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Thursday, March 15, 2012

A Medical Opinion Piece about Metzitzah (plus some logical arguments)

I will talk about this piece after the following interlude, but if you don't want to read what I have to say, either click the link or scroll down to where I have reproduced this opinion piece of Dr. Gary Gelbfish in the Jewish Week, dated March 13, 2012

I just got off the phone with a mohel colleague - we talk about the trade every now and then, on the phone, online and on Facebook! Young mohels... so in touch with technology :)

After sharing this article with me, he argued that people going snowboarding/skiing, or driving unsafely on a highway are all risks that people take, but we don't ban the activities. Therefore, perhaps one can make the argument that metzitzah is a risk people take.

I am not going to go into the probabilities and start making mathematical equations. To live life and avoid danger we don't shut ourselves into a corner. We face the world, do the best we can and hope for the best. But snowboarding and skiing is generally safe when done in a safe manner - and besides, it's a choice individuals make for themselves. Can I put myself at risk in choosing to participate in this activity?

A baby has no such luxury. Please excuse the image I am about to present. The parallel would be that if I am circumcising myself, I can choose to have someone do metzitzah on myself. Baby has no say in the matter.

I've also heard the argument proposed that "Saliva has antiseptic qualities. Isn't your first instinct to suck your finger when you cut it?" [Regardless of the fact that saliva does not have antiseptic qualities...] Again, the logic does not follow. Even if I do suck my finger when I cut it (I don't - I clean it under a sink and put pressure on it, but whatever), I don't have my friend suck my finger. So the only parallel which would work is (and again, please excuse the image) "When I do a bris on myself, I do the metzitzah." RIDICULOUS!

Furthermore, the fact that a parent may choose to drive unsafely on a highway - with kids in the car - is also not parallel to the risk posed by a metzitzah on the mouth situation.

In comparing the circumstances - On one hand you have a parent driving putting himself and his child in danger, and on the other hand you have a parent who puts a not-yet-built-up-immunities baby in a situation where a simple lesion in a mohel's mouth can be fatal [remember - you don't know if you'll be in a car accident, but you do know the mohel's mouth will touch the baby]:

Choice: Drive more carefully, use seatbelts, get a safer car – do what you can to live your life in a way that minimizes risk. Driving a car is something everyone does every day.

Choice: Either make the mohel test for herpes before each time he does metzitzah, or do metzitzah with a tube – do what you can to live your life in a way that minimizes risk. No one allows strangers to put their mouths on others' open wounds ANY day.

Does the parent have the "right" to make a potentially dangerous choice for one's child? Technically, yes. But society has the right to say, "This is unacceptable in our community. There is a limit." Can a parent utilize corporal punishment? Yes. A parent has that right. But society limits it. You want to spank your kid? A potch on the tush? A slap on the wrist? OK. You start whipping or breaking bones, however, and the police are going to get you. There's a difference between tolerable and intolerable, between technical rights and completely "endangering the welfare of a child."

I am always grateful that the bad metzitzah stories are few and far between. We definitely live in a time in which our knowledge of medicine, infection, etc is light years ahead of where it once was, and we don't see trends of babies dying.

I guarantee you, however, that if babies were dying left and right, it wouldn't be tolerated. We would hear people saying things like the Chasam Sofer, "In light of recent events, we have decided to allow a tube to minimize risk to babies." Why would it take more babies dying to bring about a conclusion like this?

We want to nip it in the bud.

WITH THIS AS A BACKGROUND, ENJOY DR. GELBFISH's OPINION PIECE. IT SOUNDS VAGUELY FAMILIAR [Although there is one error. He says the Talmud advocates MBP - which is not accurate. The Talmud says nothing about the Peh - the use of the mouth. The Talmud mentions Metzitzah as part of the procedure - though as I have pointed out here, the Talmud does not say how to do it, as the meaning of the term is vague, and it indicates that Metzitzah was a medical suggestion to keep the baby out of danger (which we would completely disagree with today), much more than it was a religious requirement. Other than this nuance, it is a well thought out piece.]

In Debating Bris Controversy, Know The Medical Facts
Gary A. Gelbfish

Tuesday, March 13, 2012

The debate about ritual circumcision with metzitzah b’peh (direct mouth-to-wound oral suctioning by the mohel) is complex, as it involves halachic, historical, social, medical, technical and potential regulatory components.

