If you’ve ever been in an emergency room in the middle of the night, waiting to be treated, you have experienced the inevitable frustration that comes with seeing other patients being taken ahead of you, even if you arrived at the hospital first. At that moment, you have been subject to a method of decision making known as triage.

Triage is the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment, or in cases of war or natural disaster, to decide which casualties require immediate life-saving attention.

During the past year, medical ethicists and hospital administrators around the world have been involved in agonizing life and death decisions during the Covid-19 pandemic, many of which have to do with triage. In the case of the coronavirus, the debate has been focused on how certain vital resources—for instance, ventilators and vaccines– should be allocated.

Imagine for instance that you have three patients – an adolescent boy with a preexisting asthmatic condition; a 35-year-old mother with three children, and a 75-year-old grandfather. All have contracted Covid, and all are struggling to breathe. But the hospital only has one ventilator available. Who gets it? The one who arrived first? The one who is sickest? The one who has the best chance of getting better if they are given the ventilator? The one who has the most quality time left in their life should they recover? The one who has the most dependents?

You are the doctor in charge of the decision. What would you do?

And what is true for ventilators is also now true for vaccines. When resources are not unlimited, and there is time sensitivity in terms of whom to treat, on what ethical basis do we begin to address these questions?

David Magnus, director of the Stanford Center for Biomedical Ethics, has outlined three ethical positions that relate to triage: egalitarianism, utilitarianism, and prioritarianism. Each theory has pros and cons, or more accurately, parts of the theory seem more ethical than others. Let’s go through them.

Egalitarianism, just like it sounds, seeks to treat patients equally, with no deference paid to their age or their level of sickness. It is first come first served, or on a societal level, perhaps a lottery system to allocate resources. This has the virtue of blind luck – nobody is a priori favoured over anyone else. It’s simply a matter, for instance, of who happens to be admitted into the hospital, when a ventilator comes free.

Utilitarianism, the second theory, goes back to the nineteenth-century British philosophers Jeremy Bentham and John Stuart Mill, who argue that the goal of ethics is the best possible outcome for the greatest number of people. Utilitarianism therefore claims to be a theory that wants to promote maximum total benefit. But how do you measure this in the age of Covid?

A strict utilitarian might ask who, after receiving treatment, would have the best chance at a long and healthy life. This can come off sounding sound quite harsh. Should we really put your sick and frail 90 year-old mother on a ventilator and take it away from the reasonably heathy thirty-year-old, if there is only one ventilator available? Who is likely to maximize quality life years? And even if the two candidates are of the same age, then who, based on an assessment of how sick they are and their chances of recovery, would be most likely to get well and live a long life?

I know that for many people this sounds cold and unfeeling, but unfortunately, in times of crisis it may come down to mutually exclusive decisions – we have two people vying for the only remaining machine.

Prioritarianism, again as it sounds, prioritizes those who are in the worst medical condition, and advises treating the sickest people first, regardless of how old they are and what their chances are of recovery. Emergency rooms will often operate on this principle, for example, choosing to treat the gunshot wound victim before the person with a broken finger.

Each of these theories can speak to some of our moral intuitions, but as you can see, each raises some serious problems. Egalitarianism, that is to treat patients equally, for example, is also to treat them without any distinctions, not taking into account the age of the patient or the severity of their condition. Is that kind of equality the same thing as fairness?

Utilitarianism is the theory that makes us squeamish because it does the opposite of egalitarianism, and makes rankings or evaluations of quality of life. In that sense, if you make your decision that way, you could end up neglecting the sickest people and opting for those you think you can save, and actually ignore the fact that you may be guaranteeing death for certain patients.

On the other hand, prioritarianism, in which you devote a lot of attention to a very sick patient when you could have genuinely saved a somewhat less sick patient, leads to the question of whether we have just wasted a very valuable resource. How do we decide?

I’d like to just briefly mention how Jewish ethics might begin to approach these problems. Rabbi Jason Weiner, the director of the Spiritual Care Department at Cedars-Sinai Hospital in Los Angeles, argues that, in general, one of the fundamental principles of triage in Jewish law is that priority must be given to saving as many people as possible.

So Jewish law might actually encourage bypassing those who are too sick to benefit or too well to absolutely need it. This approach to triage is to treat the more moderately ill and make them the focus of our efforts, perhaps enabling the curing of more people.

Rabbi Weiner’s view shades towards the utilitarian position. As he says, “when one patient can certainly or likely be saved and the outcome for the other patient is uncertain, priority must be given to the person who has better chances of being saved. When there are two patients waiting for a ventilator but only one available, if one patient has the potential to live a full lifespan after being saved and the other is terminal, one should prioritize the patient who is more likely to live a full lifespan.”

None of these solutions is ideal. Ethics is not the moral equivalent of a sterile laboratory. Rather, it is a messy business, an attempt to navigate an imperfect world without the guarantee of an ideal outcome.

Our heroic doctors and nurses face these dilemmas in real time, and they do not have the luxury of sitting down to an ethics seminar to figure it out as patients are being brought in stricken with the virus. Just the act of doing triage can be traumatic in and of itself for everyone involved. All medical care workers, especially those in the trenches and on the front lines, deserve our eternal gratitude. May we see an end soon to this global suffering and may all our families be reunited in health and joy.

This post is the first in a new series on ethics. Each month we will pose a dilemma and ask you what would you do. Please write me and tell me your thoughts on the problems raised above, and also please share what you have been going through during Covid. You can do that on this site or by writing me at elliott@livingjewishly.org

Stay safe!