I. Medical
Background
History
Historically,
circumcision has always been performed on infants without any anesthesia. This
is true both with respect to halachic Jewish circumcision and to surgical
removal of the foreskin, as performed in many parts of the world.[1] This
continued to be the case even after anesthesia was developed and used
extensively in various medical procedures, including surgery and childbirth.
There
were several assumptions underlying this approach:
The
assumption that newborns do not feel pain to any significant sense as do
grownups.
The
assumption that surgical removal of the foreskin is done quickly, with little
associated pain.
The
assumption that newborns quickly forget the sensation of pain, leaving no
emotional problems.
The
assumption that no procedure should be undertaken that might endanger the
infant, since the risk of circumcision itself is very low.
The Situation
at the End of the Twentieth
Century
This
period saw some changes, in light of certain developments:
1.
Medical science came to recognize and the public became aware, that even
infants suffer from pain and have a negative experience as a result of pain.[2]
This
assumption, that even newborns suffer from pain, was proven in a number of
ways: studying babies’ behavior (face and eye movement, body movement, etc.)
while subjecting them to a painful stimulus; timing the length of their crying
and studying the nature of their crying; measuring the levels of various
substances that the body secretes as a reaction to pain. [3]
2. The
development of effective and safe palliation and anesthesia, which permit
reducing and/or avoiding pain, even in infants.
In light
of these developments the American Academy of Pediatrics recommended anesthesia
in performing painful procedures in infants.[4] In addition there were suggestions,
requests, and recommendations regarding pain reduction for the newborn during
circumcision.[5]
Several
specific suggestions were made to reduce pain during circumcision:
Local injection of 0.5-1 ml/kg of the
anesthetic lidocaine (1%) at the base of the penis at 10 and 2 o’clock.[6] This
method was first suggested in 1978.[7]
Its advantages: good, complete anesthesia in 5070% of the cases.[8]
Disadvantages
of this method: significant pain in administering the injection at a
particularly sensitive location;[9] the
effect attenuates quickly, leaving discomfort after the circumcision; possible
complications, such as hemorrhage, necrosis, and absorption of lidocaine into
the circulatory system, which can cause irregularities in heart rhythm,
hypotension, convulsions, and auditory disorders; and the need of a physician
to perform the circumcision.
Weighing the benefits and the potential dangers
in using lidocaine, the American Academy of Pediatrics refrained from
recommending it in performing circumcisions on infants.[10] At a later date, however,
the Academy formulated a policy mentioning only some of the disadvantages
without rejecting the use of lidocaine.[11] Other
researchers dissociated themselves from the use of lidocaine in circumcision
for other reasons.[12]
Injection
of 1 ml of lidocaine (1%) in a ring around the circumference of the middle of
the penis or the base of the forskin for local
anesthesia. In this procedure the same concentration of
lidocaine is used as above.[13]
Advantage of this procedure: better anesthesia
than any other local method. Disadvantages: local pain due to the injection
itself. According to the few reports available regarding this method, no
complications were observed.[14] In
theory the same complications resulting from injection of lidocaine at the base
of the penis are likely to arise in this method as well.
Spreading
a cream with various concentrations of lidocaine locally on the area of the
foreskin about an hour before the circumcision. Some
practitioners used a 4% concentration of lidocaine in an acidic cream.[15] The
efficacy of the method is not high. Others used a 30% concentration of
lidocaine[16]
with better results.
Still
others used EMLA cream (i.e., eutectic mixture of local anesthetics)[17]
containing 2.5% lidocaine and 2.5% prilocaine with good results.[18]
This method requires topical application of 1-2 gr of the EMLA cream
about 1-1.5 hours before the circumcision.
Advantages
of this method: good anesthesia in many patients; complete absence of side
effects because the active ingredients are not absorbed into the blood stream
as long as no more than 2 gr are applied;[19] the anesthetic effect lasts
for several hours after application, thus reducing discomfort even after the
procedure; ease of application; appropriate for use by ritual mohalim who are not physicians. Disadvantages: lower
success rate than local injection of anesthetic; waiting time between
application and the circumcision procedure.
Administering sucrose with a vinyl nipple. In
this method a nipple is dipped into 50% solution of sucrose. A gauze pad dipped
in the sucrose is also inserted into the nipple. The circumcision procedure is
begun around two minutes after the infant has begun to suck on the nipple with
the sugar solution. During the entire procedure, the nipple is held in place in
the baby’s mouth. From
time to
time, the gauze pad is dipped again in the sugar solution and returned to the
nipple.[26]
Advantages
of the method: high efficacy in preventing pain throughout the procedure; ease
of application; complete absence of complications; no waiting time between the
application and the procedure; appropriate for use by ritual mohalim who are not physicians.
Disadvantages: the efficacy of the method is somewhat less than that of locally
injection anesthesia.
