The Tradition of Metzitza: Restoring a Forgotten Medical Indication
Mordechai Halperin, M.D.*
The second commandment written in the Torah is that of brit milah. A covenant between Israel and its Father in Heaven, brit milah is a mitzvah that is tied to the very identity of the Jewish nation. Throughout the generations, and recently, during the holocaust, many of our people have put their lives on the line to fulfill it. Jews began sacrificing themselves for the sake of brit milah more than two millennia ago during the tyrannical leadership of Antiochus and later in the period of shemad under the Romans. Testimony to this can be found in the Mechilta and in the Midrash:
Rabbi Natan Said: “To those who love and keep My commandments”, this is speaking of those who dwell in Eretz Yisrael and give their lives for all the mitzvot. For what are you being beheaded? For circumcising my son. For what are you being burned? For studying the Torah. For what are you being crucified? For eating matzah. For what are you receiving a hundred lashes? For fulfilling the mitzvah of lulav.
During the past two centuries war has been waged from time to time against the mitzvah of brit milah. Ironically, the chief antagonists have been members of our own people. Activists from the Reform movement of the nineteenth century sought to abolish brit milah through various stratagems, often calling upon the local authorities to help their cause. At times they tried to erode the Jewish people’s commitment to brit milah by whittling away at the mitzvah itself. In other words, by eliminating certain aspects of the practice of brit milah, they hoped to eventually call for its outright abolishment. One such aspect was metzitza, which was more vulnerable to attack, since the original knowledge upon which Chazal based their requirement had been lost, rendering it inexplicable. By attacking metzitza, the Reform activists sought to gradually erode the Jewish nation’s deeply rooted commitment to brit milah itself.
In recent years, private organizations dedicated to fighting the practice of brit milah have cropped up in Israel. As in the past, these organizations begin their attacks by trying to get the government involved. In the early stages, they appeal to health institutes and judicial authorities to ban metzitza. Next, an aggressive propagandic campaign is launched with the aim of shifting public opinion. In America a propagandic process of this sort has recently occurred, as described by Rabbi Chaim Dovid Zwieble. This process involved several factors (some of which were acceptable and innocent) in a combined attack of the metzitza b’peh tradition.
The poskim have always concerned themselves with the halachic as well as the medical aspects of brit milah. However, when the very institution of brit milah is under attack and metzitza is being used as ammunition in the assault, the poskim need to take a different approach. Therefore, any comprehensive discussion of metzitza should deal not only with the medical/halachic issues but also with some consideration of aspects of the ideological battle against metzitza, which is linked to the effort to uproot the practice of brit milah altogether.
I. A Medical Overview
Circumcision is the most common surgical procedure performed on males in the United States and in Israel. It is performed as a religious obligation on nearly 100 percent of Jewish males and on more than 90 percent of Muslim males. In the past, circumcision was performed exclusively for religious reasons, but since World War II, millions of newborns (60%-90% of newborn males in the United States) have been circumcised for medical or cosmetic reasons. A striking medical advantage of removal of the foreskin is its association with a drastic reduction in the risk of penile cancer. In the second half of the twentieth century, about 11,000 uncircumcised American men died of penile cancer, and nearly all of these deaths could have been prevented by a simple procedure of excising the foreskin at an early age.
During the last decade, another medical advantage of circumcision was discovered. In three controlled prospective study, circumcision was shown in the past year to protect against contagion of the HIV virus by a factor of about 50%-60% percent (in comparison with uncurcimcised males). In a world where there are over 40 million people who are HIV positive and over 5 million die every year – the significance of the simple procedure of circumcision that could cut these numbers down considerably is immesurable. The major difficulties in implementing this effective measure are high economic cost of adult circumcision, prejudices and psychological problems among populations of uncircumcised men. Admittedly, circumcision is not totally risk-free; however, the risks are extremely low. In the second half of the twentieth century, only four deaths caused by complications resulting from the procedure occurred in the United States, compared to the thousands of deaths that it prevented during the same period.
Since Chazal were aware of the possible risks associated with the performance of brit milah, they laid down medical instructions with the force of a halachic ruling that were designed to decrease the minimal risk even further. These rules include detailed guidelines for the entire procedure, from the preparatory stage through the performance of the surgery itself and the post-operative stage, until the follow-up care. They also include the necessary preconditions for brit milah in regard to the baby’s health condition. Maimonides’ medical-halachic guideline is a typical example:
“Only an infant free of any illness is circumcised, for danger to life precludes other considerations: brit milah can be performed after the specified time, but the life of an individual can never be restored.”
II. Stages of the Milah Procedure
Halachic brit milah involves four main stages:
1. Preparation before the brit milah – these preparations may be characterized essentially as preventive medicine;
2. The Mitzvah: performance of the surgery – incision and folding over of the remnant membrane;
4. Supportive care after the circumcision.
III. What is Metzitza?
The original technique for the performance of metzitza employs the human mouth. The mohel brings the baby’s organ into his mouth immediately after the excision of the foreskin and sucks blood from it vigorously. This action lowers the internal pressure in the blood vessels at the head of the organ and in the exposed ends of the arterioles that have just been cut. Thus, the difference between the pressure in the blood vessels in the base of the organ and the pressure in the blood vessels at its tip is increased. This requirement has religious significance as well as medical benefits.
Metzitza as a religious obligation is mentioned in the mystical portions of the Torah. In the last two centuries a number of famous poskim have declared that an attack on the tradition of metzitza is tantamount to an attack on the mitzvah of brit milah itself. Nevertheless, many poskim, including the Chatam Sofer, the Ketzot Hachoshen, the Netziv of Volozhin, the Avnei Nezer and more recently, Rabbi Shlomo Zalman Auerbach and the Tzitz Eliezer, have ruled that the purpose of metzitza is solely medical.
