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Metzitzah B'Peh--Oral Law?

Wednesday, April 7 2010

Recently I attended a Hassidic wedding and was seated next to one of my Hareidi co-religionists. During the course of the evening, it became known that I was a mohel. The question of metzitzah came up. I explained that I was a "modern" mohel and that I did not perform metzitzah b'peh (i.e. direct mouth-to-wound contact to perform metzitzah.) I used either a sterile plastic tube or a gauze pad to perform metzitzah. Having been in this situation before, I began to ask a few gentle, probing questions. "What if we know that a baby could possibly transmit a disease to a mohel or the reverse?" "What if the mohel and baby both appear healthy, yet there was something which could cause illness in either one of them?" The responses were typical. "If the baby is ill, we don't perform the Bris." "If the mohel is ill, we get a different mohel." "We've been doing metzitzah b'peh on thousands of babies, and they didn't get sick." I pressed on. "But what if it could be shown that there is the possibility that even one child could become ill or, God forbid, die from something transmitted by the mohel?" There were two responses. "You'll never get them to give up doing metzitzah b'peh;" and "Today, there is no possibility of change," accompanied by a look which I can only describe as "It does not compute." In other words, in this gentleman's mind, these two concepts could not be reconciled. In all fairness, I should point out that this gentleman is a former Rosh Yeshiva and would qualify as a talmid hakham, a very learned individual. He insisted, however, that he was not a posek, a religious decisor.

What is metzitzah? What is its origin? What is its purpose? What is the controversy?

There are three steps to performing a Berit Milah. Milah, the excision of the foreskin; periah, the drawing back (or removal) of the secondary layer of skin, the mucosal membrane; and metzitzah. Metzitzah is the drawing of the blood from the wound following the ritual circumcision. The source is found in the Mishnah, Shabbat 19:2. "One performs all the necessary steps for the milah on Shabbat: One circumcises, draws back (or tears) the secondary layer of skin (the mucosal membrane, periah), suctions, and bandages the wound with cumin powder." It was believed at that time that there was a positive health benefit to the child.
The basic understanding of the Talmud is that metzitzah is not part of the actual mitzvah of Berit Milah. It is performed to prevent any health hazard to the child after the circumcision. In the Talmud, Shabbat 133b, Rav Papa states: "Any mohel who does not perform metzitzah creates a danger, and therefore should be removed from his post." The reason the mohel is removed from his post is not because he failed to perform metzitzah, but because he endangered the life of a child. The Talmud states very clearly: "Mal v'lo para, k'ilu shelo mal." "Someone who was circumcised but for whom periah was not performed, it's as if he was never circumcised." Metzitzah is not mentioned. Referring back to Rav Papa's statement, he said the mohel should be removed from his post. Rav Papa didn't say that the milah was invalid. In Nedarim 32a, we read that if the mohel forgot to perform metzitzah, the milah was valid. Maimonides reinforces this aspect of the Gemara by stating: "After [milah and periah], the mohel suctions the area until blood flows from the far places (away from the wound). He does this so that the (health of the) child will not be endangered."
The key question is: How does one perform metzitzah? There is no description or explanation of how metzitzah was performed. It is implicit that metzitzah was performed orally. In the Shulhan Arukh, Yoreh Deah 265:10, the Rama offers the following commentary: "We spit the blood into the earth." It seems that the mohel had sucked the blood into his mouth.

There were several incidents in Europe during the nineteenth century related to metzitzah b'peh. In 1837, Rabbi Eliezer Horowitz, the Chief Rabbi of Vienna, was consulted regarding a number of children who had become ill (infected) following their circumcisions. Some of the children had died. Dr. Wertheim of Vienna asked Rabbi Horowitz if instead of using oral suction to perform metzitzah, a s'fog (a sponge, or what today we would call a gauze pad) could be used to squeeze the blood from the circumcision site. Rabbi Horowitz, before rendering a final pesak, consulted his teacher, Rabbi Moshe Sofer, the Hatam Sofer who wrote:

