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Treatment of the Ill on

Shabbos Part I:
The Basics of Pikuach
By Rabbi Joshua Flug

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I. Introduction-This is a four part series that will deal with treating the ill on Shabbos.
The series will include the following topics:
a. The Basics of Pikuach Nefesh
b. Hutrah or Dechuyah
c. Avoiding Life Threatening Situations
d. Treating Non-Life Threatening Situations
II. The Basics of Pikuach Nefesh
a. Hazariz Harei Zeh Meshubach
i. The Gemara states that the one who acts expeditiously in matters of
pikuach nefesh is praiseworthy. {}
ii. The Yerushalmi states that the one who asks a question is a murderer and
the one who is asked the question is worthy of denigration. {}
1. Question: What wrongdoing did the rabbi who was asked the
question commit?
2. R. Yisrael Isserlin (Terumas HaDeshen 1390-1460)- The rabbi
who is asked the question is worthy of denigration because it is his
responsibility to explain the importance of pikuach nefesh to his
congregation. If someone comes and asks him a question, it is a
sign that he did not do a good job in conveying that message. {}
3. R. Shimon ben Tzemach (1361-1444) {} as explained by R.
Eliezer Waldenberg (Tzitz Eliezer 1915-2006) {}- When the rabbi
is asked the question, he has two options. He can either answer the
question and tell the questioner to immediately begin his life-
saving mission or he can take the initiative and actively participate
in the life-saving mission himself. The Yerushalmi is warning the
rabbi that he should not remain as the "nish'al" but he himself
should become the zariz and move as quickly as possible to
perform the life-saving mission.
b. The source for violating Torah law for Pikuach Nefesh
i. The Gemara provides a number of sources that one violates Shabbos for
pikuach nefesh. The two most prominent are: {}
1. The Torah states "v'shamru B'nei Yisrael es HaShabbos" {} to
teach that you violate one Shabbos in order that the he can observe
many more Shabbosos.
a. Rashi (1040-1105) explains that the derasha is based on the
end of the verse "la'asos es HaShabbos." We keep Shabbos
in order to observe it. {}
2. The Torah says "vachai bahem" {} implying that the mitzvos are
there for us to live by and that performance of a mitzvah should
not be the cause of someone's death.
ii. The Gemara notes that the advantage of vachai bahem is that the other
sources don't seem to include cases of safek pikuach nefesh. Vachai
bahem even includes cases of safek pikuach nefesh.
1. Tosafos explain that vachai bahem implies that under no
circumstance should a mitzvah be a factor in a person's death.
They add that this is the source for the rule that we don't follow the
majority in life-threatening situations. {}
iii. R. Naftali Z.Y. Berlin (The Netziv 1816-1893) notes that there is another
difference between the two sources {}:
1. According to the source of v'shamru, you would violate Shabbos if
it can lead to a person further observing Shabbos. However, if it
were based on this source alone, you couldn't violate Shabbos for
safek pikuach nefesh.
2. According to the source of vachai bahem, you could only violate
Shabbos for an actual nefesh and not for potential life.
3. Therefore, if you have a fetus who is in a state of safek pikuach
nefesh you can't violate Shabbos:
a. According to v'shamru, you can't violate Shabbos because
it's a safek.
b. According to vachai bahem, you can't violate Shabbos
because the fetus is not a nefesh.
c. The Netziv {} proves this idea from a comment of Tosafos
i. Tosafos note that even though Eliyahu was a kohen,
he was allowed to resuscitate the child (see
Melachim I ch. 17) because he knew for sure that it
would work.
ii. Question: Why did he have to know for sure that it
would work? Isn't safek pikuach nefesh enough to
violate tumas kohanim?
iii. Netziv- Because the child was already dead, vachai
bahem did not apply. The only heter to violate his
tumah was v'shamru. However, v'shamru is only
applicable in a case of definite pikuach nefesh and
therefore if he was uncertain of the results, it would
have been prohibited.
4. R. Shneur Zalman of Liadi (The First Lubavitcher Rebbe 1742-
1815) anticipated Netziv's chiddush and disagrees. According to
R. Shneur Zalman, once we have the verse vachai bahem, that
teaches that we treat a safek as if it were a vaday and therefore,
even if the only basis for pikuach nefesh is v'shamru, we still
violate Shabbos in a case of safek. {}
iv. Mishna Berurah shows another difference between the sources.
1. The Gemara states that if a building falls on someone and a rescuer
finds him in a state where he only has moments to live, one can
still violate Shabbos to save those few moments {}
2. R. Menachem Meiri (1249-1306) states that the reason why one
violates Shabbos for those few moments is that during those few
moments he can perform teshuva and vidui. {}
a. Why Does Meiri state specifically teshuva and vidui? R.
Yosef Patzanovski (early 20th century, who doesn't seem to
have had a copy of the Meiri) quotes the Meiri that by
performing teshuva one can retroactively undo aveiros
from previous Shabbosos. If we allow chilul Shabbos for
future Shabbosos, we should allow it for previous
Shabbosos as well. {}
3. Mishna Berurah notes that Meiri seems to be following the opinion
that the source for pikuach nefesh docheh Shabbos is v'shamru.
However, he extends this source to not only include observance of
Shabbos but any other mitzvah. The implication is that if he can't
perform any mitzvah, one cannot violate Shabbos. Mishna
Berurah disagrees and maintains that since the source for pikuach
nefesh docheh Shabbos is vachai bahem, one can violate Shabbos
even if it is certain that the patient will not observe any mitzvah. {}
v. There are a number of acharonim who apply v'shamru as a source of
leniency in cases where v'chai bahem is not applicable:
1. Saving someone from forced conversion
a. Rashba (1235-1310) discusses a case of a girl who was
kidnapped on Shabbos in order to be converted to
Christianity. He writes that one may not violate Shabbos to
save her from conversion because one may not violate one
