Morality, homosexuality, and halachah
Fumblings toward a thought or two, in pseudo-axiomatic form.

1.1. The issue of homosexuality within (or without) halachah can be viewed in many ways. One can start with the relevant halachot and work from them "towards" the sociological reality of homosexuality -- that is to say, in a strictly constructionist vein, find those heterim [legal allowances] which might make it possible for the acknowledgment of homosexuality (not homosexual behavior itself) to exist within a halachic community. This assumes that the halachot are applicable, and that moral considerations are either (a) only intra-halachic, i.e. generated by the halachic system, or (b) never applicable to the halachic system even when generated from without.

1.1.1. Halachot are generally applicable. To be a halachically observant Jew means that there is a very strong presumption that the halachah applies in the case at hand. What the halachah is in a given case -- i.e. how that is to be determined -- is very complicated from a general point of view, and I won't go into that here.

1.1.2. There are cases in which the halachah is not applicable. Whether there is a general formulation of all such cases is beyond the scope of this blog. There is an argument among the poskim [halachic decisors] whether every state of affairs can be addressed by halachah, or whether there are some states of affairs which are halachically irrelevant.

1.1.3. Moral considerations are important for determining whether halachah applies in a given case. In opposition to R. David Halivni, for example, I believe that our halachic predecessors (Chazal) did operate with explicit moral criteria. Many of these criteria are explicit (tikkun ha-olam, for one), while others are obscured by literary style. Thus we would not be the first to use moral criteria for evaluating halachah. Whether such "firstness" is relevant is another question.

1.1.4. How moral considerations and halachah interact is not simple. There are some cases in which the moral reality has changed from what was held true according to the halachah as it stands.

1.1.5. Such changes in moral reality do not always require halachic attention.

1.1.6. When large classes of people, by virtue of their wholly moral actions, are regarded as "extra-halachic," or sinners, this requires halachic attention.

1.1.7. Note that 1.1.6. does not apply to egalitarianism, which should be defended on other grounds.

1.1.7. "Halachic attention" entails, among other things, a deliberation whether the halachah as it stands is consonant with the moral reality that we know to be the case.

1.2. Similarly, one could start with the premise that homosexuality is immoral, either because (as noted above) halachic prohibitions establish such immorality by their very existence, or the immorality of homosexuality is a fact of the matter independent of halachah. (Rabbi Joel Roth makes use of both these arguments in his teshuvah.) By this account, halachah would serve either as a guarantor of (heterosexual) morality, or a bar to homosexual behavior which is ipso facto immoral.

2.1. Adult, loving, consensual homosexual relationships are to be morally valued, i.e. are the opposite of immoral.

2.1.1. One can quarrel with 2.1., but this is not a place to rehash the arguments made elsewhere against such spurious claims as the following: homosexuals weaken heterosexual marriage; homosexuals weaken a society's moral fiber; homosexuals are sexually perverse.

2.2. A considerable minority of Jews are gays and lesbians. By 1.1.6., since the halachah as it stands considers them as sinners, liberal poskim (to whom this discussion is confined) should consider the matter closely.

2.3. The halachic ramifications of homosexuality are many, but at the root lies the de-oraita (Torah-level) prohibition of "lying with a man [as one does with a woman]," i.e. anal sexual relations.

2.3.1. Sexual relations are at the heart of a loving, consensual, adult relationship. There are sexual acts proper to heterosexuals and there are those proper to homosexuals. And, of course, there are those which overlap.

2.3.2. The moral dissonance caused by the halachic prohibition of homosexuality does not extend merely to later outgrowths of the Torah's prohibition, i.e. to "recognizing" gay-and-lesbian couples, or the like. Rather, it goes to the very root of the matter, to the prohibition of "lying with a man as one does with a woman."

2.4. A morally based halachic change must take into account the prohibition of anal sex.

Why Johnny still smokes
Unhealthy behaviors and why we can't stop.

