Triage - Rabbi Akiva Tatz

[Music] [Applause] [Music] okay the that was chosen for tonight's discussion is the question of what we call Triage triage is the problem of deciding whom you will save when you cannot save everyone right you're in a situation of threat to life you have only one pair of hands people are bleeding you can only save one or a limited number of people what is the Jewish approach to deciding whom you safe but I have been in the situation many times personally as a doctor where I've had to deal with you know multiple I was in the I was in a uh I was a military officer for a couple of years where I had to deal with people who were injured and very often you have a whole bunch of people injured before you can get assistance you have limited facilities you have to make decisions within seconds what are the Jewish principles that lie behind how you choose and a portion scarce resources and decide who will be saved when you can't save everyone that's a problem known as triage it's an old term coin during the Napoleonic Wars when lots of people were injured the first world war you saw similar situation very very large numbers of people injured and the simplest and most crude triage methodology was to divide the wounded into three groups those who are so-called walking wounded would survive anyway those who were so desperately injured they probably were going to die anyway and you concentrated all your efforts on the third group the ones that you could save with your help and possibly would die without it today they're much more sophisticated triage protocols unfortunately and tragically many of them developed in Israel right for obvious reasons and I'll try to share some of that with you but in order to take a look at this very amazing area let me share with you a very interesting and very strange triage dilemma uh and then we'll try to use that as a focus on which to or framework if you like on which to build the concepts the concepts that lie behind this area and then we'll Circle back and try to answer this particular dilemma right stay with me carefully because fine nuances in a question can make a life and death difference in the output okay so here's the question a young surgeon in South Africa a number of years ago was training in emergency surgery and he was working at a place there the Johannesburg Hospital which has a very highly developed uh what's known as an accident service it's like in America you call it the ER emergency room but there's a dedicated trauma unit and this is a very very big unit that has a very well-developed helicopter service that brings people in from hundreds of miles around in fact it's a massive institution the danburg Hospital the building is 1 km long it's the largest building in Africa and if you put your eye to the ground in the main Corridor on the ground floor you can see the curvature of the earth okay it's a massive institution and they have this very busy accident service now here's the Dilemma this young Jewish doctor was working there and the hospital had acquired a new machine it was a new ventilator or ventilator resuscitator I was no longer present at the time so I can't tell you exactly what the technology was but it was some very sophisticated machine and they had only one and the hospital had issued a very peculiar instruction the instruction was that no doctors allowed to use this machine on any patient who he considers to be non-s salvageable okay in other words you get a patient who's badly injured you can see they're not going to survive you know South African doctors can always tell exactly how long people are going to live right you know we get that down to the second usually American doctors usually you know very bad at that but we can we get it right and if you can see that this person is not going to live that's what you call that means a person can only live temporarily as opposed to which means long-term life in such circumstances the hospital said do not use the machine you got this new fangled machine you got this patient you want to put the patient on the machine do not use the machine why do you think they made that rule yeah tonight we're here to learn not only material we also learn how to think a little bit Hally right we want to think logically so let's try and see let's do effort of thinking together they were concerned that if you put the only machine you had on a self hopeless patient what would happen half an hour later when you get another person who would come in that person is salvageable you no longer have the machine available cuz it's committed to the first person and now the second person will die in the first person is going to die anyway you have only one machine and the hospital said do not use it now the reason they said was because if you put the machine on the first person is hopeless what will happen half an hour later when somebody else comes in you will not have the machine available and the second person is going to die the obvious challenge to that is why don't you simply put the first person on the machine right now when the second person arrives detach the first person from The Machine they're going to die anyway and put it on the second person why not cuz it'll take time DET no that's not what they said the Johannesburg Hospital gave the following reason they said if you put the first hopeless person on the machine half an hour later when somebody else arrives and you walk over to the first person to switch off the machine their family will object there'll be scenes of emotion chaos hysteria they won't let you we don't want to get into that and therefore don't do it now that is completely