Haredi Rift Opens Over Bris Ritual

High-ranking officials split on risk from metzitzah b’peh and whether practice should be continued.

03/27/12
Special To The Jewish Week
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A renewed focus on a controversial circumcision technique, which recently has been implicated in one infant’s death and five non-fatal cases of neonatal herpes since 2007, has exposed a rift in the haredi community over the ritual practice.

In a terse phone interview, Rabbi David Niederman, executive director and president of the United Jewish Organizations of Williamsburg, told The Jewish Week that the September death of an infant “had nothing to do with metzitzah b’peh,” or direct oral suction, despite the medical examiner’s ruling that the cause of death was “disseminated herpes simplex type 1, complicating ritual circumcision with oral suction.”

Rabbi Niederman, a prominent member of the Satmar chasidim, went on to say that “we are convinced that there is no connection” between neonatal herpes and metzitzah b’peh. And in response to a question about whether he believed that there has ever been a death or infection caused by the practice, he replied, “No, there has not.” He added, “We will continue to make metzitzah b’peh.”

Rabbi Niederman’s comments stand in stark contrast to statements made by Rabbi Shmuel Kamenetsky, the founder and dean of the Talmudical Yeshiva of Philadelphia and a senior member of Agudath Israel’s Council of Torah Sages, the prestigious haredi rabbinical policy-making body.

In a phone conversation with The Jewish Week, Rabbi Kamenetsky noted that in his community “as far as I know, they do metzitzah with a tube [a sterile pipette that prevents the mouth from directly touching the wound].”

When asked about rabbis who believe that using a tube is not valid under Jewish law, Rabbi Kamenetsky replied, “Nobody holds like that.” Told of those who make this claim, the apparently incredulous rabbi said only, “I don’t think there’s a response to them.”

The rabbi also expressed disbelief about those who would insist on the practice despite its links to the transmission of disease to infants.

“Chas v’shalom [God forbid], if [children are] getting sick [from oral suction], [you] wouldn’t do it,” under Jewish law, he said.

For its part, the Agudah, the haredi umbrella group, has never explicitly denied the risk of herpes transmission through metzitzah b’peh. But its spokesman, Rabbi Avi Shafran, recently told The Jewish Week that “to scientifically assess the risk … one would have to have more [information] than a number like the 20 [cases The Jewish Week counted in the literature],” namely the total number of metzitzah b'peh procedures done over the same time period.

Rabbi Kamenetsky also stated that because it is permissible to do the suctioning with a tube, which poses “no risk at all” to the infant, this should be the practice.

Meanwhile, a paper published in the Winter 2012 issue of the haredi periodical Dialogue — entitled “Is Metzitzah bePeh Dangerous?” — has apparently become a reference for those seeking to defend the practice.

The paper, by Dr. Daniel S. Berman, an infectious disease doctor, seeks to challenge those who argue that metzitzah b’peh carries serious helth risks and falls within a tradition of writings that defend against potential government interference for health reasons.

In the paper, Berman, who has a letter in this week’s Jewish Week, attempts to cast doubt on public health officials’ findings linking the herpes simplex virus to a particular mohel — presumably Yitzchok Fischer, who has been tied to at least four neonatal herpes infections, including one death. Berman argues that absent DNA “fingerprinting” that matches the baby’s virus to that of the mohel involved, one cannot claim that metzitzah b’peh was responsible for the baby’s infection.

Dr. Jonathan Zenilman, former president of the American STD Association and professor of medicine and chief of the Infectious Diseases Division at the Johns Hopkins Bayview Medical Center, rejects that argument. In insisting that DNA fingerprinting is the only way to conclusively demonstrate a link between MbP and a case of neonatal herpes infection, Zenilman says, Berman denies “the validity of standard epidemiological methods which are widely accepted by pretty much everyone else.”

In fact, while blood tests can determine if someone is infected with — and thus capable of transmitting — the herpes virus, it is not always possible to obtain the virus’ DNA, which is most likely to be obtained from fresh sores that have not yet scabbed over. “The lack of genetic sequencing to conclusively demonstrate that these are the exact same strains of herpes is not necessary, or even relevant, from a public health standpoint,” Zenilman emphasized.

Even when a mohel does not cooperate with testing — which has apparently happened in several reported cases — causal inferences can be made. “There is a whole paradigm of causal inference in epidemiology,” noted Zenilman, “which includes things like temporal association and biological plausibility,” a term that refers to a cause-and-effect relationship that is consistent with existing biological and medical knowledge.

Indeed, Berman himself seems to acknowledge that Fischer failed to cooperate with an investigation by the New York City department of health, refusing to undergo DNA testing because the city “offered the testing in a way that was extremely unfavorable to the Mohel with regard to his future.”

(Both the city and state departments of health have declined to comment on the investigation into Fischer, who was ordered to stop doing MbP in New York state in 2007; it appears, based on taped conversations obtained by The Jewish Week, he may have defied the order.)

Berman ultimately concludes, based on his summary of reported cases, that there is a “small risk” of herpes transmission through MbP.

