The Use of Anesthesia During Circumcision

  • Rav David Brofsky
 
Introduction[1]
 
Although the basic circumcision procedure has not changed much since the days of the Talmud, a number of contemporary innovations, intended to help the mohel and protect the child, have been introduced over the centuries. In previous shiurim, we discussed the use of the Mogen and the newer clamps, as well as the dangers associated with metzitza ba-peh and the use of tubes instead. This week we will address the use of anesthetics, general and local, when performing a ritual circumcision.
 
Halakha is always concerned with the infliction of pain, and it is especially sensitive to the pain felt by an infant. In fact, the Talmud (Ketubot 8a) rules that we do not make the blessing “In Whose abode is joy” at a brit mila due to the pain felt by the infant. Similarly, some Rishonim rule that the She-hecheyanu blessing is also omitted at a brit mila, as is the custom in Ashkenazic communities outside of Israel, due to this reason. Therefore, it is a halakhic imperative, when possible, to reduce the pain inflicted upon others, especially infants.
 
In general, the use of anesthesia during brit mila has been discussed in two contexts: the circumcision of an adolescent or adult male (either one born Jewish or one undergoing the process of conversion), on the one hand, and the circumcision of infants, on the other hand. The use of general anesthesia for adults undergoing circumcision was first raised in the 19th century. We will begin by looking at that initial discussion, and then summarize the views of the Poskim who discuss this issue in the 20th–21st century.
 
Brit Mila under General Anesthesia: 19th Century
 
The first discussion of this question appears in a Hungarian rabbinic journal, Tel Talpiyot (4, 5656). R. Tzvi Trammer questions whether chloroform, a general anesthetic, could be used during the circumcision of a convert or of an adult Jewish male. A number of rabbis participate in the discussion which ensues, and several issues are raised.
 
R. Trammer first questions whether one who is under general anesthesia is considered to be a shoteh, i.e., one who is legally incompetent and therefore not obligated in mitzvot. He argues, however, that the mitzva of circumcision is incumbent upon the beit din, and not the convert or the adult male, and therefore this concern is irrelevant. Of course, while the convert is not obligated to convert, it is questionable whether the adult Jewish male is obligated to circumcise himself, as the Gemara implies (Kiddushin 30a), or whether the beit din bears the responsibility. R. Amram Fisher disagrees with R. Trammer’s analysis, insisting that both the convert and the adult male are obligated in the mitzva of circumcision. However, since they appoint an agent to perform the circumcision beforehand, they are not considered to be shotim, and the brit mila is valid.
 
In addition, some participants question whether the use of chloroform contradicts the spirit of the law.
 
Finally, some participants suggest that pain may be an important, and even inherent part of the circumcision for converts. For example, R. Pinchas Levi Horowitz suggests that the pain of a brit mila is meant to discourage potentially insincere converts. R. Mordechai Leib Winkler bases this assertion on the Midrash, according to which Avraham acknowledges that the pain of circumcision may deter potential converts. Although they only relate to the pain of a convert’s circumcision, in future discussions of anesthesia, some suggest that even a Jewish infant is meant to experience pain.
 
Interestingly, as Dr. Reichman and Dr. Rosner note (Reichman and Rosner, fn. 36), this initial halakhic discussion is not widely cited in later rabbinic literature.
 
Brit Mila under Anesthesia: 20th–21st Century
 
We can identify three approaches towards the use of anesthesia during the performance of the circumcision among 20th-century Poskim. We will focus on the circumcision of Jewish adults and children, and later we will address the unique considerations regarding the circumcision of converts.
 
  1. R. Meir Arik (1855–1926), one of the leading Poskim of Galicia, and Chief Rabbi of Tarnów, was asked regarding applying topical anesthetic to a young man converting to Judaism. In his Imrei Yosher (2:140), R. Arik raises two concerns regarding the use of anesthetics during circumcision. First, he notes that despite being aware of the use and availability of anesthetics (Bava Kama 85b; see also Bava Metzia 83b), Chazal clearly chose not to use anesthetic during a brit mila. Second, he suggests that pain may be an integral part of brit mila, as reflected by the following midrash (Bereishit Rabbah 47:9): “‘Avraham was circumcised (nimol)’ — Rabbi Abba bar Kahana says: He suffered pain so that God would double his reward." Therefore, he prohibits the use of topical and general anesthetics during a brit mila.
 
