Desecrating Shabbat for Various Mental Disorders

Desecrating Shabbat for Various Mental Disorders

As is well known, pikuach nefesh — saving a life — overrides the entire Torah and also overrides Shabbat, as will be explained below. Halachah usually discusses physically dangerous situations in which a person’s physical life is in danger. Yet in various sources we also find reference to different mental states that likewise enter the definition of pikuach nefesh. What are these mental states? What is the nature of the danger in them? And what rules apply to desecrating Shabbat in such cases? These questions are addressed in the present article.

Pikuach Nefesh Overrides Shabbat

It is an accepted halachah everywhere that pikuach nefesh overrides Shabbat. Thus we learned in the Mishnah (Yoma 83a): “Rabbi Matya ben Charash said: One who has pain in his throat — medicine is placed in his mouth on Shabbat, because it is a possible danger to life, and any possible danger to life overrides Shabbat.” Likewise, in Shabbat (128b): “One assists a woman in childbirth on Shabbat… and Shabbat is desecrated for her.” And there (109a): “Rav said: the back of the hand and the top of the foot are like an internal wound, and Shabbat is desecrated for them.” See also Shabbat 30a and other sources.

So too Rambam writes (Laws of Shabbat 2:1): “Shabbat is overridden in the face of mortal danger, as are all the other mitzvot” [1]. See there for the details throughout the chapter. This is also ruled in Shulchan Aruch (Orach Chaim 329:2): “One who has a dangerous illness — it is a mitzvah to desecrate Shabbat for him.” See there and in chapters 329–331 for the detailed laws.

The Source for the Law That Pikuach Nefesh Overrides Shabbat

Although pikuach nefesh overrides the entire Torah (see Yoma 82a; Rambam, Laws of the Foundations of the Torah 5:1; Minchat Chinuch, mitzvah 32), Chazal sought a specific source for this law with regard to Shabbat. Thus it is taught (Yoma 85a) that Rabbi Yishmael, Rabbi Akiva, and Rabbi Elazar ben Azaryah were walking on the road, with Levi the arranger and Rabbi Yishmael son of Rabbi Elazar ben Azaryah behind them, and the question was asked: “From where do we know that pikuach nefesh overrides Shabbat?”

The Gemara there brings seven derivations. Rabbi Yishmael derives it by kal vachomer from a burglar tunneling into a house; Rabbi Akiva derives it by kal vachomer from the Temple service; Rabbi Elazar ben Azaryah derives it by kal vachomer from circumcision; Rabbi Yosei son of Rabbi Yehudah derives it from the verse “אך את שבתותי תשמורו” — “Only My Shabbats you shall keep,” with “only” limiting; Rabbi Yonatan ben Yosef derives it from “כי קדש היא לכם” — “for it is holy for you”: it is handed over to you, and you are not handed over to it; Rabbi Shimon ben Menasya derives it from “ושמרו בני ישראל את השבת” — “The Children of Israel shall keep Shabbat”: the Torah says, desecrate one Shabbat for him so that he may keep many Shabbats [2]; and Shmuel derives it from “וחי בהם” — “and he shall live by them,” and not die by them. The Gemara concludes that all the derivations can be challenged and prove only definite danger, not doubtful danger, except Shmuel’s derivation, which has no challenge and includes even doubtful danger. About this the Gemara says: “One sharp peppercorn is better than a basketful of gourds.”

Another interesting aggadic teaching appears in Shabbat (30b), in response to a question asked of Rabbi Tanchum of Noy about extinguishing a lamp before a sick person on Shabbat: a lamp is called “ner,” and a person’s soul is called “ner”; better that the lamp of flesh and blood be extinguished for the lamp of the Holy One, blessed be He. Rashi explains, however, that this is not the primary derivation; the main source is “וחי בהם,” as Shmuel taught, and this teaching merely sweetens the matter with aggadah that draws the heart. It seems from Rashi that this is not a full legal derivation, but rather an explanatory reason for the law.

Rambam too cites Shmuel’s derivation, “וחי בהם,” as halachah and adds (Laws of Shabbat 2:2): “You learn from this that the laws of the Torah are not vengeance in the world, but mercy, kindness, and peace in the world.”

Distinctions Between the Different Derivations

Besides the Gemara’s statement that Shmuel’s derivation includes even doubtful danger, our rabbis noted additional differences between “וחי בהם” and “desecrate one Shabbat for him so that he may keep many Shabbats.”