However, experts like Zenilman caution that there is likely substantial underreporting of these infections because, for example, recognized cases are not always reported and other cases may not be recognized. “It’s the tip of the iceberg,” Zenilman believes, noting that once a child is infected with herpes, if he survives, he has the virus “for life.”

Without addressing the issue of underreporting, Berman asserts that it is reasonable to assume that any “small risk” of herpes transmission can be eliminated by the mohel rinsing his mouth with Peridex or Listerine, a claim Zenilman calls “nonsense.”

In the second half of the paper, Berman criticizes the New York City health department for declaring that there is “a definite risk of infection” from MbP, and seems to suggest that Jews in particular are being targeted because he “cannot find any recommendations from the Department of Health to members of the Jehovah’s Witnesses faith telling them of the dangers of refusing blood transfusions, which is part of their faith.”

However, there have been numerous cases in which the courts have ruled that the interests of the child and the interests of the state outweigh the parents’ rights to refuse medical treatment, and in some states parents who have declined to seek medical care for their children outside of their own religious treatment have been charged with involuntary manslaughter and endangering the welfare of a child.

In fact, according to Alex Luchenitser, associate legal director of Americans United for Separation of Church and State, though it has not attempted to do so, the government does have the power to ban metzitzah p’beh in the interest of protecting the public health.

“A practice that can cause infants to die or be infected with a sexually transmitted disease is certainly a practice that the government can constitutionally ban, even if the practice is a religious ritual of some sects,” Luchenitser told The Jewish Week. 

Last Update:

09/10/2012 - 17:45

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The RAMBAM,ZT"L, states that the purpose of metzitzah is for medical therapeutic reasons: (1) to speed up the healing process following the cut, and (2) to reduce post-operative pain.Thus, unlike milah and p'riah, which are intrinsic halachic components of Brith Milah, Metzitzah b'peh is not. RAMBAM,ZT"L, states that metzitzah b'peh (oral suction) must be performed but he does not state whether oral suction must be performed directly- direct oral contact- or indirectly-using oral suction through an intervening glass (or plastic) pipette.
I know of no poskim who claim that indirect oral suction invalidates the milah. The majority opinion appears to be that direct oral suction is the preferred method of metzitzah. But if there is even the slightest risk that the Mohel may be carrying contagious germs in his mouth, that may be transmitted to the infant, indirect metzitzah should be performed. All Mohelim should be required to submit to regular periodic mouth cultures to ensure as far as possible that they can safely perform metzitzah b'peh, directly.

In light of Rabbi Shmuel Kamenetzy's statement, I think that it would be very helpful for Hella Winston to post audio of her interview with Rabbi Kamenetzky or at least a written transcript of the interview.

wish to clarify remarks that were attributed to me on the subject of Metzitzah B’Peh.

The practice is indeed time honored and is followed by the majority of the Orthodox Jewish community today around the world, as it has been for thousands of years.

To my knowledge, it has not been proven that the practice leads to contraction of illness. The halacha is extremely sensitive to health concerns and it is wrong to insinuate that Jews who are very particular in the care of their children would be engaging in a practice for thousands of years which is inherently dangerous.

We have a sacred responsibility to protect our children from danger and that responsibility is paramount. However, in the absence of an inherent danger from our performing mitzvos or following our traditions, we must follow them. In my view, there has been no demonstration of an inherent danger associated with Metzitzah B’Peh.

The statement that, “I don’t think there is a response to them,” referred specifically to those who allegedly said it would be invalid to use a tube where there are demonstrable health issues present as to either the Mohel or the child.

Similarly my comment that in my community “as far as I know they do metzitzah with a tube,” refers to a case where a health concern has been established and was in no manner intended to suggest that I believe that it should be universally adopted.

In no way should what I said be misconstrued as supporting the curbing of, or outside interference with, Metzitzah B’Peh. In fact, we have very effectively self-regulated the practice over the past 3500 years.

Jews have made tremendous sacrifices over the millennia to properly observe our religious obligations and traditions; it would be a shame to return to the days when parents and circumcisers feared performing the hallowed bris which enters every Jewish male into a covenant with God.

Rabbi Shmuel Kamenetsky.

There seems to be some confusion among the commentators here. A few points:

1)Metzitsa b'Peh is NOT in the Torah. The practice appears in the gemara, but NOT with a stipulation that it must be done directly.

2)Those who wish to follow the gemara's recommendation to do metzitsa can so with a pipette.

3)The first step is to have the mohelim cooperate with medical investgations. That will help determine the degree of danger.

4) THEN, let's see someone put into writing a responsa explaining how many deaths / brain damaged children are acceptable rather than switch to a pipette.

People keep ignoring that the prevalent practice among Orthodox Jews in Israel (even non-Haredi) is to do direct MBP. We're talking about thousands upon thousands of babies. Where are all the deaths that should have been emerging from this?

Doctors should not be overstepping their bounds and should leave halachic decisions to rabbis (including decisions regarding the issue of pikuach nefesh).

