Delaying a Bris Mila for Jaundice – Science vs. Chaza”l


Lech lecha 5780


“This is My covenant that you shall preserve between Me and you and your descendants after you: Every male among you shall be circumcised. You shall circumcise the flesh of your foreskin, and that shall be the sign of the covenant between Me and you. At the age of eight days every male among you shall be circumcised, throughout your generations.” (Bereishis 17:10-12)

It is not uncommon for a Bris to be delayed because the baby has developed jaundice. The Mishna in Shabbos (137a) rules that if a baby is sick, he should not be circumcised until he recovers, and Shmuel added that in the case of “Chaltzaso Chama” (fever) one must wait a full seven days following his recovery before performing the Bris.

The Gemara in Yevamos (71b) explains that the requirement to wait an additional seven days following recovery only applies to illnesses that affect the whole body (“Choli Kol haGuf”), such as fever. Regarding an illness or pain that affects only one of the body’s limbs[1], while one may certainly not perform the Bris until the baby has recovered, there is no need to wait an extra seven days. This is the ruling of the Shulchan Aruch (Y.D. 262:2), but the Mahari”k (Shoresh 146) asserts that the Choli Kol haGuf to which the Gemara refers is only one that may place the baby in danger.

Rav Ben Tzion Abba Shaul zt”l (Binyan Tzion 87) notes that many do not adhere to this Halacha and perform a Bris on the eighth day even when the baby had previously been ill. He does, however, urge people to conform to this Halacha.

The Status of Physiologic Jaundice

The Gemara in Shabbos (134a) offers several examples of illnesses that would warrant postponing the Bris. One of these is that the child is “Yarok”:

Abaye said: “My mother said to me, ‘[if] a child has a red complexion, [it is because] its blood has not yet been absorbed. They should wait until its blood is absorbed and then circumcise it. [If a child has a] “Yarok” complexion, [it is because] its blood has not yet come through. They should wait until its blood comes through and then circumcise it”. As we learned in a Beraisa: R’ Nasan said: Once I traveled to the cities by the sea, and a woman who had circumcised her first son and he had died, [and she had circumcised] her second son and he had died, came to me with her third son. I saw that he had a red complexion. I said to her, “Wait until his blood has been absorbed”. She waited until his blood had been absorbed and circumcised him and he survived. They would call him Nasan the Babylonian after me. On another occasion I went to Kaputkaya, and a woman who had circumcised her first son and he had died, [and she had circumcised] her second son and he had died, came to me with her third son. I saw that he had a “Yarok” complexion. I applied pressure and saw that he had no blood in the area in which he would be circumcised. I said to her, “Wait until his blood comes through”. She waited until his blood had come through and circumcised him and he survived. They would call him Nasan the Babylonian after me.

The Poskim maintain that “Yarok” (usually translated as “green”) also includes yellow, as is the often the case in the words of Chaza”l.

Both the Rambam and Shulchan Aruch rule that one may not perform a Bris on a child that is Yarok. However, there is a subtle difference in their rendition of this Halacha:

One may not circumcise a child that has a very “Yarok” complexion on the eighth day of his life until his blood comes through and his complexion reverts to resembling healthy children. Similarly, if he had a very red complexion, appearing as though somebody had painted him, one may not circumcise him until his blood has been absorbed and his appearance reverts to resembling other children. For this is an illness, and one must be extremely cautious about these matters. One may only circumcise a child that has no illness at all as danger to life overrides all other matters. It will be possible to perform circumcision at a later date, but it will never be possible to bring a person back to life (Rambam Hilchos Mila 1:17-18).

 

The complexion of healthy babies usually tends slightly towards red or yellow. Therefore, the Rambam rules that in order to postpone a Bris on account of a child that has a “Yarok” or red complexion, it must be extreme – “very Yarok” or “very red … appearing as though somebody had painted him”.

However, the Shulchan Aruch (Y.D. 263:1) whose wording is based on that of the Rambam, omits the word “very”, writing merely that a child that has a “Yarok complexion” should not be circumcised. If so, we need to determine the level of jaundice at which the Shulchan Aruch would require postponing the Bris. It is highly unlikely that the Halacha would forbid the timely circumcision of babies who exhibit small levels of jaundice in the first few days of their lives as nearly all babies do! In fact, the Chochmas Adam (149:4) reinserts the word “very” into this Halacha, and questions why the Shulchan Aruch omitted it.

The Poskim rule that the Bris should be postponed if a baby has a bilirubin level greater than or equal to 12 mg/dL, despite the fact that, according to medical opinion, a baby in this state is not ill at all and would not be endangered by circumcision. One reason for this may be that once Chaza”l forbade performing a Bris in a baby that is “Yarok” (they may not have been aware of the distinction between physiologic jaundice and pathologic hyperbilirubinemia), it cannot be permitted even if doctors maintain that it isn’t dangerous.

