How to Save a Life: Expanding Pikuach Nefesh

by Becca Shrier

I distinctly remember the first Passover following the COVID shutdown in March of 2020. As Passover was a mere four weeks after the world went into lockdown, questions arose about how to do Passover shopping, whether to ignore the shelter in home order and have a Seder with friends, or comply and have a Seder alone. For many of us - especially those who didn’t or couldn’t attend a virtual Seder - this brought about tremendous grief, sadness, and isolation. Many Shabbat-observant Jews, such as myself, don’t use electronics or phones on Shabbat and holidays - so communication and connection during this time became particularly challenging as we weren’t able to meet in person. Cognizant of the strain this could cause, my rabbi sent out an email encouraging us to safeguard our mental health and use a phone if needed to maintain connection and set up check-ins - particularly over the holidays. This was as much a matter of pikuach nefesh as a fire or other emergency. 

This week’s parsha contains one of just two passages that are the basis for the central Jewish value of pikuach nefesh - prioritizing saving a life over virtually every other commandment - including the observance of Shabbat. “You shall keep My laws and My rules, by the pursuit of which human beings shall live: I am ‘ה. (Leviticus 18:5)” But this isn’t even an explicit mitzvah - the verse doesn’t talk about the sanctity of human life or so much as mention Shabbat! We receive excruciatingly detailed instructions about what animals we can and cannot eat, how they are supposed to be slaughtered, and how they are supposed to be prepared - but on the pivotal matter of how or when to save a life - it’s crickets (which are incidentally not kosher). The rabbis of the Talmud derive from this that one should live by these statutes and laws, not die by them (Yoma 85b). But what does this mean when it comes to mental health? 

As an autistic person, I want rules. I want clear guidelines. I want to know how long I must sit on my couch ruminating before using a heter (religious exemption) to calm my brain with my “Happy Instagram”. Precisely how many minutes of barely-whispered chatter during the rabbi’s sermon must I sit through before retreating to his office with my previously-forbidden iPhone? What about pain? What is the equation that determines how much pain or discomfort is allowable before it’s ok to use a vehicle to get to and from shul or meals? On a pain scale of 0-10 - what’s the limit before sitting during Kedusha? How dysregulated does my nervous system need to be for it to be permissible to get in the shower? The hard reality is that there is no magic number. Even on an individual level - that scale changes from day to day and hour to hour. Over time, I’ve learned that I must be the one to assess my level of distress and trust that I know what I can tolerate. The Gemara understands this and states “If an ill person needs to eat and a doctor says he doesn’t need to eat, one listens to the ill person. 

לֵב יוֹדֵעַ מׇרַּת נַפְשׁוֹ - Lev yodea marat nafsho (the heart knows the bitterness of its soul). Even if the doctor is more certain, the ill person knows his own suffering better than anyone else (Yoma 83a).” So why is this so damn hard?

I’ve had more practice asking myself these questions than I care to admit. I spent 75% of 2018-2021 in and out of eating disorder treatment. So I made a Shabbat version of my stress toy bag - swapping out Silly Putty for Kinetic Sand and scented hand lotion for essential oils. Though I’d arranged to use disposable goods as I was at a non-kosher facility, I quickly noticed the food was often cold by the time I sat down to eat. Sensing my own distress, I conceded and switched to regular dishes because eating was fraught on its own - I didn’t need to make it more difficult for myself. Lev yodea marat nafsho 

There was the obvious question of why I persisted in keeping Shabbat in the first place? If things were bad enough to require treatment - it was clearly a case of pikuach nefesh - what gives? I knew in my soul that the only way to maintain my sanity and sense of connection to my “real” life was to hold on to my practices of Shabbat and Kashrut to the largest extent possible. As Rav Yoni Rosensweig - the “mental health rabbi” wisely said, “People want to [keep Shabbat]. If you tell them they can’t, they feel rejected from the group, from the community… Every exception made for a person for mental health reasons feels to them like a failure, like they are not really keeping Shabbat, that they are not strong like everyone else.” Those connections with my community, my family, and my friends were my literal lifeline. 

