Rabbi Yosef SprungA relatively uncommon topic within the realm of kashrus pertains to laxatives. These medications are used in various clinical situations to clear the bowels. The primary indication is to facilitate the evacuation of intestinal contents in preparation for medical procedures, including colonoscopy and colorectal surgery. The use of these medications ensures that the digestive tract is sufficiently emptied, allowing for accurate examination and assessment during diagnostic interventions.
In this essay, we will examine these medications in the context of colonoscopy preparation and address questions regarding their kashrus. As part of the discussion, we will also consider additional halachic implications arising from the use of laxatives. The analysis below was prepared by R’ Raziel Fredman, one of the Rabbanim of our Beis Medrash and Halachic Respondent at the Schlesinger Institute.
Preparation for a colonoscopy involves dietary restrictions along with the use of laxative medications. Generally, taking laxatives on Shabbos itself is prohibited – both because their effect detracts from Oneg Shabbos and due to the prohibition against taking medications when one is not a Choleh (see Mishna Berurah 328:40[1]).
Bowel preparation protocols vary among physicians and medical centers and depend on the scheduled time of the procedure.[2] In some cases, laxative solutions (such as Picosalax (sodium picosulfate combined with magnesium salts), Meroken (polyethylene glycol (PEG) with electrolytes), or Moviprep (PEG with electrolytes, sodium ascorbate, and ascorbic acid)) are used only on the day before the examination. A distinction must therefore be made between examinations scheduled for the morning and those scheduled for the afternoon or evening.
When the examination is scheduled for the late afternoon or evening, the first dose of the solution is taken only on the evening before the procedure (around 7 p.m.). Accordingly, even if the examination is scheduled on Sunday, the solution may be taken after Shabbos has ended. However, when the examination is scheduled for the morning, the solution must be taken around midday on the preceding day. If the examination is to take place on Sunday morning, this would require taking the laxative on Shabbos itself. For this reason, one should avoid scheduling a colonoscopy on Sunday morning.
In addition, one must also consider the instruction to refrain from eating solid food for at least twenty-four hours before the examination. If the examination is scheduled for Sunday morning, it would not be possible to eat Seuda Shelishis on Shabbos after Mincha. This is another reason to avoid scheduling a colonoscopy on Sunday morning.
In most cases, laxative tablets (such as Laxadin (bisacodyl, marketed as Dulcolax in the US) are also taken either two or three days before the examination. In that case, even if the colonoscopy is scheduled for Monday, the first tablets would need to be taken on Friday night, which is generally prohibited, as noted above.
Strictly speaking, the prohibition against taking medication applies only when the tablets are taken on Shabbos itself; one might argue that it would be possible to take them shortly before and right after Shabbos. Even so, the laxative effect detracts from Oneg Shabbos. Therefore, when the instructions call for taking laxatives three days before the examination, it is preferable not to schedule the procedure for either Sunday or Monday.
Practically speaking, the primary effects required for bowel preparation are achieved with the laxative solutions (such as Picosalax, as described above). The laxative tablets are generally utilized as a supplement and serve only as an adjunct. In consultation with the gastroenterologist or surgeon performing the procedure, it is often possible to omit at least the first dose of Laxadin. Consequently, there is no inherent objection to scheduling a colonoscopy on a Monday, as long as it is possible to delay the first dose of laxative tablets until after Shabbos.
Kashrus
Laxadin tablets, being hard pills with no taste and unsuitable for regular consumption, may be used for medical purposes without kosher certification. Sources supporting this Kula include Igros Moshe (O.C. 2:92), Shevet haLevi (7:135), Shemiras Shabbos Kehilchasa (33, footnote 1), Sefer haKashrus (21:34), Shevus Yitzchak (17:5), Kovetz Sha‘arei Hora’a 5763, in the name of R’ Avraham Tzvi Israelson, citing his grandfather, R’ Elyashiv zt”l, and others.
However, we must ask whether this leniency should apply when a healthy person is screened without symptoms or concerns of illness. While several factors justify allowing bitter-tasting medications, including having undergone processing, principles of Bitul, and additional doubts, many authorities ultimately base the leniency on two additional points:
The first is the principle of “Achila sheLo k’Derech Hana’aso” – ingesting something in an unusual way. This principle is generally applied only to one who is ill.
The second is that the medication is not fit for human consumption, negating the Isur. In principle, this rationale is not limited specifically to those who are ill. However, many Poskim maintain that this leniency applies only when the substance is taken for medical purposes. When a person consumes something that is not normally edible, he effectively assigns it the status of food (Achshavei), thereby rendering it prohibited. It is only when such an item is consumed for medical purposes that it does not confer such status. On this basis, this leniency would not apply to vitamins, which are taken for nutrition or as food substitutes (see Shevus Yitzchak, ibid. 6).
In our scenario, we are dealing with a healthy individual who is ingesting a possibly forbidden substance for medical purposes. The Heter depends on the precise reason as to why Achshavei does not apply when a substance is taken for medical reasons.