Administering
palliative medication. In this method 15 mg/kg of acetaminophen
(paracetamol)[27] are
administered orally every 6 hours beginning two hours before the circumcision
and continuing 24 hours after it.[28]
Advantages of this method: from the medical
point of view, the medication is safe even for newborns, without any side
effects; the medicine is in general palliative for mild to moderate pain in
small children. Disadvantages: no positive indications have been found that
pain levels during the procedure and immediately after it are affected.
However, there is a positive effect beginning a few hours after the circumcision.[29]
These disadvantages can probably be overcome by two changes: increasing
the dosage or by administering the medicine more frequently; but this has not
been investigated, and there are no data regarding the efficacy or safety of
these changes.
Combining
methods. Some have demonstrated that no one method is
sufficient. They recommend combining lidocaine injections, EMLA cream,
acetaminophen and a sucrose nipple. This combination has been found to be more
effective in reducing pain than any individual method. [30]
II.
Halachic Background
Historical
Background
All
agree that circumcision as a Jewish ritual was traditionally performed without
any form of anesthesia. This is true both for the circumcision of eight-day-old
infants and adults, as in the case of converts or Jews who were not circumcised
as infants. It is also clear that since the introduction of various methods of
anesthesia, it is now possible to perform the procedure without any sensation
at all or with greatly reduced levels of pain. Today, the use of anesthesia is
quite common in adult circumcisions. There are places where general anesthesia
is used; and there are places where general anesthesia is used only for
children, local anesthesia being reserved for adults. In the world of medicine
the first suggestions for using local anesthesia in the circumcision of infants
were made in the first two decades of the twentieth
. 25
century.[31]
First,
let us consider the position of the posekim
regarding the use of anesthesia in the circumcision of an adult.
The
earliest discussion of this question appeared in Tel Talpiot (1896).[32]
There rabbis disagreed on the permissibility of using chloroform as a general
anesthetic in the circumcision of an adult Jew or convert. There was further
discussion regarding general anesthesia in the circumcision of converts in Ha-Me’assef (1913-14).[33]
Rabbi
Meir Arik wrote the first systematic responsum dealing with the question[34] of
local anesthesia in the area of the circumcision for a thirty-year-old patient.
The
question of anesthetizing an eight-day-old infant for circumcision was first
raised recently.
Summary
of the opinions of the posekim:
Some poskim discuss anesthesia only in connection the
circumcision of newborns. Others add adults to the discussion. Some discuss
only general anesthesia. Others discuss local anesthesia. Some discuss both.
In
short, those who prohibit anesthesia in adults certainly prohibit it in
newborns. But some of those who prohibit it in newborns permit it in adults.
Similarly, those who prohibit local anesthesia certainly prohibit general
anesthesia. But some of those who prohibit general anesthesia permit local
anesthesia.
Some
prohibit both general and local anesthesia, both in newborns and in adults.[35]
Some
prohibit both general and local anesthesia, both in eight-day-old babies and in
adults. But they allow anesthesia in adults in certain circumstances, for
example in older people, in cases where the procedure is more complicated and
would cause great pain, or in correcting awkward presentations where the
surgery requires more time than ordinary circumcisions and would therefore
cause great suffering. In such cases, they see no problem with local anesthesia.[36]
Similarly in the case of an adult who, through no fault of his own, was not
previously circumcised as, for example, in the case of man whose older brothers
had died because of circumcision.[37]
One
authority prohibits all forms of anesthesia, even local anesthesia, in newborns
up to one year old. But he permits local anesthesia in adults or in babies over
one year of age.[38]
Other
authorities prohibit both general and local anesthesia in newborns, but are in
doubt about the permissibility of anesthesia for adults.[39]
Some posekim prohibit all forms of anesthesia, even local
anesthesia in the routine circumcision of a newborn. These posekim did not express an opinion regarding adults.[40]
There is
an opinion prohibiting general anesthesia in adults, without expressing an
opinion regarding local anesthesia.[41]
Some
prohibit general anesthesia both in adults and babies, but permit local
anesthesia in both.[42]
Others
permit anesthesia in adults, even general anesthesia, without expressing an opinion
with regard to newborns.[43]
Still
others permit local anesthesia for babies as long as it entails no threat to
the baby’s life.[44]
Objections
to Anesthesia in Circumcision
Innovation - Anesthesia constitutes an innovation, a change
with regard to earlier practice. It is inherently prohibited to change
traditional practice and we ought not try to be clever and innovate new
procedures in opposition to the will of the Creator and Jewish practice. “The
Torah prohibits innovation.”[45]
Pain - Circumcision requires pain, as is clear in the
Midrash:
R. Levi
said: It is not written that Abraham circumcised [himself]. Rather it is
written “Abraham was circumcised.” He examined himself and saw that he had no
foreskin.
