Friday, 19 April 2013

Liar, Liar, Shtreiml On Fire

The ongoing debate over the medical safety and halachic necessity of metzitzah b'peh (MBP) in the Jewish world is not showing signs of abating any time soon.  Every time another report of an infant infected with herpes on his male organ most likely as the result of contact with an infection mohel's mouth reaches the news the flames of controversy swirl up again.
It is important to take a step back and clarify terms.  As people with a fanatical devotion to any religious position will ensure happens, terms of reference often get muddied up, the better to accuse opponents of crimes they have no intention of committing and thereby avoiding serious debate on the subject.
Therefore let me be up front with my definitions.  I have no interest in abolishing MBP.  I am not stating that it is a halachically recommended part of the bris milah process.  Clear?
I also would like to point out there are four options when it comes to MBP.  First, there is the option of not doing it.  This is not as outrageous as some would like to portray it.  First of all, the Gemara makes it clear that it holds metzitzah to not be an essential part of the circumcision process which it ends with p'riah, the retraction of the membrane over the glans.  The purpose of metzitzah is one of hygeine and health safety following the procedure.  The Gemara also recommends, for example, putting cumin powder on the incision which is not something we do anymore and no one suggests it is an inviolable part of the bris milah.  Throughout history there have been poskim who have suggested not doing metzizah for various reasons.  They are not in the majority but their authority does carry some weight.
A second option is to do it through pressure, for example placing a sponge on the incision and using that to suction blood.  This follows the letter of the requirement precisely.  According to the Gemara it is the removal of blood from the incision that creates the health benefit and the sponge does it.
The third option is do to the time-honoured act of direct MBP which involves lip-to-penis contact and the use of inhalatory suction to pull the blood out.  The final one is to do the same thing but with an intervening sterile device like a syringe barrel or pipette.
The problem is that the importance of metzitzah and how it's performed does not end with the Gemara.  In the Zohar and other Kabbalistic literature metzitzah takes on a whole new importance and becomes an essential part of the bris milah procedure.  And not just any old way but direct MBP and nothing else aligns the sefiros and brings forth the heavenly shefa that the baby needs.
As a result nowadays we are often presented with the position that direct MBP is not only the oldest form of metzitzah but that it's an unqualified fact that it's the only way to properly do it.
This is not true.  When one investigates the halachic literature one finds multiple poskim, many of whom post-date the "appearance" of the Zohar, that hold like the Gemara and do not see it as essential.  Others hold it is necessary but that it can be done with the sponge or pipette techniques and still be valid.  Again, these authorities are more than balanced by those demanding direct MBP but they are still impressive in number and count among themselves many important Torah leaders.  In other words it is not heretical to hold that indirect MBP is permissible.
Enter the herpes virus.
Herpes simplex is a nasty little virus.  It comes in two basic flavours.  Traditionally type 1 was associated with cold sores and type 2 with genital lesions.  However, due to people putting their lips in places they don't belong over the last couple of centuries there is now plenty of overlap between the two.  Most importantly, herpes is transmitted by direct skin-to-skin contact and can shed from one person to another in the absence of a visible cold sore or blistering rash.  In other words, a mohel who, on Thursday will develop a cold sore on his lower lip will be contagious at the bris he performs on Monday.  After a suitable incubation period the infant will develop a herpes lesion at the site of contact and it will be 100% the mohel's fault.
So now the halachic debate begins.  If the purpose of MBP is to prevent health complications but it itself has to potential to harm the infant then how can it be performed?  If MBP is an essential part of the bris milah for mystical reasons then is the risk of herpes transmission acceptable in order to do the circumcision correctly?
There is ample support in our legal literature for the direct MBP position.  What is truly a shame and what shows the weakness of direct MBP's supporters is their refusal to deal with the problem of herpes.  Like historical revisionists who repaint history to support a pre-determined "We were all Chareidi until those blasted Reformers showed up" version the supporters of MBP resort to scientific revisionism in order to avoid the nasty implications their position implies.  Hence we have Rav Avi Shafran's latest piece in which we find the following statement.
Yes, New York Mayor (a.k.a. “Nanny-in-Chief”) Michael Bloomberg, with the assistance of the New York Board of Health, has waged war on metzitza bipeh, claiming that it has been the cause of infections of Herpes Simplex Virus Type 1 (the cold sore virus, carried by most of the population but which can be dangerous in babies). That fact was the extent of Mr. Savage’s research of the issue. But it has been compellingly asserted by objective scientists that the mayor and health board’s claims are without basis in fact
Now I generally try not to be (too) insulting when I disagree with someone on my blog.  In this case I do not think it disrespectful to say this: Avi Shafran is a bold-faced liar.  Period.
First of all, Mayor Bloomberg's "war" on MBP has consisted of asking mohels to get a signed consent from the parents of the infant before direct MBP has been performed.  Secondly, the claims he dismisses as being without basis in fact are actually true.  Shafran is lying, pure and simple.  There is no question as to how herpes simplex is transmitted.  There is no question about its contagiousness in the absence of a visible skin lesion.  To say otherwise is to either be willfully informed or a liar.
Nor is Shafran's bolstering claim of any worth:

