Doctor vs Mohel

No, it's not the fight of the century.

But it is a question which comes up a lot. So here is the simple answer, from a mohel, of course.

[Though see here for a Reform Rabbi's answer http://www.jweekly.com/article/full/15332/which-one-is-better-doctor-or-mohel/]

Every person must do research and find the best operator for your needs, and for your situation.

In an ideal world, the person you are hiring is an observant Jew, who understands the significance of Bris Milah, the covenant, and all the laws associated with the performance of a bris milah. Whatever character traits you'd like in the person might also be significant to consider, when thinking about what kind of representative you (especially the father, who is really hiring the person to perform this mitzvah in your place) want to fill your place in this very important mitzvah.

ANYONE WHO FILLS THESE ROLES TO YOUR DESIRES IS A GOOD HIRE. [Even better, if he uses a marker when operating...]

Other things to consider:

1. Specialist

Who does more procedures? Many doctors I know (they are usually observant Jews) highly recommend a mohel over a doctor. They have the attitude that the mohel is a specialist. This is his field. He is the expert. Being highly trained in a specific discipline, and specializing in this unique field, makes the mohel most qualified to do this. [Obviously if a doctor happens to also be a mohel, this will work to his advantage in some people's eyes. But honestly, the service a doctor/mohel and a mohel provide is the same thing with respect to the circumcision and the result, except perhaps in two areas as I'll note below]

2. Method

Most doctors are more comfortable using a clamp - such as the Gomco or the Mogen clamp. Do research on these items, to decide if they are right for you. Some mohels (usually on the very modern side, or in the Conservative and Reform movements) use the Mogen clamp or a modified Mogen clamp. Most traditional mohels use what is called in Hebrew a Magen (מגן), a traditional "shield" (which protects the glans and the scrotum) which does not have a clamping arm. THIS IS THE PROCEDURE I USE While no procedure is completely bloodless (a real bris is not supposed to be bloodless), the clamps are supposed to cause less bleeding. The traditional method may have a little more bleeding, but in the hands of a good mohel, it is absolutely nothing to worry about.
And, as Rabbi Cartun points out in the article I linked to above (here it is again), the speed in which a mohel operates is usually much faster than any physician.

3. Numbing

See here for a discussion about this. Most doctors will give the baby several injections to create a nerve blockage. While the baby might not feel the bris, the baby will feel the injections (and may feel them hours later as well). Some mohels recommend or provide a topical anesthetic. Depending on its strength, it may remove the pain of the actual circumcision.

4. How is baby held?

Numbing does not help the baby's discomfort at having his legs held down. Most mohels have the sandak holding the baby's legs, and letting go as soon as the procedure is over. Many doctors might utilize a circumstraint to hold the baby, leaving the baby in an uncomfortable position significantly before and sometimes after the procedure as well.

5. Track record and Touch-ups
Probably the most important question is "what is the track record?" While I don't have statistical evidence, I have spoken to pediatric urologists and pediatric surgeons who have told me anecdotally that they do many more touchups on circumcisions done by doctors than by mohels. [Don't trust me. Ask similar doctors that you may know.]
Doctors tend to take off a little less foreskin, which leaves the penis looking uncircumcised in many cases of touch-up necessity.
[Many "problems" disappear when the child gets out of diapers, and certainly by puberty. But for babies who need their circ to be revisited - it is worth asking people and doctors who has a better track record.]
A surgical marker could resolve this issue, but most mohels and doctors don't use one (though I do! :))

I guess it is clear that I prefer a good and experienced mohel over a doctor. Surprised?

Interesting Conversation About Clamps

I received a phone call today from Rabbi Yaron Amit. He is an Israeli mohel who maintains a presence in South Florida, who has an organization that provides free bris services to Jews around the world. He told me they do 28 brisses a day.

He called because I wrote a blog post in response to an article which appeared in IsraPost a few years ago in his name. As it turns out, my response was more against the way the article was translated than against the points he made. My original post has been removed - at his request, and in respect of the clarification - but I would like to share the points he made in our conversation, along with my own commentary.

Rabbi Amit's main issue is that brisses done with a clamp are not kosher. He says there is never blood from such circumcisions and that even when there is blood in the procedure it is blood which emanates from handling an open incision, which is different blood than "dam milah" - the blood of circumcision. He also referred to realities that changed for people - which he witnessed - after their circumcisions-by-clamp were corrected, such as a change in parnasah, finding a mate, and general shift in life turning positive - what he refers to as "spiritual benefits" (my translation - we spoke in Hebrew).

