- Medical and Halachic
1. Medical Background
Historically, circumcision has always been performed on infants without any anesthesia. This is true both with respect to halachic Jewish circumcision and to surgical removal of the foreskin, as performed in many parts of the world.1 This continued to be the case even after anesthesia was developed and used extensively in various medical procedures, including surgery and childbirth.
There were several assumptions underlying this approach:
• The assumption that newborns do not feel pain to any significant sense as do grownups.
• The assumption that surgical removal of the foreskin is done quickly, with little associated pain.
• The assumption that newborns quickly forget the sensation of pain, leaving no emotional problems.
• The assumption that no procedure should be undertaken that might endanger the infant, since the risk of circumcision itself is very low.
The Situation at the End of the Twentieth Century
This period saw some changes, in light of certain developments:
• Medical science came to recognize and the public became aware, that even infants suffer from pain and have a negative experience as a result of pain.2
1 See the article on circumcision in the author’s Encyclopedia of Medicine and Halacha and Wiswell TE, N Engl J Med 336:1244, 1997.
2 Anand KJS & Hickey PR, N Engl J Med 317:1321, 1987; Butler NC, Bioethics 3:181, 1989; American Academy of Pediatrics, Pediatrics 103:686, 1999; Maxwell LG and Yaster M, Arch Pediatr Adolec Med 153(5), May 1999.
This assumption, that even newborns suffer from pain, was proven in a number of ways: studying babies’ behavior (face and eye movement, body movement, etc.) while subjecting them to a painful stimulus; timing the length of their crying and studying the nature of their crying; measuring the levels of various substances that the body secretes as a reaction to pain.
• The development of effective and safe palliation and anesthesia, which permit reducing and/or avoiding pain, even in infants.
In light of these developments the American Academy of Pediatrics recommended anesthesia in performing painful procedures in infants. In addition there were suggestions, requests, and recommendations regarding pain reduction for the newborn during circumcision.
Several specific suggestions were made to reduce pain during circumcision:
Local injection of 0.5-1 ml/kg of the anesthetic lidocaine (1%) at the base of the penis at 10 and 2 o’clock. This method was first suggested in 1978. Its advantages: good, complete anesthesia in 5070% of the cases.
Disadvantages of this method: significant pain in administering the injection at a particularly sensitive location; the effect attenuates quickly, leaving discomfort after the circumcision; possible complications, such as hemorrhage, necrosis, and absorption of lidocaine into the circulatory system, which can cause irregularities in heart rhythm, hypotension, convulsions, and auditory disorders; and the need of a physician to perform the circumcision.
Weighing the benefits and the potential dangers in using lidocaine, the American Academy of Pediatrics refrained from recommending it in performing circumcisions on infants. At a later date, however, the Academy formulated a policy mentioning only some of the disadvantages without rejecting the use of lidocaine. Other researchers dissociated themselves from the use of lidocaine in circumcision for other reasons.
Injection of 1 ml of lidocaine (1%) in a ring around the circumference of the middle of the penis or the base of the forskin for local anesthesia. In this procedure the same concentration of lidocaine is used as above.
Advantage of this procedure: better anesthesia than any other local method. Disadvantages: local pain due to the injection itself. According to the few reports available regarding this method, no complications were observed. In theory the same complications resulting from injection of lidocaine at the base of the penis are likely to arise in this method as well.
Spreading a cream with various concentrations of lidocaine locally on the area of the foreskin about an hour before the circumcision. Some practitioners used a 4% concentration of lidocaine in an acidic cream. The efficacy of the method is not high. Others used a 30% concentration of lidocaine with better results.
Still others used an EMLA cream (i.e., eutectic mixture of local anesthetics) containing 2.5% lidocaine and 2.5% prilocaine with good results. This method requires topical application of 1-2 gr of the EMLA cream about 1-1.5 hours before the circumcision.
Advantages of this method: good anesthesia in many patients; complete absence of side effects because the active ingredients are not absorbed into the blood stream as long as no more than 2 gr are applied; the anesthetic effect lasts for several hours after application, thus reducing discomfort even after the procedure; ease of application; appropriate for use by ritual mohalim who are not physicians. Disadvantages: lower success rate than local injection of anesthetic; waiting time between application and the circumcision procedure.
Administering sucrose with a vinyl nipple. In this method a nipple is dipped into 50% solution of sucrose. A gauze pad dipped in the sucrose is also inserted into the nipple. The circumcision procedure is begun around two minutes after the infant has begun to suck on the nipple with the sugar solution. During the entire procedure, the nipple is held in place in the baby’s mouth. From time to time, the gauze pad is dipped again in the sugar solution and returned to the nipple.
