Refuah and Hatzolah on Shabbos – 3

Pikuach Nefesh Overrides Shabbos

Trying to Do Melachah in the Least Serious Way

1. In any life-threatening situation, a Jew may perform even deoraisa melachah. Even if one is unsure, he may do melachah if there is a chance of danger to life, as we mentioned previously (Issues 254, 255).

הותרה or דחויה?

• The Rishonim argue whether Shabbos is “הותרה” or “דחויה” in the face of pikuach nefesh. In other words, is it a broad heter, in which case one does not need to worry too much about how he does the melachah [הותרה], or is it a narrower heter that requires one to do whatever he can to minimize the issurim he violates (רש”י יומא דף ו’ ע”ב ד”ה דחויה) where it won’t cause a delay in treating the patient [דחויה]?
• הותרה. Some say there is an across-the-board heter for pikuach nefesh (מהר”ם מרוטנברג הובא ברא”ש יומא פ”ח סי’ י”ד).
• דחויה. However, most Rishonim hold the heter is narrower (רמב”ם פ”ב שבת ה”א, שו”ת הרשב”א ח”א סי’ תרפ”ט, הר”ן ביצה דף ט’ ע”ב בדפי הרי”ף, מ”ב סי’ שכ”ח סקל”ט). Thus, one should try to do things in a permissible way to minimize melachah even if doing so takes some effort, but one is not required to make a great effort (רמב”ם פ”ד ביאת מקדש הי”ד, תורת היולדת פמ”ד הע’ א’). Obviously, all of this is only when it does not endanger the patient and time is not of the essence.

Can Be Done by a Non-Jew

• The Mechaber holds that even if melachah for a dangerously ill patient on Shabbos can be done by a non-Jew without delay, it is better for a Jew to do it (שו”ע שכח סי”ב). This is because otherwise, when it is hard to find a non-Jew, people might take time to search for a non-Jew, thus endangering the patient (רא”ש, מ”ב סקל”ג). Sefardim follow this opinion.
• However, the Rama holds that if it will not take any extra time, it is better for a non-Jew to do the melachah. If there is reason to think the non-Jew will not act as fast as a Jew though, all poskim agree a Jew should do the melachah (רמ”א שם).
• Some poskim hold that whenever a patient needs urgent care, it is better for a Jew to help even if a non-Jew can also do the job, for two reasons: 1) Using a non-Jew can cause harm in the future. Even if it did not cause any delay this time, perhaps people who see a person looking for a non-Jew will think that a Jew may not do melachah, and the next time danger arises, they will cause a delay by looking for a non-Jew; 2) Human life is very important to Jews. Therefore, a Jew will always perform lifesaving activity with greater alacrity (ט”ז שם ס”ה, שו”ע הגרי”ז סי”ג, מ”ב סקל”ז).
• Urgent. Thus, in a situation where help is urgently needed, there is a patient in danger and every minute is crucial, a patient urgently needs to get to the hospital etc., and a quick-working, expert Jewish doctor or Hatzolah responder who values the sanctity of life is present, all poskim agree it is preferable for the Jew to do the necessary melachos (שו”ת אג”מ ח”ד סי’ פ’, שש”כ פ”מ הע’ ע”ד בשם הגרשז”א).
• Situation is not gravely urgent. However, if there is a patient facing danger but it is not critical that he receive care this second and there is no concern of negligence or unnecessary delay that will harm him, the above machlokes applies. Namely, some say a Jew should be the one to do melachah nonetheless (המחבר בשו”ע הנ”ל, הט”ז הנ”ל), while others say it is better for a non-Jew to do it (רמ”א הנ”ל, חיי אדם כלל ס”ח ס”ב, א”א בוטשאטש, שו”ת שבט הלוי ח”ח סי’ ע”ג). If the people present are told that really a Jew is allowed to do melachah, just there happens to be a non-Jew available in this case, then the melachah may certainly be done by a non-Jew (ט”ז שם).
• Hatzolah responder. Hatzolah protocol is that when a call comes in on Shabbos, the responder does not look for a non-Jew to do melachah. The Jewish responder does all necessary melachos for the patient until he is in the hospital. One cannot know the exact condition of the patient without seeing him, and Hatzolah volunteers are quick and do their jobs better than others. Therefore, until the responder reaches the patient and gets an idea of the situation, every call is assumed to involve a dangerously ill patient with an urgent condition that cannot wait at all.
• Different Hatzolah organizations have different protocols about returning from the hospital and returning the car or ambulance to its location. Some only use non-Jews for this; that is certainly preferable. Those who are meikel in accordance with their rav’s ruling have poskim to rely on.

