What criteria should be used to determine which population groups in the United States should be first to receive the COVID-19 vaccines once they receive final FDA approval? Throughout the course of the pandemic, ethicists have debated the allocation of ventilators and personal protective equipment (PPE).
One scholar considering these issues from a Jewish perspective is Rabbi Dr. Elliot Dorff, American Jewish University (AJU) Professor of Philosophy and ethics scholar. As chair of the Conservative Jewish movement’s Committee on Jewish Law and Standards and a former member of the ethics committee of Hillary Rodham Clinton’s Health Care Task Force, Rabbi Dorff has considered the intersection of public health and ethics and the ways in which Jewish wisdom can be applied to the pandemic response.
“The concept of regular medical ethics in the United States is based on Western philosophy,” Rabbi Dorff explained. “Life, liberty and the pursuit of happiness are the gold standards. Medical decisions are based on what the patient wants. Patients can refuse medical intervention but can’t demand it. Decisions can be based on doctor-patient interactions, advanced directives and directions from surrogates. In the U.S., I own my own body, but in Jewish law, G-d owns my body, and I don’t have the right to harm or damage it.”
He added, “The two traditions come from different perspectives, but they sometimes come to the same conclusions for different reasons.”
In the current situation, Rabbi Dorff said that the state of California has issued guidelines for the distribution of healthcare based on the concept of triage. As he explained in “Triage in the Time of a Pandemic: The Sanctity of Saving as Many Lives as Possible,” written as a guideline for Jewish medical ethics for the pandemic in the Conservative movement, “The term used for deciding whom to save and whom to ignore is ‘triage.’ It comes from the military environment, where medics had to decide which wounded soldiers on the battlefield they should try to save and which ones they unfortunately had to ignore. The general rule of triage that comes out of that environment is this: without regard to rank or other element of social status, pay attention first to those who need immediate attention in order to survive and, among those, treat first the ones who have the best chance of survival so that they can continue to fight if helped to survive now.”
The document continued, “Ancient sources in the Jewish tradition also spoke of triage, but not in a medical context. That is because although ancient and medieval medicine was remarkably good at preventive techniques, its curative capabilities were largely ineffective. Thus Leviticus 13-14 already understands that quarantine should be used to contain contagious diseases, and the Talmud tells us to avoid crowds during epidemics—remarkably astute advice for our time.”
Rabbi Dorff explained that California has issued guidelines on the distribution of healthcare that are designed to save as many lives as possible. They begin with doctors, nurses, and other front line personnel; then secondary essential workers, including suppliers, drivers, grocers and stockers; then the most vulnerable populations, including people older than 65, people with lung problems and other pre-existing conditions and overweight people; and then less vulnerable populations, which means everybody else.
Earlier in 2020, Rabbi Dorff and Rabbi Daniel Nevins debated the questions of how Jewish medical ethics from the Conservative perspective played into the situation. In “P’sak Din: Consensus Halakhic Conclusion by Rabbis Dorff and Nevins,” Rabbi Dorff wrote, “Our respective responsa addressed many of the medical, logistical, moral and spiritual challenges of medical triage in a crisis such as the COVID-19 pandemic. While our presentations differ in approach and presentation, and we reach some incompatible positions, we agree on the following practical conclusions:
1. Equal access to medical care is a moral and halakhic imperative. Triage decisions must not be based on criteria other than the best chance to save lives.
2. Scarce resources used to prevent infection such as personal protection equipment and vaccines may be assigned on a priority basis to medical professionals and other emergency responders in order to support them in their life-saving efforts.
3. Jewish law differentiates between brief respite and recovery. Scarce medical resources may be directed toward patients who are expected with this therapy to recover over those who are not expected to recover, even with this therapy. Diagnostic tools such as the Sequential Organ Failure Assessment may be used to prioritize allocation of scarce medical resources towards patients who may be rescued, and away from those who are not expected to survive to hospital discharge.
4. If a patient is already receiving medical therapy and is responding, they may not be removed from the equipment prematurely in order to rescue the life of another person based on comparison of the two patients’ age, abilities, general health or social status. The only criterion for removing a person from therapy is the determination that they cannot survive to discharge, or their own request to shift to palliative care.
5. If the triage officer determines that a patient cannot be saved, and that their medical resources must be reallocated to another patient in urgent need, the basis for this decision must be explained fully and sensitively to the patient or their representative, and the hospital must continue to support the patient with appropriate palliative and pastoral care, maintaining the respect and dignity of the patient until the end.
In terms of palliative care at the end of life, the different streams of Judaism have different viewpoints. “Most Orthodox believe that every moment of life is precious, and we must do everything to keep the body functioning, but some scholars say that one can engage in hospice care if the patient has not been intubated,” Rabbi Dorff explained. “Conservative rabbis agree that life support systems can be withheld or withdrawn in the best interests of the patient. In Reform Judaism, individual autonomy is the guiding factor, but individuals may consult a rabbi or a responsa committee.”
According to Rabbi Dorff, the distribution of vaccines will be handled similarly in Israel. COVID policy in Israel is being run by a group of government ministers, he said.
Rabbi Dorff believes that Jewish medical ethics have impacted secular medical ethics, because “a lot of Jews are involved in medicine, and a lot are involved in making policy. It comes out of our tradition. Jews are interested and involved in healthcare, because they believe that doctors are the agents of G-d in the healing process and the prevention of disease.”
ILENE SCHNEIDER is a contributing writer to JLife Magazine.