MARK WASHOFSKY

suggests that all individuals enjoy the same right to treatment and that we as a community are never permitted to make rational and purposeful choices between persons who seek medical care. If we cannot treat all at once, the only proper solution would be to arrange a lottery or other system of random selection, so long as we ourselves do not effectively decide who lives and who dies. The principle of medical efficiency, by contrast, requires that we do make such choices, that we do not treat all patients in an indiscriminately equal fashion. We are to evaluate them based on the chances of their recovery and offer treatment first to those who, in our opinion, are more likely to survive and whose illnesses are more likely to be cured. The principle of qualitative evaluation, meanwhile, demands a different kind of choice: when two or more lives are at stake at the same time, we owe first duty of rescue to that person whose life is judged more worthy of being saved. This standard is the very antithesis of equality, and it likewise has

nothing to do with medical prognosis, yet Rabbi Feinstein mentions it, along with the others, as part of his system for allocating life­sustaining resources.

With all this potential conflict, however, Feinstein does pro­duce a system: that is, he arranges all three of these criteria in an order of preference. It is clear that among the three principles he ranks the second one, the principle of equality of persons, as the first in importance. In the ordinary or sefam case, we treat and ac­cept all patients on an equal basis, making no distinctions among them for any reason. The only exception to this rule is the zereifah, the clearly terminal patient, but even this exception is limited to the narrow circumstance of two patients that present themselves for treatment at the same time. True, the criterion of medical efficacy plays an important role in patient selection: when the physicians

57