Wednesday, March 15, 2017

MbP - Knowledge is Power Revisited

A typical Bris ceremony (NY Daily News)
Although the issue has been somewhat dormant, it has not gone away. The procedure known as Metzitza B’Peh (MbP) is still going on. With pretty severe consequences should things go wrong.

For those not familiar with the procedure, MbP  a term meaning ‘drawing out by mouth’. Circumcision ( Bris) is a Halachic requirement for all male Jews except in cases where the procedure would be life threatening. If healthy the Bris is performed when a baby is 8 days old. The foreskin of the baby is surgically removed by a trained and qualified individual called a Mohel.

The Sages of Talmud require that the Bris include Metzitza as a preventative measure. Without which it would endanger the health of the baby. They required the Mohel to draw out the blood from the circumcision wound. Although not mentioned in the Talmud, the procedure that was developed and deemed best was direct suction by mouth of the circumcision wound. Thus the term ‘Metztiza B’Peh.

Chazal were likely dealing with bacterial infection. Removing the blood to prevent that was the way they dealt with it. Until 18th century Dutch scientist Antonie van Leeuwenhoek gave us the microscope, no one had any idea that microscopic entities known as bacteria even existed. But Chazal did see a problem and dealt with it the best way they knew how. There was no more efficient way for them to draw out as much blood as possible from a wound than sucking it out directly by mouth.

Although we now know that bacteria is the cause of infections to open wounds and how to deal with them efficiently via sterile procedures and antibiotics, the Halacha of Metzitza still stands. While the actual circumcision is valid without it – Metzitza is still a Halachic requirement.

For reasons that are not entirely clear to me, the Chasidic world insists that MbP is the only legitimate way to draw out the blood and that it is part and parcel of the actual Bris. And point to centuries of doing it that way to no ill effect that they knew of.

Most of the Charedi Mohelim perform MbP seeing it as at least a preferable if not required method of Metzitza. I believe that most parents are not even aware of the procedure or at least not consciously aware of it during the Bris. Which is celebratory event with many guests followed by a festive breakfast type meal.  They also do not thinkof MbP when theyl choose a Mohel. The look instead at the overall reputation and experience.  

There are some (mostly those that are Modern Orthodox or Centrist) that will use more sterile means of drawing out the blood like a sterile pipette of a piece of gauze. But many if not most Charedi Mohelim will not perform a Bris if asked to not do MbP. Which I believe means that MbP is by far the most widely used procedure for Metzitza while many  parents are not aware of it. Or if they are are not familiar with its dangers. Or I some cases - consider this danger to be negligible and actually refer MbP.

The fact the MbP is so prevalent is why the herpes virus is still occasionally found in babies post circumcision. Part of the problem is that the herpes virus may be present in the Mohel but be asymptomatic. He will not be aware of it.  And even though the vast majority of Mohalim may rinse their mouths with some antiseptic mouthwash or alcohol immediately before performing MbP, the danger still exists even if it is minimized.

The city of New York under Mayor Michael Bloomberg in a effort to honor the religious rights of those who believe that MbP is a Halachic requirement and still reduce the possibility of herpes infection – required signed consent in all cases where MbP was to be used.

This was vigorously fought as an infringement of religious freedom by the Chasidic community and the Agudah. In an effort to respect their religious rights to the extent they were asking for, Mayor Bloomberg’s successor Bill DeBlasio withdrew the signed consent requirement. A compromise was reached. If a baby was found to have herpes immediately after a circumcision, the Mohel would be tested. If he had the virus he would be banned from doing any circumcision for life.

The problem with that compromise is that it is an after the fact compromise. It only works after the baby gets infected. I understand all the arguments made by MbP proponents. Mostly having to do with the chances of a baby getting herpes by an infected Mohel being statistically very small. But to the baby who ends up with it, those chances rise to 100%. I personally find that unacceptable.

Last week the NY Daily News reported that since DeBlasio’s election, 6 cases of neonatal herpes infection have been linked to an infected Mohel:  
One unidentified baby was rushed to the hospital 15 days after undergoing the ancient ritual, known as metzitzah b'peh, which involves cleaning the circumcision wound by oral suction.
That’s when the newborn developed a rash on his genitals, buttocks, inner thigh and ankle, according to a city Health Department alert issued to all medical personnel Wednesday morning.
“We literally heard about this case at some point in the afternoon yesterday,” Mayor de Blasio told reporters at an unrelated event. “We’re right now in that process of identifying the mohel (who performed the procedure), and we expect full cooperation from the community.”  
It would seem that unless he is identified quickly the requirement for that community to identify the Mohel is being honored in the breach.

The New York Post reports the following: 
The city is zero for six in garnering full cooperation from the Hasidic community in rooting out mohels involved in neonatal herpes cases, but Mayor de Blasio says he still needs to evaluate whether a deal with the community is “working effectively or not.” 
Last week, health officials said just 2 of 6 mohels had been identified and that — rather than being tested — they were simply advised not to continue with the practice, known as metzitzah b’peh. 
Apparently the compromise worked out with the DeBlasio administration was never taken seriously by the Chasidic community. They probably want to protect the livelihood of the Mohel. But I have to wonder how the parents of those infected babies feel about that? I wonder if they even knew of the dangers their baby faced – remote though they may have been? I also wonder how many of those parents would opt out of MbP and instead use the more sterile procedures that most Poskim say are sufficient to satisfy the Halacha?

In my humble opinion, the requirement of signed consent forms ought to be re-instituted. I see nothing about that law that interferes with a parent’s right to have the procedure performed on his baby. What it does do, however, is inform that same parent about the potential danger and allows them to choose a safer one. Wouldn’t this be a win/win for everyone?