It should be noted that even the poskim who maintain that metzitza is a religious obligation (that is, that metzitza is part of the mitzvah of brit milah) may not have based their statements purely on halachic reasoning, but to a large extent were responding to attacks against brit milah. This claim is supported by the halachic literature on metzitza, which indicates rather clearly that metzitza is a medical requirement instituted by Chazal because of the risk involved in neglecting to perform it. In addition, one cannot ignore the difficulty of defending a medical guideline imposed by Chazal in the absence of sufficient medical knowledge to explain it. Furthermore, proclaiming that metzitza is an inseparable part of the commandment of brit milah is an effectual means today, as in the past, of fending off attacks against the Divine covenant of circumcision.
The Talmud states that the requirement of metzitza stems from medical considerations; it is meant to minimize risk to the infant’s life and health:
Rav Pappa said, “A mohel who does not perform metzitza endangers the baby and is dismissed”.
Is this not obvious? Since we desecrate the Shabbat for it, it obviously must be a danger to omit it [and thus it is proper to dismiss someone who fails to do it. What does Rav Pappa’s statement add?]
You might say [had Rav Pappa not made this statement] that this blood is stored up [so sucking it out is not a desecration]. Now we have learned [from Rav Pappa] that the blood is the result of a wound [thereby sucking it out is desecrating the Shabbat].
From this gemara it seems fairly clear that medical considerations are the only reason for metzitza, for the Talmud states that the very fact that metzitza is permitted on Shabbat indicates that failing to perform it poses a risk to life. From this we can derive that metzitza cannot be defined as part of the ritual of brit milah, which overrides Shabbat in and of itself, independent of the laws of pikuach nefesh.
This gemara seems to be the source of the interpretation (i.e., that metzitza is performed because of medical reasons) adopted by many poskim, both Rishonim and Acharonim.
IV. Maimonides’ Approach – “Until Blood in the Further Reaches is Extracted”
From a simple reading of Maimonides, one can conclude that the reason for metzitza is medical: “How is circumcision performed? One cuts through the entire foreskin covering the crown, and then folds over the membrane under the foreskin with one’s fingernail, pulling it this way and that way until the flesh of the crown is revealed. And then one sucks the circumcision until blood in the further reaches is extracted, so that [the infant] will not be endangered, and any mohel who does not perform metzitza should be dismissed. After metzitza, he should apply a dressing or bandage or something of that nature”.
Maimonides’ statement “And then one sucks the circumcision until blood in the further reaches is extracted, so that [the infant] will not be endangered” has been interpreted in two different ways:
1. “Extraction of blood from the further reaches” of the organ is the goal of metzitza and the reason for it; i.e., the very fact that blood stays in the further reaches poses a danger to the infant (perhaps because of concern that infectious agents harbored there should be drained away and drawn out).
2. “Extraction of blood from the further reaches” is merely an indication that metzitza was performed with the required level of force, and a flow of blood from this area tells us that the metzitza has achieved its purpose (a physiological explanation for this interpretation will follow).
Whichever way we understand Maimonides, the physiological process by which metzitza prevents endangering the infant is not elucidated in Maimonides, just as it is not elucidated in the Talmud. A decisive interpretation of Maimonides may be derived from studying the words of other Rishonim, such as those of Rabbi Yaakov Hagozer.
V. Rabbi Yaakov Hagozer – “Blood Will Clot Within the Organ, and This is Dangerous”
In the sefer of Rabbi Yaakov Hagozer, who lived in Germany during the period of the Ba’alei HaTosefot, explicit guidelines are given for the performance of metzitza, and this time with a clear medical explanation of the practice:
“How is metzitza performed? After folding over the membrane, one takes the organ into his mouth and sucks blood out with all one’s strength, because blood coagulates within the top of the organ, and a danger is posed if one does not perform the sucking. As Rav Pappa said, ‘A mohel who does not perform metzitza endangers the infant and is dismissed’ because blood will clot within the organ and this is dangerous.”
This ruling clearly cannot be referring to coagulated blood at the urethral opening, for any experienced mohel will realize that such blood can be wiped away easily, and there is certainly no need for forceful sucking to remove it. Furthermore, sucking blood for the purpose of removing the coagulated blood is not a melachah, while the Talmud states that the sucking of blood by metzitza is a melachah, and is only permitted because it prevents a potential sakkana.
VI. Explaining Metzitza
Rabbi Hagozer’s explanation might be translated into modern medical terms as follows: Immediately after incising or injuring an artery, the arterial walls contract and obstruct, or at least reduce, the flow of blood. Since the arterioles of the orlah, or the foreskin, branch off from the dorsal arteries (the arteries of the upper side of the organ), cutting away the foreskin can result in a temporary obstruction in these dorsal arteries. This temporary obstruction, caused by arterial muscle contraction, continues to develop into a more enduring blockage as the stationary blood begins to clot. The tragic result can be severe hypoxia (deprivation of the supply of blood and oxygen) of the glans penis. If the arterial obstruction becomes more permanent, gangrene follows; the baby may lose his glans, and it may even become a life-threatening situation. Such cases have been known to occur.
