by Rabbi Yair Hoffman for 5tjt.com

When it comes to Shabbos and the permissibility of injections and associated activity, not everyone has full clarity.  This is especially true with new advances in technology.  This article discusses a number of topics that deal with injections on Shabbos.

There is a new type of Smart-Insulin Pen that, in this author’s opinion, is destined to take over the market.   One example is the NovoPen^® 6 & NovoPen Echo^® Plus.  These pens are new, smart insulin pens that automatically record insulin dosing information about each injection. This type of pen, however, complicates things for Shabbos observers.  So the question is, “Can observant Jews use it?”

The biggest challenges for many insulin pen users are:

How much should they inject?  When should they inject?  What is the quality of the insulin in terms of storage conditions and shelf life?

There is also something called insulin “stacking”—when you add more insulin while remaining insulin is still active from previous doses.  This can lead to hypoglycemia (low blood sugar, also known as blood glucose), and lying on the floor (very dangerous and embarrassing).

Smart insulin pens can calculate each dose based on current blood sugar levels. They can deliver accurate half-unit doses. They can prevent skipped or missed doses and keep track of the time and amount of each dose, and remind you when it’s time for the next one.
Notify you when your insulin has expired or exceeded its temperature range, so you can replace the cartridge.  They are a nice alternative or back-up to insulin pumps.

This author consulted with Rav Shlomo Miller shlita, perhaps the leading Posaik in North America, and he stated that if someone is advanced in his or her diabetes and has difficulty properly dosing himself or herself, it would be permitted to use a Smart Pen. Many people with diabetes also have a hard time correctly calculating insulin doses. Each person should consult with his or her own Posaik or Rav.  If the person is overdosing regularly, it would also be permitted.

It is this author’s belief that Smart Pens for insulin are just the beginning. This topic not only applies to insulin-dependent diabetics, but also will perhaps soon apply to:

• people who require short-term growth hormone shots,
• women who take Ovidrel or Cetrotide (cetrorelix) for fertility issues,
• girls with Turner Syndrome,
• and a number of others, too.

But aside from the new Smart Pens, there are other issues that have to do with injections and their use or non-use on Shabbos.  What follows is a brief discussion of the different injections and their associate halachos.  Of course, always ask your Rav or Posaik.

INJECTION TYPES

There are: subcutaneous (under the skin), intramuscular (into the muscle), and intravenous (into the vein) injections.

A subcutaneous injection does not necessarily cause bleeding. It is thus considered no different than other types of medicine and is permitted for a sick person. If one is not sick but is in pain, he may ask a non-Jew to administer it.

CHOLEH SH’AIN BO SAKANAH

For a choleh she’ein bo sakanah, a sick person who is not deathly ill, it is permitted to inject with a subcutaneous or intramuscular injection, but not an intravenous injection. That may be different for Sephardim, however. Rav Bentzion Abba Shaul, zt’l, in his Ohr L’Tzion (Vol. II #20), ruled that an intravenous injection is a melachah she’aina tzrichah l’gufah, a violation that is not for the original purpose in the Mishkan. Generally speaking, an intravenous injection requires taking out a little bit of blood to ensure that it is in the correct place. Thus, Sefardim have a more lenient view.

BUT WHICH MELACHA?

There is a debate among the Rishonim as to what exact melachah is involved when taking out blood. Rashi (Shabbos 107a) states that it is on account of shochet. Tosfos, Rashba, Ritva, and Meiri agree with Rashi. The Rambam, on the other hand (Hilchos Shabbos 8:7) holds that it is on account of mefareik, a subcategory of dosh.

The difference would be (see Biur Halachah 316:8 Ha’chovel) that according to the Rambam, the amount of blood taken out that would be a Torah violation would be the volume of a fig. According to Rashi, it would be any amount. However, if there is a purpose for the lesser amount, then some may consider it a violation even according to the Rambam.

PREPPING THE NEEDLE OR SYRINGE

Many types of daily injections require putting together the needle. There are needle heads that one must screw onto the insulin pen. Many poskim consider this act a possible violation of boneh or makeh b’patish, a final act.

Makeh b’patish means, when literally translated, “the strike of a hammer.” However, in general it refers to an act of completion. Any act of perfecting an object or rendering it fit for use may be considered a violation of the melachah of makeh b’patish. Rav Shlomo Zalman Auerbach, zt’l (Shulchan Shlomo Refuah Vol. I p. 54), writes that if one throws out the needle head afterward, then one may be lenient if it is necessary. The Chazon Ish, however, forbade it even if the needle head is thrown out.

There are readings of Rav Auerbach (ibid p. 56) that may permit it with the insulin pens that are currently used, but one must consult with one’s own rav or posek.

A solution to this problem would be to affix the needle head onto the pen before Shabbos.

MIXING MEDICINE ON SHABBOS

There are some injections that need to be mixed together before use, and delaying that daily shot until motzaei Shabbos can jeopardize the treatment. For example, in fertility treatment, missing a dose of Cetrotide (cetrorelix) or taking it late lowers the chance of successful egg retrieval. When mixing on Shabbos, a shinui may be necessary in order to avoid certain halachic complications.

ALCOHOL SWABBING

There is a longstanding debate between poskim as to whether one may use baby wipes on Shabbos. The issue is that of a possible violation of sechitah, in this case, part of the melachah of laundering.

But what about the use of an alcohol swab to clean injection sites? Is there a difference between baby wipes and alcohol swabs in this regard? Before acting on anything, please consult with your own doctor and your own rav or posek.

Various health organizations, including the WHO, United Kingdom’s Department of Health, and Australia’s Department of Health, have stated that if the skin is visibly clean, disinfecting the skin (or alcohol swabbing) is not necessary and does not actually reduce infection. On the other hand, Canada’s Public Health Agency advises the practice of cleaning the skin with a suitable antiseptic solution prior to vaccination or injection.

Alcohol swabs are made of cotton, and one is squeezing out the alcohol onto the injection site when cleaning that site. Unless the skin is visibly dirty, because of the ongoing debate about whether the continued use of alcohol swabbing is clinically necessary and effective for routine subcutaneous injections or vaccinations, some have suggested that people can avoid swabbing the site on Shabbos.

May Hashem send a complete refuah to all who are sick. We beg that it be speedily, k’heref ayin! Amen.

The author can be reached at [email protected]. Read more of Rabbi Hoffman’s articles at 5TJT.com.