From
Parshat Vayera Vol.11 No.8
Date of issue: 17 Cheshvan 5762 -- November 3, 2001
Modern Brit Milah Issues - Part One
by Rabbi Howard Jachter
The Jewish people have been observing the Mitzva 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 discuss five of these issues; performing Brit Milah on a
jaundiced baby, the Metzitza 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 we should not circumcise a baby boy who is
yellow until the yellowness recedes. The Gemara recounts a story about a woman
who gave birth to three boys each of whom subsequently died from their Brit
Milah. Rabbi Natan advised the woman to delay the Brit of her fourth son until
the yellowness of the baby recedes. The family heeded the Rabbi's advice and the
boy recovered from the Brit without difficulty.
The Rambam (Hilchot Milah 1:117) and Shulchan Aruch (Yoreh Deah 263:1) rule in
accordance with this Talmudic passage. They both write (probably based on the
Gemara's anecdote) "One should be exceedingly careful about these matters," and,
"Danger to life is always cause to delay a Brit because the Milah may always be
performed later, but we are incapable of restoring a Jewish soul." They both
write that we do not perform the Brit until the baby's appearance resembles
other healthy baby boys.
The Rambam and Shulchan Aruch, however, differ about a very significant point.
The 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 the 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. The Halacha 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
and 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, Halacha and modern
medicine seem to conflict regarding this matter. This is no simple problem to
resolve. On one hand, 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, notwithstanding
current medical knowledge. 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 degree of jaundice is determined by measuring the amount of
bilirubin in the blood). A group of prominent Rebbeim who are associated with
the Hitachdut 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 the Rambam and 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 Hashulchan 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. Modern medical knowledge seems to
motivate Rav Waldenberg to rely on the Chochmat Adam's opinion to perform a Brit
on a baby that is experiencing only a mild case of jaundice. Rav Yosef Eliyahu
Henkin and Rav Yaakov Kaminetzsky (Emet Leyaakov p.355) adopt a similar approach
to this issue. They rule 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.
When a family is confronted with this dilemma, one should consult with his Rav,
a competent Mohel, and pediatrician.
The Metzitza Controversy
A similar dilemma has emerged in modern times regarding Metzitza, the
squeezing of the blood after the Brit. Chazal (Shabbat 133b and Shulchan Aruch
264:3) regard Metzitza as a medical necessity. Some Acharonim (Ketzot Hachoshen
382 and Chochmat Adam 149:14) believe that Chazal require Metzitza only due to
health considerations. Other Acharonim (Teshuvot Maharam Schick Y.D. 338 and
Teshuvot Avnei Neizer Y.D. 338) insist that Metzitza constitutes an integral
component of the Milah process and is not merely a health concern. The Avnei
Neizer emphasizes the significance of Metzitza from the perspective of the
Kabbalah. The Acharonim also debate whether Metzitza must be performed orally
(Teshuvot Binyan Tzion 1:24) or may be done manually (Chatam Sofer cited in Rav
Pirutinsky's Sefer Habrit pp.216-217). A summary of this debate appears in Sdei
Chemed 8:Kuntress Hametzitza.
On the other hand, modern science believes that Metzitza is not a medical
necessity and is dangerous if performed orally. Health concerns regarding
Metzitza have increased greatly since AIDS has become a relevant issue.
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 Metzitza orally despite the danger. He applies
the Gemara's (Pesachim 8a) assertion that, "No harm will befall those involved
in a Mitzva," in this context. Indeed, Chassidim have vigorously abided by this
ruling even since AIDS became a serious concern. This author witnessed a Satmar
Mohel perform Metzitza Bepeh at a Brit in 1990.
On the other hand, the aforementioned Chatam Sofer writes that the Halacha does
not demand that the Metzitza be performed orally. He writes that Metzitza is
done orally only because of Kabbalistic concerns. The Chatam Sofer writes that
we should overlook Kabbalistic considerations, when performing Metzitza orally
poses a health concern. Similarly, Rav Hershel Schachter (Nefesh Harav 243)
writes that Rav Yosef Dov Soloveitchik reports that his father Rav Moshe
Soloveitchik would not permit a Mohel to perform Metzitza Bepeh. It is reported
that Rav Moshe Feinstein also adopts the Chatam Sofer's approach. Some Mohelim
follow this approach in their practices.
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 Metzitza orally by using a glass 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
glass tube. He notes that the Rambam (Hilchot Milah 2:2) and Shulchan Aruch
(Y.D. 264:3) write that Metzitza 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 perform Metzitza using a glass tube
because of health concerns. Indeed, Dr. Abraham (Nishmat Avraham 4:123) reports
that Rav Shlomo Zalman Auerbach permits performing Metzitza with a glass to
avoid concern for AIDS.
Conclusion
Regarding the jaundice and Metzitza 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.