Background
Becoming a medical resident presents unique challenges, especially regarding observing the sanctity of Shabbat while providing essential patient care. Navigating the intersection of Halacha and medical duties on Shabbat requires a clear understanding of core principles. This essay provides an introductory framework for residents, outlining key concepts and patient classifications to guide initial decision-making in the hospital setting.
Core Principles of Melacha on Shabbat
At the heart of Shabbat observance is the prohibition of engaging in melacha, the 39 categories of creative "work" forbidden on the Sabbath. Biblically, one is only liable for violating a melacha if it was done in its intended way with its intended outcome. Rabbinically, to maintain the spirit of Shabbos, decrees were also instituted to prevent actions that might lead to violating these biblical prohibitions, such as performing the melacha in a non-normative way (i.e., with a shinui). The Chachomim, however, intentionally did not prohibit shinui or other guardrails for the spirit of Shabbos when it would impede the care for the sick or those in danger. Even if an action is prohibited, performing it in an unusual manner (shinui) can be permissible under specific circumstances, even for less severe patient presentations.
Patient Classifications in Halacha
Halacha classifies patients into five categories based on the severity of their illness to determine which actions may be performed on their behalf on Shabbat.
These categories are:
Holeh she-yesh bo sakanah: An individual with a life-threatening illness.
Sakanat ever: An individual whose limb or the function of a limb is in danger ( a category that has limited utility in the writing of modern poskim)
Holeh she-ein bo sakanah: A bedridden patient whose life is not in danger but is suffering severe weakness or distress.
Holeh be-miktzat: An individual with a minor illness, ailment, or wound.
Mihush: A person with slight pain or discomfort who can function normally.
Pikuach Nefesh: The Overriding Principle
A fundamental principle in Jewish law is pikuach nefesh, the obligation to save a life, which overrides almost all commandments of the Torah, including (and perhaps especially) the prohibitions of Shabbat. One is obligated to desecrate Shabbat to save a life in danger or a potentially dangerous situation, and someone zealous in this regard is praiseworthy. This principle applies even if there is only a doubt regarding the patient's critical condition or if the procedure will save their life. Delaying life-saving action out of concern for violating Shabbat is considered tantamount to murder in situations requiring immediate intervention. This concept is paramount when caring for a holeh she-yesh bo sakanah. For such a patient, all forbidden labors of Shabbat may be violated. According to many poskim, it is actually preferable for a Jewish adult to perform these actions, as they have a greater obligation to observe Shabbat, which demonstrates the importance of overriding Shabbat for life-saving purposes.
Hutra vs. Dechuya: Contrasting Sephardic and Ashkenazic perspectives
There is a general historical difference in approach between the Sephardic and Ashkenazic poskim on how they view the override of pikuach nefesh over Shabbos. Rabbi Yosef Karo takes the Hutra (meaning "nullified") approach that views Shabbat prohibitions as completely suspended for life-threatening situations, suggesting normal methods may be used without restriction. The Rama, by contrast, takes the Dechuya (literally "pushed off") approach, holding that Shabbat prohibitions remain in force but are superseded by life-saving needs, suggesting one should still minimize violations when possible. The Ashkenazi tradition generally follows the dechuya approach, recommending minimizing Shabbat violations even when treating critically ill patients—either by performing necessary actions with a shinui (unusual manner) or by asking a non-Jewish colleague when doing so won't compromise care.
Application to the Hospital Setting
In the inpatient setting, while this is somewhat nuanced, we write this guide assuming most medical care for admitted patients falls under the category of holeh she-yesh bo sakanah, or at least involves a potential sakanah (danger). Therefore, actions necessary for the patient's health and safety, including those that would normally violate Shabbat, are permitted and required. For instance, a patient with a high-grade fever whose cause is unknown should be treated as a holeh she-yesh bo sakanah, permitting Shabbat desecration for their care. Similarly, conditions like a psychotic break or a detached retina are classified as holeh she-yesh bo sakanah, necessitating immediate action even if it violates Shabbat. Care for children is generally more lenient; children may be classified as holeh she-ein bo sakanah even for some non-illness needs, permitting certain actions that would not be allowed for an adult or adolescent.
However, not all patients in the hospital or all tasks related to their care on Shabbat necessarily fall under the stringent leniencies of pikuach nefesh. For example, patients who are nearing discharge may no longer be in a life-threatening situation and might be classified as holeh she-ein bo sakanah. This category applies to those who are bedridden or severely weakened, but not in danger of losing their lives. For a holeh she-ein bo sakanah (for those that are too weak or in too much pain to function normally), biblical prohibitions may not be violated; however, one may ask a non-Jew to perform any necessary action, including biblical prohibitions, or a Jew may perform rabbinic prohibitions (or even a biblical one), with a shinui. Issues arising with discharge paperwork, coordinating follow-up, or other tasks that are not directly related to an active life-threatening condition may need to be evaluated separately, though if it will affect the care of other dangerously ill patients, there may be room for leniency.
Patient care in the outpatient setting is not directly dealt with in this guide as it is inherently more complicated halachically, and we highly recommend one discuss this context if it comes up personally with a Rov that they trust.
Future chapters delve into specific clinical scenarios and common challenges residents face, providing practical guidance based on these halachic categories, though importantly, this work is meant to serve as a primer and platform for people to seek personal rabbinic guidance and not a replacement for rabbinic consultation.