Can Be Done with a Shinui

1. If melachah can be done with a shinui without causing any delay that would endanger the patient, it should be done with a shinui to downgrade it to an issur derabanan (רמ”א שם). Each situation must be evaluated independently.
2. Driving with a shinui. Obviously, someone driving a car, motorbike, or ambulance for pikuach nefesh on Shabbos should not do any shinui for the actual driving, e.g., the way he holds the steering wheel or presses/releases the gas and brake pedals, etc. Doing so would endanger himself and others (הגרזש”א). Wherever possible, he should do a shinui for melachos not involving the actual driving, e.g., honking; turning on and off lights, heat, or AC; opening doors; and the like, if it will not cause any delay in travel.

Going to the Hospital on Shabbos

Choosing How to Travel

1. When one needs to go to the hospital on Shabbos, there are a few options of how to get there. One must always choose the best method of travel based on the situation, the level of need and urgency of receiving medical attention, and the available options.

Urgent

1. In an urgent and critical situation where medical attention is needed as fast as possible, one should call Hatzolah or an ambulance even if the driver is Jewish so that the patient also receives care in transit.

Not Urgent

1. Non-Jewish driver. If one needs to get to the hospital relatively soon but every minute is not critical, it is best to call a non-Jewish driver with a shinui to avoid deoraisa issurim. The non-Jew should be asked to open and close the doors so that the Jew does not cause any lights to go on. If there is no eiruv, the non-Jew should also be asked to carry any necessary items from the house to the car.
2. Saving the number. If one knows before Shabbos there is a chance he will need to call a non-Jewish driver, e.g., for childbirth or for a patient in the house who is in and out of the hospital, he should save the phone number in his phone before Shabbos to minimize the buttons he has to press on Shabbos. He should also press the buttons on Shabbos with a shinui, e.g., with his knuckle.
3. Driving oneself. If one cannot find a non-Jewish driver or the patient is afraid to go with a non-Jew, and there is someone in the house who knows how to drive and feels confident he can drive safely, it is better for that person to drive than to call another Jew or an ambulance with a Jewish driver. Since doing so does not involve use of a phone, it minimizes the melachos necessary.
4. Jewish driver. If no one in the house can drive or the only available person needs to be with the patient and cannot do that while driving, he may call a Jewish driver or an ambulance with a Jewish driver to take them to the hospital. When the driver is Jewish, the doors should be opened and closed with a shinui, and anything that can be done to minimize melachah should be done.
5. Shomer Shabbos or not? Some poskim say it is better to use a shomer Shabbos driver, as he will drive in the most permissible way, i.e., with shinuyim, etc. Also, he will not drive back from the hospital without a heter (קצות השלחן סי’ ק”מ הע’ ג’, שו”ת משנה הלכות ח”ג סי’ מ”ב).
6. Others hold that if there is a mechallel Shabbos who will drive his car regardless, ר”ל, it is best for him to transport patients to the hospital. This way, they save him from breaking Shabbos, and they give him the zechus of driving for pikuach nefesh (הגרשז”א, שש”כ פ”מ הע’ קצ”ג).

Taking Patient Home after He Is Discharged

• Sometimes, a patient is discharged from the hospital on Shabbos or his condition stabilizes and he does not end up hospitalized. Even if he has nowhere good to stay until the end of Shabbos or he must be at ease in his house for his health, a Jew cannot drive him home. If there is a great need, he may have a non-Jew drive him home if the non-Jew will also take his things in and out and open and close the door (פסקי תשובות סי’ שכ”ח אות י”ג).

