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In Israel, where preserving life is core medical ethos, wrenching dilemmas loom

With hospitals worldwide stretched beyond their limits by the coronavirus pandemic, and some doctors acknowledging that life-and-death choices may have to be made or are already being made as ventilators run short, fears that Israel could face similar heart-wrenching dilemmas are growing among the country’s physicians and philosophers.

“I hope we won’t get there, but if the time comes we could be forced to make decisions of life or death,” Avi Weissman, deputy director of Rambam Health Care Campus in Haifa, told The Times of Israel.

Moshe Halbertal, philosopher and co-author of the Israeli Army Code of Ethics, said that he is deeply troubled by scenarios that may emerge. “They are tragic in the sense that any choice comes at a cost,” he said.

Such dilemmas have hitherto been largely alien to a country that goes further than almost all others to keep patients alive. “We’re used to doing everything possible through to the end of life — it’s part of the culture,” Weissman noted.

But as leaders tighten restrictions and prepare Israelis for the possibility of large-scale infection by coronavirus, hospitals are bracing themselves for an influx, and hoping their personnel and other resources will not be overwhelmed. As of this writing, Israel had five fatalities from the virus, with some 40 patients seriously ill in hospitals nationwide. Prime Minister Benjamin Netanyahu was quoted warning his ministers on Tuesday, “We could reach a million infected within a month. In a bad situation there could also be 10,000 dead in Israel, as predicted by the Health Ministry’s models.” As ministerial discussions continued, Netanyahu reportedly added: “If the current pace of infection continues for another 15 days [that is, with the number of cases doubling every three days], we’ll find ourselves in a situation where we’ll have to decide who to put on ventilators and who not.”

On Sunday, Israel’s Channel 12 (Hebrew) interviewed an Israeli physician, Dr. Gal Peleg, working in Palma, Italy, amid its collapsing health system, who said that in the city’s main hospital, patients over 60 with coronavirus were not being provided extensive medical care, due in part to a shortage of equipment. He indicated, though he did not specify, that one of the factors was an acute shortage of ventilators.

Weissman said that he dreads a day when doctors in Israel, overrun by coronavirus patients and struggling with limited resources, could need to make those kinds of unprecedented choices. He is optimistic that this will be avoided, but acknowledged that in a worst-case scenario, “if we have one ventilator for two people, somebody will have to make a decision.”

He added:

“Obviously the easiest is to choose by age, but I don’t know what will happen on D-Day. It’s a terrible thing to plan.”

In a report released Monday, but prepared before the coronavirus crisis struck, the state’s comptroller warned that Israel’s healthcare system is not prepared for the outbreak of a pandemic, given its lack of strategic planning, funding, equipment and general readiness. “The Health Ministry, the healthcare service providers and the hospital system are not fully prepared for a pandemic flu outbreak,” the report said, highlighting a lack of hospital beds and isolation rooms, and ill-equipped intensive care units, among other failings.

Netanyahu has said repeatedly in recent days that Israel is working nonstop to purchase more equipment; Channel 12 reported on Wednesday afternoon that the price of ventilators has risen from $20,000 to $70,000 and Israel is competing for their purchase with wealthier nations.

Once a patient is on a ventilator in Israel, it is illegal for doctors to switch off the machine. “Regardless of who says what, we cannot stop it,” said Weissman. “We have no say and the family has no say, it’s just down to nature.”

This contributes to a situation in which, even before the feared coronavirus influx to hospitals, the majority of ventilators nationwide are routinely in use.

Weissman predicts that if coronavirus results in a desperate situation, doctors may feel they have no choice other than to break the rules and switch off some machines to make way for new patients.

He said that both this decision, and the answer to the question of how ventilators should be allocated, are likely to “be based on each doctor and each hospital.”

In Weissman’s analysis, if coronavirus facilities become overwhelmed and doctors try to manage without being prepared to switch off ventilators, patients who have no chance of recovery could end up occupying all machines, leaving no capacity to ventilate patients who would be more likely to recover. This should be avoided, he urged, and “the law should change to give the medical system more tools to decide.”

He added:

“Doctors, ethicists and academics should come up with a national agreement that says ventilators can be turned off [in certain circumstances], and specify when ventilation becomes a futile cycle, meaning this should happen. The criteria should be clear.”

But he acknowledged that there would likely be strong opposition to any such change both in the Health Ministry and among ethicists, which is why he expects doctors to be left making judgment calls.

Health Ministry officials, past and present, are reluctant to discuss what will happen if hospitals become gridlocked. A Times of Israel request for comment from the Health Ministry received no response. Gabi Bin Nun, a former high-ranking Health Ministry official, said that Israel must continue on the assumption that healthcare will be allocated to all, as has always been the case, because any other option leads to a slippery slope.

“If we start making a selection based on criteria, there’s no end to it,” said Bin Nun, a Ben Gurion University associate professor who worked in the Health Ministry for 30 years, including a stint as deputy director general for Health Economics. “Don’t go in this direction.”

He voiced optimism that the Israeli health service will cope with the coronavirus crisis, and said:

“I think health is a right of everybody regardless of age, and you need to give care to people according to need. To take a policy that says old people will die is something we shouldn’t adopt.”

Russell Mayer, a Jerusalem-based attorney, said that the push to preserve the lives of people of all ages is so ingrained in Israel’s medical and legal culture that when he writes living wills for clients, he explains there is a real chance that doctors could appeal their decision to forgo a particular treatment. Israel has very active committees that hear doctors’ objections to patients’ wishes to forgo a feeding tube, ventilator or other medical care if they deem the request unwise.

In Mayer’s view, little will change in terms of patient-care ethos in the thick of the coronavirus crisis, apart from a small amount of extra capacity opening up because doctors will become less prone to appeal living wills. “They will be more hesitant to challenge the living will of someone than when there’s a surplus of resources,” he said.

Halbertal sees more room for flexibility. He is strongly opposed to turning off ventilators, but he is open to doctors making judgment calls before allocating the machines in the first place.

“Once someone is on a ventilator, you cannot instrumentalize his life for another person,” he said. “You cannot deprive someone actively of a resource that will save his life in order to give another person life.”

However, Halbertal thinks it’s acceptable that, faced with “scarcity of resources,” doctors become less prepared to put people on ventilators if their chances of coming off the machine alive are slim. And he proposes a criteria for situations where there are several patients and one ventilator.

“When you have a few candidates for a ventilator it makes sense to give the ventilator to the one who has the most chance of surviving,” he said.

“Only that criteria [of survival],” he stressed. “Not based on a criteria of how long someone has to live. The idea that 20 years is worthier than 5 years is against my deep conviction. A clear message has to be sent that age per se is not a criterion.”

Header: The director of the epidemics service, Dr Karina Glick, checking a patient vital signs monitor at a ward, while wearing protective clothing, during a press presentation of the hospitalization service for future patients with coronavirus at Samson Assuta Ashdod University Hospital, on March 16, 2020, in the southern Israeli city of Ashdod. (JACK GUEZ / AFP)/