He maintains that any bris done by such a method is unacceptable and needs hatafat dam bris. And that a mohel who uses such a device is unfit to be a mohel, and is unfit for anyone to hire as a mohel.

He shared with me stories of surgical corrections that needed to be done to brisses done through this method, as well as horror stories of amputations of the glans that he has witnessed on account of the use of clamps.

I agree with him on almost all points. I have long advised against the use of clamps:
* For halakhic reasons: Rabbinic approval is scant        Mistake #4
* For practical reasons: Danger        Arrogance (here I outline another practice, which the Rabbi agreed should not be done - "Freehand")
* In addition, in the "methods of circumcision" I have described here (for education purposes), I have made it clear that while there are some mohels who opt to use the clamp, this practice has been forbidden by many many great rabbis and poskim


The points in which we might disagree are:
I maintain that according to Rabbi Moshe Feinstein, if there is minimal blood at the time of circumcision, the bris is valid b'dieved, as long as there was blood. Rabbi Amit believes there is never blood when a clamp is used, and any blood is not "dam brit" as I explained above. Rabbi Feinstein also makes it clear that the clamp is not to be used (Iggerot Moshe Yoreh Deah 3:99).

I am not a fan of telling thousands of people that their bris is unkosher and needs a touch-up, even if it is "merely" Hatafat Dam. With this Rabbi Amit and I will have to agree to disagree.

CONCLUSION: FIND A MOHEL WHO DOES NOT USE A CLAMP (WHO DOES USE A SHIELD) IF YOU WANT THE SAFEST RESULTS, AND NO HALAKHIC COMPLICATIONS FROM THE BRIS MILAH PROCESS. ASTHETIC RESULTS - IN ALL CASES - ARE DETERMINED BY THE SKILL OF THE MOHEL, IRRESPECTIVE OF THE METHOD. ALL MOHELS ARE HUMAN. ALL HUMANS ARE IMPERFECT. EVERY MOHEL SHOULD DO HIS BEST, AND SHOULD TAKE EVERY NECESSARY PRECAUTION TO ASSURE THE BEST ASTHETIC RESULTS HE CAN.

Rabbi Howard Jachter has penned an article in which he talks about the clamp. I don't believe all the responsa he quotes are being portrayed accurately. I also don't understand what he means when he says "As long as the clamp is used properly." The clamp being used properly happens when the clamping arm is closed. This is what all the rabbis wrote against! The clamp being used "improperly" is when the clamping arm is not utilized. If one is not closing the clamp, why not just use the more traditional shield?

The deleted post (that inspired this one) concluded with these links.
He's YOUR baby, you have a right to choose whom you'll hire.
You have the responsibility to ask all the right questions to every mohel you interview before you settle on the one you want
And you also must take care to know what you are looking for to have the right kind of experience for your needs.  Always remember that the wrong attitude is not to ask.

REMEMBER - IMPORTANT REMINDERS (similar links), as well as THE MISTAKES YOU WANT TO AVOID

So.... Do you use a Clamp?

I get this question a lot, and I think it's time to clarify what the tools of the trade are. 

The answer to the question, by the way, is NO. I don’t use a clamp.  Keep reading, to learn what it is and why some do use it. 

[The following links were added to the post below at a later date (based on when I blogged about them). While the links below address the "tools"/Bris Milah instruments that I use, what follows after the links is not addressed in the "SHIELD" blog post linked immediately below, so the remaining content of this blog post is still quite informative, even if you choose to follow the specific links that immediately follow]

The links to the specific "tools of the trade blog posts" are here - each which will give you a great overview of each item and how it is utilized.

SHIELD              TUBE               KNIFE              PROBE             HEMOSTATS 

MARKER              GLOVES             NUMBING

continuing the original blog post here....

I have blogged about the different methods utilized in bringing about the coveted circumcision result.

Here I will simply distinguish between the largely rabbinically approved, lauded and recommended device which is called a מגן - a Magen - a shield (in Hebrew).  And the "Mogen Clamp" developed by the mohel, Rabbi Harry Bronstein in the 50s (or thereabouts).

Here is a link to photos of shields. The basic gist is that a shield is a solid metal plate (once made of silver, but now more often made of steel) with a thin slit that divides the shield in half.

The foreskin is grasped with the thumb and index finger, and the shield is applied so that only the foreskin is drawn out - while the glans remains protected below the metal, and the foreskin is excised along the shield.

THIS IS THE ONLY KIND OF SHIELD FOR THE GLANS THAT I USE. 

I DO NOT OWN ANY OF THE FOLLOWING DEVICES

What Can Go Wrong At A Bris?

Aside from the cream cheese being moldy, and the family rabbi not being prepared to speak...