Advantages of the method: high efficacy in preventing pain throughout the procedure; ease of application; complete absence of complications; no waiting time between the application and the procedure; appropriate for use by ritual mohalim who are not physicians. Disadvantages: the efficacy of the method is somewhat less than that of locally injection anesthesia.
Administering palliative medication. In this method 15 mg/kg of acetaminophen (paracetamol) are administered orally every 6 hours beginning two hours before the circumcision and continuing 24 hours after it.
Advantages of this method: from the medical point of view, the medication is safe even for newborns, without any side effects; the medicine is in general palliative for mild to moderate pain in small children. Disadvantages: no positive indications have been found that pain levels during the procedure and immediately after it are affected. However, there is a positive effect beginning a few hours after the circumcision. These disadvantages can probably be overcome by two changes: increasing the dosage or by administering the medicine more frequently; but this has not been investigated, and there are no data regarding the efficacy or safety of these changes.
Combining methods. Some have demonstrated that no one method is sufficient. They recommend combining lidocaine injections, EMLA cream, acetaminophen and a sucrose nipple. This combination has been found to be more effective in reducing pain than any individual method. 
II. Halachic Background
All agree that circumcision as a Jewish ritual was traditionally performed without any form of anesthesia. This is true both for the circumcision of eight-day-old infants and adults, as in the case of converts or Jews who were not circumcised as infants. It is also clear that since the introduction of various methods of anesthesia, it is now possible to perform the procedure without any sensation at all or with greatly reduced levels of pain. Today, the use of anesthesia is quite common in adult circumcisions. There are places where general anesthesia is used; and there are places where general anesthesia is used only for children, local anesthesia being reserved for adults. In the world of medicine the first suggestions for using local anesthesia in the circumcision of infants were made in the first two decades of the twentieth century. 
First, let us consider the position of the poskim regarding the use of anesthesia in the circumcision of an adult.
The earliest discussion of this question appeared in Tel Talpiot (1896). There, rabbis disagreed on the permissibility of using chloroform as a general anesthetic in the circumcision of an adult Jew or convert. There was further discussion regarding general anesthesia in the circumcision of converts in Ha-Me’assef (191314).
Rabbi Meir Arik wrote the first systematic responsum dealing with the question of local anesthesia in the area of the circumcision for a thirty-year-old patient.
The question of anesthetizing an eight-day-old infant for circumcision was first raised recently.
Summary of the opinions of the poskim:
Some poskim discuss anesthesia only in connection the circumcision of newborns. Others add adults to the discussion Some discuss only general anesthesia. Others discuss local anesthesia. Some discuss both.
In short, those who prohibit anesthesia in adults certainly prohibit it in newborns. But some of those who prohibit it in newborns permit it in adults. Similarly, those who prohibit local anesthesia certainly prohibit general anesthesia. But some of those who prohibit general anesthesia permit local anesthesia.
Some prohibit both general and local anesthesia, both in newborns and in adults.
Some prohibit both general and local anesthesia, both in eight- day-old babies and in adults. But they allow anesthesia in adults in certain circumstances, for example in older people, in cases where the procedure is more complicated and would cause great pain, or in correcting awkward presentations where the surgery requires more time than ordinary circumcisions and would therefore cause great suffering. In such cases, they see no problem with local anesthesia. Similarly in the case of an adult who, through no fault of his own, was not previously circumcised as, for example, in the case of man whose older brothers had died because of 31 circumcision.
One authority prohibits all forms of anesthesia, even local anesthesia, in newborns up to one year old. But he permit local anesthesia in adults or in babies over one year of age.
Other authorities prohibit both general and local anesthesia in newborns, but are in doubt about the permissibility of anesthesia for adults.
Some poskim prohibit all forms of anesthesia, even local anesthesia in the routine circumcision of a newborn. These poskim did not express an opinion regarding adults.
There is an opinion prohibiting general anesthesia in adults, without expressing an opinion regarding local anesthesia.
Some prohibit general anesthesia both in adults and babies, but permit local anesthesia in both.
Others permit anesthesia in adults, even general anesthesia, without expressing an opinion with regard to newborns.
Still others permit local anesthesia for babies as long as it entails no threat to the baby’s life.
Objections to Anesthesia in Circumcision
Innovation - Anesthesia constitutes an innovation, a change with regard to earlier practice. It is inherently prohibited to change traditional practice and we ought not try to be clever and innovate new procedures in opposition to the will of the Creator and Jewish practice. “The Torah prohibits innovation.”
