabeth Kubler-Ross, of coming to accept terminal illness: denial, anger, bargaining, depression and acceptance. The article shows the ancient rabbis’ sensitivity to human feeling and the universal nature of human reaction through the dialogue and reactions they attribute to Moses. Finally, it shows how using this midrash offers a constructive model for approaching death, for Jewish and non-Jewish patients alike, as well as their caregivers. Key Words: Thanatology, death, midrash, Kubler-Ross, pastoral care, acceptance.

Introduction

Thanatology, the study of death and dying, was for many years an outsider to the host of medical specialties. Perhaps because physicians and other caregivers try so hard to preserve life, it is difficult for them to admit to themselves, to patients, and to patients’ families, that there will on occasion be no possible heroic intervention, no solution, no cure. Yet patients may be able to add dignity and meaning to their death if they are afforded the opportunity, when possible, to acknowledge that they are dying. Through honest evaluation and communication, medical professionals can, in certain situations, facilitate a “good death.” Of course, some patients will never accept the reality of death, despite caring, professional support and guidance. However, with patience and attention to the mental and emotional work involved, much can be accomplished.

I [Dr. Knight] recently visited a patient of mine who was dying in the Palliative Care Unit (PCU) of the Royal Victoria Hospital. On most of those visits, I saw a man of about fifty-five sitting in the family room. We eventually began to talk. His father, a man of eighty-five, was dying of a malignancy. I asked the son why he was there so often. He replied that his father had always supported his successes at school, had been proud of his athletic achievements, and had praised him for his work in the family business. He added, “But I was hoping that before he died, he would tell me that he loved me.”

Several weeks later I saw the son offering gifts to the PCU nurses. He informed me that his father had died, and he said, “I think that before he died, he told me that he loved me.” Only because the father knew his time was limited could he work on saying the things he had left unsaid. Only because the son knew his father was dying could he create opportunities to hear them.

Dr. Elizabeth Kubler-Ross was a pioneer in the field of palliative care, active preparation for death without medical intervention. Through clinical observation, she perceived that terminal patients usually experience a similar range of emotions and responses: denial, anger, bargaining, depression and acceptance (1). These stages are descriptive, not prescriptive, meaning that caregivers should seek to listen and affirm the patient’s emotions, when and if they surface, rather than try to move the patient along a set path or timetable. They may find that stages two, three and four appear in a different order, as in the midrash we will describe, or that a stage is skipped altogether. Still, an overall awareness of the general pattern can help families and caregivers assist the dying patient.

This paper analyzes a midrash, a rabbinic elaboration on a biblical story. This midrash, which probably dates from the middle of the first millennium of the Common Era (C.E.), portrays Moses’ response to the news of his impending death. He experiences the five stages identified by Kubler-Ross. Significantly, for physicians, it is only because God informs him of his impending death that Moses has the opportunity to move through the stages of resistance, to the point where he can die peacefully. The analysis of the midrash points out how the stages Kubler-Ross identified may be rooted in a timeless human experience. In addition, it may convince medical personnel of the important work that can be done in the months, weeks or days preceding death if they do not try to shield the facts from the patient, and if the patient is permitted or even encouraged to openly express the various feelings that arise.

The Five Stages in More Detail

1. Denial

Denial acts as a buffer from the shocking news and is usually a temporary defense. It includes thoughts like “it can’t be true” and “this can’t be happening to me,” and actions such as blaming an erroneous pathology report or mixed-up x-ray, and seeking a second opinion.

2. Anger

When denial is not maintained, it gives way to anger and resentment -responses to perceived unfairness or injury - which are often directed at family and at physicians, either in their own capacity, or as representatives of God.

3. Bargaining

This approach may be helpful to the patient in the short term. It usually consists of an agreement to accept the inevitable, but at a later date, to postpone the decree, as it were. Most patients, even those who do not have a formal religious affiliation, make their bargains with God, who is seen as having the power over life and death.

4. Depression

When the terminally ill patient can no longer deny the illness, resistance and rage will give way to a sense of great loss. Symptoms may include withdrawal into silence or limitation of human contact. Kubler-Ross calls this a preparatory depression. Perhaps the patient is preparing for the ultimate isolation. The first four stages can vary in length and intensity from patient to patient.

5. Acceptance

With enough time and help, the patient exhausts his or her anger and depression, and arrives at the stage of acceptance. Through expressing feelings and “tying up loose ends” with family, business and personal life, the patient who reaches this stage is able to discuss death with calmness and equanimity. This stage is not just a wish to end pain and suffering, but a genuine acceptance of reality.

