(2009/5769)
The Jewish people have been observing the Mitzvah of Brit Milah for approximately 3700 years. Nevertheless, Poskim have been forced to grapple with many new challenges posed by newly discovered medical and technical knowledge. In the following weeks we will (iy”h and b”n) discuss five of these issues; performing Brit Milah on a jaundiced baby, the Metzitzah controversy, using anesthetics at a Brit, using new implements such as shields and clamps at a Brit, and performing Milah on Shabbat for boys conceived by artificial insemination or in vitro fertilization.
Jaundice - Gemara, Rishonim, and Acharonim
The Gemara (Shabbat 134a) states that one should not circumcise a baby boy who is yellow until the yellowness recedes. The Gemara recounts a story of a woman who gave birth to two boys, each of whom subsequently died from their Brit Milah. After delivering her third son, Rabi Natan advised the woman to delay the Brit until the baby’s yellowness receded. The family heeded Rabi Natan’s advice and the boy recovered from his Brit without difficulty.
Rambam (Hilchot Milah 1:17) and the Shulchan Aruch (Yoreh Deah 263:1) rule in accordance with this Talmudic passage. They both write (most likely based on the Gemara's anecdote) "One should be exceedingly careful about these matters," and, "Danger to life is cause to delay a Brit. It is possible to perform the Milah later, but it is impossible to bring back a Jewish soul." They both write that we do not perform the Brit until the baby's appearance resembles other healthy baby boys.
Rambam and the Shulchan Aruch, however, differ about a very significant point. Rambam writes that we should postpone the Brit if the baby is "exceptionally yellow" but the Shulchan Aruch omits the word "exceptionally." The Chochmat Adam (149:4) rules in accordance with Rambam. He notes that the Smag and Rabbeinu Yerucham also write "exceptionally yellow" in this context, and the Chochmat Adam is puzzled why the Shulchan Aruch omits the word "exceptionally." The Aruch HaShulchan (Y.D. 263:3) rules in accordance with the Shulchan Aruch. He adds "even if the yellowness appears only on one region or limb on the body, we postpone the Brit until he appears like the other children." A major ramification of this dispute is whether we should postpone a Brit if the boy exhibits a mild form of jaundice. This issue has not been resolved. Some will postpone the Brit in case of mild jaundice, and others will not.
Another dispute is whether one must wait seven days after the jaundice has receded before performing the Brit. Halachah requires that one wait seven days after a boy recovers from an illness before performing a Brit (Shabbat 137a and Shulchan Aruch Y.D. 262:2). The Aruch HaShulchan (ibid) and Maharsham (Daat Torah Y.D. 38) rule that a seven-day wait is unnecessary for a jaundiced baby, but Rav Shlomo Kluger (Teshuvot Tuv Taam Vedaat Y.D.1:220) and Yad Ketana (Hilchot Milah 8:18) require the seven-day wait.
Jaundice - Contemporary Poskim
Modern medicine distinguishes between pathologic jaundice and physiologic jaundice. Generally speaking, modern medicine views a mild case of jaundice to be physiologic, i.e. part of the normal course of development for many babies. Thus, from a modern medical perspective there is no reason to postpone the Brit of a baby experiencing physiological jaundice. Accordingly, Halachah and modern medicine seem to conflict regarding this matter. This is not an easy dilemma to resolve. On one hand, one cannot endanger a child and on the other hand, we cannot unnecessarily delay a Brit.
Three basic approaches to this dilemma are presented by contemporary Poskim. Dayan Weisz (Teshuvot Minchat Yitzchak 8:88) rules that we must heed Chazal's view that it is dangerous to circumcise a jaundiced baby, current medical knowledge notwithstanding. He rules that we should postpone the Brit if the child displays even a mild case of jaundice and even if the child has a low bilirubin count (the level of jaundice is determined by measuring the amount of bilirubin in the blood). A group of prominent Rebbeim who are associated with the Hisachdus HaRabbanim (Satmar, cited in Rav J. David Bleich's Contemporary Halachic Problems 2:237-238) rule that one may not circumcise a child whose bilirubin count is five or higher. Moreover, they require a seven-day wait if the baby experienced a bilirubin count of ten or above. Rav J. David Bleich (Contemporary Halachic Problems 2:235) subscribes to this approach. He argues, "There does exist a distinct possibility that the jaundice is, in fact, the effect of a liver or other disorder and is misdiagnosed as physiologic jaundice."
On the other hand, Rav Shlomo Zalman Auerbach (cited in Nishmat Avraham 5:84-85) argues that Rambam and the Shulchan Aruch are speaking only of pathologic jaundice. Rav Shlomo Zalman rules that if a competent doctor establishes that the baby is completely healthy then we may perform the Brit even if the baby appears yellow. In fact, Dr. Abraham (ibid) relates that Rav Shlomo Zalman once permitted a circumcision of a child who had a bilirubin count of fourteen and a competent doctor declared that the baby was healthy.