MEDICINE MENSCH: Nobody's Perfect
March 3, 2006

When it comes to our health, we can all be careless. Why do some of us keep smoking when we have relatives who died young from lung cancer and heart disease? Why do we eat like it's going out of style when New York is chock-full of obese diabetics? Why are so many Sabbath tables heavily laden with cholent and challah with nary a fruit or vegetable?

All these behaviors are hard to change; some are even addictive. There's also ample scientific proof that some of them are partially society's fault. It is attractive to smoke when cigarettes are made to seem glamorous. It is hard to eat a healthy diet when the nearest store with fresh fruits and vegetables is 25 blocks away, in the rich people's neighborhood. To take a more familiar example, more and more of us are sedentary and overweight — with the rest of society forced to pick up the slack.

But every year there are many people who stop smoking, and there are others who manage to lose weight, even when all outside factors are stacked against them. Conversely, many of us who keep smoking, drink to excess or eat unwisely aren't doing so under duress. No one is holding a gun to our heads.

What's the cause of our errors in judgment? I don't know. But there are some potential answers.

We don't know any better. Why would someone knowingly behave in a way that has negative consequences? By nature, people strive for the good, one could say, and self-damage is only committed out of ignorance. But after years of intensive health education financed by everyone from the feds to Philip Morris, it's hard to find the untroubled soul who still believes that Marlboros are the doctor's best friend or that obesity is not damaging. Our response to being (re-)informed about the harms of this or that consumption is not a surprised "Oh, really?" but a guilty headshake and a sorrowful "I know, I know! I should stop!" There are those cases — such as in the early years of the AIDS epidemic — in which education makes, or would have made, all the difference, but not when an unhealthful behavior like smoking, poor diet or lack of exercise is already deeply ingrained.

We don't like to think about risks. Many people ride their bikes without a helmet — not because they don't know that helmets prevent injury, and not because they're foolhardy, but because they don't think about it. No one likes to think about car accidents, least of all on a beautiful spring day with the wind in your hair as you fly through Central Park.

That's an oversimplification. We do think about some risks quite a bit: The press has been preoccupied with recent disclosures about the ineffectiveness of the low-fat diet and with the pandemic of influenza among birds. But to use an unpoetic word, we misprioritize. It's not bird flu or fatty foods that are to blame for some of the world's worst and most frequent health problems — it's unwise, widespread behaviors, the consequences of which are easily predictable.

We can't be helped. Somewhere between the naiveté I started with as a medical student (just smile and be friendly, and people will cooperate to make themselves healthy) and the desperation of the cynics ("If there's a problem, it must be the patient's fault") is a disquieting truth. There are some of us who make decisions that doctors would call the wrong ones. Then, when we are involved in a conversation about our own health, given all the information and opportunities we need and provided with dedicated staff, experts in their fields who want nothing more than to help us over the rough patches — then, finally . . . we make exactly the same unwise health decision we made in the first place. Given all the necessary data, we make a different decision than public-health workers would make on our behalf.

Maybe that's because of the reasons I already mentioned: We don't know about the scientific evidence, or we can't appreciate technical discussions of statistical risk. But maybe, in the final analysis, we just don't want to. In other words:

It's out of our hands. We would change, but we can't. Quit bothering us. I don't like to exercise. I enjoy my cigarette. No one likes to be nagged. The more we're talked down to about what we should and shouldn't do, the more difficult it is for someone well meaning to broach the topic — and the more unpleasant it is for us to think about our unwise behaviors in the privacy of our own room. We avoid the issues.

Information is not the cure-all. Educating us to understand the complexities of health risks requires a shift in thinking that could take a couple of generations to take hold. Sometimes our frustrations and defensiveness seem insurmountable. So two choices are left: give up or keep trying.

Not coincidentally, these are the same choices every health-care worker has when trying to help a patient. Obviously there's only one right choice that helps both parties. To keep trying doesn't mean success; it means that patient and doctor show up at least semi-regularly — with ears open and with the hope that, equidistant from their frustrations, lies an understanding of why the other behaves the way he does. If we listen to each other in the doctor's office, maybe we'll all make fewer mistakes. Or at least we'll better understand the mistakes we keep making.

