Poskim, renowned religious scholars, have engaged in a prolonged and intricate debate spanning over a century regarding the Halachic (Jewish legal) permissibility of employing general and local anesthesia during Brit Milah, the ritual circumcision. "The Halachic Debates: Anesthesia in Brit Milah". This contentious topic has recently seen an upsurge in discussion concerning the usage of topical anesthetics during the Brit Milah procedure.
Now, let us delve into the intricate and multifaceted debate surrounding three primary Halachic issues regarding the utilization of anesthesia in Brit Milah:
Firstly, whether experiencing pain is an inherent and integral component of the Milah process.
Secondly, the concept of Mitzvot Tzrichot Kavannah, which posits that the intention and devotion of the Mohel, acting as an agent, suffices for the individual undergoing circumcision.
Lastly, the divergence from established customs and practices associated with Brit Milah.
Halachic literature presents three distinct perspectives on this matter.
Rav Yechiel Yaakov Weinberg (Teshuvot Seridei Eish 3:96) dismisses the notion that experiencing pain is an intrinsic part of the Milah process. However, he acknowledges that many Rishonim (medieval authorities) concur with the principle of Mitzvot Tzrichot Kavannah. Rav Weinberg argues against the use of general anesthesia during Milah, contending that an anesthetized individual cannot possess the requisite intention (Kavannah) to fulfill the Mitzvah of Milah. This argument gains particular significance when considering the Magen Avraham's ruling that Kavannah is indispensable for Torah obligations. Notably, Rav Weinberg emphasizes this viewpoint in relation to the circumcision of an adult convert, stating that during the Milah, the convert enters the realm of Kedushat Yisrael (the sanctity of the Jewish people). If the convert is asleep during the procedure, who then guides them into this realm of sanctity?
In contrast, Rav Moshe Feinstein permits the usage of local anesthesia for an adult convert but prohibits the application of general anesthesia.
It is essential to note that Rav Weinberg's argument solely pertains to the circumcision of adults. He does not object to the administration of full anesthesia to infants, yet he refrains from endorsing it due to its deviation from established practices. Conversely, he permits the use of a local anesthetic even for adults, stating, "We have not found anywhere that there is a Mitzva to circumcise in a manner that inflicts pain."
On the other hand, the Maharsham (Teshuvot Maharshom 6:85) and Rav Ovadia Yosef (Teshuvot Yabia Omer 5:Y.D. 22) permit the use of full anesthesia, including for adult converts. Rav Ovadia cites the celebrated responsum of the Maharach Ohr Zarua, which asserts that the fundamental Mitzvah of Milah lies in the state of being circumcised itself. Consequently, he argues that the lack of intention while under anesthesia becomes irrelevant. The fulfillment of the Mitzvah occurs simply through the act of circumcision. Rav Ovadia adds, "The Kavannah of the Mohel suffices for the one being circumcised, especially since the Mohel is the latter's Shliach (agent)." The Maharsham highlights the analogy between an anesthetized patient and a sleeping individual, drawing upon the principle that agency does not expire when the principal sleeps. Rav Weinberg, however, believes that "an anesthetized person is the Halachic equivalent of a rock, and one does not fulfill the Mitzva on a rock."
Rav Ovadia Yosef concludes his Teshuva by recounting that the Beit Din (rabbinical court) of Jerusalem authorized the performance of a Brit on an adult convert who received general anesthesia.
On the opposite end of the spectrum, Rav Meir Arik, a scholar residing in Tarnow, Galicia (Teshuvot Imrei Yosher 2:40), forbids even the use of a local anesthetic. He argues that experiencing pain is an inherent and indispensable component of the Mitzvah of Brit Milah. Citing a passage from Bava Kama 85a, which showcases the availability of anesthetics during the time of the sages (Chazal), Rav Arik contends that their deliberate choice not to employ anesthetics during Brit Milah signifies their opposition to mitigating pain in this context. He draws support for his argument from a Midrash (Breishit Rabbah 47:9), commenting on Genesis 17:26, which states, "Rav Abba said, 'He suffered pain so that Hashem will double his reward.'" Rav Weinberg counters this interpretation, asserting that the Midrash merely highlights Avraham Avinu's desire for reward for the pain he endured during Brit Milah. It does not establish an obligation to inflict pain on infant boys who do not possess the intention to be rewarded for their suffering.
In response to Rav Arik's argument, Rav J. David Bleich (Tradition Summer 1999 - volume 33 number 4 - pp.56-60) offers an explanation. Rav Bleich posits that if pain is experienced in the course of performing a Mitzvah, such as retrieving an Etrog (citron) that is surrounded by thorns, one does not receive additional reward for enduring that pain. He questions why the Midrash specifically attributes reward to Avraham for the pain endured during Brit Milah. Rav Arik's response is that experiencing pain is not an essential aspect of the Mitzvah of obtaining an Etrog, but it does constitute an aspect of the Mitzvah of Brit Milah.
Moving on to the current dispute regarding the usage of topical anesthetics, such as EMLA, to potentially alleviate the pain experienced by infants during Brit Milah, there is a mixed reaction among Poskim.
Rav Eliezer Waldenberg (Teshuvot Tzitz Eliezer 20:73) prohibits its use based on the viewpoint of the Imrei Yosher.
Rav Wosner of Bnei Brak (Teshuvot Shevet Halevi 5:147:2) also forbids the use of local anesthesia for babies, except in cases of significant necessity. Rav Wosner contends that unless there is a compelling need, one should not tamper with the traditional character of Brit Milah, which includes the experience of pain. He cites a passage from the Gemara (Gittin 57b) interpreting the verse (Psalms 44:23) "For Your sake we are killed all of the day," as referring to Brit Milah, providing support for his assertion.
Conversely, Dr. Abraham S. Abraham (Nishmat Avraham 5:83-84) reports:
Rav Yaakov Hillel, a Rosh Yeshiva of a distinguished Kabbalistic Yeshiva, conducted an investigation and found no sources in the Zohar or other Kabbalistic works that suggest any particular value attached to the suffering of an infant during Brit Milah. Furthermore, he remarks that despite the Zohar teaching that birth pains atone for Chava's sin, we make every effort to reduce the pain experienced by women during childbirth, and no rabbinic authority objects to that.
Rav Shlomo Zalman Auerbach and Rav Yosef Shalom Eliashiv both expressed to him that if the use of topical anesthesia poses no medical risks, it is indeed an obligation to employ it during Brit Milah to alleviate the suffering of the infant.
In conclusion, local anesthesia is commonly administered in almost all adult circumcisions, while general anesthesia is reserved for adult-born Jews only in cases of significant necessity. Poskim generally do not permit the use of general anesthesia for adult converts in most circumstances.
Some Mohelim have started using topical anesthetics during infant Brit Milah, but many others refrain from doing so due to reports of medical complications associated with these anesthetics, as well as the Halachic concerns. Mohelim have reported incidents where the anesthetic cream caused inflammation of the foreskin, making it highly imprudent to perform a Brit on an inflamed foreskin. Additionally, anesthetic cream has been known to cause high blood pressure and increased bleeding during Brit Milah.
Interestingly, Rav Moshe Feinstein (Teshuvot Igrot Moshe Y.D. 4:40) writes that anesthetics are not used during Brit Milah due to the associated risks. His concerns may extend to topical anesthetic creams as well.