With Regard to the Metzitza b’Peh Controversy (Editor's Summary)
Shimon M. Glick, MD
Arthur I. Eidelman, MD, FAAP, FABM
The
possible relationship between metzitza b'peh and neonatal genital herpes
has recently been discussed by a variety of medical and halachic
authorities. Summaries of their opinions are as follows: In August 2004 (in
English),[1] and subsequently in February 2005
(in Hebrew),[2] articles authored jointly by
medical academicians and Talmudic scholars on the results of a study regarding
the possible relationship of metzitza b'peh and neonatal genital simplex
infection (HSV-1) were published. Prof. Avraham Steinberg, an advocate of the
ritual tradition, had published opposing arguments. The following is a summary
of both approaches.
Position
A: Metzitza b’Peh is Dangerous
The
objective of the first study, published in Pediatrics, was to describe
neonate genital HSV-1 infection after ritual circumcision in order to initiate
antiviral treatment. Eight neonates with genital HSV-1 infection after ritual
circumcision were identified between the years 1994-2002. The study found that
in all of these cases, the mohel had performed the ancient custom of metzitza
b’peh, which is currently practiced by only a minority of mohalim.
Six infants received intravenous acyclovir therapy. Four infants had recurrent
episodes of genital HSV infection, and 1 developed HSV encephalitis with
neurologic sequelae. All four mohalim tested for HSV antibodies were
sero-positive. The authors conclude that pediatricians should be aware of a
potential transmission of HSV-1 by metzitza b’peh in order to start
appropriate antiviral treatment promptly and to avoid severe neurological
impairment.
After
contacting the Chief Rabbinate of Israel and other halachic authorities,
the same authors published a comprehensive rabbinic-historic review on this
issue, published for Israeli and Jewish physicians, rabbis and the
Hebrew-speaking readership in order to avoid Chilul Hashem.[3] They argue that while the practice
of metzitza b’peh might have been appropriate in previous generations to
protect the newborns from disease, there is no Talmudic source halachically requiring
oral metzitza and therefore, based on the potential of oral
contamination of HSV-1 to newborns as documented in their earlier publication,
strictly sterile conditions are required for the procedure. The authors
concluded: “Ritual Jewish circumcision that includes metzitza with
direct oral-genital contact carries a serious risk for transmission of HSV from
mohalim to neonates, which can be complicated by protracted or severe
infection. Oral metzitza after ritual circumcision may be hazardous to
the neonate” (p. 259). Although the cases occurred only in an extreme minority
of circumcisions, the halachic rule “in cases of pikuach nefesh
one does not follow the majority”[4] stands. Thus they wrote, “the same
consideration that led the Talmudic sages once to establish the custom of the metzitza
for the sake of the infant could now be applied to persuade the mohel to
use instrumental suction” (p. 262). The Talmud carefully protected the neonate
from potential risks associated with brit milah and is the oldest source
in the history of medicine to describe e.g. hemophilia in the context of
circumcision;[5] for these children at risk of fatal
bleeding, the Talmud requires delaying of circumcision in order to secure
medical safety, as articulated clearly by Maimonides: “We should not circumcise
a child who is afflicted with any sickness at all, since the danger to life
takes precedence over everything. Circumcision can be performed at a later
date, while it is impossible to bring a single Jewish soul back to life”.[6] Following Maimonides’ Talmudic
approach, Rabbi Moshe Sofer (1762–1839), a.k.a the “Chatam Sofer”, published his halachic
decision regarding cases of newborns contaminated by oral metzitza: He
advised to abolish oral metzitza due to potential danger for the neonate
and to replace it by alternative sterile approaches.[7]
Supported
by these Talmudic and rabbinic sources, that sparked the famous controversies
regarding the status of Metzitza b’Peh during the 19th and 20th
centuries, the authors call for the requirement of strictly sterile
conditions and replacing oral metzitza by instrumental metzitza
in order to protect the newborn; it is the authors' clear goal to encourage brit
milah in the Jewish population and therefore, metzitza
should be performed – according to the Talmudic and rabbinic sources – in a
sterile way to protect the newborn.