In the next few installments of Medicine Mensch, Zack will complete his last rotation as a medical student, travel to China, and get his M.D. Ask him about anything, or tell him how he's wrong, by writing to doctor@forward.com.

Carnaval of Consent

The many contradictions of Purim make a remarkable pairing. On the one hand, everything turned topsy-turvy and upside down.

On the other hand, the Jews "affirmed and accepted" the Torah. Why did they accept it then? Shouldn't they have done so at Mount Sinai? See the Babylonian Talmud, Shabbos 88a, which approximates a Rabbinic discussion of consent theory. (For a fuller treatment, see the Jewish Political Tradition, volume 1.)

Many theories can be advanced to explain why the Jews (re-)accepted the Torah after their victory over their Hamanite enemies. But one (certainly not original with me) is that upheaval is a natural setting for affirmation or stock-taking. At the very moment when the Jews thought they might be lost, they found reasons to accept what they might have been disinclined previously to consent to explicitly.

The poet of hospitals and Divine yearning
Yisroel Shtern: redeemed by the Internet?

Yisroel Shtern (1894-1942?) was a Yiddish poet of Warsaw. The Yisroel Shtern Project, possibly the most attractively designed and easy-to-read Yiddish-English web site now going, aims to present translations of a wide selection of his poetry and prose. (A couple of these translations are by yours truly.)

Everyone thought Shtern an eccentric -- he much preferred davening in the local shtibl than hanging out with fellow literati. To quote the web site:

Shtern stands almost alone as one who held in high regard both the secularizing I L Peretz and the traditionalist Hillel Tseitlin ; who frequented both Tlomackie 13 - the secular Yiddish writers' club, where his actor brother was a familiar - and the shtibl of the Bratslaver Chassidim. He adhered to no Party and his work appeared in Bundist and Zionist publications as well as in the Folkist daily Moment.

Other writers thought him strange but valued his work. [. . .] In the Warsaw Ghetto Shtern was starving and Ringelblum's diary records that the community moved him into an apartment at the Kehilla's expense. For that matter Shtern was starving before the War; and did repeatedly write, with authority, about the spiritual aspects of the experience.

While Shtern first published in 1919 and we know that he was writing much in the Ghetto (all of it lost), periods of marked creativity alternate in his life with lengthy periods of silence. He was hospitalized, whether for malnutrition or for a nervous breakdown is unclear. The tone of his work is generally gloomy and sometimes very fearful. Striking and characteristic is the absence of human relationship, together with the personalizing of inanimate features of the city - such as the buildings and the streets where Shtern spent so much of his days, wandering about in a shabby coat with papers poking out of his pockets.

Secular Yiddishism has had difficulty locating Shtern. Yet it is interesting that he chose to adhere to the Bratslaver Chassidim. For it is the oral transcribed Yiddish tales of the Bratslaver that secularists have honoured as among the earliest Yiddish stories. The perspective of the Bratslaver, so foreign to secular socialism, is clear in Shtern's essays and verse: through suffering we are brought closer to God; simple and poor people will be holier. Shtern is very serious about the purpose of literature in general: with Dostoyevsky as a model, to bring the reader to a truer understanding of the relation between life and God.

It is more than likely that the continuation of the Yiddish language will depend on observant Jews4. Yisroel Shtern saw himself as a bridge between them and the secular, and sought - as in his great essay Crowns - to introduce Jewish ideas to those without such knowledge. It may be that his relevance is greater now than ever before.

A novelist's intuition

I recently had the pleasure of interviewing Allegra Goodman; stay tuned for my piece in the Forward in which she talks abut her new novel.

