Safeguard or hazard?

A part of circumcision long believed to heal can cause the very problems it was meant to prevent.

By SAM SOKOL
Bris instruments (photo credit: Wikimedia commons)
Bris instruments
(photo credit: Wikimedia commons)
Anyone reading the news out of New York City over the past several months will almost certainly have come across articles dealing with a somewhat surreal Jewish rite known in Hebrew as metzitza b’peh. Metzitza, also known as oral-genital suction, is a custom in which a mohel (pl. mohelim), or Jewish ritual circumciser, applies direct oral suction to the still open circumcision wound of a newborn infant. Originally enacted by the rabbis of the Talmud as a measure to safeguard the health of the infant, the practice has come under increasing fire over the past century. Since the acceptance of the germ theory of disease, many leading rabbis have advocated either changing or completely abolishing the practice of suctioning the genital blood of those newly inducted into the covenant of Abraham.
In contemporary New York, the controversy revolves around 11 reported cases of herpes over the past decade, all of which were allegedly transmitted by mohelim. In two cases there were fatalities. The New York Board of Health, which has been tracking these cases, recently released a study under the auspices of the federal Centers for Disease Control detailing what they have concluded to be the dangers of this practice and calling for its avoidance.
According to the CDC, infants who undergo metzitza b’peh “had an estimated risk 3.4 times greater than the risk for HSV- 1 or untyped HSV infection among male infants unlikely to have had direct orogenital suction.”
“Oral contact with an open wound in a neonate risks transmission of HSV and other pathogens. Professionals advising parents and parents choosing Jewish ritual circumcision should be aware of this risk, and direct orogenital suction should be avoided,” the CDC concluded.
New York Health Commissioner Thomas Frieden was recently cited in The New York Times saying that the transmission of herpes by way of metzitza is “somewhat inevitable to occur as long as this practice continues, if at a very low rate.”
However, that low rate is enough to have the entire practice banned, at least from a Jewish legal (halachic) perspective, many Orthodox critics of the practice say. Rabbi Dr. Moshe Tendler, the son in law of Rabbi Moshe Feinstein, the late leader of American Orthodoxy, and a professor of medical ethics at Yeshiva University, stated that “the rule that’s above all rules in the Torah is that you cannot expose or accept a risk to health unless there is true justification for it. Now we have several cases of herpes in the Metro area... all we are talking about is presumptive evidence, and on that alone it would be improper according to Jewish law to do oral suction.”
While the American authorities and rabbis affiliated with the modern Orthodox movement have condemned the practice in the face of evidence that it more than triples the risk of contracting herpes, the ultra-Orthodox community both in New York and in Israel, where metzitza is much more common, have rallied to defend what they see as an assault on Judaism.
In fact, The Jerusalem Post has learned, up until several weeks ago the Chief Rabbinate was actively pushing the practice.
In a letter obtained by this newspaper, Rabbi Moshe Marciano, the head of the Inter-Ministerial Committee on Circumcision, instructed mohelim certified by the rabbinate to notify parents that they would be performing oral suction. Only if the parents refused, the letter stated, were the mohelim to explain that alternatives exist within the Jewish tradition.
The alternative is the use of a glass or plastic tube to suction the blood from the wound without direct oral contact. This practice, endorsed by the late 19th-century ultra-Orthodox leader Rabbi Moses Schreiber, also known as the Hatam Sofer, came about in response to widespread worry over a rash of cases of infection caused by metzitza.
The Hatam Sofer, known as one of the founders of the stream now known as ultra-Orthodoxy or haredi Judaism, believed that once opposition to a precept was expressed by other streams of Judaism or by the secular authorities that it was incumbent on devout Jews to raise that precept, no matter how trivial, to the level of a divine command.
While Schreiber himself saw the use of pipettes as legitimate, his students, acting in the context of opposition to the Reform movement, declared the use of oral suction to be an integral part of the commandment of circumcision, without which it would remain incomplete. To his students and later haredi leaders, any attack on metzitza was an attack on Judaism itself.
Critics in Israel are not only angry at the rabbinate’s policy of promoting the practice in what they see as a duplicitous manner but also because the Health Ministry, which is currently controlled by the haredi United Torah Judaism party, has long since maintained that circumcision and related medical issues do not fall under its purview and has refused to investigate the medical ramifications of metzitza.
Speaking to the Post, Rabbi Dr.
Mordechai Halperin, the Health Ministry’s chief officer of medical ethics, declared that the ministry does not oversee circumcision in any way and that it falls under the purview of the Chief Rabbinate exclusively.
This was confirmed by an email from the ministry stating that the matter of circumcision is the responsibility of the Religious Affairs Ministry.
However, Halperin’s statements were contradicted by Marciano, who says that the Inter-Ministerial Committee on Circumcision, which formulates guidelines for mohelim, is comprised of both the Health Ministry and the Chief Rabbinate.