New York Westchester Hospital Chief of Infectious Diseases Dr. Daniel S. Berman, Beth Israel Hospital director of epidemiologic research Dr. Brenda Breuer and Columbia University Professor Awi Federgruen, an expert in quantitative methodology, have all publicly called into serious question the claim that metzitza bipeh represents any quantifiable danger to babies
When challenged by folks about their belief that the Earth is the centre of the universe and that the sun revolves around it instead of the other way around, contrary to the understanding of modern science, Chabadniks often mention a scientist named Velvel Greene.  According to Chabad mythology Greene started off by dismissing the claims of the Rebbe, z"l, about a geocentric universe and other misconceptions based on 2000 year old scientific understandings and ended up believing as the Rebbe did.  Therefore, they conclude, not all scientists believe in a heliocentric universe.  There is authentic support for the Rebbe's position.
Yes, one scientist who, by the way, is not an astronomer.
If Stephen Hawking were to claim tomorrow that he has come to realize that gravity is a fiction or that it's not oxygen that keeps us alive but rather nitrogen his achievements and recognition would not matter.  He would be dismissed for denying scientific fact.  Shafran can find any number of Agudah toadies with medical degrees who are willing to lie or misrepresent scientific facts but that does just change those facts no more than Peter Duesberg was wrong when he claimed that HIV is not the cause of AIDS.
The proponents of direct MBP are probably not comfortable being told that insistence on their position in this day and age exposes defenseless infants to a virus that can cause life-threatening infections.  Unable to refute this opposition rationally they become irrational and deny science.  It does their side no favours to be exposed as liars and revisionists since it also draws into question the process they used in analyzing the halachici literature to come to their staunch direct-MBP-only position.
The saddest part is that the compromise position, indirect MBP, fulfills everything that metzitzah is supposed to accomplish.  There is oral suction, there is drawing of blood from the wound and if the mohel really wants, he can then smear that blood on his lips without ever exposing the baby to any danger.  But what kind of people refuse such an obvious accommodation while threatening harm to an infant and lying about that very danger?


Fred said...

This is a great column...I really enjoy your blog. You know what pisses me off the most about people like Shafran, the entire Agudas Israel, and Haredim in general? Their unhesitant alacrity to assume the position of "victims" the second their postion meets any sort of resitance. Of course they will immediately resort to accusations of "anti-semitism" if convenient (like le affair d'Rubashkin)- or in the case of MBP, they will immediately vilify their critics and resort to vacuous attempts to nullify established scientific results.

