MARK WASHOFSKY
We have seen that the principle of medical efficacy has powerful support in the sources and is arguably the better definition of this issue. Moreover, if we hold the reasonable presumption that a community’s medical resources are the property of the community, that the community pays for them and provides them in pursuance to its duty to save life—to fulfill the mitzvah of piku’ah nefesh—we have every reason to conclude that their use is at all times subject to this condition. That is to say, they remain under the community’s control so that no individual patient ever acquires a legal title to them. Since the community makes these resources available for the express purpose of saving life, it follows that the community must require them to be used in the way that will best fulfill this mitzvah.
Thus, in the cases considered in Feinstein’s responsa, we would conclude that when a physician faces a choice between caring for two individuals when one is clearly terminal and the other has a chance for recovery, the latter patient comes first. This would be true even if treatment had already started for the former, for the physician’s duty as the community’s agent in the saving of life takes precedence over any claim the terminal patient may have on the physician or the community’s resources.
Accepting the principle of medical efficacy as the criterion by which we allocate health-care resources carries some obvious and far-reaching implications when we turn to the wider social context. Just as a physician must at times make fateful choices of patient selection, so do we as a community face inescapable decisions concerning the funding of medical objectives. These determinations are no less questions of life and death than are the choices between or among individual patients: on what moral basis do we make them?
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