How to facilitate the swallowing of a pill on Yom Kippur

Question:

What is the proper method for administering a Halachically mandated pill on Yom Kippur? Specifically, is it permissible to ingest medication using a minimal quantity of water, and if so, what constitutes an acceptable limit? In cases where water use is not allowed, should the pill be taken solely with saliva, or may alternative substances such as bitter tea or salt water be used? Furthermore, is it permissible to dissolve the pill in water to produce a bitter solution?

Answer:

First off, it is recommended to consult with a qualified rabbi or healthcare professional before taking, or not taking, any chronic medication on Yom Kippur. If the medication is determined to be necessary and permitted under Jewish law due to illness, pain or medical condition, several alternatives exist to assist with swallowing the medication. Notably, the use of plain water for this purpose is prohibited except in cases where the pill is required to prevent a life-threatening situation (Pikuach Nefesh), and when none of the following alternatives are feasible. Below is a list of permissible alternatives for swallowing medication without using plain water listed in order of precedence and halachic preference:

• Best option – Saliva:

In cases where taking a pill is medically necessary and permitted, the most Halachically acceptable method to facilitate swallowing the pill is through using one’s saliva. To swallow a pill with saliva alone, first moisten your mouth thoroughly to prevent dryness. Place the pill on your tongue and tilt your head slightly—forward for tablets, backward for capsules—then swallow firmly as if taking a sip of water. If it doesn’t go down easily, wait a moment, build up more saliva, and try again without forcing it.

• Second best option – Bitter water – Through dissolving pill:

If one is unable to swallow the pill with saliva alone, such as if the pills are large, or one has swallowing difficulties, or a dry mouth, then he can swallow the pill using a small amount of bitter water. The easiest way in making the water bitter is through dissolving the pill inside of the water. This can be achieved through crushing the pill before Yom Kippur and adding it to the water, or even through simply leaving the pill in the water for several seconds until it begins to dissolve and give the water a bitter taste. While this method is halachically permissible, it may not always be clinically advisable for every pharmaceutical product. Certain medications can be safely crushed or dissolved; however, others—such as extended-release or enteric-coated formulations—must not be altered, as doing so can compromise their pharmacokinetics or cause adverse effects. Such tablets are designed for gradual or targeted release and may not function properly if manipulated. Therefore, it is essential to review the labeling on the drug and/or consult with a pharmacist or healthcare provider before consuming medication in a dissolved form.

• Third best option – Bitter water – Salt water, bitter tea, soap, ash, and more:

In the event that drug may not be dissolved prior to ingestion, as per its instructions, and it is also not feasible for the individual to swallow it using plain saliva, then the following alternative method can be used to make the water bitter. One can add a substantial amount of salt to a small amount of water hence making the water very salty and undrinkable. An alternative to salt is baking soda. This fulfills the criteria for making the water bitter, which allows it to be used for the sake of ingesting the pill. Alternatively, one can soak several teabags of black tea in a small amount of water, hence achieving that the water is bitter and undrinkable. This bitter tea essence may then be used in limitation for the sake of facilitating the swallowing of the pill. With regards to both of the above methods, it is best to prepare these bitter waters prior to the start of Yom Kippur in order to avoid any potential prohibitions of doing so on Yom Kippur itself. Another option, which we offer as a last resort due to the general apprehension of doing so, is to add a slight amount of soap to the water hence making it even slightly inedible, and using this soapy water to drink down the pill. All in all, anything that will make the water bitter even slightly is valid to be used, and hence if one has bitter herbs in his pantry closet. Quinine drops is a bitter compound extracted from the bark of the cinchona tree, which is commonly found in small amounts in tonic water, giving it its distinct bitter taste. If you want to make water bitter, adding a few drops of tonic water may be a simple and effective method. Another method of making the water bitter that is recorded in the Poskim is through adding ash to the water. This can be accomplished by making ash before Yom Kippur by burning any substance, and then adding the ash to the water.

• Last resort – Plain water:

As a last resort if none of the above options are available or practical, then if the medication is deemed necessary due to a situation potential Pikuach Nefesh, and even plain water may be used to facilitate its ingestion. However, if the medication is not being taken for a potentially life-threatening condition, then even if it is taken to prevent non-threatening illness or acute debilitating pain, nonetheless, there is no allowance to ingest it using plain water.

Explanation:

Taking a pill on Yom Kippur enters into two possible prohibitions, the more severe one being the prohibition against eating and drinking, and the less severe one being the general rabbinical prohibition against taking medicine on Shabbos. Practically, the Poskim explain that the swallowing of an inedible pill or the consumption of a bitter inedible pill, is at most a rabbinical prohibition of eating on Yom Kippur [and according to some opinions not forbidden at all], and is waived for the sake of a medical need, such as for a person who is sick, bedridden, or if he is weak in his entire body even though it is not a life-threatening situation. Likewise, the rabbinical prohibition against taking medicine on Shabbos is waived in these cases that a person who is sick, bedridden, or if he is weak in his entire body. Furthermore, even if one is not sick, but not taking the pill can cause him to get sick, then the rabbinical prohibition is waived.

