Medical Ethics

From Halachipedia

Abortion

Abortion

Donating Blood

  1. It is permissible and a mitzvah to donate blood, as it is used to save lives.[1]

Organ Donation

  1. One may donate an organ which without, the donor will have full health with no detrimental effects. [2]

Heart Transplant

  1. A heart transplant isn't allowed since it is a major dispute if taking a live heart is considered killing the donor.[3]


End of life care

Allocation of medical supplies

Triage

  1. Regarding the larger issue of halachic triage see Rav Schachter (Piskei Corona #15 Updated). Here is a relevant sourcesheet on Halachic Triage. Rav Asher Weiss (Teleconference April 6 2020, min 5-15) discusses triage in halacha and what doctors should do.[4]
  2. A doctor may and is encouraged to perform a life saving procedure if he is wearing the correct protective gear.[5]

Precedence Based on Horiyot

  1. The Mishna Horiyot 3:7 delineates a certain protocol of precedence when several people are in mortal danger and not all of their needs can be met. Most poskim accept that this Mishna is binding today.[6]
  2. However, once the doctor starts he shouldn’t stop to help someone with a higher level of priority according to Horiyot 13a.[7]
  3. The same ordering applies to those in danger of spiritual assimilation.[8]

Chayey Olam vs Chayey Shaah

Both in Front of the Doctor

  1. If there is a shortage of ventilators and there is two patients in front of you, one who according to the assessment of the doctor is not going to live more than a year and another who is going to live more than a year, the ventilator should be used for the one who can live more than a year.[9]

Already Started Treatment

  1. If the patient who can't live more than a year is already hooked up to the ventilator the doctor can not remove him in order to treat the patient who potentially could live longer than a year.[10]
  2. A doctor who started treating a patient who is assessed not to be able to live another year (chayei shaah) may not stop in order to treat a patient who can live for longer than a year (chayei olam).[11]

One Here Currently

  1. If there's only the patient who is assessed to not be able to live a year before the doctor, and the doctor thinks that another patient who could live longer might come in shortly, the doctor has the obligation to immediately help the one who is before him even though afterwards someone who can live longer might come in.[12]

Emergency Worker Responding When Called for Two Cases

  1. If a doctor is called to work on a patient first he should deal with him first even if afterwards he’s called for another patient with a higher precedence level (as in Horiyot 13a).[13]
  2. However, if the doctor knows that the second patient is in more serious danger he should go there first. This is up to the doctor’s call.[14]
  3. Alternatively, if the doctor doesn’t know how to heal the first patient but does know how to heal the second one he should go to the second one. Yet, sometimes he should go to the first one even though he doesn’t know how to heal him in order to help him calm down and not think that the doctors gave up on him.[15]
  4. All of these criteria are for when the doctor got several calls but didn’t start to treat one of them, otherwise he shouldn’t stop the one he started to work on.[16]

Endangering Yourself to Save Someone Else

  1. Some say that it is permissible to endanger yourself to save someone who is a talmid chacham and tzaddik.[17]
  2. If a terrorist threatens you "either kill another Jew or I'll kill you," you may not kill another Jew and must give up your life.[18] You must also give up your life and not even murder the other Jew indirectly such as by causing a dog to bite someone to showing a non-Jew where the Jew is hiding in order to kill him.[19]
  3. If a terrorist threatens you "either let me cut off one limb of your body that won't kill you or I'll kill another Jew," some say that you must allow him to cut off your limb, but most poskim hold that you don't have to but it is a middat chasidut to do so.[20]
  4. If a terrorist threatens you "either give me your sword so that I can kill another Jew or I'll kill you," some say that you may not give up your sword in that case, while most hold that should give up your sword.[21]
  5. A minority position holds that it isn't necessary to endure difficult pain in order to save someone else's life, but most poskim disagree and hold that is necessary.[22]
  6. Some say that it is permissible to endanger yourself to save your only son if you're too old to fulfill pru urevu again.[23]
  7. It is permissible to endanger yourself to save many Jews.[24]

