Navonim - The Ramblings of Garnel Ironheart

Navonim - The Ramblings of Garnel Ironheart
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Tuesday, 20 March 2012

To Serve and Protect... Himself

Sometimes defiance is necessary to protect Torah and tradition.  Sometimes it does the opposite despite claims to the contrary.  Such is the case in the ongoing controversy over metzizah b'peh which recently flared up in New York after a mohel there allegedly transmitted herpes to a vulnerable infant who subsequently died from the infection.
At the root of the issue is the gemara which mentions metzitzahi b'peh but isn't exactly clear if it's a third part to the actual act of the milah or part of the recommended anti-sepsis treatments mentioned after in the care of the penis.  Traditionally it has been performed by the mohel pressing his lips to the incision and sucking blood out of it.  The gemara says that this is necessary to prevent health complications to the baby but in recent decades it has become clear that at times it can have the opposite effect.
Now I'll state my bias up front.  When I was in my final year of medical school this same thing happened to the baby of friends of mine.  I got to watch as the poor little infant had a lumbar puncture to ensure that the herpes infection he had contracted hadn't entered his central nervous system.  In the aftermath of his uneventful recovery (B"H he's a healthy young man today) terrible things happened to the family when they tried to protest that the mohel had been responsible for transmitting the virus.  One thing it did for me was convince me that the traditional method for metzizah b'peh was now no longer the benign, life-saving procedure that it might have been in the times of the Sages.
As a result it seems quite a necessary thing to review how metzizah b'peh is done given that it has now become associated with the spread of a contagious, potentially lethal disease.  Unfortunately there are those who view any attempt to begin such a discussion as an all-out assault on circumcision, Torah and Judaism in general.
Rav Zev Farber, writing on Morethodoxy.org has a comprehensive piece that outlines some great compromise positions.
Keeping in mind that the point of circumcision aftercare is to encourage a quick return to health, not introduce deadly viral diseases, some of these options seem to perfectly fit the need to both maintain the traditional place of metzitzah b'peh in bris milah while eliminating the contagious dangers that have come to be associated with it.  What's more, these positions have the support of important poskim, not unknown random sources almost never heard of before or isolated positions that have been rejected by normative halacha.
Despite that there has been a backlash against this reasonable approach.  It is important not to see this as just another example of some Chareidim fighting to maintain a status quo because they see any change as a wholesale sellout of Judaism.  This is not a "We do this because this is how we have always done it" or "We do this because this is only way permitted by halacha".  This is an example of some Chareidim fighting to maintain a status quo because they have rejected the idea of change of any kind, the kind of folks who would come out in favour of smoking if YU and YCT announced that it was now assur to do such a thing. (Halevai)
And this case it is even more.  These are people who are fighting to maintain a practice that is potentially harmful to infants because in their mind not changing is more important than protecting lives.  In their zeal to protect Judaism they have taken a position that violates it and created for themselves a state of denial to avoid realizing it.  It seems some of them are even prepared to violate both Jewish and state law just to show their defiance.
Therefore Rav Farber's conclusions seem quite appropriate.  It is no longer enough to see direct metzitzah b'peh as a "frummer" version of bris mila but as an inappropriate form of bris mila unacceptable in Torah observant congregations.  It's not enough to listen to people talk about how important tradition is and how there's no good evidence that herpes and other diseases can be spread by direct metzitzah b'peh.  Instead it has to be pointed out loudly that this is not true and that the Torah value of preventing danger to life trumps slavish adherence to a dangerous form of a procedure that could otherwise be safely performed.
1) The Clean Bill of Health Model