The latest charade by Agudah- who felt privaleged to use the University of Penn. research to support THEIR recalcitrant position on MBP- is so embarrasing I cannot understand why there are no threats of a lawsuit against them (oh, wait!- that would be anti-semitism; so sorry).

Here's another spin on the latest Agudah antics. Judaism and scientific inquiry share a common approach toward the proper interpretation and application of acceptable source material. In other words, if you quote a source, you better be damn certain it is a reliable one, and the interpretation of that source better be accurate. In Halacha, it means quoting say, a certain Rishon is done in the proper context and utilizes an acceptable method to arrive at a p'sak that will withstand scutiny by rabbinic peers. In science, a source article, for exmple, that derives a potential conclusion can have vast reprecussions for a public health matter. I guess it boils down to intellectual honesty in method and conclusion as a common understanding between scientific inquiry, and Torah law.

Well,well,well- the Agudah royally blew it, and created an enormous hillul HaShem with their latest grasp at straws. They compromised an intellectual approach that is intrinsic to Talmudic discourse in persuit of their selfish and bird brained agenda, by attempting to use an incomplete scientific study- not available to the public. Its bad enough they shot themselves in the foot by citing incomplete scientific research. They also compromised the intellectual framework of Halachic Judaism (in public, no less...)by resorting to such cheap methodology.

To paraphrase George Orwell...such methods must be the work of intellectuals, for an ordinary layman could never be such a fool.

Rabbi Michael Tzadok said...

attempts to nullify established scientific results.
Well that is the first problem. There are none. There has been no scientific study that shows a direct correlation between MBP and an increase in neonatal herpes.

There has been a study Ben Haim Et Al 2005 that found that infection rates were the same between children who had a traditional circumcision including MBP and those done under medical conditions in hospital.

They compromised an intellectual approach that is intrinsic to Talmudic discourse in persuit of their selfish and bird brained agenda, by attempting to use an incomplete scientific study- not available to the public.
While I admit they shouldn't have used the study to try to prove what they did, when the conclusion of the study is that more study needs to be done. However, it is available to the public, one need only send an email to get a copy.

While I respect a parent's right to choose to go with MBP, or to have a vessel of some sort used(despite it being contrary to established halakha). However to try to villify the practice of MBP with false claims of scientific proof is just cheap.

Mighty Garnel Ironheart said...

Rav Tzadok, while I recognize your superior Torah knowledge I have to disagree with you and I really feel like this conversation is going around in circles.
First of all, as I have provided before, here are studies proving the link between herpes and MBP:

Secondly, your statement "despite it being contrary to established halacha" is incorrect. I'm sorry, but again here are a list of sources I've previously provided showing multiple poskim who are either kofrim (if your statement is correct) or upholders of a different but acceptable halachic approach:
We start with the Chasam Sofer. He shows quite convincingly that the purpose of MBP was to prevent illness and that therefore the final step of cicumcision is to prvent illness and that MBP was considered by the Chazal as a great way to do it.
The Maharam Shik, his student, came up with the idea that the CS's permission to do MBP indirectly was temporary. He has no evidence for this and, WADR to his greatness in Torah, the "it was only temporary" excuse comes up way too often whenever a great posek decides something in a manner that goes against "the grain". Did the CS pasken something controversial? Must've been temporary despite no evidence that it was. (Some Chareidim apparently are now doing this to "cleanse" Rav SR Hirsch, zt"l, by attributing all his non-Chareidi positions on science, the infallibility of Chazal, etc. to forgeries)
The Tiferes Yisrael(Shabbos 19 in Boaz), Shoel U'Meishiv 4:7, Ktzos HaShulchan 382:2 and Chochmas Adam 382:2 all hold that MBP isn't part of the circumcision process. Perhaps they're all heretics?
Then we have the Maharatz Chayot and the Mishnah Berurah in the Biur Halacha (ch 331)in the name of the Yad Eliezer where he again justifies using a sponge since the main point isn't to use your mouth but to get blood out of the wound and a sponge is superior therefore it's even permitted on Shabbos.
Word on the street is that Rav Yitzchak Elchanan permitted indirect MBP and the Briskers starting from Rav Chaim, zt"l, all forbid direct MBP. The Kores Bris (ch 264) also permits indirect MBP where direct MBP is not possible.
The Mateh Levi, acting on the advice of Rav Yaakov Posner, zt"l, also permitted indirect MBP.
The Har Zvi (YD ch 214) says you can do indirect MBP to prevent disease.
Even the Binyan Tzion, who opposed indirect MBP, apparently started that a mohel who is potentially contagious should not do MBP until he can guarantee he's not anymore. And since HSV sheds asymptomatically no mohel can guarantee a lack of a contagious state.
Shevet HaLevi 6:148:2 suggests indirect MBP can be done if there is a risk of infection. The Aruch HaShulchan rules permissively. Rav SR Hirsch and Rav E Hildeheimer permit it.
The Nishmas Avraham says his colleagues can't recall any baby getting Hepatitis or HIV from direct MBP. He does NOT mention HSV.
Finally, Daat Kohen brings the reason for defending MBP from charges that it spreads disease from the concept that since science is always changing, what doctors say today they change their mind about tomorrow. We are not going to do that with HSV. The virus and its mode of transmission are well understood. Oh, and he also permits indirect MBP (Daat Kohen 140)

