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Management of the Asthmatic, Sabbath-Observant Jewish Patient
Management of the Asthmatic, Sabbath-Observant JeWish Patient Some Guidelines In the Light of Jewish Law Howard]. Schwartz, M.D ., F.C.C.P.;* and Moshe HaleVi Spero, M.S.S.W., M.A t
The foUowing thoughtful commentary provides insights into Judaic practices and law. Please note that the precepts and principles described relate to Orthodox Judaism and may not apply to the practices of Conseroative, &constructionist or Reform Judaism. Eono a
he principles of the problem of treating asthma on T the Sabbath derive from Halakhah, the corpus of laws and customs according to which religious Jews govern their lives. The Sabbath is a day of rest, extending approximately from Friday night sundown until after Saturday evening twilight, and is characterized by abstention from numerous activities which fail under the rubric of"work." Some of the forbidden "work" activities are biblically defined; while others have been rabbinically identified. Relevant to the present topic, compounding medicine (mehikat samimanim) is forbidden on the Sabbath since this activity generally involves the biblically-proscribed activity of griilding (tohen), while taking or using medicine is rabbinically fOrbidden, lest one compound medicine. 1 . For the religious Jew, Sabbath observance in strict accor
University, Cleveland. tCbainnan, De~ent of Psychology, Notre Dame College of Ohio; Associate Edit01; Journal of Plflchology and ]udailm. IUprlnt requem: Dr. Schwam, 3609 lbrk EtUt, Beachwood, Ohio
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the basic laws but unaware of the severity of his condition and hence cannot accurately apply halakhic standards to his condition. In other cases, the patient has been infOrmed of the severity of his illness and is also knowledgeable in halakhic matters, yet declines to fullow medical recommendations on the Sabbath, does not review his halakhic options, and refuses to discuss the matter with his physician. Emergency calls to the physician after Sabbath reveal that the patients asthmatic symptoms have flared up. In such extreme cases, the patient may be manifesting psychologic denial couched in religious terms. • For the religious Jewish patient, denial of the severity of his condition is adopted by viewing it as not yet mandating the violation of the Sabbath. These situations require tactful management. The fOllowing guidelines will provide background for working together with such patients and their religious advisors. We present, first, a halakhic classification of asthma in terms of the prerogative to waive Sabbath prohibitions and in view of contemporary medical opinion regarding the treatment of asthma and, second, some tentative guidelines for the professional and patient. We suggest these be viewed as recommendations rather than definitive rulings. DEFINmoN
Asthma is generally categorized by the degree of functional disturbance. Such categorization helps stage therapeutic interventions necessary to bring relief to the patient, and is essential fur any halakhic categorization.5 1. Mild tUthma includes brie( intermittent episodes of bronchospasm with no loss of work, no activity restriction, many normal days and close to nonnal pulmonary function. 2. Motkrate tUthma is more distressful to the patient; subjective periods of breathing discomfOrt occur daily and can last up to ten or 12 hours. Such patients are unable to participate in activities requiring exertion; physical examination will reveal wheezing; pulmonary function tests are clearly abnonnal and may fluctuate at night; and the patient will often miss work or school.
3. Severe asthma is present when patients have sleep disturbance due to breathing distress and are aware that they are wheezing daily fur most of the day. Their activity is obviously restricted by respiratory difficulty; work and school perfOrmance is comprorilised, and oxygen desaturation is present. Untreated, this stage leads to respiratory failure; severe hypoxia and elevation in arteri81 carbon dioxide is present, and these in tum can lead to compromised function in other parts of the body, especially in patients with concomitant disease. There can also be confusion, disorientation, and other signs of disordered cerebral function (especially in patients with cerebrovascular disease), or compromised cardiac function in patients with coronary artery and myocardial disease.
It is also useful to categorize the asthmatic patient by degree of response to therapeutic modalities: 1. Mild: Those patients who show good response in their respiratory symptoms and pulmonary function to only occasional drug therapy. These patients may have long symptom-free periods and may be able to be sustained 24 hours or longer without therapy. 2. Moderate: Those patients who manifest good therapeutic response to non-steroid drug therapy with prolonged symptom-free periods, but in whom this good response requires longterm (daily) therapy. 3. Severe: Those patients who require chronic steroid therapy in combination with maximum use of other drugs in order to achieve successful clinical control. 4. Refractory: Those patients who demonstrate a poor response to all the above therapies and who therefore require hospitalization.
With the above categorizations in mind, we now fucus on the relevant parameters of Jewish law. JEWISH LAw
Halakhah delineates four paradigms of unhealth, partly defined in terms of relative ability to waive biblical or rabbinic Sabbath prohibitions attending specific types of medical activity:
(1) holeh she-yuh bo sakanah-life-threatening or "critical" illness, where threat to existence or normal functioning of vital life processes is present or impending; (2) holeh she-ein bo sakanahillness in general, where threat to life is not present or anticipated, but where the individual is febrile or infirm or infectious, or in great pain and/or bedridden; (3) holeh be-mikzat-"slight illness," such as cold or a mild allergy; and (4) mihush be-alma-"mere discomfOrt," where the individual has some slight malaise or distress, but is in no real sense ill, eg, mild stomachache or headache.
