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Out Of The Mailbag: A Doctor Responds To Metzitza B’peh Comments Made by Avi Billet

yw.jpgThe following is a copy of a letter that sent to the Jewish Star in regards to the article written by Avi Billet posted on YWN [link below]. It is unknown if the letter will be printed by the Jewish Star, but the doctor emailed it to YWN as well:

To the Editor:

By calling for different standards in the way brisim are performed, it seems that 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 and minhag yisroel.

Rabbi Billet himself admits, in the first sentence of his February 10 article, 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 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 the, 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 and minhag. “Shomer mitzvah lo yaida davar rah”. 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. While sterile technique is not in opposition to halacha, turning the Kisei Shel Eliyahu 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, many poskim have sanctioned the use of a pipette in order to reduce the risk of infection. Most of the Gedolei Yisroel, however, have urged that the practice metztitzah b’peh 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. 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 and involve their rav when selecting a mohel, rather than choose one based on his medical expertise.


David M. Klein, MD FAAP
Boro Park Pediatric Associates, PLLC
Brooklyn, NY

(Residing in Bayswater, Far Rockaway)

LINK to YWN article.

45 Responses

  1. With all respect to Dr. Klein, I do not see the relevance of his sanctimonious article. Rabbi Billet never degraded the Milah procedure by suggesting practical medical solutions to reduce the possibility of infection during Milah. Dr. Klien jumps too quickly to assume that the psak is like his opinion, although he is not a Rabbi by trade. What is the basis for his opinion that, “ turning the Kisei Shel Eliyahu into an operating table creates a slippery slope and a threat to the institution of milah as it is viewed by the masses” ? The father should be doing the entire mitzvah of Milah himself. He only hires the Mohel as a Shiliach. The mitzvah of Metzitza B’peh should be placed on the father if he wishes it to be done. The Mohel is not required by Halacha to put himself in danger to do a Minhag. The father should be happy to do a simple mitzvah that is easy. If one is not willing to give up a little of himself to do a mitzvah he should not hide behind the Minhag and force a Mohel to do something he himself doesn’t want to do. Rabbi Billet should be commended for advancing an easy mitzvah that can be done by anyone. We must also insure that everything medically possible should be done to make sure the Milah processes is not a danger. I do not believe that Rabbi Billet was disregarding the importance of Metzitza B’peh; he was illuminating the Mitzvah.

  2. For those who are concerned about “Rabbi” Billet’s respect:
    While I’m sure he earned s’micha, this is AVI Billet, a son to Rav of Young Israel of Woodmere, and he is all of 28-30 years old.
    I don’t even know why such a young guy’s comments warrant a response at all.

  3. en1 – I think you are thinking more technically than practically. Practically speaking most people are not desirous to do Metzitza B’peh by themselves and would rather the mohel do it.

    Furthermore, you forget that the father is usually quite nervous at his son’s bris. Even something seemingly simple like Metzitza B’peh can turn disastrous when done by a nervous father. He could accidentally start choking on it and/or cough it up on the baby which would certainly complicate things and dampen the atmosphere as well.

    Leave well enough alone to the experts.

    To end off, let’s not forget where this whole subject started from. How many years ago were those incidences? 3 year ago? 5 years ago? I don’t remember exactly, but I haven’t heard of another case since and to top it off there never was conclusive evidence that those two cases were the results of the Mohel’s Metzitza B’peh.

    Our Gedolim say to leave the minhag alone and no harm will come. Trusting them is called Emunas Chochomim.

    Those that are weaker in their emuna can certainly rely on those poskim that allow pipette. Furthermore, due to the scare of HIV many of today’s mohelim have pipettes and perform Metzitza with it, so finding a mohel that uses a pipette is not difficult at all.

  4. I think this subject does not belong here on the net, this belong to Rabunim, and their was already many “ASIFOS” with the the GEDOLI HADOR and everybody knows their “PASAK” clear. and lets not even argue with some modern so called rabbies who have no problem modifing the Shilchon Urich to their low lifestyle. and they dont care for our health. “HEI’MU KORYE VA’NUFULI ……

  5. yidlmitnfidl (no 3):
    “2 or 3 babies is still not negligeable!”

    NO, they are not. Every yiddishe child is precious. But we are comparing modern surgical technique–with all its many safeguards–with Bris Milah that includes MeTziTza BePeh, and our ancient Minhag comes out way ahead.

    The point is that “upgrading” our well-established techniques to those of “modern” science will give us worse results, not better, because we will lose the ZeChus of the Mitzvah, which is the real protector of our children’s health.

