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Circumcision Troubles

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I have to my credit (or not) several blogs about circumcision in which I contrast my visceral antipathy towards harming a child with my loyalty to an ancient, resilient, and still relevant tradition. I also draw a distinction between a ritual that permanently removes an organ of pleasure and one which is simply superficial. And, at the risk of offending tattoo lovers, I find circumcised penises much more aesthetically attractive than uncircumcised ones, and indeed more than tattoos and body piercings. But I concede unreservedly that this is very subjective and no doubt culturally conditioned.

For over two thousand years it has been enshrined in Jewish law that where the health of a child is at risk one does not circumcise. All the commandments (except for blasphemy, murder, and adultery) are overruled immediately and without reservation where life is at stake. This is why we delay circumcisions until babies are declared medically healthy and why in the case of a child suffering from hemophilia the ceremony would be delayed indefinitely. There are plenty of other halachic precautions.

So how can one explain the sad death of yet another child because a Chasidic mohel passed on herpes when he put his mouth to the wound to draw blood?

The great and very conservative leader of European Orthodoxy, the Chatam Sofer (1762–1839) was asked to rule on the procedure of Metzitzah, mentioned in the Mishna. The mohel sucks the incision site to force a bloodflow through the cut. The Chatam Sofer writes that the original reason for Metzitzah was functional, to protect the health of the child. The flow of blood would disinfect, help healing, and dislodge any blockages caused by the circumcision itself. He argued that, given the health fears raised in his day, Metzitzah with a sponge was acceptable. Opponents of his ruling argued this was an exceptional ruling rather than a general one, and only in response to the threat of the authorities to ban circumcision altogether.

However, the default position of many ultra-Orthodox Jews, particularly Chasidim, is to perpetuate the custom, and thankfully the number of fatalities is minute. On the other hand, the more Modern Orthodox and more Lithuanian Rabbinical Council of America (RCA) recommend using the glass tube or pipette. In its paper on the subject, the RCA brings plenty of authorities, even from the strictest of Eastern European authorities, who either banned or discouraged the direct mouth method.

In Britain for many years, the late Dr. Bernard Homa, head of the Machzikei Hadass community of London, campaigned against Chasidic persistence in using Metzitzah by mouth.  He wrote several articles producing all the halachic evidence, culminating in a pamphlet entitled Metzitzah, published in the UK in 1960.

A few years ago a Chasidic mohel who used the oral method in New York was found to have infected three children with herpes, one of whom died. In response, New York authorities tried to prohibit him from performing Metzitzah b’peh. However, the mohel’s attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease. In September 2005, the city withdrew the restraining order and turned the matter over to a rabbinical court. In May 2006, the Department of Health for New York State, issued a protocol for the performance of Metzitzah b’peh which purported to allow it to continue while still meeting the Department of Health’s responsibility to protect the public health.

Despite the furor at the time until after May 2007, when Fischer was linked to another case of neonatal herpes. At that time he was prohibited by the New York Department of Health from performing Metzitzah b’peh anywhere in the state. But it seems that both he and his community ignored the ruling. The Chasidic communities, being inherently conservative and opposed to outside interference, have refused concessions to modernity (except when their own lives and health are at stake).

Even so, they have been forced to acknowledge the risk and have encouraged the use of disinfectant and mouthwash. But most medical opinion doubts that this is enough. All this quite apart from the risk the mohel runs, himself, of contracting some blood-borne disease the child might have picked up from its parents. But, hey, if he wants to take the risk, no doubt he believes his Rebbe will protect him.

Once again, it is politics that is preventing anything being done. It seems to me axiomatic that if someone causes the avoidable death of anyone, whether through Herpes or AIDS or whatever, he or she should be prosecuted for manslaughter. Still, neither in Israel nor the USA will this happen. Why? Because in certain areas, the dominant Chasidic population can be commandeered by their Rebbes to vote en masse and en bloc. This is a serious factor in many closely fought political constituencies. No one wants to offend blocs of voters, if at all possible. In Europe, the inner-city Muslim vote similarly exercises a powerful influence to stall interference.