Pain - Circumcision requires pain, as is clear in the Midrash:
R. Levi said: It is not written that Abraham circumcised [himself]. Rather it is written “Abraham was circumcised.” He examined himself and saw that he had no foreskin.
R. Abba bar Kahana said to R. Levi: You are a liar; he felt [the pain of circumcision] and suffered in order to increase his reward from God.
It follows that circumcision was originally instituted with suffering. It has further been written “that everyone should consider his own suffering when [the baby] cries from the pain of circumcision because his voice rises without the impediment of any evil that his prayer might include.”
The Covenant with God - The commandment of circumcision might indeed be fulfilled when the foreskin is painlessly removed. But the fulfillment of the covenant between the newborn and God requires that he feel the cutting away of the foreskin and some bleeding. Without this, there can be no fulfillment of the covenant.
The Sages were Familiar with Anesthesia - In the Talmud we learn:
We must calculate how much one would pay to have one’s arm amputated with a drug.
Rashi explained: "With a drug - with a drug there is no pain in amputation".
Although it is clear that they were familiar with them, anesthetic drugs were never used in conjunction with circumcision It follows that pain is a requisite element in circumcision according to the earlier authorities.
Agency - The mohel is the agent of the person he is circumcising. If the person being circumcised is not conscious, he cannot appoint the mohel his agent.
Intention - Fulfillment of the commandment of circumcision requires intent. If the person being circumcised is asleep, he cannot have the requisite intention to fulfill the commandment.
God’s Will - God intended the commandment of circumcision to be performed with pain. If so, we surely cannot do anything to lessen the pain. God wants the infant to understand at his tender age that it is impossible to attain virtue without suffering. All spiritual improvement involves pain.47a
Danger - There is some threat to life in all forms of anesthesia It is entirely prohibited to endanger the person being circumcised.
Rejection of the Objections against Anesthesia
Innovation - It is true that the great Orthodox rabbis strongly opposed any changes in the performance of ritual circumcision because reform leaders in the past repeatedly tried to introduce such changes. Therefore, they went to length to reject any such innovations. Here are a few examples:
Opposition to cutting the foreskin with any instrument except a metal knife; opposition to use of any kind of protection; opposition to uncovering the corona by any means except using the fingernail; opposition to any method of suction except using the mouth.
Nonetheless, many authorities have agreed to innovations in certain limited circumstances when it is clear that the innovation is justified and does not conflict with any halacha. For example, many permit uncovering the corona with an instrument instead of the fingernail. And many have agreed to suction with an instrument instead of the mouth.
Further, some have objected only to innovations that involve the essential elements of circumcision while permitting incidental changes like introducing antiseptic methods for preventing infection despite the fact that in previous generations such methods were unknown.
Use of local anesthetic seems to be quite far from any infringement against the commandment of circumcision. If there is a rational reason for such anesthesia and if there is no substantial prohibition and no connection to the essential elements of the commandment, why should anesthesia be prohibited?
According to those who object to anesthesia in circumcision because it conflicts with fulfillment of the commandment it is clearly prohibited to use any form of anesthesia. But if using anesthesia does not conflict with fulfillment of the commandment and if the purpose behind anesthetizing the patient is to reduce pain rather than to adversely affect the performance of the commandment, there is no reason to object to this innovation more than to any other innovation.
In addition, those who prohibit local anesthesia in routine circumcision because it is an innovation and nonetheless permit anesthesia in certain complicated cases or for adults must in any event approve of some innovation unknown in previous generations. Anesthesia was, of course, unknown in earlier generations even in complicated cases. If so, we must conclude that it is acceptable to discuss which innovations are permitted and which are prohibited.
Although there are some contemporary authorities who object to any form of anesthesia for adults, it is in fact the common practice to use local or general anesthetic in every circumcision of a child or adult. A large scale study of circumcisions performed on immigrants from the former Soviet Union who had not been circumcised in their country of origin and who were subsequently circumcised in Israel in accord with the guidelines of the Israeli Chief Rabbinate presented the following data: In the years 1990-92 there were 2,857 males between the ages of 1 and 64 circumcised at the Soroka Medical Center in Beer Sheva. Fourteen percent of them were circumcised under local anesthesia and 86% under general anesthesia.
Therefore, it would seem that the decision must be based on the consideration of whether the innovation of anesthesia does not conflict with any halachic principle.