Saving Yourself by Endangering Someone Else

  1. See Violating_Torah_to_Save_Your_Life.

Sources

  1. ↑ Rav Yitzchak Yosef (Motzei Shabbat Kedoshim 5779 min 1)
  2. ↑ See Yachava Daat 3:84, Tzitz Eliezer 9:45, Minchat Yitzchak 5:7. Similarly, Rav Asher Weiss (Aguda Teleconference, April 6, 2020, min 20-22) stated that donating a kidney isn’t risk free but it is minimally dangerous and it is life saving and therefore it is a middat chasidut to do it.
  3. ↑ Rav Yitzchak Yosef (Motzei Shabbat Kedoshim 5779 min 10)
  4. ↑ Rav Asher feels that there are only two factors that we consider for halachic triage: give precedence to someone who is in immediate danger, and give treatment to whoever has a better chance for survival. Age or spiritual need for the community are not factors for precedence.
    • Rav Asher says that for choleh shebifanenu the knowledge that another choleh is going to come in soon is considered pikuach nefesh if will with certainty be helpful. Therefore, if an older patient comes into the hospital but they know a younger patient is going to come in, they can consider them as though they came in together and treat according to who is in immediate danger and who has the better chance to live. Rav Schachter felt the same way in his teshuva.
    • If a hospital has a certain regulation, does he need to disregard the hospital protocols? Rav Asher Weiss felt that the doctors should not disregard hospital protocol, for multiple reasons but partly because if he doesn't he'll lose his license and having more able doctors at this time is pikuach nefesh.
    • Pulling a patient off a ventilator because someone entered the hospital who has a better chance of living, Rav Asher (min 27) felt is forbidden. Rather the doctor should say that he feels uncomfortable to do this and should let another doctor do it. Rav Schachter felt that one should try to convince the older patient to sign a DNR at that point in order to save the younger patient.
  5. ↑ Rav Asher Weiss (Aguda Teleconference, April 6, 2020, min 18-22) explains that you can’t put yourself in danger. However, you can if you’re saving someone from an immediate danger and you’re putting yourself in minimal danger then it is a middat chasidut to do so. Therefore, a doctor should do mechanical ventilation CPR on a COVID19 patient if he has the correct protective gear.
    • Rav Asher (min 33) allowed sharing ventilators when the doctors see fit in order to save another life because moving a patient from a single ventilator to a shared ventilator isn't considered doche nefesh mipnei nefesh since it isn't proven to be dangerous to use a shared ventilator. He also cited the Chazon Ish regarding turning the arrow to the side killing fewer people to save more people.
    • Rav Asher (min 38) said that a doctor who isn't in that particular field or is retired or has vacation doesn't have to volunteer but his doing so would be a middat chasidut. However, if he is endangering himself such as if he's over 70, he is immune compromised, or has a family member who is, then he shouldn't volunteer.
  6. ↑
    • The Mishna Horiyot 3:7 states that a man is given precedence before a woman for sustenance. It also gives precedence to a Kohen before a Levi, then to a Yisrael. There is a dispute whether this is applicable to a case of life and death or only food where there's no mortal danger. Bet Yosef 251:8 explains that it is referring to giving precedence even in cases of mortal danger. Beer Sheva (Horiyot 13a s.v. ha'ish) quotes Tosfot Nazir 47b s.v. vhatanya as a proof to the Bet Yosef. Shevet Halevi 10:167:1 agrees. Rama 252:8, Taz 252:6, Shach 251:11, Yavetz 1:68, Pitchei Teshuva 252:7, Birkei Yosef 252:1, and Aruch Hashulchan 252:13 codify and agree with the Bet Yosef. However, the Rashba Ketubot 67a, Meiri Horiyot 12b, and Levush 252 understand the mishna to be dealing with sustenance and not cases of mortal danger. Mareh Panim Horiyot 3:4 shows that the Yerushalmi explains the mishna in terms of food and not mortal danger, however, Meromei Sadeh 13a answers his question.
    • Shevet Halevi 10:167:1 writes that everyone agrees that in a case of mortal danger we follow the order of precedence in the Mishna Horiyot before for man before woman as well as kohen, levi, and then yisrael. Erech Chaim Bhalacha v. 6 pp. 284-287 quotes most poskim as holding of the Mishna Horiyot 13a as binding for giving precedence when dealing with triage: Chazon Ish (B"m 62a, Likutim 20), Igrot Moshe CM 2:75:2, Minchat Shlomo 2-3:86:1, Rav Kook in Mishpat Kohen 143 and Rav Elyashiv.
    • However, Tzitz Eliezer 18:11:1-8 writes that we don't give precedence of a man before a woman today. This is on the basis of the Meiri and Rashba above and explains this as the opinion of the Rambam and Shulchan Aruch. He says that it all depends on how many mitzvot they accomplish and since it is a fixed standard policy it is left up to the decision of those involved in saving.
    • See also the Yavetz in Migdal Oz (Otzar Hatov, Even Habochen, Pina 1, n. 92) writes he didn’t see that people gave precedence to the kohen, levi, and then yisrael because today we don’t have certain kohanim. Furthermore, the Yavetz in Migdal Oz (Otzar Hatov, Even Habochen, Pina 1, n. 92) writes that there is precedence given to an old healthy person over someone old and sick. He seems to place this precedence only within each category of kohen, levi, and yisrael.