Proposed by R. Dr. Mordechai Halperin, M.D., first in Israel and then in an article in Jewish Action called: “Metzitzah B’peh Controversy: The View from Israel,” the suggestion is to devise a method to ensure that the mohalim who perform meẓiẓah be-peh do not have any illnesses, including sores in the mouth, that can transfer disease. (I have heard that this is the practice in England among mohalim that perform meẓiẓah be-peh.) The mohel would have to go through whatever testing deemed medically necessary to ensure the meẓiẓah is safe, and he would need to constantly renew this clean bill of health. Any mohel without this “license” would be barred from performing meẓiẓah be-peh, and any who did so anyway would be banned from practicing by the community.
Although Halperin’s suggestion is commendable, I am personally uncomfortable with it. Since meẓiẓah be-peh has no medical benefit and no halakhic basis nowadays, I see no reason to continue with a practice that reflects antiquated medicine in such a graphic manner. I feel that doing so, even if it weren’t dangerous, sends the wrong message (this, I hear, is R. Moshe Tendler’s argument as well). Furthermore, I can’t help worrying that even with safeguards, the practice may still pose some threat to the infant; one need only consider the amount of germs and bacteria found in a person’s mouth and the fact that illnesses often come about unexpectedly.
Nevertheless, since there are those that stridently disagree with me and believe meẓiẓah be-peh to be either a halakhic requirement or of paramount qabbalistic significance, I have included the clean-bill-of-health model in the hope that the opposition may at least adopt this, thereby protecting the lives of the infant boys who are otherwise in harm’s way.
2) The Meẓiẓah-Equivalent Model
R. Shlomo Ha-Kohen of Vilna (1828-1905) wrote in a responsum (Binyan Shlomo 2, YD 19) that there is no mitzvah to perform meẓiẓah. Instead, he argued, meẓiẓah should be viewed as part of the general requirement to keep the infant healthy. Therefore, he claims, whatever modern medicine determines to be the best medical practice for keeping the child healthy should be considered the equivalent of meẓiẓah.
According to R. Ha-Kohen, the practice he witnessed in his time period, where the mohel would wrap the penis in rags (smartutin), was the equivalent of meẓiẓah, and that he could not venture to say what the practice would look like in the future. This is because the practice is purely medical and, as he reminds the questioner, he is not a doctor.
Applying Ha-Kohen’s analysis to our times, the modern mohel should sterilize his equipment and use whatever bandages and antibacterial creams are necessary to reduce the risk of infection. In this way he has fulfilled the requirement that is at the root of the – now defunct – requirement to suck out the blood from the wound.
3) The Ritual-Meẓiẓah Model
Some authorities were less comfortable with cancelling the practice altogether, although they were certainly unwilling to risk the lives of Jewish infants to keep it. Hence the idea of a meẓiẓah performed without direct contact between the mohel’s mouth and the infant’s penis was suggested, and two basic forms of this practice were put forward. One idea, advocated by R. Moshe Schreiber (Sofer), known as the Ḥatam Sofer, was to use a sponge around the corona, with the mohel applying (slight) squeezing pressure to remove some blood.
Another method that is popular with a number of Modern Orthodox mohalim today was to use a glass pipet. The mohel would place the pipet upon the wound and suck from the other side, stopping when some blood would come out of the wound. This method was advocated (or at least permitted) by a number of halakhic authorities, such as R. Malkiel Tenenbaum, R. Elyakim Shapiro of Grodno and R. Avraham Kook. It also seems to be the preferred solution of R. Moshe Pirutinsky in his influential compendium, Sefer ha-Brit.

21 comments:

Rabbi Michael Tzadok said...

The problem Garnel is that you are ignoring a large amount of Halakhic responsum that says that metzitzah is a necessary part of the milah procedure.

Of course best medical practices should be followed, but we shouldn't ditch our tradition because of a few bad apples.

Look at the statistics more babies die every year from anesthetics given in relation to milah then do from metzitzah complications. That doesn't mean that we should put at risk a single child. A mohel should be regularly tested for blood born pathogens, as well as inoculated against them.

Also the mohel needs to check the baby's blood work to make sure that there is nothing that he could contract(and thus pass on later). From what I understand none of this is standard practice in the US however it is in Israel.

Mighty Garnel Ironheart said...