Pain - There is no source in the Torah, in halacha, or in kabbala requiring that circumcision be accompanied by pain. There is no source in talmudic literature, the Zohar, or the medieval or modern authorities that considers pain to be part of the fulfillment of the commandment of circumcision.
The poskim adduce only one source regarding pain in circumcision. It is a Midrash according to which Abraham desired pain in circumcision in order to increase his reward for performing God’s commandment. There are, however, two reasons why this source cannot serve as proof:
(1) The Midrash implies that Abraham desired to increase his pain in order to increase his divine reward, but it follows that simple fulfillment of God’s commandment does not require pain This is certainly not a proof that pain is obligatory;
(2) Abraham’s greatness and righteousness are incomparable; he surely accepted pain upon himself wholeheartedly and with pure intention. This surely does not imply that he was obligated to do so The great patriarchs determined to accept an extra measure of pain in fulfilling God’s commandments because of their love for the commandments. Thus it was with Abraham. This cannot imply any objection to anyone else avoiding pain in circumcision. Abraham acted out of supreme love of God. His behavior cannot mandate that we too perform God’s commandment with a similar level of devotion.
Since Abraham circumcised himself, one may argue that he desired to increase his divine reward by increasing his pain. But there is no reason to call upon a father to increase the suffering of his baby son in order to increase his son’s divine reward. 
Although the commandment of circumcision was first performed by Abraham, its principal authority does not derive from Abraham. Rather, the principal authority for the commandment of circumcision derives from God. Therefore, it is not necessary that the commandment be performed as Abraham did it. We do not, for example, call upon anyone to circumcise himself as Abraham did.58
Further, there are other, opposing opinions in the Midrash regarding Abraham’s pain in circumcision. In a different passage we read that Abraham was circumcised by a scorpion that God sent to him. Further, the earlier authorities make clear that God assisted Abraham in circumcising himself. These authorities make no mention of pain; it is reasonable to assume that God would not Himself cause pain.
The second source, “that everyone should consider his own suffering when [the baby] cries from the pain of circumcision because his voice rises without the impediment of any evil that his prayer might include,” is surely not sufficient to block palliative treatment of the person being circumcised. The thrust of the passage is simply that a person who is suffering should raise his voice in prayer because such prayer will be heard on high without any impediment. Even this idea has no earlier source.
Further, the leading kabbalist of Jerusalem has been quoted as saying that he searched the Zohar and other kabbalistic works and did not find any special mention of the infant’s pain during circumcision. On the contrary, the Zohar clearly indicated that the pain of childbirth atones for the sin of Eve. Nonetheless, no one has ever objected to efforts to minimize that pain.
It would further seem clear that those who favor pain in circumcision in order to increase divine reward are only referring to adults who can understand the significance of pain and its purpose But what purpose can pain in newborns have? Newborns have no understanding at all! It is incomprehensible that some authorities require pain only in newborn circumcisions but not for adults. This position is indeed problematic.
In light of all this, we can understand the opinion of the rabbi who wrote:
There is no need for the circumcision to cause pain. It is impossible that halacha would require the act of circumcision to cause pain. This idea has no source. Since none of the principal authorities and none of the poskim mentioned such a fundamental idea as requiring pain in circumcision, we may conclude that there is absolutely no reason to require pain in circumcision.
Another great rabbi wrote:
We have found no source for a commandment to cause pain in circumcision. Abraham desired divine reward for the pain he suffered in his circumcision in accord with the principle “as the pain is great, so is the divine reward.” But there is no compelling reason to require pain in a child who has no capacity to understand the meaning of the pain he experiences.
One contemporary posek concluded:
One should not use general anesthesia because it is unhealthy. Therefore, general anesthesia is not used in circumcising children. The objection to general anesthesia is not based on halachic grounds, nor is it based on mystical considerations when we know of no obstacle and no hindrance, for the sages in every generation know both the literal and the mystical principles of fulfilling the commandment.
Even those who require pain in circumcision prohibit only a drug that would entirely eliminate sensation in the penis. But applying a local anesthetic cream, and certainly administering sucrose, can only reduce, but not entirely eliminate, the sensation of localized pain. No one has proposed that there is a specific level of required pain. Therefore, even according to this opinion, it is sufficient that the infant experience some pain.
The Covenant with God - The approach here is similar to the approach regarding pain. Although there is some reason and proof that pain must accompany circumcision, the palliative methods mentioned above in the section on medical background do not completely eliminate sensation. They merely reduce the level of pain and its duration. It would seem that those who require experiencing pain do not have in mind any specific level of pain. It follows that according to them even reduced levels of pain should be sufficient to fulfill the covenant between the newborn and God.