R. Abba
bar Kahana said to R. Levi: You are a liar; he felt [the pain of circumcision]
and suffered in order to increase his reward from God.[46]
It
follows that circumcision was originally instituted with suffering.[47] It
has further been written “that everyone should consider his own suffering when
[the baby] cries from the pain of circumcision because his voice rises without
the impediment of any evil that his prayer might include.”[48]
The Covenant with God - The
commandment of circumcision might indeed be fulfilled when the foreskin is
painlessly removed. But the fulfillment of the covenant between the newborn and
God requires that he feel the cutting away of the foreskin and some bleeding.
Without this, there can be no fulfillment of the covenant.[49]
The Sages were Familiar with Anesthesia - In the
Talmud we learn:
We must
calculate how much one would pay to have one’s arm amputated with a drug.[50]
Rashi
explained: With a drug - with a drug there is no pain in amputation.
Although
it is clear that they were familiar with them, anesthetic drugs were never used
in conjunction with circumcision. It follows that pain is a requisite element
in circumcision according to the earlier authorities.45
Agency - The mohel is the agent of the person
he is circumcising. If the person being circumcised is not conscious, he cannot
appoint the mohel his 46
agent.46
Intention - Fulfillment of the commandment of
circumcision requires intent. If the person being circumcised is asleep, he
cannot have the requisite intention to fulfill the commandment.47
God’s
Will - God intended the commandment of circumcision
to be performed with pain. If so, we surely cannot do anything to lessen the
pain. God wants the infant to understand at his tender age that it is
impossible to attain virtue without suffering. All spiritual improvement
involves pain.47a
Danger - There
is some threat to life in all forms of anesthesia. It is entirely prohibited to
endanger the person being circumcised.48
Rejection
of the Objections against Anesthesia
Innovation - It is true that the great Orthodox rabbis
strongly opposed any changes in the performance of ritual circumcision because
reform leaders in the past repeatedly tried to introduce such changes.
Therefore, they went to length to reject any such innovations. Here are a few
examples:
Opposition
to cutting the foreskin with any instrument except a metal knife; opposition to
use of any kind of shield; opposition to uncovering the —
45. Resp.
Imrei Yosher, ibid.; R. M. Eliyahu in the addenda to
the Hebrew version of this article, (ibid.).
46. Resp.
Seridei Eish, ibid.
47. Koret ha-Brit, ibid.; Resp. Seridei Eish,
ibid.; Resp. Shevet ha-Levi, ibid.
47a. Sefer Tuvecha Yabbi’u (R. Y.
Zilberstein) vol. 1, p 98.
48. Resp. Iggerot Moshe, ibid.; R. Sh.Z. Auerbach and R. Y.Sh. Eliashiv in Nishmat Avraham, ibid.; Resp. Shevet ha-Levi in the addenda to the Hebrew version of
this article, (ibid.). corona by any means except using the
fingernail; opposition to any method of suction except using the mouth.[51]
Nonetheless,
many authorities have agreed to innovations in certain limited circumstances
when it is clear that the innovation is justified and does not conflict with
any halacha. For example, many permit uncovering the corona with an instrument
instead of the fingernail.[52] And
many have agreed to suction with an instrument instead of the mouth.[53]
Further,
some have objected only to innovations that involve the essential elements of
circumcision while permitting incidental changes like introducing antiseptic
methods for preventing infection despite the fact that in previous generations
such methods were unknown.[54]
Use of
local anesthetic seems to be quite far from any infringement against the
commandment of circumcision. If there is a rational reason for such anesthesia
and if there is no substantial prohibition and no connection to the essential
elements of the commandment, why should anesthesia be prohibited?
According
to those who object to anesthesia in circumcision because it conflicts with
fulfillment of the commandment it is clearly prohibited to use any form of
anesthesia.
But if
using anesthesia does not conflict with fulfillment of the commandment and if
the purpose behind anesthetizing the patient is to reduce pain rather than to
adversely affect the performance of the commandment, there is no reason to
object to this innovation more than to any other innovation.
In
addition, those who prohibit local anesthesia in routine circumcision because
it is an innovation and nonetheless permit anesthesia in certain complicated
cases or for adults must in any event approve of some innovation unknown in
previous generations. Anesthesia was, of course, unknown in earlier generations
even in complicated cases. If so, we must conclude that it is acceptable to
discuss which innovations are permitted and which are prohibited.
Although
there are some contemporary authorities who object to any form of anesthesia
for adults, it is in fact the common practice to use local or general
anesthetic in every circumcision of a child or adult. A large scale study of
circumcisions performed on immigrants from the former Soviet Union who had not
been circumcised in their country of origin and who were subsequently
circumcised in Israel in accord with the guidelines of the Israeli Chief
Rabbinate presented the following data: In the years 1990-92 there were 2,857
males between the ages of 1 and 64 circumcised at the Soroka Medical Center in
Beer Sheva. Fourteen percent of them were circumcised under local anesthesia
and 86% under general anesthesia.53
Therefore,
it would seem that the decision must be based on the consideration of whether
the innovation of anesthesia does not conflict with any halachic principle.