He expressed surprised that the ministry would deny its role in this matter.
The ministry fields several representatives to the committee, among them Dr.
Moshe Westreich, a plastic surgeon.
“The position of the Health Ministry is that circumcision is a religious practice.
This is not considered a medical procedure insofar that it has to be under the auspices of the ministry. Given that, because there is some sort of a medical connotation to it, even though it is not under its jurisdiction, the ministry does work with the rabbinate and the Religious Affairs Ministry in an inter-ministerial committee to provide oversight,” Westreich says.
This is the same committee whose head, Marciano, has endorsed metzitza and called for its promotion, critics charge.
Westreich has called the methodology of the CDC’s research into question, saying that there was no science to support the claim that oral contact with an open wound could transmit infection.
“There is no science to base an answer on,” he said. “When you think about it, when you were a kid and you cut your finger and you started bleeding, what was the first thing you did? You stick it in your mouth and you suck on it.”
The American Urological Association seems to disagree, having adopted the recommendations included in the CDC report.
He said that while some research was done on the health effects of metzitza by the committee itself, by directly polling mohelim, the ministry has not engaged in any organized research into the potential health risks.
Since the CDC report came out, Westreich says, the ministry has begun conducting research, a claim that the ministry itself denies.
In response to the CDC’s allegations, the Inter-Ministerial Committee drafted a counter-report, a copy of which was obtained by the Post, in which the committee contends with the New York Board of Health’s numbers and argues with the American researchers’ methodology.
“In general, there are situations in daily life, involving adults and children alike, that involve far greater risks than the assumed risks of MBP,” the report states.
“Examples of these are: parents allow cosmetic surgery for their children even when there is no real medical indication; parents allow their children to participate in dangerous competitive sports, parents allow children to cross busy streets, etc. In such instances there is no demand to eliminate these activities even though they have associated risks which are far greater than those associated with MBP.”
As such, “According to current medical and halachic information available to us, we are of the opinion that there is no need to ban metzitza b’peh for those halachic authorities [poskim] that consider this action a vital, integral part of the traditional observance of ritual Jewish circumcision.”
The report, which was written in part by Westreich and was reviewed prior to publication by Health Ministry ethicist Rabbi Halperin, states that “without a general or specific halachic decision by one of the great contemporary halachic authorities,” later referencing the late Rabbi Shalom Elyashiv, “MBP should not be stopped.”
The report, which is non-binding as mohelim are not legally required to be licensed by the committee, states that in “appropriate circumstances the mohel should offer the parents the choice between MBP and suction by tube [pipette], and if the family prefers MBP the mohel should inform the family of the small risk of infection, including neonatal herpes, and obtain their informed consent.”
The report did not elaborate on what constitutes “appropriate circumstances.”
Despite the committee’s attacks on the American report, the New York Board of Health did applaud the Israeli decision to require informed consent.
“We agree with the Inter-Ministerial Committee on Circumcision’s final recommendations that parents should be informed about the risk of infectious diseases, including herpes, from direct oral suction, that mohelim should obtain consent from parents before performing direct oral suction, and that mohelim should offer parents safer alternatives to direct oral suction. In fact, these are all steps we are proposing to put into place in New York City,” the board stated in an email to the Post.
The report also recommended that a mohel about to perform metzitza “rinse his mouth with wine, spirits, 70% alcohol, or a mouthwash containing [over] 25% alcohol.”
Westreich admitted, however, that he has “no idea” if this precaution could serve to mitigate the potential risks of metzitza. “It certainly could not hurt,” he says.
Westreich, writing on behalf of the Committee as a representative of the Health Ministry, derided the CDC’s research, writing that “there is no scientific proof in the cited publications regarding the etiologic connection between MBP and neonatal herpes.”
“In addition, halacha in general, including the rules of pikuah nefesh [life-threatening situations] does not require us to totally eliminate every possible risk in performing mitzvot or other activities in our daily lives. Automobile travel with children in the vehicle in Israel involves a much greater risk to the child than the danger of neonatal herpes after MBP, but there is no obligation to refrain from automobile travel. Many daily occupations involve different degrees of possible risk to life, and yet we are permitted to take these risks.”
The report also cites the Elyashiv, the former leader of ultra-Orthodox Jewry in Israel. Elyashiv, according to the report, stated that “it has been determined by specialist physicians in the US and Israel that there is no concern that MBP, as practiced for generations, will God forbid cause damage to the newborn being circumcised...
all the talk of eliminating MBP is nonsense talk.”
However, Dr. Shlomo Sprecher, an American expert on the history and medical ramifications of the practice, disagrees.
