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The Halachic View On Anesthesia

Poskim have debated for more than a century the Halachic viability of general and local anesthesia for Brit Milah. Recently, Poskim have actively debated the use of a topical anesthetic at a Brit.

 

We will begin by reviewing the classic debate regarding the three main Halachic issues in using of anesthesia at a Brit Milah: [More here]

 

  1. Is experiencing pain an integral component of the Milah process

  2. Mitzvot Tzrichot Kavannah; The Kavannah of the Mohel who is the Shliach (agent) suffices for the one being circumcised, since the Meshaleiach (principle) sleeps.

  3. Departure from accepted practice

 

Three distinct approaches to this problem appear in Halachic literature.

 

  • Rav Yechiel Yaakov Weinberg (Teshuvot Seridei Eish 3:96) rejects the idea that experiencing pain is an integral component of the Milah process. On the other hand, he notes that many Rishonim rule in accordance with the opinion that Mitzvot Tzrichot Kavannah. Rav Weinberg argues that one cannot be placed under general anesthesia for Milah, since an anesthetized patient is unable to have Kavannah to fulfill the Mitzva of Milah. This argument is especially important in light of the Magen Avraham's (60:3) ruling that Kavanna for a Torah obligation is indispensable. Rav Weinberg is even more emphatic regarding the Milah of an adult convert. Rav Weinberg writes "behold it is by the Brit that he enters into Kedushat Yisrael and if he is sleeping during the Milah, who ushers him into Kedushat Yisrael?"

 

  • Rav Moshe Feinstein permits only a local anesthetic for an adult convert but forbids a general anesthetic for an adult convert. 

 

  • Rav Weinberg's argument applies only to the circumcision of an adult. Rav Weinberg does not object to the use of full anesthesia on a baby, but he does not endorse it either, since its use constitutes a departure from accepted practice. On the other hand, he permits using a local anesthetic even for an adult. He explains, "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 full anesthesia even for an adult. Rav Ovadia cites the celebrated responsum of the Maharach Ohr Zarua (number 11) who asserts that the fundamental Mitzva of Milah is the state of being circumcised. Accordingly, he argues, it is irrelevant that one lacks Kavannah while he is anesthetized. One fulfills the Mitzva simply by being circumcised. 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 emphasizes (based on Gittin 70b) that agency does not expire when the Meshaleiach (principle) sleeps. The Maharsham equates an anesthetized patient with a sleeping individual. Rav Weinberg, on the other hand, believes "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 relating that the Beit Din of Jerusalem authorized the performance of a Brit on an adult convert to whom general anesthesia was administered. 

 

  • At the other extreme, Rav Meir Arik, who lived in Tarnow, Galicia, (Teshuvot Imrei Yosher 2:40) forbids even a local anesthetic. He argues that the experience of pain is an integral component of the Mitzva of Brit Milah. He notes that Bava Kama 85a demonstrates that anesthetics were available to Chazal. He points out that despite the availability of anesthetics, Chazal chose not to use anesthetics at a Brit. He infers that Chazal oppose using anesthetics at a Brit because pain is an essential component of a Brit. The Imrei Yosher argues that this idea is reflected by the following Midrash (Breishit Rabbah 47:9, commenting on Breishit 17:26) that states "Rav Abba said, 'He suffered pain so that Hashem will double his reward." Rav Weinberg, though, counters that this Midrash merely demonstrates that Avraham Avinu desired the reward for the pain he had to endure for Brit Milah. It does not prove that there is an obligation to inflict pain on baby boys who do not intend to be rewarded for their pain. 

 

  • Rav J. David Bleich (Tradition Summer 1999 - volume 33 number 4 - pp.56-60), in turn, explains the argument of the Imrei Yosher. Rav Bleich notes that if one experienced pain in the process of a performing a Mitzva, such as obtaining an Etrog that was ensconced in thorns, he would not receive any additional reward for the pain he endured in order to obtain the Etrogs. Why then does the Midrash state that Avraham received reward for the pain he endured during Brit Milah? Rav Meir Arak's answer is that experiencing pain is not an aspect of the Mitzva of taking an Etrog, but it does constitute an aspect of the Mitzva of Brit Milah. 

 

The Current Dispute - Topical Anesthetic

 

Topical anesthetics such as EMLA, that may or may not reduce the pain that babies experience during a Brit. There has been a mixed reaction by Poskim regarding its use at a Brit.

 

  • Rav Eliezer Waldenberg (Teshuvot Tzitz Eliezer 20:73) forbids its use based on the Imrei Yosher.

  • Rav Wosner of Bnei Brak (Teshuvot Shevet Halevi 5:147:2) also forbids the use of a local anesthetic on a baby except in case of great need.

 

Rav Wosner believes that absent great need one should not tamper with the traditional character of Brit Milah, which includes experiencing pain. He cites the Gemara (Gittin 57b) that explains the Pasuk (Tehillim 44:23) "For Your sake we are killed all of the day", to be referring to Brit Milah, as proof for his assertion. 

 

On the other hand, Dr. Abraham S. Abraham (Nishmat Avraham 5:83-84) reports: 

 

  • Rav Yaakov Hillel, a Rosh Yeshiva of a prestigious Yeshiva for Kabala studies, investigated the matter and found no source in the Zohar and other Kabalistic works that teach there is any special value attached to the suffering of a baby during his Brit. In fact, the Rosh Yeshiva remarked that despite the fact that the Zohar teaches that birth pains atone for Chava's sin, we make all efforts to reduce the pain a woman experiences during birth, and no rabbinic authority objects.

  • Rav Shlomo Zalman Auerbach and Rav Yosef Shalom Eliashiv told him that if there is no medical problem associated with the use of a topical anesthesia, then there is an obligation to use it at a Brit to reduce the suffering of the baby. 

 

Conclusion

 

An injection of a local anesthetic is administered at almost all circumcisions of adults. General anesthetic is used for an adult born Jew only in case of great need. Poskim do not permit general anesthesia for an adult convert in virtually all cases. 

 

Some Mohelim have begun to use topical anesthetics at a Brit of a baby. However, many Mohelim decline to use them due to reports of medical complications caused by these anesthetics in adition to the Halachic problem. Mohalim report of incidents where the anesthetic cream caused the foreskin to become inflamed, it is highly imprudent to perform a Brit on an inflamed foreskin. Anesthetic cream sometimes causes high blood pressure and increased blee-ding at a Brit.  [More here]

 

Interestingly, Rav Moshe Feinstein (Teshuvot Igrot Moshe Y.D. 4:40) writes that we do not use anesthetics at a Brit because of the danger associated with anesthetics. His concern might apply to the topical anesthetic creams.