Only by immediately clearing the blockage can one prevent such clotting from happening. Performing metzitza immediately after circumcision lowers the internal pressure within the tissues and blood vessels of the glans, thus raising the pressure gradient between the blood vessels at the base of the organ and the blood vessels at its distal end – the glans as well as the excised arterioles of the foreskin, which branch off of the dorsal arteries. This increase in pressure gradient (by a factor of four to six!) can resolve an acute temporary blockage and restore blood flow to the glans, thus significantly reducing both the danger of immediate acute hypoxia and the danger of developing a permanent obstruction by means of coagulation. How do we know when a temporary blockage has successfully been averted? When the “blood in the further reaches [i.e., the proximal dorsal artery] is extracted,” as Maimonides has stated.
According to the explanation of Rabbi Hagozer, which is supported by current medical knowledge, it is easy to understand why Chazal viewed the failure to perform metzitza with such severity, and ruled that one may violate Shabbat in order to carry it out. Additionally, we can understand why it is that a mohel who omits it should be dismissed and deprived of the right to perform britot.
Likewise, the words of Maimonides may now be interpreted unequivocally. “Until blood in the further reaches is extracted” constitutes only an indication that metzitza has been performed with the requisite exertion of force. Extraction of blood from the further reaches tells us that the metzitza has achieved its purpose, and any existing blockage of the dorsal arteries has been cleared.
Consider the following passage from the Tiferet Yisrael (Shabbat 19:15): without metzitza, there is a possible threat to life because the act of circumcision causes the blood in the penis to become warm and to congeal. Therefore the penis might swell.
Let me emphasize that the incidences of hypoxia in the corona is not great and depends on certain other risk factors. But from a halachic-epidemiological point of view, the Talmudic sages were concerned with even less likely risks when dealing with a large population. Since we are dealing with a surgical procedure performed on hundreds of thousands of children, even a relatively low risk is halachically defined as life threatening even if the likelihood of death is only one in 100,000. This perfectly reasonable halachic-epidemiological principle was expressed by the medieval authorities. This principle is accepted by the poskim. 
VII. The Chatam Sofer—“Metzitza is Not an Intrinsic Part of the Mitzvah; It is Practiced Only Because of Sakkana”
In 1836, Rabbi Eliezer Horowitz, author of the Yad Eliezer and a student of the Chatam Sofer, posed the following question to his teacher: Is it permissible to circumcise without doing metzitza, and to use a sponge for the purpose instead of the mouth? Rabbi Horowitz explained his question as follows:
There have been cases here in our city [Vienna] of children who were circumcised by an expert mohel, and a malignant tzara’at (severe skin lesions) broke out on their skin, covering the whole area of the circumcision, and then spread over their entire bodies, and many children have died of this illness… In the doctors’ judgment, this evil came upon them as a result of the metzitza performed by the mohel’s mouth, and yet the mohel was examined and found to be clean and uncontaminated by any trace of the illness. Nonetheless, there is cause for concern…
The Chatam Sofer responded:
…[My correspondent] has written well, for we do not find a stipulation that metzitza be performed with the mouth exclusively, except among kabbalists who say that the din is sweetened through the mouth and the lips, and we do not concern ourselves with these hidden matters in a situation in which there is even the slightest suspicion of danger… and furthermore I say that even if it were explicitly stated in the Talmud that one must do metzitza with one’s mouth, in any case this is not an intrinsic part of the mitzvah of brit milah, but is done because of danger to life, and one who circumcises and folds over the membrane and does not perform metzitza has nevertheless completed the mitzvah, and the child is eligible for trumah [i.e., if he is a Kohen], and his father may bring the Pesach offering; the child, however, is at risk until an action is performed to extract blood from the further reaches. And in tractate Shabbat, Rav Pappa learns, “Like a bandage or a medicinal powder to stop bleeding, which is necessary because the circumcised infant is in a situation of danger, metzitza, too, is necessary for a similar reason (since it is done for therapeutic reasons, we need not be particular if the doctors devise a different therapy as a substitute), and this is the law pertaining to metzitza. Even if the Mishnah had mentioned metzitza by mouth, one may still use an alternative means to accomplish the aim. But the doctors must be warned that they must be able to testify that the sponge is truly performing the same action as metzitza performed by mouth. Beyond this, there is no concern, in my humble opinion.
It is clear from the question that the situation in Vienna, in which the newborn boys were facing a tangible danger, was a case of sha’at hadchak (extenuating circumstances). The Maharam Shick adds, in his response to the question (Shu”t Orach Chaim 152), that because it was difficult to dismiss the Viennese mohel due to his highly respected status, this was truly a case of sha’at hadchak. In any case, the Chatam Sofer’s understanding of the reason Chazal instituted metzitza as a requirement is clear.
VIII. The War Against Metzitza
As stated earlier, since Chazal did not specify the nature of the risk prevented by metzitza, the medical information upon which they based their ruling was lost over time. (Rabbi Hagozer’s sefer was first printed only in 1892, and physiology books explaining the process of constriction of cut arteries were written only in the last half-century). The mitzvah of metzitza, therefore, became the soft underbelly, subject to attack in the struggle over traditional brit milah.
It is no wonder, then, that when the activists from the Reform movement started waging their war on brit milah in the nineteenth century, voices began to be heard in the medical community calling for a ban on metzitza. There were three primary arguments against metzitza:
1. Lack of a comprehensible medical reason;
2. Concern over transmission of infectious diseases from the person performing the metzitza to the infant;
3. Concern that metzitza might increase bleeding in the area of the incision.
The claim that there was no medical reason for metzitza has been vigorously rebutted. Since those who made the claim had no way of knowing what medical reason Chazal had in mind when they instituted metzitza, they could not point to any “change in nature” in the modern world that would render metzitza unnecessary. But it is not merely emunat chachamim that is the basis for rejecting the claim of those who see no purpose for metzitza. A rational assessment of the experience of generations also justifies rejecting this same claim. History demonstrates that Chazal scrutinized medical findings with a critical eye and did not see themselves as bound by Aristotelian dogma. For example, they stated that heredity is not only maternal, but paternal as well, contradicting the Greek scholars. Chazal recognized pathological anatomy 1,500 years earlier, and were aware of pathological symptoms pertaining to brit milah hundreds of years before modern medicine documented them.
