One of the many terrible results of this terrible time is that people find themselves having to make all sorts of awful decisions. We all spend a great deal of time figuring out what is the best possible bad option of the range of ghastly ones yawning in front of us.
Use the clorox/bleach/antibacterial wipes now, and deplete the supply, or hold onto them?
Get up at 4:30 in the morning to try to get a delivery slot in a week or two, or brave an actual store?
If it’s inevitable to go to a store, should it be a supermarket or a convenience store?
Take the elevator downstairs in your building or make the dogs pace and wait?
Wear a homemade face mask whenever you go outside — after you’ve read that if they’re not properly fit and then never touched and then thoroughly laundered — or not?
Cross the street whenever you see someone coming toward you, even if it means plunging into traffic, or deciding that you’d rather not risk being roadkill?
These have become the traumas of regular life, for those of us who are not doctors. They pale compared to the decisions doctors have to make.
A small percentage of people who get covid-19 get so sick that they need ventilators to survive; because so many people are infected with the virus, that small percentage includes a lot of people.
Not everyone who is put on a ventilator survives.
There is a shortage of ventilators in this country; the most hard-hit regions — New York and New Jersey — are coming to the end of their supply.
Who decides which patient should get a ventilator, if there are not enough to go around?
No matter how much intellectual pleasure someone would have gotten over the bloodless debate about this issue when it was purely academic, no one wants to have to confront it in real life
Local doctors very soon will find themselves in that position, however.
Dr. Kenneth Prager of Englewood is a pulmonologist; he’s also a professor of clinical medicine, the director of clinical ethics, and the chair of the medical ethics committee at Columbia University Medical Center in Manhattan.
He finds himself thinking and writing and talking a great deal about how to allocate scant resources, such as ventilators, when those decisions literally can make the difference between life and death. New York City has not yet run out of ventilators, but officials warn that it will, possibly within days. Then the question of what to do next will be unavoidable. “It is a very sensitive issue, because it potentially involves withholding life support from some patients who have minimal to no chance of survival in order to benefit other patients,” Dr. Prager said.
“Currently in most states this is illegal, but each state now is trying to implement policies that will allow physicians to use their clinical judgment in deciding where a rare resource should go in order to save more lives.”
Until earlier this week, in New York State, the law required “that a physician may not withhold or withdraw life support without the consent of a patient or his surrogates. So if a doctor in this crisis does that, he or she is open to civil or even criminal liabilities.
“So basically we physicians needs legal protections in order to enact a policy that will save more lives.”
That protection, the Emergency Disaster Treatment Protection Act, was just passed by New York’s legislature and Governor Andrew Cuomo signed it into law this week. It allows health care workers not to have to agonize over the possible legal implications of their actions.
The basic dilemma, Dr. Prager said, is that “there are two ways of dealing with this crisis, when we have more people who need ventilators than we have ventilators. The first one is first come, first served, regardless of the likelihood of benefit. That is one way of dealing with it” — until this week, it was the only legal way of dealing with it — “but what happens is that people who have zero percent chance of survival will be on life support using the scarce resources of ventilator, ICU bed, and nurse and physician time to the detriment of people who otherwise might have survived,” had these patients been able to be put on the ventilator.
“The other way of dealing with it is to allocate the scarce resource to the person who likely would benefit the most from it.”
Even once you’ve decided that resources must be allocated to do the most good, those are wrenching decisions to make. Most hospitals across the country “have a triage committee — they’d rather euphemize it by calling it a health resource allocation team — consisting of experts in intensive care and an ethicist,” Dr. Prager said. “They review the clinical information that is referred to them by the treating physician, and based on objective guidelines and objective criteria, they use a scoring system looking at how sick the person is and how likely to survive. Then they can make a recommendation.
“Ventilator allocation will be done on the basis of this likelihood of survival.
“The key point is to save the most lives possible. There has to be some form of stratification of people who are or are not likely to benefit.”
There are yet more considerations — risking the heath and even the lives of the healthcare workers, using even more scarce resources, causing the patient even more pain. “In many cases, on presentation at the ER the patient is in the process of actively dying, and will not benefit from being on a ventilator or having someone attempt CPR,” Dr. Prager said.
“Attempting CPR endangers the healthcare workers, because it aerosolizes the virus. Putting a scarce resource — healthcare workers — at risk in a situation where a medical intervention cannot help the patient is an inappropriate act that makes no ethical or medical sense whatsoever. In addition, it can cause the dying patient unnecessary suffering.
“We attempt to sedate patients, but we are running low on that medication also. So using it on people who should not even be on a ventilator is another reason not to intubate them.”
When we consider scarce resources, we should remember that it’s not only about the ventilators, Dr. Prager said. “Even if we do have enough ventilators, we may run out of the doctors and nurses who can manage them. Not every doctor or nurse has the skill set to manage them, and that is the greatest risk right now. It is a fallacy and an oversimplification to suggest that we just need more ventilators. We also need doctors and nurses who know how to use them.”
