Is Metzitza b’Peh a Risk Worth Taking?
The review of metzitza b’peh and the risk of neonatal herpes[I] presented a highly conceptual, theoretical, and philosophical assessment of the issue. While there is certainly a value to this method of halachic analysis, there are a number of practical perspectives that should be addressed as well. Though it may be convenient to dismiss “isolated case reports” as anecdotal, and that they therefore “border on speculation”, it should be recognized that a great many significant medical findings came from following up on anecdotal reports. The AIDS epidemic was first identified after isolated case reports of unusual outbreaks of Kaposi sarcoma That smoking directly causes heart and lung disease was only conclusively proven many years after initial reports found an association. Unfortunately, this allowed cigarette manufacturers to hide behind the smokescreen of “no conclusive evidence” while continuing to peddle their wares unhampered, and to our shame, it kept Yeshivot from prohibiting rampant smoking that plagued batei midrashim until very recently.
In view of the reported possible association between metzitza b’peh and the highly fatal or disabling neonatal herpes infection, it behooves us all to study the issue further, and get the facts. Instead the authors present a speculative statistical analysis concluding that the risk is “indeed quite minimal”. Without any stated evidence they even hypothesize that the wine in the mohel’s mouth and the “unidirectional contact” (presumably referring to the one way suction?) will further decrease transmission. They also report that the mortality rate “could potentially be reduced by early intervention with antiviral medication”, though hidden in a footnote citing the study, they acknowledge that “less than 30% of patients were developmentally normal and approximately 60% had moderate to severe disability”, an outcome that should still fall under the rubric of pikuach nefesh. The situation calls for a practical not philosophical response; a large-scale study comparing the rates of neonatal herpes infections among those with direct metzitza b’peh and those without. While some may feel that this is the job of the medical community, and that the halachic world does not have to respond until conclusive proof is brought, can we really so easily wash our hands of it in the setting of potential pikuach nefesh?
Among those who believe that traditional metzitza b’peh is the only option, some have argued that the scientific community is biased against religion, and that as the Torah commanded this, a truly impartial study could not possibly find significant risk. While this Talmudic logic seemingly makes a study unnecessary, it could equally be twisted to argue that if significant risk is present, the Torah must not have required the direct form of metzitza b’peh. In any case, this whole point could be obviated in a practical way; allowing only those recently tested negative for herpes to perform traditional metzitza b’peh. An analysis balancing the halachic concerns for protecting the livelihood of infected mohels, against the pikuach nefesh risk they may pose, would have been valuable in this regard.
Larry Eisenberg M.D
Response:
We thank Dr. Eisenberg for his comments that we read with great interest. We are somewhat saddened however, by their negative and often somewhat derisive tone. Moreover, while we acknowledge his suggestions for future studies, we believe that the article successfully accomplished that which it initially set out to do We chose to analyze halachic risk taking, its nature and scope, and test any possible theories using metzitza b’peh as a current method of tweezing out the various issues.
Dr. Eisenberg challenges several aspects of our article:
1. Halachic methodology;
2. Scientific methodology;
3. Interpretation of data and suggestions for future research.
We will respond to each in turn:
1. Today, there is little value in memorizing the text of Shulchan Aruch as a guide for halachic living, as Modern man will not find within this great tome answers to today’s many technical question Viewing Halacha as a mere practical system of law reflects a faulty understanding of the halachic process. Rather, the core basis of the halacha must first be analyzed and understood - its depths plumbed, its nature verified, and its scope stretched to the farthest possible limits so as to form a basis for positing and understanding its practical guidelines. Only by doing so, by testing various halachic hypothesis in such a way, can we even attempt to answer the many modern questions that have arisen and have yet to arise in our lifetime. Therefore, we believe that presenting “a highly conceptual, theoretical, and philosophical assessment of” risk taking in Halacha is far from lamentable, but is rather of utmost importance if we are even to begin to analyze how the possible risks of metzitza b’peh fit in to the larger halachic framework. We trust that Dr. Eisenberg fundamentally agrees with our approach.
As a further methodological point, we doubt that “protecting the livelihood of infected mohels” weighs heavily in a halachic analysis of the issues of risk taking in Halacha and therefore did not include such a discussion in this analysis.