Rav Tzadok, I am not advocating doing away with metzitzah. If the gemara advocates it then we do it. I am saying that there is a safer way to do it so that the baby and, as you cogently pointed out, the mohel remove health risks from the procedure.

LTC said...

I'm sorry, but this is absurd. You simply cannot say that metzizah be'peh is "no longer" a way to prevent infection. It NEVER was a way to prevent infection. The amora'im might have thought it was, but they knew nothing about the germ theory of infection or about microbiology in general.

Anyone who attempts to make the specious argument that anesthesia is more dangerous is just wrong. I write this as an orthodox Jewish surgeon - so I think I know more about antisepsis than ANY and ALL rabbinic scholars out there.

This is a technique that was assumed to prevent infection. That assumption, based on modern science is simply wrong.

If the above commenters think that this is healthy, I challenge them - when they have to undergo a surgical procedure, to tell their surgeon to put his mouth to their open wound and lick it.

This needs to stop. And I should add - I have three sons. I was the mohel for all of them after sitting and learning hilchot milah while my wife was pregnant. And I - even knowing my HIV and Herpes status - would not put my mouth on my sons' open wounds.

This serves no medical function. It is blatantly endangering the life of newborn boys. If it is determined that halacha mandates drawing blood to the surface, then it must be done without oral contact.

Rabbi Michael Tzadok said...

@LTC

Metzitzah was never meant to be a disinfectant. HOWEVER, it is an integral part the milah. The vast weight of halakhic responsum says this. Failure to perform the procedure is cause to lose one's license in Israel.
As I have said, I cannot speak for Milah in the US, however Milah in Israel is governed by BOTH the ministry of health as well as the Rabbinut and in order to be licensed one must sit and pass exams as well as practicums for both.
In that respect it is not simply Rabbis who are saying that Metzitzah B'Peh is safe, it is also a board of Healthcare professionals.
As far as anesthetics being more dangerous that Metzitzah, that is a statistical fact, look up the statistics. How many babies die each year from the anesthetic administered during milah, and how many die from Metzitzah b'Peh. Here are hard statistics for you, in the US each year(both Jew and non-Jew) the mortality rate from circumcision is 9.01/100000(admittedly Metzitzah b'Peh is not part of the normal procedure there). The mortality rate in Israel is 1/500000 where Metzitzah B'Pe is required. Obviously whatever the US health establishment believes to be best practices fall well behind those of the Rabbinically trained that you look down your nose at.

LTC said...

I would appreciate your sources for those statistics before I can comment on them. There are numerous anti-circ organizations that publicize spurious numbers to promote their agendas.

Just for the record, the American Academy of Pediatrics publishes a US death rate of 1/500,000. That would be identical to your figures for Israel (where I live, by the way.)

I won't argue halacha (or Kabbalah!) with you, but I would caution you about arguing medical science with me. (I mean that collegially, not angrily or threatiningly, so don't get upset.)

I don't thumb my nose at rabbis. As someone trained in milah, who has done circs with rabbis and physicians, I can honestly say that a good mohel is infinitely slicker at milah than the average doctor. That's simply because they do more. Practice makes perfect - I know that from my own professional life.

But, drawing blood does NOTHING to prevent infection or promote health or healing. Period. If halacha mandates for whatever reason that blood be drawn to the surface, I will not ever argue. But, I do not believe that any sage of that era, were they to learn the science behind this, would still advocate oral contact with the open wound. There are other ways to draw blood.

And I will say again, if you come to me to have your hernia fixed, or appendix removed, would you let me have one of my OR staff spit into your open wound?

Anonymous said...

What is very strange regarding "LTC"'s comments, is that he does not seem to know what metzitzah is. First he defines it as "...to tell their surgeon to put his mouth to their open wound and lick it..." then in his next post he describes it to "...spit into your open wound..."