Theologians argue intelligent design

Karl Giberson, the editor in chief at Science & Theology News, attacked Intelligent Design theory last December. Alvin Plantinga, a philosopher from Notre Dame (the university, not the cathedral), responds:

Giberson also complains that ID hasn’t generated further research or research projects. This may be true. At any rate the proponents of ID haven’t, as far as I know, actually come through with much by way of further research. Perhaps even the central claims of ID are by nature not fecund. They are not such as to suggest further lines of research, at least of the sort [the physicist] George Gamow came up with. Perhaps that’s true. Still, their conclusions might very well be “scientific.” They might very well be true, and they might very well be of great importance, very much worth knowing.

Exchange filched from Prosblogion.

What I bought at the candy store
[Many links to pages in Hebrew, which is probably not good linking etiquette.]

1. Yehuda Feliks, Animals and Plants of the Torah. Because I've always wanted to own it.

2. Moshe Tzvi Segal, The Complete Ben-Sira. Because of a certain discussion we've been having over here, Dov W. and I.

3. Jacob Katz, Between Jews and Gentiles. Because I've been reading Jacob Katz ever since I became interested in Jewish history. And because the book cost five dollars.

4. Yitzkhak Klein, Religion as a Philosophical Problem. I have no idea if the book's any good or not, but a cursory browse caught my interest. And this too cost me only five dollars.

5. Sha'agas Aryeh, the responsa.

What I didn't buy, but wanted to

A history of medieval Hebrew linguistics.
A visual Hebrew dictionary.
Mysterious Creatures.
A Dictionary of Babylonian Aramaic. (Someday it'll drop below $100.)

What was supposedly in stock at the sale, but couldn't be found by the salesperson

The Festivals and Jewish Law, by Zevin.

What I already own, and plan to write about soon-ish on this blog

Medicine and Jewish Law, volume III.

What I noticed at this year's sale

Less people, less kitsch Judaica, fewer books. Or maybe that was just my imagination.

Bravo, Sherwin Nuland!

The doctor tells it like it is in this past week's Forward with a necessary editorial about metzitzah b'peh.

Field trip!

On Sunday, to the YU Seforim Sale. Not just a great place to buy seforim, but a once-yearly opportunity for amateur sociology among the (modern) Orthodox. Uninformed observations coming your way next week.

It would be nice to meet Gil, Menachem, S., Mississippi Fred MacDowell, anyone else from Maven Yavin, Steg - pretty much any blogger, J- or not.

PS: And prolific commentator Dov W., of course.

A real epidemiology blog

Perhaps they'll cover the recent, mildly surprising finding from the Women's Health Initiative: calcium and vitamin D supplementation does not reduce the risk of hip fracture in healthy, post-menopausal women. Or maybe I'll talk about that later.

Je ne parle pas la radiologie

Without language, the doctor can't diagnose. But what happens when the doctor has to switch languages?

John Bruzzi, an Irish radiologist, recently spent time on a fellowship in France. In a surprisingly well-written essay for the New England Journal of Medicine, he describes what it was like to translate his painstakingly honed diagnostician's vocabulary into his not-quite-perfect French.

When I arrived, I was proficient enough in French to formulate a radiology report, though it involved a long, painful process of interpreting the images and mentally translating my thoughts into French. My reports were short and full of curt, declarative sentences that read like barked military orders. ("The right lung is normal. In the left upper lobe there is a mass. A big mass. 5x6 cm. Probably lung cancer.") Subordinate clauses, subjunctives, and commas went out the window. When asked my opinion about something, I could only point to the relevant images and describe abnormalities as "cancer" or "infection," "big" or "small." There were no gray areas, no doubts, no conjectures. Sitting on the fence — a radiologist's stock in trade — necessitates using words for balance, weighing diagnostic probabilities, and leaning toward the heavier side. But because I couldn't use the subjunctive mood, I was forced into the realm of apparent diagnostic certainty.

The Journal requires subscription for full-text access. Far be it from me to steal a dollar from the Cambridge biomedical establishment -- I'm not going to post the whole article here. Ask someone to get it for you, since it's well worth reading.

Presenting future poetic greatness!