My personal interest and experience in ritual circumcision is long standing. I studied to be a mohel in Israel and was certified as a mohel by the Israeli Rabbinate in 1983. I have performed many circumcisions, mostly on babies of family members, and occasionally on children and adults from the former Soviet Union. Furthermore, as a vascular surgeon for the past 22 years, I have frequent interaction with infection and wound healing issues.

My first interaction with probable disease transmission from metzitzah b’peh (MBP) was in 1998, when an infant in my wife’s pediatric practice was treated for herpes infection of his genital area soon after a bris that included MBP. The latest case of an infant death in New York attributed to herpes associated with MBP is deeply disturbing to any parent, mohel, rabbi or public health official. Clearly we need to discuss MBP and at least entertain potential changes in ritual practice.

For those in a position to influence the debate, I present the following medically related points.

Transmission of herpes via MBP does occur in some cases. This has been amply established by multiple case studies reported in the medical literature and many unreported cases. These cases showed herpes in the genital area soon after a bris that included MBP; with little probability of a source for the infection other than the mohel’s mouth. While the frequency of such infection is difficult to quantify, it must be noted that medical case literature most often under-reports the frequency of unusual disease presentations prior to a widespread awareness of the disease having emerged amongst medical practitioners.

Even if we did not have these case reports, the potential for infection is totally consistent with what we know about herpes virus transmission, via oral contact. Would any sensible adult knowingly kiss a person infected with herpes, especially with an open wound? In our modern society, we accept this line of reasoning without question, yet somehow in the MBP discussion, arguments are presented which inexplicably imply that this logic somehow does not apply to a newborn. To the contrary; newborns may be at even greater risk since they are known to be relatively immune compromised.

In the 19th century, even before the widespread acceptance of Pasteur’s Germ Theory of Disease, there were many reports of children with genital syphilis and tuberculosis attributed to MBP. At the time, this generated significant halachic debate and led many rabbis to restrict MBP, most notably Rabbi Moshe Schreiber (the Chasam Sofer), who ruled that MBP could be accomplished by instrumental suction or a gauze/sponge. Ample evidence exists that in many European cities, the custom of many Orthodox communities was changed as a result.

Over time and with the essential elimination of syphilis and tuberculosis as a risk factor, MBP has had resurgence amongst some elements of the Orthodox community. We seem to have forgotten what was obvious to many over a century ago — that communicable diseases can be spread via MBP.

The herpes virus is a relative newcomer to the known pantheon of communicable diseases, most frequently associated in adults with oral and genital lesions. Is there any reason, however, to postulate that it behaves in some special way during a bris? Do we really need additional case studies to reconfirm the medical paradigm of infection transmission?

Herpes infection in a newborn may lead to lifelong infection, chronic neurological impairment and, at times, death.

The Talmud recommends MBP as beneficial to the health of the baby, consistent with ancient Greek and Roman medical theory. However, based on the current mainstream medical understanding of wound healing and infection prevention, there is no known medical benefit to MBP; certainly none that would outweigh its currently observed potential for harm.

A person may not be aware that he is infected with herpes, and virus shedding from the mouth surfaces may at times, occur without obvious oral sores. This is why we cannot expect caring and well-meaning mohels to be able to solve this problem by not performing MBP when they know themselves to be ill. To lessen the incidence of transmission we may construct an elaborate public health system to track and ensure that our mohels are “disease free” via frequent, perhaps monthly physical exams, blood and salivary immunoglobulin tests and perhaps viral cultures. Even if effective, are our mohels willing to accept this burden or are we willing or able to impose this on them?

From a technical standpoint, the goal of MBP is to apply suction and draw out blood from the wound. It can be easily demonstrated that suction may be equally accomplished via a sterile tube or to an even greater extent with a mechanical apparatus that does not involve any oral contact.

In order to have a sound and effective dialogue, we need to first accept the obvious — that MBP does entail a certain, yet at present, unquantified, risk of herpes transmission, and when transmission does occur, the results can be catastrophic. If this truism is accepted, rabbis and communal leaders can then productively discuss the other issues that may be pertinent and come to a conclusion.

Some of these questions are: Is the practice based on strict halacha or is it a less restrictive “minhag” (custom)? Are the origins of this practice and the historically attributed medical benefits relevant today, considering current medical knowledge that disavows the benefit of MBP and instead documents potential harm? Does the perceived threat to the “mesorah” (Jewish tradition) that any change in ritual practice would potentially cause, justify the risk of significant harm to the occasional newborn? What role, if any, should governmental regulation have?

I hope that medical misinformation will not cloud the discussion.

Gary A. Gelbfish is a practicing surgeon and certified mohel.

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