Current controversy J Med Ethics: first published as 10.1136/medethics-2020-106242 on 10 April 2020. Downloaded from Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective Amy Solnica,1,2 Leonid Barski,3,4 Alan Jotkowitz3,4 1Henrietta Szold School of ABSTRact transparency, consistency, proportionality and Nursing, Faculty of Medicine, The novel COVID-19 pandemic has placed medical accountability. During a time of disaster there is a Hebrew University, Jerusalem, triage decision- making in the spotlight. As life- saving paradigm shift from focusing on the individual to Israel 3 2Department of Obstetrics and ventilators become scarce, clinicians are being forced providing the best outcome for the population. In Gynecology, Hadassah- Hebrew to allocate scarce resources in even the wealthiest March 2020, the National Academy of Medicine, University Medical Center, countries. The pervasiveness of air travel and high rate formally known as the IOM, published a discussion Jerusalem, Israel of transmission has caused this pandemic to spread paper regarding planning of care during the time 3Faculty of Health Sciences, Ben- Gurion University of the Negev, swiftly throughout the world. Ethical triage decisions of a pandemic with specific focus on the current Beer Sheva, Israel are commonly based on the utilitarian approach of COVID-19 outbreak. The authors reiterate that the 4Department of Medicine, maximising total benefits and life expectancy. We present goal of CSC planning is to have processes in place Soroka University Medical triage guidelines from Italy, USA and the UK as well as before the crisis to manage the availability of crit- Center, Beer Sheva, Israel the Jewish ethical prospective on medical triage. The ical resources, thus avoiding the need to make diffi- Jewish tradition also recognises the utilitarian approach cult triage decisions. Part of the planning involves Correspondence to Amy Solnica, Henrietta Szold but there is disagreement between the rabbis whether ‘graceful degradation of services’ by making step- 4 School of Nursing, Faculty of human discretion has any role in the allocation of scarce down changes to care that is provided. Decision- Medicine, Hebrew University, resources and triage decision- making. making should be performed using the principal Jerusalem 91120, Israel; of proportionality, weighing the compromising of amysolnica@ gmail. com usual standards against optimisation of benefits Received 26 March 2020 INTRODUCTION to the greater society. For example, recycling life- Accepted 27 March 2020 The current worldwide pandemic of the novel saving respiratory equipment after careful sterili- COVID-19 virus is taxing the global healthcare sation, making home continuous positive airway system including vital life-saving medical supplies pressure machines, respiratory aide devices, avail- and equipment. Healthcare workers are faced able for hospital use, adjustment of standard criteria with an epic proportion of medical and ethical for intubation and weaning from ventilators. These decisions regarding allocation of these precious measures will provide greater availability of life- 4 resources, especially ventilators. This paper will saving equipment. focus primarily on the Jewish ethical prospective The American Medical Association Code of to the allocation of scarce resources during the Medical Ethics delineates that decision- making in COVID-19 pandemic. times of scarcity of equipment should be based on http://jme.bmj.com/ Physicians in Italy, the first European country three factors: ‘urgency of (medical) need, the like- plagued by the corona pandemic, were overwhelmed lihood and anticipated duration of benefit, and the with difficult triage dilemmas as around 10% of change in quality of life’.5 Opinion 11.1.3 further those effected with COVID-19 require some form calls on healthcare professionals and institutions to: of respiratory assistance.1 On 7 March 2020, the prioritise treatment to those for whom treatment Italian College of Anesthesia, Analgesia, Resuscita- will prevent premature death or extremely poor tion and Intensive Care published new guidelines outcomes. Physicians should use ‘an objective, flex- on September 30, 2021 by guest. Protected copyright. regarding the triage of patients due to underavail- ible, transparent mechanism to determine which ability of resources. ‘It is a scenario where criteria patients will receive recourse when there are not for access to intensive care and discharge may be substantial differences among patients and requires needed, not only in strictly clinical appropriateness that allocation policies be explained both to patients and proportionality of care, but also in distributive who are denied access to limited resources and to justice and appropriate allocation of limited health- the public’.5 care resources.’2 On 20 March 2020, in response to the COVID-19 Similar to the battlefield model of triage, privi- pandemic, the National Institute for Health and lege is given to those with the ‘greatest life expec- Care Excellence in the UK published the Guide- tancy’, thus