Lastly, we question the notion suggested by Dr. Eisenberg, that “Among those who believe that traditional metzitza b’peh is the only option, some have argued that the scientific community is biased against religion, and that as the Torah commanded this, a truly impartial study could not possibly find significant risk.” We are somewhat troubled how this relates to our article. We attempted to provide both a thorough halachic as well as scientific analysis in our article as we believe that both are reflections of that which is true This article represents an effort to synthesize the two worlds; harmonizing between that which we learn in the Beit Midrash and that which we learn at the hospital bedside and laboratory Attempting to undermine the basis for our analysis on these grounds is rather perplexing.
2. The “scientific” evidence for an association between neonatal herpes and metzitza b’peh is highly tenuous at best, as we stated in our paper. We indeed did “dismiss ‘isolated case reports’ as anecdotal,” as even a cursory reading of the current scientific papers on the subject reveal them to be. Case reports admittedly have their pros and cons. Where anecdotes shed their subjectivity and bias and confounders become credible, or even objective and reproducible, is difficult to determine. It is our humble opinion that anyone reading the three particular referenced cases with a critical eye will find them wanting in terms of objectivity and methodology While these reports make claims regarding metzitza b’peh for the general community, none define how the subjects of these reports were accumulated nor how representative they are of any community at all. There is also no discussion of the study sample or method of sampling in any of them. Lastly, the simple factual inaccuracies present in some of them to even a casual non- medically trained reader raise significant questions and doubts as to the veracity and accuracy of the papers in their entirety. For example, historical proof for rabbis rallying against metzitza b’peh is brought by a photograph of a broadside in Jerusalem of 5661 signed by numerous rabbis in this vein (as quoted by the Sedei Chemed) [see HaRefuah 2:144 (2005): 129]. A careful reader will note that the sign in fact states quite the opposite of these authors intention - namely that it is forbidden to abandon the practice of metzitza b’peh, and a more learned reader will recall that the Sedei Chemed himself fought adamantly to defend this age-old tradition.
We share Dr. Eisenberg’s sentiment regarding smoking. There are instances in which policy shouldn’t have to wait for a peer reviewed double blind randomized placebo control trial with a p- value less than 0.05. Where and when this should happen is difficult to pinpoint. However, in the face of overwhelming evidence to the contrary - namely, if 60-70% of all people indeed carry and shed HSV, we would expect far more cases of neonatal herpes - while this question still must be asked, it must be asked with caution While, as we noted, the true incidence may be underreported, it is difficult to know.
Though we agree with these general sentiments, we strongly oppose the parallel invoked by Dr. Eisenberg. “That smoking directly causes heart and lung disease was only conclusively proven many years after initial reports found an association Unfortunately, this allowed cigarette manufacturers to hide behind the smokescreen of “no conclusive evidence” while continuing to peddle their wares unhampered.” Though we cannot pretend to know Dr. Eisenberg’s true intentions, we find the inferred parallel or nimshal if you will, quite offensive. Namely, that the rabbis permitting metzitza b’peh are “hiding behind a smokescreen” of some sort in efforts to accomplish an unmentioned goal. This suggestion has no place in scholarly Jewish discourse and we will not grant it credence by discussing it further.
3. We appreciate Dr. Eisenberg’s enthusiasm towards “getting the facts” and agree that the currently available data and therefore our presented statistical analysis are incomplete. Indeed, for someone to play the role of investigator rather than reporter and launch “a large-scale study comparing the rates of neonatal herpes infections among those with direct metzitza b’peh and those without” would be a praiseworthy task. However, we believe that such idealism will not find practical manifestations in the near nor far-off future. Constructing such a study would be difficult in itself let alone convincing parents and more importantly mohalim to participate. Given these conditions, we are left to speculate to the best of our ability, which we readily admit is far from complete, to provide analyses and theories that may help establish guidelines and policies in the present.
Lastly, Dr. Eisenberg joins several others in suggesting that “allowing only those recently tested negative for herpes to perform traditional metzitza b’peh” would certainly reduce this risk. We certainly agree that some form of testing would be preferable, but given the current state of medicine, the blood test will label far too many false positives while a mouth swab to identify only active infection is not practical in terms of cost, availability and timing This issue must be explored further in hope of identifying a more accurate, reliable, and cost efficient method of obliterating the risk entirely.
David Shabtai and Raymond Sultan
Source: ASSIA - Jewish Medical Ethics,
Vol. VI, No. 2, October 2008, pp. 67-69
[I] Rabbi D. Shabtai, M.D., R. Sultan M.D., “Metzitza b’Peh - Paradigm for Halachic Risk Taking” pp. 138-173.