  6. Softwords (7.) I am in agreement with you, however, it is important to clarify that comments like (4.)(8.)(9.) make absolutely no sense when they assume the open letter was ‘upgrading’, ‘downgrading’, ‘challenging’ ect. the Minhag of Metzitzah B’peh. they are reading negativity when there was none. If readers cannot analyze a piece of writing properly they are guilty of being ignorant which I believe is more damaging than the article. I challenge anyone to show me where Rabbi Billet wrote to change the minhag and eliminate it entirely because of medical reasons. Explain to me why using a pipet or having the father do it is a ‘downgrade, upgrade’ (whatever you want to call it) of the Minhag.

  7. Dr. Klein writes a beautiful letter. The only problem is that he clearly did not read Avi Billet’s article. Avi Billet wrote an article for a loca newspaper about a sterile bris. Within the limitations of the venue of most Orthodox Shul’s he advocated maximizing a sterile environment. It is something a Mohel,a family, and a doctor should applaud.The article’s main focus was not about metzitzah.
    He also NEVER CAME OUT AGAINST METZITZAH b’peh.In fact he advocated metztitzh bepeh. Metztitzah with a suction tube is also metzitzah bepeh and it is more sterile than the Mohel’s mouth. Rabbi Billet suggested that if the family preferred mouth to organ direct contact that the father and not the mohel do it.
    I am amzed at how many people, including Dr. Klein, flippantly comment on an article without reading it.Gentlemen have some self respect and intellectual honesty.

  8. To #11
    Gentlemen have some self respect and intellectual honesty.
    good idea show some respect to all GEDOLI HADOR and not to a yongster who have no problem to tear out the TORAH. Metztitzah with a suction tube is “N O T ” metzitzah bepeh

  9. As a healthcare professional, I applaud and appreciate the prolific words of Dr. Klein, a well-known and respected pediatrician in Brooklyn. While there has been much discussion and debate on whether Metzitza B’peh is safe or not one can not ignore the prescient words of a Pediatrician who deals with these issues from a medical standpoint day in and day out. While it is entirely reasonable for one to argue for the use of more sterile equipment or newer less resistant antiseptics at a bris, Avi Billet has gone too far in suggesting a drastic change in minhag yisroel that has been proclaimed safe by Infectious Disease experts and by Dr. Klein’s anecdotal experience.

    Kudos to Dr. Klein for sharing his medical expertise with us and helping us understand the minimal role contemporary Judaism should play in altering minhagei Yisroel.

  10. “How the, can we explain this discrepancy between bris milah and other surgeries?”
    Mohelim are driven by the concept that a potential danger is treated more stringently than a Biblical prohibition as taught early on in the Gemara Chulin. Not every doctor treats potential danger as stringently.

  11. The following excerpt from Wikipedia will, I believe, help to enlighten everyone on this subject:

    “…Rabbi Chaim Chizkiya HaLevi Medini, the Sdei Chemed, printed a 50 page section called Ma’areches Hametzitzah, also claiming the practice to be Halacha l’Moshe m’Sinai, quoting R’ Yehudah Assad and others. He also elaborates more on what prompted the Chasam Sofer to give the above ruling:14.

    He tells the story, that a student of the Chasam Sofer – Rabbi Elazer Hurvitz, The author of responsa Yad Elazer and Chief Rabbi of Vienna at the time, (The incident is mentioned in responsa 54)- needed the ruling in defense of a governmental attempt to ban bris milah completely if it included Metztitzah b’peh, because of the concern of spreading disease to the baby. He therefore asked the Chasam Sofer to give him permission to do Brit milah without metzitzah b’peh.

    When he presented the defense in court, they erroneously recorded his testimony to mean that the Chasam Sofer stated it as a general ruling.

    He then adds, “Nevertheless it is my opinion that the Chasam Sofer never even wrote this letter. It is a forgery, in my opinion, and even if the letter was written by the Chasam Sofer, he certainly didn’t state it as a general ruling, given that it was not printed in his book of halachic responsa, as was the custom with all halachic rulings intended for the public.”