As for the concern about the transmission of infectious diseases, three main ways of preventing this have developed over the years:
1. Insistence on a healthy mohel (not forgetting the advantage gained by the presence of AgA antibodies in the saliva of a healthy person, which can even contribute to the healing of the wound, a well-known phenomenon in the animal world).
2. Disinfecting the mouth with antiseptic substances such as alcohol or wine.
From a medical standpoint, the claim that metzitza is liable to increase bleeding at the site of the incision is unsupported. The isplanit (bandage) and the kamon (a medicinal powder) mentioned in the Mishna, and the “powder of medications that stop bleeding” mentioned in the Shulchan Aruch were intended to prevent prolonged bleeding. Since these measures are taken immediately after metzitza under the mohel’s control, from a medical viewpoint, this claim lacks any validity.
IX. Prioritization of Metzitza
In light of the medical purpose of metzitza, metzitza and its alternatives can be placed in order of preference. From a physiological point of view, metzitza performed with the mouth should be given first preference. The pressure gradient created by forceful sucking with the mouth is greater by a factor of six or more than the pressure gradient between the base of the organ and its top when there is local blockage between the two areas. Metzitza b’peh enables better control over the force exerted, so as to ensure the desired result.
Second preference should be given to metzitza through a tube. If the dimensions of the tube are suited to the size of the baby’s organ and allow for the required rise in the pressure gradient, then the difference between metzitza b’peh and metzitza through a tube is negligible. Metzitza b’peh is nonetheless preferable, as it does not depend on mechanical adjustment of the tube to fit the organ.
Third preference should be given to metzitza performed by a pumping machine connected to a 'metzitza tube'. In addition to the proportional disadvantages caused by the use of a tube, the use of a machine makes it difficult to control the force of the suction.
Last preference is given to the use of a sponge. A sponge scarcely raises the pressure gradient, and certainly does not raise it enough to open an obstructed artery. Suction applied by hand through a sponge is almost tantamount to willfully omitting metzitza (although, it should be noted that such an omission might possibly be required in certain cases where metzitza itself poses a high risk to the infant).
X. The Situation in Israel
With the precedents of Vienna and other places, with the increase in public awareness on hygiene and with the loss of our knowledge of the medical benefits of metzitza, we have come to a situation where approximately 90 percent of britot in Israel are carried out with a substitute for metzitza b’peh, i.e., suction by means of a tube. Nevertheless, among the Ultra-Orthodox population there is continued insistence upon doing traditional metzitza b’peh while taking appropriate hygienic measures.
In Israel, metzitza b’peh is performed at less than 10,000 britot annually (in the Ultra-Orthodox sector) out of some 70,000 britot that take place in the total population. It should be noted that in Israel, until this past decade, no harm had been observed during the past century among babies upon which traditional metzitza was performed. Similar studies carried out in Israel have shown that britot performed by mohalim are at least as safe as those performed by physicians.
XI. The AIDS Problem
With the spread of the HIV virus during the past generation, metzitza has come into question more sharply than ever, but from an opposing perspective. There is concern among mohalim about performing metzitza on as-yet-uncircumcised adults who have immigrated to Israel from countries where AIDS is widespread, or on newborns whose mothers’ health conditions are unclear, in view of the fact that the AIDS virus can easily pass through the placenta from the mother’s bloodstream to that of the fetus. Undoubtedly, metzitza b’peh performed on an infected individual poses a danger to the mohel.
Poskim faced with this question could make any of three possible rulings:
1. To continue performing metzitza b’peh despite the risk.
2. To delay the brit milah until a blood test confirms that the candidate for brit milah (or his mother, in the case of a newborn) is not infected with a deadly virus.
3. To perform metzitza through a tube, so as to avoid direct contact between the subject’s blood and the mohel’s mouth.
When this question came up nearly thirty years ago, both Rabbi Auerbach and Rabbi Yosef Shalom Elyashiv chose the third alternative—that the mohel should perform metzitza through a tube — for cases of infant circumcision. Rabbi Shmuel Wosner wrote a similar pesak concerning brit milah on adult immigrants. Rabbi Elyashiv clearly explained the reasoning behind his pesak: “The sages of the previous generation have already struggled with this problem. HaRav HaGaon Rabbi Yitzchak Elchanan of Kovno, HaGaon Rabbi Yitzchak Yaakov [Reb Itchele] of Ponevezh, HaGaon Rabbi Yechiel Michel [Epstein] of Navardok, HaGaon Rabbi Chaim Ozer of Vilna and others, all of blessed memory, came to the conclusion that ‘in a situation in which the slightest concern of danger to life exists, one should not insist on meticulous fulfillment of the custom of our ancestors,’ in the words of Rabbi Chaim Berlin (aside of the widely known answer of the Chatam Sofer to the Rabbi from Vienna)”.
XII. New Conditions Among the Israeli Ultra-Orthodox Population
In the beginning of the past decade, the following data was brought before Israel’s Interdepartmental Committee for Supervision over Mohalim, an advisory committee composed of rabbis, doctors and mohalim: during the three years leading up to that time, seven newborns from the Ultra-Orthodox sector were infected with herpes simplex virus (HSV), all of whom had undergone traditional metzitza b’peh. Five of the mothers were examined to determine if they were carriers of the virus; four of them were not carriers, whereas one mother was found to be a carrier with a low level of antibodies.