irrelevant jewishly the family's emotional response in that circumstance completely irrelevant but but jewishly there's a very good reason for this and that is that if you put a hopeless person on a ventilator and it's keeping them alive moment to moment you may not switch off that machine and kill them even to save another life and the reason is we have a very basic principle in radical called you cannot push aside one life for another and in Judaism you cannot kill somebody even a temporary life to save someone even a long-term life you cannot kill for that purpose and therefore translate the question in Jewish terms if you put the first person on the machine and the second person arise salvageable despite the fact that the first person's dying you may not switch off the machine on the person and therefore they're both going to die so maybe it would be better to obey this Hospital instruction and not put the first person on the machine hold the machine in the background let the first person die sooner wait till the second person Ares and save the life with the machine and that's what the hospital wanted him to do this young doctor was concerned to know whether this in fact agrees with his Jewish principles and he went to a world famous Rabbi who happened to be in South Africa at the time and he asked him what is judism require does it require me to obey this Hospital instruction which means Save a Life later let the first person die or does judism require me to disobey the hospital instruction maybe they'll discipline me lose my job who knows what will happen but if that's what I'm required to do that's what I'll do I'll use the machine in an ilicit fashion against their instructions and who knows what will happen to me not only that half an hour later I know someone else is going to die in addition and listen carefully to this he added to his question the following information he said this hospital is so busy that the scenario guar guaranteed in other words there's a statistical guarantee here that the second person is going to be here I'm not talking about whether there's a doubt about that and I'm not going to argue this evening about whether we accept statistical certainty as a reality I'm going to assume that's the case it's a very interesting question in but let's assume that you have a statistical guarantee that means he even said this place is so busy that I will guarantee you that a Jewish patient is going to arrive who'll need the machine let's leave it out it's complicated enough without that but that's what he said so our question is this I have patient one who's I have this machine which will give him the best chance of survival in the short term but if I hold it in abeyance I will be able to Save a Life lad which is guaranteed to be here so in those circumstances where I have the first person who's not salvageable guaranteed to be here second person what do I do in that circumstance if you think about it you'll realize this is a weird triage dilemma normally triage means I stop at an accident two people I don't know people stop at accidents anymore do they do they yeah well in uh in America they don't cuz they don't want to get sued in South Africa they don't cuz they don't want to get AIDS in Britain where I live now they don't cuz they're too polite but you know anyway in Australia they do I'm sure I'm sure Australia is perfect so um so what is you stop at an accident you have two people who are bleeding you can only save one that's the classic triage dilemma in our Strange Case we have two people but one of whom is here and one of whom is not here yet in fact the second person isn't even a patient yet right now at 8: in the morning he's mumbling at his wife from behind the newspaper not knowing that in half an hour he's going to run into a truck on the highway and be badly injured but he is so this did you see that that's a strange triage dilemma we do have two people one who's here now and one who's guaranteed to be here by statistical guarantee but he's not here yet okay strange but that's our dilemma let's think about it the first of all let me point out to you that triage is not only an immediate acute emergency situation triage is a very broad issue for example let's say you are a hospital director and your job is to a portion the budget right this is for you are you allowed to spend money on a Well Baby Clinic where they measure the kids and give them vitamins and all that if you don't have enough intensive care surgical beds that's a triage problem what about a country is a country allowed to spend money on its parks and museums and tourist attractions if it doesn't have enough money for military and emergency that's a triage problem political level so this cuts across Society throughout the Tet says if you have a river flowing past two cities where there's enough water in the river that if the Upstream people drink there'll be enough water for the downstream people to drink as well but if the Upstream people drink and wash there'll be no water left and these people will die of thirst what's your duty as a Jew living in the Upstream City do you drink and wash and let them die of thirst or you constrained to drink only and leave enough water them for drink for them to drink what would you think the conclusion in the talmud is that these people drink and wash and they let them die reason is says the talmud if they don't wash there'll be an outbreak of hygiene related epidemic in their community whether the word means tyus or we we're not so sure what the Aramaic word means for that type of epidemic but although it won't kill them as rapidly as thirst will kill him the next day they're