The Midrash

Midrash is homiletical rabbinic commentary on the Hebrew Bible, often responding to perceived redundancy, inconsistency or a curious turn of phrase in the text. In addition to their ostensible goal of elucidating the biblical text, early preachers of midrash sought to teach lessons of contemporary relevance. At some point, the oral interpretations became codified according to the order of the Bible. “Midrash” (plural “midrashim”) refers to the individual nugget of commentary, as well as to each edited volume and also the entire genre. While it is difficult to date individual midrashim, collected works of midrashim were completed as early as 400 C.E., with the bulk of them being edited during the period 600– 900 C.E. and some later collections in the early Middle Ages (2). This particular midrash, which presumably had meaning for congregations or audiences at the time of its composition, also addresses dilemmas which still face us today.

This midrash is long, so I will just refer to the relevant parts, but the text can be found in full in the Hebrew in Midrash Rabbah, Parashat VeZot HaBracha, 11:10 and in English translation in The Book of Legends, ed. HN Bialik, YH Ravinitzky; transl. WG Braude; New York: Schocken Books; 1992. pp. 101–105. It comments on the Biblical verses:

“The Lord said to Moses: the time is drawing near for you to die ...”                    Deuteronomy 31:14

and "Moses went up from the steppes of Moav to Mount Nevo, to the summit of Pisgah, opposite Jericho, and the Lord showed him the whole land: Gilead as far as Dan; all Naphtali; the land of Ephraim and Menasseh, the whole land of Judah as far as the Western Sea; the Negev and the Plain — the Valley of Jericho, the city of palm trees — as far as Zoar. And the Lord said to him, ‘This is the land of which I swore to Abraham, Isaac and Jacob: I will assign it to your offspring. I have let you see it with your own eyes, but you shall not cross there.’ So Moses the servant of the Lord died there, in the land of Moav, at the command of the Lord. He buried him in the valley in the land of Moav, near Bet-Peor; and no one knows his burial place to this day. Moses was a hundred and twenty years old when he died; his eyes were undimmed and his vigor unabated. And the Israelites bewailed Moses in the steppes of Moav for thirty days." Deuteronomy 34:1– 8

At the point where the midrash begins, Moses has had a long and fruitful, though difficult life. “Moses was a hundred and twenty years old when he died; his eyes were undimmed and his vigor unabated.” He is not yet ready to die. When God informs him that he will not merit entering the land of Israel, which he has labored so long to reach, Moses’ first response is denial. (Most likely, Moses understands that God is telling him, in a gentle, indirect manner, that he will die. A second possibility is that not entering the Land of Israel is tantamount to death for Moses.) The midrash tells us:

"The High Court revealed itself to him and declared, ‘It is my decree that you should not pass over,’ [as it is said], ‘For you shall not go over the Jordan’ (Deuteronomy 3:27). Moses, however, made light of this, saying, "Israel have many times committed great sins, and whenever I prayed for them, God immediately answered my prayer..." (Exodus 32:24, Numbers 14:12). "Seeing then that I have not sinned from my youth, does it not stand to reason that when I pray on my own behalf God should answer my prayer?"

Moses is unwilling to believe that the decree is true. He continues acting with confidence and cool nerve. However, this stage does not last permanently. As Moses realizes that the forces ranged against him are too powerful for him to ignore, he enters a stage of inwardness and withdrawal:

"When, however, Moses saw that the decree against him had been sealed, he took a resolve to fast, and drew a small circle and stood therein, and exclaimed, ‘I will not move from here until Thou annullest that decree."

Kubler-Ross would call this stage depression. The fasting symbolizes great sorrow, and the drawing of the circle, which elsewhere in Jewish sources (3) is a way of protesting and persuading God to reverse a negative decree, here seems to represent Moses’ cutting himself off from other people and sitting for days in isolation.

From depression, Moses moves immediately into anger. He cries out to God about the unfairness of the decree:

"Is this the reward for the forty years’ labor that I went through in order that [Israel]should become a holy and faithful people?"

After this outburst, Moses’ resolve is weakened, but he still does not want to give in. With only one hour left, according to the midrash, the stage of bargaining begins. Here we cite only Moses’ side of the dialogue, though the midrash includes God’s responses as well:

"Whereupon Moses said to God, ‘Master of the Universe, if Thou wilt not bring me into Eretz Israel [the Land of Israel], leave me in the world so that I may live and not die’... Said Moses to God, ‘Master of the Universe, if Thou wilt not bring me into Eretz Israel... let me become like the beasts of the field that eat grass and drink water and live and enjoy the world... Master of the Universe, if not, let me become in this world like the bird that flies about in every direction and gathers its food daily and returns to its nest toward evening; let my soul likewise become like one of them."