The source for the requirment to perform metzitzah is the Gemara in Shabbos that instructs the Mohel to suck, to draw out the blood from within the wound. The great Rabbis of the Talmudic era ruled that the act of sucking out the blood from the wound, is of medical benefit for the baby. Secular modern science has evolved tremendously since the time of the Gemara, but anyone in a Science or Medicine profession would know that it continues to evolve. Many medical theories and science, stated as fact only 30 years ago, has since been disproved and replaced. It is not our job to decide whether the Divrei Chazal(Rabbis who the Gemara recounts were able to perform techiyas hameisim) were mistaken- let us assume they were correct. However, we must protect the baby, and since even a safek of pikuach nefesh warrants us to act, the metzitzah must be done in a way which doctors will agree is not risking the childs life. If there is ample evidence that it is a risk today to the baby if the metzitzah is done b'peh, then I don't think you will have any recognize Rabbi not instruct to use a tube. But one must strive to accept and abide by the great words of Chazal at the same time as acting upon the word of modern science.

Anonymous said...

By the way, could anyone post factual statistics as to known cased of babies who got sick or died from herpes- due to metzitzah b'peh? I read the 2004 study and it listed a total of 8 documented cases, without any definitive proof linking the herpes to the Mohel. I am not saying that the herpes was not from the Mohel, it simply does not seem to have been verified. If no futher proof or science is available, the simple question arises, is the illness of 8 children out of tens of thousands, which were not proven to come from the Mohel- reason enough to require the population not perform metzitzah b'peh? Perhaps "LTC" could offer some comparison statistics of medical procedures that have harmed 8 patients in ten years, which cause modification of the treatment. Is anyone aware of any examples of modern science giving weight (and thus altering a procedure, medicine, etc.) to such a tiny statistic? Again, I am not saying that metzitzah must be done b'peh, all I am saying is that both sides of the question have to be addressed. If you want to be intellectually honest.

Mighty Garnel Ironheart said...

Yet there is a reasonable solution here that satisfies both sides in the debate - metzizah al pi tzinor. A pipette is placed against the incision and the mohel sucks out the blood from the other side.
According to the germ theory of disease there is no direct contact betweeen the mohel and the baby, therefore no chance of herpes transmission. According to halacha the blood is sucked out from the wound satisfying the gemara's requirement. My point is that this should be the preferred way of doing it.

LTC said...

Anonymous levels a few accusations at me that I cannot allow to pass:

From a medical standpoint there is NO difference whatsoever between oral-penile contact and spitting in an open wound.

The 2004 article about the 8 cases is laughable. The medical literature going back to the 18th century is replete with medical reports of venereal infections (even tuberculosis, no less) after metzitza bepeh. I am literally writing between cases in the OR, but would be happy to provide sources upon request.

Even more recently, the literature of the past twenty years, has citations about many such cases. There is a report of one pediatrician alone reporting 10 cases. Tragically, the attempt to deny the obvious is killing infants.

As to the argument that "science has changed, and maybe we don't know the truth about this phenomenon." That's just absurd. Yes, we have changed. We've gone from the sages of the mishna and gemara who had no knowledge of microbiology, and a completely erroneous understanding of biology and medicine, to an understanding of this on the cellular level.

We're not going to suddenly discover that bacteria don't cause infection, or that antisepsis isn't really all that important.

As the host of this blog has pointed out, there are other ways to draw out blood. The problem lies in those who insist that it can only, al pi halacha, be done via oral genital contact. To allow that in the modern era is criminal.

All medical treatment decisions are based on a cost/risk/benefit assessment. But, that is when a particular therapy has risks as well as benefits. This "therapy" has NO medical benefit, and a totally unacceptable risk. Particularly since there are perfectly acceptable halachic alternatives.

As an aside, if memory serves, numerous elderly mohelim who worked in pre-Holocaust Europe have commented that in Vilna, metzitza bepeh was rarely, if ever, done. Alternative methods were employed.

Again: if there is a "spiritual" (for lack of a better term) reason for drawing blood, who am I to argue with halachic scholars? There is no medical reason for this, though. And, if the reason is that chazal determined that milah include drawing blood, then halacha mandates it be done in such a way as to not put a single child's life at risk. The risk of transmission of venereal disease during milah should be ZERO. If there is a single case and a single Jewish child dies as a result, we are to blame.