REPAIRABLE

If a mohel has, minimally, a decent reputation, he will not likely do anything during the bris that will cause permanent damage. Obviously the foreskin will be removed, but depending on what else comes off with the foreskin, even a foreskin has a possibility of regenerating.

Here are a few samples of things that can "go wrong," that are entirely fixable/correctable within a few minutes of the bris:

1. Not enough foreskin removed (talk about undercutting the competition!)

2. Excessive membrane (or ha'priah) remains, either on account of not having been touched, having been partially removed (but not completely), or on account of it looking aesthetically unpleasing

3. the glans is slightly twisted in how it sits back in the shaft, misalligned from post-bris bandaging (or natural state).

Just like after a bad haircut one can always take off more hair, if not enough skin is removed (which can happen), or not enough of the or ha'priah is removed, it is always possible to fix. And if a mohel notices or realizes it either during the bris or upon checking the baby right after the bris, the best time to take care of it is that moment.

Don't Use the Mogen Clamp!

An article in the Atlanta Journal-Constitution has reported on a lawsuit against the makers of the Mogen clamp. (text of article produced below)

I have never been a fan of this clamp (see method 1 here), and even the FDA has issued warnings against clamps because of their potential of irreversible damage

Simply put, no step in the circumcision procedure should be irreversible until the actual removal of the foreskin. Once the shield is in place, it is important to double check that the proper area of skin is ready to be excised. In the event the shield was initially applied incorrectly, it can simply be removed and repositioned - no harm done.

Once a clamp is put in place, anything in its clamping mechanism is essentially dead skin, and the excision/amputation which follows is irreversible.

PLEASE TELL ALL YOUR FRIENDS AND FAMILY - DO NOT ALLOW A MOHEL TO USE THIS DEVICE ON YOUR BABY, UNLESS HIS TRACK RECORD IS PERFECT WITH IT!

*****************************************************************************
Atlanta lawyer wins $11 million lawsuit for family in botched circumcision
By Ty Tagami


The Atlanta Journal-Constitution
Monday, July 19, 2010

The maker of an instrument used in circumcisions claimed that injury was impossible with its use, but after an infant lost a portion of his penis during an operation with the Mogen clamp, a judge awarded $10.8 million in damages against the company.

The judgment handed down Friday in New York involves an Atlanta lawyer who has been crusading against circumcision as a dangerous and unnecessary practice.

Attorney David Llewellyn won a similar case in Atlanta last year and the injury behind that prior lawsuit in Fulton County Superior Court put the New York clamp manufacturer on notice about the danger of the device, his current lawsuit said.

The baby in the current case, identified in court documents only as L.G., lost the entire glans, or head, of his penis after it was pulled into the jaws of the clamp, according to a federal magistrate's order. On Friday, U.S. District Judge Jack B. Weinstein ordered Mogen Circumcision Instruments of New York to pay $10.8 million in compensatory and punitive damages to the Florida boy, now 3, and his parents.

The parents "are extraordinarily distraught and angered that this company tells people it can't happen," Llewellyn said.

It's unclear whether they will ever collect the money. Mogen is already in default on a $7.5 million judgment in 2007 from a Massachusetts lawsuit, Llewellyn said.

The company is going out of business, according to a woman who answered the phone at its Brooklyn headquarters Monday. The woman, who said she was a secretary and would identify herself only as D. Rotter, the person whom Llewellyn said was served papers in the lawsuit. She said increased competition has undermined their business.

"It's just kind of dwindling down to nothing," she said, adding that the phones at the Mogen office were scheduled to be disconnected Tuesday. Mogen didn't defend itself in court, and Rotter said it was because the company couldn't afford it.

She said the Mogen clamp is "painless and safe" when used properly. The case involving the Florida boy was "unfortunate," she said, adding that "any medical mishap is unfortunate."

In this case, a New York mohel, or Jewish ritual circumcisor, performed the operation in the baby's home, Llewellyn said. The mohel negotiated a separate settlement, the terms of which Llewellyn would not disclose.

Llewellyn won another circumcision case in 2009 over an operation at South Fulton Medical Center. In that case, which involved a baby identified only as D.P. Jr., the mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding.

The tip of the penis was placed in a biohazard bag and might have been reattached if he'd gotten attention in time, Llewellyn said in 2009. His lawsuit in New York says D.P. Jr. lost a third of his glans.

The jury found that both the pediatrician and the physician who performed the circumcision were negligent, and awarded $2.3 million to the plaintiffs. South Fulton Medical Center was absolved of liability.

