Monday, February 4, 2008

Class: Allocation of Scarce Medical Resources

Tomorrow I'll teach a Jewish Medical Ethics class at Lehigh Valley Hospital, the last in our two-year series. Our topic is: Allocating Scarce Medical Resources.

Interestingly, as Rabbi Steinberg points out in the Encyclopedia of Jewish Medical Ethics, this is a fundamentally new field. Historically, physician care was personal rather than communal or institutional, treatment was based largely on accessible items, and the outcome was either healing, death or acceptance of a chronically untreatable condition. Today, though, we have research investment costs, expensive treatment options and extended treatment periods as well as preventive medicine, all of which drain our resources - and so we need to make choices.

Our class will address two topics:
1. Me as an individual vs. You as an individual
2. Society vs Individual, and the issue of spending on one patient and thereby depriving society of resources

We'll address the first case by looking at the classic "Ben Petura" and "Water supply" cases (and also see Rav Moshe's interesting look at the Ben Petura case, in Igros Moshe Yoreh Deah 1:145):

Talmud, Bava Metzia 62a
If two people were traveling, one of them holding a pitcher of water, and the result of both drinking would be that they would both die, but if one would drink then he would reach civilization:
Ben Petura taught: Better for both to drink and die, rather than for one to see the other die.
Rabbi Akiva taught: It is written, ‘The life of your brother will be with you’ - Your life precedes that of your brother.

Talmud, Nedarim 80a
If a spring is owned by a certain town, and there is a choice between their lives [in access to the spring] and the lives of others, their lives come before those of others. Their animals precede the animals of others, and if there is a choice between their laundry and that of others, their laundry comes before that of others. If there is a choice between the lives of others and their laundry, the lives of others precede their laundry.
Rabbi Yosi said: Their laundry precedes the lives of others.

We'll then look at Society vs. Individual.
First, we'll ask whether Society is the same as a collection of individuals, or whether Society has a set of rights unto itself.
We can view this through the prism of the Torah's narrative, such as re: the Mabul and the Givonim.
We can view this as the Kuzari put it, through Tefilah (3:19).
We can view this from a business ethics perspective, in terms of the rights and obligations of a corporation, as Rav Chaim Soloveitchik did in contrasting the mitzvah of Tzedakah in Behar and in Reeh.
And we can view this in terms of life and death, per the Sheva ben Bichri case and the Hostage ransom case:

Talmud Yerushalmi, Terumot 8:10
We learned: If groups of people were traveling on the road and they encountered non-Jews who said, “Give us one of yours and we will kill him, and if you don’t then we will kill all of you,” then even if all will be killed they should not give over anyone. If the non-Jews specified a victim, such as Sheva ben Bichri, then the group should give him over and not be killed.
R’ Shimon ben Lakish said: Only if the victim is liable for death like Sheva ben Bichri.
R’ Yochanan said: Even if he is not liable for death like Sheva ben Bichri.

Mishnah Gittin 45a
One may not redeem captives for more than their value, due to Tikkun haOlam.

Talmud, Gittin 45a
Does Tikkun haOlam refer to the burden upon the community, or to a concern that the captors may capture and bring more captives?
Come and hear: Levi bar Darga redeemed his daughter for 13,000 gold dinar.
Abayye argued: Who says that the sages agreed with this? Perhaps he did it against the desire of the sages.

Talmud, Gittin 58a
Rabbi Yehoshua ben Chananiah said: I will not budge from here until I redeem him for whatever sum they demand.

Maimonides, Laws of Gifts for the Needy 8:12
One may not redeem captives for more than their value, due to Tikkun haOlam, lest the enemies pursue them to capture them.

Code of Jewish Law, Yoreh Deah 252:4
One may not redeem captives for more than their value, due to Tikkun haOlam, lest the enemies endeavor to capture them. But one may redeem himself for any sum he chooses. The same is for a Torah scholar, or even one who is not a Torah scholar but is a sharp student and may become a great man - one redeems him for a great amount of money.

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