Tosafot (Yoma 85a) explains that the rule “we do not follow the majority in pikuach nefesh” stems from “וחי בהם — ולא שימות בהם,” meaning that one must not allow matters to reach, in any manner, the death of a Jew [3]. Thus, according to other derivations, perhaps one would follow the majority as in the rest of the Torah, whereas according to “וחי בהם” one does not.

The Minchat Chinuch cites Or HaChaim on the verse “ושמרו בני ישראל את השבת לעשות את השבת,” who homiletically explains that one must “guard” a Jew even where this overrides Shabbat, but only when he can later “make” Shabbat; if one saves him only for a short life, this would not override Shabbat. The Minchat Chinuch challenges this from Yoma 85a: if a person is found alive under a collapsed building, the rubble is cleared even for temporary life; this is ruled in Shulchan Aruch 329:4. He answers that according to the view deriving the law from “so that he may keep many Shabbats,” perhaps temporary life is not included; but the halachah follows Shmuel, whose source is “וחי בהם,” and according to that source there is no distinction: one saves even for temporary life, and one desecrates Shabbat even for a baby found among a majority of non-Jews, despite issues of mitzvah-obligation.

The Biur Halachah (329:4) likewise writes that practically the matter does not depend on mitzvot: the reason is not that one mitzvah is pushed aside for many mitzvot, but that all mitzvot are pushed aside for Jewish life, as Shmuel learned from “וחי בהם.” Therefore one saves even a child who will not observe Shabbat and will not confess, and likewise a deaf-mute and a mentally incompetent person, even though the reason “so that he may keep many Shabbats” does not apply to them; the case of an apostate out of spite is a separate matter.

It emerges that the derivation “וחי בהם” is broader, including even cases where the person may not observe Shabbat or the mitzvot. However, the reason “so that he may keep many Shabbats” can broaden the law in a different direction: cases with no physical risk but with mental or spiritual risk concerning future mitzvah observance, as will be explained below in the name of Shevet HaLevi. In practice, both reasons have halachic significance.

Pikuach Nefesh in Relation to Mental States

As noted, halachah generally speaks of physically dangerous situations: illness, a collapse, childbirth, and the like. It deals less explicitly with mental states, both regarding the physical danger involved — such as concern that the person may harm himself or others, extreme exhaustion, and so forth — and regarding the mental danger itself, meaning irreversible damage to the faculties of the mind and “loss of sanity.”

Nevertheless, we do find discussion of danger whose primary nature is mental.

a. The Mishnah (Shabbat 29b) states: “One who extinguishes the lamp because he is afraid of non-Jews, of bandits, of an evil spirit, or for a sick person so that he may sleep — is exempt.” The Gemara (30a) asks what kind of sick person is meant: if dangerously ill, the Mishnah should have said “permitted,” not “exempt”; if not dangerously ill, according to Rabbi Yehudah one should be liable. The Gemara answers that it indeed refers to a dangerously ill person, and “exempt” here means “exempt and permitted.” Rashi indicates that this applies to the other exemptions as well, including “evil spirit,” so that “ruach ra’ah” is considered a dangerous illness permitting desecration of Shabbat. Rambam, in his commentary to the Mishnah, explains “ruach ra’ah” as a type of illness called in Arabic melancholia [4], in which the patient departs from ordinary human conduct, is distressed by light or people, and finds relief in darkness and isolation. Tiferet Yisrael similarly explains: “ruach ra’ah” — a melancholic person. Though it is hard to identify precisely whether the ancient term “black bile” corresponds to what is today called depression or to a broader group of severe mental states, it is clear that some mental illness is meant; thus this Mishnah shows that Shabbat may at times be desecrated for mental illness.

One must note, however, that since the halachah follows Rabbi Shimon, who exempts for a melachah she’einah tzrichah legufah, the Mishnah might be read as referring to a non-dangerous patient. Yet according to Ramban and Rashba, the other cases in the Mishnah were always assumed to involve danger or possible danger. Even according to Rashi, there is no need to say that Rabbi Shimon and Rabbi Yehudah dispute reality; rather, there are cases of dangerous “ruach ra’ah” and non-dangerous “ruach ra’ah,” and they differ only in how to establish the Mishnah.

