Even Maimonides Would Agree: Hazardous Rite Should Be Retired
By Sherwin Nuland
February 17, 2006
One of the first things I was taught when I began my surgical training about 50 years ago was that I must never spit into an open wound. To my knowledge, that is still a good rule.
As ridiculous as such a statement sounds, it is not much more ridiculous than the idea of deliberately exposing a freshly cut incision on the penis of a newborn — whose immune mechanisms are, of course, not yet fully developed — to the germs in human saliva. Any fool should know that such virulent bacteria and viruses must never come into direct contact with a wound, much less that of a neonate.
The only rationale for putting lips to an open incision is the possibility that the alternative may be worse, such as the absorption of a more toxic substance such as snake venom. And yet, there currently rages a violent dispute about whether some of our ultra-Orthodox brethren should be permitted to continue a practice about which there seems to be only debatable probability of halachic justification. A custom is not a law, any more than a superstition is the manifestation of religious faith.
One can only wonder why not only New York's mayor, Michael Bloomberg, but also its health commissioner, Dr. Thomas Frieden, has been wearing kid gloves instead of mailed fists in his dealings with the Satmar and other Hasidim who insist on their right to metzitzah b'peh — the practice of sucking the blood from the lacerated foreskin of a newly circumcised child in order to "purify" it in some perverse way. Even the suggestion that the custom be fulfilled through the intermediary of a sterile tube has been rejected by the stubborn adherents, who apparently look on the unhygienic practice as a great honor to the perpetrator.
As is by now well known to everyone who reads newspapers, three infants have recently been identified to have contracted herpes simplex infection from a single mohel, and one of them has died. The wonder is that more of such cases have not been reported, because it is virtually certain, given the high frequency of the organism in the mouths of all of us, that far more infections of this and other sorts have resulted from the practice than is now publicly known.
Under normal conditions, the human mouth is home to streptococcus, staphylococcus and about five other forms of bacteria, several of which are capable of causing serious — and even lethal — infections. Every emergency room physician knows that these germs make a human bite more dangerous than a similar wound inflicted by a dog or cat, so much so that standard medical protocol demands that all such injuries be surgically explored and the damaged tissue cut out. The only exception is a bite on the face, where cosmetic considerations allow some leeway, but only with careful discrimination and close follow-up.
These precautions are in place because of the highly dangerous bacteria, but the herpes simplex virus adds problems of its own. To quote a standard textbook used by medical students and residents in training, "ntreated neonatal herpes simplex has a case fatality rate exceeding 60%, with half of survivors severely damaged," frequently as the result of encephalitis. Other texts provide similar figures.
Fortunately, the disease is rare in the general population — but the general population does not suck on the newly cut penises of its neonates. Who knows the real number of fatalities and illnesses among ultra-Orthodox infants from either viral or bacterial infection, a figure on which the recently reported cases shed no light?
Jewish physicians traditionally revere the memory of the most renowned of their number who ever lived, Maimonides, or as the Satmar and many others prefer to call him, the Rambam. One should be very cautious in intruding a historical figure into a contemporary debate, but I will do it anyway. My justification for such boldness is that I recently wrote a biography of the great scholar and interpreter of Halacha, and none of its many reviewers or my correspondents have yet told me that my understanding of him as either a rabbinical authority or as a doctor is wrong.
Maimonides railed against superstitions of all sorts, though it is true he was somewhat more lenient with local customs that could not be shown to have a basis in rabbinic law. But regardless of the position he might take in matters of human behavior, he never wavered from the precept that health trumps virtually anything else. Any commandment may be violated in the name of health, except those injunctions against idolatry, blasphemy, sexual immorality and murder.
This was not only an ironclad dictum of the Rambam, but it has guided rabbinic thought throughout Jewish history, both before and after him. To Maimonides — and he said this directly — the practice of medicine was a religious undertaking, because without health and life one could not study God and achieve an understanding of His ways.
It is this argument that ultimately supersedes any halachic argument that may be brought forward to justify metzitzah b'peh. The Shulhan Arukh, the code of Jewish law, could not be clearer on the matter of circumcision: "The fulfillment of all ordinances [of the brit milah] are suspended if there is danger to human life."
The danger of metzitzah b'peh has been more than amply demonstrated. Were the Rambam alive today, he would certainly agree.
Sherwin Nuland, a clinical professor of surgery at Yale University, is the author of the National Book Award-winning "How We Die: Reflections on Life's Final Chapter" (Knopf, 1994) and the memoir "Lost in America" (Knopf, 2003).
