Bava Metzia 30b ~ Visiting the Sick

 בבא מציעא ל ,ב 

דתני רב יוסף והודעת להם זה בית חייהם את הדרך זו גמילות חסדים (אשר) ילכו זה ביקור חולים בה זו קבורה ואת המעשה זה הדין אשר יעשון זו לפנים משורת הדין

Rav Yosef taught: The verse states (Ex. 18:20):

"You shall make known to them" -this refers to their livelihood

"The way" - this refers to good deeds

"That they may walk"  - this refers to visiting the sick...

According to Rav Yosef, Moses was instructed to let the people know that they must pursue a livelihood, perform kind acts and visit the sick.  Let's remind ourselves of the importance of that last one, with a repost from Nedarim 39. There, we read the following:

נדרים לט, ב - מ, א

תניא ביקור חולים אין לה שיעור ... אמר אביי: אפי' גדול אצל קטן רבא אמר אפי' מאה פעמים ביום אמר רבי אחא בר חנינא כל המבקר חולה נוטל אחד מששים בצערו

יצא ר' עקיבא ודרש: כל מי שאין מבקר חולים כאילו שופך דמים. כי אתא רב דימי אמר: כל המבקר את החולה גורם לו שיחיה וכל שאינו מבקר את החולה גורם לו שימות

Visiting the sick is a mitzvah that has no limit... Abaye said that even an important person must visit a lesser person who is ill...Rava said: [you must visit a sick person] even one hundred times a day...Rabbi Acha bar China said: "Whoever visits a sick person takes away one-sixtieth of his suffering...

Rabbi Akiva expounded and said: "Whoever does not visit the sick, it is as if he sheds blood." When Rav Dimi came [from Israel to Babylon] he said: "Whoever visits the sick causes the person to live, and whoever does not visit the sick, causes the person to die." (Nedarim 39b-40a)

Some time ago I visited the famous Grady Memorial Hospital in Atlanta, and was privileged to be given a tour of their new Neurocritical Care Unit, part of the Marcus Stroke and Neuroscience Center (and thank you, Bernie "Home Depot" Marcus).   While the unit has all the fancy equipment you'd expect, what impressed me the most was a feature I had not seen in any other intensive care unit (ICU): every patient room has an adjoining suite where a family member can eat, sleep, shower and wait (and there is a lot of waiting in ICUs). There are no visiting hours; the family member literally lives in the ICU with their loved one.  My tour guide explained that the unit sees the presence of  visitors as a way of offering the best care to the patient. It is a wonderful approach to the care of the sick - but it wasn't always like that.

A HISTORY OF VISITING THE SICK - IN HOSPITALS

Visiting times in hospitals still vary greatly, and many have an open door policy. But not too long ago, you might only be able to visit a patient in a hospital for a couple of hours each week. In the 1870s, Doncaster Royal Infirmary in Britain limited visiting to three afternoons a week - which was a more generous policy than that of the Royal Berkshire Hospital, which allowed only one 15 minute visits twice a week. In a survey of over 400 British hospitals conducted in 1988, over a quarter of those which replied allowed visiting for no more than two hours a day. Perhaps these restrictive policies were in response to some visitors who abused the generosity of Britain's glorious National Health Service. 

““[A more open visiting policy] proved to be a disaster, primarily because of abuse of the system by visitors. Many would arrive promptly at 8 am and stay all day. They would bring sandwiches and flasks . . . and camp out by their relative’s bed . . . Others would eat patients’ food, [and] ask for extra cups of tea...there was even a threat of violence from a visitor asked to leave temporarily...”

— Alderman B. Hospital visiting hours. BMJ 1988;296:1798-9.

HELP PATIENTS GET WELL SOONER - BY VISITING THEM

In 2006 an Italian group reported the results of a study on the effects of hospital visitors on patient outcomes in its small intensive care unit.  The ICU changed its visiting policy from a restricted one (one visitor twice a day for thirty minutes) to an unrestricted one every two months.  After two years of this alternating policy, the authors compared the outcomes of their 226 patients. Despite significantly higher environmental microbial contamination during the unrestricted visiting periods, septic complications were similar. But the risk of cardiocirculatory complications was twice as high in the restricted visiting periods, which were also associated with a (non-significantly) higher mortality rate. The unrestricted group was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. The authors concluded that "liberalizing the visiting hours seems to be more protective because it is associated with a reduction in severe cardiovascular complications."