See further:

Rabbi Michael Tzadok said...


Neither of those are scientific studies and you know it. They are no more reliable than the Andrew Wakefield assertions regarding vaccinations. I mean he took twelve children who received MMR vaccination and then developed Autism. So clearly MMR carries serious risk of autism. You are simply repeating Wakefield's same bad science. Meanwhile you ignore the only scientific study done to date that sought to clarify the differences in infection and complication rates between ritual and medical circumcisions because you don't like it's conclusions.

We seem to have very different opinions on what is accepted halakha. Like I said, if you want to hold a minority position(which those are, if you really wish I will deal with each one at a time, and bring those who argued on them and so fort) that is fine. Just stop using fruity science and scare tactics to do it.

Mighty Garnel Ironheart said...

Both are scientific studies. Yes, neither are the highest level of evidence which would be a randomized double-blind trial in which you lined up 10 mohels with known HSV and 10 without, had them circumcise 10000 babies each during the asymptomatic phase and then looked for the incidence of HSV in the babies in both groups afterwards. But could you imagine any responsible parents signing up for such a trial?
So in the meantime we know that herpes is spread from skin to skin contact. We know that there is skin to skin contact in MBP. We have evidence of transmission occurring after such procedures. And sadly we have precedent after precedent of rabbinical authorities doing everything possible to cover up when bad things happen in the frum community. What further evidence would you like?
Furthermore, when the authors of the Penn study themselves are saying that the Agudah completely misread the study and that its conclusions aren't anything close to what you're saying they are you lose the only study out of many that even suggests support for your position.
As for these positions being minority positions, I wasn't aware that Judaism is a democracy. Further, I have a problem with opposing opinions using statements like "Well it was a hora'as sha'ah" or "He didn't really mean it, he was just saying it for PR purposes". Take out those poskim who oppose those on my list using such excuses and the numbers change. But what's more, Judaism isn't a democracy. If it was we'd all be Reform.
How many of the poskim who supported direct MBP-only through the ages would still do so if they knew about HSV and infacts becoming terribly sick or dying from it?

Rabbi Michael Tzadok said...

Furthermore, when the authors of the Penn study themselves are saying that the Agudah completely misread the study and that its conclusions aren't anything close to what you're saying they are you lose the only study out of many that even suggests support for your position.

What you just said, is simply not true. There is the Ben Haim study, which is the only study that even meets scientific standard, which is a huge support for MBP. Which is why you prefer to pretend it doesn't exist.

The Penn study, simply says that there isn't enough evidence to say either way, because of the lack of scientific studies.

