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Sunday, March 11, 2012

Metzitzah - an explanation for non-Jews in light of recent news stories

When the story in the Daily News came out, I honestly thought it was shoddy reporting. The information provided would never stand in a court "A baby died 6 months ago, says the unnamed spokesperson, from complications from herpes allegedly transmitted by an unnamed mohel to an unnamed baby of an anonymous family."

I was interviewed for an article, from a mohel's perspective, and the article in question found its way to the Huffington Post, among a whole host of blogs. Many of those involved have made disgusting and unwarranted comments about me, mohels in general, and Judaism. I will not give those comments the dignity of a response.

I have seen the story be re-translated in a number of venues – as news and in opinionated-blogs (everyone is entitled to an opinion), so I am writing here to make a few clarifying remarks and to explain metzitzah to a non-Jewish audience in particular.

Those who view mohels as pedophiles are completely in the wrong. It's the same as saying a Gynecologist assaults women. No mohel touches a baby unless he has been hired by the baby's parents, and they have called him based on his experience and reputation.

In addition, the circumcision is done with a metal blade. The mouth is not used to perform the circumcision. It's utilization in the ritual will be described below – and you will see where the mouth's role was developed, how I believe it is utilized wrongly, and how it can be included in the ritual in a safe manner that could satisfy the desires and sensibilities of all persons involved [see the very end of this posting].

My comments on metzitzah (until this point - see here here and here) have been towards those looking specifically for a bris. But this latest news has brought metzitzah to the fore again, and it cannot be ignored.

We live in a country made up of arguably the most religious population in the world, with a media that is the most anti-religious in the world. An unhealthy cynicism and hatred of people of faith makes discussions surrounding religious practices difficult to be heard for their merits.

For example, it is very important to people that President Obama is a Christian (as opposed to a Muslim), but heaven forfend that the nature of his religious practice, actual beliefs, etc be subject to scrutiny. On the other hand, Sarah Palin and Rick Santorum have been ripped apart for their beliefs, and the fact that Mitt Romney is a Mormon is also "problematic." Even in JFK's time, many made a big deal over his Catholicism. All of this may play a role in defining a personal ideology, may or may not effect political decisions, and should be a universal question in any and all candidates. Either we make a big deal about religion always, or we do not ever.

There are religious practices which seem odd to outsiders in general, and may even seem out of place to the practitioners and adherents themselves. Why does water – applied in a specific place and under the instruction of a specific individual – turn a person into a Christian? How does emergence from water – in a specific place and with a rabbinical court present or nearby – turn a person into a Jew?

Why does wine play such significance in different ceremonies?

Why do we put so much stock in the archaic form of wedding ceremonies?

Religions have rich histories, and adherents to the ways of their religion do what they can to follow their traditions – sometimes when they understand them, and sometimes even when they don't understand them.

In Judaism, there are reasons for just about every practice imaginable. That people do not always know the reasons for the things they do speaks more of their education than for Judaism's lack of answers.

Over the last two centuries the Reform and Conservative movements have spent much time putting ancient practices to scrutiny, and in many cases, rejecting the ways of old in favor of newer ways, sensitivities, sensibilities, realities and modernity.

While one can argue the benefits of such an approach, these innovations are not universally heralded as a boon to Judaism. Sometimes it is in fact to Judaism's detriment.

The ancient practice of Bris Milah, ritual circumcision, has been put to much scrutiny. It's Biblical sources are in Genesis 17 and Leviticus 12 – in both cases Abraham and his descendants are enjoined to circumcise their sons on the eighth day of a baby's life.

Regardless of what one thinks about circumcision – whether it is a right of the parents, of the child, whether it has medical benefits or does not have benefits – most doctors will tell you that the procedure itself, when done properly on newborns (and it is one of the most common surgical procedures done in the United States today), is not dangerous, it has a very quick healing time, and it does not change a baby's growth and development in any way. In many cases, it may even be quite beneficial to the baby, taking care of a problem he might have otherwise had to take care of himself when older – such as a bad case of phimosis, or speeding up a necessary reconstructive surgery which may have been overlooked had the parents not been looking to have a circumcision done.

All arguments to the contrary are generally made by circumcised individuals who, as adults, wish they had a foreskin. Making this an obsession is an unfortunate result of people having too much time on their hands.