aveirah in order to save someone else from another aveirah.
b. R. Yosef Karo (1488-1575) notes that Tosafos disagree and
maintain that one may violate Shabbos in this situation
because Tosafos allow one to violate a smaller aveirah to
save someone else from a larger aveirah in a case where the
original aveirah was caused under duress or when there is a
greater purpose (mitzvah rabbah). {} For this reason,
Shulchan Aruch rules that one may violate Shabbos to save
the girl. {}
c. R. Avraham Gombiner (c.1633-1683) writes that there is
another kula that's applicable. Since we are dealing with
the kidnapped girl not keeping Shabbos in the long term,
one can employ chalel alav Shabbos achas. {}
2. R. Shlomo Kluger (1783-1869) discusses whether it is permissible
to violate Shabbos in order to prevent loss of sight. He notes that
notwithstanding the discussion about whether loss of limb warrants
chilul Shabbos (which will be discussed later in the series), there is
another reason to be lenient if the patient has the potential of
becoming totally blind: {}
a. There is a dispute in the Gemara whether a blind person is
exempt from mitzvos.
b. While most rishonim follow the opinion that a blind person
is obligated to keep mitzvos, Rabbeinu Yerucham is of the
opinion that a blind person is exempt from mitzvos.
c. Therefore, one can employ chalel alav Shabbos achas in
order to allow this person to remain obligated in mitzvos
according to Rabbeinu Yerucham.
3. R. Moshe Sofer (1762-1839) has a discussion about a child with a
mental disability whose parents would like to send him to an
institute that serves non-kosher with the hopes that this institute
would cure him of his illness. One of the considerations of the
teshuva is that if this institute can bring the patient from a shoteh to
a non-shoteh, he is going to be obligated in mitzvos through this
treatment. Therefore, one can employ chalel alav and argue that
by violating the prohibition of kashrus now, he will be able to keep
all of the mitzvos in the future. Chasam Sofer concludes that
although halachically, this argument is valid, nevertheless, when it
comes to kashrus, we have a tradition that eating non-kosher has a
damaging effect on a person and it is better that he remain a shoteh
rather than becoming a non-shoteh through eating non-kosher
food. {}
c. Pikuach Nefesh in cases of remote possibilities
i. There is rule that we don't follow statistical majorities when it comes to
pikuach nefesh. {} This means that we violate Shabbos even if it is very
likely but not definite that:
1. The person will live without the treatment.
2. The given treatment is not going to work in this situation.
3. The person is already dead.
ii. Nevertheless, there are cases that are not just very likely but almost
definite. Do we still employ the principle that we don't follow statistical
majorities, or is there some threshold where we ignore the remote
iii. This idea is alluded to by Tosafos. Tosafos ask: why can't someone cook
on Shabbos based on the fact that the food could potentially be used for a
choleh sheyesh bo sakanah (based on the principle of ho'il)? Tosafos
answer that a choleh sheyesh bo sakanah is not common. The implication
of their answer is that possibility of using that food for a choleh sheyesh
bo sakanah is so remote that we can't categorize it as pikuach nefesh. {}
iv. This concept is discussed by the Acharonim in various contexts:
1. R. Akiva Eger (1761-1837) writes that when the risk is one in a
thousand, it is not considered pikuach nefesh. {}
2. R. Ya'akov Etlinger (1798-1871) writes that when there is no
choleh l'faneinu, it is not considered pikuach nefesh. {}
v. It is possible that they are both giving different descriptions of the same
principle that we don't violate Shabbos for remote possibilities.
1. R. Avraham Yeshaya Karelitz (Chazon Ish 1878-1953) states that
the real criterion is whether it is a situation where we would gather
in prayer as a response to the situation. {}
2. R. Moshe Feinstein (1895-1986) presents a similar idea. He
suggests that it depends on the person. Some people are very
nervous and they may violate Shabbos in certain situations where
more relaxed individuals may not. {}.
3. R. Shlomo Zalman Auerbach (1910-1995) gives a practical litmus
test: If this situation occurred during the week and one would act
with great alacrity and nervousness, it is considered pikuach
nefesh. If not, it is not considered pikuach nefesh. {}
a. One example given is an IDF military vehicle whose spare
tire is flat. If during the week you would repair the tire at
the expense of something important, you can consider it
pikuach nefesh. If not, you can't consider it pikuach
nefesh. {}
vi. Practical applications
1. R. Yechezkel Landa (1713-1793) discusses performing autopsies
on cadavers in order to search for cures. He prohibits based on the
fact that there is no choleh l'faneinu. {}
a. Chasam Sofer- If in fact there is a choleh l'faneinu you can
perform an autopsy in order to learn how to treat someone
else in the same predicament. {}
b. R. Moshe Feinstein asserts that even if you have a choleh
l'faneinu and performing the autopsy will might teach you
about an illness, you still can't perform an autopsy because
learning medicine is not considered pikuach nefesh.
Pikuach nefesh means that you apply what you do know to
a life-threatening situation and there is no obligation to
make yourself more qualified. {}
c. R. Shlomo Zalman writes that learning medicine is not
considered pikuach nefesh because during the week,
students or residents don't act with alacrity and nervousness
to learn the information. {}
2. R. Zalman Nechemiah Goldberg, Halacha U'Refuah Vol. III has a
long article about a physician answering the telephone on Shabbos.
Part of the discussion includes whether one can assume that the
chances that the phone call is for pikuach nefesh is high enough to
call it choleh l'faneinu.
3. In a recent RJJ article, (Vol. 50) the issue of choleh l'faneinu was
discussed regarding whether it is permissible to violate Shabbos to
bank umbilical cord blood.
‫מדידהו וחי בהם ולא שימות בהם ‪ ...‬וכולהו‬ ‫יומא פד‪:‬‬
‫אשכחן ודאי ספק מנא לן ודשמואל לית ליה‬
‫ירושלמי יומא ח‪:‬ה‬