We Jews are the first to cry foul. Why aren’t we all crying foul now? I am not suggesting a total ban. After all, we don’t ban sexual intercourse because one can pass on HIV. But I would like to prosecute any mohel who causes the death of a child through a practice that could have been avoided without infringing Jewish law. If one wants to be so holy, then one needs to take very serious precautions to avoid turning sanctity into tragedy.

The case against legislation is interference in religious affairs. But this is not a case of preventing a religious practice. It is not a ban on circumcision. It is merely closing one seemingly optional avenue of religious behavior when others are still open, even in the most diehard of communities.

Political correctness is a serious disease, all the more so when it really causes death. It can lead to the failure to stop terrorism by refusing to narrow down the field of suspects, and it can also put lives at stake by fearing or refusing to interfere with religious practice. If we cannot take the steps to stop it, we must at least enable the courts to.

18 thoughts on “Circumcision Troubles

  1. A 2004 study in the official journal of the American Academy of Pediatrics (http://pediatrics.aappublications.org/content/114/2/e259.full.pdf) concluded that "ritual Jewish circumcision that includes metzitzah with direct oral– genital contact carries a serious risk for transmission of HSV from mohels to neonates".

    Given this fact, and the fact that we have seen more than 15 such infections reported in the media, including at least two resulting in death and at least one case resulting in brain damage, AND given the fact that, as you acknowledge, there are perfectly kosher methods of performing metzitzah which do not require oral-genital contact, why do you not support a complete ban on the practice of metzitzah b'peh?

  2. Those who "perpetuate the custom" do so not because it's a custom, but because they rule it's part of the Torahitic mitzvah of milah. The mishnah says milah requires 3 things: milah (cutting), periah (pealing back the membrain), and metzizah (sucking). And if so, changing how it's done may be tantamount to not having a beris altogether.

    German Jews and Oberlanders (including the Chasam Sofer) held it was a custom based on the then-medical notion of bloodletting, and thus can be altered or even omitted with no halachic outcome.

    It's not what my ancestors ruled, but I have some empathy for those who did. One cannot bring the sources for one side of a dispute, present it as the sole opinion, and thereby question the practices of those who follow the other.

  3. Torah puts a tremendous value on life, and one of the beautiful things about halacha is that it is possible to rely on other opinions when there are compelling reasons to, rather than clinging to a ruling that endangers health, safety, or life.

  4. Anon
    A complete ban would be as ineffective as it was under the Romans to those who believe it is an absolute obligation and a matter of principle. You cannot stop people from choosing to martyr themselves over religious matters. But what you can do is use the Law of the Land to convict them if they cause harm. The example I gave was having sex and infecting someone with HIV. They will prosecuted but you dont ban sex.
    J

  5. You can't prosecute someone for infecting someone through sex unless they knew ahead of time that they were infected and did not inform their partner of that fact.

    Are you suggesting that mohelim only be prosecuted if they KNOW they carry the virus at the time of the bris?

  6. Thank you Micha for your comments.
    You are right for many Metzitzah Be Peh is a full obligation and even something to martyr oneself over. I probably did understate it. And if one accepts the Kabbalah then indeed it is all the more serious.
    That is precisely why I did not argue to ban Metzizah Be Peh ( despite the weight of halacha on the other side). Let everyone follow his religious conscience.
    But, as with autopsies, let the Law of the Land have its say and insist on autopsies when required and prosecute anyone who impedes. Similarly here let it prosecute anyone who causes serious injury, infection or death even if in the course of what they perceive as a religious obligation. The Law does prosecute deaths by Voodoo!!!!. And if it leads to just one life being saved, then Tavo Aleyhrm Beracha.
    J

  7. Anon:
    Yes you are right but halacha is neither monolithic not monochromatic and as you surely know for every halachic argument one way there is often another in the opposite direction. Many Chassidim regard this as such a fundamental issue they almost regard it as seriously as a ban on circumcision altogether. I do not, but then they probably think I'm a lost cause as I do of them.
    J

  8. Anon:
    I suggest that since mounting evidence shows there is a serious chance then I think one can indeed claim negligence. It is indeed like someone who knows he has a high chance of infecting someone and still has sex regardless.
    J

  9. Your last post, about not being able to deny the risks, makes more sense to me.

    But as for not impeding religion, there comes a point where we draw a line.

