Q: My doctor has told me that I have sleep apnea, and advised me to use a sleep apnea machine. Can this device be used on Shabbos?
A: Sleep apnea is a disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep. Obstructive sleep apnea, the most common form of the disorder, is caused by the relaxation of the walls of soft tissue in the airway of the throat during sleep. Common symptoms include loud snoring, restless sleep, and daytime sleepiness. Sleep-disordered breathing is associated with an increased risk of cardiovascular disease, stroke, high blood pressure,arrhythmias, diabetes, and sleep deprived driving accidents.1 Recent studies have shown that sleep apnea affects about 16% of men and 5% of women between 30 and 65 years of age.2
Untreated obstructive sleep apnea can have life-threatening consequences. Upon comparing men with sleep apnea to similar men without sleep apnea, one study found that the apnea patients were two and a half times more likely to develop diabetes over a six year period. Another study found that apnea patients were five times more likely to have serious car crashes. Data from further studies strongly suggest that obstructive apnea significantly contributes to the development of cardiovascular disease.3
For moderate to severe sleep apnea, the most common treatment is the use of a continous positive airway pressure (CPAP) device. The patient typically wears a plastic facial mask connected by a flexible tube to a small bedside CPAP machine, which generates the required air pressure to keep the patient’s airways open during sleep. The CPAP machine delivers a stream of compressed air via the hose to the mask, splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible, reducing and/or preventing apneas. The CPAP machine assists only inhaling, whereas a Bipap machine assists with both inhaling and exhaling and is used in more severe cases.4
There are a number of halachic issues involved regarding the use of a CPAP machine on Shabbos. Firstly, the machine needs to be turned on. Obviously, a person can either turn on the machine before Shabbos or activate it on Shabbos by means of a time clock. However, many CPAP machines do not generate the required air pressure until the face mask is actually worn. Although the user turns on the machine before Shabbos, he only causes the machine to generate the required air pressure when he subsequently puts on the mask during Shabbos. Furthermore, when he puts on the mask, he may cause lights on the CPAP machine to change color and may also affect the digital display on the machine. A number of contemporary Poskim say that, while these activities are forbidden m’derabonnon (Rabbinically) on Shabbos, they are not prohibited m’deoraisa (according to the Torah).5 The question therefore arises, ‘Can a person perform an issur derabonnon on Shabbos in order to treat sleep apnea?’
As is well known, the requirement to save someone with a life-threatening medical condition overrides the prohibition of melacha on Shabbos. Although untreated sleep apnea can lead to life-threatening illnesses, it is not obvious that the use of a CPAP machine on Shabbos would be permitted. This is due to the fact that any one particular night of sleep apnea may not be life-threatening, depending upon the patient’s condition. It may be that only the cumulative effect of many nights of sleep apnea may lead to life-threatening conditions. Therefore, for some patients, forgoing the use of a CPAP machine on any one Shabbos will not be life-threatening, but forgoing the use of a CPAP machine on every Shabbos of the year will statistically increase the risk of life-threatening ailments. Is one allowed to perform a melacha on Shabbos for a condition which is cumulatively life-threatening?
Rav Heinemann shlit”a contends that a condition which is cumulatively life-threatening is certainly no less severe than a condition of incapacitating illness. Therefore, a person with sleep apnea can certainly do anything on Shabbos which would be allowed for a choleh kol gufoh. A choleh kol gufoh may ask a non-Jew to perform a melacha on his behalf on Shabbos.6 Thus, a person may ask a non-Jew to activate a CPAP machine on Shabbos. However, it is impractical to ask a non-Jew to do this every time a person sleeps on Shabbos.
A Jew is permitted to carry out an issur derabonnon with a shinui (in an irregular way) on Shabbos for a choleh kol gufoh.7 Therefore, a person would be allowed to activate a CPAP machine by putting on the mask on with a shinui. However, it is difficult to find an appropriate shinui for this activity. The Chayei Odom8 states that if it is not possible to use a shinui, one is allowed to perform an issur derabonnon for a choleh kol gufoh. Based on this ruling of the Chayei Odom, Rav Heinemann paskens that a person may use a CPAP machine on Shabbos.
Philips Respironics has informed me that at the highest setting, the water in the humidifier may reach 125oF, and the hot plate which is heating the water may reach 158oF. Water should not be heated to this temperature on Shabbos, as the temperature is above the shiur of yad soledes bo. Therefore, the humidifier should be used only on Shabbos at a lower setting which will keep the water temperature below yad soledes bo, or the humidifier should be turned off for the duration of Shabbos. Some CPAP machines record information concerning the patient’s sleep patterns onto a chip, which can subsequently be brought to a medical professional. Rabbi Heinemann paskens that there is no need for the patient to remove this chip before Shabbos.9
ResMed has informed me that some models of the CPAP machines, which generate the required air pressure when the mask is worn, also have a setting to enable the machine to generate the air pressure as soon as it is turned on. Switching to this setting will allow the patient to use the CPAP machine with a time clock. The user manual should be consulted to ascertain whether or not this is an option. CPAP machines made by Respironics are activated only when the mask is worn.
In conclusion, a person who has sleep apnea should discuss with his doctor which CPAP machine would be medically best for him. If he is presented with a choice of machine models, he may want to discuss with his Rabbi which of them will best minimize the halachic issues of Shabbos use. He should use the CPAP machine on Shabbos, and he should do what he can to minimize the halachic issues of Shabbos use.10
5.ידוע דעת הגרש”ז אויערבאך זצ”ל בשו”ת מנחת שלמה ח”א סי’ יא שהשימוש בחשמל בשבת אינו אסור מדאורייתא כל שאינו מוליד אש וכמש”כ בשו”ת בית יצחק יו”ד מפתחות לסי’ לא, וגם כתיבה במחשב אינו חשוב כתיבה מדאורייתא לדעת הגרשז”א הובא בנשמת אברהם ח”ד או”ח סי’ שמ ס”ק א, ובפרט כאן שהוא כתב שאינו מתקיים, ועי’ כעי”ז בחזו”א או”ח סי’ סא ס”ק א שכתב שע”ג צידי הדפים חשיב כתב שאינו מתקיים כיון שהספר עומד להפתח ולהסגר
6.מ”ב סי’ שכח ס”ק מז
7.מ”ב סי’ שכח ס”ק נז
8.חיי אדם כלל סט סעי’ יב, ועי’ מ”ב שם ס”ק קב וס”ק קכא
9.שמעתי ממו”ר ר’ היינעמאן שליט”א
10.עי’ ג”כ מש”כ ר’ מדרכי הלפרין (מנהל מכון שלזינגר ועורך כתב העת אסיא) – http://www.medethics.org.il/DB/showQ.asp?ID=4063 , ועי’ ג”כ במכון צמת – http://www.zomet.org.il/_Uploads/dbsAttachedFiles/cpap-medtechnica-2-f%281%29.pdf
Thanks to sleep-disorder specialist Dr. Arthur Turetsky, Kevin Rush of Respironics and Lori Bellis of ResMed for their assistance in the preparation of this article