allowed to factor that in that's called P so they very broad issues here right I'll give you another example a few years ago a couple living in a certain European city found themselves unable to have children for many years they ended up at a very slick fertility unit at a tel avive hospital and they had a child this couple happens to be exceptionally wealthy and the father in Joy made a massive donation to the hospital on condition that it's only allowed to be used to help other people have children but this was an Israeli situation I don't have to tell you Israelis often have their own quite definite opinions about things and the hospital director said I'm not taking your money for that it's immoral of you it's immoral of you to pay for people to have children when I've got dying people who need to be treated I've got people in my Hospital who dying and you want to spend your money I'll helping new people come into the world that's immoral I'm not taking your money so the man said fine I'm not giving it and they had a big argument about it instead of just taking the money you know it reminds me in the last generation was a rabbi called a panovich arov he was a very very amazing individual and very shrewd and this Rabbi had a friend who was je jewishly he was extremely wealthy and extremely generous but he was a little jewishly challenged this man promised the rabbi enough money to build an entire Yesa on condition that the students would not have to wear these the rabbi promised he took the money and he built a girl school that's the way to handle these situations okay but in this case the man refused to give his money so they went to see ralash great rabic Authority in Jerusalem and they asked him what to do and Rashi said the man's fully entitled to give his money to the fertility unit so the hospital director said Rabbi how can you say that P talking about saving lives and the rabbi said as follows he said that when a country funds only emergencies people get an embattled mentality that affects their morale and that's a life and death matter as well now you need very broad H shoulders to be able to say that right but that's what he said so societal and broad level issues high level broader issues are also relevant in trios not only the emergency situation you get all sorts of weird one weird situation I can think of is that some years ago in Nat you know l hospital in Nan as a hospital to run on religious lines a wealthy American donated a kidney dialysis machine to the hospital on condition that the machines only allowed to be used for tourists why cuz he was concerned that American in kidney failure could never visit Israel no one's going to dialy you in a country that doesn't have enough facilities for its own people so put the machine into natana American and kidney failure will visit Israel he'll tour around the country every two or three nights he'll sleep over in Nan be dialyzed and between sessions he'll fly home you can guess what happened they put the machine in immediately someone arrived in kidney failure who was not a tourist they went to the rebi in charge of the hospital closenberg rby he said P used the machine now it's used fully all the time do not ask me what would happen if a tourist and a non-tourist arrived at the same time I have no idea but that is a so you get all sorts of weird triage situations not only that but in civilian medicine first of all you know that in disaster situations as I said the protocols give me a second just many of them are developed in Israel you know that for example one of the main triage principles that's used in the military and in Mass disasters is that before you treat anyone you need to triage everyone so you come up a disaster scene you got 20 people injured you have to rapidly assess everybody before you treat anyone and there's a special color coding you use a black tag means a person's Dead red means something else yellow means something else it's a whole organized system does not always accord with Jewish law now for example let's say you're treating people as a young lady doctor in Tel Aviv she arrived at at a a terrorist attack she rapidly tried to assess everybody and she came across a seven-year-old child bleeding badly from the neck she put her finger on the bleeder and sto the bleeding and now what's she supposed to do takes her finger off to check everybody else the kid will die according to most Tri protocols that's what you have to do cuz there may be 10 other people dying but in Judaism you can't do that you can't you you can't cause this person to die now even if you may find others and the reason is this is called a vad and the others are called a safik this is a certainty the others are doubtful and therefore you'd have to stop here right now there would be exceptions in the military situation right I give you an example I heard from a certain Israeli doctor I was at a meeting of Israeli doctors one of us told us about a friend of his who is a senior Israeli Army surgeon who was sent into Lebanon with a group of Israeli soldiers and he had with him one paramedic so very senior doctor a paramedic and a whole bunch of soldiers after they crossed the border one of the soldiers was very badly injured and this doctor said completely secular doctor about totally secular Israeli doctor he said this Soldier was so badly injured that he was confident that if he had a helicopter radio for helicopter and had him flown back to Kaa the soldier would almost certainly survive but only if he went with him in the helicopter but to do that he have to leave the other soldiers without a doctor but if he stayed with his men and he sent him back