סק דרגא בחר שושבינא
Go up a level to choose a friend. (Tractate Yevamos, 63a)

The above is all the more relevant when one chooses a friend who's a poet. I'm lucky to have someone I can train my sights on as he scrambles nimbly up the brambled slopes towards an unimagined art.

In other words, catch him now before you have to pay admission. I present Andrew Sage, and an ideal opportunity to listen to him read (together with Jan Heller Levi and Sally-Ann Hard):

Saturday, Feb 25, 3pm, at the Ear Inn (326 Spring Street, west of Greenwich St).

Did I mention I'm going to China?

Well, I am. I hope you're not the last to know.

In any case, there are many preparations to make, desperate requests to issue, Chinese characters to learn, Pesach supplies to jerry-rig, etc., etc.

What comes to mind now is that I have to leave my books behind, or at least most of them.

For now, one simple question: if you could only bring five books on a trip abroad, what would they be? Feel free to tailor the question to you. (If you're an observant Jew, please answer this question: which five seforim would you take on a trip abroad?)

Please leave answers in the comments, or train a eagle to fly over the frozen avenues of Manhattan and tap its beak on my window in code.

Translation

wool his snow
frost his ash
ice his scattered
crumbs. his cold!

melts by his word.
his wind, water flows.

Original here.

Be nice to your doctor!
You never know when you might need him.

The following is my favorite midrash for this week's Torah portion. It should soon become obvious why that is:

מדרש רבה בשלח פרשה כא

דבר אחר מה תצעק אלי הדא הוא דכתיב (איוב לו, יט) היערוך שועך לא בצר מהו כן אמר רבי אלעזר בן פדת המשל אומר כבד את רופאך עד שלא תצטרך לו ורבי שמעון בן לקיש אומר ערך שוע כלפי בוראך כדי שלא יהיו לך צרים מלמעלן

Midrash Rabbah, portion Beshalach, 21
Another matter regarding "Why do you cry out to Me? [Exodus 14:15]": It is written (Job 36:19): "Will Your riches avail, that are without stint (or all the forces of Your strength?)" What does this mean? According to R. Elazar ben Pdas: The parable says, "Honor your healer until you need him." Similarly, R. Shimon ben Lakish says, "Prepare a cry before your Creator so that you won't have enemies Above."

In this week's portion, Moses cries out to God -- a thing which puzzles the commentators, since God had already told Moses explicitly that Egypt would fail and the Israelites would be saved. In any case, one simple meaning of God's question, "Why do you cry out to Me?", is that Moses should not be crying out to God: it is the time for action. "Speak to the Israelites and [tell them that] they should go." Quit praying!

The midrash connects the verse in Exodus to an even more obscure verse in the Book of Job. Some take the word שוע in this verse to mean "riches," and render the word צר as "narrowness." Hence the translation above: "Will Your riches avail, that are without stint?"

The Rabbis quoted in this midrash, however, take שוע to mean "cry, petition" (in the sense of prayer), and צר to mean "foe." They might translate the verse this way: "Will you put your prayer in order before the foe has even appeared?" To this way of thinking, God's question to Moses is not "Why are you praying when there's action to be taken," but "Why are you praying before there's even anything to be worried about," i.e. before the Egyptians are even threatening to overtake the Israelites?

In other words, the general thrust of this midrash is that one should pray to God before one's enemies appear -- before one is in trouble. (The parallel versions of this midrash, in the Jerusalem Talmud and in the Midrash Tanchuma, support this understanding. In the Yerushalmi, the verse from Job is brought as an explanation for the parable, which there appears in Aramaic.) But the support brought in the midrash for this way of thinking -- the proverb brought by R. Elazar ben Pdas -- is what makes it fascinating.

"Honor your healer until you need him": what does this mean? First off, we should say that the Hebrew word רופא (royfe), though familiar in Modern Hebrew as the equivalent to English "doctor," means something else again in Rabbinic texts. (A lengthy review of the etymology and various meanings of the word is here.) A רופא is what could be called in other contexts a "soul healer," an expert who has the power to keep others healthy through Divine intercession.