Regarding his first objection, some question whether R. Arik’s assumption, i.e., that the use of medicinal anesthetics was known and used, is a proof that it should not be used during a brit mila (Avnei Zikaron 3:3). Others suggest that even if pain relief is withheld from a child during the performance of his first mitzva, there would be no reason to refrain from using anesthesia during an adult’s circumcision, as he has already performed many mitzvot, and at times withholding anesthesia may discourage the person from submitting to a circumcision at all (see Eretz Ha-tzevi 56).
 
Regarding the second objection, i.e., his assertion that the sensation of pain is an integral part of the brit mila, the Olelot Efrayim (cited in R. Eliezer Guttmacher’s comments to Shabbat 130) adds that a person should have his own troubles in mind while hearing a child crying during his circumcision, as “the child’s voice ascends without any impediment and his prayers are included [with the child’s cry].” R. Eliezer Weinberg (Tzitz Eliezer ibid.) explains that “this is a proof regarding the great significance of the child’s cry from the pain of circumcision, that it rises to the heavens, unimpeded, and its strength is able to help others who are standing near him, that their prayers should be accepted, and they should be redeemed from their troubles.” He attributes this idea to “Kabbalistic sources.”
 
Based upon these sources, some Acharonim (Tzitz Eliezer 20:73, Shevet Ha-Levi 5:146) agree with R. Arik and insist that unless there is a fear of significant pain, e.g., the circumcision of an adult, anesthetics of any kind should not be used.
 
R. Yaakov Yechiel Weinberg (Seridei Esh 3:96), and others reject this idea. Furthermore, Dr. Abraham S. Abraham, in his Nishmat Avraham (Vol. 2, pp. 309-310) writes that R. Yaakov Hillel, a well-known expert of Kabbala and head of the Yeshivat Ha-mekubalim (Ahavat Shalom), insists that there is no written Kabbalistic source for this notion. Furthermore, he notes that while the Zohar says the pain of a woman in childbirth “atones” for the sin of Chava, it is common practice to minimize the pain of childbirth as much as possible.
 
 
  1. R. Yaakov Yechiel Weinberg, in his Seridei Esh (ibid.) rejects the reasoning of the Imrei Yosher, ruling that there is no fundamental objection to minimizing pain during a circumcision. R. Weinberg allows general anesthesia for a child, although he views it as a departure from normative practice, and writes that circumcising a child under general anesthesia looks more like chabbala (assault) than welcoming the child into the covenant of Avraham. He does, however, permit the use of local anesthetics for children and adults.
 
R. Weinberg, however, offers another reason to prohibit circumcising an adult Jewish male while under general anesthesia. He argues that since a person must preferably have intention in order to fulfill a mitzva (mitzvot tzerikhot kavana), especially when fulfilling a biblical mitzva (see Magen Avraham 60:3), a person under general anesthesia does not have “intention,” and therefore general anesthesia should not be used.
 
Whether or not the mitzva of brit mila requires intention is discussed in depth by later authorities. Some suggest that this may depend on whether the mitzva of mila, as we have previously discussed, is the ma’aseh (act) or totza’a (result). If the focus of brit mila is the result, i.e., that the child should be nimol (circumcised), then there appears to be no requirement of intention (Zekher Yitzchak 5; see also Minchat Asher, Sefer Devarim, pg. 325). In a previous shiur, we noted that R. Chaim Eliezer, known as the Maharach Or Zarua (11), writes that the mitzva of brit mila is to ensure that that the child is no longer an arel, i.e., that merely being circumcised is itself a mitzva. He cites a passage from the Talmud (Menachot 43b) as a proof. The Gemara relates:
 
When King David entered the bathhouse and saw himself naked, he exclaimed: “Woe is me! I am no longer clothed with Your mitzvot.” When, however, he remembered that he was circumcised, he regained his calm.
 
