Torah and Triage Life Lessons in a Pandemic Shavuot 5780

As the the coronavirus began spreading, health workers braced for heart-stopping dilemmas: Would they have to ration ventilators? How do you choose who will have a chance at life and who won't? Jewish sources on the value of human life confront us with ethical questions for which there are no good answers.

Ezekiel J. Emanuel: Maximizing Benefits and Saving More Lives

"Previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including our own prior research and analysis, converge on four fundamental values:

  • maximizing the benefits produced by scarce resources,
  • treating people equally,
  • promoting and rewarding instrumental value, and
  • giving priority to the worst off."

Ezekiel J. Emanuel, et. al, “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” New England Journal of Medicine 382;21, 2051.

Thomas A. Bledsoe, et al., "Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes" Annals of Internal Medicine, April 24, 2020.

Two Conservative Rabbinic Responses

"This will mean that some patients who would ordinarily receive and benefit from treatment may either not receive treatment, have the initiation of treatment postponed, or have treatment discontinued and, as a result, may die or suffer some other adverse health-related consequence. This is the tragedy of the necessity to triage."

-Rabbi Elliot Dorff, “Triage in the Time of a Pandemic,” Committee on Jewish Laws and Standards, April 17, 2020, as cited in Nevins, "Triage and Sanctity of Life."

"Emanuel, et al., . . . state, 'we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission.'

"If the previous sentence did not catch your attention, it should. Removing a viable patient from a ventilator or an ICU bed, even without their consent, and perhaps over their desperate objections, will often result directly in their death. The authors do not limit this permission to end the life of a patient to a person who is actively dying or even terminally ill."

-Rabbi Daniel Nevins, "Triage and Sanctity of Life," Responsum dated April 17, 2020,

Talmudic Sources on the Value of Life

א"ר יוחנן משום ר"ש בן יהוצדק נימנו וגמרו בעליית בית נתזה בלוד

כל עבירות שבתורה אם אומרין לאדם עבור ואל תהרג יעבור ואל יהרג חוץ מעבודת כוכבים וגילוי עריות ושפיכות דמים

Rabbi Yoḥanan says in the name of Rabbi Shimon ben Yehotzadak: The Sages voted and concluded in the upper story of the house of Nitza in Lod:

With regard to all the transgressions in the Torah, if a person is told: Transgress and you will not be killed, let him transgress and not be killed, except for idol worship, forbidden sexual relations, and bloodshed.

גמ׳ ת"ר עוברה שהריחה בשר קודש או בשר חזיר תוחבין לה כוש ברוטב ומניחין לה על פיה

אם נתיישבה דעתה מוטב

ואם לאו מאכילין אותה רוטב עצמה

ואם נתיישבה דעתה מוטב ואם לאו מאכילין אותה שומן עצמו

שאין לך דבר שעומד בפני פקוח נפש חוץ מע"ז וגילוי עריות ושפיכות דמים

GEMARA: The Sages taught: In the case of a pregnant woman who smelled [and craved] consecrated meat or pig meat, one inserts a thin reed into the juice and places it on her mouth.

If her mind become settled, that is best. And if not, one feeds her the gravy itself. If her mind becomes settled, that is best. And if not, one feeds her the fat itself, as there is nothing that stands in the way of saving a life except for idol worship, and forbidden sexual relationships, and bloodshed. . .

ורוצח גופיה מנא לן

סברא היא דההוא דאתא לקמיה (דרבא) אמר ליה אמר לי מרי דוראי קטליה לפלניא ואי לא קטילנא לך

א"ל נקטלך ולא תקטול מאי חזית דדמא דידך סומק טפי דילמא דמא דההוא גברא סומק טפי

And regarding the case of the murderer itself, from where do we know [that saving a life does not override the transgression]?

It is a matter of reason, as when that person came before Rava.

He said to him: The master of the village said to me: Kill so-and-so, or else I will kill you.

He said to him: Let yourself be killed, and do not kill. Why should you think that your blood is redder? Perhaps the blood of that man is redder.

. . . 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

. . . And Rabbi Yoḥanan, what does he do with this verse: “And your brother shall live with you?” (Leviticus 25:36)

He needs it for that which is taught:

Two people were walking on the road and one of them held a jug of water. If both of them drink, they both die, but if one of them drinks, he will reach a settlement.

Ben Petora taught: It is better that both of them drink and die, so that neither one sees the the death of his fellow.

Along came Rabbi Akiva and taught: “And your brother shall live with you,” (Lev 25:36)--your life takes precedence over the life of your fellow.

What to do?