    Included in the Kuntres Hamiliuim at the end of Ma’areches Hametzitah is a pronouncement by several hundred noted Hungarian and Russian Rabbis not to change the procedure, as well as statements by doctors at that time (circa 1890), that Metzitzah was not a danger if performed as prescribed in Shulchan Aruch…”

  12. #15,
    Some changes suggested by Avi Billet:
    1. “Metzitzah B’peh Should Only Be Done By Father & Not Mohel”
    2. “A pre-packaged sterile drape is easily accessible and should be standard for every mohel to use.”
    3. “Mohels should be required to wear sterile gloves, donned immediately before touching sterile instruments and the sterile field of the bris. If it is time consuming, he can wear two pairs, removing the outer pair immediately prior to beginning.”
    4. “Any parent who insists that metzitzah be done with direct oral contact should do the metzitzah himself.”
    5. “The sandak, who holds the baby during the bris, does not touch the baby directly. Baby’s legs are covered with a blanket or wrapped with a conform bandage.”
    6. “When metzitzah is done, there is no direct bodily contact between mohel and baby.”

  13. 15, whom are you comparing to whom, Gedoli Hador, Tzadikim from all doras, to a young Machitzaf E.T.C., that comes from college, whats going with you ?

  14. In addition Rabbi Billet ignores the fact that Metzizta is a technique that the father may not be capable of doing at all. It requires a deep draw of blood from the organ which the father may not be aware of aside from his nervous state at the time of the bris. It should be left to the professionals. As Rabbi Billet is wont to do it I would suggest AVOIDING his services should you insist on the ancient custom of Metzitza B’peh

  15. (17.) if according to you those items that you quote are considered changes in the Minhag of Milah why don’t you use the original knife Avraham used because of minhag? Why can you change the Minhag and use a different knife? Furthermore only Avraham can do metizitzah at all brisim because the Minhag was to use Avraham’s mouth to do Metzitzah? How can you use any other mouth? The answer is that we try to do the best we can with the knowledge we know. Show me one Posek (or psak in a teshuvah sefer) that says you can’t make any of the ‘changes’ you wrote above. With all the respect for the Gedolim mentioned above, they would agree to do all you can to provide adequate medical protection for the nimol. For the Am Haratzim above who never opened a sefer in their life they should let the Mohel do metzitzah for their child, it would be better than to let them mess it up. For (18.) It is nice that you like to defend the ‘Gedolim’ that you profess to know so much about and respect, you are the only one who made the comparison between ‘Gedolim’ and the article. As a practicing mohel, no matter his age, Rabbi Billet has the authority to suggest some improvements in the technique of Milah to protect the nimol with common medical knowledge. What he is suggesting is not related to the actual Minhag or Mitzvah. If your Mohel wore a bekishe does that mean it becomes Minhag Yisroel? I know not!

  16. 20, I think you shall open a Shi’er here on all this Halachos, but please post original copies of this “POSKIM” not what you are dreaming in your mind,

  17. Another mistake of Dr. Klien is to compare surgical infection rates to infection for brissim. The rate mentioned includes surgeries on boys, girls, men and women and all types of surgeries and a much larger population, there is no wonder why he has not seen more complications from brissim because they are a much more minute amount of brissim done. His logic is incorrect and misleading. It leads me to believe Dr. Klien is making a plug for his doctor practice if you ask me…

    “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 in the past year. I have seen two or three in the last five years.”

  18. An interesting thought:
    Why don’t any of these anti-metzitzah fellows, who seem to be very worried for the health of Klal Yisroel, to the extent of even of a 0.1% risk of infection, then why don’t they try to ban most sports? The risk of serious injury by skiing, football, hockey, etc. is far greater! And what about the travel risks when people travel on vacation? There is also risk of disease in many of those countries that people travel to!
    Well, they will say, but the risk is still low. Well, so is the risk of a bris! And yes, doing the Bris the old way, means more to us than their sports and trips.
    Don’t let them fool you, they don’t really care for your health, they just want to degrade our Torah & Mesorah.

  19. 25. You do not have a Mesorah,or you made it up, I’m sorry to say. Unless your mesorah is to be dumb and ignorant. You make up your own mesorah as you see fit. Non of the above comments were anti-Metzitzah; just anti ignorance, which I believe you and your mesorah has a lot of. True Torah and Mesorah is to analyze the issue honestly and conclude the truth which you obviously did not do. Using the knowledge Hashem gave us to protect ourselves is not anti-Mesorah. Unless you made up your own.

  20. 20
    and other rabonim have rules that it HAS TO BE made Be’Peh.
    So who does Billet think he is, to PUSH HIS POINT OF VIEW, and it HAS TO BE DONE his way.

