A common situation that arises on Shabbos is whether it is permitted to suture a laceration or whether it is preferred to glue the wound instead. What is the better choice on Shabbos, from a Halachic perspective?

שלחן ערוך, סימן ש”מ, הלכה ו
.חוט של תפירה שנפתח אסור למתחו משום תופר

It is forbidden to tighten a running stitch that has loosened because of sewing.
(Shulchan Aruch, Orach Chaim 340: 6)

The forbidden Shabbos violations (melachos) involved in the surgical repair of a wound are:
1) Sewing – תופר
2) Tying knots – קושר
3) Untying knots – מתיר
4) Creating something new (liquid to solid glue) – מוליד
5) Performing the last action to complete an object – מכה בפטיש
6) Building – בונה

Based on this the Nishmat Avraham quotes many differing opinions on whether the act of suturing a wound on Shabbos is either a Torah or a Rabbinic prohibition. There is more room for leniency, of the Shabbos restrictions, if the violation is of Rabbinic origin. However, if the violation is a Torah prohibition, it can only be allowed if there is a clear threat to human life.

The Shemiras Shabbos KeHilchasah (פל”ה הערה סב, Rav Abramsky and Rav Waldenberg state that there is no evidence that suturing a wound is forbidden by Torah law. Rav Zilberstein rules ( תורת היולדת עמוד רי”ג) that the melachos of “sewing” and “building” do not apply to a human being.

Many Poskim hold that suturing a wound on Shabbos is a sofek issur d’oraisa (possible Torah violation) and is thus forbidden. However, one must make a distinction between a wound that has no risk of a life-threatening infection/bleeding and a wound that has a possible risk of life-threatening infection/bleeding. Therefore, a wound may not be sutured by a Jewish doctor unless it is pikuach nefesh (life threatening).

One way to define a possible pikuach nefesh situation is if the wound is deep. This is defined as penetrating the full thickness of skin into the fatty tissue or muscle. A deep wound may need to be sutured in order to stop bleeding or to prevent infection. In such a case, this is considered a medical emergency. Similarly, any actively bleeding wound is pikuch nefesh and immediate care must be given on Shabbos.

Sefer Nishmat Avarham quotes Rav Yosef Shalom Eliashiv’s opinion that it is uncertain if the melacha of sewing applies to the human body and is a sofek d’oraisa, thus it is probably forbidden by the Torah. Rav Eliashiv did not differentiate between the melacha of suturing and the use of adhesive plaster (“steri-strip”) or surgical glue to close wounds; he ruled that they are all forbidden on Shabbos except when there is pikuach nefesh. Rav Eliashiv is uncertain if the melacha of sewing applies to the human body. Nonetheless, since there is doubt of a Torah violation, suturing is therefore probably forbidden by the Torah (ספק איסור דאורייתא לחומרא).

If stitches are needed to prevent an unsightly scar, the wound may be sutured by a non-Jewish doctor. Rav Karelitz (ספר חוט שני ח”ד עמ’ ק”פ) clarifies, that when a Jewish doctor is suturing a wound on Shabbos he can only place the minimal number of sutures needed for pikuach nefesh.

Rav Shlomo Zalman Auerbach (שולחן שלמה ש”מ ט”ו) allows the use of adhesive tape, butterfly tape, steri-strips or glue, since there is no action of sewing. These treatments are not considered sewing actions but rather they prevent the separation of skin.

However, Rav Auerbach was not sure if suturing is forbidden by Torah law, therefore, he only permitted it where there is a danger to life. He explains that suturing is similar to gluing two pieces of paper together, which is forbidden by Torah law as a violation of (תופר) “sewing”. This maybe the same issur when suturing together the skin of a human being. On the other hand, since the two edges of the wound constitute living skin of the same body, they are not separate like two edges of a garment. Prior to suturing, human skin can be considered as already joined together and not two separate entities.

Is glue permitted?

As to the use of adhesive plaster (butterfly, steri-strip) or surgical glue to close the wound, Rav Eliashiv said that he did not differentiate between these techniques and suturing. Therefore, they are all forbidden on Shabbos, except when there is danger to life.

Rav Yisroel Pinchas Bodner writes in Halachos of Refuah, that one should not apply aerosol spray bandages or liquid bandages [glue] on Shabbos, since this is an issur of maka bipatish and molid, since it changes the glue from a liquid to a hard mass. One should therefore preferentially use adhesive bandages instead. However, on Shabbos, one is not permitted to cut a piece of tape to the length needed.

