Medicine in Practice on Yom Kippur - Dr. Tal Nir

00:02 Speaker 1 You’re listening to the “Lema’an Yishme’u” podcast from Machon Halacha Chabad.

00:09 Speaker 2 Good evening, everyone. A good, sweet year, and may all the Jewish people—and indeed the whole world—be sealed for a good year. We’re here to talk about medical matters on Yom Kippur. There are a few basic principles we need to know, both as Jews and as Jewish doctors. First of all, Yom Kippur is not an ordinary fast instituted by the rabbis; it is a fast commanded by the Torah: “You shall afflict yourselves, for any person who is not afflicted shall be cut off.” This is no simple matter, and the medical approach to this fast is not simple either, quite unlike the other fasts, where there is much more room for leniency. On the other hand, there is also the command, “You shall take great care of your lives.” We need to know that every Jew is a great treasure, a soul in a body. The Jewish body is an immense treasure, and the Jewish soul that dwells within it is certainly an immense treasure too. And we desecrate one Shabbos for a person so that he can observe many Shabbosos. Even on Yom Kippur, if someone, G-d forbid, feels unwell in shul, the person in the congregation with the greatest medical expertise—and that is not necessarily the rabbi—takes charge, examines him, and decides whether he needs to be taken for medical care because his life is in danger or there is a concern that it may be. So this is a very complex matter, and we have to be precise about the details. We certainly won’t cover every question this evening. We’ll try to address general issues, and anyone with a specific question can consult their own doctor, or a G-d-fearing doctor of their choice, and give them the details of their illness or the patient’s illness, the medications they take, and how they feel. That way, they can receive an answer on the spot that is right both medically and halachically. There is also consultation with a rabbi, so it is always possible to bring about this wonderful synthesis between rabbis and doctors that, baruch Hashem, we

02:21 Speaker 2 do in Chabad—and here, too, with Rabbi Yaroslavsky, may he be well. For many years, every Yom Kippur eve, we have exchanged a great deal of information and many questions and answers. And baruch Hashem, with help from Heaven and with the Rebbe’s help—the Rebbe certainly gives us his blessing in this whole endeavor—no mishap has come from our work. That is no simple thing; it is truly remarkable and miraculous. So, with your permission, let’s begin. A few general words. Many questions are asked about medications on Yom Kippur. What should one do about medications on Yom Kippur? We need to know which medications we’re talking about, who is taking them, and what conditions require them. There is a big difference between conditions involving pain and conditions such as diabetes, high blood pressure, heart failure, joint problems, or other problems. Unfortunately, people suffer from many ailments—may it not happen to anyone. In principle, if a medication is taken once a day, there is no problem taking it shortly before the fast begins and then after the fast, skipping that daily dose during the twenty-six hours of the fast. Usually that is not a problem, and if a person wants to fast, they can do so. Of course, we need to know that some medications are taken with food, some without food, and some must be taken because otherwise the body will lose its delicate balance. As a general rule, someone with a mild condition—“mild,” as we say in medicine—can do this without any problem. With mild diabetes, I would even say that fasting is good for the person. When a person fasts, they aren’t putting carbohydrates, sugars, and other harmful things into their body, so their blood sugar will go down and they won’t need their usual medications for mild diabetes at all.

04:48 Speaker 2 If a person needs injections and insulin, their situation is somewhat more complicated. Here too, if they very much want to fast, it is possible to plan to take insulin only when they eat, and not to take it when they aren’t eating. But this has to be done sensibly, together with their doctor. It can be done. For someone who takes many medications for different conditions, of course it is more difficult. But remember that, baruch Hashem, we sleep seven or eight hours every night. The Rambam says to sleep eight hours. Most of us sleep less than eight hours, but even then, during those hours we don’t take medication, and we aren’t afraid to go to sleep because we might miss a dose. A person can go eight hours without taking any medication and nothing happens to their body, because while we sleep, most of the body’s systems are less active and the medications aren’t needed as much. Besides, some medications certainly continue working through the night. So if a person knows this, they won’t be afraid or anxious, or have a panic attack over not taking their medications for twenty-six hours. They should remember that every night they go eight hours without taking them. If they feel confident that they can get through the fast and won’t be harmed, then there is no need to worry. Sometimes it is possible not to take medications for twenty-six hours, and in most cases nothing serious will happen. Of course, if someone feels very unwell in the middle of the fast because of dehydration, or because another illness is worsening as a result of not eating or not taking medication, they should immediately begin eating or drinking in measured amounts, if they can. If the situation is more serious, they should not keep to measured amounts. The rabbi will certainly explain the measurements, but generally the practice is to say that for solid food—cake or