According to Sprecher, metzitza’s origin came from rabbinic medical concerns based upon the Greek medical practice of the day. The accepted Greek view was that the body’s health depended upon the balance of four distinct “humors” and that not suctioning the wound would allow these elements to become unbalanced and thus pose a risk to the child.
“The entire talmudic reference to the act of metzitza [note, the Talmud never specifies nor utilizes the term ‘by mouth,’] consists of the following few lines of text.
There is a mishnaic dictum that reads: ‘We perform all the necessities of circumcision on Shabbat: We may circumcise, uncover and draw out, and we place upon the wound a bandage with cumin powder.’ Rav Pappa adds the following comment: ‘The expert surgeon who does not draw out is a danger.’ The Gemara then questions the need for Rav Pappa’s comment – the Mishna specifically allows the drawing out to be done on Shabbat, which entails a violation of Shabbat law, a waiver of which can be due only to circumstances of danger!” Should a practice established to prevent medical complications be found to cause them, Sprecher believes, a reevaluation of the necessity of the original enactment is in order.
THE HAREDI refusal to accept the original medical nature of metzitza is symptomatic of a larger rift between the modern and ultra-Orthodox camps, Rabbi Natan Slifkin believes. Slifkin, an expert on the conflict between science and tradition, especially as it relates to the haredim, recently explained in an essay that haredim are, for the most part, unwilling to believe that the sages of the Talmud could be mistaken regarding basic scientific facts and that any claims regarding nature included in the Talmud must be part of the Revelation from Sinai. This rift is the basis of the fight over metzitza.
Between the fight to protect and elevate the status of any precept that is perceived to be under attack and the general haredi antipathy towards a rationalist reading of scripture, there is little possibility that the haredi establishment will change its mind about metzitza any time soon.
The crux of the matter, explain many critics of metzitza b’peh such as Sprecher and Tendler, is that when the original rationale for the practice is discarded, there is no reason to continue performing oral suction, especially as it can, even if rarely, cause the very problems it was meant to prevent.
Besides the debate over the potential danger of the practice of metzitza, however, lies another, just as contentious issue: that of the government’s willingness to disregard its responsibility to investigate potential public health risks and the increasing role of anti-Zionist ultra-Orthodox elements in the state rabbinate.
One statement in the Westreich report that has raised particular ire is a letter appended from Rabbi Y. Efrati to Dr. Avraham Steinberg, one of the authors of the report, on behalf of Rabbi Elyashiv.
“Concerning your suggestion that the Supervisory Committee of Mohelim should issue an instruction that ‘a mohel who is suspected of transmitting herpes infection to more than one baby should not perform metzitza b’peh himself but rather appoint someone else to do so’ – I hereby inform you that in the opinion of Rabbi Elyashiv they can issue such an instruction.”
This letter permitting the committee to issue its report, Westreich explained, was included due to the likelihood that haredim would otherwise ignore his recommendations.
Using Elyashiv’s imprimatur could, he believes, secure haredi support.
On the other hand, Rabbi Uri Regev asserts that including Elyashiv’s statement indicates that the rabbinate, an arm of the state, is taking its marching orders from the former leader of the ultra-Orthodox.
Regev is a Reform rabbi who, through his NGO Hiddush, has been involved in some of the most contentious issues of religion and state in Israel today.
“The rabbinate has demonstrated its inability to stand up to extreme influences within the haredi community,” Regev states. “The rabbinate itself is becoming controlled more and more by haredi circles in the religious community and therefore, unfortunately, I wouldn’t expect it to do the right thing. That makes the need for the Ministry of Health to intervene in the matter all the more crucial.”
However, he believes, a general desire on the behalf of the secular authorities to minimize conflict with the haredim, in conjunction with the current haredi leadership, under de-facto Health Minister Ya’acov Litzman (UTJ), has led to a situation in which the guardians of public health refuse to get involved.
“There is no doubt in my mind that ministry officials understand that their chief would not look kindly at them imposing medical criteria and medical considerations in an area which his rabbis hold to be out of bounds for them,” Regev says.
“This is one point that is beyond the merits of just the MBP but has to do with the fact that I hope Israel will wake up and the government agencies wake up and understand and realize that they can no longer hide behind years of neglect of their responsibility in thinking that the fact that this has been a religious domain can exempt them from exercising their responsibility for public health.”
Responding to the committee’s claim that metzitza does not pose a enough of a danger for its continued practice to be reevaluated, Regev says that he is “devastated to think that any rabbi would claim that putting people’s health in danger to the point of recorded cases of infant mortality is within the level of tolerance. I think it is shameful and in clear contradiction to anything that I know of Judaism which first and foremost stands for the preservation of life.”
However, until there is a public discourse on this issue and the medical authorities in Israel perform the necessary studies, it seems that this issue will continue to be dominated by polemics, without a much-needed resolution one way or the other.