Incidence, with Odds Ratio and 95% Confidence Intervals, of septic and major cardiovascular complications in patients enrolled during the restricted (RVP) and unrestricted visiting periods (UVP) adjusted for age, gender, and time of enrollment. RR indicates relative risk; UT, urinary tract; pul., pulmonary; and CV compl., cardiovascular complication. From Fumagalli et al. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial. Circulation. 2006;113:946-952.

Writing in The Journal of the American Medical Association in 2004, Donald Berwick and Meeta Kotogal called for a change in the policy of restricted visiting hours in intensive care units.  They noted three areas which are often of concern to ICU staff when considering the question of visiting hours.  They also noted that although these concerns seem reasonable, the scientific literature tells "quite a different story."

Physiologic Stress for the Patient: "The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress." 

Barriers to the Provision of Care: "The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians." 

Exhaustion of Family and Friends: "The third concern is that constant visiting with the patient may prove exhausting for family and friends who fail to recognize the need to pace themselves. While that does sometimes happen, it is also true that open visiting hours help alleviate the anxiety of family and friends, allowing them to spend time with the patient when they want and to feel more secure and relaxed during the time they are not with the patient. One study found that open visitation had a beneficial effect on 88% of families and decreased anxiety in 65% of families."

A review of visitation policies in ICUs produced by the American College of Critical Care Medicine Task Force went one step further and found "no evidence that pets that are clean and properly immunized should be restricted from the ICU environment." So don't forget to bring the dog next time you visit a family member or friend in the ICU (or anywhere else for that matter). 

“...the preponderance of the literature supports greater flexibility in ICU visitation policies. Descriptive studies of the physiologic effects of visiting on mental status, intracranial pressure, heart rate, and ectopy demonstrated no physiologic rationale for restricting visiting. In fact, in seven of 24 patients with neurologic injuries, family visits produced a significant positive effect, measured by decrease in intracranial pressure.”

— Davidson et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Critical Care Medicine 2007; 35 (2): 612.

HOW TO VISIT A FRIEND WHO'S SICK - THEN, AND NOW

Most of the evidence about the benefits of visiting the sick that we've been discussing have centered on the ICU- because that's where most of the research has been done. But for most of the time, an ill friend will not be in the ICU, or even in the hospital. Instead they will be at home, and so that is where the visit will occur.  Sadly, the ability to be a friend to a friend who is sick does not come easy to all of us.  Here's what Letty Pogrebin noted, in her recent book How to be a Friend to a Friend Who's Sick:

It's not uncommon for people to freeze or panic in the company of misery, botch gestures that were meant to ease, attempt to problem-solve when we have no idea what we're talking about, say the wrong thing, talk too much, fidget in the sick room, sit too close to the patient or stand too far away. Some of us don't visit our sick friends at all...

The Talmud sensed that visitors need some guidelines as to how to behave, and so in the daf that we will learn tomorrow, Rav Shisha suggested the following rule: "One should not visit a sick person in the first three hours of the day or in the last three hours of the day." In addition, the Talmud notes that "one who goes to visit the sick should not sit on the bed nor on a bench or a chair, but instead should wrap himself up in his cloak and sit on the ground, because the divine presence rests above the bed of a sick person." While we may no-longer follow this advice, the suggestion that we take our visits to the sick seriously is one that we should heed. Let's close with some more advice, updated for the modern era, from Pogrebin's 2013 handbook (p86-86):

1. Ask the patient to be honest with you and all their friends.

2. Be honest with yourself about your attitude toward the visit.

3. Think through your role in the visit.

4. Don't visit if you can't abide silence.

5. Be prepared to respond without flinching to whatever scene or circumstances greet you during your visit.

6. Be sensitive to your friend's losses.

7. Talk honestly with your children about the demands illness makes on friendship and how important it is to visit people who want company.

