Amy Scheinerman has called our attention to an effort by the Ethics Committee of the Israeli Medical Association (IMA) to establish a policy of triage in terrorism incidents that prioritizes the victims – both Jewish and Arab – over the perpetrators. The policy was adopted in 2008 but abandoned last year on the grounds that the policy does not conform with international standards of triage. I – Mark Washofsky, that is – am not sure about that – what, exactly, are the international standards of triage? – and perhaps some of our readers can help us with the question. Of particular interest to this blog is the fact that the IMA justified its policy as a Jewish one, justifying it by appeal to traditional text. The implication is that Jewish tradition or “the” halakhah supports this particular approach to triage. I’m not sure about that, either.

Here’s the text that the IMA relied upon. It’s from B. Bava Metzi’a 71a, it deals with tzedakah, and it reads  עניי עירך ועניי עיר אחרת – עניי עירך קודמין, literally “(if the choice is between) the poor of your city and the poor of another city, the poor of your city take precedence.” This does set a clear guideline: if there is not enough money to go around, we help those who are “closest to us” first and only then offer aid to those more “distant.” Now it’s hard enough to apply this philosophy to tzedakah: should we give to global or foreign causes only after we have sufficiently met local needs? If so, you’ve just cut the legs out from under much of Jewish philanthropy as it’s practiced today. But how in the world do we apply it, as the IMA sought to do before it reversed itself,  to triage, to pikuaḥ nefesh, the saving of human life? Do we really think that physicians or hospital administrators – and, for that matter, the politicians who tend to enact these policies and give them the force of law –  should decide who lives and who dies based upon a criterion of “closeness”? Do we favor the resident of our town over the visitor from out of state? The citizen over the illegal immigrant? Shall we ask to see a government-issued form of identification before deciding whether to treat a particular victim of a mass trauma? If you find these possibilities repugnant, then maybe you don’t want to base your triage policy on Bava Metzi’a 71a.

But there’s another, more fundamental problem with that passage. It begins as a midrash on Exodus 22:24, “If you lend money to My people, to the poor among you” (אם כסף תלוה את עמי את העני עמך), from which we derive  עמי ונכרי – עמי קודם, that is, if you have a choice between an Israelite (“My people”) and a non-Israelite, the Israelite takes precedence.  We might apply this insight, as do the halakhic authorities,[1] to set a priority upon giving to Jewish causes before giving to general causes, although here, too, we’d have to do so with caution.[2] But do we learn triage policy from this text? If so, then we could justify treating the Jewish victims (“עמי”) of a mass trauma before turning our attention to the non-Jews (“נכרי”). Of course, the IMA would reject such a racist conclusion, just as we, in the progressive halakhic community, reject any notion that Jews enjoy a preference over non-Jews when it comes to our moral or ethical duty. So perhaps they read “My people” as Israelis, of whatever ethnicity, as opposed to non-citizens? But that doesn’t take us very far either. What happens when the terrorist is him/herself an Israeli? And what of the non-citizen who happens to get caught up in the violence, such as the Eritrean whom Amy mentioned in her post? Shall we deny or delay treatment to such a person on account of a simple accident of birth? Do we examine the t’udat haz’hut, the ID card of each victim before we decide to treat him or her? Somehow, I doubt that we would, just as I don’t think we could justify that policy on moral grounds.

I’m not saying that the IMA’s desire to prioritize the victims over the attackers is an unreasonable one. Most of us, I trust, would favor such a triage policy on an instinctual or “gut” level (סברת הכרס in yeshivah lingo), but we have trouble formulating it as an exalted principle of moral responsibility. Is it possible to do that? Can we find adequate support in Jewish law for the “victims first” triage policy? Bava Metzi’a 71a is a bad source to use if we want to establish a morally satisfactory approach to medical triage. Is there any other source that works better?

Stay tuned. Meanwhile, we invite your suggestions and comments.

Mark Washofsky

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[1] See Rambam, Mishneh Torah, Malveh v’loveh
5:7:  מלוה להקדים הלואת ישראל בחנם להלואת עכו”ם ברבית.

[2] Again: do we give to general causes only when the needs of the Jews have been fully met? If so, we’d never give to general causes. It’s one thing to set a priority as a general rule; it’s quite another thing to apply that rule in a purely literal fashion.