A wound may ultimately heal without sutures, since the wound heals as the edges join together naturally or by secondary intention. Nevertheless, once it has been sutured together, the end result of the suturing is permanent. However, the two edges of the wound constitute living flesh of the same body; they are not separate like two edges of a garment. Thus, as discussed above, a laceration in human skin may be considered as already joined together. Yet, according to Rav Auerbach, this logical deduction is not a sufficient reason to permit leniency when there is a possibility that it is forbidden by the Torah.

Rav Auerbach wrote that adhesive plaster or surgical glue to keep together the edges of a wound is not like sticking two pieces of paper together. One is only juxtaposing the two edges and allowing them to close naturally. However, he did not feel comfortable to permit this, initially. Rav Auerbach told Rav Neuwirth that he still believed suturing is forbidden by the Torah. Later on, Rav Auerbach updated his pesak and stated that he now believes that the use of adhesive plaster (glue) is permitted. This is because the plaster only serves to prevent the two edges of the wound from separating and using it is not considered sewing. Thus, using glue should not be considered “tofer”.
Rav Abba Shaul allows the use of adhesive plaster to close a wound, since this is not like sewing. Whereas, he holds that suturing is like sewing. Thus, his psak is to forbid sewing Shabbos (שו”ת (אור לציון ח”ב פל”ו סע’ ט”ו.

Suturing and knot tying

The Shemiras Shabbos KeHilchasah writes that the tying of double knots during suturing involves setting aside a Torah law for each knot. However, Rav Auerbach is of the opinion that tying surgical knots is not forbidden by the Torah. He does not consider surgical knots permanent; even though, after several days or weeks, the sutures may be cut and removed without undoing the knots.

Are we allowed to add additional sutures on Shabbos to prevent and ugly scar once sutures are being placed b’heter (allowed by Jewish law) to avoid infection?

Rav Auerbach is quoted in Nishmat Avraham allowing this. He compares adding sutures to the halachos of milah on Shabbos, where the Mohel is permitted to remove shreds of skin that are not needed to complete the mitzvah of milah. As long as the Mohel is still performing the milah he may remove shreds of skin that would not render the milah invalid were they to remain.

This is allowed since we are commanded to beautify our mitzvos before Hashem (יו”ד סי’ רסו סע’ ב). When Shabbos laws are set aside in order to save a life, it is permitted to produce a finished act and prevent an ugly scar that may cause shame and suffering in the future. In this manner preventing an ugly scar in a seriously ill patient completes the mitzvah of pikuach nefesh (רש”ש יומא פד:, שש”כ פ”מ פ”ב).

Plastic Surgery

There is a machlokes Poskim if a plastic surgery operation is allowed for improving beauty for marriage purposes or for shalom bayis.

There are those Poskim who allow it:
הגר”מ פיינשטיין בספר הלכה ורפואה כרך א עמ’ שכג
שו”ת אג”מ חו”מ ח”ב סי’ סו
חלקת יעקב ח”ג סי’ יא שו”ת

There are is also an opinion who forbids this:
שו”ת ציץ אליעזר חי”א סימן מא

Rav Yakabovitz writes that even if there is no heter to allow this except for men, there is room to allow this surgery if the wound occurred because of an accident or illness; since it can lead to a serious depression. For example, without the operation a man may not be able to secure a proper job. It is clearly important to be able to work and support a family. Tosafos, in Talmud Shabbos states that ultimate suffering occurs when someone is embarrassed to go out in public:

:תוספות ד”ה בשביל, שבת נ
ואם אין לו צער אחר אלא שמתבייש לילך בין בני אדם, שרי, דאין לך צער גדול מזה.

The Tzitz Eliezer (שו”ת יא:מא), forbids one to undergo plastic surgery, when there is no disease for pain present and entire purpose of the operation is only to enhance a part of the body. He writes that it was not for this purpose that the Torah gave permission to heal. Therefore, one may not allow a surgeon to operate on him for this reason and neither is the surgeon permitted to perform the operation. We should know that there is no artist like G-d and everyone was given the physical form best suited for him/her.