Metzitzah b'peh is a requirement of a few of the mekubalim (the kabbalists). Therefore, as long as we can draw the blood out from the faraway places, it may be done in any way. We should rely on the experts regarding which technique is as effective as metzitzah b'peh...Even if the Talmud had stated that one must perform metzitzah with the mouth, metzitzah is not part of the mitzvah of milah, i.e. it is done to prevent danger to the child. According to the halakha, if one circumcises and does periah but neglects to perform metzitzah, he has completely fulfilled the mitzvah." (The letter of the Hatam Sofer was first printed in 1845 by Menachem Mendel Stern in the periodical Kokhvei Yitzhak. The ruling is also quoted in Rabbi Moshe Bunim Pirutinsky's book, Sefer haBerit.)

The Hatam Sofer continued by saying that applying cumin powder is also listed in the Mishnah, yet no one argues that only cumin must be used. Since talmudic times we have found more effective ways of bandaging and achieving hemostasis. This is why there is no halakhic requirement to use cumin powder. The Hatam Sofer argued that based on the Mishnah, no one could say that the mouth alone had to be used to draw the blood out. (The background to these events is the religious battle between the Orthodox and the Reform movements in Germany. During this time, the Reformists were attempting to change and or abolish certain religious practices. Milah, or anything related to it, was high on their agenda.)

In 1888, Rabbi Samson Raphael Hirsch and Rabbi Azriel Hildesheimer, the chief rabbis of Frankfurt and Berlin respectively, publicized a halakhic ruling that metzitzah could be performed using a new instrument, a glass tube. It could be placed over the circumcision site and the mohel could use the tube to suction the blood with his mouth without any direct physical contact. This method seemed superior to the Hatam Sofer's suggestion of a cotton sponge. It protected the health of infant and the mohel. When I was trained as a mohel, my teacher, the former Chief Mohel of Jerusalem, Rabbi Yosef Hakohen Halperin of blessed memory, set up his instruments, which included a glass tube for metzitzah. He took a small wad of cotton and inserted it in the tube to prevent the blood from flowing up the tube and entering the mouth.

Rav Yosef Dov Soloveitchik reported that his father, Rav Moshe Soloveitchik, would not permit a mohel to perform metzitzah b'peh with direct oral contact, and that his grandfather, Rav Chaim Soloveitchik, instructed mohalim in Brisk not to do metzitzah b'peh with direct oral contact, either.

Another element of concern is the elevation of metzitzah b'peh from an ancillary step not even considered part of the mitzvah, to a "halakha l'Moshe miSinai," a law transmitted by Moses on Mount Sinai. The goal is to put metzitzah b'peh out of reach of any change. I have spoken to several ultra-Orthodox individuals, mohels and non-mohels, who have told me that a number of their rabbis have issued rabbinic responsa indicating that if metzitzah b'peh is not performed, the berit milah is invalid!

Five years ago, there was a public controversy related to metzitzah b'peh. An Orthodox mohel had allegedly transmitted the herpes simplex virus to a number of infants resulting in illness and death. The New York City Department of Health ordered the mohel to stop performing metzitzah b'peh. The Department of Health also recommended that metzitzah b'peh not be performed. Needless to say, the outcry form the Hareidi community was great. This was a religious matter in which the Department of Health had no business getting involved! They also disputed the data connecting herpes simplex to metzitzah b'peh. Finally, there were non-religious Jews in the Department of Health who, according to the Hareidi response, wanted to stop metzitzah b'peh and ultimately ban Berit Milah altogether.

This adverse publicity had an unintended affect in the non-religious Jewish community and in the non-Jewish world. Non-religious Jews now associated Berit Milah with illness and death, and instead of having a berit performed by a mohel, they opted to have their children circumcised in the hospital. As for the non-Jewish world, explaining metzitzah b'peh and not have it sound like child abuse was virtually impossible. This was publicity that we did not need.