Halakhah recognizes that illness can progress from less to more severe levels, and adjusts its leniency accordingly regarding initiating otherwise forbidden activity. For example, when illness of a specific limb or organ system does or is anticipated to adversely effect the entire body, most halakhic authorities view this state as no longer merely ein bo sakanah but possibly {1) yesh bo sakanah ("life-threatening"), meriting initiation on the Sabbath of any action deemed medically necessary. 6 While slight discomfort is generally classified as {4) mihush be-alma, more extreme or pervasive distress or pain is viewed more leniently. Practically, the following general parameters obtain:7
(1) For "life-threatening illness" any biblical or rab-
binic activity may be initiated in order to save life. {2) For "non-life-threatening illness" one may not violate biblical prohibitions, but may perform rabbinically forbidden activities in modified form (in order to lessen the gravity of infraction), or instruct a non-Jew to perform even biblically forbidden activities. {3) For a patient in severe pain or who feels so ill as to become bedridden, even in the absence of obvious threat to life, one may violate rabbinic prohibitions in modified form as in the case of {2).8 {4) For a holeh she-ein bo sakanah whose condition includes "danger to limb" {even in the absence of bedriddenness or severe pain radiating throughout the body), one may violate rabbinic prohibitions without modification. 9 Furthermore, according to the authorities who consider "danger to limb" in our day to generally involve the possibility of "danger to life," one may initiate even biblically-forbidden activities. (5) When there is illness in a limb but no danger of its destruction or loss of normal function, and the individual overall is in no severe discomfort or unhealth, then one can only initiate rabbinicallyforbidden activities through the assistance of a nonJew.1o The Thlmud mentions asthma, 11 and the Jewish talmudist-physician Maimonides {11th century) wrote a treatise on asthma, 12 but neither satisfies the need for specific categorization. Three contemporary halakhic authors view asthma as an example of holeh she-ein bo sakanah or "non-life-threatening illness. "13 Rabbi I. Neuwirth indirectly indicates that this categorization applies only when there is no danger to life, 14 but Dr. A. S. Abraham, who cites Neuwirth, does not note this qualification. Several comments concerning this categorization are in order: {1) The aforementioned authors also categorize epilepsy as ein bo sakanah though other halakhic authorities classify epilepsy as potentially lifethreatening. 15 In fact, epilepsy and asthma seem generally to be more severe kinds of illnesses than holeh sheein bo sakanah. Current medical opinion confirms that for many very young and elderly and for most untreated patients, one of the concomitants of the moderate-to-severe asthmatic crisis is temporary loss of bodily control and occasionally mental confusion. Certainly, status asthmaticus constitutes "danger to life." (2) The physiopathology of the untreated, more than mildly asthmatic lung can represent "danger to limb" (sakanat ever) in that asthmatic airways are abnormally sensitive and chronically disposed to potentially life-threatening reaction. Thus, more-thanmild asthma may involve "danger to limb" which can potentially extend into "danger to life" depending on concurrent medical complications, age, psychologic make-up, and quality of treatment. {3) Neuwirth's classification of asthma as generally a CHEST I 84 I 6 I DECEMBER, 1963
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"non-life-threatening illness" (holeh she-ein bo sakanah) is misleading. (a) Asthmatic patients may "walk about like a healthy person" but still present clinically-abnormal organ functioning on a level which is categorized as "danger to limb." 16 (b) It is potential with all asthmatics that without the maintenance of appropriate medicine levels, relatively innocuous stimuli can unpredictably elicit asthmatic crises which deteriorate rapidly (sometimes in less than five minutes). Thus, asthma should not be viewed generally as a condition which in the absence of appropriate medication will not result in threat to life. (4) When true danger to life or great potential for danger to life or limb impends, should medication begun prior to the Sabbath be discontinued on the Sabbath, one could violate biblical and certainly rabbinic prohibitions. 17 When assessing the potential of danger, Halakhah also admits into the assessment process the elements of "zar" or psychologic distress, especially child patients, 16 and the psychosocial zar incurred by an asthmatic whose alternative to continuing medication on the Sabbath is to remain homebound.18 (5) The Talmud generally forbade preparation of medicine on the Sabbath. liD Taking already prepared medicine when there is pain beyond the level of mihush was never in question. 21 It is permissible to take medicines already available to the patient when "great distress" (zar gadol) is present and certainly for the prevention of"non-life-threatening illness." In this case, no perfunctory modification (shinuy) in the manner of taking medicine is required since no "work" whatsoever is involved. 