Letters to the Editor 2-20-09


Issue of Feb. 20, 2009 / 26 Shevat 5769

Back and forth on infection control at a bris

To the Editor:

By calling for different standards in the way brisim are performed (Raising bar on bris practices; Your Health; Feb. 13, 2009), it seems that Rabbi Avi Billet has fallen into the same trap that many others have in recent years — using current medical knowledge and practice to invade areas of psak halacha (rulings of Torah law) and minhag yisroel (Jewish custom).

Rabbi Billet himself admits, in the first sentence of his Feb. 10

article, (Raising bar on bris practices; Good Health section) that

bris milah carries a "surprisingly low risk rate." Surprising, indeed.

The rate of surgical site infections in the United States ranges from

2 to 5 percent. Extrapolated to the newborn boys in my pediatric

practice, one would have expected at least seven babies with bris

complications, chas v'shalom (G-d forbid), in the past year. I have

seen two or three in the last five years.

Anyone who has been in the operating room knows that the precautions

taken to prevent infection are numerous, and may even seem excessive

to the lay observer. If a surgeon even touches the back of his

colleague's sterile gown he must re-glove. Antibiotics are routinely

administered at the beginning of each procedure, and the surgical

wound is usually sutured closed. It would seem from Rabbi Billet's

article that even he does not adhere to this level of infection

control. How, then, can we explain this discrepancy between bris milah

and other surgeries?

The reason, I believe, is that bris milah is not a surgical

procedure. It is a mitzvah. The way by which it is performed is

dictated by halacha (Jewish law) and minhag (custom). "Shomer mitzvah

lo yaida davar rah" (One who performs a mitzvah should not know of a

bad outcome). While we need to be aware of developments in the medical

field that are relevant to milah, the medical profession dare not

overstep this boundary. Just as with fasting on Yom Kippur, the

medical opinion needs to be provided by the physician, but the final

ruling is subject to the algorithm in the Shulchan Aruch (Code of

Jewish Law). While sterile technique is not in opposition to halacha,

turning the Kisei Shel Eliyahu (Elijah's chair at a bris) into an

operating table creates a slippery slope and a threat to the

institution of milah as it is viewed by the masses.

As for metzitzah (suctioning blood from bris wound), many poskim

(halachic decisors) have sanctioned the use of a pipette in order to

reduce the risk of infection. Most of the Gedolei Yisroel (Torah

sages), however, have urged that the practice metzitzah b'peh (direct

contact oral suction) should be continued, notwithstanding several

cases of complications which have occurred in recent years. We find

that even though the medical basis for metzitzah b'peh is unclear, the

gedolim allowed its practice on Shabbos, despite the possibility of

chilul shabbos shelo b'makom sakanah (Sabbath desecration when no life

threatening situation exists). They recognized the dangers of

tampering with minhag yisroel. Certainly, the risk of infection is not

altered by having the father perform metzitzah; he may be more

infectious than the mohel.

As a pediatrician, I will continue to provide my medical opinion only

when sought by a rav or a mohel. Parents should consider their own

minhagim (customs) and involve their rav when selecting a mohel,

rather than choose one based on his medical expertise.

David M. Klein, MD FAAP


Rabbi Avi Billet responds:

Dear Dr. Klein,

Thank you for your comments.

Should we be going back to bloodletting with leeches to uphold the

ways of psak halacha and minhag yisroel? Perhaps inoculating and blood

testing go against the laws of chavala (wounding). Please justify your


The low risk rate in bris allows people to fulfill this mitzvah

without anxiety. They need not be ignorant either. The bris should

have a zero risk rate, which sterility can accomplish.

Your undocumented observation of newborns who visit your practice are hardly what we may call "good statistics."

You say, "sterile technique is not in opposition to halacha." Kudos.

Most metzitza b'peh (MBP) people disagree with you about sterility.

Who said anything about "turning the Kisei Shel Eliyahu into an

operating table?" Since when does cleanliness and sterility make the –

correction – sandak's lap (which is compared to a miz'be'ach – an

altar) an operating table? We want the "offering" to live a long life!

Cleanliness is the key.

Random "Gedolei Yisrael" is meaningless. Bring real sources please.

You are right. Neither father nor mohel should be doing MBP with the

mouth. Either one should use a tube.

Metzitzah with direct contact has no basis in the Talmud, Maimonides,

Tur, Shulchan Arukh [halachic sources], yet you will sooner advocate a

mohel put his mouth on an open wound even though this goes against

everything you ever learned in medical school. Bris is a mitzvah. But

an open wound and bleeding that will not stop on its own requires

medical attention, which direct-contact metzitzah is not.

According to your view of medicine, we'd be better off back in the

Middle Ages when the infant mortality rate was much higher, and was

accepted because people did not know better.

I say, now that we know better, we should do everything we can to

protect our sons.

Rabbi Avi Billet, Mohel

No cop-outs on brother's obligation

To the Editor:

I am responding to the editorial "Nasty views on The View" (Feb. 6,

2009). I share the anger expressed by the writer regarding having

Torah Jews and Judaism mocked on network television. In this new age

of tolerance, Torah Judaism, it seems, is, as always, fair game.

But the issue from the article I wish to address is that of Yivum ––

marrying one's childless brother's widow –– and how nowadays would-be

couples are instructed to perform the mitzvah of Chalitzah instead.

The mitzvah of Yivum is just that: a command in the Torah, and not

just some ancient permissibility; the Torah even first states that the

widow should not marry outside the family. So how can we override this

biblical command (even in the face of polygamy)? The option of

Chalitzah is a Torah sanctioned and sometimes-necessary cop-out, like

divorce. It's not preferred. The Torah is just being kind to us.

Dying without children is a horrendous fate that Hashem should spare

us all from. Yivum provides the rectification. However, the man who

opts to eschew his responsibility to build his late brother's

house/name is held in contempt. In Chalitzah, the woman spits in a

shoe and says, "Such is done for the man who wishes not to build his

brother's house." This is what the honorable man must opt for

nowadays? Yehuda's second son, Onan, was killed by Hashem for

specifically not wanting to build his brother's name/house.

How naive would I be to believe that there exist among the sons of

Israel men of honor who would take on their childless brother's widow

for the sake of Heaven and their dearly departed brother? Is not the

Torah eternal? Doesn't it fulfill our very nature? We should allow

this all-important mitzvah to once again be fulfilled.

But most of all, may we see the time now where the application of

this mitzvah is purely hypothetical.

Ariel Weisz

Far Rockaway