Long COVID and Yom Kippur

Dear Rabbi Klapper,

I had COVID last November, and have been enduring “long-COVID” ever since. Thank God, I feel that overall I am improving. However, I have “flares” in which I experience fatigue, chest pain, and shortness of breath, and I cannot ever exercise for more than 10-minute increments (which more than I was able to do just a few weeks ago, and vastly more than many with long COVID). I do not take care of my children alone, and I don’t read chapter books aloud to children because that causes shortness of breath. When I received my second COVID vaccine, I experienced a 3-week setback. While I have not experienced much post-exertional malaise in several months, that is probably because I have been so careful. I am very scared to test my body.

I have never been a good faster. When I fasted on Yom Kippur while nursing, it took me several days to recover even though I was otherwise healthy and spent the whole day in bed.  One of the things I do to manage my illness is eating small quantities and drinking large quantities throughout the day. I fear that fasting on Yom Kippur this year would set me back for weeks at least.

Can you tell me how my situation affects my obligation to fast? I encourage you to publish a response as well. I think many people are in situations similar to mine, but either unwilling to ask or don’t think there’s a real question here.  With great appreciation,  Jane Doe

Dear Jane,

There is certainly a real question, and also a widespread impression that asking rabbis about it is pointless or counterproductive. I hope that my answer justifies your courage and confidence. Let me also wish you a refuah shleimah umeheirah along with all others suffering from COVID.

Here’s a brief statement of what it seems medicine can say with some confidence about Long COVID: Long COVID sometimes involves measurable damage to specific organs such as the lungs or heart, but in most cases all we can identify are symptoms. Regular eating and drinking are a standard mode of mitigation symptoms, and deviations from that routine can cause regressions for an extended period of time. If patients were not hospitalized during the initial infection, there is very little chance of a relapse leading directly to death.

Therefore, if the standard for allowing eating on Yom Kippur is that fasting would significantly increase one’s chance of dying in the short term, or even within the next year, then long COVID probably would not qualify for any leniency. This is true with regard to both eating/drinking normally and the strategy of “shiurim” (eating/drinking less than the amount that generates the punishment of karet), since we rule, following Rav Yochanan against Resh Lakish (Yoma 74a and others), that eating less than the amount necessary for punishment is still Biblically prohibited, and the source for violating any Biblical prohibition is וחי בהם = “and live by them – not die by them”.[1]

However, that is not the correct standard. The consensus position, articulated specifically by Rav Velvel Soloveitchik (GRYZ), is that “and live by them” applies to anything that has a halakhically significant impact on lifespan. Safek pikuach nefesh extends to the extremely long term.

However, there is no statistical or objective empirical basis for determining the effect on overall lifespan of a new and poorly understood condition, let alone for whether fasting will meaningfully affect that effect. We are roughly in the same scientific position as all our predecessors with regard to such conditions. Once a person is plainly ill, our fundamental criterion is how they feel. The halakhic challenge is to articulate a standard that either enables a person to determine for themselves whether their subjective experience warrants eating on Yom Kippur, or else enables a posek to evaluate the patient’s expression of how they are feeling.

What is the halakhic standard?

Mishnah Yoma 8:5-6 states that an ubrah (=pregnant woman) who experiences a food craving on Yom Kippur must be fed “until her nefesh is restored”, and a person in the throes of a fit (=bulmus) must be fed even nonkosher food “until their eyes light up”. A Talmudic narrative (Ketubot 61a-b) extends these rules to an ordinary man experiencing a food craving. In all of these cases, the agent of the psak is an outside party, and it seems that he or she is responding based on a visual evaluation of the patient’s condition, namely that the ubrah’s nefesh requires restoration, the eyes of the person in bulmus are dimmed, and on Ketubot 61a Rav Ashi saw a ruach tzora’at (=leprous spirit) spreading over Mar Zutra. It seems very unlikely that the last condition reflected an imminent danger of death. However, the Mishnah and Talmud provide descriptions of symptoms but no clear standard.