22 (6) In terms of the categorizations discussed in Definitions, some mild asthmatics may be no more than "slightly ill" ([3] holeh be-mikzat), for whom violating the Sabbath in order to take medicine is only permitted where failure to take medicine on the Sabbath will lead to more serious consequences. More complicated levels of "mildness," however, especially in the case of children, may reach the level of "nonlife-threatening illness" and probably "danger to limb." Some halakhic authorities might permit taking medicine in such cases. Moderately and severely ill patients, to the degree that their health requires maintenance of daily medication lest they enter a state of potential "danger," are certainly regarded in a more lenient capacity. The refractory stage usually represents "lifethreatening illness," certainly when the refractory state threatens to complicate other conditions within the patient. GUIDELINES
The following additional guidelines apply to the actual implementation of therapeutic or preventative measures on the Sabbath. (I) All things being equal, whenever it is possible 784
with no risk of iU effect to the patient to not initiate otherwise forbidden activities of Sabbath, even in the case of a condition technically categorized as "lifethreatening illness," then one ought not to. 13 (2) 1n the case of moderate-to-severe asthma who are on a chronic (daily) preventive regimen-and under certain conditions, even lesser afBicted asthmatics-the patient must be made to recognize that the possibility of ill effect begins to increase the longer the interval between medications (many of these medications are short-acting drugs, passing through the body with loss of therapeutic benefit four to six hours after use). Thus, a patient may wish to skip a Friday night or Saturday morning dose of medicine, but this is less advisable as the Sabbath continues, and completely inadvisable under certain physiologic or environmental conditions. (3) Leniency with waiving rabbinic prohibitions on the Sabbath-and certainly with taking medicine-is warranted when actual or anticipated bronchial crises represent "danger to limb" has the potential to extend into "danger to life. "14 (4) In all cases where forbidden rabbinic activities are initiated on the Sabbath in anticipation of danger to life or limb, such activity should be performed in modified manner if possible so long as "danger" is not yet present. 115 Taking already prepared medicine would not require a "modified manner." (5) When no reasonable risk exists consequent to the temporary suspension of prophylactic therapy, yet the patient remains extremely anxious about the possibility of risk, the patient may continue to take medicine, though in a" modified manner" if possible. 1111 That is, even though treatment would not be medically necessary in this case, Halakhah still allows treatment to continue if this will appease the patient and promote Sabbath joy. (6) As far as specific methods of treatment are concerned: (a) When it is permissible to use medicine on the Sabbath, no additional biblical or rabbinic prohibitions are involved in the use of hand-operated aerosol sprays or mists (nebulizers) through which anti-asthma or bronchodilator medicine is delivered (eg, beclomethasone [Vanceril], isoproterenol [Isuprel], etc). 27 Inhaling vapors per se represents no halakhic problem. 28 (b) Some medications (cromolyn [Intal]) are administered through a simple hand-operated device in which a capsule is placed in a two-piece tube wherein downward pressure of the top piece closes two small "teeth" which puncture the capsule (eg, Spinhaler). Such devices are discussed by halakhic authorities and are considered permissible for use on the Sabbath by a patient categorized at least as "non-life-threateningly ill. "29 (c) Spinhalers are supplied with an optional piece
which fits over the end of the device and makes a whistle sound during air intake. This device is used as an indicator to aid young patients in drawing a full breath. In principle, the rabbis fOrbade making musical sounds on the Sabbath even when not in the customary manner of music, so long as one is utilizing an instrument specifically made to produce sound (eg, a door knocker). 30 However, the Talmud states that one may use such an instrument in order to lull a sick person to sleep. 31 This precedent applies to the present case, especially since the Spinhaler is not designated as a sound instrument, and certainly in the case of a holeh fur whom mere rabbinic proscriptions may be waived. (d) Though rare, some asthmatic patients are treated with daily injections of fOrms of epinephrine. Intramuscular injections are viewed as rabbinically furbidden and could thus be implemented when conditions warrant the waiver of rabbinic prohibitions, or could be administered by a non-Jew.32 In acute circumstances, the patient is usually classifiable as "endangered in limb" or worse so that such injections are certainly permissible. (e) The use of electric air pump nebulizers for the administration of medication (eg, Intal, isoetharine HCL [Bronkosol]) involves the halakhic problem of the use of electricity on the Sabbath. Because the use of electricity may involve biblically-forbidden