b. In Ta’anit (22b) we learned: a city surrounded by non-Jews or by a river, a ship foundering at sea, and an individual pursued by non-Jews, bandits, or an evil spirit — in all these cases an individual may afflict himself by fasting. Rashi explains: “because of an evil spirit” — a demonic spirit entered him and he runs off; perhaps he will drown in a river or fall and die. Ran adds: or it is one of the illnesses. This is ruled in Shulchan Aruch, and Mishnah Berurah cites both explanations. Although there the issue concerns rabbinic prohibitions such as crying out in prayer or blowing shofarot to gather help, the comparison of “evil spirit” to the other dangers proves that it is an illness with danger. Ran states explicitly that from here we learn that for any sick person in danger that day, one cries out on Shabbat; “evil spirit” was mentioned because it is a dangerous illness on that day. This too shows that mental illness may be included among dangerous illnesses.

c. We also find (Yoma 84b) regarding a child: “If one saw that a door had locked before a child, he breaks it and takes him out, and the zealous person is praiseworthy.” Rashi explains: “the child became frightened.” This is ruled in Mishnah Berurah 328:38. Thus a state of terror constitutes danger, at least in a child. A similar idea appears in Shabbat 141b regarding carrying muktzeh for “a child who longs for his father,” out of concern that he may become ill, though there the concern is for illness without danger.

This case, however, is not a true mental illness, but panic that may lead to danger, at least in a child. It may therefore be regarded as physical danger, similar to the halachic concept of calming the mind of a woman in childbirth or of a sick person.

d. More explicit words appear in Responsa Rashba, attributed to Ramban (no. 281), regarding a man who swore in public not to engage in any game involving money, then became insane and afterward partly recovered, though he sometimes relapsed. One day people played before him and he found relief; the question was whether he could be released from his oath for this reason.

Rashba answers from the Mishnah in Shabbat about extinguishing a lamp because of “ruach ra’ah,” as discussed above, which implies that “ruach ra’ah” is included in dangerous illness. He adds that even if it is only a doubtful danger it is permitted, since doubtful danger to life is treated leniently. He further adds that even if the action merely settles the mind of the patient, it is permitted, as seen in Shabbat 128b regarding a woman in childbirth for whom her companion lights a lamp even if she is blind, in order to settle her mind. Rashba concludes that although one may doubt whether this game will settle the patient’s mind, nevertheless it should be permitted because of possible danger to life.

Thus Rashba clearly teaches that mental illness may entail danger; even possible danger has the status of possible pikuach nefesh; and actions not directly medical but capable of settling the patient’s mind may be permitted.

e. Additional sources appear among later authorities. See Magen Avraham (554:8) in the name of Maharil, regarding one who was lacking in mental capacity and recovered gradually: he may eat meat and drink wine throughout the week and does not fast on Tisha B’Av. Mishnah Berurah cites this, and Pri Megadim explains that the same applies to Yom Kippur: he does not fast because of concern for danger.

See also Igrot Moshe (Even HaEzer I, 65) regarding a woman who became insane after bearing two children and whose doctors forbade pregnancy. Rav Moshe Feinstein permits the use of contraception, because insanity is a matter of danger not only for herself but also for the small children: even one whose insanity does not presently lead him to do harm may turn to doing harm to himself or the children, Heaven forbid, and guards cannot be posted constantly. Regarding her eating on Yom Kippur, he writes that it is obvious she may eat, for insanity is danger; although the illness itself may not kill her, since because of it she may kill herself or others, it is pikuach nefesh.

See also Responsa Shevet HaLevi (IV, 34), asked about a person liable to lose clarity of mind and live as a shoteh exempt from mitzvot, and whether one must save him by desecrating Shabbat. He permits for two reasons: first, the concern that he may harm himself, as Rashi in Ta’anit explained, and he assumes this concern applies to every shoteh; second, the reason stated in Yoma 84b, “desecrate one Shabbat for him so that he may keep many Shabbats.” Even though we rule like Shmuel that the derivation is “וחי בהם,” nevertheless practically both reasons are true, as is evident from Magen Avraham regarding desecrating Shabbat to save one’s daughter from apostasy.

f. An interesting treatment appears in the book Pikuach Nefesh by Rabbi A. M. Feivelson, where he discusses whether insanity may be considered a “makkah shel chalal,” an internal wound, which is considered dangerous. He writes that even according to those who require an actual wound or swelling, who knows whether the illness does not come from an internal injury, such as insanity from a wound in the brain or nerves. In this he seems to have anticipated the modern view that mental illnesses are connected in some way to brain disturbances, with interaction between biological and psychological components.

From all the above it emerges that mental illness may be considered a dangerous illness with regard to desecrating Shabbat. Moreover, if the nature of the danger is the concern that the person may harm himself or others — or any other physical concern arising from his condition — no proof is needed: wherever there is danger of any kind, it is pikuach nefesh. What difference is there whether one is pursued by non-Jews, by bandits, or by himself?

