Medication on Shabbat

A Medical Perspective

Background

The Gemara Shabbat (53) describes the difference between an animal or person suffering from some form of hematoma where a person can bathe on shabbat to treat his hematoma while an animal cannot. Olah explains that the animal cannot bathe due to a gezira of schikat sammamanim while a person can as bathing^[1] is something done by healthy individuals. Rashi explains that the Rabbanim instituted a prohibition of using medication on Shabbat as they were concerned an individual involved with preparing medication will accidently grind (tochen) the ingredients – a biblical prohibition—needed to prepare the medication.

This Gemara informs us of a few implications of this gezira. First, there is a gezira of using medication due to the concern of transgressing tochen. Second, that gezira is not limited to medication but all forms of r’fuah on Shabbat. Third, the Gemara immediately limits the gezira to actions that appear medicinal; if the same act is performed by otherwise healthy individuals (maachal b’riyim), it would be permitted even if done for r’fuah^[2].

The Rif further limits the parameters of this gezira by codifying the position of Rav Oshiya (listed earlier in the same Gemara) who allows the animal to bathe on Shabbat. When treating human patients, the practitioner is fully focused on the medicinal process and we are therefore concerned they may inadvertently forget it is Shabbat thereby grinding the ingredients needed for the medication. However, people are not as concerned with the health outcomes of their animals and would not forget they cannot grind the medication on Shabbat.

The Rambam by ammeding the Gemara (Shabbat 140a) provides for the justification for another limitation of this gezira. The Gemara argues that a medication that was initiated prior to Shabbat can be continued to be taken on Shabbat because discontinuing its use would endanger the patients life. The implication of the Gemara’s exception is that medication whose disuse for one day would not harm the patient is prohibited on Shabbat. However, the Rambam (21; 20) expands the exception to “kdie shlo yichla,” taking medication on Shabbat that was initiated prior to Shabbat is permitted even prophylactically.

The Gemarot never define which patient population is included within this gezira. Obviously, patients that suffer from life threatening diseases (choleh shyish bo sakanah) can utilize any therapeutic means necessary to alleviate their condition. The Rashba (Shabbat 121a) argues that the gezira also does not include patients suffering from diseases that are not life threatening (choleh shein bo sakkanah). That would then necessarily include patients suffering from conditions that threaten the function of an organ^[3].

These guidelines would allow us to include patients that do not suffer from an acute illness but whose function is not physiological. That is a women suffering from infertility that needs to take scheduled medication at precise times would be allowed to do so as she would be considered a choleh skaanat eiver—an individual suffering from a non-functioning limb. Similarly, a diabetic suffering from peripheral neuropathy should be allowed to take Viagra as he is a choleh not included within this Rabbinic decree.

This would then limit our discussion to michush b’alma, only individuals suffering from slight discomfort would have a prohibition of using medication for fear they may inadvertently grind the ingredients on Shabbat.

Peripheral neuropathy, sometimes seen in patients with uncontrolled diabetes, can result in erectile dysfunction. Viagra can assist patients with ED and allow them to maintain an erection. Rabbi Katan wrote an article analyzing the use of Viagra on Shabbat and reached the conclusion it was permissible for four reasons. The gezira is limited to medications that heal. Viagra allows for symptom relief but does not heal the underlying pathology. Viagra allows the patent suffering from ED to perform the mitzvat onah, the mitzvah to maintain weekly relations with his wife. Viagra is a medication that is taken more than one day at a time. As such it follows the principle of the Rambam that medication that requires more than one day is not included in the gezira.

These arguments all require further analysis. It is very difficult to define the difference between medication used for symptom control and those used for treatment of the underlying disease. Beta blockers, for instance, treat heart failure by reducing heart rate. Narrowly that seems to indicate they are a medication that is used only for symptom control. However, studies have demonstrated that patients on beta blockers have positive remodeling effects on the heart, illustrating a curative component. Nitroglycerin on the other hand, decreases anginal pain by dilating the veins and does not have an effect on increased patient’s life expectancy. It would then seem that nitro is not a treatment but a medication used for symptom control. However, that would only be the case if we define the sickness as “heart failure,” if the sickness is defined as “chest pain” then nitro is in fact the cure.

Comparatively, Viagra does not treat the peripheral neuropathy caused by diabetes mellitus. It does however allow for maintaining an erection. The question then becomes what is the sickness and what is its treatment. Viagra does not treat diabetes. It does however treat impotence. For that matter, insulin, a treatment for diabetes, does not treat peripheral neuropathy. It would reduce the blood sugar which would then limit damage caused by high glucose levels leading to peripheral neuropathy. We could however take it a step further. Insulin does not treat diabetes. Diabetes (at least type 1) is caused by an autoimmune condition that destroys the cells in the pancreas that produce insulin. External hormone replacement by means of insulin does on treat the underlying condition, the pancreas will still not produce the required hormones. Then insulin will be permitted on Shabbat not only because it offers life saving therapy but because it is not even a medication as defined by Halacha.

This definition seems tedious and there is little evidence to suggest that it is in fact correct. Moreover, gzirot are limited to how they were originally enacted. Only recently have we attained the medical knowledge to have the capacity to differentiate between medications that treat symptoms versus those that can cure an underlying pathology. Therefore, the gezira should include all types of medications, even those limited in scope to symptom control. There may, however, be a distinction between pills used for therapeutic purposes and those used to maintain a lifestyle. Birth control pills for women who either do not want to bleed every month or do not want to get pregnant, daily vitamins or aspirin (back when it was considered healthy) may all qualify for pills that are not therapeutic in halachic terminology^[4].

1. This Gemara was written before the gzira of taking a bath on Shabbat was enacted. ↑

2. Two other Mishnayot in Shabbat (109 and 111) support this claim. The Mishna on 109b describes foods that a patient cannot eat as they are not foods eaten by otherwise healthy individuals. And the Mishna on 111 forbids using vinegar for therapeutic purposes unless the patient uses the vinegar as a dip, where then it would be considered maachal b’riyium, analogous to using olive oil for chapped lips. If you dab the olive oil on your lips it would be prohibited but if you eat salad with olive oil it would be permitted. ↑

3. See our introduction to Medicine of Shabbat for further clarification. ↑

4. Folic acid prior to pregnancy is a little more complicated. Folic acid is taken by women prior to conceiving in attempts to ensure the fetus does not develop pathology in their brain stem. They are therapeutic for a condition that may occur to someone else. ↑