FASTING ON LINE: Intravenous and other Artificial Feeding Procedures on Yom Kippur
By Rabbi Moshe Donnebaum
Halachic Disclaimer:The issues discussed in this article are of a general nature, and are intended to give the reader an overall view. However, due to the many intricacies involved, a competent halachic authority should be consulted with regard to the practical application of these issues.
One of the basic axioms of Jewish law is that preservation of life take precedence over all other injunctions excluding three: idolatry, murder and immorality.(1) Thus, someone seriously ill or one who might take ill by fasting, is not only permitted to eat on Yom Kippur, but indeed is obligated to do so.(2) One who fasts in these situations is considered to have needlessly endangered his or her own life (3). This is included in the prohibition against suicide, found in Bereishis (9:5), "Ach es dimchem lenafshoseichem edrosh - The blood of your soul I shall demand".
Halacha notwithstanding, many people find it simply too distressing to eat. The story is told of Rabbi Shlomo Lorincz who was bedridden in 1951 in Asutta Hospital in Tel Aviv with typhoid fever. His condition required a carefully monitored diet, and his doctors decided that he must eat on Yom Kippur. Feeling uncomfortable with the thought of eating on this sacred day, Rabbi Lorincz sent the question to the Chazon Ish, hoping to be allowed to fast. The Chazon Ish responded that he must comply with the doctors' orders. But the story doesn't end there. On Erev Yom Kippur afternoon, the Chazon Ish journeyed from his home in Bnei Brak to the hospital in Tel Aviv - which in those days meant a journey involving three buses and an hour's travelling time - to visit Rabbi Lorincz and impress upon him the urgency of heeding his doctor's instructions. The Chazon Ish obviously sensed his reluctance to eat and felt the need to personally assure him that he must.
As mentioned, it is forbidden to fast when there exists a possible danger to human life. However, with modern medical techniques, certain procedures can be performed which would eliminate any potential health risk. These include, among others, the insertion of a nasogastric feeding tube (4), a gastrostomy feeding tube (5), and intravenous infusion (6). Thus a twofold question arises. Firstly, is it considered fasting while food is entering the body via these procedures? Secondly, if it is fasting, should one be encouraged, or perhaps is he obligated, to arrange for one of these procedures to be done to enable him to fast on Yom Kippur?
1.Rambam Mishne Torah, Hilchos Yesodei Hatorah 5:2.
HANOAS GRONO OR HANOAS MEIAV
In Meseches Chulin (7) there is a dispute regarding the prohibition of forbidden foods. Does it depend on hanoas grono, one's throat must derive pleasure from the taste of the food, or hanoas meiav, one's stomach must have pleasure, that is the satisfaction of filling an empty stomach? The difference is when the forbidden food enters a person's stomach bypassing the throat or wrapped in tissue paper, thereby giving a feeling of being full without enjoying its taste. According to the opinion of hanoas grono, one has done no wrong, but according to hanoas meiav one has transgressed.
Halocho (8) sides with the opinion of hanoas grono. Yom Kippur though, may be different for we know that Yom Kippur differs from all other forbidden food with regard to the shiur, the amount one needs to transgress. Generally, the shiur is a kzayis, an olive, for this is considered the minimal act of eating. Yom Kippur however, isn't dependent upon eating, for the Torah doesn't specify the word achila but rather v'eeneesem, pain, which would mean hunger pangs. Thus Yom Kippur has a larger shiur of koseves (9), a date, which causes yesuvai datei, mitigating hunger pangs. This proves, says Chasam Sofer (10), that the prohibition of Yom Kippur requires hanoas meiav, and this also seems to be the opinion of the Minchas Chinuch (11).
However, Chasam Sofer makes no mention if the stipulation of hanoas meiav with regard to Yom Kippur is in addition to hanoas grono or on its own, with the later Poskim disagreeing on this point (12). Yom Kippur could still require hanoas grono as well in order to be liable, which would then permit artificial feeding. Also, Maharsham (13) understands Chasam Sofer to mean that hanoas grono isn't necessary, yet he brings another exemption of shelo k'derech achila - not eating in the usual manner. With regard to a nasogastric tube situation, the Eretz Zvi (14), based on these points raised by Maharsham, rules that one may continue being fed in this manner on Yom Kippur. Rav Chaim Ozer Grodzensky (15) on the other hand, disagrees with the above interpretation of Chasam Sofer, and learns that Chasam Sofer himself was of the opinion that hanoas goron is required in addition to hanoas meiav. Accordingly he also concludes that an invalid may be fed artificially on Yom Kippur.
Having thus established that artificial feeding is considered fasting, the question arises if a patient who must eat is obligated to arrange such a procedure to enable him to fast.
At first glance, our question seems to depend on one of the most renowned halachic controversies concerning medical care and Biblical prohibitions - whether danger to life (pikuach nefesh) completely sets aside any and all injunctions (hutra), or whether this danger only suspends them (dechuya) (16). Seemingly, according to the view of abrogation (hutra), the seriously ill person does not have to pursue means to enable himself to fast, whereas according to the view of suspension (dechuya) one would have to do anything he could to avoid eating on Yom Kippur (17). However, for various reasons, the majority of Poskim rule that one is not obligated to do so, as will be explained.