The Sages were Familiar with Anesthesia - The Sages’ refraining from using anesthesia with which they were familiar proves nothing in our case. There are several reasons why no proof can be brought in this case from the Sages:
The drug mentioned by the Sages was used in the amputation of a limb. A straightforward reading of the Talmudic passage indicates that they were referring to a drug that would accomplish the amputation, not an anesthetic drug. This is consequently no proof that they were familiar with anesthetic drugs.
In a similar vein we can explain the Talmudic passage mentioning a drug in connection with the boring of a hole in the ear of a slave. This too should be taken to refer to a drug that, when placed on the ear, causes a hole to form. This interpretation fits with the other means of forming the hole that are mentioned in that passage.
The surgery of R. Elazar b. Shimon71 is at first glance a clearer source for anesthesia in the days of the Sages since the drug mentioned induced sleep. This however is also no proof that they were familiar with anesthesia because the drug mentioned was probably dangerous. Such a drug is of course prohibited in circumcision; only in major, essential operations like the surgery of R. Elazar b. Shimon would it be permitted.72 It is further unlikely that the drug was commonly available.
In fact, the drug was rarely used and circumcision was of course quite common.
Even if the Sages were familiar with anesthesia and refrained from using it in circumcision, it must also be true that they refrained from using it in childbirth as well. Further, they refrained from using it to palliate Rabbenu ha-Kadosh’s great pains and let him die rather than suffer.73
In a similar vein R. Chanania b. Tardion was not treated with any anesthesia.74 There are numerous other examples of Talmudic passages describing pain with no mention of anesthesia.
In any event, there is no source in halachic literature prohibiting anesthesia or other palliative treatment for pain in childbirth, where it would seem more reasonable to be strict because of the verse: In pain shalt thou bear children.75 Nor is there any source prohibiting anesthesia or pain relief in suffering terminal patients.76
In general, the Sages opposed unnecessary suffering, aside from some extraordinary cases.77 It follows that the Sages would permit preventing the pain of circumcision whenever possible.78 The Sages’ silence regarding the use of anesthesia in circumcision can clearly not prove that they prohibited it.
Agency - Some authorities have proven that even an adult can fulfill the commandment of circumcision while under general —
71 Bava Metzia 83b.
72 Resp. Avnei Zikkaron 3:3.
73 Ketubbot 104a.
74 Avoda Zara 18a.
75 Gen. 3:16.
76 See the extensive discussion on the permissibility of palliative treatments in terminal patients in the author’s Encyclopedia of Medicine and Halacha, s.v. noteh lamut (1), n. 302 ff.
77 See the author’s Encyclopedia of Medicine and Halacha, s.v. yesurim, n. 176 ff.
78 Resp. Mi-Ma’amakim 2:15; R. A. Baron in Ha-Darom 58:13, 5749. anesthesia. There are several reasons why unconsciousness does not detract from the fulfillment of the commandment:
Although he is asleep, the deed of circumcision is still performed. It follows that if someone appointed an agent prior to going to sleep or prior to undergoing anesthesia, the appointment is valid and being unconsciousness does not detract from the fulfillment of the commandment.79
This conclusion seems inevitable because if a man appoints an agent to betroth a woman for him in some distant place and the agent goes and does it at a moment when the man who sent him is asleep, the betrothal is surely valid.
Agency is invalid in commandments that depend on the one’s person, but the commandment of circumcision merely requires that a person be rid of his foreskin. Further, the act of circumcision does not require a valid agent since a minor is qualified to do it80 although minors are disqualified as agents. 81
If all this is correct with respect to the circumcision of an adult, is it all the more correct with respect to the circumcision of an eight-day-old baby, since in such a case it is the baby’s father who appoints the agent. Now the father is certainly conscious even if the baby is asleep or anesthetized. It follows similarly that local anesthesia does not detract from the fulfillment of the commandment.
Intention - The poskim have proven that absence of intention to fulfill the commandment of circumcision does not detract from the fulfillment of the commandment. There are several reasons for this:
Intention expressed prior to undergoing anesthesia is sufficient.82
Since the deed is performed by someone other than the person being circumcised, it is sufficient if the mohel has intention to fulfill the commandment.83
Circumcision requires no special intention.84 This follows from the permissibility of a minor performing the circumcision. —
79 Resp. Maharsham 6:85; Resp. Yabbia Omer, ibid.
80 Tur Y.D. 264:1.
81 Resp. Yabbia Omer, ibid.
82 Resp. Shevet ha-Levi, ibid.
83 Resp. Yabbia Omer, ibid.
84 Minchat Chinnuch 2. See also Ha-Ketav ve-ha-Kabbala, Gen. 17:13.
These reasons are needed only in cases of general anesthesia. In local anesthesia of a newborn none of the reasons are needed because local anesthesia of an adult does not block him from intending to fulfill the commandment, and newborns have no intentions at all.
