Study with Rabbi Perlin (4/2/2020)

August 3, 2019

Public Health and the Public Good in Jewish Sources

Study with Rabbi Amy R. Perlin, D.D. during the Covid-19 Pandemic

Thursday, April 2, 2020  @1 P.M.

The Allocation of Scarce Resources, and the Individual Versus Societal Ethics

Brian Glenville, a London heart surgeon, gives an excellent insight into some of the problems facing physicians on a daily basis.  He states:

Planning for intensive care is… a problem.  We have a fixed number of beds and if I do not plan my week in a fairly crude and harsh manner, I will not be able to practice.  If I operate on an eighty-three-year old who needs a double valve replacement, she will occupy an intensive care bed for five days. If I select that patient for Monday, her bed will not be available to me until Saturday. If I perform that operation on Friday, there is a good chance that I might be able to get her to a High Dependency Unit on the following Monday. If so, I will be able to carry on with the list. If I operate on a Monday, I am stopping four CABG (bypass) patients who would have zipped through on Tuesday, Wednesday, Thursday, and Friday.

Yearbook of the Centre for Medical Ethics, Nisson Shulman, ed., Jews’ College, London, Vol. 1, 1993, p. 113

Rabbi [Moshe] Tendler discusses the question of triage in connection with the allocation of scarce medical resources and develops the discussion as follows: Triage at the societal level is a series of conflicts of one good against another, rather than good versus bad.  Everyone seeks to heal, but everyone has his own priority in achieving this goal.  In this series of conflicts of good versus good, the individual must react differently than society may, for there is more to society than the individuals in it. Rabbi Tendler marshals two talmudic texts to support his thesis:

Triage decisions are made between two communities – one has water, the other does not (Nedarim 80b). They are made between two departments – who gets the allocation of funds?

A town on a hill was successful in digging a well and a town lower down was not. Of course there is moral obligation on the town above to provide water for both towns.  You cannot let the other town die.  If the higher town had only enough for itself, then the town below should move.  If the town above had enough for both only if they refrained from laundering their clothes, then the Talmud rules that the town above should wash its clothes and not provide water to the lower town. Why?  Because in the long run, it is impossible to survive without washing your clothes.  The immediate danger is to the lower town. The long-range danger affects both towns equally. Typhus would certainly decimate the higher town in time if not one washed their clothes.

(Talmud, Nedarim 80b, 81a)

Society differs from the individual in the timescale that it uses for decisions.  An individual responds to the problem at hand. Society has a long-range view. Society must deal with its future survival.  Of course, each individual should worry about the future of society, but the individual’s decision-making process concentrates on the here and now.  The long-range view must be taken by society.  [What is a leader of society obligated to do?]

But triage decisions between one generation and those yet unborn must also be made.  With all our modern technology, we have great difficulty in disposing of radioactive waste.  Can we seal in cement canisters and sink it into the sea?  We have enough technology now to hide waste for five hundred years. But what happens after that? What about the yet-unborn generations?  After five hundred years, how many people will develop leukemia and how many will have malformed children? Whose concern is this? Do triage concerns extend to other generations?  Of course, they do.  The individual must place the immediate problem of saving life first.  Society can be excused if it considers the future first.

Rabbi Moshe D. Tendler, “Rabbinic Comment: Triage of Resources,” The Mount Sinai Journal of Medicine, Vol. 51, No. 1 (Jan.-Feb. 1984),  p. 106-109  quoted in Pioneers in Jewish Medical Ethics, edited by Fred Rosner, M.D., Jason Aronson Press, 1997, p. 217-18 and Jewish Answers to Medical Ethical Questions:Questions and Answers from the Medical Ethics Department of the Office of the Chief Rabbi of Great Britain, by Nisson E. Shulman, Jason Aronson, Inc., 1998, p.152-4.

Do states have to share ventilators? 

Do the states that need them the most get them? 

Can states hold onto them if they believe this is not over and we will be faced with all of this again in the fall?

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Are we allowed to prioritize the young or those without pre-existing conditions when triaging limited medical resources according to Jewish sources?

In any moral system there must exist a hierarchy of values or a set of rules which enables a person to determine which of two or more conflicting principles must be subordinated to the another. Jewish law bestows a privileged position upon the preservation of human life as a moral value.  As a moral desideratum it takes precedence over virtually all else [except murder, idolatry, and sexual offenses].  All purely ritual laws are suspended for purposes of conservation of life.  Even the mere possibility of saving human life mandates violation of such laws (Orech Hayyim 329:3)…The quality of the life which is thus preserved is never a factor to be taken into consideration. Neither is the length of the survivor’s life expectancy a controlling factor.  Judaism regards not only human life in general as being of infinite and inestimable value, but regards every moment of life as being of infinite value.

Rabbi Dr. J. David Bleich, Contemporary Halakhic Problems (Library of Jewish Law and Ethics, Vol. IV,, KTAV, 1977, p. 129f.

Many authorities say we cannot choose.  We must accept either such principles as first come first served, or random selection, or a lottery, or some other arbitrary measue.  Rabbi Moshe Feinstein was asked about eight meningitis patients at Hadassah Medical Center. Penicillin had just arrived, but there was only one dose, enough for eleven injections.  Without even thirty seconds’ hesitation he answered, “The first bed the doctor comes to.” (Responsa Iggrot Mashe, No. 251)

…There is no argument that choices must be made. There is a great deal of opposition to succumbing to social pressure that perceives some as worth more than others, whether because of contribution to society, age, quality of life, number of dependents, sex, marriage, intelligence, race or any other criterion.

Yet, in the real world there are finite resources, and what can we do?…

Given a set of priorities, preferably set by the hospital and not be the individual physician, and given the assumption that highest or very high on that priority list is the patient who already had the procedure and has now relapsed, may the individual doctor remove a patient from such a high priority if the damage done is his own fault?  May a doctor warn a patient with the words, “If you persist in smoking and it causes you a setback, I call that suicide and I don’t want to know you. You’ll wait till the end of the line.”  After all, such patients who do not heed their warnings are harming themselves. Do they forfeit their place?

Jewish Answers to Medical Ethical Questions:Questions and Answers from the Medical Ethics Department of the Office of the Chief Rabbi of Great Britain, by Nisson E. Shulman, Jason Aronson, Inc., 1998, p.151-6.

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Should America help other nations who are our enemies?

Rabbi Alexandri said,

Two donkey drivers who hated each other were walking on a road when one of the donkeys collapsed under its burden. The other driver saw this but continued on his way.  But, then he reflected: “Doesn’t the Torah say, ‘If you see the donkey of one who hates you lying flat under its load and [your inclination is to] refrain from raising it, you must nevertheless raise it with him’ (Exodus 23:5)”  So he returned, lent a hand, and helped his enemy to rearrange the load.  He began talking to his enemy:  “Loosen it a bit here, pull a little tighter here, unload over there.”  Before long peace developed between the two of them, so that the driver of the unloaded donkey reflected, “I thought he hated me, but look how compassionate he was.”  By the by the by, the two entered an inn, ate and drank together, and became friends.  What caused them to make peace and become friends?  Because one of them kept what was written in the Torah.  Hence, “You have established harmony.” (Psalm 99:4)

From Striving Toward Virtue: A Contemporary Guide for Jewish Ethical Behavior, by Rabbis K. Olitzky and Rachel Sabath, KTAV, 1996, p.100-101.