In one of the cases, no antibodies at all against HSV-1 were found in the mohel, indicating that he had never been exposed to the virus. In the rest of the cases, in which antibodies were discovered in the mohel, in no case was the subspecies of the virus found in the mohel’s body positively identified by DNA examination with the subspecies found in the infected newborn. Thus in each of the cases there was no proof that the mohel was, or was not, the source of the infection. The question is, how much caution must we take?
The recent occurrence of HSV-infected newborns in the Ultra-Orthodox sector is caused, apparently, by three epidemiological facts:
1. More than 80 percent of the adult population in Israel, including mohalim, are latent carriers of HSV-1.
2. Forty percent of young mothers in the Ultra-Orthodox sector are not carriers of the virus, apparently as a result of better hygiene and living conditions that prevail among the younger generation. This change has caused fewer women of childbearing age in the Ultra-Orthodox sector to be exposed to HSV, and the percentage of mothers with antibodies to the HSV-1 virus has dropped from about 80 percent to about 60 percent. This seems to reflect a new situation, in contrast to the prevalent situation in the past.
3. An absence of antibodies in the mothers’ blood means that their newborn sons received no such antibodies through the placenta, and therefore are vulnerable to infection by HSV-1.
XIII. The Memo to Mohalim
Although the epidemiological data does not provide a sufficient foundation for an unambiguous medical conclusion, it was agreed that they indicate a possible risk to newborn boys in the Ultra-Orthodox sector. This situation obligates us to take steps to eliminate, or at least reduce, the risk while recognizing the Jewish people’s sensitivity to external limitations placed on the procedure of brit milah. In other words, careless action is liable to adversely affect Jewish communities around the world and to be detrimental to their freedom to carry out the mitzvah of brit milah as prescribed by tradition. Therefore, on May 22nd, 2002, Rabbi Avraham Babayof, director of the Department of Britot at Israel’s Chief Rabbinate and head of the Interdepartmental Committee on Supervision of Mohalim, issued a memo to mohalim on the subject of metzitza. The document pointed out that halacha permits metzitza through a tube in cases where there is concern of contagion, and that the mohel has a duty “to inform the parents of the infant, at the time he is engaged to perform the brit [milah], of the two options for carrying out metzitza, and to come to a decision with their participation”.
As more cases of HSV in newborns in the Ultra-Orthodox community emerged, it was decided to conduct further discussions on the matter. The deliberations took place in the office of the general director of the Chief Rabbinate on Thursday, March 13th, 2003. The participants included Rabbi Babayof and the members of the Interdepartmental Committee, which included Rabbis, mohalim, doctors, the legal advisor of the Chief Rabbinate and the writer. The subject under discussion: the significance of new epidemiological data indicating possible risk of HSV-1 infection among newborns in the Ultra-Orthodox community as a result of undergoing metzitza b’peh.
In light of the Jewish people’s sensitivity to external limitations placed on the procedure of brit milah, it was decided that the new epidemiological information should immediately be submitted for halachic judgment, with the aim of considering a temporary halachic ruling (hora’at sha’ah) on the proper method of performing metzitza in light of the new situation.
XIV. Meeting with Rabbi Wosner
On Monday, April 7th, 2003, a thorough meeting took place in the home of Rabbi Wosner. It was attended by representatives of the Interdepartmental Committee, including Dr. Moshe Westreich of the Ministry of Health, Dr. Eli Yosef Schussheim, Rabbi Babayof and the writer. After the details of the problem were presented to Rabbi Wosner by the participating doctors, he clearly repeated the main points of the facts he had just heard, and then summed up his halachic opinion in the following principles:
1. “It is not within our ability or power to annul the mitzvah of metzitza, which has been handed down from our ancestors as metzitza b’peh, nor would we ever contemplate it.”
2. “The risks of HSV infection are not to be ignored. And therefore, metzitza b’peh is to be carried out only by mohalim or other persons who do not harbor the virus in their bodies.”
3. “A mohel who is a talmid chacham and sees that risk is present in the situation he is in must act according to the halacha and not cause endangerment; but if he makes a change in the technique of metzitza, this is to be only as a hora’at sha’ah [applicable to the situation at hand].”
These statements were written down by the writer as they were said, and were read back on the spot to Rabbi Wosner, who confirmed their accuracy. But because of the sensitivity of the issue, a copy of the statements was immediately handed over to Rabbi Wosner’s office, and we were asked to delay its publication until we received authorization.
When no authorization was received in the course of a month, I conducted about ten discussions on the issue by telephone with Rabbi Shlomo Gelber, an experienced mohel and a repersentative of Rabbi Wosner. In the course of these discussions, it became evident that at the time in Israel an ideological war was being waged against the performance of traditional brit milah in general, and against the tradition of metzitza in particular. In times of war, there is a calling for great dedication and self-sacrifice as well as absolute insistence on observing tradition. Throughout 2003, news reports and pseudo-news reports in Israel left a clear impression that a relentless struggle was being conducted by parties interested in shifting the national consensus on brit milah and, as a first step, reducing the performance of britot by traditional mohalim.
In the wake of our continued deliberations, and as a result of Rabbi Wosner’s justified assessment that the attack on traditional metzitza constitutes part of a more general war on brit milah itself, handling of the issue was entrusted to Rabbi Moshe Shaul Klein, a moreh tzedek in Rabbi Wosner’s beit din.