Another alternative is that since doctors would also agree that a high level of bilirubin (such as 25 mg/dL) can, on rare occasions, endanger babies (particularly if they are premature), we must therefore treat any elevated bilirubin level, even physiologic, as an illness as Chaza”l asserted (even in cases where the levels are low, and doctors maintain that the child is not ill at all).

Either way, if Chaza”l determined that jaundice is an illness on account of which one must postpone a Bris, it should be considered a “Choli Kol haGuf“. If so, the Halacha should be to wait a further seven days following the child’s recovery. Why then is it the custom to perform a Bris as soon as the bilirubin levels decrease?

The Approach of the Aruch haShulchan

The Aruch haShulchan (Y.D. 263:2-3) discusses this question. He maintains that there is certainly no need to wait an additional seven days after a baby’s recovery from jaundice as “it isn’t an illness at all” and is part of the regular physiological development of babies (almost all of whom have a complexion that tends towards yellow). He proves this from the fact that the Poskim do not mention that one is required to wait an extra seven days following jaundice and neither does the Gemara. If we were to rule that one must wait seven days (as some Poskim did), the majority of babies would not have their Bris on the eighth day!

 

It appears that according to the Aruch haShulchan, physiologic jaundice is not an illness but a symptom of a phenomenon that can cause harm to a newborn if it reaches a certain level. Therefore, unlike a regular illness following which one must wait seven days (to allow the infant to completely heal), in this case there is only a question of harm or damage when the baby is jaundiced. Therefore, as soon as the jaundice resolves, the Bris may be performed immediately.

The approach of the Aruch haShulchan has been corroborated in recent years by medical studies.

The Approach of Rav Shlomo Zalman Auerbach zt”l

Rav Yoel Katan relates that the Mohel R’ Chaim Moshe Weisberg told him that, to the best of his knowledge, Rav Shlomo Zalman ruled that if a baby’s bilirubin level is less than 12 mg/dL one may perform the Bris (if the level is coming down). If the bilirubin reaches 18 mg/dL, one should wait an additional seven days following the resolution of the jaundice.

However, the Yerushalmi Mohel, Rav Shlomo Shochet, testified that he heard Rav Shlomo Zalman say that even if the baby has a level of 19 mg/dL of bilirubin there is no need to wait an extra seven days as it is not considered a “Choli Kol haGuf”. He also added that Rav Shlomo Zalman told him that the level of jaundice on account of which one must postpone a Bris depends on the appearance of the child. While we are accustomed to delaying a Bris on account of a bilirubin level of 12 mg/dL, if the child does not appear particularly yellow, one may perform the Bris even if his bilirubin level is as high as 13 mg/dL.

Professor Avraham Steinberg records that Rav Shlomo Zalman ruled that if doctors agree that physiologic jaundice is not an illness, then even if the child had very high bilirubin, there is no need to wait for seven days following the resolution of the jaundice.

Ostensibly, Rav Shlomo Zalman’s approach was that where jaundice is concerned, Chaza”l obligated us to be stringent (and not perform a Bris). This ruling removes the question from the domain of medical opinion and makes it a halachic matter.  However, once the level of jaundice has dropped, one need not consider it to be an illness at all and it is up to the doctors to decide. If they do not consider it an illness, there is no need to wait for an additional seven days.

Additional Examples where Chazal and Medical Opinion Differ Regarding Bris Mila

There are many cases in which Chaza”l take a different stance than the medical community regarding specific illnesses and each warrants its own discussion.  In this essay, we will briefly discuss a famous case in Hilchos Shabbos that is also relevant to Bris Mila.

The Shulchan Aruch (O.C. 328:3) rules:

One desecrates Shabbos on account of any “Makah Shel Chalal” (internal injury or disease), in other words, from the teeth and inwards, including the teeth themselves. However, it is only when one of the internal organs has been damaged by an injury or boil. Symptoms that are merely bothersome are not considered an injury or disease.

 

The Mishna Berura (ibid. 7-8) adds:

And certainly if the disease is in the gums that is considered to be an internal disease…when it causes considerable pain and his entire body feels ill because of it, even though he hasn’t had to lie down in bed, excluding a merely bothersome feeling in his teeth…And certainly, the disease called Tzafdina (see below) that begins in the mouth and spreads to the stomach – its symptoms are that when the person puts anything in his mouth, blood appears between his teeth – we would desecrate Shabbos on its account. But there is a difference between them: Regarding Tzafdina, even if the patient and the doctor opine that one needn’t desecrate Shabbos, we maintain that they are not knowledgeable about this disease as Chaza”l (Avodah Zarah 28a) state that Tzafdina is dangerous. However, regarding other tooth pains (that are considered internal diseases), while we do desecrate Shabbos on their account, if the doctor or patient maintains that one needn’t desecrate Shabbos for him, we do not desecrate it.

