COVID-19, the disease outbreak caused by the new coronavirus, has already pushed health care systems to their limits. Overburdened American doctors may have to rely on triage, a system of prioritizing patients — and ultimately, lives — over one another.
Looking from the outside, triage medicine can appear heartless and arbitrary. For doctors, it can be agonizing. Medical professionals must grapple with these weighty decisions in the moment, and face the psychological and emotional effects later on as well.
No one, in or outside the medical profession, needs to make these considerations in a vacuum. Students of a sub-branch of traditional rabinic law, or halacha, have debated these ethical dilemmas for centuries. Medical halacha applies Talmudic principles like pikuach nefesh to medicine, resolving quandaries for patients and practitioners alike. Experts say that it may help us cope with the effects of coronavirus, too.
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“Triage decisions are amongst the most difficult to make because a person is basically saying, ‘I’m going to decide who’s going to get a treatment, who will live in, and unfortunately, rachmana litzlan, who is not going to get this treatment and who might not live as a result of that,’” said Rabbi Dr. Aaron Glatt, the chair of medicine and hospital epidemiologist at Mount Sinai South Nassau. “From my perspective, knowing that I’m doing what the halacha says takes a lot of the ‘guilt’ and difficulties and decisions off me.”
Because human life is valued above all else, only a handful of rabbis living and dead are considered to have the authority to decide situations involving triage. Multiple rabbis contacted for this story requested that their comments not be on the record, or insisted a different rabbi comment instead, as they did not feel that they had the authority to speak on these decisions.
The gravity with which these decisions are taken is one of medical halacha’s most helpful aspects, said Rabbi Jason Weiner, senior rabbi and director of the Ceders-Sinai Spiritual Care Department.
“[A halachic expert] earns that kind of authority and respect because they’ve proven themselves to be sincere and authentic and knowledgeable and caring, and God-fearing,” he said’. “Sometimes, you just need someone who has that knowledge and that communal authority.”
Three basic principles underlie the halachic debate around triage: pikuach nefesh, ein ma’avirin al hamitzvot, or, “you cannot bypass a mitzvah,” and ein dochin nefesh mipnei nefesh, “you cannot choose between lives.” Interpreted literally, ein ma’avirin al hamitzvot means that a person should always choose the mitzvah — the commandment — that is closer to them, if presented with two simultaneously. “Closer” can encompass physical distance, temporality, or strength of an interpersonal relationship. The meaning of ein dochin nefesh mipnei is alternately summarized as “you may not kill to save another,” and it is often applied to issues surrounding organ donation.
In instances where these principles are in seeming conflict with one another, thinkers stretching back centuries have passed judgment on hyper-specific scenarios. Taken together over time, these rulings form a decision-making hierarchy similar to the structure of triage itself.
One difference between a halacha-endorsed triage and what doctors in Italy, where the pandemic has forced doctors to triage patients, is how the elderly are treated. On an episode of the New York Times podcast, “The Daily” from March 17, Fabiano Di Marco, a doctor treating coronavirus patients in Bergamo, said that all the beds in the intensive care unit were being assigned to younger patients who had a higher chance of surviving the illness.
“If you are 85, I give the bed to another one who is 45,” he told host Michael Barbaro.
But age is not a consideration in assigning triage according to halachic principles, because of the dictate that one cannot choose between lives. In a chapter on triage from the book “Dangerous Disease and Dangerous Therapy in Jewish Medical Ethics” by Rabbi Dr. Akiva Tatz, the medical halachic scholar writes that “[e]ven extremely old patients must be treated fully and aggressively, and even where a patient himself claims advanced age as a reason to be allowed to die, such a claim is not valid.”
Priority of care is instead given on a first-come, first-serve basis as dictated by the principle of not bypassing a mitzvah, though this rule is malleable and subject to interpretation depending on the scenario.
What about doctors faced with a limited numer of ventilators? Once a person is placed on a ventilator, the principle against choosing between lives holds that the ventilator cannot be removed and given to someone else, no matter how terminal the first person’s illness is. Indeed, any sort of action that results in a person’s life being taken would run counter to the principle
These structured teachings can help us today. Weiner said that doctors and nurses at the frontlines of the pandemic may experience significant moral trauma. Even if they themselves are not Jewish, he added, knowing that there has been a tradition of thinking through these sorts of questions may provide comfort and assuage any guilt they feel. Glatt agreed.
“I think I think it’s easier to live with [for] that person making the decision, knowing that you did exactly what God wanted you to do, and you can never go wrong if that truly is the case,” Glatt said.
“It doesn’t mean that you’re not sad for the family that unfortunately was hurt or not helped. It doesn’t mean that you don’t cry over the pain and suffering that resulted, and the mourning that might result, but from a ‘Did I do the right thing?’ standpoint, I think one can say, ‘Yes, I did the right thing.’”
Maddie Bender is a science journalist whose work has appeared in VICE, CNN, and Massive Science. Follow her on Twitter @MaddieOBender
What Jewish medical ethics can teach us about coronavirus