The two studies that you cite, are no more scientific than Andrew Wakefield's piece against MMR. Do you also believe that MMR vaccinations should be stopped?

As for these positions being minority positions, I wasn't aware that Judaism is a democracy.
Well since that is your view, their is no place to do MBP via a vessel. As the Rabbinut position paper makes clear, contemporary poskim all hold that MBP is a necessity and that a vessel should not be used.

RAM said...

Garnel, as a doctor, maybe you can help with this:

Assuming that a baby and his mohel are both free of disease, what has been the demonstrated positive physical effect of metzitza (direct or through a tube) on the baby? I'm trying to distinguish physical effects from other potential effects (spiritual, mystical).

RAM said...

Just to clarify my last question. It boils down to, "how does extraction of blood by some form of suction actually cause better health results than something else, such as wiping the wound with sterile gauze?"

MIghty Garnel Ironheart said...

Is this the study you're referring to: Isr Med Assoc J. 7(6):368-70, 2005 Jun.Complications of circumcision in Israel: a one year multicenter survey
If so, there's an excellent reason I'm ignoring it: it's irrelevant and frankly you should not be bringing it up. It compares complication rates between mohels and trained physicians and the mohels turn out to have a significantly higher complication rate albeit the overall numbers are low. But from what I can see they are looking for routine post-procedure complications like bleeding, tissue damage and standard wound infection. It is therefore not relevant to the HSV discussion.
And bringing in Andrew Wakefield is similarly irrelevant. His study was a fraud and he was subsequently defrocked. These studies that I referenced have been validated.
As for the Rabbanut, let's say they had said the obvious and that there is halachic permissibility for indirect MBP. Would all the "Gedolim" now change their minds and allow it? The Rabbanut is a funny institution that way - it paskens but no poskim listen to it.

Micha Berger said...

RAMM: I'm pretty sure those who require direct MbP do so because the issue is not medical. They have Qabbalistic sources, which I don't know well enough to discuss. I glean it has something to do with milah being a partial rectification of the sin of the fruit of the tree of knowledge, and eating is a sin of the mouth. But there is indication in the gemara that metzitzah bepeh isn't about blood letting.

It is possible that after the circumcision there is left extra skin that doesn't invalidate the beris milah. If the beris is on Shabbos, then the mohel can clean them up as long as he didn't finish the beris. Once he finished doing the beris, it is not a health risk, it's not part of the mitzvah, it can't be done on Shabbos. The wound would have to be reopened after Shabbos.

The definition of finishing the beris given in this discussion in the gemara is after metzitzah, but not including bandaging and medicine (which was cumin). Similarly the Rambam (Milah 2:2) groups metzitzah with milah and peri'ah, not with asplanis vekamon (bandage and cumine).

AND, while the Chasam Sofer does say gauze was okay (and I agree that the Maharam Shik couldn't have seen his rebbe's actual teshuvah), his is a lonely opinion. R SR Hirsch and Litvisher posqim came up with methods of using oral suction without direct contact. Again, because it is believed that metzitzah bepeh is required for non-medical reasons, and therefore other forms of blood letting aren't just as good. Which really does open the door to a valid pesaq in which metzitzah must not only be done, and not only orally, but by direct contact.

Yes, on Shabbos 133b, R' Papa tells you to fire a mohel who doesn't do metzitzah because he risks babies' lives. That doesn't mean the problem is /only/ medical. But R' Papa, like most fathers (we know of his 7 sons from the siyum formula), isn't going to talk about milah being done wrong when lives are at stake. The big problem is the health risk; not necessarily the only problem.

Also, another different between metzitzah and the other parts of milah: while the mitzvah was apparently not completely fulfilled without metzitzah, the result is not an areil. Even if you hold that metzitzah bepeh is a requirement of beris milah, the child who lacks one can still eat a qorban pesach, etc..

MIghty Garnel Ironheart said...