Pain - There is no source in the Torah, in halacha,
or in kabbala requiring
that circumcision be accompanied by pain. There is no source in talmudic literature, the Zohar, or the medieval or modern authorities that
considers pain to be part of the fulfillment of the commandment of
circumcision.
The posekim adduce only one source regarding pain in
circumcision. It is a Midrash54 according to —
which
Abraham desired pain in circumcision in order to increase his reward for
performing God’s commandment. There are, however, two reasons why this source
cannot serve as proof:
(1) The
Midrash implies that Abraham desired to increase his pain in order to increase
his divine reward, but it follows that simple fulfillment of God’s commandment
does not require pain. This is certainly not a proof that pain is obligatory;[55]
(2)
Abraham’s greatness and righteousness are incomparable; he surely accepted pain
upon himself wholeheartedly and with pure intention. This surely does not imply
that he was obligated to do so. The great patriarchs determined to accept an
extra measure of pain in fulfilling God’s commandments because of their love
for the commandments. Thus it was with Abraham. This cannot imply any objection
to anyone else avoiding pain in circumcision.[56] Abraham acted out of
supreme love of God. His behavior cannot mandate that we too perform God’s
commandment with a similar level of devotion.[57]
Since
Abraham circumcised himself, one may argue that he desired to increase his
divine reward by increasing his pain. But there is no reason to call upon a
father to increase the suffering of his baby son in order to increase his son’s
divine reward. [58]
Although
the commandment of circumcision was first performed by Abraham, its principal
authority does not derive from Abraham. Rather, the principal authority for the
commandment of circumcision derives from God. Therefore, it is not necessary
that the commandment be performed as Abraham did it. We do not, for example,
call upon anyone to circumcise himself as Abraham did.58
Further,
there are other, opposing opinions in the Midrash regarding Abraham’s pain in
circumcision. In a different passage[59] we read that Abraham was
circumcised by a scorpion that God sent to him. Further, the earlier
authorities[60]
make clear that God assisted Abraham in circumcising himself. These authorities
make no mention of pain; it is reasonable to assume that God would not Himself
cause pain.
The
second source, “that everyone should consider his own suffering when [the baby]
cries from the pain of circumcision because his voice rises without the
impediment of any evil that his prayer might include,”[61] is surely not sufficient to
block palliative treatment of the person being circumcised. The thrust of the
passage is simply that a person who is suffering should raise his voice in
prayer because such prayer will be heard on high without any impediment. Even
this idea has no earlier source.
Further,
the leading kabbalist of Jerusalem has been quoted as saying that he searched
the Zohar and other kabbalistic works and did not find any special
mention of the infant’s pain during circumcision. On the contrary, the Zohar
clearly indicated that the pain of childbirth atones for the sin of Eve.
Nonetheless, no one has ever objected to efforts to minimize that pain.[62]
It would
further seem clear that those who favor pain in circumcision in order to
increase divine reward are only referring to adults who can understand the
significance of pain and its purpose. But what purpose can pain in newborns
have? Newborns have no understanding at all! It is incomprehensible that some
authorities require pain
only in newborn circumcisions but not for adults. This position is indeed
problematic.
In light
of all this, we can understand the opinion of the rabbi who wrote:
There is
no need for the circumcision to cause pain. It is impossible that halacha would
require the act of circumcision to cause pain. This idea has no source. Since
none of the principal authorities and none of the posekim mentioned such a fundamental idea as requiring
pain in circumcision, we may conclude that there is absolutely no reason to
require pain in circumcision.[63]
Another
great rabbi wrote:
We have
found no source for a commandment to cause pain in circumcision. Abraham
desired divine reward for the pain he suffered in his circumcision in accord
with the principle “as the pain is great, so is the divine reward.” But there
is no compelling reason to require pain in a child who has no capacity to
understand the meaning of the pain he experiences.[64]
One
contemporary posek concluded:
One
should not use general anesthesia because it is unhealthy. Therefore, general
anesthesia is not used in circumcising children. The objection to general
anesthesia is not based on halachic grounds, nor is it based on mystical
considerations when we know of no obstacle and no hindrance, for the sages in
every generation know both the literal and the mystical principles of
fulfilling the commandment.[65]
Even
those who require pain in circumcision prohibit only a drug that would entirely
eliminate sensation in the penis.[66]
[67] But
applying a local anesthetic cream, and certainly administering sucrose, can
only reduce, but not entirely eliminate, the sensation of localized pain. No
one has proposed that there is a specific level of required pain. Therefore,
even according to this opinion, it is sufficient that the infant experience
some pain.