To see this, compare Exodus 15:26, where God says (JPS translation): "'If thou wilt diligently hearken to the voice of the LORD thy God, and wilt do that which is right in His eyes, and wilt give ear to His commandments, and keep all His statutes, I will put none of the diseases upon thee, which I have put upon the Egyptians; for I am the LORD that healeth thee.'" That is, אני ד´ רופאך, I, God, am your רופא, your healer. But what sort of a healer cures diseases that have not been "put upon thee"? One which keeps the diseases from emerging in the first place. God the public-health worker? That would be an anachronism, unfortunately. God the faith healer makes more sense.

One more thing we need to understand: what does it mean to say "Honor your healer until you need him"? Jastrow lists a second meaning of the verb כבד, "to offer a gift." The healer is to be supported (financially!) by his community until such time as he's needed. Thus the prayer the Rabbis suggest in this midrash is in the nature of an investment. Prayer is "laid up" by the petitioner against a rainy day, or, rather, against the day when enemies come. (Maybe this provides the link between the verse in Job and the cited parable: the root ערך can also have the meaning "valuation.")

In other words, make sure to support your local healer. You never know when they might come in handy.

An unmistakable Divine message

Town and Village Synagogue: 334 East 14th Street.

Curly's Vegetarian Diner: Now at 328 East 14th Street.

The message:

Pray. Eat veggie nachos.

Why do African- and Hawaiian-Americans have a higher risk of lung cancer?
This article is illuminated by an accompanying background article in the Journal. See here, if you have NEJM access.

Ethnic and Racial Differences in the Smoking-Related Risk of Lung Cancer

Christopher A. Haiman, Sc.D., Daniel O. Stram, Ph.D., Lynne R. Wilkens, Dr.P.H., Malcolm C. Pike, Ph.D., Laurence N. Kolonel, M.D., Ph.D., Brian E. Henderson, M.D., and Loïc Le Marchand, M.D., Ph.D.

ABSTRACT

Background There is remarkable variation in the incidence of lung cancer among ethnic and racial groups in the United States.

Methods We investigated differences in the risk of lung cancer associated with cigarette smoking among 183,813 African-American, Japanese-American, Latino, Native Hawaiian, and white men and women in the Multiethnic Cohort Study. Our analysis included 1979 cases of incident lung cancer identified prospectively over an eight-year period, between baseline (1993 through 1996) and 2001.

Results The risk of lung cancer among ethnic and racial groups was modified by the number of cigarettes smoked per day. Among participants who smoked no more than 30 cigarettes per day, African Americans and Native Hawaiians had significantly greater risks of lung cancer than did the other groups. Among those who smoked no more than 10 and those who smoked 11 to 20 cigarettes per day, relative risks ranged from 0.21 to 0.39 (P<0.001) among Japanese Americans and Latinos and from 0.45 to 0.57 (P<0.001) among whites, as compared with African Americans. However, at levels exceeding 30 cigarettes per day, these differences were not significant. Differences in risk associated with smoking were observed among both men and women and for all histologic types of lung cancer.

Conclusions Among cigarette smokers, African Americans and Native Hawaiians are more susceptible to lung cancer than whites, Japanese Americans, and Latinos.

The Cherry Tree

1.

How many weeks of rest
with the sour cherries
before the summer sparks
what it can't have – sudden red
rising from the steaming ground

You can’t shut your eyes. They’re fixed
(though foreboding) on the ground forever
subsuming, reforming, engrossed in its layers
like a queen at her trousseau
again and again smoothing and folding knowing

thousand-root years bring growth and decay
to no conclusion but repetition.
Yet you stay to admire how this particular
season justifies itself before the magistrate
of the eye: distinct branches, self-defining trees

2.

Back now on peopled street: the mass is
miniature – diorama nestled in vastness.
This city is all facets’ fastness.

