Rav Schachter's Landmark Teshuva on Ventilator Triage Mekor Sheet

Rabbi Haim Jachter

Rav Schachter's Landmark Teshuva on Ventilator Triage

At the peak of the Covid-19 pandemic in April 2020 there were hospitals worldwide that did not have sufficient respirators to handle the flood of arriving Covid patients. Hospitals were faced with the unenviable task of having to decide “Mi Yichyeh UMi Yamut”, who will live and who will die. In the midst of this horror, Rav Hershel Schachter stepped in and issued dramatic rulings as to how to manage these horrifying dilemmas1.

Kudos to Rav Schachter, who along with other leading Poskim such as Rav Asher Weiss, Rav Mordechai Willig and Hacham Yitzhak Yosef, provided desperately needed guidance for this and a myriad of other Halachic issues that emerged as the world confronted the onslaught of the Corona virus in 2020.

Nine Introductory Concepts

Nine basic Halachic concepts must be clarified In order to grasp the significance of Rav Schachter’s Pesakim.

האישה שהיא מקשה לילד--מחתכין את הוולד במעיה, - Mishna Ohalot 7:6 .1 ומוציאין אותו אברים אברים: מפני שחייה קודמין לחייו. יצא רובו--אין נוגעין בו, שאין .דוחין נפש מפני נפש

This Mishna teaches that we are forbidden to kill in order to save the life of another.

מאי חזית דדמא דידך סומק טפי דילמא דמא דההוא גברא סומק - 25b .2 טפי

The reason we may not kill one to save another is the famous Talmudic teaching “How is one to know if one’s blood is redder than another.

1 https://www.yutorah.org/sidebar/lecture.cfm/951531/rabbi-hershel-schachter/piskei-corona-15-triage-in- medical-decisions-updated-/

האיש קודם לאישה להחיות, ולהשיב אבידה. - Mishna Horiyot 3:7 and 8 .3 והאישה קודמת לאיש לכסות, ולהוציא מבית השבי; ובזמן ששניהן עומדין בקלקלה, האיש קודם לאישה

כוהן קודם ללוי, לוי לישראל, ישראל לממזר, וממזר לנתין, ונתין לגר, וגר לעבד משוחרר. אימתיי, בזמן שכולן שווין; אבל אם היה ממזר תלמיד חכמים, וכוהן גדול עם .הארץ--ממזר תלמיד חכמים קודם לכוהן גדול עם הארץ

These Mishnayot set forth a list of who enjoys precedence to save before the other. Priorities include a Kohen before a Levi and a Levi before a Yisrael.

כל המקיים נפש אחת, מעלים עליו כאילו קיים עולם - Mishna 4:5 .4 מלא

The Mishna famously teaches the infinite value of each life as an “entire world”.

5. Rav Moshe Feinstein – Early 1950’s Ruling Regarding Penicillin .( 43a) אין מעבירין על המצוות :Distribution

An oft-cited Halachic principle is that one does not bypass Mitzvot. In one well known example, a man places his Talit before donning Tefillin, but if by mistake he encounters the Tefillin first, he may not leave the Tefillin in favor of his Tallit. In this light of this rule, Rav Moshe Feinstein2 told Israeli Ashkenazic Chief Rabbi Yitzchak Herzog3 that doctors with a limited supply of penicillin should provide the medicine to the first patients he encounters in the hospital.

(Chullin 10a) אין ספק מוציא מידי ודאי 12b) and) ברי ושמא ברי עדיף .6

The Halacha assigns priority to those with a high chance of survival over those with a lower chance of survival (Rav Akiva Eiger to Yoreh De’ah 339:1 s.v. V’Chol HaMe’ameitz).

2 Cited in Kevod HaRav page 169. 3 Rav Herzog consulted Rav Moshe when the first small quantities of penicillin reached hospitals in Eretz Yisrael and there was insufficient of this life saving medicine for all those in need. ומנא תימרא דלחיי שעה לא חיישינן דכתיב )מלכים ב ז( אם - Avoda Zara 27b .7 אמרנו נבוא העיר והרעב בעיר ומתנו שם והאיכא חיי שעה אלא לאו לחיי שעה לא חיישינן

This accords value of a normal life expectancy (“Chayei Olam”) over only a very brief life expectancy (Chayei Sha’ah). Rav Moshe Feinstein (Teshuvot Igrot Moshe 3:36) defines Chayei Sha’ah as one who doctors expect to live no longer than one year. Rav Schachter follows this view in his landmark Teshuva.