God’s Will - Everything that happens to us happens because of God’s will. Nonetheless, we intervene in cases of illness and suffering and the halacha of healing requires us to alleviate pain and suffering as far as we can. The fact that circumcision involves pain proves nothing. Therefore, alleviating pain does not contradict God’s will any more than does alleviating of any other suffering. There is no special significance to the suffering of an eight-day-old infant, who can surely not understand that “every spiritual acquisition requires pain.”
Circumcision does indeed involve pain. But if the purpose of that pain were to inculcate the idea that every spiritual acquisition requires pain, then anesthesia would equally be prohibited in adults. In fact, most authorities permit anesthesia in adults. It follows that there can be no special will of God that the infant suffer.85 
Several more general points can be adduced:
We have seen authorities who permit even general anesthesia in adults without requiring any pain at all and without prohibiting newly developed methods of anesthesia despite the Sages having refrained from using them. These same authorities also permit even general anesthesia in newborns.
In principle “its ways are ways of pleasantness, and its paths are peaceful.” If it is clear that there is significant pain in circumcision and that the pain can be prevented without violating any prohibition, it would seem that we should be lenient, not strict.
It follows that the only acceptable reason to be strict is the possibility of endangering the person being circumcised. We should therefore permit only those forms of anesthesia that are, from the medical point of view, definitively not life threatening.
On the other hand, it must be emphasized that there is a significant difference between “surgical removal of the foreskin” as performed for medical purposes (even by non-Jews) and “ritual circumcision” as performed by mohalim for the purpose of fulfilling the commandment.
In surgical circumcision, a clamp is used to prevent bleeding from the incision. This can lead to necrosis of the foreskin and ongoing severe pain. This surgical procedure is routinely performed by young house officers who do not have much experience, and the procedure is slow. The experienced, professional mohel, however, performs the procedure very quickly without a clamp. In this way the duration and intensity of the pain is much lower than in the cases described in the American medical literature.
We should also distinguish between two cases:
(1) injected anesthesia that fully anesthetizes the penis. This procedure involves some danger and must be performed by a qualified physician;
(2) using anesthetic cream, which attenuates the pain but does not eliminate it entirely. This procedure involves no danger and can be performed by a mohel.
Source: ASSIA - Jewish Medical Ethics,
Vol. VI, No. 1, December 2007, pp. 15-24
 Owens ME, Pain 20:213, 1984; Attia J, et al, Anesthesiology 67:A532, 1987; Weatherstone KB, et al, Pediatrics 92:710, 1993.
 Poland RL, et al, Pediatrics 80:446, 1987.
 American Academy of Pediatrics, loc. cit.
 DPNB = dorsal penile nerve block.
 Kirya C & Werthmann MW, J Pediatr 92:998, 1978.
 Taddio A, et al, N Engl J Med 336:1197, 1997; Taddio A, et al, Arch Pediatr Adolesc Med 154:620, 2000.
 Weatherstone KB, et al, loc. cit. ; Taddio A, et al, loc. cit.
 American Academy of Pediatrics, Pediatrics 84:388, 1989.
 American Academy of Pediatrics, Pediatrics 103:686, 1999.
 Schoen EJ, N Engl J Med 322:1308, 1990; Weatherstone KB, et al, loc. cit.
 Lander J, et al, JAMA 278:2157, 1997.
 Masciello AL, Obstet Gynecol 75:834, 1990 American Academy of Pediatrics, Pediatrics 103:686, 1999.
 Mudge D & Youngner JB, J Nurse Midwifery 34:335, 1989.
 Weatherstone KB, et al, loc. cit.
 EMLA = Eutectic Mixture of Local Anesthetics.
 Benini F, et al, JAMA 271:274, 1994; Taddio A, et al, loc. cit.; Wiswell, loc. cit.
 American Academy of Pediatrics, Pediatrics 103:686, 199. When, however, some of the cream remains on the site of the circumcision, it is likely to be absorbed. In such cases, hemolysis has been observed in babies with G6PD deficiency.
 Blass EM & Hoffmeyer LB, Pediatrics 87:215, 1991; Smith BA, et al, Dev Psychol 26:731, 1990; Herschel M, et al, Arch Pediatr Adolesc Med 152:279, 1998.