XV. Rabbi Klein’s Letter
On August 19th, 2003, Rabbi Klein wrote a long letter to me in which he restated Rabbi Wosner’s position. After a short introduction about the importance of brit milah in general, and about the mitzvah of traditional metzitza in particular, and after citing the Jewish people’s self-sacrifice throughout the generations for the sake of observing this mitzvah as prescribed by halacha, Rabbi Klein went on to state a few major principles in the name of Rabbi Wosner, namely:
1. The mitzvah of milah, commanded to us by Hakadosh Baruch Hu, has withstood attack throughout the generations, and Gedolei Yisrael have been forced to stand in the breach to prevent any alteration of the laws of brit milah, which were commanded to us at Sinai, including any change in the received technique of metzitza.
2. “If it is known that the mohel has a particular illness which, by means of metzitza b’peh, could infect the infant, if the harm is prevalent (shachiach hezeika), one should exercise leniency in this manner only: by performing metzitza with an implement.” In other words, deviating from the traditional method of performing metzitza should be done only in situations defined in halacha as “shachiach hezeika”.
3. The definition of “shachiach hezeika” as it pertains to this issue is a halachic decision of great significance, and therefore it is put into the hands of the chachmei hador.
4. Therefore, the major practical conclusions are as follows:
5. A mohel who is known to be infected with a virus in a situation defined as shachiach hezeika should not perform brit milah using an implement for metzitza if there is another mohel who is able to do the metzitza in accordance with tradition, without deviations.
6. If there is no other mohel, and the mohel infected with the virus in a situation defined as shachiach hezeika is performing the brit milah, then he is required to carry out metzitza with a sterile implement and he is forbidden to carry out metzitza b’peh.
7. “A policy that mohalim should check themselves for infectious diseases (when there are no symptoms arousing suspicion) should not be instituted, for this is the beginning of the breach in the battle to abolish metzitza b’peh, and the holy Torah is eternal in every generation, to carry out the mitzvah unchanged, as received by Moshe on Sinai.”
XVI. Preventive Measures in the Age of Herpes
The medical data includes no scientific proof that any particular mohel actually infected an infant he circumcised with a virus. On the other hand, the epidemiological data point to the possibility that there have been cases of contagion of newborns, although it has not been proven who caused the infection. Likewise, even if we attribute all the isolated reported cases of infection to the mohalim, it still remains a very rare phenomenon, roughly one case in tens of thousands britot, a substantially lower risk than that posed by other surgical procedures.
In light of these facts, it is imperative to find a balance between the responsibility to prevent even “the slightest concern of danger to life,” and the responsibility to avoid leaving any opening for attack upon the mitzvah of traditional brit milah. The task of achieving this balance is in the hands of the poskim. The following lines, therefore, should be viewed as a halachic-medical deliberation before the chachamim.
On the practical level one must differentiate, in my opinion, between five situations.
Situation 1: If the mohel has never been suspected of transmitting HSV to an infant he has circumcised, there is no medical or halachic impediment to allow him to continue performing metzitza b’peh in accordance with the tradition received from our ancestors.
Situation 2: On the other hand, if a medical examination identifying the subspecies of the virus has shown that the mohel is the source of the child’s infection, then, according to all opinions, this mohel is forbidden from this point on to perform metzitza in the traditional manner.
The third, fourth and fifth situations are intermediate:
Situation 3: HSV has appeared in a newborn shortly after his brit milah, but the subspecies of viruses found in the baby do not match that of the virus in the mohel’s system. It is difficult in this case to prohibit the mohel from performing traditional metzitza in the future (unless his rabbis have instructed him otherwise), since the possibility that he is the source of the infection has been to a large extent controverted.
Situation 4: If another possible source for the infection has been discovered (a parent, for example), in this case, too, the mohel should not be prohibited from performing traditional metzitza, since many infants had been circumcised by him without ill effects, and furthermore, there is another plausible source of the infection.
Situation 5: HSV has appeared in newborns shortly after their brit milah, yet, while no other likely source for the infection has been found and the possibility that it was transmitted by the mohel has not been negated, there is no proof from a subspecies examination that that mohel is actually the source.
In the last situation, on the scientific level we have no proof that the mohel is the cause, nor do we have proof that he is not. Therefore we must bring into our calculations the rule derived from the sugya of “one whose brothers have died as a result of [brit] milah” (Yevamot 64b), which determines that sometimes, in cases of evident risk, there is no need for absolute proof in order to attribute the illness to a plausible cause. In other words, the rules of chazakah now enter into the calculations. The question here is not so simple. Is it proper to prohibit metzitza b’peh in this situation on the grounds that “danger is regarded with more stringency than a Torah prohibition” and we have a responsibility to prevent even “the slightest concern of danger to life,” or is there still room to permit it, with certain limitations?
XVII. The New York Agreement
The New York State Department of Health recently formulated the following solution to the metzitza b’peh controversy. The agreed-upon solution is to permit metzitza b’peh in situations 1, 3 and 4, and a subsequent metzitza after situation 5 takes place only if the mohel takes preventive anti-herpes medication on the day of the brit milah and for at least three days before it.
It should be noted that this is a somewhat problematic solution. From a medical standpoint, this treatment has yet to prove affectiveness in preventing contagion, even though, logically, according to medical knowledge, it should be useful. Yet, this solution was agreed upon since the very transmission of the virus by metzitza b’peh has not been completely proven, and the precautions are based only on a medical understanding that transfer could occur in this way. Regarding situation 5, my opinion is that the solution agreed upon in New York, can only be acceptable if contagion was a one-time occurrence. On the other hand, when we are faced with a chazakah of repeated viral infections after circumcision performed by a specific mohel, it is appropriate that he should refrain from metzitza b’peh until proven that he did not cause the infection.