תנא דבי ר' ישמעאל –''ורפא ירפא'' )שמות כא', יט'( - 85a .8 .מכאן שניתנה רשות לרופא לרפאות

The Torah grants humanity a license to heal. Tosafot (ad. loc. s.v. Shenitenah) explain that otherwise we would be forbidden to attempt to override the divine decree for the individual to fall ill. Ramban (Torat HaAdam, Mossad HaRav edition, page 41) explains that the Torah grants permission for physicians to risk the patient lives in the attempt to save his life.

שנים שהיו מהלכין בדרך וביד אחד מהן קיתון של מים אם - 62a .9 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

In a classic Talmudic scenario, two people are walking in the desert and only one of them has sufficient water to survive. Rabi Akiva famously rules that one is not obligated sacrifice his life and to share his water.

Five Cases Addressed by Rabbi Hershel Schachter in April 2020

Case Number One: Only One Ventilator is Available When Two People Arrive at the Hospital Simultaneously – one person has a high chance of survival and the other has a low chance of survival.

This case is straightforwardly resolved. The ventilator is given to the patient with a higher chance of survival. Dr. Abraham S. Abraham (Nishmat Avraham, Yoreh De’ah 252:2) records this ruling citing Teshuvot Igrot Moshe (Choshen Mishpat 2:74) and Teshuvot Tzitz Eliezer (9:17:10:5). This ברי ושמא ברי עדיף - ruling is in accordance with the Talmudic principles of Chullin 10a). The order set forth) אין ספק מוציא מידי ודאי Ketubot 12b) and) in Horiyot applies only to patients with an equal chance of survival.

Case Number Two: Removing a ventilator from a very sick person to save someone with a high chance of survival for whom no ventilator is available.

In such a case, Dr. Abraham (ibid.) notes that the Halacha forbids removing a ventilator from a very sick person not expected to survive a year even to save a patient expected to active a full recovery if given a ventilator. In this מאי חזית and אין דוחין נפש מפני נפש situation, we apply the principles of .דדמא דידך סומק טפי דילמא דמא דההוא גברא סומק טפי

Dr. Abraham notes that this applies even if the ventilator is attached to a very aged and ill individual who contributes little to society and the arriving patient is someone who enormously benefits society.

Case Number Three: A person with little chance of survival arrives at the hospital but people with a greater chance of survival are expected to arrive shortly – there is only one ventilator available.

In such a case, one would expect the Halacha to obligate attaching the אין מעבירין על ventilator to the patient who arrives first due to the rule of However, Rav Schachter boldly rules in such a case that one may .המצוות withhold the ventilator from such a patient and save it for those with a dramatically greater chance of survival that are anticipated to arrive within “an hour or two”. Rav Schachter explains that the in such a scenario, we view “as if the stronger patients are already present”.

We suggest a basis for this bold ruling. Halacha permits violation of or Yom Tov only for a current situation of Pikuach Nefesh (Choleh L’faneinu) following the rulings of the Noda BeYehuda (2 Yoreh De’ah 210) and Chatam Sofer (Yoreh De’ah 336). However, the Chazon Ish (Ohalot 22:32) rules that one may violate Shabbat not only if the dangerously ill person (Choleh) is L’Faneinu, but even if the sickness (Choli) is L’Faneinu.

In our case although the Choleh is not L’Faneinu but since the Choli is L’Faneinu we may view as if the patients expected to arrive are if they are already present. this applies only to ,אין דוחין נפש מפני נפש Although Halacha teaches actively killing a patient but not to passively withholding care in the attempt to save the lives of others much more likely to fully recover4. Rav Schachter explains that the overarching Halachic principle is helping the patient who will benefit the most from the limited treatment available. He explains that the priorities set forth by the Mishna in Horiyot are no longer operative today. He cites Rav Moshe (Choshen Mishpat 2:74) to that effect and Rav Schachter notes that this has emerged as the normative Halachic position5. Case Number Four: Doctors already intubated a patient not expected to live longer than a year. Shortly after doing so, patients with a much greater chance of long term survival arrive and there is no ventilator left to save their lives.