activity, such pumps should not be used unless "danger to life" is anticipated, or "danger to limb" which is expected to become extensive. Practically, the patient can switch on the Sabbath to hand-operated nebulizers (see 6a) or to pill or liquid medicine. However, in the case of small children who are only responsive to drugs which can only be administered via nebulizers, (atropine, Intal) and who have great difficulty utilizing hand-operated nebulizers, and where such children need continuous treatment in order to avert" danger," the options are: (1) have a non-Jew turn on the electric pump; (2) set the pump prior to Sabbath on an electric timer; and, when no other options are available, (3) one may operate the electric pump. 33 (7) It is permissible to eat on Yom Kippur (the sacred Jewish fast day) when danger to health is anticipated. When necessary, one may swallow medicines without water (or with water to which some bitter taste has been added) since this is not the customary "pleasurable" manner of eating. 34 The same is true on the socalled minor fasts, even when the patient is in no graver state of unhealth than "non-life-threatening illness.''35 The use of inhalers and aerosol mouth sprays on Yom Kippur does not involve any special halakhic problem. 36 (8) Measuring specified amounts of medicine is permissible on the Sabbath fur the needs of patients. 37 REFERENCES
2 Jakobovits E. Jewish medical ethics. New York: Bloch Publishing Co, 1975; 54, 89 3 Talmud, 'fractate Hulin lOa; Yoma 84b; Shabbat 109a; Thr shulhan arukh: Oreh hayim, 328:2 4 Dirks JF, Schraa JC. How patient attitudes may foil asthma management. J Resp Dis 1982, 3:24-36 5 Schwartz HJ, Tuthill TM. Bronchial asthma. In: Baum GL, Wolinsky E, eds. Textbook of pulmonary medicine. Boston: Little, Brown (in press) 6 Karo Y. Shulhan arukh: Oreh hayim, 328, Mishneh berurah, nos 49, 57; Shulhan arukh: Yoreh deah, 157, Shakh, no 3; Resp. Ziz Ellezer, 8:16(10:9-14); Resp. Melamed lehoil; Yoreh deah, 32 7 Zevin SY, ed. Encyclopedia Talmudit 1973; 13:275-77 8 Shulhan arukh: Oreh hayim, 17, Rama, Mishneh berurah, nos 1, 10, 100, ll8, 121; Oreh hayim 3/J1, Mishneh berurah, no 5; Neuwirth I. Shmirat Shabbat kehilkhetah. Jerusalem: Feldheim, 1965, p 200; Neuwirth I. Shmirat Shabbat kehilkhetah. Jerusalem: Feldheim, 1979; 475 9 Shulhan arukh: Oreh hayim, 328:3; Shmirat Shabbat kehilkhetah. 1979 ed, 459n 10 Shulhan arukh: Oreh hayim, 328, Mishneh berurah, no 52 11 Thlmud, 'fractate Bekurot 44b 12 Muntner S, trans. Sefer hakazeret. Philadelphia: J. B. Lippincott, 1963 13 Abraham AS. Lev Avraham. Jerusalem: Feldheim, 1979; 28; Shmirat Shabbat kehilkhetah. 1979 ed, 459; Resp Avnei Zikaron
3:40 14 Shmirat Shabbat kehilkhetah. 1965 ed, 194 15 Shulhan arukh: Yoreh deah, 84, Taz, no 76; Epstein YM. Arukh hoshulhan: Yoreh deah, 84:95 16 Shulhan Arukh: Oreh hayim, 328:3, Baer hetev, sv vedavka 17 Shulhan arukh: Oreh hayim, 321 :18; 328, Mishneh berurah, no 5 18 Thlmud, 'fractate Yoma 84b; Resp Hilkhot ketanot 2:10; Schneerson SZ. Shulhan arukh harav: Oreh hayim, 328:15 19 Thlmud, 'fractate Shabbat SOb, Tosafot sv bishvil 20 Thlmud, 'fractate Shabbat 140a; Shulhan arukh: Oreh hayim, 321:18; Hiddushei haRan: Shabbat 140a 21 Shulhan arukh: Oreh hayim 328, Mishneh berurah, no ll1, Magen Avraham, no 44; Braun S. Sheiurim mezuyanim behalakhah. New York: Feldheim, 1978, v2, 294 22 Shulhan arukh: Oreh hayim, 328, Mishneh berurah, no 111; Naeh AC. Kezot hoshulhan, 7:134 (Badei hoshulhan, no 7) 23 Shulhan arukh: Oreh hayim, 328:11; Resp. Minhat Yizhak
1:28(4-5) 24 Arukh hoshulhan: Oreh hayim, 328:18 25 Talmud, 'fractate Shabbat 134b; Bet Yosef, Thr Shulhan arukh: Oreh hayim 328; Shulhan arukh: Oreh hayim, 328:12, Rama 26 Resp. Igrot Mosheh: Oreh hayim, 3:53; Resp. Yosef omez 40; Kaf hahayim: Oreh hayim, 328:216 27 EiderS. Sefer hilkhot Shabbat. New Jersey: Lakewood Yeshiva, 1974; 107, 131 28 Kaf hahayim: Oreh hayim, 328:214 29 Shmirat Shabbat kehilkhetah, 1979 ed, 468, n 87; Shulhan arukh: Oreh hayim, 314, Mishneh berurah, no 7 30 Thlmud, 'fractate Eruvin 104a; Shulhan arukh: Oreh hayim, 338:1 31 Shulhan arukh: Oreh hayim, 338, Mishneh berurah, no 1(3) 32 Lev Avraham, 1979, 91-92; Shmirat Shabbat kehilkhetah, 1979 ed, 463 33 Shmirat Shabbat kehilkhetah, 1979 ed, 468 34 Resp. Shoel umeishiv tinyana 1:55; Resp. Igrot Mosheh: Oreh hayim 3:91; Resp. Ziz Eliezer 10:25(22); Resp. Ketav sofer: Oreh hayim 111 35 Resp. Ziz Eliezer 10:25(22) 36 Shulhan arukh: Oreh hayim, 612, Mishneh berurah, no 18 37 Shulhan arukh: Oreh hayim, 306:7, Mishneh berurah, no 36
1 Karo Y. Bet Yosef, Thr shulhan arukh: Oreh hayim, 328:1 CHEST I 84 I 6 I DECEMBER, 1983
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The foUowing thoughtful commentary provides insights into Judaic practices and law. Please note that the precepts and principles described relate to Orthodox Judaism and may not apply to the practices of Conseroative, &constructionist or Reform Judaism. Eono a