  21. to #21 torahis1

    He has expertise??

    would you say a Dr right out of medical school has more expertise then a doctor with 30 years of experience???
    yes young does make a big difference

  22. There are some very intelligent posts on this article and some very ignorant ones. The doctor who wrote the letter may have gotten into medical school but he would fail as a book reviewer. He clearly did not read Rabbi Billet’s article. He misrepresented what Rabbi Billet said. Rabbi Billet never suggested not to do metztizah bepeh. He mentioned both ways of doing it and which was more sterile. But his article was not about metztitzah bepeh. It was about common sense ideas of how to have a safer glatt kosher bris with less danger to the baby.
    Rabbi Billet does an outstanding Bris. He uses none of the short cuts that some mohalim use such as a clamp. He does not use a clamp. He does metzitzah bepeh with a suction tube.And he does a
    sterile Bris.And he has yiras shomayim. He goes to mikvah before each bris
    Some of the posters are either very ignorant people or they are comedians. Some of them have a very low level of intelligence.

  23. to Fearless Lion (25) Gut Gezugt, very refreshing.

    While I agree all the way that as far as Halacha and Minhag goes one must ask a COMPETENT Rav, however, I think it’s healthy to give SVOROS on both sides even by lay people as long as it’s done in that vein and with the right KOIVED ROSH. After all that’s what Toira is all about.
    As a matter of fact it’s probably one of the good things about the web. LEHAGDIL TOIRA VEYADIR.

  24. 34 – Well, what makes him a rabbi? Because he calls himself one?
    – The doctor on the other hand – an MD is an MD. One can assume if he has a practice that he is a doctor. (Notice the doctor signs with his credentials, the “Rabbi” does not)

  25. Paramodox – Which Godol signs with his semicha? (No, I’m not comparing him with your gedoilim)

    If a person puts Rabbi on his title, you can be sure if he has not earned the title, he will be called on it. Rabbi Billet has semicha from Yeshiva University. You may or may not like that institution, but many fine rabbonim are RIETS musmachim.

  26. Metzitzah with the mouth directly does not come from any classic Torah source. Even Rambam and others who list the “halacha l’Moshe MiSinais” do not include metzitzah. [See Rambam’s introduction to his commentary on the Mishneh; Maharatz Chayes “mavo LaTalmud”; Shut Chavos yair 192, Hasagos of Ramban on the Rambam’s Sefer Hamitzvos 1]

    FURTHERMORE In Rabbi Yitzchak of Corbeil’s introduction to “Sefer Mitzvos Katan” he categorizes the commandments of the Torah based on the different parts of the body which will fulfill them. Mitzvos 102-151 are to be fulfilled with the mouth. Metzitzah is not listed. See also Yalkut Shimoni Tehillim 723 in which Dovid Hamelech reportedly praises all the parts of his body and the mitzvos he fulfills through them.
    The mouth and lips are mentioned only with reference to davening and singing praise of God. Any reference to the practices of Bris Milah in this section always group milah and priah together – with no mention of metzitzah as being part of the mitzvah, let alone metzitzah b’peh!
    The male organ is for milah and priah, the knees are for holding a baby as a sandak, so milah and priah can be done.

    Hillel Moshe Gruenstein

  27. To all those defending “Rabbi” Billet’s character;

    Whether Avi Billet is a nice person in everyday life, (I’m sure he smiles nice while performing a bris (while, of course, exhibiting some sort of expression to portray the seriousness of the “operation” at hand,)) and whether he receives a document that proves he studied the pertinent texts that are requisite for one to be ordained a Rabbi is not the issue of any “character bashing” that is associated to reaction to his words.

    The point is the fact that he found it his place to take issue with the way Klal Yisroel does something.
    It is NOT the place of a thirty year old aspiring mohel to deride and demean the practices of mohelim the world over.
    It his NOT his place to make recommendations of how milah should be done.
    It is NOT his place to decide how important Metzitzah B’peh is, and who should administer it.
    It is NOT his place to choose which precautions are worthy of concern and which are not.

    The above points not only question his character, they obliterate any glimmer of merit we could have to view him favorably.

  28. Shtenderbender (#43) and Krunch (#6) – How ironic that you bring a person’s age into the equation. When did Rav Elazar ben Azarya become the leader of his colleagues?
    When did the ktzos write the shev shmaytsa?
    When did the Rambam write his Peirush Hamishnayos?
    What does Rabbi (no quotations marks please) Avi Billet’s age have anything to do with his right to have an opinion?

    RABBI Avi Billet has been a mohel for ten years. Most doctors are given the “right” to a credible opinion much sooner after they complete medical school.

  29. To #46: I fully agree with you. Those who claim to follow Daas Torah should ask a Sheilah before posting personal attacks – there would be A LOT fewer of them.