Rav Eliezer Waldenberg (Teshuvot Tzitz Eliezer 13:81 and 83) presents a nuanced approach to this issue, which has emerged as normative practice in many observant circles. Rav Waldenberg writes that we may not ignore Chazal's teaching that performing a Brit on a jaundiced baby is dangerous. On the other hand, we must consider the assertion of modern medicine that circumcising a jaundiced baby is not dangerous. Rav Waldenberg rules that we may rely on the opinions of the Aruch HSshulchan and the Maharsham that we need not wait seven days after the jaundice disappears before performing the Brit. Moreover, he rules that if we observe that the jaundice is in the process of dissipating and that the signs of jaundice have disappeared from most of the body, then we may perform the Brit. Rav Yaakov Kaminetzsky (Emet LeYa’akov on Shulchan Aruch p.355) adopts a similar approach to this issue. He rules that one may perform the Brit if the bilirubin count indicates that the jaundice is in the process of receding. Dr. Abraham (Nishmat Avraham 4:119) records the practice in many circles to perform a Brit if the bilirubin count is twelve or less. In fact, some have even suggested (see Techumin 19:335-340) that one may ask non-Jewish medical personnel to perform a bilirubin test on Shabbat to determine if we may circumcise the baby on that Shabbat. A family that is confronted with this dilemma should consult with its Rav, a competent Mohel and a competent pediatrician.
The Metzitzah Controversy
A similar dilemma has emerged in modern times regarding Metzitzah, the squeezing of the blood after the Brit. Chazal (Shabbat 133b and Shulchan Aruch 264:3) regard Metzitzah as a medical necessity. Some Acharonim (Ketzot Hachoshen 382:2 and Chochmat Adam 149:14) believe that Chazal require Metzitzah only due to health considerations. Other Acharonim (Teshuvot Maharam Schick Orach Chaim 152 and Teshuvot Avnei Neizer Y.D. 338) insist that Metzitzah constitutes an integral component of the Milah process and is not merely a health concern. The Maharam Schick writes that the Chatam Sofer’s aforementioned ruling was issued only in the context of a specific difficult situation and was not intended to apply to all situations. The Avnei Neizer emphasizes the significance of Metzitzah from the perspective of the Kabbalah. The Acharonim also debate whether Metzitzah must be performed orally (Teshuvot Binyan Tzion 1:24) or may be done manually (Chatam Sofer in a responsum printed in Rav Mosheh Pirutinsky's Sefer Habrit pp.216-217). A summary of this debate appears in Sdei Chemed 8: Kuntress HaMetzitzah.
On the other hand, modern science believes that Metzitzah is not a medical necessity and is dangerous if performed with direct oral contact. Physicians warn of the danger of transmission of dangerous infectious diseases such as herpes either from Mohel to baby or vice versa.
Three approaches to this dilemma appear in the nineteenth and twentieth century responsa literature. Teshuvot Avnei Neizer adopts a particularly strong stand and requires the performance of Metzitzah orally (direct contact of the mouth to the wound) despite the danger. He applies the Gemara's (Pesachim 8a) assertion that, "No harm will befall those involved in a Mitzvah," in this context. Indeed, many rigorously observant Jews have vigorously abided by this ruling even after AIDS became a serious concern.
On the other hand, the aforementioned Chatam Sofer writes that the Halacha does not demand that the Metzitzah be performed orally. He writes that Metzitzah is done orally only because of Kabbalistic concerns. The Chatam Sofer writes that we should overlook Kabbalistic considerations, when performing Metzitzah orally poses a health concern. Similarly, Rav Hershel Schachter (Nefesh Harav p. 243) writes that Rav Yosef Dov Soloveitchik reports that his father Rav Mosheh Soloveitchik would not permit a Mohel to perform Metzitzah Bepeh with direct oral contact.
Rav Yitzchak Elchanan Spektor (cited in the aforementioned Sdei Chemed) and Rav Zvi Pesach Frank (Teshuvot Har Zvi Y.D. 214) adopt a compromise approach. These authorities permit performing Metzitzah orally by using a sterile tube. Rav Zvi Pesach, though, cautions that this technique is not simple and requires training to perform properly. On the other hand, the Avnei Neizer objects to using a tube for Metzitzah. He notes that the Rambam (Hilchot Milah 2:2) and Shulchan Aruch (Y.D. 264:3) write that Metzitzah must extract the blood from the "furthest places." The Avnei Neizer contends that this cannot be accomplished when using a glass tube. Nevertheless, many Mohelim both in Israel and North America perform Metzitzah using a sterile tube because of health concerns. Dr. Mordechai Halperin notes (Jewish Action Winter 5767/2006) that blood can be extracted from the “furthest places” using a tube, when conducted properly. Indeed, Dr. Abraham (Nishmat Avraham 4:123) reports that Rav Shlomo Zalman Auerbach permits performing Metzitzah with a glass to avoid concern for AIDS. Rav Mosheh Snow reports that Rav Mosheh Feinstein also permits Metzitzah to be conducted with a tube.
In 2005 the Rabbinical Council of America (RCA) issued a policy statement regarding Metzitzah B’peh which concluded as follows: “The RCA urges its member rabbis, their congregants, synagogues and institutions, as well as the larger Jewish community, to encourage and wherever possible necessitate, that Metzitzah be’Peh be fulfilled via a tube”.
Conclusion
Regarding the jaundice and Metzitzah issues we find different approaches in the various Torah communities. Some do not take modern medical concerns and insights into account, while others incorporate modern medical concerns without compromising the Halacha. Next week, Bli Neder and God willing, we will discuss the use of anesthetics at a Brit and the use of shields and clamps at a Brit.