Cardiology, BMWs, and Shabbos

by Rabbi Yair Hoffman

What follows is a halachic discussion about a device that has been described by some cardiologists as the financial equivalent of implanting a BMW in the heart.  Other cardiologists have described it as the financial equivalent of a Tesla implanted in the heart.   The device can be called in layman’s terms, “an Implanted Defibrillator/Pacemaker Combo.”

Regardless as to the debate about actual value, there seems to be a debate as to whether one may walk up numerous flights of stairs with an implanted pacemaker.  The goals of this article is to:

1. Prove that this debate DOES NOT APPLY to the Combo unit
2. Introduce the reader to these devices and
3. Weigh in on the debate about pacemakers and argue that one may even go up numerous flights to go to shul or home.

We will start with the second goal.

What is an Implanted Defibrillator/Pacemaker Combo?

Think of it as a super-smart guardian of  the heart. This special device combines two important heart helpers: a pacemaker that keeps your heart beating at the right speed, and a defibrillator that can give your heart a strong electrical shock if it starts beating dangerously fast or irregularly.

How is it Different from a Regular Pacemaker?

A regular pacemaker only helps when your heart beats too slowly. This combo device does more – it’s like having both a gentle guide (the pacemaker part) and an emergency rescue team (the defibrillator part) inside your body.

How Does Your Heart Usually Work?

Your heart is a muscle about the size of your fist, sitting in your chest behind your ribs. It has its own natural “drummer” called the SA node that tells it when to beat. Normally, your heart beats 60-100 times per minute, pumping blood to your whole body.

When Do You Need This Device?

You might need this combo device if:

• Your heart sometimes beats too slowly (that’s when the pacemaker part helps)
• Your heart is at risk of developing dangerous fast rhythms (that’s when the defibrillator part stands ready to help)
• You’ve had a serious heart problem before
• Your doctor sees signs that you’re at risk for sudden cardiac problems

How Does the Device Work?

1. The pacemaker part watches your heart all the time and sends small electrical pulses to it if your heart beats too slowly
2. The defibrillator part acts like a watchdog, jumping into action with a stronger shock if it detects dangerous heart rhythms
3. Both parts use wires (called leads) that connect to the heart
4. The device’s “brain” is in a small metal box placed under the skin below the collarbone

How is it Put In?

The surgery is similar to getting a regular pacemaker:

• The doctor makes a small cut under the collarbone
• They create a pocket under the skin for the device
• They thread the wires through a vein into the heart
• They test the device to make sure it works properly and then close the cut with stitches

Living With The Device

• You can do most normal activities
• You’ll need regular check-ups
• The battery usually lasts several years
• You’ll get a special ID card to carry
• You should tell your doctors and dentists about your device

GOAL #3 – Weighing in on the Pacemaker Debate

The Question

In the Torah Journal entitled “Me’ir Derech (Gilyon #12) the following question is addressed by Rav Mordechai Gross shlita, the Av Beis Din of Chanichei HaYeshivos in Bnei Brak:

Someone has a pacemaker that does not use electricity all the time, but only does so when effort is needed for regular activities.

The doctor says that if he climbs several flights of stairs, the pacemaker will certainly kick in.  Is it permissible for him to go to a shul that is located on a high floor, or that is up a steep incline?

Also, in general, if the doctor states that whenever the heart rate goes above a certain number the device kicks in –  is he permitted to do that walking which will make him reach that number or is it considered a Psik Raisha of Malacha?

The Stringent View

Rav Mordechai Gross shlita answered that one must distinguish between cases where the doctor specifically states that the pacemaker will definitely kick into action, versus where the pacemaker might kick into action.

The prohibition of use of electricity is only when there is a Psik Raisha that it will happen. If, however, the doctor states that in action X the heart rate will definitely reach the point where the pacemaker will kick in one must be very careful not to do that action.  So if the shul is on a high floor and the doctor says that such a height will definitely cause the pacemaker to kick in – he must daven at home.  Because davening in shul is not a reason that can permit a Psik Raisha to operate an electric device, and according to the majority of Poskim this is considered a Psik Reisha on a Torah prohibition.