with a paramedic he'd almost certainly die and he said he had no idea what to do he said terribly frustrated on the battlefield and he said for the first time in his secular life he began praying very hard and actually what happened was a big helicopter came and took them all now that's not the point of the story when he got home he asked his religious friend what he should have done and he went to ask ralash great Rabbi in Jerusalem and Rashi said that if that would have been a civilian scenario there's no question that he would have to take the man back because here's a vad dying person and a suff maybe others will be injured later but in the Army you stay put in the military situation you job is to be with those men and to support the mission and if the Danger's been already factored into the situation that's what you do and you send him home although he may may die so you get many many varieties not only that but in civilian medicine if you walk into an NHS Hospital in England where where I live right now and you say you've got chest pain the first thing you'll hear is triage and somebody's skilled at rapid assessment of how urgent your case is will run over immediately and I'll check you out if they decide that you're an absolute total absolute amazing emergency you only have to wait wait until Wednesday you know and if they decide it's a normal emergency you wait until October you know but the point is that they stratify people in a hierarchy of risk so that they can abortion treatment and all sorts of crazy questions I mean some months ago here in Israel somebody asked one of the rabbis when we come to a terrorist attack are we allowed to walk undying people to get to someone we might save we might extinguish lives in doing so and every time you bring in heavy machinery to excavate a building that has been exploded to dig out people who might be surviving you might Crush on the way right these are real time questions in triage and of course there many other varieties as well but let's try and focus briefly this evening on the immediate acute problem you got two people in front of you what are the Jewish principles we use in deciding whom we save let's study those principles and they will Circle back and deal with our ventilator question so imagine I walk into a room here picture is worth a th000 words there two dying people okay I got one pair of hands and I can only save one what would you look look at first as a differential between the two people what what would you look at in order to decide whom you would save age age age is not a hardcore criteria in Judaism some rabic authorities say that You' save the younger some say you save the older this interesting interesting question but age is not the first thing gender gender gender yeah the usual uh yeah which gender would you say first women why because they're more vulnerable because women can have children cuz they can reproduce uh men are required you know I mean you okay um you obviously haven't studied biology no but but um no we don't save women first in fact there's no gender differentiation the only difference is that talmud says for example if terrorists capture people and you can only Ransom back a limited number we save the women before the men before the men but the reason is because they almost certain to be sexually interfered with which will not happen to the men and because of differential suffering you would save the women the code of Jewish law says that if the terrorists are homosexuals you have to save the men first because that's a greater indignity right so therefore it's not a question of whose life is worth more it's a question of differential suffering but in terms of value of life we will not save men or women first any other differentials you know the Americans always say who's got insurance you know who's got insurance that's not right what else would use to differentiate current medical condition let's say the current medical condition is exactly the same what else would you look at yeah where they are relation to you yes yes probably the most basic of all Criterion is criteria you save the one who closest to you if I walk into the room from here I have to save this person first what's the reason if you walk past the first person then they'll be they why why do you say the one is closer first because then it's like you're walking past them why cannot you walk why can you not walk past the closer person you're killing basically killing no you're not how am I killing here's the first one first the reason is like this yeah that maybe how they do in Australia yeah you can move that person out of the way and then get other people in there no no no you you say I'll tell you the reason the reason this there's a principle in called you're not allowed to bypass a mitvah in other words as you approach these two people right now you have a you incumbent on you is a life-saving Mitzvah of saving life you cannot walk past that to an equivalent more distant Mitzvah very important principle in that's called you cannot bypass a Mitzvah so when you go two equivalent Mitzvah and one is closer you can't walk past it okay now now just just one second what if I walk in from here the equidistant one's my brother one's a stranger who do you say first your brother right why because your mother will be upset why do you save your brother first so why do you save the person you have a personal relationship with first uh you know there lots of brothers that the brothers don't care about you know there lots of relatives that yeah the other fellow somebody else's brother brother distracted if you don't save your brother and what if this is a brother