 Howard CR, et al, Pediatrics 93:641, 1994.
 Howard CR, loc. cit.
 Taddio A, et al, Arch Pediatr Adolesc Med 154:620, 2000.
 See the medical background above.
 Tel Talpiot, vol. 4, 5756, pp. 61 ff. The positions discussed there are summarized in Reichman E and Rosner F, Tradition 34(3):6, 2000.
 Ha-Me’assef 18(1-2); 19(1).
 Resp. Imrei Yosher 2:140, sect.3.
 Resp. Imrei Yosher, ibid.; Resp. Tsur Ya’akov, be-She’erit Ya’akov 5 (who only wrote: “Since the Rabbi from Tarna in his Resp. Imrei Yosher wrote that the practice is not to use any drug, I cannot raise any objection to that practice.” He did not, however, explain his understanding of the basis of the prohibition); Resp. Eretz Tsvi (Frommer) 1:56; R. A. Shapiro in: Medicine and Halacha: Practical Aspects, Schlesinger Institute, 2006 (here in after: Medicine & Halacha) , pp. 364-365.
 Resp. Tzitz Eli’ezer 20:73; Resp. Shevet ha-Levi 5:147, sect. 2. Regarding R. Wosner’s position, see note 39 infra.
 Resp. Eretz Tsvi, ibid.
 R. M. Bransdorfer in Medicine & Halacha pp. 361-363.
 R. M. Eliyahu in Medicine & Halacha p. 360.
 Resp. Tzitz Eli’ezer 20:73; R. Y.Sh. Eliashiv and R. Moshe Halberstam in Medicine & Halacha pp. 363-364. Regarding R. Eliashiv’s position, see note 38 infra.
 Koret ha-Brit, Nahal Brit 261:4.
 Resp. Seridei Eish 3:97; Resp. Teshuvot ve-Hanhagot 1:490, 2:510 and 3:308. See Sha’arei Halacha u-Minhag 3:97, which prefers local or epidural anesthesia rather than general anesthesia in an adult so that he will be conscious and aware during the procedure.
 Resp. Maharsham 6:85; Resp. Da’at Kohen 194; R. Y. Weingarten in Yarchon Ohel Mo’ed, Fasc. 1:7; Resp. Ma’archei Lev, Y.D. 53; Resp. Kappei Aharon 19 (who wrote that this was the practice in Munkatch); Resp. Chelkat Yo’av, Ohel Mo’ed 1:7; Resp. Pitchei She’arim 4:5; Resp. Radbaz 125; Resp. Mi-Ma’amakim 2:15; Resp. Chemdat Tsvi 4:48; O. Yosef in No’am 12, pp. 1 ff.; Resp. Yabbia Omer 5, Y.D. 22, according to which R. Yosef acted thusly with the approval of the Rabbinic Court in the year 5723. R. Y.Sh. Eliashiv has also told me that he approves of general anesthesia in adults.
 Resp. Iggerot Moshe Y.D. 4:40, sect. 2; R. Sh.Z. Auerbach and R. Y.Sh. Eliashiv quoted in Nishmat Avraham 5:260, sect. 1 (end). See, however, Resp. Iggerot Moshe, ibid., which quotes a letter by R. Sh.Z. Auerbach to R. Sh. Frankel, according to which no changes should be made in the procedure of circumcision even if there is no halachic problem involved. This contradicts his opinion as quoted in Nishmat Avraham. Further, I have met with R. Eliashiv, who told me that although he objects to anesthetizing an infant by injection when he is circumcised on the eighth day, he does not in principle object to the use of a cream. In addition, he did not want to publicize a clear and sweeping permissive opinion. Rather, he preferred that I inform mohalim orally that if the families insist on using cream, it is permitted to do so. In his opinion, the principle problem is changing the procedure of circumcision, not the pain or other incidental prohibitions. This, too, contradicts his opinion as quoted in Nishmat Avraham. See further note 47a infra.
 Rabbis Sh. Wosner, M. Halberstam, and M. Eliyahu in Medicine & Halacha pp. 360, 363-364.
 Bereishit Rabba 47:11.
 See Resp. Imrei Yosher, ibid.; Sha’arei Halacha u-Minhag 3:97; Resp. Tzitz Eli’ezer 20:73; Resp. Shevet ha-Levi 5:147, holding that pain is a principle consideration in circumcision.
 Olelot Efrayyim 446, quoted in the notes of R. A. Gutmacher on Tract. Shabbat 130a.