The Covenant with God - The
approach here is similar to the approach regarding pain. Although there is some
reason and proof that pain must accompany circumcision, the palliative methods
mentioned above in the section on medical background do not completely
eliminate sensation. They merely reduce the level of pain and its duration. It
would seem that those who require experiencing pain do not have in mind any
specific level of pain. It follows that according to them even reduced levels
of pain should be sufficient to fulfill the covenant between the newborn and
God.
The Sages were Familiar with Anesthesia - The
Sages’ refraining from using anesthesia with which they were familiar proves
nothing in our case. There are several reasons why no proof can be brought in
this case from the Sages:
The drug
mentioned by the Sages was used in the amputation of a limb. A straightforward
reading the talmudic passage indicates that they were
referring to a drug that would accomplish the amputation,1 not an
anesthetic drug.[68]
This is consequently no proof that they were familiar with anesthetic drugs.
In a
similar vein we can explain the talmudic passage
mentioning a drug in connection with the boring of a hole in the ear of a
slave.[69]
This too should be taken to refer to a drug that, when placed on the ear,
causes a hole to form.[70]
This interpretation fits with the other means of forming the hole that are
mentioned in that passage.
The
surgery of R. Elazar b. Shimon[71] is
at first glance a clearer source for anesthesia in the days of the Sages since
the drug mentioned induced sleep. This however is also no proof that they were
familiar with anesthesia because the drug mentioned was probably dangerous.
Such a drug is of course prohibited in circumcision; only in major, essential
operations like the surgery of R. Elazar b. Shimon would it be permitted.[72] It
is further unlikely that the drug was commonly available.
In fact,
the drug was rarely used and circumcision was of course quite common.
Even if
the Sages were familiar with anesthesia and refrained from using it in
circumcision, it must also be true that they refrained from using it in
childbirth as well. Further, they refrained from using it to palliate Rabbenu ha-Kadosh’s great pains and let him die rather than
suffer.[73]
In a
similar vein R. Hanania b. Tardion was not treated
with any anesthesia.[74]
There are numerous other examples of talmudic
passages describing pain with no mention of anesthesia.
In any
event, there is no source in halachic literature prohibiting anesthesia or
other palliative treatment for pain in childbirth, where it would seem more
reasonable to be strict because of the verse: In pain shalt thou bear
children.[75] Nor
is there any source prohibiting anesthesia or pain relief in suffering terminal
patients.[76]
In
general, the Sages opposed unnecessary suffering, aside from some extraordinary
cases.[77] It
follows that the Sages would permit preventing the pain of circumcision
whenever possible.[78] The
Sages’ silence regarding the use of anesthesia in circumcision can clearly not
prove that they prohibited it.
Agency - Some authorities have proven that even an
adult can fulfill the commandment of circumcision while under general
anesthesia. There are several reasons why unconsciousness does not detract from
the fulfillment of the commandment:
Although
the subject is asleep, the deed of circumcision is still performed. It follows
that if someone appointed an agent prior to going to sleep or prior to
undergoing anesthesia, the appointment is valid and being unconscious does not
detract from the fulfillment of the commandment.[79]
This
conclusion seems inevitable because if a man appoints an agent to betroth a
woman for him in some distant place and the agent goes and does it at a moment
when the man who sent him is asleep, the betrothal is surely valid.
Agency
is invalid in commandments that depend on the one’s person, but the commandment
of circumcision merely requires that a person be rid of his foreskin. Further,
the act of circumcision does not require a valid agent since a minor is
qualified to do it[80]
although minors are disqualified as agents. [81]
If all
this is correct with respect to the circumcision of an adult, is it all the
more correct with respect to the circumcision of an eight-day-old baby, since
in such a case it is the baby’s father who appoints the agent. Now the father
is certainly conscious even if the baby is asleep or anesthetized. It follows
similarly that local anesthesia does not detract from the fulfillment of the
commandment.
Intention - The posekim
have proven that absence of intention to fulfill the commandment of
circumcision does not detract from the fulfillment of the commandment. There
are several reasons for this:
Intention
expressed prior to undergoing anesthesia is sufficient.[82]
Since
the deed is performed by someone other rather than the person being
circumcised, it is sufficient if the mohel has intention to fulfill the
commandment.[83]
Circumcision
requires no special intention.[84]
This follows from the permissibility of a minor performing the
circumcision.[85]
These
reasons are needed only in cases of general anesthesia. In local anesthesia of
a newborn none of the reasons are needed because local anesthesia of an adult
does not block him from intending to fulfill the commandment, and newborns have
no intentions at all.
God’s Will - Everything that happens to us happens because
of God’s will. Nonetheless, we intervene in cases of illness and suffering and
the halacha of healing requires us to alleviate pain and suffering as far as we
can. The fact that circumcision involves pain proves nothing. Therefore,
alleviating pain does not contradict God’s will any more than does alleviating
of any other suffering. There is no special significance to the suffering of an
eight-day-old infant, who can surely not understand that “every spiritual
acquisition requires pain.”