The Maharach Or Zarua proves from this passage that one fulfills the mitzva of brit mila merely by being circumcised, and not through the act of circumcising. We have discussed this in previous shiurim. It is interesting to note that the Seridei Esh himself cites the Beit Ha-Levi, who suggests that there are two aspects of the mitzva, the act and the result. R. Ovadya Yosef (Yabia Omer YD 5:22) adds that the intention (kavana) when appointing an agent to perform a brit mila is sufficient.
 
In addition, some relate this issue to a larger question regarding whether one who circumcises an adult Jewish male functions as his “agent.” The Maharsham (6:85) argues that just as agency (shelichut) doesn’t expire when one sleeps (see Gittin 70b), so too a person’s intention before being anesthetized is sufficient.
 
  1. The Maharsham (ibid.), R. Ovadya Yosef (ibid.), and other Poskim permit full general anesthesia during circumcision. As demonstrated above, they reject the notion that ritual circumcision must include pain, and they are not concerned about intention, as others suggest.
 
Some Acharonim (see Shevet Ha-Levi 5:147) note that general anesthesia entails risk, although minimal, and therefore it should be avoided unless the procedure is complicated, or the person being circumcised is elderly or weak.
 
The Use of General Anesthesia for a Convert
 
Much of the halakhic literature regarding circumcision under general anesthesia relates to adult converts. Some Poskim note that the halakhic considerations concerning an adult convert may differ from those for an adult Jewish male.
 
For example, R. Yaakov Yechiel Weinberg, in his Seridei Esh (ibid.), emphatically prohibits circumcising an anesthetized adult male in the process of converting. He argues that since the person is meant to enter into the covenant and the sanctity of Israel (kedushat Yisrael) through the act of mila, it is inconceivable he can do so while unconscious. He cites the Chatam Sofer (YD 300) who proves that the mila of a convert, unlike the mila of a person born Jewish, requires that it be done with specific intention (lishma).
 
This question of whether a convert must be conscious during the brit mila, may depend upon whether brit mila is an integral part of the conversion process, in which case the convert might need to be awake, or only a preparatory phase (hekhsher), in which case he may be fully anesthetized.
 
R. Moshe Sternbuch (Teshuvot Ve-hanhagot 3:308) suggests that this debate may be dependent upon another disagreement regarding whether brit mila must be performed in the presence of a beit din. If the brit mila must be performed in front of a beit din, this may indicate that the brit mila is part of ikkar geirut, the essence of conversion, and subsequently we may also conclude that the convert must have the proper intention during the circumcision. Alternatively, if the mila is merely a hekhsher, and not an inherent part of the conversion process, we would not require any specific intention.
 
R. Soloveitchik (Kol Dodi Dofek, pg. 98, fn. 21) further explains this in a slightly different manner. He suggests that that the Rishonim disagree as to whether the foreskin, and all that it symbolizes, prevents the chalot of the giyur, or whether the circumcision is itself viewed as one of the two essential steps of conversion. He suggests that this may depend upon on another debate regarding a case in which a person is immersed in the mikve (tevila) before being circumcised. While the Ramban (Yevamot 47b, s.v. Nitrapa) rules that the conversion is valid, the Re’a (cited by the Nimukei Yosef, Yevamot 16a) disqualifies the conversion. The Nimukei Yosef (ibid.) explains that according to the Re’a, one who immerses before being circumcised is similar to one who is tovel ve-sheretz be-yado (immerses while holding a rodent in his hand). The Ramban, however, understands the mila and tevila as two separate stages of the conversion process, and their order, after the act, is irrelevant.
 
Most Rishonim rule in accordance with the Re’a, who does not view the mila as an inherent part of the conversion, but rather as allowing the tevila to complete the giyur (Rema YD 268:1 cites both views). Furthermore, regarding whether the mila must be performed in the presence of a beit din, the Shulchan Arukh (ibid. 3) cites two opinions.
 
R. Sternbuch concludes that since the mila should preferably (le-khatechilla) be performed in the presence of a beit din, it therefore follows that the mila should be performed without general anesthesia. However, since, in his view, be-diavad (after the fact), if the brit mila was not performed in front of the beit din, the conversion is valid, then be-diavad an adult male may undergo a circumcision while anesthetized, as the brit mila is not perceived as an integral part of the conversion process requiring intention lishma. R. Sternbuch concludes, however, that a child may be fully anesthetized, as he does not have any da’at (halakhic competence) in any case.
 