Back to kitchens and quick-wristed cooks which
train palates, tongues on new-thought dishes.

Back to those on battle pay, and
those who sent them, temples graying.

These wholes will lose their parts, but live as
cherry tree will have much to give us.

3.

The whole world an abstraction. This piece world
horizon not embracing but demanding
a sand-grained wind to tear the flag unfurled,
not suffering domestic understanding.
Domestic merely: home is not a womb
nor spouse a bosom friend. The unmet names
that know the truth of home are just in bloom
among those fields where runaway you came
to taste the flowers of what cannot be grown
except against the wall. Right there you found
what gardeners of every age have known:
since world is round its every part is round.
Each piece of fruit that stains the fingers orange
is only trap for seeds of future orange.

How to talk to people

Sick people, I mean.

MEDICINE MENSCH: So...? How Are Things?
By Zackary Sholem Berger
February 3, 2006

Do you like to talk to other people? Sometimes I do; it depends how many there are. If I'm at a party, I slink toward the chips and-salsa or talk only to my wife. (Wallflowers don't blossom; they just climb farther up the wall.) If I'm talking to a friend of mine, it can take me some time to shut up. But if I'm face to face with a person who's providing a paid service — a checkup, a haircut, a repair — I have to remind myself to use the pleasantries that keep ordinary conversation going. I clam up.

Now that I'm almost a doctor, and, more to the point, now that I'm starting a rotation called Ambulatory Care (outpatient medicine, where patients are seen in clinic), I'll get to see the entire range of patient-conversationalists. But I have to figure out how to talk just enough.

This is both easier and harder than it sounds. Easier because the person you're talking to gives signals; following those signals is a well-marked route to conversing in a non-annoying fashion. (If the patient is checking her watch, rolling her eyes, or — as in the movie "Airplane" — tying a noose round her own neck, it's a good sign that her patience is wearing thin.) Talking less is generally good advice in any situation. No one likes a bore, least of all a bore whose favorite topic is your illnesses. Even though patients would like to be fully informed, most of them would like their information in a few concise paragraphs, not in a long-winded discourse.

On the other hand, a doctor needs to talk to get his work done. A silent doctor, like a silent lawyer, invites suspicion. But so does talking: Like lawyer and client, doctor and patient never can have a normal conversation; each of them is waiting for the other word to drop. The patient dreads the openings "There's something you need to know" or "We need to take a look at that" in the same way that the doctor never can escape the "doorknob questions" that the patient remembers just when she's about to leave: "Oh, I've been meaning to ask you something"; "Just one more thing."

If the conversation starts off on the right foot, it won't be so fraught for the parties involved. The accepted pedagogy in medical school is that one must begin in an "open-ended" way, and only later "cone in" to more specific, useful questions. Translated from jargon, this means that ideally the physician would welcome the patient into the office, invite him to sit and then wait silently, like an oracle. If necessary, at the very most one can utter a single word: "Well?" or "So?" Thus encouraged, a patient will spill the whole story without undue interference from the doctor.

If this oracular opening actually were to be adopted in most doctors' offices, patients would get confused and think they wandered into the psychotherapy suite by mistake. I've tried it myself a couple of times, and it spooks the patient. Of course, there's a compromise available: You can start off without a torrent of detailed questions, but your intro can be friendly and personable.

I've tried to see which opener works best for me. There's "What brings you here today?" An old favorite, but I can never say it without thinking of the old, jokey answer: "A taxi, doctor." I could ask, "What seems to be the problem?" Fine, I suppose, but it's nothing I actually would say in the course of a normal conversation. "How are things?" I used that once, and the patient said "Fine, thanks" — and stopped talking right there. I had to restart the conversation from a standstill.

There's a difference between what's supposed to happen (according to the theory of the clinic visit) and what actually happens. According to theory, I open up in a general vein and then become more specific as the patient reveals her problems. But the truth is that our conversation only traces the surface of the problems affecting the patient. What people say to their doctors often doesn't point to the true nature of their ailment. An office visit that the doctor considers notably successful (a problem correctly diagnosed, inroads made into diabetes control or reduction of cardiovascular risk) can appear completely useless to the patient: Her annoying cough hasn't gone away, and her back still hurts.