he principles of the problem of treating asthma on T the Sabbath derive from Halakhah, the corpus of laws and customs according to which religious Jews govern their lives. The Sabbath is a day of rest, extending approximately from Friday night sundown until after Saturday evening twilight, and is characterized by abstention from numerous activities which fail under the rubric of"work." Some of the forbidden "work" activities are biblically defined; while others have been rabbinically identified. Relevant to the present topic, compounding medicine (mehikat samimanim) is forbidden on the Sabbath since this activity generally involves the biblically-proscribed activity of griilding (tohen), while taking or using medicine is rabbinically fOrbidden, lest one compound medicine. 1 . For the religious Jew, Sabbath observance in strict accor
University, Cleveland. tCbainnan, De~ent of Psychology, Notre Dame College of Ohio; Associate Edit01; Journal of Plflchology and ]udailm. IUprlnt requem: Dr. Schwam, 3609 lbrk EtUt, Beachwood, Ohio
44122
712
the basic laws but unaware of the severity of his condition and hence cannot accurately apply halakhic standards to his condition. In other cases, the patient has been infOrmed of the severity of his illness and is also knowledgeable in halakhic matters, yet declines to fullow medical recommendations on the Sabbath, does not review his halakhic options, and refuses to discuss the matter with his physician. Emergency calls to the physician after Sabbath reveal that the patients asthmatic symptoms have flared up. In such extreme cases, the patient may be manifesting psychologic denial couched in religious terms. • For the religious Jewish patient, denial of the severity of his condition is adopted by viewing it as not yet mandating the violation of the Sabbath. These situations require tactful management. The fOllowing guidelines will provide background for working together with such patients and their religious advisors. We present, first, a halakhic classification of asthma in terms of the prerogative to waive Sabbath prohibitions and in view of contemporary medical opinion regarding the treatment of asthma and, second, some tentative guidelines for the professional and patient. We suggest these be viewed as recommendations rather than definitive rulings. DEFINmoN
Asthma is generally categorized by the degree of functional disturbance. Such categorization helps stage therapeutic interventions necessary to bring relief to the patient, and is essential fur any halakhic categorization.5 1. Mild tUthma includes brie( intermittent episodes of bronchospasm with no loss of work, no activity restriction, many normal days and close to nonnal pulmonary function. 2. Motkrate tUthma is more distressful to the patient; subjective periods of breathing discomfOrt occur daily and can last up to ten or 12 hours. Such patients are unable to participate in activities requiring exertion; physical examination will reveal wheezing; pulmonary function tests are clearly abnonnal and may fluctuate at night; and the patient will often miss work or school.
3. Severe asthma is present when patients have sleep disturbance due to breathing distress and are aware that they are wheezing daily fur most of the day. Their activity is obviously restricted by respiratory difficulty; work and school perfOrmance is comprorilised, and oxygen desaturation is present. Untreated, this stage leads to respiratory failure; severe hypoxia and elevation in arteri81 carbon dioxide is present, and these in tum can lead to compromised function in other parts of the body, especially in patients with concomitant disease. There can also be confusion, disorientation, and other signs of disordered cerebral function (especially in patients with cerebrovascular disease), or compromised cardiac function in patients with coronary artery and myocardial disease.
It is also useful to categorize the asthmatic patient by degree of response to therapeutic modalities: 1. Mild: Those patients who show good response in their respiratory symptoms and pulmonary function to only occasional drug therapy. These patients may have long symptom-free periods and may be able to be sustained 24 hours or longer without therapy. 2. Moderate: Those patients who manifest good therapeutic response to non-steroid drug therapy with prolonged symptom-free periods, but in whom this good response requires longterm (daily) therapy. 3. Severe: Those patients who require chronic steroid therapy in combination with maximum use of other drugs in order to achieve successful clinical control. 4. Refractory: Those patients who demonstrate a poor response to all the above therapies and who therefore require hospitalization.
With the above categorizations in mind, we now fucus on the relevant parameters of Jewish law. JEWISH LAw
Halakhah delineates four paradigms of unhealth, partly defined in terms of relative ability to waive biblical or rabbinic Sabbath prohibitions attending specific types of medical activity:
(1) holeh she-yuh bo sakanah-life-threatening or "critical" illness, where threat to existence or normal functioning of vital life processes is present or impending; (2) holeh she-ein bo sakanahillness in general, where threat to life is not present or anticipated, but where the individual is febrile or infirm or infectious, or in great pain and/or bedridden; (3) holeh be-mikzat-"slight illness," such as cold or a mild allergy; and (4) mihush be-alma-"mere discomfOrt," where the individual has some slight malaise or distress, but is in no real sense ill, eg, mild stomachache or headache.