“What is the reward given for visiting the sick in this world? “God will guard him and restore him to life and he will be fortunate on earth, and You will not give him over to the desire of his foes.” [Ps 41:3.]:
”God will guard him” - from the evil inclination.
”And restore him to life” - from his suffering.
”And he will be fortunate on earth”- in that everyone will take pride in him.
”And You will not give him over to the desire of his foes”- for he will have good friends... ”

— Nedarim 40b

[Repost from Nedarim 39 and Sotah 14.]

Bava Metzia 24a ~ Torture

בבא מציא כד, א

מר זוטרא חסידא אגניב ליה כסא דכספא מאושפיזא חזיא לההוא בר בי רב דמשי ידיה ונגיב בגלימא דחבריה אמר היינו האי דלא איכפת ליה אממונא דחבריה כפתיה ואודי

Mar Zutra the Pious was involved in an incident in which a silver cup was stolen from his host. Later, Mar Zutra saw a certain student wash his hands and dry them on his friend's garment. Mar Zutra said: "this is the one who stole the cup, for he has no consideration for his friend's property. Mar Zutra bound the student to a post and coerced him, and he confessed to the crime (Bava Metzia 24a).

This is an incredible passage. When I first encountered it I wasn't certain I had understood it correctly. But there it was, in black and white. The Pious Mar Zutra had, in essence, tortured a confession out of a student.

Courtesy of Wikimedia.

The phrase that describes this is כפתיה ואודי "they bound him and he confessed." The root of the word to bind is כפת, which is used in rabbinic literature to mean to tie or to bind. Rabbi Asher ben Yechiel (Germany ~1250-1327), known as the Rosh, is certain that the suspect was tortured. In his commentary on this passage he wrote וכפתיה בשוטי עד דאודי "he flogged him with rods until he confessed." (As in חושך שבטו שונא בנו ואהבו שחרו מוסר "spare the rod and spoil the child," from Proverbs 13:24.) Rabbi Betzalel ben Avraham Ashkenazi (Israel ~1520-1594) in his commentary called Shitah Mekubetzet agrees that coercion was used, although he is unsure if it was physical or psychological:

כפתוהו ואודי. יש מפרשים כפתוהו על העמוד והלקוהו בשוטים. ויש מפרשים כפתיה בדברים שנדוהו אם לא יודה האמת

Some explain that he was tied to post and flogged. Others explain that he was verbally coerced (and threatened with excommunication) until he confessed.

False Confessions

In a 2010 paper published in the Stanford Law Review, Brandon Garett notes that DNA testing has now exonerated over forty people who falsely confessed to rapes and murders. He wonders how an innocent person could convincingly confess to a crime he never committed. For example, in 1990  Jeffrey Deskovic a seventeen-year-old, was convicted of rape and murder. Deskovic was a classmate of the fifteen-year-old victim, had attended her wake, and was eager to help solve the crime. During one of several police interrogations he “supposedly drew an accurate diagram,” which depicted details concerning “three discrete crime scenes” which were not ever made public. "In his last statement, which ended with him in a fetal position and crying uncontrollably," wrote Garrett, "he reportedly told police that he had “hit her in the back of the head with a Gatoraid [sic] bottle that was lying on the path.” Police testified that, after hearing this, the next day they conducted a careful search and found a Gatorade bottle cap at the crime scene."

“Scholars increasingly study the psychological techniques that can cause people to falsely confess and have documented how such techniques were used in instances of known false confessions.”

— Garrett, B.L. The Substance of False Confessions. Stanford Law Review 2010. 62 (4): 1051-1119.

Deskovic was convicted of rape and murder and served more than fifteen years of a sentence of fifteen years to life. Then in 2006, new DNA testing not only exonnerated him, but also matched the profile of a murder convict who subsequently confessed and pleaded guilty. So how did Deskovic know all the details of the crime to which he confessed? Here is what the District Attorney noted in the post-exoneration inquiry:

...Given Deskovic’s innocence, two scenarios are possible: either the police (deliberately or inadvertently) communicated this information directly to Deskovic or their questioning at the high school and elsewhere caused this supposedly secret information to be widely known throughout the community.