Rabbi Michael Tzadok said...

My understanding of MB"P is that it is necessary to draw forth blood for dam brit. The blood that is there immediately after the cut is blood from the foreskin, not from within the organ itself, which is what is necessary to bring forth to satisfy the requirements of dam brit.

Again this has nothing to do with healing or antiseptic. Furthermore if that were the primary reason it would be forbidden to perform on Shabbat.

That the Rabbis of the Gemarra may have thought that it had a side benefit of antisepsis... well that is beside the point. It would appear that they were in error, which the Rambam and the Ben Ish Hai both had already said anyway. LTC is quite correct it is an inherently risky procedure which is why the Ministry of Health in Israel requires various sterilization procedures to occur before hand(antiseptic mouth rinse and application of sterilization powder to the beard and lips). If this is done correct and according to Halakha(which also forbids a sick Mohel from performing the procedure himself... thus requiring either a pipet or another person depending upon the era) the risk is minimized.

Anonymous said...

It is hard to understand why "LTC" seems to respond to questions and opinions as personal "accusations." Perhaps he has a strong bias on this topic?

The point I made regarding your "spitting" comments was simply to express the fact that in your transparent attempts to villify a procedure that the majority of the great sages approved of and recommended, you fell into the trap of overstating you case. I am more than pleased to discuss each point, but let us please make an attempt to stick to facts. Metzitzah done by oral suction of the wound was accepted by great sages as having a health benefit for the child. They did not specify what that health benefit is (although many have theorized), and I think it's silly to state that it is impossible that it indeed has benefits. The logical (and might I say mature) argument, is that whatever benefit comes from oral suction, there may be more dangers, that outweigh the benefit. Which is exactly the reason that many Rabbis accepted the approach of performing the metztitzah with the use of a suction tube. Thus the Gemara's stated health benefit of sucking the internal bloods out from the wound, and the elimination of health risks of oral contact. However, unlike "LTC" those Rabbis and laymen don't have the arrogance to state with certainty that the procedure called metztitzah which has been accepted by our greatest minds and leaders- is a big mistake and "has NO medical benefit." They simply adjusted their approach to accomodate concerns based on tradition AND modern science.

Regarding your claims that there is "medical literature going back to the 18th century...replete with medical reports of...infections...after metzitza bepeh..." I would appreciate if you could provide sources of your medical literature that is "replete" with reports of metzitzah causing disease. I assume you know that it's now accepted that TB is not spread by saliva, but only by the respiritory system?

Please cite the all your sources that metzitah was verified (according to the litmus test that would be accepted by modern science as proof) to cause sickness to the child.

LTC said...

Sorry. The great sages were scholars with regards to Torah and halacha. They, however, had the limitations of the medical knowledge of their era. In other words, they knew nothing of physiology, microbiology, pathology. Saying that in no way denigrates their greatness in Torah. It merely states a necessary fact.

If they believed that metzitzah had a medical benefit, they were expressing the prevailing theories of disease of their day. They were wrong. There is no benefit medically. Spiritually? I am in no position to dispute.

However, I have twelve years of post graduate scientific education, academic titles, a 13 page CV of scholarly research articles and academic presentations in the basic and clinical sciences.

I am not writing this to boast. I am simply saying that while I may be able to hold my own in the daf hayomi, my torah scholarship pales in comparison to theirs. However, I have infinitely more scientific knowledge than they did.

And for the record, not every great sage of the past few centuries insisted on metzitzah bepeh.

I am out of town starting in a few hours. I will happily back up everything I have written with detailed sources and references.

Oh, and for the record, the tubercle bacillus is quite present in saliva and can be transmitted with direct salivary contact.

Anonymous said...

"I will happily back up everything I have written with detailed sources and references"

I am confident that every reader of this blog will appreciate that.