It's interesting to ponder... if the state can intervene to prevent harm to children from withheld blood transfusions... why can't the state overrule a parent's "right" to circumcise in the first place, which puts the child at risk for infection, injury or death?
Any unnecessary surgery without consent is unethical, unless there is medical indication.
After all, we all know that circumcision is inherently damaging by removing the most sensitive parts of the penis, and hurts sexual function.

You are bringing up a interesting issue about how the state should be dealing with Circumcision in the first place, you mention that you are very concerned about the ramifications that a Circumcision can have in the child’s life... although these are very important issues, but the Good news is, that our forefathers and the Torah already addressed these issues and worked out what we all need to do in order to have a successful life (and after life...) so the same as you understated you can’t just change the constitution, same and more applies that you can’t change things that were worked out with the details (Including Metziza Bepeh) throughout all generations by wiser people then you and I, and Jews gave up their life’s for this in country’s that it was forbidden and punished with death penalty...
Of course we need to make sure that we don’t transmit any diseases, but the Torah has laws for that as well, for when it is, or is not allowed to do certain things... like when you are, or not allowed to perform a Circumcision, and even many times when medically its allowed, the Torah still bans it if it’s not safe. So this should be discussed with professional Mohalim who know the Torah rules.
Besides the point that the Torah is more concerned for human life then you and I and any politician, and never suggests anything that’s in contrast to human life.

Ironicaly, the most recent edition of Dialogue with Dr. Berman's article was distributed about one week before the most recently reported death linked to MbP. One need not be a trained scientist -- one need only be able to read critically and analytically -- to see that Dr. Berman's article is replete with obfuscation, distortion and faulty conclusions. It is obvious that he constructed an argument to fit a pre-ordained conclusion. As an Orthodox Jew who grew up in a chassidic home and who retains ties both to the chassidic world and the Agudah, I am particulalry ashamed of the Agudah and its knee jerk need to defend a practice that is required by only a portion of the chassidic world and that clearly places infants at risk. What does it say about the Agudah when one of its lay leaders, Rabbi Shafran, feels the need to be more reactionary than Rabbi Kamenetsky, a member of the organization's ruling Council of Torah Sages (or can we expect the organization to force Rabbi Kamenestky to recant or at least "clarify" his remarks)?

Dr. Berman acknowledged in an earlier article that the mohel in question refused to undergo DNA testing because the city “offered the testing in a way that was extremely unfavorable to the Mohel with regard to his future.”

Perhaps I'm wrong, but I think this means that the mohel believed that were he to submit his DNA, the link between himself and the infected child's virus would, in fact, have been proven -- even according to Dr. Berman's criteria.

I don't begrudge the mohel for wishing to avoid self-incrimination; that is his constitutional right.

I also do not begrudge Dr. Berman for his compassion in wishing to justify the mohel's decision, given that the mohel is known to be an extraordinarily fine person and that the consequences for him might have been quite onerous -- perhaps unfairly.

However, I do not understand how Dr. Berman can have it both ways: On the one hand, justifying the mohel's decision to not self-incriminate and on the other, using this lack of evidence as a basis for saying, as a scientist (as opposed to a friend), that the scientific case is weak and that parents need not be overly concerned.

How many people die in hospitals yearly from infections caught while in the hospital, including visitors? Is there any study how many people die direct from doctors and nurses operating on humans necessary and un necessary procedures? , were there any DNA test made on these doctors? , Will you ban all gay activity! Married and otherwise when so many more people catch diseases and even die from it? Would you ban gay marriage because of it? Or even all sexual activity because it 'could' and 'did' result in people transmitting one kind or another disease? Why single out one category only, the possibilty of MbP caught disease from a religious practice! When only a minuscule percentage wise of fatal cases, if at all happened? What’s behind it? Is this another anti religious assault in disguise?!

Jehovah's Witnesses blood transfusion confusion

Jehovahs Witnesses take blood products now in 2012.
They take all fractions of blood.This includes hemoglobin, albumin, clotting factors, cryosupernatant and cryopoor too, and many, many, others.
If one adds up all the blood fractions the JWs takes, it equals a whole unit of blood. Any, many of these fractions are made from thousands upon thousands of units of donated blood.
Jehovah’s Witnesses can take Bovine *cows blood* as long as it is euphemistically called synthetic Hemopure.
Jehovah's Witnesses now accept every fraction of blood except the membrane of the red blood cell. JWs now accept blood transfusions.
The fact that the JW blood issue is so unclear is downright dangerous in the emergency room.
--
Danny Haszard http://www.ajwrb.org

Thomas Frieden was in charge of the NYC health dept. a few years ago when the other babies died/were sickened/were brain damaged by mohel-introduced herpes infections. Frieden did nothing. Now he has blood on his hands.

Thomas Frieden is now the head of the US Centers for Disease Control. He should resign from the CDC due to his demonstrated ineptitude at controlling disease.

Thank you for your in depth coverage of this crisis, please keep it up. Children are being made ill so that a fringe group can stubbornly deny common medical knowledge. They must be made to stop.

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