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Kanievsky, showed me that the Mishnah Berurah (ibid. 78) writes:
“This is speaking about a person who transgressed unintentionally
or even on purpose by digging a hole to hide money from marauders,
or something similar. However, a person who deliberately desecrates
Shabbos in order to fulfill his desires requires much greater atone-
ment, for he is liable to be stoned to death, or at any rate to incur the
kareis penalty, therefore he needs full repentance.” These comments
are surprising for it appears that a person who desecrates Shabbos
in order to protect his money does not incur death by stoning, [even
after having been forewarned – similar to the person who desecrates
Shabbos “deliberately, in order to fulfill his desires” who only incurs
the death penalty when he was forewarned] and this is astonishing,
for there is no piku’ach nefesh involved. Perhaps the reason [for
exempting a person who deliberately desecrates Shabbos to rescue
his money] is because he is considered an annus, because not every
person is capable of withstanding the huge test of losing all his assets
[rather than desecrate Shabbos]. At any rate, even if we do not accept
this novel assertion [of the Mishnah Berurah] that even after having
been forewarned he will be exempt from stoning, it’s still possible that
he will be exempt from kareis, which is inflicted by Heaven.

According to this, if aforementioned patient himself desecrates
Shabbos in order to spare himself tremendous suffering, he will be
exempt from punishment because he is an annus. We find in Tosfos
(Kesuvos 33b, s.v. ilmalei) that there exist types of sufferings that are
worse than death, and if they would have inflicted unlimited torture
upon Chananiah, Mishael and Azariah they would have been allowed
to serve the idol in order to be avoid torture. Although halachah re-
quires that a person be killed rather than worship an idol, terrible
suffering is worse than death and they would therefore have been
considered annusim.

But only the patient himself will be exempt for desecrating Shab-
bos because he is considered annus, not another person who is not an
annus. Similarly, the gemara in Yoma (85a) states, “Rabbi Yishmael
and Rabbi Akiva were once going somewhere together and the ques-
tion was asked of them, ‘How do we know that piku’ach nefesh sets

386 1 Medical-Halachic Responsa of Rav Zilberstein