triage in Jewish thought

One of the classes I took at Hadar this week was on making triage decisions -- nicely, and explicitly, topical. The class was taught by Rabbi Ethan Tucker. These are some assorted notes, not a proper write-up.

At the beginning of the class, he asked participants to list things we thought might be factors in deciding which of two patients in dire need gets the ventilator. Other people said age (prefer the younger person), overall health (bias against the person with other illnesses), family status (bias in favor of the person with children to take care of), "merit" in various forms (bias against the drug addict, bias for the "important" person, etc), who you think has a better prognosis of this illness (regardless of other factors), and more I'm not remembering. I said: who got there first or, failing that, lottery. This was not a popular suggestion.

We examined a bunch of sources, some of which were familiar to me from a previous class about programming self-driving cars (whom should the programmer prioritize in an impending accident?). Some key points:

• All human life is precious, and you can't kill someone else to save yourself (except some special cases not applicable here). If the governor points a gun at your head and says "kill so-and-so or I'll kill you", you take the bullet. Who's to say your blood is redder than his?

• So that your fellow lives with you: two men and one water bottle in the desert; if they share it both will die, but if one drinks all of it he will live. Ben Peturi says they should die together; Rabbi Akiva says the owner of the bottle should drink all of it, citing a verse about your fellow living with you, meaning your own life is your top priority. Ben Peturi says we all go down together and don't even toss a coin to decide. The Chazon Ish extends Rabbi Akiva farther and says that a third party in the role of deciding (like a triage officer) must give a scarce resource (like medicine) all to one person so that somebody will live. One full life (chayei olam) is better than two people living for just a few more hours each (chayei sha'ah).

• But don't infer life-years from that, saying that the younger person has longer to live yet and so gets priority over the elderly. Even when we talk about people with terminal illnesses, the distinction is only between "expected to die within the year" and "longer". There are no further gradations. (By the way, the literature refers to the person expected to die within the year as a t'reifah.)

• If a mob demands that a group turn over one of its own to be killed or they will all die, they can't do it. They don't get to decide, even by lottery, who should die so the rest of them can live. There is an opinion that they can turn over one to save many, but then there's a response that this is only for someone who is subject to death anyway (the walking dead). The sources here talk about one liable to the death penalty (Sheva ben Bichri is the case they cite), but it's also been applied to one who is terminally ill in the short term. There is also a story of Eliyahu rebuking a sage who followed that, saying, basically, "yes you're allowed but that is not what a pious person would do". (The Rambam codifies this as: if he's guilty of a capital crime you can turn him over but shouldn't; in any other case you can't.) And this is all about handing someone over; nobody says that it would be ok to actively kill the person (go back to redder blood).

• You can violate Shabbat to save a life (any human life, even the walking dead), even if you are only concerned that there might be danger. But if you have to choose, you prioritize the one you will definitely save over the one you might save. This was in an 18th-century source (P'ri Megadim) which was the first one we saw where prognosis enters the picture.

• A 19th-century source (Badad -- yeah, I have to look all these up; I don't know who that is) says you can't prioritize one soul (nefesh) over another, but a terminally-ill person doesn't count as a nefesh and has lower priority (!).

• We discussed active killing versus passively letting someone die. (Insert abortion discussion here.)

• R' Moshe Feinstein (modern): if two come at once we give priority to the one we can help more fully (the one who needs it more for this illness), provided the situation is urgent and care must start right now. But if you've already admitted the first one and given him a bed, you can't take it away to give it to someone else. This is true even if the hospital made a mistake in giving him the bed; what's done is done. It's true even if he bribed someone to get the bed. The patient has no obligation to save someone else, at the cost of his own life, by giving up the bed (jug of water). Even if he's not paying (has no insurance), he has acquired the right to be saved. Every minute of every human life is of infinite value, so there is no basis for valuing one life over another. And this is true even if another otherwise-healthy person comes, one who will definitely die if he doesn't get treatment -- you allow the person already in the bed to live another hour even if the other will definitely die. One is obligated to save anybody to the utmost of one's ability. Also, no life-years games; age isn't a basis. If it's truly a tie, hold a lottery.

Who knew my instincts would line up with R' Feinstein's conclusion?