Alzheimer’s Disease and Yom Kippur


Vayelech 5780


Moshe spoke these words to all of Israel. He said to them, “I am a hundred and twenty years old today; I can no longer go out and come in”… (Devarim 31:1-2)

Although this Pasuk implies that Moshe was physically weak at the end of his life, this wasn’t in fact the case, as is evident from the Pasuk in Vezos haBracha that attests (Devarim 34:7) that when Moshe Rabbenu died at the age of 120 years, “his eye[sight] had not dimmed and his vigor had not diminished.[1] Nowadays, although average life expectancy has risen drastically and many live well into their nineties, they are often afflicted by illness, deterioration in their cognitive functioning, and the onset of dementia or Alzheimer’s disease.

 

The early stages of Alzheimer’s disease are characterized by memory loss, diminished spatial orientation, and impaired ability to think clearly and draw conclusions. At a later stage, motor skills are also affected and many patients require around-the-clock nursing care.

 

The Poskim discuss a wide range of questions[2] regarding Alzheimer’s patients, including whether the patient is considered a Shoteh, particularly in the early stages of the disease. These are weighty questions that are beyond the scope of this essay. We will focus on those patients who would definitely be considered Shotim and the approach that their caregivers should take with regard to their patient’s fulfillment of Mitzvos.

 

There are three main questions to consider:

  1. Does a Shoteh have any obligation to fulfill Mitzvos?
  2. Must his caregivers prevent him from sinning if he is inclined to do so?
  3. May his caregivers provide him with forbidden items?

 

An actual Shoteh has no obligation to fulfill Mitzvos. He may eat and drink on Yom Kippur, and others are not obliged to prevent him from doing so. Nevertheless, HaGaon Rav Asher Weiss Shlit”a (Minchas Asher 2:48) maintains that although Beis Din cannot punish a Shoteh for any of his misdemeanors or sins, in Heaven, where all matters are known, a Shoteh will be judged in accordance with the extent of his intellect. Therefore, if he is capable of understanding some of the Mitzvos, he is expected to fulfill them and we may not tell him otherwise. If he will observe the fast of Yom Kippur if instructed to do so, we must instruct him to fast.

 

However, as stated, if a Shoteh begins eating or drinking on Yom Kippur we have no obligation to stop him, for ultimately his actions stem from his inability to remember or recognize that eating and drinking are forbidden. Therefore, one needn’t prevent an Alzheimer’s patient from eating on Yom Kippur as he only does so because he does not appreciate what day it is.

 

The question of whether caregivers may actively provide forbidden items (such as food on Yom Kippur) to Shotim is a more complex issue. In the advanced stage of Alzheimer’s disease, when the patient needs to be fed by others, would his caregivers be permitted to feed him on Yom Kippur since he would not actually be endangered by fasting?

 

In general, it is forbidden to feed a person forbidden food. This prohibition is known as Sefiya. Chaza”l explain that the Pasuk which forbids ingesting Sheratzim (“creeping animals”, including insects and bugs) – “Lo Sochlum” (“do not eat them”), can also be read “Lo Sa’achilum” (“do not feed them [to others]”), thus prohibiting adults from feeding Sheratzim (or other forbidden foods) to children (Yevamos 114a). Whether the prohibition of Sefiya is a mi’d’Oraysa or mi’d’Rabbanan is a matter of discussion, but all the Rishonim agree that it applies to all of the Issurim in the Torah[3].

 

Most Poskim agree that the prohibition of Sefiya is not limited to placing forbidden food into a child’s mouth, but applies equally to instructing or commanding him to eat it. However, some contend that this is only an Issur d’Rabbanan (even if actively feeding him is an Issur d’Oraisa).[4]

 

Aside from the Issur of Sefiya to a child, the Rishonim and Acharonim also discuss whether there is an Issur of Sefiya to a Shoteh. The Rashba (Gittin 55a) holds that Sefiya does apply to a Shoteh as does Rabbenu Yerucham (18:3, cited by the Beis Yosef Y.D. 157:3). This is also the conclusion of the Shulchan Aruch (O.C. 267) who discusses whether a person who is traveling on Erev Shabbos and will not reach the city in time for Shabbos should place his purse of coins on his donkey or hand it to a non-Jew, child or Shoteh. The Shulchan Aruch rules that if it is a question of an Issur d’Oraisa, he may not hand the purse to a child or Shoteh because of the Issur of Sefiya. (See Se’if 6 ibid. and Mishna Berura ad. loc.) This matter is also discussed extensively by the commentators on the Shulchan Aruch in Orach Chaim 343 – see the Pri Megadim ad. loc.[5]