In Friday's decision, the court determined that Mogen had to pay for medical expenses and for the years of psychotherapy that will be needed. The boy suffers pain when he urinates, the court order says. He will eventually be able to have sex, but he is likely to be embarrassed and will likely have trouble forming "meaningful" relationships with girls, it adds. "At 3 years old, L.G. is aware that he looks different from other boys based on both his own observations and comments from other children which make him feel inferior ."

Methods of Circumcision

Most parents looking to have their son circumcised just want it to be done as efficiently as possible, as speedily as possible, with minimal pain to the baby.

Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.

When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.

However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.

Please note that I use Method #2 presented below and as described at the end of this post.

There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.

Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.

Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:

INTRODUCTION

Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood

The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.

In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.

And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]

Method #1. Clamp

The foreskin and membrane are grasped with a hemostat and a clamp is applied to the foreskin. There are two kinds of clamps that have been utilized by mohels over the last sixty years. The first is the Gomco (on the right in the photo), which is often the method of choice for doctors in hospitals, but is not largely used by mohels. The second is the Mogen or Bronstein clamp (on the left), which is the method of choice for many mohels in the US (though most Orthodox mohels, including me, do NOT use it). The foreskin and membrane are then removed together in one incision, with a scalpel or bris knife.

Method #2. Shield

The foreskin and membrane are grasped either with a hemostat (as in method #1) or skillfully with the fingers. A metal plate with a thin slit is applied to the foreskin, leaving the foreskin resting above the plate, with the glans safely shielded below. A scalpel or bris knife is used to excise the foreskin.

If the membrane is removed along with the foreskin, metzitzah follows.
If the membrane is not completely removed along with the foreskin, it will either be cut with scissors, or the mohel will tear it with his sharpened thumbnails - in both cases to reveal the entire glans.

Method #3. Free hand

Without using any device other than a blade, the mohel will estimate the length of the foreskin, grasp it with the thumb and forefinger of one hand and excise the foreskin with the knife in his other hand.

Membrane removal will follow that of method #2. Metzitzah will follow.

PROS AND CONS OF THE METHODS

Obviously, the "con" of the baby having skin tissue removed and being subject to the pain of circumcision, and any bleeding are a given. If you are having your baby circumcised, it is assumed you understand that this is the down side (if you even view it as a downside) of the spiritual, national and Jewish significance attached to this procedure - which is the fulfillment of a commandment.

The pro: Baby bears the mark of the covenant established between God and Abraham, and all of the Jewish people, which established God as our only God, and we, the Jewish people, as His firstborn, the chosen people who have a mission on this earth to spread monotheism and ethics to as many people as we can.

Pros and Cons of #1 (Clamp)

Benefits include:
* Usually a bloodless circumcision.
* The mohel may not even need to use a bandage.
* If applied correctly, the glans is protected.

Cons:
* Usually a bloodless circumcision. (Blood is an essential element of the bris)
* Estimating the end of the foreskin along the shaft is inexact
* The FDA has issued severe warnings about the use of the clamp, as it could grasp and amputate the glans or the tip of the glans.
* The pain of the crushing of the foreskin is immense
* Once the clamping mechanism is applied, the estimation of the foreskin is irreversible. Even if one were to remove the clamp and then reapply it correctly before excising the skin, the skin tissue that remains would be dead, and would liekly either become the equivalent of a growth or fall off on its own.

* In order to achieve its desired effect, the clamp usually needs to be on for a significant amount of time - from 30 seconds to five or ten minutes. This is significantly longer than the next methods which take 3-4 seconds.
* Rabbinic approval is scant.

While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.

Pros and Cons of #2 (Shield)

Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible

Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.

The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.

Pros and Cons of #3 (Free-hand)

Pros:
* Quickest procedure
* Relatively painless

Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous

The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.

THEREFORE

You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.

I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."

My Method

In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.

When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.

I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me

The Danger of Arrogance

Before you read this, please note: I share this conversation with you not to scare you, but to help you become aware of the possibilities out there, and to know there are ways to avoid many of the problems discussed here. My suggestions appear at the end of this entry, so please make sure to read through to the end.

Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.

Mild Problems

In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.

Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.

Different Problems

There is a small margin of difference between removing too little skin and removing too much skin.

Too little

Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)

Too much

Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.

All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.

Below, I will explain steps that can be taken to help avoid these problems.

[See this posting about the different methods for how to do a bris]

Bigger Problems

My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.

But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.

The DANGER of ARROGANCE

Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.

But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.

Methods ALL Mohels Should Employ

To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:

1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)

2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.

The Arrogance

If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.

To suggest that "God wants it to be done this way" is arrogance of the highest order.

I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.

But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.

I repeat (and add):

EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.

With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.