* The following takes S. Sprecher's article, "Mezizah be-Peh – Therapeutic Touch or Hippocratic Vestige?" published in Hakira – the Flatbush Journal of Jewish Law and Thought 3;15-66:2006, opposing Metzitza b'Peh, into account and seeks, among other goals, to meet the objections raised by Sprecher.
 See, for example, Brit Milah be-Seter in: Rabbi Efraim Oshri (ed.), Hurban Lita (New York, 5712), quoted in: Mordechai Eliav (ed.), Ani Ma'amin (Mosad ha-Rav Kuk, Jerusalem, 5734); Neria Gutel, Yahadut Tsorfat ba-Sho'ah in: Ha-Tsofe (6 Tevet 5766), p. 12.
 I Maccabis 1:47; II Maccabis 6:11.
 Mechilta Bachodesh, chap. 6, cited in Perush HaRamban al HaTorah, Aseret HaDibbrot.
 Yalkut Shimoni, parashat Yitro, remez 292; also in Vayikra Rabba (Vilna ed.), parasha 32, starting from “vayeitzei ben”.
 Chaim Dovid Zwieble, “Between Public Health and Masores Avos”, The Jewish Observer, April 2006, pp. 5-19.
 This principle is also reflected in differences found in halachic rulings – see hereinafter.
 S.D. Niku, et al., “Neonatal Circumcision”, Urol Clin North Am 22, no 1 (February 1995): 57-65.
 Sharon Bass, “Circumcision Persists Despite Doctors’ Disapproval”, Maine Times 29, no. 9 (January 1997).
 Thomas E. Wiswell, “Circumcision Circumspection”, New England Journal of Medicine 336, no. 17 (April 24th 1997): 1244-1245.
 An editorial in the New England Journal of Medicine, the world’s most widely distributed medical journal, stated:
Furthermore, circumcision reduces the risk of penile cancer. In uncircumcised men, the lifetime risk of this cancer is about 1 in 500, as compared with a risk of 1 in 50,000 to 1 in 12 million in circumcised men (Thomas E. Wiswell, ibid.).
In other words, the risk of penile cancer in uncircumcised men is from 100 to 24,000 times higher than in circumcised men.
 B. Auvert, et al., “Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial”, PLoS Med 2, no. 11 (1995): e298.
 Most recently, a commentary published in JAMA listed various medical benefits resulting from circumcision, see: Aaron A.R. Tobian, MD, PhD and Ronald H. Gray, MD, MSc, “The Medical Benefits of Male Circumcision”, JAMA (Oct. 5th, 2011), pp. 1479-1480.
 See: David Brown, “Use of Circumcision to Fight AIDS Epidemic is Debated”, Washington Post, Wednesday, August 16th, 2006; A03.
During the winter of 2007 the World Health Organization came out with a special announcement calling for the inclusion of circumcision in the package of measures taken in the batlle agains AIDS. See: “WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention”, World Health Organization, News releases March 28th, 2007.
 See Shabbat, chap. 19, mishnayot 3-4, and the ensuing sugyot in the Talmud, and poskim.
 Hilchot Milah, chap. 1, halacha 18.
 Citations are found in Sefer Habrit, siman 265, p. 215-216, and similarly in the Chatam Sofer quoted below.
 Among them are the Maharam Shick, the Binyan Tzion, the Mahari Assad, the Divrei Yatziv and the Minchat Yitzchak.
 Shu”t Meshiv Davar, chelek 2, siman 55, beginning from “Michtav.…”.
 Shu”t Avnei Nezer 10, siman 338.
 See Avodah Zarah, chap. 2, mishna 5; Talmud Bavli, ad loc., 35a; Perush Rabbeinu Chananel, ad loc., citing the Palestinian Talmud.
 Shabbat 133b.
A similar point appears in a different context: certain rules and regulations of Torah Sages designed to prevent dangerous situations are characterized as being "religious" in nature in addition to their being safety precautions.
An interesting example of this is found in the Palestinian Talmud, tractate Shabbat 6:2. Unlike the Babylonian Talmud, according to the Palestinian Talmud nail-studded shoes were not retrospectively prohibited on Shabbat in order to preserve the memory of a great disaster. Instead, the prohibition was an ancient one deriving from the days of the disaster itself when many innocent people were trampled to death because others wore such shoes. This prohibition was never annulled; its purpose was to preserve public safety by preventing the use of such shoes in the future, thus averting a potential future disaster. According to the Palestinian Talmud, prohibiting these shoes on Shabbat also prevents their use during the week because most people had only one pair of shoes. Therefore, it was sufficient to prohibit the shoes on Shabbat.
Nevertheless they did not simply prohibit the shoes all week long because such a prohibition, intended to preserve public safety, would have been contentious as ordinary citizens thought of themselves as qualified to express an opinion on public safety. "Religious" laws, on the other hand, were accepted without question since they were strictly in the realm of the great Torah scholars (a similar principle lies behind the Talmudic Rabbis decision to suppress the true reasons for their legislation; they wanted to avoid disputes regarding the validity of their laws, as explained in the Talmudic passage about the prohibition on gentile cheese, see: b.Avoda Zarah 29b; 34b-35b). It seems reasonable that similar considerations might apply to the decision to categorize metzitza as a "religious" law, not only as a law intended to prevent danger in rare cases.