While there are certainly methods of circumcision which are barbaric and should be outlawed, and while there are certainly operators who should not be allowed to circumcise, this is not sufficient reason to ban the practice. Circumcision is done for religious, social, medical, and even asthetic reasons. And when done in a quick procedure by an experienced operator, the pain is minimal and the healing quick.

The Talmud is the transcription of the Oral Law of Judaism – the tradition handed to Moses at Sinai along with the Five Books known as the Torah. Observant Jews look to the Talmud as the guide for all of Jewish law, as, in addition to being the basis for most matters of civil law and holiday practices, it is also the source turned to first to address contemporary questions of business and medical ethics.

The discussion over organ donation and the definition of the end-of-life for such purposes, for example, begins in the Talmud.

When it comes to the Jewish practice of bris, the Talmud describes in clear terms what the steps of the bris are: milah – excision of foreskin, priah – removal of the mucosal membrane, and metzitzah – which Maimonides described as the drawing out of deeper blood.

It is metzitzah which is the subject of debate and controversy, simply because it is not clear a. how the word is best defined (and therefore what the action is), and b. what purpose it is meant to serve.

The Hebrew word metzitzah can mean to squeeze, compress, drain, or suck. If it is any of the first three terms, metzitzah can be easily understood by everyone. The best way to bandage an open wound is by compressing it, done now with gauze, thereby drawing blood away from the incision spot, allowing the bandage to be immediately applied in order to achieve stasis. This is standard first-aid procedure and has an excellent track record for achieving the desired result. If, however, the term means "suck," then the Talmud is suggesting that the best way to bring about this result is through creating a vacuum at the incision spot, and drawing the blood away through the power of the mouth. We will revisit this point in a moment.

The next question to be addressed is what is the purpose of the metzitzah? Is it a required part of the procedure, a ritualistic remnant that is beyond our comprehension? In other words, is it a part of the "mitzvah" – an essential element of the fulfillment of the commandment to circumcise? Or, was it instituted for health reasons, as advice or as a strong suggestion as to how to best achieve stasis?

If it's the former, those who follow the Talmud's instructions to carry out Jewish law to the "t" will continue to do metzitzah (method subject to debate). If it's the latter, perhaps metzitzah ought to be abolished. Modern science and medical knowledge gives no credence to placing a mouth, laden with all its bacteria, on any open wound, especially that of a newborn.

At the same time, we must recall that knowledge of the "germ theory" is little over one hundred years old. Historians will tell you that President James Garfield more likely died at the hands of his doctors than at the hand of the bullet shot into him. His body had formed a cyst around the bullet, by no means leaving him comfortable, but also preventing his wound from being fatal. His doctors sticking their fingers in his body to try to get the bullet out is what brought on the infection that took his life.

There is one caveat. In addition to what has been said until now, the Talmud says that if milah (removal of the foreskin) is done without priah (removal of the membrane) it is as if the circumcision was never done. In other words, it would need to be revisited; the child would need to undergo another circumcision

While it does not mention metzitzah as being a factor which, were it not done, would cancel the bris and cause a revisit, it does say that a mohel (ritual circumciser) who does not perform metzitzah is to be removed from his post. The reason? He has put the baby in danger through skipping the metzitzah step.

It doesn't take a degree in rocket science to see that this last explanation gives every indication that metzitzah is to be regarded as a medical necessity from the Talmud's perspective. This would imply that if the medical reality changes, we need not follow it. There are many bizarre medical suggestions in the Talmud which are not taken literally today – they are clearly a reflection of the medical knowledge of the time when the Talmud – the oral discussions that had carried on for centuries – was finally recorded to avoid its being lost forever.

And yet, the Talmud says that a mohel who does not do metzitzah is to be removed from his post. This is a statement that many people take quite seriously. On the one hand, I think that metzitzah is unnecessary, on the other hand, according to the Talmud, if I don't do metzitzah I am no longer fit to be a mohel. What to do?

Let us consider that metzitzah means to compress, squeeze, or drain. Would anyone argue that metzitzah is not be done? On a fresh wound that requires immediate attention, it is the best way to go. Put enough pressure, and bleeding stops. But if metzitzah means to suck, every sensible person would say it should not be done – should be abolished, in fact.

OK. We revert to the latter discussion – is metzitzah a requirement, part of the mitzvah or was the Talmud making it a medical mandate?

This is the source of the debate and the controversy over the years. The rabbinical authorities throughout the centuries have been split on the matter – some saying it is part of the mitzvah, to varying degrees of obligation; others have said it was a medical necessity, subject to the scrutiny of medical knowledge changes.