The responses of God are omitted here so as to highlight the arguments brought forward by Moses, exhibiting his desperate efforts to avoid death. He is willing to give up almost anything, including his very humanity, in order to avoid death. The willingness to sacrifice in return for a compromise, along with the continuing arguments, 'lowering the ante' each time, clearly identify this behavior of Moses with the stage of bargaining. This stage can last any length of time, but Moses does not have much time. Fortunately, due largely to the gentle care and support of his caregiver, in this instance God, Moses is able to reach a gradual acceptance of the decree.

Sammael, the wicked angel, the chief of all the accusing angels, was awaiting the death of Moses every hour, saying, "When will the time or the moment arrive for Moses to die, so that I may descend and take away his soul from him?"

Moses is not willing to surrender his soul to Sammael, but when God Himself offers to attend to Moses, the servant of God begins to accept his imminent death. This section of the midrash is based on the biblical verse “So Moses the servant of the Lord died there, in the land of Moav, at the command of the Lord. He buried him in the valley in the land of Moav, near Bet-Peor; and no one knows his burial place to this day” (4). The verse states explicitly that God buried Moses and reiterates that no human was there (according to other traditional interpretations of the text, God arranged this situation so that the burial site of Moses would not become a site of undue attention and worship). Here our midrash continues:

"Said Moses to God, ‘Master of the Universe, remember the day when Thou didst reveal Thyself unto me in the bush ... remember the time when I abode on Mount Sinai for forty days and forty nights ... I implore Thee, do not hand me over into the hand of the Angel of Death.' Thereupon a Heavenly voice was heard saying to him, ‘Fear not, I myself will attend to you and your burial.’ At that hour Moses arose and sanctified himself like the Seraphim [angels], and God came down from the highest heavens to take away the soul of Moses, and with Him were three ministering angels, Michael, Gabriel and Zagzagel. Michael laid out his bier, Gabriel spread out a fine linen cloth at his bolster, Zagzagel one at his feet. Michael stood at one side and Gabriel at the other side. God said, ‘Moses, fold your eyelids over your eyes,‘ and he did so. He then said, ‘Place your hands upon your breast,‘ and he did so. He then said, ‘Put your feet next to one another,’ and he did so."

In this section we see Moses coming to an acceptance of his death. As the angels initiate several of the Jewish rituals which honor the deceased — wrapping the body in white linens, having it attended until the funeral by guardians (shomrim) — Moses himself begins to take an active role in preparing for death. As he purifies himself, perhaps with water, which is part of the pre-funeral ritual of washing or taharah, as he closes his eyes and as he assumes the position of eternal rest, Moses is literally exhibiting his willingness to accept death.

Discussion

On one level, the midrash fills in the blanks left by the biblical story of Moses’ death — How did he react when he heard the news? Who actually buried him if no one knew of his place of burial? Did he resent not being able to enter the Land of Israel after he had led his people so devotedly for forty years? More important, however, the midrash shows that the sage(s) who composed it were in touch with human nature, and that human nature has not changed much in 1500 years. Although their understanding of human reactions to mortality was probably intuitive (or perhaps inspired) rather than scientific, the rabbis of the midrash sensed that each of the reactions which Elizabeth Kubler-Ross later formalized into five stages is natural and helpful in its own way.

However, just as experience suggests that the order and relative length of each one may vary from case to case, stages 2, 3, and 4 are manifested in a different order in the midrash than in Kubler-Ross’ research. (Perhaps the humble Moses was more likely to turn inward, examining his own actions, before blaming God. Thus fasting, symbolizing contrition and depression, precedes anger in the midrash.) Indeed, Kubler-Ross conceded that these stages may not occur in the same order and in the same manner for everyone. However, the essence of a path through different emotions still applies. The inherent goal of this ancient process, seemingly God-given, is an exhaustion of the possibilities and a gradual reconciliation. If the patient has not been able to express and thereby exhaust the stages of anger or bargaining, they will resurface and interfere with the attainment of final peace.

The account of Moses’ journey toward accepting his inevitable death points to several elements which can be of guidance to patients as well as to caregivers who are trying to help their patients come to terms with death. It is important to be aware that most patients experience most of the stages, for varying lengths of time. To express these feelings, patients will often initiate conversation, but it is the responsibility of caregivers not to block this line of communication. By legitimizing and listening to all of the patient’s reflections, be they angry, somber or morose, a caregiver or family member can be of great help. Setting aside one’s own discomfort with death can help the patient work through feelings that may eventually bring a sense of peace and acceptance.