07:04 Speaker 2 something like that—one takes thirty grams, and for liquids, less than a cheekful. A cheekful is less than forty, and the intervals are every nine minutes. They can be longer, but not shorter. This may mean that the person is no longer considered to be fasting, but it ensures they are not violating the command to take great care of their life. There is no pleasure in it; eating and drinking in measured amounts is difficult enough as it is. In any case, this calls for consultation with a rabbi. But someone who becomes seriously ill, faints, or has severe dizziness certainly does not need to fast. The fast was given for healthy people, not for the sick. Someone who is ill does not need to fast. Now, what counts as ill? There are many illnesses for which one need not fast. For example, someone with tonsillitis, a fever of thirty-nine degrees, and chills; or someone who has COVID, G-d forbid, which is in the headlines today and everyone is taking care to avoid. Such a person certainly feels very, very unwell. They have difficulty breathing, muscle pain, chills, and a fever. They certainly do not need to fast. Period. It isn’t a question. Period. Take, for example, someone with a severe stomach infection who is taking three or four medications because they have the bacterium Helicobacter pylori in their stomach. While they are taking those medications, whether they can fast is certainly a difficult question, because it is not really feasible. Fasting is also very difficult for someone with severe gastritis or an ulcer. Someone who wants to fast and is not currently in an acute condition can take an Omepredex tablet, a Lansor tablet, a Nexium tablet, a Lanton tablet, or whichever tablet they use before the fast. That tablet should help them for at least twelve hours. If, during the fast, someone suddenly feels severe pain in the stomach, in the upper abdomen, and has

09:17 Speaker 2 He has severe heartburn or pain that radiates to his back. He can take another such pill during the fast with a drop of water, and it will definitely, definitely help him. The same goes for people who vomit at the end of the fast because they have too much acid in their stomach, which irritates the whole system and causes nausea and vomiting. They can certainly take a pill, even without water, though they can also take it with a little water. It will calm the burning in their stomach. As for heart failure, heart failure is a complex problem. It involves fluids, salts, and medications, and you have to know the condition of a person who has heart failure at all times. There are four grades of heart failure: grade one, grade two, grade three, and grade four. Someone at grade four certainly should not fast. If a person walks a meter and starts to feel short of breath, that person is not well and cannot fast. But someone who can fast can also take care during the fast to avoid the things that bring on heart failure. For example, not eating a lot of salt at the pre-fast meal or drinking too much water. I mean flooding his system, because any such disruption, together with the medications he takes, can upset his equilibrium, his balance. He needs to consult his doctor. But here too, with mild heart failure, a person who wants to fast can do so, provided he is stable. I want to return to dialysis and kidney failure. Here the situation is even more complicated, because fasting can worsen a person’s kidney failure, so one must be very, very careful. Someone whose creatinine level is, say, above 1.5 needs to drink in measured amounts. Without a doubt. Someone whose

11:24 Speaker 2 creatinine is above 2 may not be able to fast at all, because we are very concerned that the remaining nephrons in his kidneys will lose their function if he fasts and deprives his body of fluids. So he needs to consult about this too. Dialysis patients certainly should not fast at all. Someone who has dialysis three times a week or home dialysis should not fast. People always ask about pregnancy. Pregnancy is one of the difficult, complex questions regarding fasts in general, and especially the Yom Kippur fast. We need to remember that the One who gave us the child also gave us the fast. But—and this is a very broad “but”—if an older woman has become pregnant for the first time, Boruch Hashem, and she is now in critical months of the pregnancy, it is very difficult to tell her to fast. In our medical judgment, she should start with measured amounts and not place that burden on herself. I mean particularly an older woman, not a young woman who has already been through a pregnancy and has no health problems. A pregnant woman with preeclampsia should not fast either. It is a complex condition involving protein in the urine, swelling, and high blood pressure. She certainly needs to take her medications, and she certainly should not fast. The same applies to someone with a history of repeated miscarriages: if these are critical weeks of her pregnancy, she should not fast during those weeks in which she has miscarried several times, may it never happen to anyone. She can begin with measured amounts. Then, since anxiety is an important part of being able to get through this fast, as we said earlier, it will certainly help her to know that she can get through it because she has something to fall back on. That will help

