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September 27, 2016 / 24 Elul, 5776
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Metzitzah B’Peh – Where We Are And Where We Need To Go

Gelbfish-041312

As a vascular surgeon for over 20 years I care for wounds daily. As an occasional mohel for 30 years I am familiar with all aspects of milah. I thus feel obligated to share my perspective on this most important topic. If I don’t, who will? In order to decide halachic matters, rabbis need accurate and representative medical input. This is my only goal.

From a medical perspective, the controversy over metzitzah b’peh (MBP) has focused on whether indeed there is any serious risk of transmission of the herpes type-1 virus from the mohel to an infant. Why is this a concern? It is well established that over 50 percent of adults show serological evidence of previous infection with oral herpes and some of these people will shed herpes from their mouth even without open sores. A 1999 study found that 70 percent of adults shed virus at least once a month even without oral lesions. This data suggests a theoretical risk of herpes infection transmission when a mohel has direct oral contact with the bris wound. An infant is immunocompromised, and an infection that is relatively mild in an adult can be deadly in an infant.

Is this just a concern, or does such infection transmission actually happen? There are a number of cases with a high index of suspicion that link MBP to herpes infection of an infant’s genital area. There were three such cases in the 1990’s (one of whose care I was involved in); eight cases reviewed in a paper in the medical journal Pediatrics in 2004; three cases between 2004 and 2006 in New York City, including an infant death and another who survived but with significant neurological damage; an additional four recently published cases in New York City from 2006-2010, and a death in 2011 in New York City attributed to MBP. These total 19 cases. It is almost certain that there are others, since not all cases are reported. Mandatory reporting was instituted in New York State in 2006. In New Jersey, no such requirement exists today.

It is the opinion of many infectious disease specialists and public health authorities that the association between MBP and herpes is adequately established by these cases, considering the location of the herpes in the infant’s genital area, the timing of infection soon after the bris, the clusters of association with a given mohel and other epidemiological parameters. Furthermore, basic medical theory eschews oral contact with a wound, especially since our current medical knowledge does not attribute any benefit to MBP. The risk/benefit ratio is thus infinite. As such, these specialists recommend modifying MBP by either using a gauze or glass tube instead of direct oral contact. This was the solution approved by the Chasam Sofer and other rabbanim, and adopted by many Jewish communities, when faced with the same issue more than 150 years ago.

A dissenting, minority opinion is presented by Dr. Daniel S. Berman, an adult infectious diseases specialist who has published in the lay press on this topic. He has reviewed the above data, critiqued the authors of previous medical articles, and has questioned the validity and motivations of their medical opinions. He suggests anti-religious bias as a significant factor in their conclusions and in the actions of the New York City department of health. He doubts that MBP is the cause of infection and posits that herpes is more likely contracted from other sources, such as caretakers of the infant. He also argues that no absolute confirmation of a causal relationship in any of these cases has ever been proven. To prove causality would require DNA evidence linking the specific herpes strains and this has never been done. It must be noted, however, that to perform DNA analysis, community and mohel cooperation would, of course, be necessary and this has not been forthcoming.

I am unaware of other physicians who share the essence of Dr. Berman’s point of view. Nevertheless, my observation is that Dr. Berman’s opinion has been accepted by the overwhelming majority of the chassidish and yeshivish communities. “Nothing has been proven and MBP is absolutely safe” has become the mantra in this discussion. Furthermore, there has been no halachic call to modify MBP at this point except from the Rabbinical Council of America.

I have described the status quo, but now come the real issues. Is it appropriate to accept a minority view in matters of fact and pikuach nefesh? How should halachic authorities decide in a case where medical facts and their interpretations are of such prime importance and where those facts are the subject of debate?

Furthermore, I shudder to think of the almost unrecoverable stain and loss of confidence on the integrity of the halachic process that would result, should MBP be ultimately proven (via DNA or other means) to be a source of herpes transmission. Many will appropriately ask, “How could we have permitted such significant halachic decisions to be made based on the unconventional and minority opinion of Dr. Berman, when most other specialists felt that an association between MBP and herpes had been amply established? What type of system permits this to happen? Why didn’t we seek a wider consensus?”

Some have said that the Chasam Sofer’s p’sak has no relevance today, since they claim that it was only a hora’at sha’ah; a ruling under unusual circumstances that is applicable only for a given time and place. Even if so, perhaps we qualify for a hora’at sha’ah p’sak today, considering that infection with herpes type-1 virus today is at epidemic levels in adults and the consequences to an infant who contracts it is so great. Let those who claim that MBP is absolutely safe prove its safety and we can then reverse this temporary modification.

What do I recommend? I believe that the time has come to establish a formal medical committee that will consider the input and opinions of multiple national experts on pediatric infectious disease, virology and public health. There are plenty of such experts who can weigh in on this debate. This committee will issue a report and make a best-determination of probable fact, considering what is known today. It will also highlight legitimate differences of opinion where they exist. This report can be updated as further data emerges. Poskim can then use these finding of fact to make a determination of halacha.

I know there are many halachic issues. Amongst them: Is MBP a minhag or part of the actual bris? Is it only a medical recommendation by the Talmud that can be modified or discarded as medical knowledge changes? Does metzitzah need to be b’peh or is any other suction source or method of drawing away blood equivalent? Since I am not a rabbi, I am not qualified to rule. I merely seek a way to have fair representation of medical facts and judgment for those ruling on halachic matters.

I believe an organized approach will increase medical factual accuracy, and also result in increased confidence in the halachic process. Our children deserve nothing less than both of these outcomes.

Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.

Dr. Gary A. Gelbfish

About the Author: Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.


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