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A Jewish Ethical Perspective Amy Solnica,1,2 Leonid Barski,3,4 Alan Jotkowitz3,4

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A Jewish Ethical Perspective Amy Solnica,1,2 Leonid Barski,3,4 Alan Jotkowitz3,4 Current controversy The healthcare worker at risk during the COVID-19 J Med Ethics: first published as 10.1136/medethics-2020-106294 on 18 May 2020. Downloaded from pandemic: a Jewish ethical perspective Amy Solnica,1,2 Leonid Barski,3,4 Alan Jotkowitz3,4 1Henrietta Szold School of ABSTRact fatalities occurred in healthcare workers,5 as well Nursing, Faculty of Medicine, The current COVID-19 pandemic has raised many as in the 2014 Ebola outbreak in West Africa that Hebrew University, Jerusalem, questions and dilemmas for modern day ethicists and left hundreds of physician and healthcare workers Israel 6 2Department of Obstetrics and healthcare providers. Are physicians, nurses and other dead. One of the first reports of the characteris- Gynecology, Hadassah Medical healthcare workers morally obligated to put themselves tics of 138 hospitalised patients with COVID-19 Center, Jerusalem, Israel in Wuhan, China, found that close to 30% of all 3 in harm’s way and treat patients during a pandemic, Ben- Gurion University of occurring a great risk to themselves, their families and patients were healthcare workers, presumed to have the Negev, Faculty of Health 7 Sciences, Beer Sheva, Israel potentially to other patients? The issue was relevant been infected in the hospital. 4Department of Medicine, during the 1918 influenza epidemic and more recently The AMA Code of Ethics has undergone Soroka University Medical severe acute respiratory syndrome epidemic in 2003. many revisions since first being accepted and has Center, Beer Sheva, Israel Since the risk to the healthcare workers was great, there expanded to include a section regarding Physi- was tension between the ethical duty and responsibility cians’ Responsibilities in Disaster Response and Correspondence to to treat and the risk to one’s own life. This tension was Preparedness.1 The physician’s responsibilities are Amy Solnica, Henrietta Szold School of Nursing, Faculty of further noted during the 2014 Ebola outbreak in West to ‘provide urgent medical care during disasters,’ Medicine, Hebrew University, Africa that left hundreds of healthcare workers dead. The an obligation that holds ‘even in the face of greater Jerusalem 9959113, Israel; AMA Code of Ethics states that physicians are to ’provide than usual risk to physicians’ own safety, health or amysolnica@ gmail. com urgent medical care during disasters…even in the face life.’1 A consensus statement was recently issued by of greater than usual risk to physicians’ own safety, the General Medical Council (GMC), the National Received 10 April 2020 1 Revised 27 April 2020 health or life.’ Classic Jewish sources have dealt with Health Services (NHS) and the UK’s four Chief Accepted 4 May 2020 this question as well. There is an obligation ’to not stand Medical Officers.8 This statement reiterated the by idly when your friends life is in danger’; however, GMC Guidance that physicians ‘must not deny the question arises as to whether there are limits to treatment to patients because their medical condi- this obligation? Is one required to risk one’s own life tion may put you at risk. If a patient poses a risk to to save another’s? There is a consensus that one is not your health or safety, you should take all available required but the question open to debate is whether it steps to minimize the risk before providing treat- is praiseworthy to do so. However, regarding healthcare ment or making other suitable alternative arrange- workers, there is agreement for ethical, professional and ments for providing treatment.’9 societal reasons that they are required to put themselves in harm’s way to care for their patients. JEWISH PERSPECTIVE http://jme.bmj.com/ The classic Jewish sources have dealt with this ques- INTRODUCTION tion as well. There is an obligation ‘to not stand by The current COVID-19 pandemic has raised many idly when you friends life is in danger’; however, questions and dilemmas for modern day ethicists the question arises as to whether there are limits to and healthcare providers. In the past century, the this obligation? Is one required to risk one’s own world has experienced other pandemics with life to save another person? on October 2, 2021 by guest. Protected copyright. unimaginable death tolls. The nature of these The Talmud in Baba Mezia (62a) relates pandemics places physicians, nurses and other healthcare professionals at great personal risk. Are Two people were traveling on the road and one of them has a bottle of water. If both drink the water, physicians, nurses and other healthcare workers they will both