Even so, I struggled with what level of distress was tolerable before breaking Shabbat. One particularly challenging erev Shabbat, I called my rabbi and said the only thing I thought would help were crafts - what could I do instead. He said, without hesitation, if I needed to do the crafts - do them. I expressed my concern over breaking Shabbat when I wasn’t sure I “needed” to. I felt like my suffering needed to be at a 7 or worse to use a heter. He told me not to let it go above a 4. In other words, pikuach nefesh for mental health can be significantly more lenient - because you never know when a 4 can turn into a 10 - and why risk it? Lev yodea marat nafsho.

As I transitioned home - my mental health strengthened, but my physical health started to decline. Over time, my mobility steadily decreased and my pain steadily increased until even a ¼ mile walk from a bus stop became impossible - so I applied for paratransit benefits. But nothing could prepare me for January of 2025. Over the course of 10 days - I went from having Shabbat dinner in my friend’s 2nd story walkup to being inexplicably bedbound. I could not sit in a “normal” chair for more than about 5 minutes without being in excruciating, unrelenting pain. I was almost completely horizontal and normal activities such as eating, drinking, and even reading were out. The overwhelming escalation in pain and drastic increase in my disability status - compounded with two missed mental health treatments and a hospital-induced stomach flu - threw me into a brutal case of autistic burnout and soul-crushing despair. My mental health was extremely precarious and there was no question that using my phone and other resources were cases of pikuach nefesh. But as the weeks went on with my status unchanging - I went back to my philosophy in treatment and focused on keeping even the smallest positive mitzvah rather than abandoning my practice of Shabbat. I went about the daunting task of redefining Shabbat for myself. Again.

As it turned out, the Talmud had partially taken care of this for me. As I was bedbound, I fit into an official halakhic category - Choleh She’ein Bo Sakanah - a sick person who is not dangerously ill. Even though the Ramban, the Shulchan Arukh, and Ovadiah Yosef assert that a person in my position "is permitted to perform all Rabbinic prohibitions…even in the normal manner. For the Sages did not apply their decrees in a place of illness or great pain (Chazon Ovadiah, Shabbat, pp. 257)" - this still felt “wrong” somehow. Yes - I was bedbound and in unbearable pain - but the reason I really needed the exemptions was for my mental health - not necessarily my physical health. I reconciled this with myself by saying that it was the inability to keep Shabbat that was impacting my mental health - so this was the ultimate definition of pikuach nefesh; and so, I soldiered on.

I spoke with a breadth of rabbis, people in the Jewish disability world, leaders, and trusted friends to figure this out for myself. What was the essence of Shabbat for me? If I could only pick one practice - what would it be? I read the weekly Torah portion and dug into the commentary at the bottom of the page. I read Divrei Torah from different perspectives. As I’d been a fixture at my shul - working both as a gabbayit and chair of the Accessibility Committee - maintaining my connection with the community was vital. For the first few weeks, I had visitors every day - both coming to vist and to help with tasks I wasn’t able to do. The Shabbat visits meant the most to me and I was thrilled for whoever was able to come by - even if just for a few minutes. But this schedule became difficult to coordinate for an indefinite amount of time. As happens with many of us with disabilities and chronic illness - the combination of compassion fatigue, other people’s struggle to deal with illnesses that aren’t improving, and lack of bandwidth meant those visits gradually decreased. The resulting grief became a central topic in therapy as I tried to navigate what this would look like as we moved into May and June with Shabbat ending as late as 9:00pm. 