Topical Anesthetics
 
Newborns clearly experience pain during the circumcision. This is evident from their crying, as well as their elevated blood pressure and heart rate. There are currently three methods of local anesthetic drugs used during neonatal (infant) circumcision: a dorsal penile nerve block, a subcutaneous ring block, and the topical application of EMLA (eutectic mixture of local anesthetics) cream.
 
Regarding the local injected anesthetics, administered to the base (penile nerve block) or shaft (ring bloc) of the penis, some studies indicate that the ring block may be the most effective anesthetic and carries the least risk. However, the injection itself causes significant pain, and it is accompanied by a slight risk of blood clots or absorption of the anesthetic to the bloodstream. Many eyewitnesses testify to the intense pain felt during the injection, greater than the pain caused by the circumcision itself. In addition, only a doctor can give a penile injection.
 
Application of an EMLA cream is largely effective, and it lasts for a number of hours. It is also not absorbed into the blood. In order to be fully effective, the cream must be applied an hour before the procedure. In addition, the area must be wiped clean before the circumcision. Some mohalim report that as the application of topical anesthetics causes vasodilation, at times this causes additional bleeding. 
 
In addition to the anesthetic methods mentioned above, some mohalim advise the parents to administer Tylenol an hour before the circumcision, reducing the infant’s discomfort. It is also common to give the child concentrated sugar water during the circumcision, a known neonatal analgesic, which is commonly given in emergency rooms across America to ameliorate pain in infants.
 
In recent years, hospital circumcisions have often been performed with a nerve block injection and a clamp or plastibell. Although the child is pacified during the circumcision itself, the shot itself is accompanied by severe pain. It should be noted that a ritual circumcision is much quicker; it takes 15-20 seconds, and it is therefore less painful than surgical circumcision.
 
From a halakhic perspective, as we saw above, two objections are raised to local and topical anesthetics: the requirement for pain, and the concern for the safety of the child. R. Eliezer Waldenberg (Tzitz Eliezer 20:73), and R. Wosner (Shevet Ha-Levi 5:147) generally discourage the use of local anesthetics due to the reasoning of the Imrei Yosher. Dr. Abraham S. Abraham, in his Nishmat Avraham (5:83-84), not only disproves the basis for the requirement to feel pain during the circumcision (see above), he also cites R. Shlomo Zalman Auerbach and R. Yosef Shalom Elyashiv, who told him that if topical anesthetics were proven to be safe, it would be permitted, even obligatory, to use them in order to reduce the child’s pain.
 
Some suggest that since application of the EMLA cream before the circumcision does not completely eliminate pain, and its risk is negligible, “it is permitted and perhaps even desirable, to use it” (see Reichman and Rosner, pg. 18). R. Bleich (pg. 60), on the other hand, appears to side with the traditional performance of a brit mila, without anesthesia, even though the halakhic arguments against their use “cannot be described as compelling.”
 
It is important to note that for those parents especially concerned about the pain caused to the child, the use of an EMLA cream is extremely effective not only in reducing the pain of the circumcision, but in assuaging the parents’ fears.
 
Summary
 
In practice, there are different customs regarding infant circumcision. There are three methods of pain alleviation available to the mohel: EMLA cream, Tylenol and concentrated sugar water. Most mohalim use one, two or all three of these methods.
 
Adult circumcisions are usually performed with an injected local anesthetic. In certain circumstances, the circumcision is performed under general anesthesia. The circumcisions of children who are no longer infants, out of concern that they will be scared and will not remain still during the procedure, are often done under general anesthesia.
 

[1] This shiur relies heavily upon the following articles: Edward Reichman and Fred Rosner, “The Use of Anesthesia in Circumcision: A Re-Evaluation of the Halakhic Sources,” Tradition 34:3 (2000): 6-26; and J. David Bleich, “Circumcision: The Current Controversy,” Tradition 33.4 (2000): 45-69. See also Uri Betzalel Fisher, “Brit Mila im Sam Hardama,” Emunat Itekha 115. I am also thankful to Dr. Daniel Kasovitz, a (dentist and) mohel, whose medical knowledge and circumcision experience has been an invaluable source for preparing this and other shiurim.