abandoning the traditional ‘first come, line with clinical decision- making. This Guideline © Author(s) (or their provides a clear and detailed algorithm for the allo- employer(s)) 2020. No first served’ model. Unfortunately, due to the high commercial re- use. See rights number of patients needing respiratory support, cation of critical care beds and treatment of crit- and permissions. Published these decisions are occurring at greater frequency ical patients during the COVID-19 outbreak. The by BMJ. and at a faster pace. Factors such as age, comorbidi- basis of the Guideline is to maximise patient safety To cite: Solnica A, Barski L, ties and functional are evaluated in the decision for and appropriate use of resources. Admission to an 2 Jotkowitz A. J Med Ethics critical care admission. intensive care unit is based on some assessment of Epub ahead of print: [please In 2009, the Institute of Medicine (IOM) devel- frailty, comorbidities and likeliness to recover from include Day Month Year]. oped a guidance for the establishment of crisis stan- the intensive treatment.6 doi:10.1136/ In surveying triage protocols, Persad et al7 iden- medethics-2020-106242 dards of care (CSC) based on the ethical principles of fairness, duty to care, duty to steward resources, tified four overarching principles used in treating Solnica A, et al. J Med Ethics 2020;0:1–3. doi:10.1136/medethics-2020-106242 1 Current controversy J Med Ethics: first published as 10.1136/medethics-2020-106242 on 10 April 2020. Downloaded from people equally: these include lottery and first come, first served Rabbi Moshe Feinstein, the pre- eminent Jewish decider of models; favouring the worse off based on the rule of recuse; the 20th century, writes regarding triage: in my opinion if both utilitarian approach of maximising total benefits; and rewarding arrive at the same time [to the hospital], the decision should be social usefulness which favours essential professions but is made on the basis of medical suitability. The one who has the fraught with potential biases. In relation to the novel COVID-19 best chance of being treated and cured should be given the avail- virus, Emanuel and colleagues8 delineated the ethical values to able bed.12 guide the rationing of scare resources. In line with the utilitarian Another important modern decider, Rabbi Shlomo Zalman approach of maximising benefits, priority of treatment should Auerbach writes ‘that one should primarily take into account be given to those with the greatest chance of survival. Health- the degree of danger and chance for cure’13 in making triage care workers should be given preference to promote and reward decisions. This is in fact how many physicians make their triage usefulness. Care should not be based on first come, first served decisions, they look at the balance between the acuteness of the model but rather, random selection should be used, when all patient and the reversibility of the disease to decide who should patients have a similar prognosis. receive scarce resources. Rav Eliezer Waldenberg, another modern decider, maintains that one can even hold in abeyance life- saving equipment from AN ANCIENT DISPUTE a patient not expected to live in anticipation of the arrival of Most ethical guidelines relating to triage, as we have seen above, a patient with a better prognosis.14 These approaches are all are utilitarian in nature and heavily emphasise the principle consistent with a utilitarian approach to triage based on maxi- of maximising total benefits. The question remains whether mising potential life- saving. However, they all agree that once Halakha (Jewish law) accepts this approach as well. you have initiated treatment with life-saving equipment you In determining Jewish ethics regarding triage, Orthodox Jews cannot remove it to treat another patient. look to the Talmud for guidance. The issue of allocation of scarce resources was addressed thousands of years ago in this book of Jewish law. MODERN APPLicatiONS The Talmud in Baba Mezia (62a) relates: Regarding the case of the two travellers discussed above, Rabbi Karelitz maintains if there is a third person who has one bottle of Two people were traveling on the road and one of them has a bottle water that can only save one person, according to Rabbi Akiva, of water. If both drink, they will both die; if one drinks he will he should give it to who he wants, a position that Rabbi Walden- arrive at the town. Ben Petura expounded; it is better that they both berg agrees with. It appears that the Halakha gives much leeway drink and die and one of them not witness the death of his fellow to the rescuers in deciding who to save. It is not too much of an traveler. Until Rabbi Akiva came and taught ‘and your brother shall 9 intellectual leap to say that in this halakhic void, it is society that live with you’. Your life takes precedence over the life of your brother. should decide as opposed to the individual rescuer and thus the decisions of a national ethics committee are in line with halakhic Sokol explains that the basis of the argument between Ben thinking.