RAMM, In terms of hygiene and health issues we have to be careful. I could point out that saliva has anti-Bacterial properties which means metzitzah might reduce the post-procedure complication rate but Chazal would not have been aware of that. There is clearly a belief of a beneficial effect of metzitzah on the infant but we don't have a physical reason for it.

RAM said...

Micha Berger wrote, "R SR Hirsch and Litvisher posqim came up with methods of using oral suction without direct contact. Again, because it is believed that metzitzah bepeh is required for non-medical reasons, and therefore other forms of blood letting aren't just as good."

Or maybe not for your reason, Micha, but because it's closer to the traditional suction method, namely MbP with no tube, than other immediate blood removal methods are.

Micha Berger said...

RAM: If the reason were pragmatic, rather than a belief that metzitzah is part of milah, then why does one care about "more similar"? And for that matter, why not advocate neosporin as "metzitzah"?

The idea of trying for some definition of MbP, albeit indirect, is because we care about the process, not any supposed medical benefits.

RAM said...

Micha, you could be right, but...

Some people who see a need to modify a minhag nevertheless want to preserve as much of the original minhag as possible. This is what a traditionalist might do.

Rabbi Michael Tzadok said...

If so, there's an excellent reason I'm ignoring it: it's irrelevant and frankly you should not be bringing it up. It compares complication rates between mohels and trained physicians and the mohels turn out to have a significantly higher complication rate albeit the overall numbers are low. But from what I can see they are looking for routine post-procedure complications like bleeding, tissue damage and standard wound infection. It is therefore not relevant to the HSV discussion.

The only way to categorize that statement is willful dishonesty. I find it sad that you have to stoop to that level.

Regarding the relevance of Andrew Wakefield, if you checked his methodology, and that of the mimic studies that immediately follwed his initial study, you will find that it is exactly the same as the methodology used in the studies that you are quoting. The Rabbinut position paper points out the problems with those studies. The Rabbinut position paper, I would like to point out, was written, not by Rabbis, but by physicians, two of whom happened to also be Rabbis.

Yes Wakefield was fired from his position in a British hospital, though I am not sure you can say that was "defrocked". Though the ire came because of his shoddy science(which is being repeated in these "studies") which lead to a world wide scare regarding immunizations. You are unlikely to find the same outrage over the bad science being touted here.

Micha Berger said...


But that was only half the argument. I also wrote that based on the halakhos of cutting any remaining tzitzin on Shabbos that there is reason to assume metzitzah is part of the beris itself, unlike the rest of the post-op treatment.

I think that makes the assumption that they felt it was part of the mitzvah more plausible than their simply not wanting to change a minhag.

But whatever the various rabbanim in Germany or Litta held, that's grounds for the posqim who insist on direct metzitzah bepeh to feel that the alternative is giving up on the mitzvah altogether.

There is also another oddity... When did direct MbP begin? Today there are far fewer diseases than can linger in a mohel than ever before, and far fewer of those diseases can't be treated if the baby were to ch"v contract them. And today we have things like scope, toothpaste, etc... If the risk today is too high to permit, how was metzitzah bepeh EVER safe enough to be permitted?

Mighty Garnel Ironheart said...

Rav Micha, remember the surrounding environment. In a place without antibiotics, alcohol-based mouthwash and toothpaste, contagious disease was not abnormal. If MBP was done and the infant got sick, well he had a more than 50% of getting sick no matter what.
Nowadays it is the exception for an infant to get seriously ill, B"H. That's why it's now noticed. In an era when sterility was an unknown concept direct MBP didn't cause anything outrageous. Today's standards and expectations are different.

Micha Berger said...

Does the fact that babies were dying for a million other reasons mean that a higher risk for MbP was more permissible then than now? I mean, people might not have noticed it, but why wouldn't G-d drop a hint to Moshe, Yehoshua or Ezra with a way to do metzitzah without killing babies?