This is the conundrum of outpatient medicine. Since the patients seen in hospitals (where young doctors get their start) are sicker on average than they were decades ago, the bulk of today's training is focused on keeping them alive, or, in rare instances, on curing them. But day-to-day clinic medicine (and the role of doctors throughout much of history) has been not to save lives but to improve them, to make the acute problem less acute and the chronic one easier to bear.

When residents talk, they often say that clinic patients are hard to deal with. Do they mean that hospitalized patients, with their long lists of potentially fatal medical problems, are easy to treat? Maybe it's that patients in clinic, with their multiple medium-sized problems, come with the same considerable challenges and small-scale opportunities that are present in any interaction. The aim is to make incremental improvements while keeping an eye out for those brief openings that allow a significant change for the good. For the average clinic visit of 10 minutes or so, that's plenty to talk about.

That's all we have time for today, I'm afraid. Same time next month?

Zackary Sholem Berger has another patient waiting, but he cares about you personally. Write to him at doctor@forward.com.

Take your bundle of [spice]...

I forgot, or more likely never knew, the meaning of אזוב (Exodus 12:22, שמות פרשת בא, ולקחתם אגדת אזוב). Onkelos translates it unhelpfully as איזובא. Saadiah Gaon says it means זעתר (za'athar), which Ibn Ezra translates as אוריגנו (origano/oreygano). (Ibn Ezra says of Saadiah's gloss that it "isn't likely" [זה לא יתכן] for Biblical and botanical reasons, but admits that he doesn't know what plant the word refers to.) Yidish-taytsh, I think, calls it אזובֿ, as does Yehoash.

The Septuagint renders the word as hyssopos 'hyssop.' Here's where I quote William H.C. Propp in Anchor Bible Exodus 1-18, where he chooses to call it "marjoram":

The LXX rendering . . . is based on the phonetic similarity to Hebrew 'ezob, a common translation technique for LXX (Tov 1979). But even when Hebrew and Greek words are truly related via borrowing, their meanings may differ slightly. 'Ezob is "Syrian hyssop" (Origanum syriacum l.) or marjoram, still used by Samaritans for Pesakh (Saadiah; Crowfoot and Baldensperger 1931). Greek hyssopos is a different plant altogether (Zohary 1982:96). A literalist might object that we should seek a native Egyptian plant, rather than a Palestinian, but no doubt later Israelite practice has been transplanted into an Egyptian setting.

The marjoram tuft, readily available (cf. 1 Kgs 5:13), is essentially a brush (Cassuto 1967:143 [this is also implied in the commentaries of Ibn Ezra and Saadiah -- ZB]). Segal (1963:159) and Jacob (1992:328) plausibly infer that it insulates lay officiants from the dangers of the holy; true priests, in contrast, manipulate blood with their fingers. Marjoram is also used to apply blood in ritual purifications (Ps 51:9), particularly from skin disease (Leviticus 14 passim) and death (Num 19:18, cf v 6). According to Heb 9:19, it was also used for the Covenant ceremony of Exod 24:8.

What relationship Saadiah's term za'athar has to modern-day zaatar, and why marjoram is called Origanum (so what's oregano, then?), are puzzles for wiser minds to solve.

Oh, here's a useful note:

In the countries of the Eastern Mediterranean, there is often no clear distinction made between a couple of aromatic herbs of the mint family: Names like Turkish kekik or Arabic zatar/satar [زعتر, صعتر] and related forms in Hebrew and Persian, often in conjunction with qualifying or descriptive adjectives, may be applied to a varity of native herbs including, but not restricted to, oregano, marjoram, thyme and savory. Usage may vary even within a given language, depending on the region and particularly on the local flora. In Jordan, zahtar usually means a spice mixture containing such herbs (see sumac for more).