The prime directive of the mohel is to safeguard the health of the child. If there is the slightest suspicion that the child is not well, we delay the berit. A mohel must also follow the strictest aseptic techniques. His instruments must be autoclaved (heat steam sterilized). Gloves must be worn, the mohel should use disposable blades and so on. I have been told by several of my Hassidic colleagues that they can't wear surgical gloves because it would be looked down upon by the people in their communities. How many times have I seen the mohel place his instruments in a stainless steel tray and pour alcohol on them to soak them prior to the milah; yet certain viruses won't be killed with alcohol alone. I even saw a mohel wearing the izmel (knife) around his neck on a chain! It wasn't until the mid- to late eighteenth century that it was discovered that washing one's hands could prevent the spread of diseases. And at the time, this concept was met with great hostility. Today, this is common knowledge and common sense. There are many ways that a mohel can spread illness to an infant, such as by using dirty or improperly cleaned instruments or not wearing gloves. And now, by performing metzitzah b'peh, we are placing the mouth, the most contaminated part of the human body, on an open wound.

Another very prominent issue related to Berit Milah is jaundice. Jaundice is a yellowish discoloration of the skin caused by increased levels of bilirubin. In the time of the Talmud (and still today), diagnoses were made by using visual methods. If the tint of baby's skin was blue or green or yellow, it indicated that the child had a particular health condition often resulting in the postponement of the berit. Today, we know that jaundice in newborns is normal. We have ways of measuring the bilirubin levels to determine if the jaundice is physiological (normal) or pathological (abnormal). Therefore, if the jaundice is normal, there is no need to postpone the berit. The baby is healthy and the berit may proceed. If a physician determines that the jaundice level is too high and recommends that the berit be delayed, the mohel must follow the directive of the physician. Conversely, the physician may opine that the berit may proceed, but the mohel may overrule the doctor on grounds and delay the berit. Again, every precaution is taken to safeguard the health of the child but we now know that jaundice is normal and should not prevent the berit from taking place. This concept is generally not accepted in the Hareidi community. If the baby is jaundiced, the berit is delayed until the jaundice clears up. Period.

In my opinion, the greatest difficulty as it relates to some in the Hareidi community is to convince them that bacteria and viruses exist, that they cannot be seen and they can cause illness or death. It is possible that a mohel (or baby) can carry a virus (herpes simplex, HIV, etc.), be asymptomatic and still transmit a disease that could result in illness or death. Both individuals appear healthy, yet one can infect and therefore, harm the other. This is clearly a matter of sakanat nefashot, danger to life. Knowing what we know today about the transmission of diseases, a mohel who performs metzitzah b'peh (i.e. direct oral contact) is potentially endangering his health, the health of the child, and the health of the other babies with whom the mohel will have contact that day or that week.

The other element of this discussion is that the Hareidi community does not recognize the opinions of secular individuals or government authority in relation to religious matters. Not long after the metzitzah scandal in 2005, I was a guest on a radio program pitting me, a modern mohel, against a representative of the Hareidi community. The topic was metzitzah. Certain things became very clear to me as a result of that radio program. The Hareidi community does not recognize the opinion or authority of anyone who is not part of their community. When I asked what would happen if it could be shown that a child could become ill, or God forbid, die as a result of a mohel transmitting a communicable disease, the response was that "The people in our communities don't get those diseases. Our people are holy;" and "We have been performing metzitzah b'peh on thousands of babies. How come they did not get sick?" Change, in this case, has been rendered virtually impossible.

For those who demand, insist, or require metzitzah b'peh, it can be performed orally by using a sterile glass or plastic tube. One uses the mouth, yet there is no direct contact. One may also follow the ruling of the Hatam Sofer and use a gauze pad. Metzitzah is performed and the health of the mohel and baby is protected. The custom is fulfilled.

Maimonides wrote "It is impossible to restore the lost life of a Jewish child" (Hilkhot Milah 1:18). This was written to allow the delaying of a berit on a child who is not considered healthy. Similarly, nothing done during a berit should allow the possibility that harm will come to the child, whether it is by unclean hands, improperly sterilized instruments or direct oral contact through metzitzah. Today, Rav Papa's statement might be modified to read, "Any mohel who performs metzitzah b'peh creates a danger, and therefore should be removed from his post." Knowing what we know today about the transmission of diseases, every precaution must be taken to safeguard the health of the child and the mohel.