Anger may be especially disconcerting, but it is an integral part of the process. Moses enjoyed a close relationship with God and felt that he could communicate with God directly. Since God was the perceived source of the decree and since Moses had conversed with God over a lifetime of prayer, Moses could direct his anger at the source of his grief. If a patient perceives God as the source of illness, based on theology or emotion, the patient may well be angry at God. A lifetime of communication with God is a good basis for honest expression of anger at this point. For those who feel uncomfortable expressing anger with God or who assume that their tradition discourages such feelings, reading a psalm (5) may be a good starting point. Alternatively, the psalms may allow a very devoted person who has not realized that one is permitted to be angry at God, to express these feelings; if the psalmist could do it, the patient may realize, then surely it is permitted within the Jewish and Christian traditions.

Most important, perhaps, the responses of Moses in the midrash can give an authentically Jewish model to a patient who wishes to approach death with equanimity but has been trained to fight it till the end. Moses was at first highly resistant to dying. If generalizations can be made, Jewish patients tend to fight against death even past the point when other patients may say, “It is in God’s hands.” “Central to Jewish culture is a passion for life, which can prove difficult in the palliative care setting ... Despite the fact that the ‘good death’ has strong biblical antecedents, it is not what is normally emphasized” (6).

More familiar in a Jewish setting is the sanctity of life, the duty to preserve life, and a predominantly positive attitude toward healing. Death is especially unwelcome to Jews, who do not share the Christian view of death, namely that “it is inevitable and not to be feared but to be accepted as the closing out of one form of being in hope of another, an eternal existence with God” (7). While there are Jewish visions of an afterlife, they are not so immediate or so central as is the Christian concept of “being with Jesus now.” It is significant that, according to the midrash, even Moses, who was so attuned to God’s wishes and plans, felt comfortable crying out to preserve his life and lengthen his days, despite God’s decree to the contrary.

On the other hand, if Moses could come to a gradual acceptance of his mortality, even though he still had the will to see and accomplish many more things, perhaps reconciliation to this fate is not something beyond the patient’s reach; certainly it is an approach condoned by Jewish tradition, as expressed by the dramatic dialogue of the midrash.

Finally we learn from the midrash how great an honor it can be to attend someone in their last hours of life and what a difference a calm, loving presence can make to the dying person. God’s presence in the midrash ultimately allays Moses’ fears and enables him to confront death. Of course, there is a time for medical intervention and treatment, but when the end really comes, it is the time for peace. Our most sacred mission as human beings is to imitate God’s attributes of love, compassion and giving. The midrash concludes, “Thereupon God kissed Moses and took away his soul with a kiss of the mouth, and God, if one might say so, wept ...”

Conclusion

It is frightening and painful to be in the presence of terminal illness. However, if physicians and caregivers can help release the emotional blockages — letting the patient guide the conversation, experience each stage to its fullest, and ultimately attain a more peaceful death — they need not fear their inability to make any further medical contributions toward prolonging life. The emotional and spiritual contributions of listening to the patient’s deepest thoughts when others are simply trying to cheer him up, can be extremely valuable in their own right. Most important, shielding the patient from the true nature of the disease can rob that person of the opportunity to have this kind of closure. Some deaths occur without warning; when the patient does have the opportunity and the mental capacities to come to terms with approaching death, physicians should err on the side of reality rather than protecting the patient from bad news. Though this approach, to encourage the patient to overcome the illness, can have beneficial effects at early stages of disease, its well-meaning value dissipates when death becomes inevitable and imminent. If the father in the case cited in the introduction had not been sure he was going to die, he probably could never have mustered the courage to tell his son, “I love you.”

Acknowledgments

I would like to thank Rabbi Joshua Weisberg of Jerusalem for drawing my attention to this midrash, Ms. Bunny Abraham for preparing the manuscript, and my father, Dr. Lawrence Knight, for writing the introduction.

 References

1. Kubler-Ross E. On Death and Dying. New York: Macmillan; 1970.
2. For more detail, see the entry “Midrash” in Encyclopedia Judaica. Jerusalem: Keter Publishing; 1972. 383
3. For example, in the exploits of Honi the circle drawer in the Babylonian Talmud, Tractate Ta’anit, 23a.
4. Deuteronomy 34:5– 6.
5. Psalms 10, 22 express anger and 5, 6, 16, 17 express anger coupled with a plea for attention: “Hearken to the sound of my outcry, my Lord ...”; “attend to my entreaty, give ear to my prayer.” The “enemies” in Psalms 3 and 5 can be interpreted as the illness; thus, by reading these psalms the patient can enlist God’s help to gain power to fight the illness.
6. Neuberger J. Judaism and Palliative Care. Eur J Palliative Care 1999; 61(5):166– 167.
7. Mermann AC. Spiritual Aspects of Death and Dying. Yale J Biol Med 1992; 65:137– 142.