you don't especially like obligation to your family why why do you have obligation to your family first you're the same because the Tor says do not ignore your flesh so there's a verse in the Torah that says that you have an obligation to a relative just just stay with me this law by the way is the reason you have to give charity to relations before strangers your parents come first after that grandparents interesting hierarchy of priority but you have to give charity to people that are related to you you also have to give to a friend or a neighbor before a stranger you also have to give people in your city before people in more distant cities you have devolving layers of concentric layers of responsibility and Jews living in a particular City have to give Jewish causes in Jewish and non-jewish causes in their City before mod dist except for Jerusalem wherever you live you can prioritize y equivalent to your city cuz notionally we all live inim and many authorities say anywhere in Israel as well that's notionally your where you where you live but certainly your own Community comes first and therefore you have an obligation to treat family before strangers now stay with me here has a chance to use your black belt thinking what's the next dilemma I'm going to put to you come on what's the next question before you put your foot in it use logic come on what's the next essential question here make my day two family members two family members not not logical two strangers not logical a family member and your husband or wife uh family member or husband or wife who would you say first husb husband yeah Hally husband and wife are considered the same person husband are not considered relatives they're considered the same person a Jewish husband has to pay for his wife's all her medical needs all her fines her burial expenses he has to Ransom her from captivity if she's captured by terrorists assuming he didn't hire the terrorist in the first place you're not being logical okay come on I want logic here yeah what if the two people were equidistant from you no that's not logical you're not being logical if Mom would you pick your husband or wife over your children that's interesting question probably yes could be but that's not the question come on what's the next question call call Emergency Services hey I'm the emergency service right you're that's not logical if you're what if you're can't you had to byass excellent of course the next the question is this what happens if I walk in from here the first person is is closer and the further is my brother yeah we have two principles proximity is the first Criterion the second criterian relationship which priority takes priority isn't that the logical next question you look isn't that the logical next question even if you're Australian yeah and therefore we are learning to think Hally logically okay criteria number one proximity do not by criteria number two who's related to me which priority takes priority brother yes in fact it's one of the rare situations where you walk past the closer person and you treat your brother okay that's what you do for homework why this is a black belt T question both of these have Torah derivations do not bypass a Mitzvah is derived from the Torah do not ignore your flesh is derived from the Torah so how come you prioritize your relationship over proximity this takes a little time to think but think about it okay this is worth a lot of thought and for every correct answer Jackie is going to buy you a whiskey cocaine whatever you into in these days um that's interesting question why do we bypass the closer mitah to prioritize the Criterion of relationship okay now next one I walk in from here they're both equidistant they're both equally related to me one is terminal and one is salvageable this one is called this one is called namely is is that clear this person has got cancer they're going to live for 3 months or 6 months Hally life less than a year is called terminally ill without going to derivation for that means the person will live for less than a year so this person's got a terrible disease they're going to die in six months time this person's perfectly healthy right now they've been disastrously injured they're both bleeding to death if I save this person he will live in the long term if I save this person he will die in 3 months time from his disease which one do I save this is a no-brainer right you save the long-term life what Happ if I walk in from here the first person is a this person can live for 6 months there's no question you have to save a person for 6 months right Hally you break Shabbat to save a person for one extra second of life even if he's unconscious so no question that I have to save this person but if I walk past him I will save a person who live in the long term what do you do no you walk listen carefully you walk past the closer person and you save the person who's more distant provided the first person is not conscious if the first person's conscious you do not walk past him why because if he's aware he will why can you not walk past somebody who's aware because he'll be feel abandoned and hopeless and therefore die sooner because a person's emotional status is very relevant to their survival any experienced doctor knows that and therefore feelings of Abandonment hopelessness pain anguish despair depression those are additive tangible lethal factors in Judaism and so if he's aware you cannot walk past him but if he's unconscious or unaware you walk past the non-s salvageable person and you save the salvageable person everything we're discussing tonight here comes the key notice what's happening I'm walking