Halakhah recognizes that illness can progress from less to more severe levels, and adjusts its leniency accordingly regarding initiating otherwise forbidden activity. For example, when illness of a specific limb or organ system does or is anticipated to adversely effect the entire body, most halakhic authorities view this state as no longer merely ein bo sakanah but possibly {1) yesh bo sakanah ("life-threatening"), meriting initiation on the Sabbath of any action deemed medically necessary. 6 While slight discomfort is generally classified as {4) mihush be-alma, more extreme or pervasive distress or pain is viewed more leniently. Practically, the following general parameters obtain:7
(1) For "life-threatening illness" any biblical or rab-
binic activity may be initiated in order to save life. {2) For "non-life-threatening illness" one may not violate biblical prohibitions, but may perform rabbinically forbidden activities in modified form (in order to lessen the gravity of infraction), or instruct a non-Jew to perform even biblically forbidden activities. {3) For a patient in severe pain or who feels so ill as to become bedridden, even in the absence of obvious threat to life, one may violate rabbinic prohibitions in modified form as in the case of {2).8 {4) For a holeh she-ein bo sakanah whose condition includes "danger to limb" {even in the absence of bedriddenness or severe pain radiating throughout the body), one may violate rabbinic prohibitions without modification. 9 Furthermore, according to the authorities who consider "danger to limb" in our day to generally involve the possibility of "danger to life," one may initiate even biblically-forbidden activities. (5) When there is illness in a limb but no danger of its destruction or loss of normal function, and the individual overall is in no severe discomfort or unhealth, then one can only initiate rabbinicallyforbidden activities through the assistance of a nonJew.1o The Thlmud mentions asthma, 11 and the Jewish talmudist-physician Maimonides {11th century) wrote a treatise on asthma, 12 but neither satisfies the need for specific categorization. Three contemporary halakhic authors view asthma as an example of holeh she-ein bo sakanah or "non-life-threatening illness. "13 Rabbi I. Neuwirth indirectly indicates that this categorization applies only when there is no danger to life, 14 but Dr. A. S. Abraham, who cites Neuwirth, does not note this qualification. Several comments concerning this categorization are in order: {1) The aforementioned authors also categorize epilepsy as ein bo sakanah though other halakhic authorities classify epilepsy as potentially lifethreatening. 15 In fact, epilepsy and asthma seem generally to be more severe kinds of illnesses than holeh sheein bo sakanah. Current medical opinion confirms that for many very young and elderly and for most untreated patients, one of the concomitants of the moderate-to-severe asthmatic crisis is temporary loss of bodily control and occasionally mental confusion. Certainly, status asthmaticus constitutes "danger to life." (2) The physiopathology of the untreated, more than mildly asthmatic lung can represent "danger to limb" (sakanat ever) in that asthmatic airways are abnormally sensitive and chronically disposed to potentially life-threatening reaction. Thus, more-thanmild asthma may involve "danger to limb" which can potentially extend into "danger to life" depending on concurrent medical complications, age, psychologic make-up, and quality of treatment. {3) Neuwirth's classification of asthma as generally a CHEST I 84 I 6 I DECEMBER, 1963
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"non-life-threatening illness" (holeh she-ein bo sakanah) is misleading. (a) Asthmatic patients may "walk about like a healthy person" but still present clinically-abnormal organ functioning on a level which is categorized as "danger to limb." 16 (b) It is potential with all asthmatics that without the maintenance of appropriate medicine levels, relatively innocuous stimuli can unpredictably elicit asthmatic crises which deteriorate rapidly (sometimes in less than five minutes). Thus, asthma should not be viewed generally as a condition which in the absence of appropriate medication will not result in threat to life. (4) When true danger to life or great potential for danger to life or limb impends, should medication begun prior to the Sabbath be discontinued on the Sabbath, one could violate biblical and certainly rabbinic prohibitions. 17 When assessing the potential of danger, Halakhah also admits into the assessment process the elements of "zar" or psychologic distress, especially child patients, 16 and the psychosocial zar incurred by an asthmatic whose alternative to continuing medication on the Sabbath is to remain homebound.18 (5) The Talmud generally forbade preparation of medicine on the Sabbath. liD Taking already prepared medicine when there is pain beyond the level of mihush was never in question. 