Can religion provide boundaries that extend beyond those of clinical psychiatry?
I feared the worst when my ordinarily reliable patient did not respond to my emails. No, not the worst, since suicide is definitely the worst, and suicide was very low on my differential, given this individual’s unwavering will to live, even under the direst circumstances. Still, doctor discussion boards frequently comment about ways to cope with a patient’s suicide, so this dreaded outcome is clearly high on the radar of many psychiatrists. Earlier in the pandemic, it was not uncommon to hear my residents detail their distress from witnessing so many patients succumb in New York City, which suffered far more than its fair share of pandemic fatalities. Back in the 1980s, and even into the 1990s, I myself lost several patients—as well as medical colleagues—during the AIDS epidemic.
Perhaps there is something about epidemics and mass fatalities that either inures one to such losses or at least leads one to brace for them and prepare for them. Consultation-liaison (C-L) psychiatrists who work in hospital settings no doubt confront end-of-life issues and patient deaths on a regular basis, as do psycho-oncologists, geriatric psychiatrists, and psychiatrists who work in hospice and palliative care settings. But for me, as an outpatient psychiatrist in private practice, it is rare to follow a long-term patient through a life-threatening medical illness that required extensive treatment, but which eventually ended—not 2 weeks after the original diagnosis, as predicted by a surgeon at a general hospital—but 2 years later instead, thanks to aggressive medical interventions available at a specialty hospital known for its “Hail Mary” approaches to otherwise incurable medical conditions.
During those years, this patient shared far more of their hopes and fears, their achievements, and their aspirations than they had disclosed in the years before when they confronted psychiatric symptoms alone, without any hint of what was to come. The last appointment focused on the escalating pain that they endured during their recent hospital stay—yet this individual retained their dignity and humanity just the same.
When this punctilious patient did not confirm their biweekly appointment despite repeat emails, a veil of dread descended on me. Eventually we reconnected, and they told me of a 2-week hospitalization admission that impeded access to cellphones. Hearing of a 2-week stay in a tertiary care hospital was ominous enough, but not hearing back from the patient after their last appointment was even worse. At the patient’s request, I had forwarded contact information for 2 pastoral counselors, but did not get the expected acknowledgement from this typically gracious individual who recently asked me to pray for them—even though they knew that we practiced different religions and they were quite committed to their own religious traditions.
“Any prayers would help,” the patient importuned, undeterred by any religious differences. Those were desperate words, spoken when one senses that one’s time is coming to a close.
Even though the last appointment had not been confirmed, I phoned the patient just the same. When my patient’s phone did not answer at our usual time, I left a voice message, consoling myself that their voice message remained active, yet still wondering about the worst. Then I dialed the spouse’s phone number, knowing that it was time to reach out to the emergency contact whose name had been listed several years before. That phone answered immediately. I introduced myself, and the spouse acknowledged me just as immediately. They addressed me by name, as if they were expecting my call. Without delay, they delivered the worst news—news that I was expecting, yet dreading to hear.
After wiping my tears, stifling my spontaneous sobs, and hearing the unrestrained sobs of the spouse, we spoke for a while, using the time that I had set aside for my now deceased patient’s appointment and knowing that they and I would never have another appointment.
My initial inclination, after ending that call, was to say Kaddish, the Jewish prayer for the dead, but I stopped myself—but not because the patient was not Jewish. The patient had, after all, beseeched me to add a prayer for the sick at the Saturday morning Sabbath service at the synagogue, although they themselves followed a very different faith. It was not a matter of religion that stopped me. My second thought was about boundary-breaking, which itself is close to a cardinal sin in psychiatry.
It is always difficult to draw the fine line between compassion and caring and overreaching in clinical care—but exceptional circumstances permit more wiggle room than is ordinarily accorded. I considered consulting the American Psychiatric Association’s (APA’s) committee on Religion and Spirituality. It crossed my mind to call my rabbi to ask for advice—until I remembered that one says Kaddish for 7 people only: a spouse, a son or daughter, a sister or brother, or a mother or father. (Those gender-specific rules were devised long before nonbinary identities came into being.) Some people say Kaddish for those who perished in the Shoah/Holocaust without leaving survivors.
In orthodoxy, only men say Kaddish, and female mourners are expected to find a male to pray on their behalf. This tradition is so ingrained that some 19th-century Yiddish authors, writing in first person, refer to their son as “my Kaddish”—and do not allude to “my son, the doctor,” like the more Americanized stereotypes. For having a son—rather than a daughter—ensured that a parent’s memory would live on forever when the son recited this prayer for the dead.
Gender roles, sexism, and religious regulations aside, there were other valid reasons for my hesitation. If people said Kaddish for anyone and everyone who passed, the world would be in a constant state of mourning, and that is not the goal of most religions (except perhaps world-renouncing religions that aspire to such sad states). But there was another, equally important reason it was not appropriate to me to say Kaddish for this patient—or for any other patient. Even though this patient’s passing caused me such pain, my saying Kaddish would imply that I felt the same degree of grief as the bereaved spouse, and that presumption would disrespect the spouse’s distress. Having never been widowed, I could barely imagine how painful it must be to lose one’s spouse, especially one so young.
And so, I answered my own question without consulting a rabbi or a committee on religion: No, it is not appropriate for psychiatrists to say Kaddish for their patients. I cannot speak about mourning practices in different traditions—and I am well aware that there are many, many varieties of Jewish practice and belief as well—but I felt relieved to realize that the rules of my own religion provided useful boundaries that went beyond the clinical practice of psychiatry. To channel my distress, I drafted this article instead, expecting that other psychiatrists have encountered similar dilemmas themselves, and perhaps this piece will help them put their own situations in perspective.
Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.