Some explain that the person’s illness itself designates the substance as Refua rather than Achila. Whether this applies in our case could be a matter of debate. Nevertheless, the prevailing implication of the majority of Poskim is that the very fact that the substance is taken for medical purposes prevents the application of Achshavei, since it is not ingested as food but as Refua (see Igros Moshe ad loc., the rulings of R’ Elyashiv cited above, and Chazon Ish, Y.D 116:8). On this basis, the use of laxatives may be permitted in our case as well.
Regarding the laxative solutions, these are drunk in a normal manner and, in some cases, have a pleasant taste, making the potential Kashrus issues more serious. Inquiries conducted with Kashrus experts and a review of the ingredients indicate that there are significant differences among the various preparations, which may be ranked as follows (from most problematic to least):
Orange-flavored Picosalax is the most problematic. This solution contains lactose, which may present a Chalav Akum issue, although many are lenient on this point (see the extended discussion in Alehu liTerufah, pp. 117 ff., and last week’s essay). In addition, the product contains natural flavorings, which are often dissolved in alcohol or produced using acids derived from wine. As a result, there is a concern of Stam Yeinam, along with additional Kashrus concerns commonly associated with natural flavoring agents.
Forest Fruits-flavored Picosalax: This solution does not contain lactose but does contain “natural flavorings”; thus, there remains uncertainty about the solvents and other ingredients.
Moviprep and Meroken (preferable from a Kashrus perspective):
These solutions do not contain dairy ingredients, and their flavoring agents (usually lemon-flavored) are made with artificial sweeteners. As a result, they raise fewer Kashrus concerns. In addition, due to their high salt content, they are difficult to drink. This strengthens the basis for classifying them as a “Davar Pagum”, such that drinking them is considered sheLo k’Derech Hana’ah.
The above is true from a Kashrus perspective. From the patient’s perspective, however, the opposite is true. Picosalax is generally considered easier and more convenient, both because it requires a smaller volume of liquid and because its taste is more tolerable. By contrast, Meroken and Moviprep are less pleasant due to their salty taste and the need to drink large volumes of the solutions.
As a practical Halachic ruling, it appears that a distinction should be drawn between different categories of patients:
When the examination is performed due to a positive fecal occult blood test, a previous finding of polyps, or a family history of disease, there are grounds to view the procedure as a matter of Safek Pikuach Nefesh. Even when the risk is remote, the principle applies that in matters of Pikuach Nefesh, we do not follow the Rov (statistical majorities). The Poskim explain that whenever people ordinarily flee from a given risk as they would from danger, it is considered a case of possible Pikuach Nefesh.[3]
However, even in cases involving potential danger, the rule remains that “haKal Kal Techila” – the least-problematic Halachic option should be given precedence. Therefore, when possible and in coordination with the gastroenterologist or surgeon who will be performing the procedure, preference should be given to Meroken or Moviprep. However, if it will be difficult to consume these solutions and there is a concern that the preparation will be incomplete, leading to a compromised examination or procedure, the patient should take Picosalax. In such a case, one could add a substance such as salt to make it less palatable.
When the colonoscopy is performed solely for screening, without prior symptoms, findings, or other medical indications, it is difficult to classify the patient as a Choleh sheYesh Bo Sakana or even as a Choleh she’Ein Bo Sakana. Accordingly, greater stringency should be applied to Kashrus laws, and he should specifically use either Meroken or Moviprep. If this is not feasible, a Rav should be consulted to evaluate whether there is room to permit the use of Picosalax (with reduced palatability as above).
In conclusion:
- It is preferable to avoid scheduling a colonoscopy on Sunday to preserve Oneg Shabbos and eliminate the necessity of taking medication during Shabbos. However, if the examination is urgent or no other options are available, scheduling it for Sunday may be considered.
- When laxatives need to be taken near Shabbos, they should be used before Shabbos begins and after it ends.
- Individuals who use laxatives should recite the blessing Asher Yatzar after each instance of using the restroom, except when they continue to experience a need for further relief.
- Regarding the available laxative solutions, Meroken and Moviprep are preferred from a Halachic standpoint. However, when the examination is indicated for medical reasons, there is room for leniency and the use of Picosalax. It is advisable to reduce its palatability when possible.
- Laxadin tablets are permitted for use.
- As always, any changes to the prescribed protocol must be approved by the treating physician.
Tefila and Hoda’ah
Before undergoing a medical procedure, one should Daven: May it be Your will that this act be for my Refua, for You are a gracious Healer” (Shulchan Aruch, O.C. 4; Mishna Berura ad loc.) This should be said before a colonoscopy or any other procedure.
After a medical intervention, one says, “Blessed is the Healer of the sick” (ibid.). A colonoscopy sometimes includes a therapeutic procedure during the examination (e.g., a polypectomy). When the procedure included such treatment, this expression of thanksgiving should be recited afterward.
[1] The laxatives during the time of the Mishna Berura (“Shemen Kik” and “Melach Angli”) were much harsher on the stomach than the laxatives of today. Nevertheless, today’s products still constitute Refua and are detrimental to Oneg Shabbos.
[2] [Editor’s note: This essay was written in Israel and references medications and issues (e.g., scheduling elective procedures on Sunday) that are common there but may not be identical or relevant in Chutz la’Aretz.]
[3] See Minchas Shlomo 2:69.
Rabbi Yosef Sprung