21 It is permissible to take medicines already available to the patient when "great distress" (zar gadol) is present and certainly for the prevention of"non-life-threatening illness." In this case, no perfunctory modification (shinuy) in the manner of taking medicine is required since no "work" whatsoever is involved. 22 (6) In terms of the categorizations discussed in Definitions, some mild asthmatics may be no more than "slightly ill" ([3] holeh be-mikzat), for whom violating the Sabbath in order to take medicine is only permitted where failure to take medicine on the Sabbath will lead to more serious consequences. More complicated levels of "mildness," however, especially in the case of children, may reach the level of "nonlife-threatening illness" and probably "danger to limb." Some halakhic authorities might permit taking medicine in such cases. Moderately and severely ill patients, to the degree that their health requires maintenance of daily medication lest they enter a state of potential "danger," are certainly regarded in a more lenient capacity. The refractory stage usually represents "lifethreatening illness," certainly when the refractory state threatens to complicate other conditions within the patient. GUIDELINES
The following additional guidelines apply to the actual implementation of therapeutic or preventative measures on the Sabbath. (I) All things being equal, whenever it is possible 784
with no risk of iU effect to the patient to not initiate otherwise forbidden activities of Sabbath, even in the case of a condition technically categorized as "lifethreatening illness," then one ought not to. 13 (2) 1n the case of moderate-to-severe asthma who are on a chronic (daily) preventive regimen-and under certain conditions, even lesser afBicted asthmatics-the patient must be made to recognize that the possibility of ill effect begins to increase the longer the interval between medications (many of these medications are short-acting drugs, passing through the body with loss of therapeutic benefit four to six hours after use). Thus, a patient may wish to skip a Friday night or Saturday morning dose of medicine, but this is less advisable as the Sabbath continues, and completely inadvisable under certain physiologic or environmental conditions. (3) Leniency with waiving rabbinic prohibitions on the Sabbath-and certainly with taking medicine-is warranted when actual or anticipated bronchial crises represent "danger to limb" has the potential to extend into "danger to life. "14 (4) In all cases where forbidden rabbinic activities are initiated on the Sabbath in anticipation of danger to life or limb, such activity should be performed in modified manner if possible so long as "danger" is not yet present. 115 Taking already prepared medicine would not require a "modified manner." (5) When no reasonable risk exists consequent to the temporary suspension of prophylactic therapy, yet the patient remains extremely anxious about the possibility of risk, the patient may continue to take medicine, though in a" modified manner" if possible. 1111 That is, even though treatment would not be medically necessary in this case, Halakhah still allows treatment to continue if this will appease the patient and promote Sabbath joy. (6) As far as specific methods of treatment are concerned: (a) When it is permissible to use medicine on the Sabbath, no additional biblical or rabbinic prohibitions are involved in the use of hand-operated aerosol sprays or mists (nebulizers) through which anti-asthma or bronchodilator medicine is delivered (eg, beclomethasone [Vanceril], isoproterenol [Isuprel], etc). 27 Inhaling vapors per se represents no halakhic problem. 28 (b) Some medications (cromolyn [Intal]) are administered through a simple hand-operated device in which a capsule is placed in a two-piece tube wherein downward pressure of the top piece closes two small "teeth" which puncture the capsule (eg, Spinhaler). Such devices are discussed by halakhic authorities and are considered permissible for use on the Sabbath by a patient categorized at least as "non-life-threateningly ill. "29 (c) Spinhalers are supplied with an optional piece
which fits over the end of the device and makes a whistle sound during air intake. This device is used as an indicator to aid young patients in drawing a full breath. In principle, the rabbis fOrbade making musical sounds on the Sabbath even when not in the customary manner of music, so long as one is utilizing an instrument specifically made to produce sound (eg, a door knocker). 30 However, the Talmud states that one may use such an instrument in order to lull a sick person to sleep. 