Inexplicably, after 5 ½ months, I was suddenly able to be vertical again. But 5 months in bed caused tremendous deconditioning and I was severely limited. Even so - my first Shabbat morning back in shul - saying the prayer for those who have recovered from a grave illness or taken a perilous journey was one of the most special moments of my life. Even after extensive work with my OT, I could only last about 20 minutes in the sanctuary and needed to take an Uber to go the mere 700 feet to my synagogue. I had my phone in shul on Shabbat for the first time in 10 years and this caused tremendous discomfort and grief. I then reminded myself that my rabbi(s) told me that getting to shul was a matter of pikuach nefesh for me and that the threshold for taking an Uber was minimal. Again, though, I had to figure out what was best for me and what met the needs of my disability. Though one rabbi told me it would be ideal to schedule the Uber before Shabbat -  my pain and my body were unpredictable - and I decided I would order them in the moment. Years of practice empowered me to make this decision without asking my rabbi for an additional heter. And yes - last week - a full 15 months after the onset of my condition - I felt the need to sneak into the bathroom to order an Uber so I wasn’t doing it in the open. 

I would argue that we need to do these things in the open. We need to publicize that pikuach nefesh looks different for everyone; that a person with ADHD using their phone to stave off boredom is, in fact, practicing pikuach nefesh - and it’s nobody’s business why. I spoke with a trusted Rav recently and asked for a universal heter to use my phone on Shabbat and Yontif. Given the complicated interplay resulting from the precarious state of my physical and mental health - it was becoming exhausting to do constant self-assessments of my mental state, I was tired of doing these mind-bending calculations - and I needed a break. Lev yodea marat nafsho.

I’ve done a lot over the last year or so to make my Shabbat practice distinct and meaningful. I created makeshift TV covers with different designs emblazoned with “Shabbat Shalom” to visually transform my apartment. I set up Alexa routines to countdown to candlelighting, remind me to get up in the morning, and wish me a Shavua Tov when Shabbat is over. I put my books in their own bag so I can seamlessly swap out my weekday crafts for my Shabbat reading. My disabilities sometimes necessitate ordering food on Shabbat - so I put a reversible sign on my apartment door where one side says to ring the bell and the other says to knock. 

I will admit that it takes a tremendous amount of work, and I don’t always have it in me - but adapting Shabbat for the various hurdles in my life has strengthened my faith, my resolve, and my absolute love for Shabbat and my Jewish life. At Kiddush we say - וְשָׁמְר֥וּ בְנֵֽי־יִשְׂרָאֵ֖ל אֶת־הַשַּׁבָּ֑ת לַעֲשׂ֧וֹת אֶת־הַשַּׁבָּ֛ת לְדֹרֹתָ֖ם בְּרִ֥ית עוֹלָֽם׃ - the children of Israel shall keep the Sabbath to observe the Sabbath for their generations. A person needs to be able to stick around to fulfill this obligation. Pikuach nefesh isn’t just about preserving the body - it’s about preserving the soul. The Mekhilta tells us - “Desecrate one Sabbath in order to keep many Sabbaths”. May we all keep many more Sabbaths.

Becca Shrier (she/her) calls herself ba’al teshuva-ish and serves as both a gabbayit and the Accessibility Committee Chair at Anshe Shalom B’nai Israel in Chicago. Though Judaism has been a central part of her life and identity since childhood, she fell in love with Torah study at Pardes Institute in Jerusalem. She loves music and has written several song parodies including “Hey There, Elijah” to “Hey There, Delilah” and “You’re Not Throwing Away my Shas” to “You’re Not Throwing Away My Shot”. 

She identifies as a late-diagnosed Autistic and lives with multiple conditions including Ehlers Danlos Syndrome, MCAS, Lipidema, and mental health concerns. She feels her purpose is to be an advocate for not just disability - but accessibility as a whole and developed a comprehensive guide for Halakhic Issues in Residential Eating Disorder Treatment. She lives with her two cats in Chicago and works as an email developer for a large financial services company. She is an avid crafter and is always working on at least two simultaneous cross-stitch, needlepoint, embroidery, and/or crochet projects at a time.