 Although some (the Mahari Assad and others) have contrived to reject this conclusion, it is difficult to take the sugya out of its simple context.
 Hilchot Milah, chap. 2.
 I.e., “or a medicinal powder that stops [the] bleeding,” Shulchan Aruch, 14, 264, 3.
 Zichron Brit LaRishonim (Berlin, 1892), p. 20.
 The constriction is caused in part by a nervous reflex, but principally by a local reaction of the smooth muscle layer of the artery. This apparently leads to induction of an action potential (resulting in contraction) that can travel along several centimeters of the arterial wall (See A.C. Guyton, Textbook of Medical Physiology, 5th ed. [Philadelphia, 1976], 99).
 It should be noted that in most cases, this blockage would have no effect on the alternative blood supply of the glans, which comes from the well-protected and padded urethral arteries. However, in those instances where a congenital anomaly affects the urethral arteries (and there have been not a few such instances), a transient blockage of the dorsal arteries can cause severe hypoxia of the glans.
 For cases where hypoxia after circumcision has lead to necrosis and loss or the corona, see Mordechai Halperin, MD, David Fink, PhD, and David Rosen, MD, “Metzitza and Bathing in Warm Water in the Performance of Jewish Ritual Circumcision”, JME V, vol. 2, June (2006), pp. 26-44.
 See reference in note 29 for descriptions of such cases.
 See R. Hai Gaon, quoted in Rach and Rashba (Shabbat 42a) in connection with red-hot metal and trapping snakes. Since there is some slight danger to the public, these are considered life-threatening situations and violation of Shabbat is permitted (quoted in Minchat Shlomo 1:7:1); In Beit Yosef Y.D. 178, Torah prohibitions are superseded by future dangers even when the danger is not yet present.
 See Daat Kohen 140; and see my reference to R. Sh.Z. Auerbach in Medicine. Realia and Halacha, Jerusalem: 2011, Sect. 1, ch. 4.
 In the absence of a clear tradition on the nature of the danger averted by metzitza, there has been much speculation. See the Sedei Chemed, addenda to Rabbi Moshe Bunim Pirotinsky, Kuntres HaMetzitza; Sefer HaBrit (New York, 1973), siman 264; Rabbi Avraham Kahn, Brit Avraham HaKohen al Rabbeinu Ya’avetz, Hilchot Milah (Brooklyn, 1994), 190-91 and Avraham Steinberg, Encyclopedia of Medicine and Jewish Law Vol. 3 (Jerusalem, 2006), under ‘Milah’.
 See Rabbi Avraham Yitzchak HaKohen Kook, Da’at Kohen, 140-42; Brit Avraham HaKohen 191-92; Tiferet Yisrael, Shabbat 19, mishna 2.
 See Rabbi Samson Raphael Hirsch, Shu”t Shemesh Marpeh, simanim 54-55, cited in Brit Avraham HaKohen, 194-195.
 Rabbi Yitzchak Bar-Sheshet (Ribash), Shu”t HaRibash, 447.
 Ribash, ibid.
 Avraham Steinberg, Chapters in the Pathology of the Talmud, Jerusalem: The Schlesinger Institute, 1975, pp. 5-8.
 Shu”t Shemesh Marpeh, siman 54; Rabbi Asher Anshil Greenwald, Zocher HaBrit (Ozharad-Ungver, 1931), 12, 31.
 Zocher HaBrit 11, 18-19.
 Shu”t Shemesh Marpeh, siman 58, cited in Brit Avraham HaKohen, 195; Da’at Kohen, 141-142.
 See Avraham Steinberg, "Circumcision: Medical and Halachic Aspects" (Hebrew), in Medicine and Halacha: Practical Aspects, ed. M. Halperin (Jerusalem, 2006), pp. 253-316.
 Cited in Nishmat Avraham 4, 1st ed., part 14, siman 264a.
 Kovetz Teshuvot 1, siman 102.
 Shu”t Shevet ha-Levi 8, siman 267.
 Rabbi Wosner, as a posek, is known to be a follower of the Maharam Shick.
 A situation in which the risk is real from an epidemiological point of view.
 See also Avnei Nezer, 10, 325, ot gimmel, which states that even if the child’s brothers were endangered, the third son is not to be circumcised; Shu”t Shem Aryeh, siman 31, which prohibits circumcising even a child whose first two brothers died, but the next two lived; the line of reasoning attributed to Rabbi Chaim of Brisk on the definition of a chazakah based on an event that occurred three times and the Talmudic Encyclopedia 13, under ‘chazakah’, pp. 739-760, comments 1, 5 and 7. I have dealt with this issue elsewhere at length, and space prohibits delving deeply into it here. See note 50.
 For full text of the NYSDOH circumcision protocol, see pp. 36-39 infra.
 In cases of danger (sakkana), according to the Jewish Law halachic standards are stricter and two occurrences are enough in order to deem a repetitive situation as chazakah.
 Rabbi Elyashiv agrees, as indicated in R. Yosef Efrati's letter to Prof. Avraham Steinberg: "Regarding your suggestion from the 13th of Tishrei 5768 that the Inter-Departmental Committee for Circumcision issue a directive that "a ritual mohel suspected of infecting infants with herpes during circumcision more than once refrain from performing oral metzitza and that someone else perform the metzitza" – I am happy to inform you that according to Rabbi Elyashiv such a directive is proper".
See also Rabbi David Kahn, Abraham Yagel Yitzchak Yerannen (Brooklyn, N.Y.: Moriah Offset Corp., 5760, p. 199): It is known that R. Aaron Kotler insisted on omitting oral metzitza after a case when a child was infected and died.