‫שמות לא‪:‬טז‬
‫תרומת הדשן א‪:‬נח ד"ה תשובה‬

‫שו"ת תשב"ץ א‪:‬נד‬

‫רש"י שם‬

‫ויקרא יח‪:‬ה‬

‫שו"ת ציץ אליעזר ח‪:‬טו‪:‬ב‬

‫תוספות פה‪ .‬ד"ה ולפקח‬

‫יומא פה‪:‬‬
‫ר' שמעון בן מנסיא אומר ושמרו בני ישראל‬
‫את השבת אמרה תורה חלל עליו שבת אחת‬
‫כדי שישמור שבתות הרבה א"ר יהודה אמר‬
‫שמואל אי הואי התם הוה אמינא דידי עדיפא‬
‫כו' לא ידעינן בספיקא עיין שם‪ .‬ומיהו בר"ן‬ ‫העמק דבר א‪:‬ח‬
‫פרק יום הכיפורים מבואר בהדיא דמחללין‬
‫אפילו בעובר מהאי טעמא‪ .‬ואפשר דלבתר‬
‫דגלי לן קרא דמחללין מספק גבי פיקוח נפש‬
‫אם כן הוא הדין בשביל שישמור שבתות‬
‫הרבה‪ ,‬שהוא חשוב גם כן כפיקוח נפש‪ .‬ומיהו‬
‫בר"ן דוחק לומר כן‪ ,‬שהרי מותר להרגו‪ .‬וצ"ע‪.‬‬