Position
B: Proof is far from Conclusive
According
to Prof. Avraham Steinberg,[8] the aforementioned cases and
conclusion are extremely problematic: 7 of these cases occurred in Israel and
another has occurred in Canada over the course of eight years (1994-2002). It
should be noted that in four of the eight cases the mohalim were not
tested for HSV antibodies and in one other case a positive level was found both
in the mohel’s blood and in the mother’s blood. This all adds up to
offer a very low level of probability, even in cases where metzitza b’peh
is performed, and the association has not been firmly proven. During the
mentioned duration of time, in Israel at least 40,000 brit milah
ceremonies with traditional metzitza b’peh had taken place, of which, 7
may have resulted in contagion of HSV, although in half of these cases, there
is no proof whatsoever that the mohel had positive levels of HSV
antibodies, and in one of these cases it may have been the mother that caused
infection. Moreover, in the articles by Gesundheit et al there is no
explanation how these few cases were accumulated, whether or not there were
other cases of HSV infection during that time and by the same mohalim,
and whether or not other family members of these babies suffered from HSV.
Finally, no test of DNA between Mohel and infant had been taken, a test
which is the only scientifically reliable way to prove contagion. Such serious
limitations of the study, which at most creates a chashash rachok
(a very far concern), cannot serve as a contra-indication to any medical
procedure, and since metzitza b'peh is considered by many halachic
authorities to be essential for the mitzvah of brit mila this study is
scientifically insufficient to consider the annulment of metzitza b'peh.
Hence, the
most authoritative Rabbis – Rabbi Y.S. Elyashiv and Rabbi S. Wosner – issued a
clear and firm objection to the annulment of metzitza b'peh.
Either
way, Steinberg concludes, the mohel should take cautious measures in
order to relieve us even of this far concern of infecting an infant with HSV.[9]
C.
Editor's Note
Review of
the data of the published articles[10] and above noted comments does not
support, at this time, a categorical ban on metzitza b'peh nor a need
for routine screening of mohalim for potential herpes infectivity.
However, if the clinical experience of an individual mohel or the
results of his serologic tests suggest a possibility of him being infective,
then instrumental suction should be strongly considered.
It is
relevant to point out that, to the best of our knowledge, no public health
authorities in the US or in Israel have forbidden metzitza
b’peh at the present time.
[1] Benjamin Gesundheit, M.D., Galia Grisaru-Soen, M.D., David Greenberg, M.D., Osnat Levtzion-Korach, M.D., David Malkin, M.D., Martin Petric, Ph.D., Gideon Koren, M.D., Moshe D. Tendler, Ph.D., Bruria Ben-Zeev, M.D., Amir Vardi, MD, Ron Dagan, M.D., Dan Engelhard, M.D., “Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition”, Pediatrics, Vol. 114 No. 2 (August 2004), pp. 259-263 [hereinafter cited by page number]. May be found at the author’s site:
http://www.jewishmedicalethics.org/?page_id=30 – Quotes are given with the author’s consent.
[2] Benjamin Gesundheit, M.D., David Greenberg, M.D., Shlomo Walfish M.D., Ron Dagan, M.D., Gideon Koren, M.D., David Malkin, M.D., Moshe D. Tendler, Ph.D., “Infectious complications with herpes virus after ritual Jewish circumcision: a historical and cultural analysis” (Hebrew), Harefuah, Vol. 144 No. 2 (February 2005), pp. 126-32; 148-9 [hereinafter cited as “Gesundheit: Harefuah”]. May be found at the author’s site:
http://www.jewishmedicalethics.org/?page_id=30
[3] See note 2.
[4] b.Yoma, 84b; b.Ketubot, 15b – and Gesundheit: Harefuah, p. 131.
[5] Tosefta Shabbat 15:8 and parallels.
[6] Maimonides, Mishneh Torah, Hilchot Milah 1:18; see also Shulchan Aruch, Yoreh Deah 263;2.
[7] This Responsa of the “Chatam Sofer” was published in 1845 in Kochavei Yitzchak, Vienna, p. 40. The original full text and its discussion is also available on B. Gesundheit’s website: www.jewishmedicalethics.org.
Editor’s Note: M. Halperin addressed this specific issue in his article “The Tradition of Metzitza” and suggested a different approach: see pp. 23-35 supra.
[8] A. Steinberg, entry 'Milah' (Hebrew), in: Encyclopedia of Halacha and Medicine2, Jerusalem 2006, pp. 492-494.
[9] i.e. If he has sores in his mouth he should refrain from doing metzitza b’peh; he should either use a tube or let another perform the metzitza b'peh; he should thoroughly wash his mouth with 70% alcohol and salve the area of circumcision with a proper anti-herpes ointment (zovirax etc.).
[10] See also Sprecher S., "Mezizah be-Peh – Therapeutic Touch or Hippocratic Vestige", Hakirah – The Flatbush Journal of Jewish Law and Thought 3;15-66:2006 and the letters in the subsequent issue Hakirah – The Flatbush Journal of Jewish Law and Thought 4;9-19:2007.