Various Forms of First Aid

Wound, Cut

• To stop bleeding. If a person has a bleeding cut, he may apply pressure to stop the bleeding, but he should not press too hard in a way that will extract more blood (חוט שני ח”ב פל”ב).
• Gauze. One may also apply pressure with a tissue, bandage, or gauze. Even though there is an issur to put a cloth on a bleeding wound because the blood will color it (שו”ע סי’ שכ”ח סמ”ח) – albeit derabanan, as it is mekalkeil (מ”ב ס”ק קמ”ו) – since it dirties the cloth and it is a pressing situation, it is mutar (מ”ב שם). Especially today that we dispose of the cloth that absorbs the blood, it is obvious that putting a cloth on a wound has nothing to do with dyeing (הגרח”פ שיינברג, חי’ בתרא).
• Cleaning a wound. One should clean the blood from a wound before bandaging it to minimize the amount of blood that will get absorbed into the bandage. One may use a disinfectant to minimize risk of infection by pouring a bit of the solution around the wound and wiping it with dry gauze. To avoid a potential issur of sechitah, the solution should not be poured onto the gauze.
• Bandage. One may put a bandage on a wound. If there is potential for infection, one may apply an antibiotic cream on the wound before bandaging it. To close the bandage, it is best to tie the two ends with a single knot and a bow; this is preferable to cutting a piece of medical tape.
• Opening package of bandages. To open a package of bandages, gauze, or pads in a non-urgent situation, it is best to tear the whole package open, thereby totally ruining it. It should not be opened at the designated spot by separating flaps attached with a bit of glue. When possible, one should also take care not to tear through letters or a picture (ע”פ מ”ב סי’ ש”מ סקמ”א).

Stitches/Sutures

• The poskim discuss various circumstances to determine when and how a wound may be stitched on Shabbos.
• Tofeir with human tissue. Some poskim hold that stitching human tissue entails deoraisa melachah (שו”ת מנחת שלמה ח”ב סי’ ל”ד אות ל”ב). Others say it is only derabanan since stitches are not meant to hold tissue together forever; they merely hold the edges together until they fuse back together. Then, the stitches are no longer necessary; in fact, they are removed (הגרשז”א שם, שו”ת אבן ישראל ח”ח סי’ כ”ז).
• Kosheir with stitches. During and after stitching, the doctor makes a strong double knot, potentially involving an issur deoraisa of making a lasting knot [קשר של קיימא], as the knot is never untied (שו”ת אבן ישראל שם). Some say it is not a lasting knot – the only reason the thread is eventually cut instead of untied is because that is easier (מנחת שלמה שם). Due to concerns of kosheir, stitching on Shabbos has some restrictions, as will be explained.
• Danger. If a cut needs to be stitched for pikuach nefesh, e.g., the bleeding must be stopped or the cut is deep and if it is not stitched right away, there is a chance of infection, even a Jew may violate Shabbos to stitch it. Hence, one may transport such a patient to a doctor or hospital to close the wound.
• If a few stitches, e.g., four, would be enough to close a wound and get out of danger but it is standard to do more, e.g., eight, for aesthetic purposes, one may do all the stitches. It is all included in pikuach nefesh care, and as long as the doctor has not finished stitching, he is engaged in treatment that is essential for the patient (תשוה”נ ח”ג סי’ קג).
• No danger. A cut that does not present any danger or risk of infection may not be stitched by a Jewish doctor just to prevent a mark or scar. Also, even when stitches are necessary, if it can wait until after Shabbos [usually one can wait up to six hours for stitches], a Jewish doctor may not do it. If there is a great need, a non-Jew may do the stitching. The patient may only be transported by a non-Jew since there is no danger. The reason for the heter is that preventing a permanent scar is considered kavod haberiyos, for which one may violate amira l’akum on a derabanan melachah (שם).

Butterfly Suture, Surgical Glue

• For some cuts, a butterfly suture or surgical glue is enough to keep the skin on either side of the wound together. If that is the case, it is certainly better to use a butterfly suture or glue than stitches since they involve less of a concern of tofeir or kosheir, as they just hold the skin on either side of the wound together until it heals (הגרשז”א, נשמת אברהם ח”ה עמ’ מ”א).

Terrifying Situation

Locked in a Room

• If a child is locked in a room and cannot be extricated in a permissible way, one may break down the door because it is considered potential pikuach nefesh. Whenever someone might become terrified or panicky, one can be meikel like in a case of possible pikuach nefesh, even for an older child (מ”ב סי’ שכ”ח סקל”ט).

Missing Person

• Child. There is a great risk that a missing child is in danger due to his terror. Thus, even a Jew may violate Shabbos to search for him. A child is defined as someone up to about six, depending on the circumstances (מו”ק על המ”א סי’ שכ”ח סק”ח). Certainly, if there is potential danger to life, one may violate Shabbos even for an older person.
• Adult. If an adult is missing, people should search in places he frequents. However, if he is emotionally unwell, mentally unstable, severely depressed and there is reason to fear for his life, or near a dangerous place, one may violate Shabbos for the chance of pikuach nefesh. If there is no concern of danger, deoraisa issurim may only be done by a non-Jew. Each situation must be evaluated individually.