 

However, others contend that there is no Issur d’Oraisa of Sefiya to a Shoteh. The Shivas Tzion[6] (4) explained that Sefiya only applies to a child, as he will ultimately become obligated in Mitzvos when he reaches adulthood. Therefore, one should not cause him to violate prohibitions even while he is a minor and not yet obligated. A Shoteh, by contrast, is unlikely to be suddenly cured and obligated in Mitzvos. Therefore, Mitzvos are of no relevance to him and there is no Issur Sefiya. Moreover, according to the Chasam Sofer (O.C. 83 & Yevamos 114a), the reason for the Issur of Sefiya is to avoid a child becoming accustomed to transgressing Issurim. This is not a concern regarding a Shoteh who will likely never be required to avoid Issurim.

 

Regarding fasting on Yom Kippur, the same distinction can be drawn between a child and a Shoteh. In fact, according to some Poskim, there is no Issur of Sefiya to a child on Yom Kippur at all because he has absolutely no obligation to fast.[7] It is only regarding Issurim such as Neveila (meat of an animal that has not been ritually slaughtered) which will never be considered a “permitted item” that the Issur of Sefiya applies.

 

The Shu”t Zichron Yosef [8](6) suggests two reasons why there is no Issur of Sefiya to a child on Yom Kippur.  Firstly, food on Yom Kippur is not an inherently forbidden object – it is only forbidden because of the restrictions of the day. Since those restrictions do not apply to a child who has no obligation to fast, there cannot be an Issur of Sefiya. Secondly, it may be dangerous for a child to fast and it is self-evident that there cannot be an Issur of Sefiya in a case of Pikuach Nefesh.

 

The question of Sefiya to a Shoteh on Yom Kippur will depend on these two approaches. If there is no Issur of Sefiya when the person in question has no obligation to fast, the same will be true of a Shoteh. But if it is a question of Pikuach Nefesh then perhaps there would be an Issur of Sefiya to a Shoteh who, unlike a child, is not always endangered by fasting.[9]

 

The Chelkas Yoav (1, O.C. 1) adds an additional reason why the Issur of Sefiya to children does not apply on Yom Kippur. Since the Torah says that the reason for afflicting oneself on Yom Kippur is for atonement, and children are exempt from Mitzvos due to their immature intellect and therefore have no need for atonement, there cannot be an Issur of Sefiya. The same would apply to a Shoteh.

 

One further explanation is offered by the Chachmas Shlomo (Gilyon Shulchan Aruch 611). The Mitzva of afflicting oneself on Yom Kippur is defined as avoiding eating or drinking that leads to “Yesuvei Da’ata” – calmness and composure of mind. The Chachmas Shlomo contends that since a child does not have “Da’as” (intellect), he cannot have Yesuvei Da’ata by definition, therefore, there is no Issur to feed him on Yom Kippur. Rav Yitzchak Zilberstein Shlit”a notes that the reasoning of the Chachmas Shlomo would apply to a Shoteh as well.

 

However, as Rav Zilberstein notes, the explanation of the Chachmas Shlomo is difficult to understand. The concept of Yesuvei Da’ata surely has nothing to do with intellect, as the Torah certainly did not command a person to be bereft of his intellect on Yom Kippur! Rather, an absence of Yesuvei Da’ata refers to the feelings of hunger (that tend to confuse a person) which are also experienced by a child or indeed a Shoteh.

 

Rav Zilberstein concludes that since there are reasons to forbid Sefiya to a Shoteh on Yom Kippur, a person who is caring for an elderly senile person (who is considered a Shoteh) should not actively feed him on Yom Kippur. Instead, he should set the food out before the onset of the fast and allow the patient to take the food and feed himself. If he is unable to do so, a non-Jew should be hired feed him.

