The Metzizah B’Peh Controversy

Controversy has recently arisen over the part of a brit milah known as metzitzah. After performing the Brit, the mohel is obligated to remove the first appearance of blood from the wound. The source for this custom is a gemara (Shabbos 133b) which explicitly states that it is a medical necessity to do so. Therefore, one is obligated to do the metzitzah on Shabbos because it is considered pikuach nefesh.

There are two modern issues with performing the metzitzah. First of all, our doctors say that there is no danger in not drawing the blood. Thus, it is possible that we would no longer be permitted to do metzitzah on Shabbos. Since metzitzah involves drawing blood, it would constitute a Torah prohibition, and without a real danger to the baby’s life, we would have no reason to permit it on Shabbos.1

This is a side issue of metzitzah, and not really the one that has caused controversy. What is making the news now is how the metzitzah is done. The common custom, until relatively recently, was that the mohel would use his mouth to suck out the blood. The potential health issues with this should be obvious.

The controversy over this is not new, however. As long ago as the early 19th century, some claimed that metzitzah b’peh (MBP) could be dangerous to the baby. Recently, after a mohel infected with Herpes Simplex Virus type 1 (HSV-1) possibly caused the deaths of two babies, the controversy has arisen again (This is not to be confused with the sexually transmitted disease commonly known as herpes, which is a related, but not identical, virus).

HSV-1 is incredibly common. In fact, if you’ve ever had a cold sore in your life, you carry the virus. Herpes is also the leading cause of virus-induced blindness in the world and can have other severe effects. A baby, with a still-developing immune system, could be greatly harmed by the virus if exposed to it too directly.

Those are the basic facts of this case. The issues are that no one agrees on how to deal with these facts and that people do not argue logically when they feel the need to defend something connected to an integral part of our religion. A study from seven ago years ago at Louisiana State University found that 98% of people have HSV-1. The anti-MBP crowd uses this to prove that there is no way to safely do MPB. The pro-MBP crowd says that since everyone carries the virus anyway, the baby will be exposed within days or weeks regardless, if he hasn’t been already.

Why are so many people so ferociously pro-MBP? If the issue that mandated metzizah in the first place is a no longer a health concern, who cares how you perform the metzitzah? That’s actually a very good question. The fact remains that MBP has been treated as an integral part of the brit milah for at least 2000 years. The mishnah mentions metzitzah, and even though the halachic literature does not necessitate it being performed b’peh, that is presumably how it was done the entire time. Whether that was because suction by mouth was the most expedient way to do it or because it carries an integral part of the mitzvah is up for debate. I do not claim to be an expert in Kaballah, but at least in the halachic portions of Torah there is no source to say that metzitzah has to be by mouth.

More important, though, is the way this controversy came to light. It was an issue that was brought up in communities and in the media by the government and by some Rabbis (some of whom are great talmidei chachamim), but not by the gedolei hador. It is possible that if statistics and details were provided to some of the leading poskim ten years ago that they would have outlawed MBP, and this whole issue would not exist. Those who honestly just want to protect their mesorah were immediately put on the defensive, preventing them from being able to look at the issue objectively. Indeed, the Agudah’s lawsuit over New York’s new law is much less about actual legality or protecting MBP as it is a fear that the passage of any legislation connected to milah could possibly lead to outright bans on parts of religious life down the road (as was attempted in San Fransisco).

That is why there is so much dispute about even the cases where we can almost definitely say that a baby was killed or got sick from HSV-1 due to MBP. Everyone rationally knows that it is possible to contract a virus this way, but people are forced to find ways to explain that it never happened because they are now on the defensive about the entire issue.

The fact that MBP is probably not technically a halachic necessity does not mean that we should be cavalier about no longer doing metzitzah by mouth. Something that has been accepted practice for over 2000 years carries tremendous weight. If there is a safe way to do MBP (and someone once told me that there isn’t, but that definitely bears further research), then there really is no reason to stop people from doing MBP. It is certainly no worse than doing it with a sterile pipette, so long as it can be done safely. The Aruch Hashulchan (Yoreh Deah 264:19) was presented with this issue over a century ago, and his words still ring true: “Chazal were smarter than them; but it should be guaranteed that the one who does the metzizah has a clean mouth without any disease and clean teeth.”

If anything good has come out of this entire controversy, it is that there is no way from now on that any mohel who even thinks he has a sore in his mouth will do MBP. If that means using a pipette, great. If that means finding a definitely healthy mohel who will do MBP, that’s also great. I think that everyone can definitively say now that any mohel with an open sore who will still do MBP has the halachic status of a rodef, an attempted murderer. One baby getting sick or, God forbid, dying from MBP is too many. However, if there is a way to safely do it, there really is no reason to stop it. At the end of the day, as long as no more babies are harmed, who cares whether that is because we are more careful with MBP or because we don’t do MBP at all?

1. The Tzitz Eliezer in several places in his responsa, including 14:89 and 19:29, states that once chazal determined something to be considered a threat to human life, our doctors do not have the ability to state that there is no danger in the action. Even though we believe them that it is perfectly safe not to do the metzitzah, according to the Tzitz Eliezer we must still treat it as a safek sakanah, a possible danger, and therefore we can violate Shabbos for it. See 14:89 for his reason. While this would defend the common custom of still doing the metzitzah on Shabbos, it would not explain how, according to him, we do not put a cumen-soaked bandage on the wound, which that same Gemara also mandates because of danger to the baby’s life.