Circumcision
does indeed involve pain. But if the purpose of that pain were to inculcate the
idea that every spiritual acquisition requires pain, then anesthesia would
equally be prohibited in adults. In fact, most authorities permit anesthesia in
adults. It follows that there can be no special will of God that the infant
suffer.[86]
Several
more general points can be adduced:
We have
seen authorities who permit even general anesthesia in adults[87]
without requiring any pain at all and without prohibiting newly developed
methods of anesthesia despite the Sages having refrained from using them. These
same authorities also permit even general anesthesia in newborns.
In
principle “its ways are ways of pleasantness, and its paths are peaceful.” If
it is clear that there is significant pain in circumcision and that the pain
can be prevented without violating any prohibition, it would seem that we
should be lenient, not strict.
It
follows that the only acceptable reason to be strict is the possibility of
endangering the person being circumcised. We should therefore permit only those
forms of anesthesia that are, from the medical point of view, definitively not
life threatening.
On the
other hand, it must be emphasized that there is a significant difference
between “surgical removal of the foreskin” as performed for medical purposes
(even by non-Jews) and “ritual circumcision” as performed by mohalim for the purpose of fulfilling the commandment.
In
surgical circumcision, a clamp is used to prevent bleeding from the incision.
This can lead to necrosis of the foreskin and ongoing severe pain. This
surgical procedure is routinely performed by young house officers who do not
have much experience, and the procedure is slow. The experienced, professional mohel,
however, performs the procedure very quickly without a clamp. In this way the
duration and intensity of the pain is much lower than in the cases described in
the American medical literature.[88]
We
should also distinguish between two cases:
(1)
Injected anesthesia that fully anesthetizes the penis. This procedure involves
some danger and must be performed by a qualified physician;
(2)
Using anesthetic cream, which attenuates the pain but does not eliminate it
entirely. This procedure involves no danger and can be performed by a mohel.[89]
[1] See the article on circumcision in the author’s Encyclopedia of Medicine and Halacha and Wiswell TE, N Engl J Med 336:1244, 1997.
[2] Anand KJS & Hickey PR, N Engl J Med 317:1321, 1987; Butler NC, Bioethics 3:181, 1989; American Academy of Pediatrics, Pediatrics 103:686, 1999; Maxwell LG and Yaster M, Arch Pediatr Adolec Med 153(5), May 1999
[3] Owens ME, Pain 20:213,
1984; Attia J, et al, Anesthesiology
67:A532, 1987; Weatherstone KB, et al, Pediatrics 92:710, 1993
[4] Poland RL, et al, Pediatrics 80:446, 1987
[5] American Academy of Pediatrics, loc. cit.
[6] DPNB = dorsal penile nerve block
[7] Kirya C & Werthmann MW, J Pediatr 92:998, 1978
[8] Taddio A, et al, N Engl J Med 336:1197, 1997; Taddio A, et al, Arch Pediatr Adolesc Med 154:620, 2000
[9] Weatherstone KB, et al, loc. cit. ; Taddio A, et al, loc. cit.
[10] American Academy of Pediatrics, Pediatrics 84:388, 1989
[11] American Academy of Pediatrics, Pediatrics 103:686, 1999
[12] Schoen EJ, N Engl J Med 322:1308, 1990; Weatherstone KB, et al, loc. cit.
[13] Lander J, et al, JAMA 278:2157, 1997
[14] Masciello AL, Obstet Gynecol 75:834, 1990 American Academy of Pediatrics, Pediatrics 103:686, 1999
[15] Mudge D & Youngner JB, J Nurse Midwifery 34:335, 1989
[16] Weatherstone KB, et al, loc. cit.
[17] EMLA = Eutectic Mixture of Local Anesthetics
[18] Benini F, et al, JAMA 271:274, 1994; Taddio A, et al, loc. cit.; Wiswell, loc. cit.
[19] American Academy of Pediatrics, Pediatrics 103:686, 199. When, however, some of the cream remains on the site of the circumcision, it is likely to be absorbed. In such cases, hemolysis has been observed in babies with G6PD deficiency.
[26] Blass EM & Hoffmeyer LB, Pediatrics 87:215, 1991; Smith BA, et al, Dev Psychol 26:731, 1990; Herschel M, et al, Arch Pediatr Adolesc Med 152:279, 1998
[27] acetaminophen
[28] Howard CR, et al, Pediatrics 93:641, 1994
[29] Howard CR, loc. cit.
[30] Taddio A, et al, Arch Pediatr Adolesc Med 154:620, 2000
[31] See the medical background above.
[32] Tel Talpiot, vol. 4, 5756, pp. 61 ff. The positions discussed there are summarized in Reichman E and Rosner F, Tradition 34(3):6, 2000.
[33] Ha-Me’assef 18(1-2); 19(1).