What does he think will happen? “People will die unnecessarily,” Dr. Prager said. “They will die for the want of human and material sources necessary to save them.”
The stress on healthcare workers is enormous. How do they stay sane? How does Dr. Prager retain his own sanity?
“I think that the doctors and nurses, all the hospital staff, who are in the trenches, who are actively treating patients, are 100 percent heroes,” he said. “Heroes with a capital H. They are great heroes.
“Just as we call the men and women who fought and beat the Nazis during World War II the greatest generation, the greatest generation of the 21st century will be the healthcare workers who have been on the front lines.
“They are under terrible stress. The risk is pervasive. They have families, spouses, children; they are worried that if they become infected they will spread it to their families, so some have chosen to separate voluntarily from their families.”
He has not seen anything like this in his lifetime, Dr. Prager said. No one has. The closest we’ve come to it, at least in the First World, probably is the 1918 flu epidemic, which is just out of living memory. But the analogy is weak, Dr. Prager said. “Back then, there was nothing that doctors could do.”
That’s not a good thing, but it is a true thing, which means that the emotional toll on doctors in both outbreaks was massive and heartbreaking, but it was different. Back then, “there was no treatment,” Dr. Prager said. There were no ventilators. There was no nothing. That means that “there wasn’t the emotional angst of having to decide what to do.”
Last week, Dr. Prager was one of two panelists in a webinar about the ethics and halacha of triage and ventilator allocation. He talked about the civil ethics; Rabbi Jason Weiner talked about the halacha. They were in agreement on what morality and halacha demand.
Rabbi Weiner is the senior rabbi and director of spiritual care at Cedars-Sinai Medical Center in Los Angeles and leads Congregation Knesset Israel there; he’s got degrees from Yeshiva University and smicha from Yeshivat Chovevei Torah and from Rav Zalman Nechemia Goldberg in Jerusalem. His experience, therefore, is wide-ranging, and both theoretical and highly hands-on.
“It’s a complicated issue,” Rabbi Weiner said, talking about triage and device allocation on a phone call from Los Angeles. “Trying to find the ways to be as compassionate as possible and to treat people in the same way; not to make rash decisions.
“Halacha is not that different from American triage protocol in emergencies,” he said.
“Halachic principles are based on an ethical issue that is very common in ethics classes and also happens to be in the Talmud. It’s the train going down the tracks.” It can be diverted in two ways, so what do you do? Divert it? Who do you allow it to kill, and whom do you save? “The Chazon Ish wrote about it from Bnai Brak,” he said; the Chazon Ish, Avrohom Yeshaya Karelitz, who escaped the Holocaust and died in 1953. Bnai Brak is a charedi stronghold in Israel. “Now, self-driving cars have to be programmed to make those decisions, so we are asking those questions today,” Rabbi Weiner said.
The way it’s posed in the Talmud is that there is an arrow being shot at a group of people. “It can kill six people, or you have the opportunity to defer it so it will kill just one person,” he explained.
“One of the commentators thought that the Jewish value is passive inactivity; when you have two bad choices, it’s better not to make one. The Chazon Ish said that if you have the choice between letting six people die or killing one, your action in diverting the arrow is something you would do to save lives. It doesn’t matter who the six or the one are. That’s generally not the point. It’s that you are saving more lives.
“Based on that, a lot of Israeli poskim” — halachic decisors — “have developed a triage approach which is not first come, first served, or treating the sickest first. It’s how do you save the most people?
“You treat first the people who would take the least amount of time and resources. It’s about how do you save the largest number of people. Some people may come in deathly ill, and require six doctors and nurses and an ICU room and a respirator. Or three people may come in who are less sick and you can treat them all and then move on.
“It’s about hatzalat rabim — saving the many. Saving as many as possible. That’s what underlies the whole process.”
What about the thorny issue of whom to save when resources are scarce? “One of the classic ways is to judge whether one of them has less than six months, or even less than a year, to live,” Rabbi Weiner said. “You choose the person who could live longer. That’s not necessarily based on age.” Instead, it’s based on a range of possibly complex (but possibly straightforward) criteria.
“Halacha is a comfort,” he said. “There is so much insecurity. No matter how much we know, we are not sure that we are making the right decision. Sometimes things are gray, and we need to choose the least bad.
“But we have a wise tradition, based on God and the Torah and our rabbis, and it gives us a sense of confidence and support.
“Medical staff are dealing with so much moral trauma and distress now. The feeling I have is that I can get guidance based on my religion and my tradition, so that I don’t have to feel guilty when I make decisions. It is great to have a sense of guidance and support in a time when we have to make very murky decisions.”