Remember they have to be cases that were scientificaly CONFIRMED AND PROVEN to be caused by the metzitzah b'peh. Not cases that are "suspected" or stated as a "possibility" by individuals with a bias towards any circumcision (with or without metztitzah). And yes I have seen those studies that would be laughed at by any unbiased medical authority.

But if you have legitimate sources...I am looking forward to reading them.

Anonymous said...

Btw, when LTC writes:

"... I write this as an orthodox Jewish surgeon - so I think I know more about antisepsis than ANY and ALL rabbinic scholars out there... I would caution you about arguing medical science with me...I have twelve years of post graduate scientific education, academic titles, a 13 page CV of scholarly research articles and academic presentations in the basic and clinical sciences...I have infinitely more scientific knowledge than they did..."


Are you serious? Time to get off the high horse. You do realize that are very experienced doctors (I assume with more credentials than you) who have written letters of support for Metzitzah B'Peh (some have been published in a book by Rabbi Goldberger). If you want to present your case, you are going to need some facts, not just talk about how you passed medical school.

Adam Zur said...

to mohalim,First do no harm.

MIghty Garnel Ironheart said...

Anonymous, I agree that there are rabbonim out there with a great deal of scientific knowledge. However, I have heard bizarre things said in their name. I am told, for example, that a world-renowned specialist in infectious disease assured Rav Eliashiv a few years ago that there were no risks of mohels giving herpes to babies because herpes isn't transmitted from skin to skin contact!
If it was indeed said then I have to wonder about this specialist's competence. If his comments were edited and presented to Rav Eliashiv in a form that was more in accord with his halachic position and less in accordance with the medical facts then who cares about their experience?

Anonymous said...

MGI, I agree with you- there is never an excuse for anyone to present inaccurate information to a Rav for a psak. If that ocurred in this case then that specialist would not be a legitimate source since he is clearly biased. However, I was referring to a book published in 1990 (over a decade before the most recent debate on this topic)-it was no written by a doctor, but he received some impressive letters from specialists. Again, it is obvious that there are two stong sides of the argument-as far as the best halachic approach based on the modern science considerations. However, one approach that is not legitimate or viable for any Torah believing Jew is that any Metzitzah should no longer be done- because we don't think it is of any health benefit anymore. Which is the path that the other poster on this site appears to be taking. Once one thinks there Torah knowledge trumps the opinion of the Gemara and any current Sage who bases his psak on medical professionals, they are slipping down the (age old) slope of haskalah. We must do anything and everything to protect the health of the children. There is no great sage in the world who thinks differently- however, they must rule according to, and based on facts- not biased opinions FROM EITHER SIDE of the debate.

Anonymous said...

I looked online for the letter you mentioned. The most important thing is that the clears medical FACTS are given to the great Rabbis who issue the psak based on applying their halachic knowledge. When each side makes claim, theories, and their personal opinion, it causes the debate to become biased and personal. For no reason- it only causes difficulty in receiving a unanimous psak from the Rabbis. If both sides presented the raw data and science, without their opinion, all would be benefiting. I assume you mean these?

http://failedmessiah.typepad.com/failed_messiahcom/files/dr.%20Daniel%20S.%20Berman%20Letter%20To%20Rabbi%20Elyashiv.pdf

http://www.yasharbooks.com/MBPLetters.pdf

http://www.matziv.com/pictures/drbermanarticlemetzitzah

Anonymous said...

And a very fair component to this debate is: What statistic is called "a risk" to the child. Is it 1/5 or 1/10000000, or somewhere in between? These statistics are relevant for a Rabbi to rule if the risk is clasified as a sakanah to the baby. In order to determine any statistic of risk, someone has to present some raw data of cases where a child got sick from herpes, and medical tests VERIFIED AND PROVED that the virus in the child had the same DNA markers as the virus of the Mohel. Has this ever been done? If so, how many times? Perhaps LTC will let us know when he presents his sources.

Anonymous said...

Is "LTC" going to post the sources to his claims?

The Quote said...

Discussion regarding milah,metzitzah,etc.:

http://www.mohelinsouthflorida.com