    • Chashukei Chemed Ketubot 49a isn’t sure if the precedence of a boy before a girl is only after they have reached chinuch or even beforehand.
  7. ↑ Shevet Halevi 10:167, Igrot Moshe 2:74:1
  8. ↑ Yavetz 1:68 holds that if a boy and girl are both in spiritual danger of being assimilated because of being taken in captivity, precedence is given to the boy as we find by saving the life of a boy before a girl. Pitchei Teshuva 252:7 and Chashukei Chemed Ketubot 49a cite this.
  9. ↑ Shevet Halevi 6:242 regarding a defibrillator writes that if there's someone who the doctor assessed cannot live a year and another who will live more than a year the defibrillator should be given to the one who can live more than a year. Since halacha values chayey olam more than chayey shaah it has precedence similar to the other priority in the Mishna Horiyot 13a. He notes that this is a contradiction between the Chazon Ish b"m 62a and Chazon Ish on Grach Yesodei Hatorah, whether to give it to the one who can live more than a year or it should be split even though both will die. Igrot Moshe CM 2:73:2 agrees with the Shevet Halevi.
  10. ↑ Shevet Halevi 6:242 writes that once the person who cannot live a year is already hooked up he cannot be removed in order to save someone else who could live more than a year.
  11. ↑ Igrot Moshe CM 2:73:2 agreed that a patient who is chayey shaah can’t be removed from his bed in the emergency room for a chayey olam patient since the chayey shaah patient has the right to be treated and doesn’t need to sacrifice his life for the other patient. Rav Elyashiv in Kovetz Teshuvot 3:160 seems to agree that once a doctor is treating a patient in mortal danger he shouldn’t stop to attend to a patient who is more seriously in danger. See also Minchat Shlomo 2-3:86:1 in this vein. See, however, Rabbi J David Bleich (Tradition Winter 2021 p. 16) who argues that chayey olam is given greater weight than chayey shaah even if one already started to treat the chayey shaah patient. He considers the rule of osek bmitzvah to be outweighed by the pikuach nefesh of the chayey olam patient. He cites that this is also the opinion of Rav Elyashiv (Shiurim Lrofim v. 2 p. 109) that osek bmitzvah doesn’t apply to pikuach nefesh.
  12. ↑ Shevet Halevi 6:242. Igrot Moshe CM 2:73:2 writes that if a chayey shaah patient comes in first he should be brought in first, even though a chayey olam patient can come shortly. He adds that even though they didn’t start to work on the chayey shaah patient they can’t remove him for the chayey olam because doing so might cause the chayey shaah patient to think that the doctors gave up on him.
  13. ↑ Igrot Moshe CM 2:74:1, Shevet Halevi 10:167. Igrot Moshe 2:75:2 writes should respond to the patient he was called to first, even if he gets another call before he starts treatment of the first. Rabbi J David Bleich (Tradition Winter 2021 p. 15-16) argues that ein maavirin al hamitzvot or osek bmitzvah does not apply by merely determining to go do a mitzvah.
    • Tzitz Eliezer 18:69:3 in regards to ordering patients (where there is no mortal danger) writes that we follow whoever came first in line and not the ordering system of Horiyot so as not to come to fights. He distinguishes between if patients come before the doctor arrives and after; before there's no concept of a line in halacha but since it is the practice it is binding, whereas afterwards there is a basis for a line in halacha.
  14. ↑ Igrot Moshe CM 2:74:1, Shevet Halevi 10:167
  15. ↑ Igrot Moshe CM 2:74:1
  16. ↑ Erech Hachaim Bhalacha v. 6 p. 188. See also Igrot Moshe CM 2:73:2.
  17. ↑ Sefer Chasidim, Yabia Omer, Yavetz (Migdal Oz Otzer Hatov pina 1 n. 85)
  18. ↑ Sanhedrin 74b
  19. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 82)
  20. ↑ Maharam Ricanti holds that in this case it is an obligation to give up your life. However, Radvaz holds that it is only a middat chasidut. Yavetz (Migdal Oz Otzer Hatov pina 1 n. 83) agrees that it isn't obligation but it is a voluntarily mitzvah if he chooses.
  21. ↑ Radvaz holds that you may not give your sword in that case. However, Yavetz (Migdal Oz Otzer Hatov pina 1 n. 82) argues because you only need to give up your life not to actively kill someone, but you don't need to give up your life not to passively watch another Jew die.
  22. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 83) holds that it isn't an obligation to go through pain in order to save someone's life. However, Magen Avraham and Yabia Omer 9:12 disagree.
  23. ↑ Yavetz (Migdal Oz Otzer Hatov pina 1 n. 85). Rav Zilberstein (Shabbat Shabbaton p. 172-3) quotes Yavetz that a person may not endanger himself to save someone else unless the other person is a bigger talmid chacham and a tzaddik than you, your father, or your rebbe. Even to save your only son it is forbidden to endanger your life for him, unless the father is too old to fulfill pru urevu anymore. Rabbi Zilberstein asks why this is permitted and suggests that since the child could have more children it is like endangering yourself to save many people which is allowed. He also quotes a story about the Shaar Efraim that when his son was deathly sick he davened to Hashem to take him instead and so it happened that his son was healed and he died. However, it isn't a clear proof, says Rav Zilberstein, since davening isn't the same as doing an action.
  24. ↑ Gemara Tanit 18b, Rav Zilberstein (Shabbat Shabbaton p. 173)
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