 

Rav Moshe Sternbuch Shlit”a (Teshuvos v’Hanhagos 4:150) also discusses the question of feeding an Alzheimer’s patient on Yom Kippur. He notes that although there may be an Issur of Sefiya to a Shoteh in general, an Alzheimer’s patient who is not cognizant of Yom Kippur at all and “doesn’t know his right from his left” is in a lesser state than the average Shoteh. In fact, he is similar to a baby and his acts are akin to “Misaseik” (wrought with no intention whatsoever), and eating on Yom Kippur is not even a “Nidnud Issur”. The Issur of Sefiya does not apply to a person in this state, though one should still not feed him forbidden foods such as Neveila or blood.[10]

 

Furthermore, a Shoteh may not be capable of communicating to us that he is feeling ill. If we do not feed him (or even if we feed him “Shiurim”[11]), he may be endangered and will not inform others that he needs to eat.

 

Rav Sternbuch concludes that if a decision is taken to feed a Shoteh on Yom Kippur, it is better to hire a non-Jew to do so[12]. If this isn’t feasible, one may be lenient and feed him directly since his condition is unclear and he isn’t capable of communicating how he feels. Rav Chaim Brisker permitted a person with a certain respiratory disease whose condition would be improved by eating to eat on Yom Kippur. In this case too, any change in a Shoteh’s diet may worsen his condition, though a doctor should be consulted in each case, as every case is different.

 

Elsewhere (Teshuvos v’Hanhagos 5:193) Rav Sternbuch adds an additional explanation. He contends that if the person has no enjoyment (“Hana’as Grono”) from eating, it is not considered Hana’ah – and it is as though he is eating in his sleep.  There is only an Issur of eating on Yom Kippur (or of eating any forbidden foods) where there is Hana’as Grono (see Achiezer 3:61), therefore, if a person is not cognizant that he is eating, he is not transgressing and it is permitted to feed him. Though one should refrain from feeding him forbidden foods such as blood or Sheratzim, as they harm the soul even when ingested accidentally or unintentionally, eating on Yom Kippur in this fashion does not harm the soul. The Issur of Sefiya to a Shoteh on Yom Kippur only applies to a Shoteh who is still somewhat cognizant of his acts and who therefore experiences Hana’as Grono.

 

[1] See Rashi s.v. Lo Uchal Od laTzeis v’laVo (ibid.31:2)

[2] For example, the Poskim discuss the extent of the obligation to treat and save the life of Alzheimer patients or others whose intellect is compromised. Rav Moshe Feinstein zt”l (Igros Moshe, C.M. 2:74) writes explicitly, that aside from certain exceptional circumstances, it is clear that one is obligated to treat even those who are in a vegetative state or Shotim and not distinguish between people based on their cognitive state or intellect.

[3] As stated by Rashi (Yoma 78b s.v. Inshi), the Ramban (Vayikra 21:1), Rashba, Ritva, Ran (Shabbos 153b) et al. See also Kovetz Hearos 75.

[4] See Yabia Omer 2, O.C. 13:2 who cites the various opinions in this regard.

[5] See also the Minchas Chinuch in Mitzvos 5:4, 9:4, 11:18, 17:14 & 20.

[6] R’ Shmuel Landau (1750-1834), the son of the Noda b’Yehuda

[7]  See Yoma 82a and Gemara ibid., Rashi ad. loc. and Shulchan Aruch O.C. 616. See also Mishna Berura (ibid. 5) in the name of the Magen Avraham regarding a child who has reached the age of Chinuch.

[8] R’ Yosef b. Menachem Steinhart (1720?-1776), Bavaria

[9] This is the conclusion of the Sefer Mikraei Kodesh (Yamim Noraim, Hearos Harerei Kodesh 43) who notes that the Zichron Yosef did not rule leniently purely based on the first approach but added the argument of Pikuach Nefesh as well which does not apply to a Shoteh.

[10] See Rema Y.D. 81:7.

[11] I.e. small amounts of food and drink (less than the prohibited Shiurim) in intervals that are longer than K’dei Achilas Pras. (See Shulchan Aruch O.C. 618:7-8.)

[12] Rav Moshe adds that he is not certain that hiring a non-Jew is necessarily effective in avoiding the Issur of Sefiya. Perhaps it is still considered Sefiya since one instructed the non-Jew to feed the Shoteh who cannot feed himself, even though the non-Jew is not considered to be one’s Shliach.


Rabbi Yossi Sprung

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