Knot on Shabbos: Meleches Kosheir & Medical Practice (3)

{In the past three weeks, we have reviewed the fundamentals of Meleches Kosheir and analyzed several practical ramifications of the Melacha, particularly with regard to medical practice. This week, we will complete our discussion of this fascinating topic with additional Halachic applications.}

Patient Identification Bands

Last week we discussed cable (zip) ties and whether their use on Shabbos violates Meleches Kosheir. We concluded that it is permissible to fasten a cable tie on Shabbos if it will only remain in place temporarily. If it will remain in place for a significant amount of time, it would be an Issur d’Rabbanan, but permissible for the sake of a sick person. If it will remain in place permanently, fastening it may even violate an Issur d’Oraisa.

This week we will discuss identification bands that are widely used by hospitals for their patients and for visitors to certain wards.

In one sense, identification bands are similar to cable ties in that they also cannot be undone and the band must be cut or broken apart in order to remove it. On the other hand, it is generally possible to undo the securement of a cable tie after it has been cut (by pulling the cut end of the tie through the head), unlike that of an identification band. Therefore, there is more reason to consider these bands to be a Kesher Shel Kayama.

Moreover, when bands are placed on patients it  often isn’t known how long they will be hospitalized. Therefore, one could argue that the tag is at least an “intermediate knot” which is usually an Issur d’Rabbanan.

The Shemiras Shabbos k’Hilchasa (40, footnote 82) cites Rav Elyashiv zt”l who rules that attaching identification bands is not a violation of Meleches Tofeir since the two sides of the tag are not combined to become a single entity. However, he doesn’t discuss Meleches Kosheir.

In light of our conclusions regarding cable ties there is good reason to suspect that attaching identification bands may also be an issue of Meleches Kosheir. Since the clasps of patient identification bands are not undone, and the band itself is cut in order to remove it, the attachment may well be considered a Kesher Shel Kayama.

Last week, we cited the opinion of Rav Shlomo Zalman Auerbach zt”l (as quoted in Shemiras Shabbos k’Hilchasa) that if a Kesher is only to remain in place during the Shimush (the use) of the item in question, then it is by definition a temporary Kesher. If so, it should be permissible to tie (or detach) an identification band on Shabbos.

According to the Shiltei haGiborim, any Kesher Amitz (tight knot) is forbidden, even if it is only temporary. This would mean that applying  identification bands on Shabbos should be forbidden. However, we have seen that the Chazon Ish (52:17) considered the opinion of the Shiltei haGiborim to be a Chumra and ruled that one may be lenient where necessary.

Regarding identification bands that are attached upon admission to an inpatient ward, one could argue that the Kesher should be considered temporary since the patient may be discharged on that same day or within a week. On the other hand, it is possible that the patient will remain hospitalized for an extended period, and the Kesher would not actually be temporary.

All things considered, since the Mishna Berura rules that one may be lenient if a Kesher will remain in place for less than a week if necessary, and since the majority of patients do not remain hospitalized for an extended period, one may be attach an identification band to an inpatient upon admission. In fact, the Shulchan Aruch haRav (O.C. 317) writes explicitly that it is permissible to tie a knot Lechatchila if it will certainly not be permanent and it is doubtful whether it will last for a significant amount of time.

The above discussion pertains to identification bands attached to inpatients or their visitors who are expected to remain admitted for some period of time. However, bands that are attached in the emergency room but replaced if the patient is admitted should only be considered temporary. Therefore, if a patient already has a band from the emergency room, it would seem to be preferable to refrain from attaching a new one upon admission to the inpatient ward until Motzaei Shabbos. Although we have explained that the identification bands attached on the inpatient ward are, at best, a Kesher of an intermediate length which would be permissible for the sake of a sick person, it wouldn’t appear to be justified to attach a new one if the original band includes all of the necessary patient information.

One further point to consider is that it is an Issur d’Oraisa of Tofeir to attach a sticker to the band on Shabbos. Therefore, a Shinui should be employed. In fact, a Shinui should also be employed when fastening the identification band on the patient’s wrist. Using one’s left hand would be an adequate Shinui as it makes the task more difficult to perform.

Twist Ties

Twist ties can be undone simply by untwisting them. It could therefore be argued that they don’t constitute a Kesher at all. However, the Rambam (Hilchos Shabbos 8:5) explicitly states that twisting threads together is considered a Kesher since doing so creates a Chibur. If so, it should be forbidden to use twist ties on Shabbos if the Kesher is to remain in place for a significant amount of time. This is the conclusion of the Shemiras Shabbos k’Hilchasa (15:9) who rules that one may not open twist ties unless they were only meant to remain in place for less than a day, or perhaps less than a week.