31 This precedent applies to the present case, especially since the Spinhaler is not designated as a sound instrument, and certainly in the case of a holeh fur whom mere rabbinic proscriptions may be waived. (d) Though rare, some asthmatic patients are treated with daily injections of fOrms of epinephrine. Intramuscular injections are viewed as rabbinically furbidden and could thus be implemented when conditions warrant the waiver of rabbinic prohibitions, or could be administered by a non-Jew.32 In acute circumstances, the patient is usually classifiable as "endangered in limb" or worse so that such injections are certainly permissible. (e) The use of electric air pump nebulizers for the administration of medication (eg, Intal, isoetharine HCL [Bronkosol]) involves the halakhic problem of the use of electricity on the Sabbath. Because the use of electricity may involve biblically-forbidden activity, such pumps should not be used unless "danger to life" is anticipated, or "danger to limb" which is expected to become extensive. Practically, the patient can switch on the Sabbath to hand-operated nebulizers (see 6a) or to pill or liquid medicine. However, in the case of small children who are only responsive to drugs which can only be administered via nebulizers, (atropine, Intal) and who have great difficulty utilizing hand-operated nebulizers, and where such children need continuous treatment in order to avert" danger," the options are: (1) have a non-Jew turn on the electric pump; (2) set the pump prior to Sabbath on an electric timer; and, when no other options are available, (3) one may operate the electric pump. 33 (7) It is permissible to eat on Yom Kippur (the sacred Jewish fast day) when danger to health is anticipated. When necessary, one may swallow medicines without water (or with water to which some bitter taste has been added) since this is not the customary "pleasurable" manner of eating. 34 The same is true on the socalled minor fasts, even when the patient is in no graver state of unhealth than "non-life-threatening illness.''35 The use of inhalers and aerosol mouth sprays on Yom Kippur does not involve any special halakhic problem. 36 (8) Measuring specified amounts of medicine is permissible on the Sabbath fur the needs of patients. 37 REFERENCES
2 Jakobovits E. Jewish medical ethics. New York: Bloch Publishing Co, 1975; 54, 89 3 Talmud, 'fractate Hulin lOa; Yoma 84b; Shabbat 109a; Thr shulhan arukh: Oreh hayim, 328:2 4 Dirks JF, Schraa JC. How patient attitudes may foil asthma management. J Resp Dis 1982, 3:24-36 5 Schwartz HJ, Tuthill TM. Bronchial asthma. In: Baum GL, Wolinsky E, eds. Textbook of pulmonary medicine. Boston: Little, Brown (in press) 6 Karo Y. Shulhan arukh: Oreh hayim, 328, Mishneh berurah, nos 49, 57; Shulhan arukh: Yoreh deah, 157, Shakh, no 3; Resp. Ziz Ellezer, 8:16(10:9-14); Resp. Melamed lehoil; Yoreh deah, 32 7 Zevin SY, ed. Encyclopedia Talmudit 1973; 13:275-77 8 Shulhan arukh: Oreh hayim, 17, Rama, Mishneh berurah, nos 1, 10, 100, ll8, 121; Oreh hayim 3/J1, Mishneh berurah, no 5; Neuwirth I. Shmirat Shabbat kehilkhetah. Jerusalem: Feldheim, 1965, p 200; Neuwirth I. Shmirat Shabbat kehilkhetah. Jerusalem: Feldheim, 1979; 475 9 Shulhan arukh: Oreh hayim, 328:3; Shmirat Shabbat kehilkhetah. 1979 ed, 459n 10 Shulhan arukh: Oreh hayim, 328, Mishneh berurah, no 52 11 Thlmud, 'fractate Bekurot 44b 12 Muntner S, trans. Sefer hakazeret. Philadelphia: J. B. Lippincott, 1963 13 Abraham AS. Lev Avraham. Jerusalem: Feldheim, 1979; 28; Shmirat Shabbat kehilkhetah. 1979 ed, 459; Resp Avnei Zikaron
3:40 14 Shmirat Shabbat kehilkhetah. 1965 ed, 194 15 Shulhan arukh: Yoreh deah, 84, Taz, no 76; Epstein YM. Arukh hoshulhan: Yoreh deah, 84:95 16 Shulhan Arukh: Oreh hayim, 328:3, Baer hetev, sv vedavka 17 Shulhan arukh: Oreh hayim, 321 :18; 328, Mishneh berurah, no 5 18 Thlmud, 'fractate Yoma 84b; Resp Hilkhot ketanot 2:10; Schneerson SZ. Shulhan arukh harav: Oreh hayim, 328:15 19 Thlmud, 'fractate Shabbat SOb, Tosafot sv bishvil 20 Thlmud, 'fractate Shabbat 140a; Shulhan arukh: Oreh hayim, 321:18; Hiddushei haRan: Shabbat 140a 21 Shulhan arukh: Oreh hayim 328, Mishneh berurah, no ll1, Magen Avraham, no 44; Braun S. Sheiurim mezuyanim behalakhah. New York: Feldheim, 1978, v2, 294 22 Shulhan arukh: Oreh hayim, 328, Mishneh berurah, no 111; Naeh AC. Kezot hoshulhan, 7:134 (Badei hoshulhan, no 7) 23 Shulhan arukh: Oreh hayim, 328:11; Resp. Minhat Yizhak
1:28(4-5) 24 Arukh hoshulhan: Oreh hayim, 328:18 25 Talmud, 'fractate Shabbat 134b; Bet Yosef, Thr Shulhan arukh: Oreh hayim 328; Shulhan arukh: Oreh hayim, 328:12, Rama 26 Resp. Igrot Mosheh: Oreh hayim, 3:53; Resp. Yosef omez 40; Kaf hahayim: Oreh hayim, 328:216 27 EiderS. Sefer hilkhot Shabbat. New Jersey: Lakewood Yeshiva, 1974; 107, 131 28 Kaf hahayim: Oreh hayim, 328:214 29 Shmirat Shabbat kehilkhetah, 1979 ed, 468, n 87; Shulhan arukh: Oreh hayim, 314, Mishneh berurah, no 7 30 Thlmud, 'fractate Eruvin 104a; Shulhan arukh: Oreh hayim, 338:1 31 Shulhan arukh: Oreh hayim, 338, Mishneh berurah, no 1(3) 32 Lev Avraham, 1979, 91-92; Shmirat Shabbat kehilkhetah, 1979 ed, 463 33 Shmirat Shabbat kehilkhetah, 1979 ed, 468 34 Resp. Shoel umeishiv tinyana 1:55; Resp. Igrot Mosheh: Oreh hayim 3:91; Resp. Ziz Eliezer 10:25(22); Resp. Ketav sofer: Oreh hayim 111 35 Resp. Ziz Eliezer 10:25(22) 36 Shulhan arukh: Oreh hayim, 612, Mishneh berurah, no 18 37 Shulhan arukh: Oreh hayim, 306:7, Mishneh berurah, no 36
1 Karo Y. Bet Yosef, Thr shulhan arukh: Oreh hayim, 328:1 CHEST I 84 I 6 I DECEMBER, 1983
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