past a person whom I have an obligation to save correct this person I have an obligation to save him even though he's only going to live for 6 months but I'm bypassing him why because I have a prior life-saving Mitzvah and here comes the rule whenever you break a Torah mitv you ever you you you desecrate the shabas you eat UNC food you eat you break any Tora law to Save a Life there's one Criterion that needs to be satisfied and that is that the life you're trying to save must be here now that's called a in other words to break a Tora law for knowledge that may save lives in the future you're not allowed to do that's below the red line right for example can you break Shabbat to save life can you eat uncos food to save life can you eat on keeper to save life but show me the life there's got to be a person here and now for example Give an example in Judaism you cannot dissect a dead body right no autopsies allowed three potential Torah prohibitions in desecrating a body many rabic authorities say it applies to Jews and non-jews because the human body is formed in the Divine image not specifically a Jewish thing you cannot dissect the human body three potential Torah prohibitions can you dissect a human body to save life yes yes because the only things you cannot do to save life are sexual immorality idolatry and murder without going into the background of the details those three things you cannot do to save life just one second but desecrating a human body is not one of those things right desecrating a body is not murder the guy's dead it's not idolatry unless you're very strange it's not sexual imor immorality unless you very kinky right and therefore and therefore right you are dissecting you work in a hospital you have a patient in your W who's got a weird disease he's got yellow squares all over his body and he's flashing like a neon light right you don't even see that in Chile do you weird disease suddenly the patient dies everyone wants to get their hands on his liver and spleen to see what's doing nothing doing in Jewish law you prepare the patient for burial suddenly the patient to the next bed gets yellow squares and starts flashing Jewish law says you go find the first person and you cut him up now why cuz there's a there's somebody in front of us now who may be in danger and by the way the degree of danger is irrelevant and the probability of saving is irrelevant cuz when it comes to saving life we don't look at majority or statistics do you know in all of Jewish law we use majorities you're aware of that but not in Saving life if you're cooking a meat soup and a few drops of milk fall in accident don't don't try this at home okay but if you're cooking a meat soup and a few drops of milk falling accidentally it's kosher if you throw it out cuz you think you being religious you guilty of wasting cuz the majority anuls the minority but not in lifes saving so if there's any chance this person might be at risk and if there's any chance you could save him you cut up a person in order to Save a Life and therefore we breaking just one sec we breaking law in order to save life provided that the life is here now that's called a is this clear that principle okay now listen carefully what is the meaning ofu one of the great authorities who writes about this he makes it plain that lefanu does not mean the same room or the same Hospital same city it means a real identified extent individual for example in virtually every Western Country today organ trans transplantation is done by a computerized National matching list so when kidneys are taken from a hospital for transplantation in the the morning the doctors taking the kidneys don't even know who's going to get them but 6 hours later somebody in another city may get the kidneys and the reason is because there's a national computerized list and the next best match on the list is the person who's going to get the organs even though they may not be in the same city I don't even know his name but that is called lean is that clear in military situations again it's different in Israel for example all hak authorities allow the harvesting and freezing of skin and bone right in other words people can donate skin bone corners of eyes to be banked and Frozen because soldiers may need them if they get burned or injured and although there's no one burnt or injured now because there's a real and present danger in a country facing a military threat that's good enough right and to take Bone and Skin of course you can wait until the person is dead not like taking a heart there's no problem with that so you need a real and present danger unit person present that is the red line and that's called I'll give you an extreme example I think we mentioned this the other night but I'll repeat it again 1986 a baby was born with heart disease in California the surgeon was a famous chess surgeon Norman shamway decided for the first time in history to transplant a heart into a baby there was no other hope for the child right you know hot transplantation only began in 1968 as we mentioned before in a certain well-known country um and um by 1986 no one had ever tried to transplant a child but there was no other hope the only heart they could find for the child was in Vermont and although it was 3,000 Mi away there was no other hope they flew one of the young surgeons in this um in a private jet that they hired across the country he cut out the heart of the child in Vermont and unfortunately they could not get the plane started they couldn't get the plane started they ended up scrambling United States f for supersonic fighter put a terrified young surgeon in the back of a supersonic fighter