[34] Resp. Imrei Yosher 2:140, sect.3.
[35] Resp. Imrei Yosher, ibid.; Resp. Tsur Ya’akov, be-She’erit Ya’akov 5 (who only wrote: “Since the Rabbi from Tarna in his Resp. Imrei Yosher wrote that the practice is not to use any drug, I cannot raise any objection to that practice.” He did not, however, explain his understanding of the basis of the prohibition.); Resp. Erets Tsevi (Frommer) 1:56; R. A. Shapiro in the addenda to the Hebrew version of this article, published in “Medicine & Halacha: Practical Aspects” Ed. Rabbi Dr. Halperin 2006, pp. 348-370
[36] Resp. Tsits Eli’ezer 20:73; Resp. Shevet ha-Levi 5:147, sect. 2. Regarding R. Wosner’s position, see note 39 infra.
[37] Resp. Erets Tsevi, ibid.
[38] R. M. Bransdorfer in the addenda to the Hebrew version (ibid.).
[39] R. M. Eliyahu, addenda to the Hebrew version (ibid.).
[40] Resp. Tsits Eli’ezer 20:73; R. Y.Sh. Eliashiv and R. Moshe Halberstam in the addenda to the Hebrew version (ibid.). Regarding R. Eliashiv’s position, see note 38 infra.
[41] Koret ha-Brit, Nahal Brit 261:4.
[42] Resp. Seridei Eish 3:97; Resp. Teshuvot ve-Hanhagot 1:490, 2:510 and 3:308. See Sha’arei Halacha u-Minhag 3:97, which prefers local or epidural anesthesia rather than general anesthesia in an adult so that he will be conscious and aware during the procedure.
[43] Resp. Maharsham 6:85; Resp. Da’at Kohen 194; R. Y. Weingarten in Yarhon Ohel Mo’ed, Fasc. 1:7; Resp. Ma’archei Lev, Y.D. 53; Resp. Kappei Aharon 19 (who wrote that this was the practice in Munkasz); Resp. Helkat Yo’ev, Ohel Mo’ed 1:7; Resp. Pitchei She’arim 4:5; Resp. Rabaz 125; Resp. Mi-Ma’amakim 2:15; Resp. Hemdat Tsevi 4:48; O. Yosef in No’am 12, pp. 1 ff.; Resp. Yabbia Omer 5, Y.D. 22, according to which R. Yosef acted thusly with the approval of the Rabbinic Court in the year 5723. R. Y.Sh. Eliashiv has also told me that he approves of general anesthesia in adults.
[44] Resp. Iggerot Moshe Y.D. 4:40, sect. 2; R. Sh.Z. Auerbach and R. Y.Sh. Eliashiv quoted in Nishmat Avraham 5:260, sect. 1 (end). See, however, Resp. Iggerot Moshe, ibid., which quotes a letter by R. Sh.Z. Auerbach to R. Sh. Frankel, according to which no changes should be made in the procedure of circumcision even if there is no halachic problem involved. This contradicts his opinion as quoted in Nishmat Avraham. Further, I have met with R. Eliashiv, who told me that although he objects to anesthetizing an infant by injection when he is circumcised on the eighth day, he does not in principle object to the use of a cream. In addition, he did not want to publicize a clear and sweeping permissive opinion. Rather, he preferred that I inform mohalim orally that if the families insist on using cream, it is permitted to do so. In his opinion, the principal problem is changing the procedure of circumcision, not the pain or other incidental prohibitions. This, too, contradicts his opinion as quoted in Nishmat Avraham. See further note 47a infra.
[45] Rabbis Sh. Wosner, M. Halberstam, and M. Eliyahu in the addenda to the Hebrew version of this article, published in “Medicine & Halacha: Practical Aspects” 2006, pp. 348-370.
[46] Bereishit Rabba 47:11.
[47] See Resp. Imrei Yosher, ibid.; Sha’arei Halacha u-Minhag 3:97; Resp. Tsits Eli’ezer 20:73; Resp. Shevet ha-Levi 5:147, holding that pain is a principal consideration in circumcision.
[48] Olelot Efrayyim 446, quoted in the notes of R. A. Gutmacher on Tract. Shabbat 130a.
[49] R. A. Schapiro in the addenda to the Hebrew version (ibid.).
[50] Baba Kama 85a.
[51] Regarding these opinions see the article on circumcision in the author’s Encyclopedia of Medicine and Halacha.
[52] See Resp. Maharats Chajjoth 60; Resp. Ahi’ezer 3:65, sect. 12; Resp. Iggerot Moshe, Y.D. 1:155; R. Sh.Z. Auerbach, quoted in Nishmat Avraham, Y.D. 264:2.
[53] Sh. Wahlfisch et al. in Ha-Refu’ah
127:119, 1994.