On the other hand, the Chelkas Yaakov (שו”ת ג:יא), permitted a young girl to undergo plastic surgery to straighten and reduce the size of her nose, even though she submitted herself to bodily injury. He explained that we see that the vast majority of patients are cured by these procedures. In certain situations we may take risks based upon the principal of “שמר פתאים ה’ ”, “G-d watches over the simple” .(תהילים קטז:ו)

Rav Moshe Feinstein was asked if a young girl would be permitted to undergo plastic surgery to make her appearance look more beautiful in order to more easily get married (אג”מ שו”ת חושן משפט חלק ב ס”ו) . He quotes the Rambam (הל’ חובל ומזיק פ”ה ה”א), who only forbids causing injury when the purpose is to harm. This does not apply here since the purpose of the injury is to beautify the girl. Therefore, when surgical injury is part of the treatment, it is permissible. Thus, an operation would be permitted for the benefit of a person, even if it does not treat an illness.

Rav Auerbach writes that when plastic surgery is performed for the purpose to prevent shame and suffering caused by a physical defect in ones’ appearance (such as an abnormal nose), surgery is permitted. This is only allowed since the purpose is to remove a blemish. However, if the only reason is for beauty, this type of surgery is not permitted.

Suturing a facial laceration on Shabbos

Rav Neuwirth evaluated a case of a young girl with a deep laceration on her face, on Shabbos, where there was no danger to life. If the wound would not be treated properly, she would be left with an unsightly scar, which would make a marriage proposal later in life difficult. An unmarried girl may suffer from depression later in life, if she remains single.

מסכת קידושין מא.
טב למיטב טן דו מלמיתב ארמלו
It is better to live as two together than to live alone.
(Talmud Kiddushin 41a)

Is it permitted to suture a facial laceration on Shabbos, assuming one will be violating a Torah prohibition?

According to most poskim, a young girl with a facial injury is allowed to undergo Plastic Surgery with the risks of general anesthesia, in order to prevent problems with getting married in the future or shalom bayis.

Rav Shlomo Zalman Auerbach wrote, that one can not violate Torah prohibitions for this purpose on Shabbos. In addition, one can not violate rabbinical issurim on Shabbos in this case. However it is permitted to perform amira linachri, to ask a non-Jewish doctor to suture the wound.

The Shabbos day has healing powers

Harav Mattisyahu Salomon teaches us that the Shabbos day itself has medical healing powers. In the Ten Statements (עשרת הדיברות) we are told to remember the Shabbos day and to sanctify it (זכור את יום השבת לקדשו). The Ramban explains that we are to use the day for hold pursuits ((דבר שבקדושה. On Shabbos we need to feel that we are making a connection with G-d every moment. Faith in G-d (אמונה) and trust in G-d (ביטחון) are intensified on Shabbos.

In the Grace After Meals (ברכת המזון) we add an additional prayer on Shabbos called “רצה”. In the “רצה” prayer we ask G-d that there should not be sadness suffering or sighing on the Shabbos (…שלא תהא צרה ויגון ואנחה ביום מנוחתינו…). We don’t want sadness or suffering on any day not even Sunday. Why do we pray for this only on Shabbos? The Eitz Yosef explains there are times when a person must suffer and have pain and we must let out a sigh. We say to G-d “please, don’t test us on Shabbos”.

We know that it is not the medicine that heals us, but it is G-d. It is the prayers which accompany the medicines that produce the healing effect. We are not allowed to pray for medical healing on Shabbos, as is stated in the Talmud (Shabbos 12b), Shabbos is not a day for crying out ((שבת היא מלזעוק; thus we do not wish an ill person on Shabbos to have a speedy recovery (רפואה שלמה).

Shabbos itself is empowered to heal. When we can feel and trust in G-d, a trust that can only be felt on Shabbos. When we honor Shabbos by not praying for the recovery from illness and show confidence in G-d; we are thereby closer to G-d. In this manner Shabbos brings the refuah! The day of Shabbos itself takes the place of the prayers (תפילות) and all the medical treatments (רפואות) that are prohibited on Shabbos. It is not a deprivation rather it is a special segulah of Shabbos that Shabbos itself can bring about a refuah (שבת היא מלזעוק ורפוא קרובה לבא). We don’t allow ourselves to feel sadness or worry on Shabbos. This realization on Shabbos is what brings the healing (רפואות), because G-d is the source of all salvation and comforts –”כי אתה הוא בעל “הישועות הנחמות.

References:
Nishmat Avraham, Abraham S Abraham MD. Orach Chaim (pages 242-244)
Nishmat Avraham, Abraham S Abraham MD. Yoreh Deah (pages 60-62).
Halachos of Refuah, Rabbi Yisroel Pinchas Bodner. (pages 331-337).

Arie E. Pelta MD
ariepelta@gmail.com
www.drpelta.wix.com/surgeon