VIEW OF MAHARSHAM
Maharsham was asked whether an ill person who must eat on Yom Kippur should have an enema (18) performed to enable him to fast. He answers negatively, and explains that feeding the body in this way lacks proper digestion. It therefore doesn't provide the same degree of nourishment and causes undue suffering, thereby bringing the sick person into a situation of danger.
Seemingly, the reason given by Maharsham does not pertain to nasogastric or gastronomy procedures, however Tzitz Elizer (19) extends Maharsham's logic to all artificial feeding methods, as they do not render the same benefit as eating in a normal manner. All doctors encourage their patients to discontinue artificial feeding and begin eating normally as soon as possible, for they recognise that chewing and swallowing enhance the nutritional value of food. To place a patient on a drip for Yom Kippur would deprive him of essential nourishment. This is besides the physical pain of inserting the needle when setting the drip. Therefore, concludes Tzitz Eliezer, one should not arrange such a procedure for a patient who is permitted to eat.
18.Insertion of tube in which fluid is passed into the rectum, and commonly used to wash and clear intestines. From Responsa Maharsham VI No. 123, it seems that in his days, this procedure was also used as a form of artificial feeding. However see Responsa Chelkos Yakov OC:216 who questions Maharsham on this point, for how can the liquid traverse the walls of the bowels into the stomach to provide nourishment.
VIEW OF RABBI MOSHE FEINSTEIN ZT"L
Rabbi Moshe Feinstein zt"l (20) writes that not only is a drip not required, but it is in all probability forbidden, and he cites three alternate prohibitions. Firstly, since Hashem has made this person ill and he can't fast, it is possibly forbidden to override Hashem's wishes through medical intervention. For healing purposes the Torah expressly allows doctors to do their job, verapo yerapeh (Shmos 21:19), but to enable someone to fast is beyond the scope of their permitted activity. Secondly, it is forbidden to inflict a wound for non-healing purposes. And finally, all drugs and medication may have side effects. Although tested and meeting governmental health authority requirements, there always remains the prospect of some unforeseen damage.
Rav Moshe continues that there is no halachic obligation prior to Yom Tov to prepare oneself for fasting. Since the time for doing the mitzva isn't upon him, it follows that he cannot be required to ready himself for fasting by inserting a drip (21). Interestingly, we find that by Yom Kippur specifically there is a designated idea of preparing oneself for the fast by eating on Erev Yom Kippur. Yet, Rav Moshe explains that the mitzva to eat on Erev Yom Kippur is a mitzva on its own, and the reasons given to lighten the fast have no halachic ramification. Therefore there is no obligation to arrange any type of procedure on Erev Yom Kippur.
20.Responsa O.C. 3:90
In another responsa (22) Rav Moshe writes that the discussion above was only in regard to introducing a drug. This would be forbidden for the three reasons listed. However, a common intravenous saline solution, which is nothing more than water and sodium chloride (salt) and is used in place of drinking water, should be permitted.
Moreover, it should be obligated even on Yom Kippur itself. Although inflicting a wound on Yom Kippur is prohibited, it will only be done once and the fluid will then flow continuously throughout the day, whereas if he eats, he'll be eating a few times and committing thereby numerous transgressions of Yom Kippur. This is comparable to the Mishnaic ruling that one who must eat forbidden food should minimise his transgression to the greatest extent possible, taking the least severe type of prohibited food.
Nevertheless, Rav Moshe concludes that one is not obligated to arrange intravenous for two reasons. A) Although nourishing, it does not engender the same satisfaction (yesuvei datei) as eating orally, and this can upset the delicate condition of the patient and cause him to deteriorate. B) Even though it is widely used and has no known detrimental side effects, there is always a remote possibility of some long-term harm that has yet to be determined.
. In yet a third teshuva (23), Rav Moshe deliberates the halacha of inserting a vitamin suppository to enable one to fast. Consistent with his other teshuvos, he writes that one is not obliged to utilise medicinal procedures for fasting. He then adds that it may very well be prohibited under the rabbinic restriction of taking medicine on Shabbos and Yom Tov. However, if the patient is in severe distress at having to eat, this rabbinic prohibition does not apply.
22.Responsa O.C. 4:101:3
VIEW OF RABBI SHLOMO ZALMAN AUERBACH ZT"L
Rabbi Shlomo Zalman Auerbach zt"l (24) takes our original question one step further. It is common knowledge that foods differ in kilojoules and calories, thus the question arises: If someone must eat on Yom Kippur, should he eat foods high in calories, to minimise the food intake? Or perhaps a high caloric drink should be concocted to avoid 'eating' altogether?
Rav Shlomo Zalman proves that one is not obligated to do so, for during the Talmudic era, people were well aware that meat and eggs provided more nutrients than other foods. Yet we don't find any mention, either in the Talmud or the Rishonim, of any preference for these foods, even though it would minimise the food intake. Accordingly this applies to any artificial method as well. Rav Shlomo Zalman explains the reason behind this consent as follows. If one were obligated to explore other artificial feeding methods, Chazal were concerned that in their absence an ill person might refrain from eating and endanger his life. Therefore they only restricted the amounts and time span of foods, but assigned no preference to high caloric foods or other artificial possibilities.