Rabbi Tzvi Ryzman shlita, author of the well-regarded Ratz K’Tzvi Actualia b’Halacha (2019; Siman 7 p. 161) comments on this saying that:

This ruling does not align with the words of the Chazon Ish and Rav Elyashiv, who considered an artificial organ implanted in the body to be considered as a part of the body. This is because according to their words, it is clear and simple that an implanted heart in the body becomes part of the body, and there is no doubt that a person whose heart is implanted in them, which is part of their body, is permitted to perform any action that comes to their mind with their body without limitation.

The implication of the author of the Har Tzvi is that according to the opposite view (e.g. that of Rav Asher Weiss in Minchas Asher Vol. II #132) – that an implanted  battery operated device is not considered part of the body – it would be forbidden.

I would like to suggest that even according to the opposite view, there is still significant basis to permit it.  The basis to permit it based upon the combination of the following factors:

1. There is no apparent Tzurah of a Malacha and it is derech halichaso. The electricity is being produced while he is walking normally, but the readily apparent Tzurah of Malacha is absent. Everything is obscured within his body and no one can detect it from outside.  Nor can the patient detect the electricity. The patient can only detect the normalization of things but this is the natural form of the heart function.  The need for Tzurah of a Malacha in order to clearly forbid a Malacha while walking is found in Rav Nissim Karelitz zt”l’s Chut Sheini Volume One 12:3.  And while he employs this rationale for a case where it is not a Psik Raisha, and even when he desires the action, he uses the term “v’gam – and also” which indicates it is an additional rationale and that he is unsure whether there is a prohibition when there is no Tzurah of a Malacha.
2. The Maggid Mishna Hilchos Shabbos 12:2 writes that if the person does not intend to perform the Malacha per se, even if it is happening anyway – there is no violation and the Psik Raisha would be permitted. Many meforshim have qualified this Maggid Mishna as specifically referring to the case of forming a Kli.  But here, that is the very Malacha that may be that is in violation. Makeh b’Patish or Binyan function in that very capacity.
3. The Taz (OC 315:10), according to the Mizhbetzes HaZahav’s explanation views derech halichaso as Misasaik and not a regular violation of a Malacha. Even though this position is rejected by the Mishnah Brurah in 315:3, his view may be employed as a possible snif l’hatir because Tefillah b’Tzibbur is also considered rachamim ninhu and we need it.  As far as returning to his apartment the Shach at the end of Siman 242 in his Klalei Horaah rules that when it is shaas hadchak one may rely on an individual’s opinion – lechatchila – even at the outset.
4. The action being performed is through a sustained double grama. The excess walking is causing the heart to work slower, which is then causing the pacemaker to kick in within milliseconds.  The slowing of the heartbeat does not happen immediately upon the excess walking. There are many Poskim who would permit this.
5. A pacemaker works as a form of mavri’ach ari – preventing the lion from coming. It is the detection of a regular heartbeat that blocks the electricity from coming to the heart. And even though there are Poskim that write clearly that mavri’ach ari is considered as if one is actively doing the malacha – that is only when one flicks a light switch – but here the Choleh is merely walking.     And while it is true that Mavriach Ari is inapplicable when the device is made for that exact purpose – here it only comes into use because he is walking normally.  How do we know that the limitation of Mavriach Ari is even during regular walking?
6. It could very well be that there is a doubt here in that perhaps the opposing view may be correct and we are only following this opinion when there are no other factors. Since we are dealing with a choleh, there is a principle of bemakom choli lo gazru rabanna,

It would seem that based upon the combination of the aforementioned mitigating factors as well as the idea of using multiple snifin – there would be ample room to be lenient even according to Rav Weiss’ view that it is definitively NOT PART OF THE BODY.

Of course, it is highly likely that Rav Reisman and Rav Asher Weiss would agree to these points and that Rabbi Ryzman was just pointing out one particular point.

A freilechin Chanukah to all.

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