Physical or Mental Risk

We must now define the danger in mental illness. Is the concern a physical risk arising from the mental condition, such as harm to oneself or others, dangerous exhaustion, catatonic states, and the like? Or is the concern the patient’s mental condition itself, which may reach irreversible loss of sanity and clarity of mind?

The practical difference is in cases not physically dangerous — for example, the patient is under supervision or clearly unable to harm himself or others — but mentally dangerous, in that they may deteriorate into irreversible loss of sanity. In most sources above there is no proof, and in some the concern is explicitly harm to the patient himself or others. Yet Shevet HaLevi’s second reason indicates that the very concern of becoming insane and losing one’s mind permits desecrating Shabbat because of “desecrate one Shabbat so that he may keep many Shabbats,” saving him from loss of mitzvah observance for the rest of his life.

One point requires discussion: according to this, in a person who is not observant, perhaps there would be no permission — from “וחי בהם” there is no physical danger, and from “so that he may keep many Shabbats” he is not expected to observe mitzvot. Yet according to Biur Halachah in the name of Meiri, even when saving only temporary life, this reason applies because perhaps in that time he will repent and confess. All the more so here, perhaps during his lifetime he will repent and return to mitzvah observance.

The basic point of Shevet HaLevi, that both reasons are halachically true, is explicit in Magen Avraham regarding desecrating Shabbat to save one’s daughter from apostasy.

Various Mental Disorders and Risk Situations

As explained, mental states that include bodily or mental risk may, under certain conditions, permit desecrating Shabbat. Since the field of mental disorders is very broad and includes many mild and severe disorders — some gravely impairing thought and reality testing, others primarily emotional and less impairing of functioning — a brief classification is needed.

In general, three categories are relevant. 1. Psychotic disorders: disorders involving impairment of thought and reality testing, chiefly various schizophrenic disorders. These are considered severe, and in their serious forms are closest to the halachic concepts of shoteh, loss of reason, and insanity. However, there are transient brief psychotic disorders that leave no permanent damage, as well as circumscribed psychotic disorders that do not impair general sanity or functioning. 2. Affective disorders: mood disorders, chiefly various depressive or manic states. These are generally less severe, and aside from psychotic episodes, general sanity and functioning are preserved. 3. Neuroses: disorders in which basic insight is preserved, but psychological difficulties cause suffering and functional impairment — anxiety, phobias, conversion disorders, post-trauma, eating disorders, and more. These are generally the mildest, since insight and reason remain intact and the suffering is mainly internal.

Naturally, psychotic disorders include both physical and mental risks: the risk of harming oneself or others, especially during or after a psychotic episode, and the risk of severe mental deterioration. Affective disorders may also be dangerous: the depressive side is among the leading risk factors for suicide, and the manic side in its stormy form can cause dangerous physical exhaustion, apart from possible psychotic states that are dangerous in themselves. Common neurotic disorders such as anxiety and phobias are usually not dangerous, despite the suffering involved, except for rarer severe conditions such as dissociative identity disorder, severe post-trauma, certain eating disorders, and the like. Yet even these may aggravate more serious background conditions — physical or mental — and then reach danger.

This article is not intended to give practical rulings about desecrating Shabbat in various mental states. The topic is too broad for one article, and absolute rules are difficult to provide. In general, the matter is entrusted to halachic authorities knowledgeable in the field, with every case judged on its own merits.

Still, in summary, the primary concern regarding desecrating Shabbat is in situations where there is even the slightest risk of harm to oneself or others — often psychotic, post-psychotic, or depressive states — as well as psychotic states by their very nature, both because of the risk of harm and because of the risk of mental deterioration, as cited above from Shevet HaLevi, and stormy manic states, which may lead to dangerous physical exhaustion. Common neurotic disorders usually do not reach danger, apart from the rarer cases noted above, but even they may become dangerous when accompanying more serious background conditions. Acute, traumatic anxiety attacks, such as after terror attacks, also require discussion, as they may at some level lead to danger.

Milder Mental Disorders Against a More Serious Background

As explained, one must distinguish generally between more severe mental disorders, such as schizophrenic and affective disorders, which may reach danger and pikuach nefesh, and milder disorders, such as neurotic disorders — anxiety, phobias, and the like — which usually do not reach danger.

However, even milder disorders, such as panic attacks, can constitute danger when the overall condition is more serious: for example, a schizophrenic patient whose state becomes more anxious, or a physically ill and frail patient who experiences a panic attack. In such cases, the situation must be judged according to the patient’s overall condition, not the isolated milder disorder.