See Resp. Maharam Schick, O.H. 152; Resp. Divrei Malchi’el 4:87; Resp. Beit Yitshak, Y.D. 89; Resp. Da’at Kohen 141-142; Resp. R. Y.I. Herzog, Y.D. 84; Hazon Ish, quoted in Resp. Shevet ha-Levi 6:148, sect 2. See in extenso the author’s Encyclopedia of Medicine and Halacha, s.v. mila.
[54] Bereishit Rabba 47:11.
R. A.M. Yisra’el in Ha-Ma’or 27(6):4, 5735.
[55] Resp. Erets Tsevi 56; Resp. Hemdat Tsevi 4:48; Rabbi M.D. Tendler in Carmy S (ed), Jewish Perspectives on the Experience of Suffering, 1999, pp. 79-83.
[56] Resp. Yabbia Omer 5, Y.D. 22:4.
[57] R. Moshe ha-Levi Steinberg, Hukkat ha-Ger 15, n. 31
[58] R. A. Baron in Ha-Darom 58:13, 5749.
[59] Tanhuma, Lech Lecha 17.
[60] See Rashi ad Gen. 17:24; Da’at Zekeinim mi-Ba’alei ha-Tosafot, ibid., 26
[61] Olelot Efrayyim 446, quoted in the notes of R. A. Gutmacher on Tract. Shabbat 130a.
[62] Nishmat Avraham 5, Y.D. 260:1.
[63] Resp. Ma’arachei Lev, Y.D. 53.
[64] Resp. Seriedei Eish, ibid.
[65] Resp. Iggerot Moshe, ibid.
[66] As made clear in Resp. Imrei Yosher, ibid. This is the principal source requiring pain in circumcision.
[67] As Rashi wrote: “to amputate it by means of a drug”. Rambam (Hovel u-Mazzik 2:10) wrote: “to cut it off by means of a drug.”
[68] Resp. Hemdat Tsevi, ibid.
[69] Kiddushin 21b.
[70] Rashi, ibid., s.v. mi’et sam.
[71] Baba Metsia 83b.
[72] Resp. Avnei Zikkaron 3:3.
[73] Ketubbot 104a.
[74] Avoda Zara 18a.
[75] Gen. 3:16.
[76] See the extensive discussion on the permissibility of palliative treatments in terminal patients in the author’s Encyclopedia of Medicine and Halacha, s.v. noteh lamut (1), n. 302 ff.
[77] See the author’s Encyclopedia of Medicine and Halacha, s.v. yesurim n. 176 ff.
[78] Resp. Mi-Ma’amakim 2:15; R. A. Baron in Ha-Darom 58:13, 5749.
[79] Resp. Maharsham 6:85; Resp. Yabbia Omer, ibid.
[80] Tur Y.D. 264:1.
[81] Resp. Yabbia Omer, ibid.
[82] Resp. Shevet ha-Levi, ibid.
[83] Resp. Yabbia Omer, ibid.
[84] Minhat Hinnuch 2. See also Ha-Ketav ve-ha-Kabbala, Gen. 17:13
[85] Tur Y.D. 264:1. See also Yalkut Yosef, Sova Semahot 2, Hil. Mila 15:1.
[86] R. Y. Zilberstein is the authority who prohibits anesthesia in infants because of God’s commandment. See his Tuvecha Yabbi’u as referenced above in note 47a. R. Zilberstein in his Torat ha-Yoledet 34:8, however, permitted anesthesia for a woman in childbirth, even on Shabbat, in order to prevent her experiencing pain. It follows that the principle “in pain shalt thou bear children” refers only to childbirth. Although there is room to say that preventing pain in childbirth is therefore a violation of divine will, such cannot be said about circumcision, regarding which neither Scripture nor rabbinic literature requires pain (as explained in note 62 above). R. Zilberstein’s position remains to be clarified.
[87] See Resp. Maharsham 6:85; Resp. Da’at Kohen 197; Resp. Ma’archei Lev Y.D. 53; Resp. Kappei Aharon 19; Resp. Hemdat Tsevi 4:48; Resp. Yabbia Omer 5, Y.D. 22; R. Moshe ha-Levi Steinberg, Hukkat haGer 15, n. 31.
[88] See Shechet J, et al, JAMA 279:1170, 1998; Reichman E and Rosner F, Tradition 34(3):6, 2000.
[89] This follows from Iggerot Moshe, ibid., and from oral communications from R. Y.Sh. Eliashiv and R Sh. Wosner. R. Y.Sh. Eliashiv told me that he opposes using a syringe to anesthetize infants circumcised on the eighth day. But he does not in principle object to using an anesthetic cream; in addition, he did not want to publicize a clear and sweeping permissive opinion. Rather, he preferred that I inform mohalim orally that if the families insist on using cream, it is permitted to do so. In his opinion, the principal problem is changing the procedure of circumcision, not the pain or other incidental prohibitions.