die; if one drinks he will arrive at the morally obligated to put themselves in harm’s way town. Ben Petura expounded; it is better that they and treat patients during a pandemic, occurring a both drink and die and one of them not witness great risk to themselves, their families and poten- the death of his fellow traveler. Until Rabbi Akiva tially to other patients? came and taught “and your brother shall live with In the 1918 Spanish influenza pandemic of the you”.10 Your life takes precedence over the life of last century, physicians continued to care for their your brother. © Author(s) (or their patients and an estimated 600 civilian physicians employer(s)) 2020. No 2 commercial re- use. See rights died as a result. The ethical debate regarding The argument between the sages, Ben Petura and and permissions. Published professional risks when treating patients arose Rabbi Akiva might revolve around this very issue. by BMJ. again in the literature surrounding the HIV/AIDS Ben Petura maintains that you have to put your- 3 To cite: Solnica A, Barski L, pandemic beginning in the 1980s. The conclusion self at risk to save your friend while Rabbi Akiva Jotkowitz A. J Med Ethics was that healthcare workers were not able to refuse maintains that you have to save yourself. Jewish Epub ahead of print: [please to care for patients on the basis of their HIV status.4 law follows the opinion of Rabbi Akiva. Other include Day Month Year]. In more recent times, the world has been authorities make the opposite inference from the doi:10.1136/ medethics-2020-106294 plagued by the severe acute respiratory syndrome Talmudic passage; they feel that one is obligated to epidemic in 2003 where estimates of 10% of all save oneself only if its definitive that both will die Solnica A, et al. J Med Ethics 2020;0:1–3. doi:10.1136/medethics-2020-106294 1 Current controversy if you share the water, but if there is a chance that both will be a limb. However, he continues that if giving the limb endangers J Med Ethics: first published as 10.1136/medethics-2020-106294 on 18 May 2020. Downloaded from rescued you must share the water. This parallels a famous debate his life (as he assumes), only a holy fool would agree. between English and American maritime law about what to do This position has obvious relevance for organ donation but for in an overloaded lifeboat. According to American law, a lottery is our question as well. The Radbaz apparently is critical of those acceptable, but according to British law it is ‘grotesque,’ and all who are willing to self-sacrifice to save others, calling them ‘holy must wait, and either be rescued or die together. Judge Cardozo, fools.’ in accepting the British decision, writes, ‘who shall know when This ancient rabbinic debate unfortunately became very rele- masts and sails of rescue may emerge out of the fog.’11 vant during the Holocaust. We have written previously18 on the As we have discussed previously,12 the Rabbis learnt from this tragic moral dilemmas faced by many Jews during this time and story that saving one life for an extended period of time is prefer- on the questions, they asked their spiritual leaders. One of the able to saving two lives for a short time and preference should be queries is directly relevant to our discussion. Rabbi Ephraim given to your life. However, R Yechiel Yaakov Weinberg, a Holo- Oshry was asked whether one is allowed to put oneself at risk caust survivor, writes regarding the case of the two travellers to save another. The details of the question are as follows. Jews that ‘if one desires to die in order to save his friend he is called were rounded up in the Kovno ghetto in Lithuania and taken to holy and pious.’13 The implication of this position is that in a a fortress out of town, and Rabbi Oshry was asked whether one modern situation of limited medical resources one can choose to is allowed to go to the castle to plea for the Jews release with self- sacrifice so other patients may live. Certainly, one can then the knowledge that the visit endangers the life of the supplicant take a risk to save others. Shatz argues that this position is based as well. He answers that one is not required to do but one is on an ethic that highly values the character and motivation of allowed to do so if one desires.19 the agents that carry out these actions.14 This virtue- based ethic We have seen that from ancient times the question of self- would more readily accept acts of altruistic self-sacrifice that one sacrifice has been debated by the rabbinic authorities. There is a solely based on evaluating the morality of a specific act. consensus that one is not required to do so but the question open Interestingly, many of the ancient Jewish sources that deal to debate is whether it is praiseworthy to do so.
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