However, in conclusion, Rav Shlomo Zalman differs from the poskim mentioned earlier and notes that if someone does organise a feeding arrangement, then Tavo Olov Brocho, a blessing should come upon him. (Understandably, this is only when it has been established that there is no possible danger to the choleh.)
24.Responsa Minchas Shlomo V2 No. 58:26. See also No. 69:2.
Although his conclusion may be referring to the high caloric drink only, the word 'Tachbulos' seems to imply the inclusion of all methods mentioned in the paragraph.
A reason must be given to explain why pursuing artificial feeding isn't encouraged, yet the Mishna rules that one should seek to minimise the severity of the transgression when possible.
ARTIFICIAL FEEDING FOR A WELL PERSON OR A PATIENT ABLE TO FAST
Our discussion so far concerns an invalid who is exempt from fasting due to his condition, if artificial feeding should be arranged to enable him to fast. However, there is another dimension to this topic, in a reversed scenario. May a regular person who must fast ingest food artificially to ease or eliminate the discomfort of fasting? On this question, the poskim differentiate between an unwell person (choleh she'ain bo saconoh) and a healthy person.
We have seen previously that although Yom Kippur depends on hanoas meiov, nevertheless becoming satiated without eating in a normal manner would not be transgressing the issue of eating on Yom Kippur. Hence Maharsham and Achiezer allow a choleh who is well enough to fast, to be fed artificially. Similarly, Chelkos Yakov (25) permits the insertion of a suppository on Yom Kippur for an individual who suffers migraines when fasting.
However with regard to a healthy person whose sole intention is to avoid the discomfort of the fast, Chelkos Yakov prohibits any form of artificial food ingestion. Rabbi Moshe Sternbach (26) opines that artificial feeding may even be a Biblical transgression. He explains that our whole thesis that without physically eating there is no Biblical transgression may only apply to the negative mitzva against eating on Yom Kippur, but the positive mitzva to fast may apply to any kind of nourishment (27). Therefore though we may be lenient for a choleh who is able to fast, a well person should definitely not use any form of artificial feeding to lessen his hunger pangs.
25. O.C. 216, 217. Our discussion relates to a chole she'ain bo secono who is chole kol gufo, who suffers pain or weakness to the extent that his entire body feels weak. Hence the rabbinic restrictions on medicines and therapeutic treatment on Shabbos and Yom Tov do not apply (as they only apply to a minor ailment). See O.C. 328:17.
It seems that the Chelkos Yakov is explaining that the words of the Shulchan Aruch O.C. 328:49 also are referring to such a choleh. Hence the question raised in the Biur Halocho S.V. Losum why there is no issur of refuah in the case mentioned in Shulchan Aruch is answered.
ARTIFICIAL NOURISHMENT PRIOR TO YOM KIPPUR
Another debate found in the poskim concerns taking a pill or an injection prior to Yom Kippur in order to ease the fast. Sdei Chemed (28) in the name of a "certain Gaon" prohibits this practise as it is contrary to the Torah's intention. The Torah explicitly states (Vayikra 23:27), "On the tenth day of this seventh month, there shall be a Day of Atonement, and you shall afflict yourselves." What could be clearer than this open call to afflict ourselves as an atonement for our sins.
However, many poskim (29) oppose this view citing the mitzva of eating on Erev Yom Kippur as proof. The Rishonim (30) explain the reason for this mitzva to assuage the pinch of fasting. This demonstrates that one may alleviate the discomfort caused by the fast.
TEFILOS ON LINE
In conclusion, it is worthwhile noting the words of Mateh Ephraim (31) who elaborates on the importance of enduring the fast b'simcha, just as every mitzva one is obligated to perform with joy and excitement.
The verse says (Devarim 28:47), "Tachas asher lo ovadto es Hashem Elokecha b'simcha u'vtuv levov meirov kol - Because you did not serve Hashem your G-d with gladness and goodness of heart, when everything was abundant". Rabeinu Bachya there writes that simcha when serving Hashem is not merely an addendum to the mitzva being performed, rather it is a mitzva in its own right. It is not the polish on the silver, but a piece of silver in itself. Ari Hakadosh interprets the words in the verse, meirov kol, one should serve Hashem with such simcha, with such thrill and enjoyment, 'meirov' more than 'kol' - more than one who has acquired all the wealth and pleasures of the entire world. Imagine winning a multi-million dollar lottery, how great his happiness would be, so too, one's joy at doing mitzvos should be in that league, if not more (32).
Surely, on the holiest day of the year, when fulfilling the mitzva of afflicting oneself as an atonement for his sins, he should appreciate the golden opportunity in his hands. How foolish, continues Mateh Ephraim, are those who continuously look at the clock thinking, "How much longer to go?" On the contrary, as the discomfort of fasting hits, one should be well satisfied. In this merit, may we be found worthy of having our Tefilos "on Line" to Heaven to be inscribed and sealed for a happy, healthy and prosperous New Year.
28. Yom Kippurim end siman 1
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