However, Rav Shmuel Wosner zt”l (8:55) rules that twist ties do not create a Kesher. The Rambam who rules that twisting threads together is forbidden only means to forbid twisting threads to form a single piece of string, for a true Chibur is formed. However, twisting threads around another item without forming a knot is not a Kesher at all, as they can easily be untied. Twist ties are most similar to a bow which is not considered a Kesher, even if it is meant to remain permanently in place, because it can be easily untied.

Sutures

Suturing incisions and lacerations on Shabbos presents an issue not only of Meleches Tofeir but also of Meleches Kosheir. If the knots would ultimately be untied or torn open, they could be considered to be temporary and therefore permissible. However, since sutures are generally not cut through the knot when they are removed, one could argue that the knots should be considered a Kesher Shel Kayama.

The Nishmas Avraham (317) cites two opposing opinions on this matter. Rav Shlomo Zalman Auerbach zt”l held that it is permissible to suture wounds on Shabbos because they will ultimately be cut and are therefore temporary. Rav Elyashiv zt”l held that since the knot itself will remain intact, it is considered a Kesher Shel Kayama and should therefore only be used in cases of Pikuach Nefesh.

The Sefer Minchas Ish[1] (30:62) rules that Lechatchila one should  staple the wound until Motzaei Shabbos, and then stitch it. However, if this isn’t feasible, one may rely on the lenient opinions and suture it on Shabbos itself.

Absorbable Sutures

If a doctor needs to close a wound on Shabbos, is it preferable to use absorbable or regular suture? At first glance, absorbable suture would appear to be preferable because it will dissolve and not remain in place permanently, so it should not be considered a Kesher Shel Kayama.  However, Rav Nissim Karelitz zt”l (Chut Shani, Shabbos 34, p220) makes the case that in fact, knots in absorbable sutures are considered Kesher Shel Kayama because they remain in place throughout the life of the thread. He proves this from the Mishna Berura (317:34) who rules that if a person ties a linen belt to his pants and doesn’t intend to remove it until the belt wears out, it is considered a Kesher Shel Kayama.

R’ Yitzchok Zilberstein Shlit”a (Chashukei Chemed, Shabbos 157b) contends that this matter is subject to a Machlokes Rishonim. The Ra’avad (Hasagos on Rambam Hilchos Shabbos 10:3) maintains that if a person ties a knot in a moist reed it is not considered a Kesher Shel Kayama because it will come apart when the reed dries out. However, the Magid Mishna argues that a Kesher Shel Kayama does not depend on the quality of the rope or string in which it is tied but on the nature of the knot itself. This implies that one can create a Kesher Shel Kayama in a material that isn’t strong or durable. Since the Ra’avad is lenient, the Chashukei Chemed concluded that it is preferable to use absorbable suture on Shabbos as the Ra’avad would not consider them to be a Kesher Shel Kayama.

One could contend that even the Magid Mishna would agree that a Kesher Shel Kayama cannot be formed in a very weak material. He only argued that one needn’t have a very durable material, as the Ra’avad held, but in the case of absorbable suture, even he might agree that it wouldn’t be considered a Kesher Shel Kayama.

Bandages & Patient Restraints

Regarding tying a knot in bandages – if the knot will soon be untied, it is considered to be temporary and therefore permissible. However, a double knot should be avoided as the Rema (317:1) holds that it is considered a “Kesher Amitz” and an Issur d’Rabbanan. One should tie a single knot and a bow which is certainly not a Kesher Uman (see the Rema ibid. 5) and therefore permissible if it is intended to remain tied for only a short time.

If the knot in a bandage will remain in place for a significant amount of time (though not permanently), it is permissible to tie it because one may violate Issurim d’Rabbanan for the sake of a sick person (Mishna Berura 317:29). Ordinarily, when violating an Issur d’Rabbanan on behalf of a patient, one would be obligated to employ a Shinui. However, in the case of tying a knot, a Shinui isn’t required. Just as the Chachamim permitted tying a knot for a person who is in distress, they would similarly permit it for a sick person.

The Shemiras Shabbos k’Hilchasa (35:23) rules that a bandage that will be undone every day may be tied even with a loose double knot. This is the same basis for the Gemara’s ruling that a woman may tie a knot in order to fasten her clothes.

If a bandage will be cut away and the knot itself will remain in place, it is questionable whether it is permissible to tie it on Shabbos in the first place. It is preferable to use a bandage that will ultimately be untied.

Tying patient restraints is likely to be permissible because the restraints will most certainly not remain tied for a significant amount of time. One may therefore use a single knot and bow, or, if necessary, a loose double knot. The Nishmas Avraham (328:20) rules that one may use a double knot Lechatchila since it will be untied that same day.

[1] R’ Avraham Yeshaya Shapira Shlit”a