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ShareTwo weeks ago, Italy had 322 confirmed cases of the coronavirus. At that point, doctors in the country’s hospitals could lavish significant attention on each stricken patient.
One week ago, Italy had 2,502 cases of the virus, which causes the disease known as COVID-19. At that point, doctors in the country’s hospitals could still perform the most lifesaving functions by artificially ventilating patients who experienced acute breathing difficulties.
Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.
Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow as these already extraordinary circumstances worsen. The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”
The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.”
Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”
In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”
These guidelines apply even to patients who require intensive care for reasons other than the coronavirus, because they too make demands on the same scarce medical resources. As the document clarifies, “These criteria apply to all patients in intensive care, not just those infected with CoVid-19.”
רוצח גופיה מנא לן סברא הוא דההוא דאתא לקמיה דרבה ואמר ליה אמר לי מרי דוראי זיל קטליה לפלניא ואי לא קטלינא לך אמר ליה לקטלוך ולא תיקטול מי יימר דדמא דידך סומק טפי דילמא דמא דהוא גברא סומק טפי
The Gemara asks: From where do we derive this halakha with regard to a murderer himself, that one must allow himself to be killed rather than commit murder? The Gemara answers: It is based on logical reasoning that one life is not preferable to another, and therefore there is no need for a verse to teach this halakha. The Gemara relates an incident to demonstrate this: As when a certain person came before Rabba and said to him: The lord of my place, a local official, said to me: Go kill so-and-so, and if not I will kill you, what shall I do? Rabba said to him: It is preferable that he should kill you and you should not kill. Who is to say that your blood is redder than his, that your life is worth more than the one he wants you to kill? Perhaps that man’s blood is redder. This logical reasoning is the basis for the halakha that one may not save his own life by killing another.
לְפִיכָךְ נִבְרָא אָדָם יְחִידִי, לְלַמֶּדְךָ, שֶׁכָּל הַמְאַבֵּד נֶפֶשׁ אַחַת מִיִּשְׂרָאֵל, מַעֲלֶה עָלָיו הַכָּתוּב כְּאִלּוּ אִבֵּד עוֹלָם מָלֵא. וְכָל הַמְקַיֵּם נֶפֶשׁ אַחַת מִיִּשְׂרָאֵל, מַעֲלֶה עָלָיו הַכָּתוּב כְּאִלּוּ קִיֵּם עוֹלָם מָלֵא.
Therefore, Adam the first man was created alone, to teach you that with regard to anyone who destroys one soul from the Jewish people, i.e., kills one Jew, the verse ascribes him blame as if he destroyed an entire world, as Adam was one person, from whom the population of an entire world came forth. And conversely, anyone who sustains one soul from the Jewish people, the verse ascribes him credit as if he sustained an entire world.
ורבי יוחנן האי וחי אחיך עמך מאי עביד ליה מבעי ליה לכדתניא שנים שהיו מהלכין בדרך וביד אחד מהן קיתון של מים אם שותין שניהם מתים ואם שותה אחד מהן מגיע לישוב דרש בן פטורא מוטב שישתו שניהם וימותו ואל יראה אחד מהם במיתתו של חבירו עד שבא ר' עקיבא ולימד וחי אחיך עמך חייך קודמים לחיי חבירך
מתני׳ האשה קודמת לאיש לכסות ולהוציא מבית השבי בזמן ששניהם עומדים בקלקלה האיש קודם לאשה:
MISHNA: A woman precedes a man with regard to which of them to provide with a garment first, because her humiliation is great, or to release from captivity first, due to the concern that she will be raped. When they are both subject to degradation, i.e., there is also concern that the man will be raped in captivity, the release of the man precedes the release of the woman.
מתני׳ כהן קודם ללוי לוי לישראל ישראל לממזר וממזר לנתין ונתין לגר וגר לעבד משוחרר אימתי בזמן שכולם שוים אבל אם היה ממזר תלמיד חכם וכהן גדול עם הארץ ממזר תלמיד חכם קודם לכהן גדול עם הארץ:
MISHNA: A priest precedes a Levite. A Levite precedes an Israelite. An Israelite precedes a son born from an incestuous or adulterous relationship [mamzer], and a mamzer precedes a Gibeonite, and a Gibeonite precedes a convert, and a convert precedes an emancipated slave. When do these halakhot of precedence take effect? In circumstances when they are all equal in terms of wisdom. But if there were a mamzer who is a Torah scholar and a High Priest who is an ignoramus, a mamzer who is a Torah scholar precedes a High Priest who is an ignoramus, as Torah wisdom surpasses all else.
ענייך ועניי עירך ענייך קודמין עניי עירך ועניי עיר אחרת עניי עירך קודמין
From the term: “Who is with you,” it is derived: If your poor person, meaning one of your relatives, and one of the poor of your city come to borrow money, your poor person takes precedence. If it is between one of the poor of your city and one of the poor of another city, the one of the poor of your city takes precedence.
The life of someone who can be saved and live a normal life gets precedence over someone who is dying and the physician is unable to cure, but the dying patient does not have an obligation to save someone else with his life, and if he was treated first he does not have to give up his place.