‫יומא פה‪.‬‬

‫מאירי שם‬
‫אף על פי שנתברר שאי אפשר לו לחיות אפי'‬
‫שעה אחת שבאותה שעה יבוש בלבו ויתודה‪.‬‬

‫פרדס יוסף שמות לא‪:‬טז‬

‫העמק דבר קסז‪:‬יז‬

‫ביאור הלכה שכט‪:‬ד ד"ה אלא‬

‫תוספות ב"מ קיד‪ :‬ד"ה אמר ליה‬

‫שלחן ערוך הרב קונטרוס אחרון שו‪:‬א‬

‫ומכל מקום הכא בהצלת עבירה )צ"ע( אם‬
‫מחללין מספק‪ ,‬דהא אמרינן בגמרא פרק‬
‫בתרא דיומא דדוקא מוחי בהם מוכח דמחללין‬
‫מספיקא אבל משום שאמרה תורה חלל עליו‬
‫הפוסקים חולקים עליו מכל מקום אין הולכין‬ ‫שו"ת הרשב"א ז‪:‬רסז‬
‫בפ"נ אחר הרוב וא"כ יש לחוש לדעת רבינו‬
‫ירוחם דסומא פטור וכו' וא"כ יש לו' בסכנת‬
‫שאר אבר דאין בו ביטול תורה ומצות וכן‬
‫בגמרא בעין שמרדה דמיירי בעין אחת אף אם‬
‫לא יהיה לו עין יהיה חייב במצות לכך נידון רק‬
‫כסכנת אבר וצריך לטעם משום דהוי סכנת כל‬
‫הגוף‪ .‬אבל בשתי עיניו דיהיה סומא לגמרי‬
‫ויפטור מכל המצוה יש לו' דודאי מוטב לחלל‬
‫שבת אחת כו' לשמור שבתות הרבה‪.‬‬

‫שו"ת חת"ס או"ח ס' פג‬

‫בית יוסף או"ח ס' שו‬

‫יומא פד‪:‬‬

‫שלחן ערוך שו‪:‬יד‬

‫תוספות פסחים מו‪ :‬ד"ה רבה אמר‬
‫ואם תאמר אי אמרינן הואיל א"כ בטלת כל‬
‫מלאכת שבת הואיל וראוי לחולה שיש בו‬
‫סכנה וי"ל כיון דלא שכיח כלל לא אמרינן‬
‫הואיל‪.‬‬ ‫מגן אברהם שו‪:‬כט‬
‫ומיהו אם הבת קטנה צ"ע אם יעשה הגדול חטא בשביל‬
‫הקטן דהא אין מצוין להפרישו עסי' שמ"ג א"ד מידי דהוי‬
‫אפ"נ שמחללין על הקטן דאומרים חלל עליו שבת א' כדי‬
‫כדי שישמור שבתות הרבה ה"נ כן וצ"ע‪.‬‬

‫חכמת שלמה או"ח שכח‪:‬מו‬

‫מיהו כד דייקינן נראה לחלק בין עין אחת ושתי‬
‫עינים כיון דלטעם אחד לכך פקוח נפש דוחה‬
‫שבת מכח דמוטב לחלל שבת אחת כדי‬
‫שישמור שבתות הרב' וא"כ הרי לדעת ר"י‬
‫סומא פטור מכל המצות ולדעת רי"ו הובא בב"י‬
‫הלכות פסח סי' תע"ג קיי"לן כר"י וניהו דרוב‬
‫אגרות משה או"ח א‪:‬קכז‬ ‫שו"ת רבי עקיבא איגר ס' ס‬

‫שו"ת בנין ציון ס' קלז‬

‫שלחן שלמה ערכי רפואה חלק א' עמ' רלא‬

‫חזון איש אהלות כב‪:‬לב‬

‫הצבא כהלכה עמ' קנט‬

‫‪ .1‬אגרות משה יו"ד ב‪:‬קנא‬ ‫שו"ת נודע ביהודה יו"ד ב‪:‬רי‬

‫שו"ת חתם סופר יו"ד ס' שלו‬