In between the ubrah and bulmus cases, the Mishnah teaches that in the absence of experts, a choleh (= ill person) must be fed on their own authority “until they say ‘Enough!’”. That is to say, the Mishnah gives an endpoint. What does the patient have to say in order to initiate feeding?

The ROSH and Rabbeinu Tam each report a Talmudic manuscript of Yoma 83a which apparently requires the choleh or experts to declare that not feeding the choleh carries a risk of death. Each then insists that the text must be either rejected or reinterpreted, on different but compatible grounds. ROSH declares that experts rarely make such a claim directly, while Rabbeinu Tam protests that cholehs are not prophets. The upshot of their position, which is adopted by Shulchan Arukh and to my knowledge undisputed in contemporary halakhah, is that the proper standard is “lest the illness intensify and put the choleh at risk”.

We must ask: “At risk” of what, if not of death? And how does this standard relate to the cases of ubrah, bulmus, and ruach tzora’at?

The best explanation is that halakhah recognizes that conditions which are not fatal in themselves may stress a person physically to the point that their constitution is damaged. This may cause either a short-term vulnerability to fatal illnesses etc., or else a long-term weakening that is likely to yield a shortened lifespan. I have confirmed with doctors that this concern still seems reasonable to contemporary medicine. Moreover, they agreed that long COVID is just the kind of condition likely to be a dangerous overall stressor in some cases.

The correct procedure for a person with Long Covid, therefore, is to ask them whether their past experience leads them to believe that fasting will risk causing that sort of intense short-term or sustained weakening. If it will, the second question is whether in their experience this risk can be prevented by eating as soon as certain cues are experienced, or whether such cues come too late or unreliably.

If they believe that fasting risks causing that sort of damage, and that they cannot reliably prevent the risk by drinking or eating on cue, then of course they must not even try to fast. If they believe that eating or drinking on cue is reliably effective, then they may wait to eat until they experience the cues.

The remaining question is what they should eat or drink, and in what amounts.

If they are fully convinced that eating or drinking “shiurim” will suffice, or that they will realize with enough advance notice when “shiurim” are insufficient, then they should begin with “shiurim”. However, they should not take risks in this regard, any more than they should with regard to fasting completely.

If sufficient, they should drink only water[2].

If they are certain that this will not prevent them from drinking enough, they may try to ‘flavor’ the water with something that is not food and that almost no one would consume voluntarily except for medicinal purposes. But this is not necessary.

If they need more water than would be possible via the standard practice of “shiurim”, they should still drink in amounts of “shiurim” per drink, even if they will need to take many drinks in rapid succession[3].

In principle, there is no need to involve a posek in these evaluations. However, for generally admirable reasons, many people will be too machmir on Yom Kippur, and too meikil on pikuach nefesh, if they take the entire responsibility on themselves. Also, I recognize that there are many conditions other than Long COVID that might be subject to the same psak. Therefore, cholim are welcome to contact me at moderntorahleadership@gmail.com to set up times to discuss their specific cases[4].

[1]See however Rabbeinu Manoach to Hilkhot Shevitat Asor 2:9, who contends that the standard is lower for prohibitions that carry lesser punishments; Rav Shaul Dovid Botschko (BeIkvot Hamechaber vol. 2 p. 231-245) who suggests inter alia (based on Sefer HaChinukh Emor # 313 and Tosafot Shavuot 23b) that the standard may be lower specifically for “shiurim”; and Rav Aryeh Tzvi Frommer (published as Appendix 3 to Sridei Eish 2:4), who argues that “and live by them” extends to significant diminution of vitality short of death.

[2] This is because Halakhot Ketanot 2:282 states that drinking water is not Biblically forbidden on Yom Kippur.

[3] This is because “shiurim” for eating/drinking on Yom Kippur are defined as amount/time, but the baseline halakhah likely has a minimal time for drinking, even though standard practice is to give eating and drinking the same length of time.

[4] Rabbeinu Manoach to Rambam Shevitat Asor 2:9 expresses concern that people may tailor their symptoms to generate a leniency from a posek. However, it seems to me that he refers only to societies where eating on Yom Kippur carries a social cost. In a voluntary society, as confirmed by my experience, the risk of risky chumra is much greater than that of unjustified kula.