"In the throes of a pandemic or other health emergency in which clinicians must choose among patients (or have a triage officer choose for them) to receive intensive medical treatment, utilitarian analysis is not the only ethical option. Jewish law provides several criteria for the prioritization of care based on the sacred obligation to heal those who are ill. Patients who have the most urgent need should be the first to receive treatment, unless they are unlikely to survive, in which case patients who are expected to survive with intensive therapy should receive priority. After that, the first patient to request the resource has priority.

". . . it is forbidden to remove a patient from a ventilator, causing their death, based only on the utilitarian assessment that another patient has a better prognosis, or meets some other socially valued criterion."

--Rabbi Daniel Nevins, "Triage and Sanctity of Life."

״וַיִּתְיַצְּבוּ בְּתַחְתִּית הָהָר״, אָמַר רַב אַבְדִּימִי בַּר חָמָא בַּר חַסָּא: מְלַמֵּד שֶׁכָּפָה הַקָּדוֹשׁ בָּרוּךְ הוּא עֲלֵיהֶם אֶת הָהָר כְּגִיגִית, וְאָמַר לָהֶם: אִם אַתֶּם מְקַבְּלִים הַתּוֹרָה מוּטָב, וְאִם לָאו — שָׁם תְּהֵא קְבוּרַתְכֶם.

אָמַר רַב אַחָא בַּר יַעֲקֹב: מִכָּאן מוֹדָעָא רַבָּה לְאוֹרָיְיתָא.

אָמַר רָבָא: אַף עַל פִּי כֵן הֲדוּר קַבְּלוּהָ בִּימֵי אֲחַשְׁוֵרוֹשׁ, דִּכְתִיב: ״קִיְּמוּ וְקִבְּלוּ הַיְּהוּדִים״ — קִיְּימוּ מַה שֶּׁקִּיבְּלוּ כְּבָר.

“And they stood beneath the mountain” (Exodus 19:17). Rabbi Avdimi bar Ḥama bar Ḥasa said: this teaches that the Holy One, Blessed be He, held the mountain above them like a vat, and said to them: If you accept the Torah, excellent, and if not, there will be your burial.

Rav Aḥa bar Ya’akov said: This is a great challenge to the Torah.

Rava said: Even so, they again accepted it in the time of Ahasuerus, as it is written: “The Jews confirmed and accepted,” (Esther 9:27)--they confirmed what they had already accepted.

Emmanuel Levinas: Infinite Responsibility for the Other Person

"Here is where the the logical integrity of subjectivity leads: the direct relation with the true, excluding the prior examination of its terms, its idea--that is the reception of Revelation--can only be the relation with a person, with another. The Torah is given in the Light of a face. The epiphany of the other person is ipso facto my responsibility toward him: seeing the other is already an obligation toward him. A direct optics--without the mediation of any idea--can only be accomplished as ethics. . .

"Such a knowledge does not need to interrupt its course to ask itself what road to follow, oriented as it is from the beginning. 'We will do and we will hear. . .'"

-Emmanuel Levinas, "The Temptation of Temptation, Nine Talmudic Readings, translated by Annette Aronowicz, 47-48.

Jean Wahl: You spoke of the State. I very much want us to criticize the State, but I also sense its utility. Without it, what would happen?

Emmanuel Levinas: . . . There are cruelties which are terrible because they proceed from the necessity of the reasonable Order. There are, if you like, the tears that a civil servant cannot see: the tears of the Other (Autrui). In such a situation, individual consciences are necessary, for they alone are capable of seeing the violence that proceeds from the proper functioning of Reason itself.

-Emmanuel Levinas, Basic Philosophical Writings, edited by Adriaan T. Peperzak, Simon Critchley, and Rober Bernasconi, 23.

Just before Matan Torah commenced, Moshe Rabbenu ascended the mountain and eagerly anticipated the onset of revelation. Much to Moshe’s chagrin, Hashem charged Moshe to descend the mountain, r​eid ha’ed ba’am​, so as to warn the Jewish people once more regarding the dangers to their lives posed by inappropriately trespassing upon the mountain while the presence of the Almighty was there.

Moshe protested that the warnings had already been properly issued. The prophet par excellence could hardly wait for a moment for which humanity had already waited twenty six generations, the moment for which the world itself had been created, as our Sages teach us, y​om ha-shishi​, for the sake of the Torah.

And yet, Hashem would not yield to Moshe’s impatience. Mattan Torah must be put on hold until the Jewish people had been offered the fullest measure of protection: lest they break through unto the Almighty to see, and many will fall, ​Pen Yehersun el Hashem Lirot, V’Nafal Mimenu Rav.

The Mechilta teaches us that many, in this case, means even one, “even one from amongst you is considered as many to me.”

-Rabbi Daniel Fridman of the Teaneck Jewish Center