with a heart in a box on his lap when they got back to California they to resuscitate the surgeon but they did and they saved the life of the baby in California right that 6,000 miak is called Le do you see that are we together yeah because the distance is not the issue the issue is that there was a real identified person that's the concept of Leu let's come back to that question the question was young surgeon employed by Hospital got new fangled machine the hospital has told him do not use this machine on anyone who's not salvageable okay and he doesn't know whether that's correct or not so he went to ask a rabbi the the question and there were three answers to this the question went to three reic author and there were three completely different answers to this very simple yes or no question he was given a particular instruction by the rabbi he asked and so that satisfied him Hally if you ask a rabbi for a that means a ruling you're bound by the ruling you can ask 10 rabbis their opinions and make up your own mind but if you ask a rabby for a ruling then you fixed by that you can't shop around you they have a joke about this in Israel there's a CD ROM made by Baran University on that CD is every single question that has ever been asked the joke is like this you ask it what you want to hear and it tells you whom to ask that's wrong that's wrong okay if you ask for a ruling from Arab then you're bound by that so he was told what to do by the rabbi but the rabbi sent the question to two other great authorities one in Jerusalem and one in benra and there were three completely different answers to the question and I'll tell you what those answers were but before we uh before we do that let's let's get the scenario clear again I got my new fangle machine I got my hopeless patient and the question is do I commit it to the patient and watch someone die an hour from now or do I hold it in abeyance let the first person die and save the life that's coming and that's our problem right correct that is the question so the first answer that he was given was and let's think about the situation right I walk in from here the first person is hopeless I bypass them if they're unconscious and I save the second person so let's assume that I come on duty at 8:00 in the morning I'm a trauma surgeon I sit there studying my page of gamor like all good trauma surgeons do and they call me over and they say someone badly injured injured I rush over check out the patient I can see he's completely hopeless okay this person is a there's no way that he could survive but I have my new machine and I would like to connect it to the patient but just before I do I see the door open and I see that they're wheeling in a somebody who could live in the long term do I quickly commit the machine to the first hopeless person or do I wait till the first second person arrives absolutely unconscious no Hope Of Consciousness doesn't know what's going on do I wait okay even though he's more distant because from here to the door is is that called leanu yes excellent number two 8 in the morning come on duty badly injured person new fangled machine as I'm about to put the machine on the phone rings on the phone they tell me that there's an ambulance on its way 10 mil away in the ambulance is a salvageable patient wait 10 minutes he'll be here do I wait 10 miles where is hopeless number three 8 in the morning badly injured person about to put the machine on the radio crackles to life on the radio they tell me that the helicopter's on the we it's 150 Mi away in the helicopter is a salvageable person if I wait for an hour I'll save his life do I wait 150 mil okay now listen very carefully and if this doesn't move you there's no hope for you come on duty badly injured person about to put the machine on no door opening no phone call no radio call but there's a statistical guarantee that someone's going to be here now for now is a statistical leanu called leanu well one second you have enjoy the question isn't that amazing question isn't that amazing question even if you're Australian yes what's the concept of Le does it mean a real person here or does it mean the life you wish to save normally both of those are conflated in one situation I've got a person here whom I want to save in our Strange situation we don't have a person here but we have a life to save cuz if we use the machine on the first person we guaranteed that half an hour from now somebody's going to die even though it doesn't exist yet what's the concern of Lan you see the problem so what would you say no you said that you can't um like bypass Miss City the first one if it's to save a future life that you don't really know yet well the question is he's guaranteed to be here let me tell you what happened the first Rabbi asked the question said to this young doctor the hospital's correct in my opinion don't use the machine let the first person die do whatever you can for him save the life that's coming second that's called the fin and of course he was told that don't have to lose your job that's what he did second opinion was I don't call that lefanu you treat the first person now what will happen hour from now you have to do and the third opinion was very interesting and listen carefully it sounds weird but listen well the third opinion was a famous Rabbi in Ben bra of zilberstein of's son-in-law he said they're both wrong and here's what you do you take your new fangled machine and you attach to it a clock and a bell and as soon as the first person arrives right away you set the machine running and you switch on the timer the machine runs for half an hour Rings a Bel to warn you that it's going