This allowance, however, only applies to the medication itself, however any food or liquid that one desires to consume together with the medication is strictly forbidden unless they too are deemed necessary due to potential Pikuach Nefesh. This creates a serious problem with regards to ingesting the medication which is typically swallowed down using water, and cannot be done on Yom Kippur due to the reason explained above.

The best alternative then is to try to swallow the pill using ones saliva, as we explained above in the main article. If this is not feasible, which is often the case for many people, then the only choice left is to facilitate that the water used to swallow the pill is bitter, and hence it itself becomes demoted from its biblical prohibitory status to a mere rabbinical prohibition which can be waived for the sake of medicine for the ill.

Now, as to the million-dollar question, how can one achieve making the water bitter? So, the best method to do so is by using the pill itself, by either crushing it or dissolving it into the water. This process not only results in the water acquiring a bitter taste, but also transforms the water into the medicinal agent itself, hence making the water part of the medication which is permitted to be taken. This option however is limited to only those drugs that are permitted to be ingested in a dissolved form as per their label and/or pharmaceutical instructions. However, for those pills which may not be dissolved prior to ingestion due to the reasons we explained above in the main answer, one must resort to other methods of making the water bitter.

Numerous alternative approaches for rendering water as bitter are documented in Poskim, though many of these methods are considered impractical or raise apprehension in people. For example, some suggest placing earth or ash into the water for the sake of making it inedible. Others suggest adding soap to the water. Others recommend adding a bitter herb, or Quinine drops into the water which is not something that every person has available. Accordingly, some leading authorities suggest a more practical option such as making bitter tea essence or very salty water. The downside of this option is twofold: 1) Whenever the water itself is not part of the medication, even if bitter, it becomes a secondary substance that is not intrinsically required for the illness which may be subject to rabbinical restriction. 2) Specifically, in the recorded option of using teabags or salt, aside for not being recorded in the classical Poskim, in truth, these are considered foods that people regularly eat, and are biblically forbidden to be ingested on Yom Kippur. [Certainly, one who drinks tea or coffee without sugar transgresses a biblical prohibition on Yom Kippur even if it is bitter. Likewise, according to Halacha a regular blessing is recited over salt and saltwater, hence proving that it is edible according to Jewish law.] Hence, in order to escape this problem one would need to add a large amount of salt to the water until it is inedible, and seep enough teabags in the water until it is so bitter that no one would drink it. While this is feasible, it is not our first choice, and hence our first-choice recommendation is to dissolve the pill, as we explained.

Sources: Encyclopedia Hilchatit Refuit Erech Yom Kippur Volume 3 p. 794; See regarding the general allowance for taking pills on Yom Kippur for one who is ill or to prevent an illness: Sdei Chemed Yom Kippur 3:8; Yeshuos Yaakov 612; Kesav Sofer 111; Pischeiy Teshuvah Y.D. 155:6; Shoel Umeishiv Mahdura Daled 1:55; Orchos Chaim 618:1; Eretz Tzevi 88; Kaf Hachaim 554:34 in name of in name of Kesonos Yosef 4, Ikarei Hadaat 29:36, Pischei Olam 554:6 regarding regular fast days; Meishiv Shalom 179; Igros Moshe 3:91; Tzitz Eliezer 10:25; Shevet Halevi 10:89; SSH”K 39:8; Nishmas Avraham 612:7; Toras Hayoledes 52:9 footnote 27; Piskeiy Teshuvos 612:2; Nitei Gavriel 37:23; 39:12-15; Encyclopedia Hilchatit Refuit Erech Yom Kippur Volume 3 p. 794; See regarding crushing the pill and drinking it with water: Kaf Hachaim 554:34 in name of Poskim regarding Tisha B’av; Heard from Rav Yaakov Yosef that the same applies on Yom Kippur, and so seems Pashut; Nishmas Avraham 5 612:2; SSH”K ibid; Piskeiy Teshuvos ibid; Nitei Gavriel ibid; Encyclopedia Hilchatit Refuit Erech Yom Kippur Volume 3 p. 795 footnotes 340-343; See regarding entering soap into the water: Rav SZ”A in Nishmas Avraham 612:6 p. 724; Encyclopedia Hilchatit Refuit Erech Yom Kippur Volume 3 p. 794; See regarding entering salt into the water: Ruling of Rav Wozner a”h, the Shevet Halevi, printed in Asia medical journal Vol. 109 p. 9. See regarding entering teabags or baking soda into the water: Or Letziyon 3:29-11 regarding Tishe Beav