    But what about Yeshiva World’s editorial policy? Why not only publish comments, on either side of an issue, that are expressed respectfully, sans the personal attacks? What is the Heter to print anonymous vilifications from people who apparently are not yet Frum (in Bein Adam l’Chaveiro)?

  30. #44
    Thankfully, our religion isn’t shaped by people based on what they choose as their profession.

    As I wrote, he may have studied the proper texts to be ordained a Rabbi, and he may have apprenticed under another mohel, competent or otherwise.

    Neither give him credibility to offer Klal Yisroel an opinion to change the way we’ve performed the mitzvah of milah for three thousand years.

  31. The mid-19th century Austro-Hungarian physician/obstetrician Ignaz Semmelweiss, discovered the germ theory of disease, where simple hand-washing was utilized to prevent prepueral infection. He was scorned and ostracized at the time. Similarly, during the Civil War physicians used to thread suture material by first putting the thread in their mouth so they could easily thread the material through the needle. Do we want to go back to Civil War times? Kudos to Rav Billet!

  32. torahis1 – I believe that you are misjudging people. Those that are coming out against him are doing so out of concern for daas torah. They feel that he is stepping out of line. I feel that way as well. I can’t judge him as an individual because I don’t know him at all. However, it is clear that he is not in a position to make authoritative decisions for Ganz Klal Yisrael. I see nothing wrong with him placing his suggestions before the Gedolim, but to try to publicly make changes on his own is out of line. I don’t care what color his kippa is, where he learnt, or from whom he received smicha. He could be from Ponevitch and have received Yoda Yoda from Rav Shaich, ztl. I don’t care. He is not one of the Gedolim and therefore is not allowed to determine halacha for Ganz Klal Yisrael; for his kehila, yes; for Ganz Klal Yisael, no.

    Keep in mind, the Anshe Kineset Hagedola established takanas for Klal Yisrael. It consisted of the 120 top Chochomim. That means that number 121, as great as he may have been, was not allowed to take part in their decisions.For his Kehilla, yes; for Ganz Klal Yisrael, no.

    To all of us – Know your place!

  33. Shimen, the point was not to compare – it was to show that a person’s age is irrelevant once the person is a bonafide adult. Even children should be heard, by the way, even if we view their fewer years as making them more naive.
    While I agree with “torahis1” about the disgraceful “sinas chinam” of one side of the equation here, shtenderbender in particular (#43) exhibits the character traits of a real sonei yisroel.
    It’s amazing how once one hides in the shame of anonymity, the rules of lashon hara are thrown away because you don’t have to protect your own name from the bad things you say.
    Shimen and shtenderbender, your animosity towards Yeshiva University is quite clear and apparent. I am sure you never stepped foot in the institution, nor in its Beis Medrash, and you have no idea what kind of makom torah it really is. You should be ashamed – at your ignorance and at the way you disgrace your fellow Jews.

    Hillel Moshe Gruenstein

  34. #43
    If he’d prove himself first as being on the level of the personalities you refer to, than I agree he mas all the authority necessary. Until then my words remain accurate.

    Don’t be so quick on the defense!

    I definitely have stepped foot in the institution and its Beis Medrash in question, and I have relatives who are respected graduates as well.

    I have never written any comment that accentuates any degradation of the institution, its students or its faculty. I only wrote about an individual who may have graduated from the institution you refer to or not -I don’t know and I don’t care.

    If you educate me and insist that my remarks can be interpreted as a fair description of the beliefs this institution espouses you are either doing the institution an injustice or…

  35. 51.
    I think your misconception of the article was that it changed or determined Halachah a new way.. far from it. It was not changing or out to change anything; except to educate those people who want to know how to scientifically minimize infection risk. The ideas contained did not deviate from Halacha as defined in Shulchan Aruch. You will not find these suggestions in a Teshivah Sefer with a haskamah from the ‘Gedolim’ because they do not belong there. The same way you don’t have pictures or details of the bandages. That is technique.

  36. can someone answer this Q?

    where did he say not to do Metzitzah?

    All he said is that the father should do it, not the mohel.

    You have corrupted the mitzva of milah if you believe any aspect of the milah is a chiyuv of the mohel. It’s all a chiyuv on the father, and the mohel is just a shaliach, as most father’s cannot do the milah safely. However, almost all fathers can do Metzitzah safely. Therefore, there is no problem with a father doing it.

    I would strongly argue that any doctor that argues that its better for a mohel to do Metzitzah instead of a father (as a general case), should be stripped of their license to practice medicine as they are encouraging behavior that can turn a mohel intro a transmitter of disease.

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