to switch off and it switches off you rush over and switch it on again machine works for another half hour warns you switches off you switch it on again you keep doing that till the second person arrives when the second person arrives you wait till the machine switches off and instead of switching it on on the first person you switch it on on the second now whether the Johannesburg Hospital would like Shabbat clocks on its ventilators I don't know but amazing as that suggestion was it's about to happen hadasa hospital and Sh sedic have just built a machine like that and the reason is very interesting listen carefully because at first glance this sounds like a cowardly way to switch off machines on people cuz you're not prepared to switch them off yourself and that's not the logic so listen very carefully this has very extreme right-wing hakik approval and the knesset has approved it in fact they are waiting now for knesset subcommittee um Insurance approval and they're about to run a human trial they've now got the machine working successfully on on models and they're about to go human but the logic is important to understand and it's this here here's here's the drama and here's the tragedy in every hospital in the world today people working intensive care have the following dilemma and I've been in the situation myself and it's absolutely nightmarish you get a person in your hospital in respiratory failure they've got swine flu or some disease of their lungs and they need ventilation urgently the problem is will they recover on the machine or will they not recover your worst fear is putting a person like that onto a machine that will not recover cuz you'll have them on the machine for 3 months and then they'll die anyway and during that time lots of other people will not be safe cuz the machine's not available and you don't have enough machines so what do we do we try our best to assess the patients and only accept the ones that look like they'll recover and you cannot do that accurately so lots of people are sent home to die because we don't think they're going to recover and without question many people who could have recovered are dying how do people sleep at night making those decisions so here's the solution don't do that have all ICU ventilators on timed cut offs I was at Mount sa Hospital in New York recently I gave a talk to the Ethics Committee there they told me they're about to put all their ICU ventilators onto time cut offs why cuz when a person comes in respiratory failure instead of making a judgment about whether you think they'll survive or not put them on the machine right away but you say to them my dear sir you have two options you either go home and die in respiratory failure or we'll give you 5 days trial of therapy on this machine if your lungs appear to be recovering during that time we'll keep you going if it becomes apparent that your case is hopeless when the machine switches off we will not switch it on again or more accurately we'll switch it on on somebody else so this is not a cowardly way of switching off machines it's a way of giving people a trial of therapy that they wouldn't have had otherwise you see the logic and what's happened now is that they have selected a group of patients in Israel they're about to grow human I'll stop for questions in a moment they're about to grow human they've chosen an interesting group of patients they've chosen people who have respiratory failure due to neurodegenerative disease people who are have neurological problems that are leading to respiratory failure will not be able to breathe and they'll die because they cannot breathe they've taken a group of these people who have signed a request that when they stop breathing they do not want to be put on machines so they've gone to a number of these people and said do us a favor when your time comes and you cannot breathe allow us to put you on a machine for one week extra when the machine switches off we promise you we'll let you die give us an extra week of your life to prove the technology and they all said of course we can help other people absolutely the reason they've chosen these people is so that nobody can accuse them of having killed people by means of this machine all you'll be able to accuse the researchers of is having given people an extra week of Life do you understand and that is the situation and coming to a hospital near you soon without doubt is going to be this technology by the way I'll finish with this developing the electronic circuitry to switch off the machines at a timed cut off was very challenging okay it took the Israelis a lot of a long time to develop the electronics to make a timer that would work successfully why isn't that a trivial problem go to your local hardware store get a timer that you stick in the ET put your machine in and it'll work switch off what's the problem that if you switch off the current to an ICU ventilator it refuses to switch off it goes crazy it starts alarming and bleeping and soring it's backup batteries they do not switch off they design not to fail so you've got to design a circuit that will cut the power and switch off the machine but not override the alarms and the backups when it shouldn't that's a life and death problem now they're confident they've got the electronics reliable enough that will switch off the machines when they want them to but will not defeat the backups and alarms and they're about to run a human trial and I have no doubt that this is become the standard technology and the reason is to solve the problem of inadequate machines we will use pre-timed cut offs and we'll use them for Trials of [Music] therapy