Friday, June 08, 2012

MbP, Herpes, and Acceptable Risk

The issue of Metzitza B’Peh (MbP) is in the news again. And once again – not in a good way.

For those who do not recall what that is, it is part of the procedure of a Bris Mila (ritual circumcision) that Chazal require for purposes of health. The blood of the circumcision is suctioned away from the wound since leaving it there was considered to be mortally dangerous to the infant. Not only did they mandate this, the Gemarah’s dictum of “Chamira Sakanta Me’Isurah” applies. Mortal danger is considered a far more serious issue in Judaism than violating a forbidden act.

Although the Gemarah does not talk about suctioning the blood with the mouth, this has been the way it has always been done – probably since the inception of the Mitzvah. Nonetheless - as important as suctioning the wound is, it seems clear from the Gemarah that it is not part of the actual Bris. There are those (mostly in the Chasidic world) who dispute this and hold that Mitzitza is an integral part of the Bris. And that doing it by mouth is an integral part of that.

Until the19th century this was not a controversial issue. It was standard operating procedure. But when it was determined that a infant had died because a Mohel had transferred an infection from his mouth onto the infant’s genitalia, great rabbinic figures like R’ Yitzchok Elchanan Spector,  R’ Chaim Soloveichik, and R’ Moshe Sofer recommended that  Metziza not be done by mouth. It could instead be done in a non direct method such as the use of a pipette or an absorbent piece of sterile gauze.

In our day, the Rav advised his students not to do MbP telling them that his father forbade it based on his grandfather’s directives to Mohalim in that era. The RCA’s position is that the preferred method is the use of a pipette and not MbP.

A few years ago there was an incident where twin infants delivered by cesarean section had become infected by the Herpes Simplex I Virus - one of them dying as a result. The mother had no evidence of history of the disease. But the Mohel did. He had performed MbP. It was widely believed that the virus was transferred by the Mohel and all hell broke loose.

City government officials threatened to ban the practice. Rabbinic bodies like the Agudah got involved defending the practice. They argued that the constitutional right to freedom of religion would be violated by any such ban.  Chasidim said that even if MbP were to be banned they would nonetheless continue to do it.

On the other side of the argument there were Orthodox rabbis who supported abolishing the practice, among them Rav Moshe Tendler who is expert in the both Halacha and the field of human biology. Accusations against him were hurled comparing him to the ancient Greeks who tried to abolish Mila altogether. The issuehas remained unresolved and The debate over MbP has continued unabated.

One would think that since there were great rabbinic figures who Paskined that Metzitza did not have to be by direct oral contact, that the vast majority of non Chasidic Jews would not use that method. Although there are many Jews who do not subject their infant sons to MbP (including the entire German Jewish community if I understand correctly)  a far greater number still insist on it – believing it to be more ritualistically pure.

In a lengthy article in Dialogue Magazine Dr. Daniel S. Berman, an expert in infectious diseases and an Orthodox Jew defended the practice of MbP and disputed the New York City Department of Health study claim that there is a significant danger of transferring Herpes to an infant via MbP.

Dr. Berman disputed their conclusions using a combination of lack of conclusive DNA evidence that any child who had died of Herpes was directly caused by an infected Mohel, the very low statistical occurrence of Herpes deaths  in infants, and the fact that even that very low risk was lowered even further by the use of an alcohol based mouthwash. He ended up by saying that he was the Sandek (who holds the infant during the actual circumcision) at his own grandson’s Bris in Yeshiva University. MbP was done and he was perfectly comfortable with it.

Last September long after the dust had long settled another infant was determined to have died via Herpes Simplex virus. There too it was believed to be contracted by an infected Mohel using MbP. The argument was resurrected. Again nothing was resolved.

But now the Centers for Disease Control and Prevention (CDC) has done its own examination of the issue. Using statistical data they determined that the risk for neonatal Herpes infection from MbP was estimated to be 3.4 times greater than the risk among male infants unlikely to have had it.

For me there are 2 issues. One is a health issue and the other a freedom of religion issue.

From a Jewish point of view, I think the procedure ought to be either banned or strongly discouraged. The very same concern that Chazal had that MbP was required because of health reasons can be used to ban or discourage the procedure now. That there has been a relative rarity of it will give no comfort to a bereaved parent whose child contracted the disease from a Mohel and died from it.

Why should rarity be an issue if one can follow Halacha and still purge the occurance of Herpes  through MbP for good?  How many infant deaths resulting from MbP are considerd an acceptable risk? One in a 100,000? 1 in a million? Really? Is even one death in a million an acceptable risk if that too could be avoided?

On the other hand, I believe that the government should stay out of it. The slope becomes too slippery when the government gets involved in religious matters. The people doing the banning should not be the government. It should be a religious body that people are used to seeing ban things. Like the Agudah. At the very least they ought to be discouraging it the same way that the RCA does.

The best thing the government can do is to educate the public about the dangers of MpB. But in my view they should otherwise stay out of it.