    You have previously written that you agree with the French ban on religious headgear, even though many Muslims would say it is a real religious requirement for girls and women. And that is not even a life-threatening issue.

    There are a variety of religious practices that are outlawed because they are inherently dangerous or detrimental. They can be prosecuted even in cases where no actual harm was done.

  10. I agree with the idea of laying serious charges on the mohelim whose practice of this leads to illness, injury, or death. But there are two other issues.

    1) Just as you say a ban will not prevent it, wouldn't prosecution just drive the practice underground? Or lead to parents not seeking treatment for infected babies?

    2) Do you believe that parents should also be charged? And either way, don't you agree that they should be informed of the risks of this procedure (just in case they aren't all diehard "it must be done this way" types)?

  11. Anonymous 1:45:

    1- Since most of those who practice it believe it's part of the obligation, yes they would just go underground. In imitation of the Maccabees, actually.

    2- The risks are insignificant. We have a handful of horror stories per hundreds of thousand of brissim. Charging the parents would be like charging the parents of any preteen who (G-d forbid) is injured or killed crossing the street alone — that's a higher risk.

    In the 19th cent, most German and Lithuanian Jews switched over to using a glass straw, which allows the blood to be drawn through oral suction, but no contact between mohel and the baby or his blood.

    Saves the "eww" factor, IMHO.

  12. Excellent points. Yes, the question of where we draw the line is a difficult one and I agree a good case can be made out both ways.
    Most Westerners do not accept a ban on Muslim headgear for women. France is unique in its strictly secular/religious divide, more so than the USA. And my general objection to covering up was and is based on security issues and applied only to the complete head and face covering, not to purely head covering. But in France the Kipa is also banned in public schools etc so if that is the case then Muslim headcovering should be banned too or both allowed.
    J

  13. Yes there is a risk of it going underground but that shouldnt stand in the way of a law. And yes parents should be prosecuted just as Christian Scientists who deny blood transfusions are prosecuted. All Mohels who use Metzitzah be Peh should be obliged to present a written statement to parents of the risks beforehand!
    j

  14. micha,

    The degree of risk is really UNKNOWN. We only know about the 15 or 20 cases that have been reported in the media. Most places do not have a mandatory reporting law for neonatal herpes. We cannot possibly make a statement about the percentage risk.

    All we know is that in cases where infants ARE infected, there is a high likelihood of death or long-term disability (and even for those who don't suffer those consequences, herpes and the treatment for it are no fun for a baby and worried parents to have to deal with, not to mention the cost).

    There are those who think there should be no regulations and only charges if damage is done. I, on the other hand, am comfortable with things like food purity laws, health ordinances, and safety regulations, when warranted.

    People drank unpasteurized milk for thousands of years and only a certain percentage were sickened or died as a result, but I'd rather not take that risk.

  15. Why can't they use dental dams? If none are manufactured that are suitable it's a niche opening in the market. They could be made in small, medium and large — or Vandyke, Lenin and Lubavitch, to accommodate different degrees of bushiness in beards. Or with flavours. Or in different coloured latex. The manufacturing plants could be inspected and blessed. Extra revenue could be generated by making kosher for Pesach circumcision dental dams. For people with usually an extraordinary vigilance against microscopic potential impurities, the opportunity to really get to work on the halacha of latex dental dams would surely be irresistible.

  16. Well they could practice. Ask the wife for some cling film, the stuff usually used to wrap sandwiches, and while away a dull evening in front of the box, trying to get a good suck. Then report back to Circumcision Dental Dam Headquarters on the thickness, thinness, floppiness, breadth and width of the fabric, until armed with sufficient reports on the suction possibilities, a glatt kasher prototype neonate dental dam would be produced for further testing. Mandatory attendance at lessons in what to do with a dental dam will be vigorously enforced. At the end of the training, certificates will be issued for grades sucker, super sucker and suckiest. If none of this appeals, they could just enter the same century as the rest of us, and face the consequences if they accidentally kill someone.

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