This is true for several reasons:

a. Direct danger. The field of mental disorders is not as sharply defined as bodily disorders. Mental disorders combine different states and components that influence each other. Thus anxiety in a schizophrenic patient, for example, directly affects his overall mental state and may lead to a dangerous worsening.

b. Settling the mind. We find that Shabbat may be desecrated to settle the mind of the sick person, even if this is not directly connected to medical treatment. The Mishnah (Shabbat 128b) teaches regarding a woman in childbirth that if she needs a lamp, her companion lights it; the Gemara explains that this applies even if she is blind, because it settles her mind, for she thinks that if she needs something, her companion will see and bring it. This is ruled in Shulchan Aruch 330:1. The same applies to other sick people. On the other hand, some sources permit only rabbinic prohibitions, not Torah prohibitions, for general settling of the mind, such as asking a non-Jew to go beyond the techum to bring relatives after Shabbat. The distinction is that Torah prohibitions were permitted for settling the mind when it relates to treatment of the patient, whereas general emotional comfort was permitted only at the rabbinic level. In our matter, treating psychological distress against a serious background is clearly “settling the mind” related to the patient’s treatment, and even more so, since the patient knows that any change in his feeling affects his general condition.

c. Strengthening the limbs. Biur Halachah writes, based on Meiri, that things that strengthen the organs of a dangerously ill person are permitted even if withholding them would not itself be dangerous. Treatment of the mental state of a dangerously ill person is at least included in strengthening his limbs, because improvement of the mental state affects the general and even physical state, as it is written, “ורוח איש יכלכל מחלהו” — “A man’s spirit will sustain him in his illness.”

d. Needs of the sick person. Biur Halachah discusses at length the Maggid Mishneh’s view, based on Ramban, that all needs of a dangerously ill patient may be done even when they do not involve danger, and the views of those who disagree, concluding that for Torah prohibitions one should be stringent. In our matter, where there are independent reasons to permit, the Maggid Mishneh’s opinion joins the lenient side. Regarding rabbinic prohibitions, such as acting with a shinui, one may permit in any case, as Mishnah Berurah writes.

[1] Rambam’s wording implies that Shabbat is “overridden” for pikuach nefesh and not entirely “permitted,” as the Kesef Mishneh writes. This is also the view of Rashba and Ran. Maharam of Rothenburg, however, holds that Shabbat is fully permitted in cases of pikuach nefesh, and there are many practical ramifications. The primary halachah is that Shabbat is overridden; see Taz, Magen Avraham, Pri Megadim, and Mishnah Berurah, though Biur HaGra implies that it is permitted.

[2] This teaching also appears in a baraita (Shabbat 151b): “Rabban Shimon ben Gamliel says: for a living one-day-old infant one desecrates Shabbat; for David king of Israel when dead one does not desecrate Shabbat. For a living one-day-old infant one desecrates Shabbat — the Torah said: desecrate one Shabbat for him so that he may keep many Shabbats.”

[3] The rule that “we do not follow the majority in pikuach nefesh” is not absolute. Regarding “kol deparish meruba parish,” we do follow the majority even in pikuach nefesh; only where the original fixed status remains in place do we not follow the majority. Likewise, in some medical disagreements one follows the majority, while in other cases one does not follow the majority of opinions in danger to life. On the other hand, for a woman in childbirth Shabbat is desecrated even though only one in a thousand dies; most sick people live, yet Shabbat is desecrated for them; even several doubts override Shabbat. The question of percentages of risk requires analysis. Rav Shlomo Zalman Auerbach wrote that whatever people perceive as real danger is included in pikuach nefesh.

[4] It should be noted that a similar term, “melancholia,” from Greek, still denotes a depressive mood in English and other languages, and may have passed from Greek into Arabic.

[5] See Shulchan Aruch 316:8 with Mishnah Berurah, Shulchan Aruch 334:27, and in contrast Shulchan Aruch 328:31 and 340:1 with Biur Halachah; this is not the place for a full discussion.

[6] Although concern for mental deterioration might at first seem to be an illness for which one can wait until after Shabbat, since it is usually a prolonged process dependent on long-term treatment and not one immediate action, nevertheless even some worsening of a psychotic state can lead to further deterioration and complicate treatment in a way that may ultimately cause danger. A similar point appears in the words of Rav Shlomo Zalman Auerbach regarding surgery to repair the femoral head: even if doctors do not consider it urgent immediately, it should not be postponed until after Shabbat when the illness is urgent for the patient.

See the sources