 R. A. Schapiro in Medicine & Halacha pp. 364-365.
 Bava Kama 85a.
 Resp. Imrei Yosher, ibid.; R. M. Eliyahu see note 33 supra.
 Resp. Seridei Eish, ibid.
 Koret ha-Brit, ibid.; Resp. Seridei Eish, ibid.; Resp. Shevet ha-Levi, ibid.
47a Sefer Tuvecha Yabbi’u (R. Y. Zilberstein) vol. 1, p 98.
 Resp. Iggerot Moshe, ibid.; R. Sh.Z. Auerbach and R. Y.Sh. Eliashiv in Nishmat Avraham, ibid.; Resp. Shevet ha-Levi (R. Wosner) see note 39 supra..
 Regarding these opinions see the article on circumcision in the author’s Encyclopedia of Medicine and Halacha.
 See Resp. Maharats Chayuth 60; Resp. Achi’ezer 3:65, sect. 12; Resp. Iggerot Moshe, Y.D. 1:155; R. Sh.Z. Auerbach, quoted in Nishmat Avraham, Y.D. 264:2.
 See Resp. Maharam Schik, O.C. 152; Resp. Divrei Malchi’el 4:87; Resp. Beit Yitshak, Y.D. 89; Resp. Da’at Kohen 141-142; Resp. R. Y.I. Herzog, Y.D. 84; Chazon Ish, quoted in Resp. Shevet ha-Levi 6:148, sect 2. See in extenso the author’s Encyclopedia of Medicine and Halacha, s.v. mila.
 R. A.M. Yisra’el in Ha-Ma’or 27(6):4, 5735.
 Sh. Wahlfisch et al. in Ha-Refu’ah 127:119, 1994.
 Bereishit Rabba 47:11.
 Resp. Eretz Tsvi 56; Resp. Chemdat Tsvi 4:48; Rabbi M.D. Tendler in Carmy S (ed), Jewish Perspectives on the Experience of Suffering, 1999, pp. 79-83.
 Resp. Yabbia Omer 5, Y.D. 22:4.
 R. Moshe ha'Levi Steinberg, Chukkat ha-Ger 15, n. 31.
 R. A. Baron in Ha-Darom 58:13, 5749.
 Tanchuma, Lech Lecha 17.
 See Rashi ad Gen. 17:24; Da’at Zekeinim mi-Ba’alei ha-Tosafot, ibid., 26.
 Olelot Efrayyim 446, quoted in the notes of R. A. Gutmacher on Tract. Shabbat 130a.
 Nishmat Avraham 5, Y.D. 260:1.
 Resp. Ma’arachei Lev, Y.D. 53
 Resp. Seridei Eish, ibid.
 Resp. Iggerot Moshe, ibid.
 As made clear in Resp. Imrei Yosher, ibid. This is the principle source requiring pain in circumcision.
 As Rashi wrote: “to amputate it by means of a drug”. Rambam (Chovel u-Mazzik 2:10) wrote: “to cut it off by means of a drug.”
 Resp. Chemdat Tsvi, ibid.
 Kiddushin 21b.
 Rashi, ibid., s.v. mi’et sam.
 Tur Y.D. 264:1. See also Yalkut Yosef, Sova Semachot 2, Hil. Milah 15:1.
 R. Y. Zilberstein is the authority who prohibits anesthesia in infants because of God’s commandment. See his Tuvecha Yabbi’u as referenced above in note 47a. R. Ziblerstein in his Torat ha-Yoledet 34:8, however, permitted anesthesia for a woman in childbirth, even on Shabbat, in order to prevent her experiencing pain. It follows that the principle “in pain shalt thou bear children” refers only to childbirth. Although there is room to say that preventing pain in childbirth is therefore a violation of divine will, such cannot be said about circumcision, regarding which neither Scripture nor rabbinic literature requires pain (as explained in note 62 above). R. Zilberstein’s position remains to be clarified.
 See Resp. Maharsham 6:85; Resp. Da’at Kohen 197; Resp. Ma’archei Lev Y.D. 53; Resp. Kappei Aharon 19; Resp. Chemdat Tsvi 4:48; Resp. Yabbia Omer 5, Y.D. 22; R. Moshe ha'Levi Steinberg, Chukkat ha-Ger 15, n. 31.
 See Shechet J, et al, JAMA 279:1170, 1998; Reichman E. and Rosner F., Tradition 34(3):6, 2000.
 This follows from Iggerot Moshe, ibid., see note 38 supra.