For close to a thousand years, metzitzah through suction was the method recorded in rabbinic literature (though surprisingly, the method of metzitzah is not described in the major codes of Jewish law - such as Maimonides and the Shulchan Arukh). And it makes sense. Bandages of yesteryear were nothing like what we have today. And the Hippocratic method of medicine advocated sucking blood out of wounds in various instances – particularly from poisons, to remove toxins, and sometimes through the use of leeches. Mohels doing this was no different than what everyone else was doing.

That babies may have died in the last millennia from circumcision was not a particular fact people would have noticed. For hundreds of years, 1 out of 3 babies was not expected to survive very long – mortality of infants was accepted as a fact of life. While there were incidents recorded in different towns, where a number of babies died post bris, it was only in the last 200 years when people particularly took notice and blamed it on the mohel. And they were usually right.

Science has evolved, medicine has evolved, and we know things now that were not known 150 years ago.

The problem, and the source for the story that became known in the first week of March 2012, is that there are people in the Jewish community who still believe that despite all the evidence suggesting otherwise, metzitzah is part of the mitzvah, meaning it must be done, and that the only acceptable method of doing metzitzah is by putting the mouth on the baby.

Before I continue, I would like to point out that there are many people who follow this latter method, and despite this being the case, it is surprisingly rare to hear a story like this, of a baby dying as a result. The number should be zero – zero babies dying from herpes contracted during the circumcision. The fact is that the herpes from brisses cases are quite uncommon, but unfortunately, the number is not zero.

To give you a sense of how even bright people will go against all of their sensibilities in this matter, I bumped into an old acquaintance from my camp days who is now a cardiologist. When he asked me what I do, and I mentioned I am a mohel, we got to talking and the subject of metzitzah came up. I asked him his opinion, and he said "My family's custom is to do it with the mouth directly on the baby." When I asked him how his medical knowledge jives with this practice, he said, "It doesn't." Then why do you still do it? "Because it's our family practice."

I understand that people might feel this way – which is why I have advocated that if a family insists it be done this way, let the father take the responsibility and do it himself. Why have a mohel, who deals with many many babies, be the conduit for the sharing of bacteria? [I know, this sounds quite archaic and wrong. But I am trying to explain the convictions and beliefs of people, and where they are coming from – even if they, were they to think for a moment, would see how wrong it is. The problem is that many don't even think about the possible repercussions.]

The alternative, in light of the Talmudic pronouncement that a mohel who does not do metzitzah is to be removed from his post, is to do metzitzah in an alternative way. There are those who accomplish the metzitzah through the simple application of gauze.

And there are those, such as myself, who view the metzitzah as a remnant of a ritual – which certainly had importance once upon a time – which can be accomplished with the power of the mouth through the utilization of a method that is harmless to the baby, no different than the application of an additional gauze pad.

Using a sterile glass pipette (first invented in the late 1800s) stuffed with a sterile gauze pad, is the method I utilize because:

  • the vacuum pressure can be achieved with the power of the mouth, 
  • it fulfills the obligation according to those who think metzitzah means sucking with the mouth, 
  • it avoids the removal from one's post (as mohel) advocated by the Talmud for not doing metzitzah, 
  • it avoids any transfer of body fluid from mohel to baby and vice versa, 
  • while most importantly it is an act which is harmless to the baby on the one hand (because the glass and gauze are sterile) and so meaningful, on the other hand, to those who view metzitzah as part of the mitzvah.

If you read any of my writings about bris and the sterile technique I advocate in the public ceremony that surrounds the ritual circumcision of Jewish babies, you will know where I stand. I advocate that:
• mohels be held to higher standards in their sterile techniques
• no aspect of the circumcision procedure (beyond removal of the foreskin which is biblically mandated) should possibly put the baby in danger
• babies' lives are far more important than any religious convictions a mohel may personally carry

Remember that every mohel who performs a bris does so because parents have called him and hired him to perform the circumcision on their behalf. Mohels have a responsibility to inform parents of what they intend to do.

More importantly, parents must be informed, and must make sure that when they hire a mohel to do a bris, that he performs the metzitzah (and other aspects of his circumcision technique) in a sterile manner that conforms to their sensibilities.

Mohels who will not comply will quickly be out of business.

And if parents take the bull by the horns, metzitzah with direct oral contact can become a thing of the past, and we will finally move past the days when we hear stories of babies contracting herpes and dying from the bris.

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