13:47 Speaker 2 her, and with Hashem’s help she will succeed. As for patients with dementia: these are people whose understanding has been impaired, who do not know where they are, what time it is, or who is speaking to them. They certainly should not fast, and they certainly should not be forced to fast. It is unnecessary; it is not for them. Cancer patients—that is also a very complex question. With someone receiving biological treatment, it is a little simpler, especially between injections. But someone receiving chemotherapy certainly should not fast under any circumstances. He must eat and drink. Former cancer patients who are still anemic, still in pain, or still weak and at a very low body weight should not fast either. The comparison is not exact, but just as a small child must not fast because his body weight and metabolism do not allow him to go without food and drink for twenty-six or twenty-four hours, so too with people who have lost a great deal of weight and whose internal biological functioning has been badly affected by the treatments and by cancer, may it never happen to anyone. They certainly should not fast, almost as a general rule. Patients with depression: they barely eat as it is. One of the symptoms of depression is a lack of appetite and a lack of desire to eat at all, and they must be allowed the little that they do eat. Someone who wants to fast may fast, but someone who does not want to fast and whose depression is unstable should certainly be allowed to eat and drink like any other patient. With other psychiatric patients, it depends on their condition. If they are stable, they can manage like everyone else—that is, not eat or drink. But if they are not stable

16:07 Speaker 2 and cannot function except with strong medications that they must take, then even if they very much want to fast, they can take measured amounts. If they cannot fast and say they cannot do it, they should not be forced to fast. As for children under nine, they certainly do not fast at all. Do not even suggest that they fast. You can delay their meal, but up to age nine, definitely not. For girls, even up to age ten. Someone who is very, very thin should certainly not be made to fast, even when a little older—still below bar mitzvah age, of course, but older than nine or ten. There is no need to force them to complete a full fast either. You can have them fast for shorter periods of time, without forcing them. I would say, as a heading or a general framework for everything said here, that we need to think positively. What do I mean by thinking positively? There is a way to get through the fast. We got through it last year. We managed it two years ago. We felt a little unwell, but Hakadosh Boruch Hu helps every person complete this fast, so there is no need to become anxious. If you become anxious, it will certainly be much harder to get through those hours and that affliction. But if you know that no evil descends from Above, that it is the nature of the Good to do good, and that this fast is for the sake of our souls—to refine us and atone for all our sins—that will certainly give you the strength to get through the fast much more easily. The Rebbe said in a sicha that everyone is surely quoting now, in 5751, the year of “I will show him wonders,” that even burning anger must be transformed into wonder, into “I will show him wonders.” And even when “it is a time of distress for Yaakov,” one must know that from it

18:24 Speaker 2 When we talk about coronavirus these days—and it’s impossible not to talk about it, certainly among chassidim, among people who observe Torah and mitzvos, and among the Jewish people as a whole—we need to know that the health authorities’ instructions are sound. There’s no need to argue with them or fight them, G-d forbid. The simplest thing is to wear masks and keep your distance. It’s the simplest thing every person can do, should do, and must do, certainly when around others. If people keep two meters apart, both at davening and at weddings, even with only a small number of people, and at any event—a bris, a davening, or anything else people do over the holidays or during this period—and if you wear a mask and everyone else wears a mask and keeps their distance, then there probably won’t be much illness, certainly not a rise in cases. There will surely still be some cases, but the numbers will go down. As I said, we must do this; it isn’t a question. We spoke earlier about “You shall be exceedingly careful with your lives” in connection with the fast. That certainly applies to an illness like this, which is an epidemic, a worldwide pandemic. And certainly we care about the lives of our loved ones, the lives of the Jewish people, and the lives of everyone in the world. Anyone who cares about their relatives and cares about the Jewish people—and we Chabad chassidim grew up with this message of Lubavitch, the city of love, that every Jew is precious to us—we’ll walk several kilometers in the heat of Rosh Hashanah to blow shofar for a woman in an old-age home, and we say that the Rebbe takes pleasure in it and Hakadosh Boruch Hu takes pleasure in it. So surely Hakadosh Boruch Hu takes pleasure when each person protects the lives of those close to him and the lives of the Jewish people. And Rabbi Landau summed

20:37 Speaker 2 it up in a clip sent to people very, very clearly: Just as you put on a gartel, you need to put on a mask. And just as your prayers ascend when you daven properly, so too your prayers ascend when you’re wearing a mask—and perhaps when you aren’t wearing a mask, your prayers don’t ascend. So I think this is the time, during the Ten Days of Teshuvah, the Days of Awe, first of all to bless the Jewish people. As the Rebbe concluded his letter with a blessing from the Frierdiker Rebbe: May Hashem grant a good inscription and a good final sealing, a good and sweet year, materially and spiritually, to engage in Torah and avodah. Those who have families—may Hashem help them have nachas from them and an ample livelihood. Those who need to build a home—may Hashem help them, materially and spiritually. May we all merit abundant, abundant, abundant health, with joy. With Hashem’s help, just as we entered this whole situation from Heaven, surely the Rebbe, who agreed that the Jewish people should enter this situation, had only our good and the good of the entire Jewish people in mind. And in our days, may we emerge from this whole situation to salvation and the complete and true Geulah, with our King at our head. L’chaim, l’chaim. A good year and a good final sealing to all the Jewish people.