In such, a case Rav Schachter permits placing a DNR (do not resuscitate) order on the patient not expected to live a year. In such a case, if the patient’s heart fails then he need not be resuscitated and the ventilator may be used to save those with a dramatically greater chance of survival.

This is quite a shocking application of the Halachic preference for Chayei Olam over Chayei Sha’ah. It is rather shocking to place a DNR order without the consent of the patient or his health proxy6. Nonetheless, Rav Zalman Nechemia Goldberg adopts a similar approach (Techumin 36:209- 213).

4 Tosafot (Pesachim 25b s.v. Af and Sanhedrin 74b s.v. V’ha Ester) support this distinction. Tosafot write: “In a situation where one is not actively killing such as if bandits threaten to push someone on a baby to kill it, it appears that one is not required to sacrifice his life instead of cooperating in this terrible deed. The reason for this is that he can claim, “how do I know that the baby’s blood is redder than my blood” since he is merely passively cooperating in the murderous act. 5 Rav Shlomo Zalman Auerbach concurs with this ruling (Teshuvot Minchat Shlomo 2:82:2). However, Rav Shmuel Wosner (Teshuvot Sheivet HaLevi (10:167:1) writes that even today we apply the standards set forth in the Mishnayot in . The Chazon Ish (Choshen Mishpat, Likkutim number 20, Bava Metzia 62a) seems to agree. 6 I am uncertain as to whether this is permitted under American civil law.

Case Number Five: A patient has a ventilator to himself and doctors wish to share the ventilator with other patients.

Rav Schachter permits sharing the ventilator with others even if it creates a fifteen percent or even higher chance of death on the patient who originally had the ventilator7. He writes that doctors may risk the lives of one patient to save the life of another who would otherwise definitely die. Rav Schachter applies the Ramban who explains the Torah’s license to heal as permitting physicians to risk life in the attempt to save lives.

This is a bold application of the Ramban. The Ramban permits risking a patient’s life to save the life of that patient. Rav Schachter expands this notion to risk the life of one patient to save the life of another8.

.אין דוחין נפש מפני נפש ,Halacha forbids killing one to save the other However, it permits risking one to save another.

Rav Asher Weiss (Minchat Asher on Corona, number 6 in the second edition) concurs with Rav Schachter’s ruling. He notes that standard procedure in Israeli hospitals is to remove less critically ill patients from the intensive care units in favor of those in dire need of the intensive care units.

Conclusion

Rav Schachter in this landmark Teshuva places two major limitations on the it applies only to active killing and does not – אין דוחין נפש מפני נפש rule of apply to placing at risk to save the life of others. The Eternal word of

7 Once the patient shares the ventilator, he is exposed to the infections of the patient with whom he shares the respirator. Health care workers seek to reduce the risk by matching patients with similar levels of infection and body size. Nonetheless there is a significant elevation in risk by sharing ventilators. This is why under ordinary circumstances ventilator sharing is unheard of. 8 Halacha, in an area of great discussion, does not obligate one to risk his life to save another (Teshuvot Tzitz Eliezer 9:45 and Teshuvot Yechave Da’at 3:84). This principle emerges from Bava Metzia 62a where that one does not have to risk his life and share his water in order חייך קודמים לחיי חבירך Rabi Akiva rules to save another. However, the Chazon Ish (Choshen Mishpat, Likkutim number 20, Bava Metzia 62a) writes that a third party with water should allocate it in a manner that preserves the greatest amount of life possible. Rav Schachter’s ruling fits with the Chazon Ish.

Hashem continues to shine brightly shedding light even in the darkest days of the corona pandemic. The greatest Poskim of our time apply Hashem’s Eternal Word even to the most ethically complex dilemmas arising in the desperate days of the peak of the Corona virus. We never ceased to be amazed to see Poskim readily apply Halacha to any and all issues arising in all circumstances. The subtle divine hand involved in the composition of the Gemara and in the ongoing Halachic process is evident for all to see.