What is Tzafdina? The Gemara in Avodah Zarah (28a) states that a person contracts Tzafdina if he eats wheat-based foods during the winter that are overly cold, barley-based foods that are overly hot, or dishes made from small fish that have been fried in their fat and flour and left out overnight. This disease is no longer known although some suggest that it refers to a disease caused by a lack of vitamin C.

The Mishna Berura cites the Pri Megadim who rules that while this disease is no longer extant, and its symptoms, namely an infection of the gums, would certainly not be considered by anybody to be a danger to life, nevertheless one does desecrate Shabbos on its account as Chaza”l stated that it is a dangerous disease.

            The Poskim discuss a number of illnesses and diseases that Chaza”l  determined to be dangerous, but which are no longer considered to be as such. In such instances, would one follow a doctor’s instructions and not consider them life-threatening?

            Metzitza (the sucking of the blood from the area of the circumcision) is performed for the purposes of Refua (see Shabbos 133b and Shulchan Aruch Y.D. 264:3). According to Chaza”l, it is dangerous if it is not performed. For this reason, a Mohel must perform Metzitza even at a Bris that takes place on Shabbos.

            Current medical opinion is that a baby is in no danger if the Mohel does not perform Metzitza. However, the Tiferes Yisrael (Shabbos 19, Boaz 1) maintains that it should still be carried out, even on Shabbos. Though there are cases where we consider the natural world to have changed since the times of Chaza”l (see Mishna Berura 173:3 and Shu”t Chasam Sofer Y.D. 101) and we often take into account the opinions of doctors (even in cases that would involve Kareis or capital punishment) and they are more knowledgeable in the field, we must nevertheless not veer from the words of Chaza”l.

            The Tiferes Yisrael questions this conclusion, for we find that it is no longer permitted to heat up water on Shabbos to wash a child before and after his Bris and on the third day following the Bris. Though during the times of the Gemara washing the baby was considered to be a matter of Pikuach Nefesh (and they would desecrate Shabbos to heat up water for this purpose), we no longer do so (see Shulchan Aruch 331:9) as doctors maintain that it is not a matter of Pikuach Nefesh and we therefore assume that nature has changed (as explained by the Mishna Berura ibid. 31) and it is no longer necessary. If so, why do we not make the same argument for Metzitza?

            He answers that there is a difference between the need to wash a child before and after its Bris and the need to perform Metzitza. With regard to washing, since it is clear that nature has changed and it is no longer necessary, the Halacha changes accordingly. However, in the case of Metzitza, doctors agree that it is beneficial as it prevents swelling of the penis. Therefore, the Halacha remains in place.

            According to the Tiferes Yisrael, it seems that in a case where doctors maintain that something is not a matter of Pikuach Nefesh, one would not be permitted to desecrate Shabbos.

            Would the Tiferes Yisrael dispute the ruling of the Pri Megadim regarding Tzafdina? Some argue that the ruling of the Pri Megadim (that one should desecrate Shabbos for Tzafdina) only applies when a minority of doctors maintain that the patient is not in danger. However, if the established medical position is that it poses no danger, one would not be permitted to desecrate Shabbos. See also Shemiras haGuf v’ha’Nefesh 1, Introduction 6 where Rav Elyashiv zt”l is cited as making a similar argument.

            In light of the above, in cases where there may be no discrepancy between the words of Chaza”l and the doctors, as nature may have changed, one would certainly relate to the illness according to current medical opinion and the Halacha would follow accordingly.

The Novel Ruling of the Mahara”m Shik

 

            The Mahara”m Shik (Y.D. 244) takes a different approach. He maintains that since during the times of Chaza”l refraining from Metzitza would endanger the baby, it remains a matter of Pikuach Nefesh until it is clear that the Halacha has changed.  Since medical science reaches its conclusions from studies that determine the condition of the majority of patients, it cannot be relied upon in cases of Pikuach Nefesh where do not follow the majority.

This ruling is extremely significant. Although Mahara”m Shik concedes that we would most certainly base our conclusions on the medical opinion when Chaza”l do not express an opinion regarding a particular illness, where they do have a position we would follow it. Therefore, if Chaza”l consider an illness or disease to be a matter of Pikuach Nefesh, we would ignore the dissenting opinion of medical science.

            Returning to the question of performing a Bris Mila on a baby with jaundice, it seems unlikely that the natural world has changed such that jaundice was previously a matter of Pikuach Nefesh but is no longer a danger. Rather, Chaza”l considered physiologic jaundice as a disease, regardless of its severity. Therefore, we may not veer from their position, and must postpone a Bris Mila for a baby with jaundice. However, as explained above, there are grounds to be lenient regarding waiting seven extra days following the resolution of the jaundice, relying on the position of doctors that jaundice is not a disease at all.

[1] The Gemara’s example is “pain in the eyes”


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