Another paper, this time in the North Carolina Law Review, analyzed 125 cases of "proved interrogation-induced false confessions, which, the authors note with some pride, is "the largest cohort of interrogation-induces false confession cases ever identified and studied in the literature." It makes terrifying reading.  

It is of course really hard to study in the laboratory the psychological effects of torture and coercion and how they produce false confessions.  But scientists try anyway. For example, a very recent paper from a team from the New School for Sociological Research in New York and the University of California studied the effect of sleep deprivation on false confessions.  When compared to those who had rested, participants were over four times more likely to sign a false statement if they were deprived of one night's sleep.  In another recent peer-reviewed paper, (Constructing Rich False Memories of Committing Crime) psychologists used suggestive retrieval techniques on some rather nice Canadian undergraduates. They found that up to 70% of those interviewed 

were classified as having false memories of committing a crime (theft, assault, or assault with a weapon) that led to police contact in early adolescence and volunteered a detailed false account. These reported false memories of crime were similar to false memories of noncriminal events and to true memory accounts, having the same kinds of complex descriptive and multisensory components.

They continue: 

Our finding that young adults generated rich false memories of committing criminal acts during adolescence supports the notion that false confessions and gross confabulations can take place within interview settings. The Innocence Project has shown that about 25% of false convictions are attributable to faulty confession evidence...The kind of research presented here is essential in the quest to help prevent memory-related miscarriages of justice.

Back to Mar Zutra the Pious

We know little about Mar Zutra, but for those studying the one-page-a-day Daf Yomi cycle, the last place we learned his teachings was in Bava Kamma. On Shabbat, when using a stone from a wall to wipe himself after using the bathroom, Mar Zutra the Pious would then return the stone to its place in the wall. He would later instruct his servant to cement the stone back into place, so as not to damage the wall.  He was, then, a man who acted to preserve the property rights of others, even in the most intimate of circumstances, when he knew no one would be watching.  And there's another story about Mar Zutra's piety - this one with more bearing on today's teaching in the Talmud. In the tractate Nedarim, we are taught the following:  

דמר זוטרא חסידא כי מחייב בר בי רב שמתא משמית נפשיה ברישא והדר משמת בר בי רב וכי עייל לביתיה שרי לנפשיה והדר שרי ליה ואמר רב גידל

When Mar Zutra the Pious placed excommunicated a student, Mar Zutra first excommunicated himself, and only then the student.  On arriving home, he lifted the ban from himself and then from the disciple.

Tosafot offers two explanations for this rather unusual behavior. First, he excommunicated himself so as not to forget that he had done so to a student. This would force him to recall his student, and when the time came, he would lift the ban. The second proposal offered by Tosafot is that Mar Zutra acted in this way as a sort of penitence: excommunicating another person was an extreme measure, and Mar Zutra reminded himself of this by imposing the same punishment on himself.

תוספות נדרים דף ז, ב 

פר"ת שזה היה עושה כדי שלא ישכח להתיר הנידוי של בר בי רב אבל עכשיו שמשמת נפשיה מתוך כך שהיה זכור להתיר שלו זכור יהיה נמי להתיר של בר בי רב ור"י פירש דלכפרה היה עושה כך שלא יענש במה שמנדה צורבא מדרבנן כי בקושי יש לנדותו

Do you recall the explanation of today's passage from Rabbi Betzalel ben Avraham Ashkenazi in his commentary called Shitah Mekubetzet with which we opened?  He wrote that in order to coerce the student to confess, Mar Zutra threatened the suspect with...excommunication.  And so perhaps we can now better understand the severity of this coercion, for Mar Zutra himself went to extraordinary lengths to avoid imposing it.

Mar Zutra was a complex man, who would use methods we call torture to extract a confession.  The Talmud also points to his sensitivities.  But do the latter ever forgive the former?