Delaying the Brit Mila (Part 3) Hemophilia and Laser Circumcision

  • Rav David Brofsky
In previous shiurim, we discussed illnesses and congenital conditions that may justify delaying the brit mila. This week, we will briefly relate to the circumcision of a child born with a blood clotting disorder, such as hemophilia, and whether in such a case the circumcision may be performed by a laser.
A Child Whose Brother Died Due to Circumcision (Meitu Machamat Mila)
The Talmud (Yevamot 64b) discusses a tragic case in which two sons died following a brit mila:
If a woman had her first son circumcised and he died, and she had the second one circumcised and he died, she should not have the third son circumcised. These are the words of R. Yehuda Ha-Nasi. R. Shimon ben Gamliel, however, said: She may circumcise the third son, but must not circumcise the fourth son.
R. Yehuda Ha-Nasi and R. Shimon ben Gamliel appear to debate how to determine how a chazaka – i.e. a presumption that the final child will also die – is established. The Rif and Rosh (Yevamot 6:13) rule that regarding brit mila, a chazaka is established after the death of two children, as we are particularly concerned regarding matters of health.
The Rishonim disagree regarding whether this chazaka applies only to two children from the same mother, or even to two children from the same father and different mothers. The Shulchan Arukh (YD 263:2) rules in accordance with Rabbeinu Manoach, who prohibits performing a circumcision on the third brother from the same father. The Rema disagrees, although he concludes that since this matter relates to pikuach nefesh, one should be strict and not circumcise the third brother.
The gemara further teaches that this chazaka relates to sons of sisters as well:
It once happened with four sisters from Tzippori that the first had her son circumcised and he died, the second sister had her son circumcised and he died, the third sister had her son circumcised and he also died. The fourth sister came before R. Shimon ben Gamliel, and he told her: You must not circumcise your son. Perhaps if the third sister had come [to R. Shimon ben Gamliel], he would have ruled the same? If so, why did R. Chiya bar Abba recount the story? Perhaps R. Chiya bar Abba was teaching us that events occurring to sisters can create a chazaka.
These passages indicate that the rabbis were aware that this condition, passed from mother to son, is found among families.
The Rishonim debate whether a child who is not circumcised because his brothers died due to circumcision (meitu machamat mila) may eat the korban pesach, as the Torah prohibits an arel, one who is uncircumcised, from eating the korban pesach (Shemot 12:48). Rashi (Pesachim 60a) rules that in this case, the uncircumcised person may not eat the pesach. Tosafot (Chagiga 4b, s.v. diktiv) cites Rabbeinu Tam, who disagrees and rules that only a person who purposely avoids circumcision cannot eat the pesach.
Similarly, the Rishonim disagree as to whether a child who cannot be circumcised is considered to be an arel, and therefore may not eat teruma. The mishna (Yevamot 70a) teaches that an arel may not eat teruma. Rashi (s.v. he-arel; see also Meiri) explains that the mishna refers to a child whose brother died due to circumcision and who was therefore not circumcised. However, the Rashba (Yevamot 60a) cites Rabbeinu Tam, who disagrees and rules that since this child is uncircumcised due to health concerns, he is considered to be an ones, and he may therefore eat teruma. According to this view, the mishna refers to a person who purposely chose not to be circumcised.
Rashi and Rabbeinu Tam appear to disagree regrading whether the disqualification of arel from eating the korban pesach and teruma relates solely to the person's physical status (i.e., one who has a foreskin) or whether it reflects a religious orientation (i.e., one who has rejected the covenant and refused to be circumcised). 
What is the condition described by the Talmud? And is there a way to circumcise these children in a safe manner? A number of modern scholars assume that the Talmud refers to children who suffer from a blood-clotting disorder, such as hemophilia.
When a person cuts or injures himself, proteins and particles in the blood known as platelets stop the bleeding by forming a blood clot. This process is called coagulation. Some people inherit a condition known as hypercoagulation; their blood forms thick clots, which may cause some medical problems. Others suffer from an inherited disorder that impairs the body's ability to stop bleeding, such as hemophilia.
There are different types of hemophilia. Both Hemophilia A and B are X-linked recessive disorders, and therefore generally only affect men. (Men have one X and one Y chromosome, such that if the X chromosome carries the gene for hemophilia, there is no other X chromosome to counterbalance it.) Furthermore, the disorder is inherited from the mother, who transmits the X chromosome to her sons.
Although hemophilia was first described in the medical literature in 1803 by Dr. John Conrad Otto, it is widely acknowledged that the earliest mention of this disease, as well as its genetic pattern, appears in the Talmud, when it grapples with the phenomenon of children who died as a result of circumcision. In light of modern medical knowledge, the Acharonim have revisited this topic and discuss whether they may be an alternative to the traditional brit mila.
Dr. Abraham Abraham (Nishmat Avraham, YD vol. 2 262:3) states that these passages refer to children who died due to hemophilia. He therefore rules:
The blood in affected males cannot clot normally, and therefore bleeding will continue and can reach life-threatening proportions. Such a male can obviously not be circumcised until the defect is (albeit temporarily) treated. Diagnosis of the condition is fairly simple and the baby cannot be circumcised, even if his older brothers have been circumcised without any problem.
Similarly, Dr. Fred Rosner writes (Medicine and the Talmud, p. 48):
For practical purposes, in this day of hematological sophistication, where antihemophilic globulin (factor VIII) assays can establish the diagnosis of hemophilia at or shortly after birth, one is not permitted to circumcise any child so diagnosed even if he did not have older siblings who exsanguinated after this operation. A positive diagnosis established by the finding of low to absent antihemophilic globulin levels in the plasma of a newborn infant is equivalent by Jewish law to a history of two siblings having died after circumcision. A woman whose brothers bled to death after circumcision cannot have her child circumcised until the coagulation profile of her son is shown to be normal.
A child diagnosed with a clotting disorder may not be circumcised. As recently as January 2019, a child in South Africa was diagnosed with hemophilia only after being circumcised and needing immediate medical care.
In recent years, it has become possible to inject clotting agents into the child for enough time to perform a brit mila. Dr. Abraham records (ibid.):
The missing factor can be injected before and after the brit, and R. Auerbach zt”l told me that it would be permissible to circumcise such a baby. R. Neuwirth wrote to me asking why this is not considered a disease, such that, although treatment is available, the disease remains. R. Auerbach zt”l answered that as long as the baby does not bleed unnaturally, he is not considered ill.
Of course, this should only be performed under the strictest medical supervision.
Laser Circumcision
Some Acharonim discuss whether, in such cases, circumcision may be performed by a laser, which would minimize or even eliminate the concern of bleeding.
Although the commandment of brit mila does not mention the precise method of circumcision, it is customary to use a sharp instrument. Indeed, the Torah relates that Tzippora used a "stone" to circumcise her son (Shemot 4:25), and later, Yehoshua used "knives of stone" (charvot tzurim) to circumcise the Jewish males upon entering the land of Israel (Yehoshua 5:2-3).
Interestingly, the Rambam (Hilkhot Mila 2:1) writes: 
Any utensil may be used for circumcision, even a flint, glass, or any article that cuts. One should not circumcise with the sharpened side of a reed, because of the danger involved. The optimum manner of performing the mitzva is to use an iron utensil – either scissors or a knife. Throughout the Jewish community, it has become customary to use a knife.
The preference for a knife is mentioned by the Midrash (Midrash Ha-Gadol, Shemot 4:25). The Targum Yonatan (Yehoshua 5:2) also mentions "izmalavin charifin" (sharp knives).
May circumcision be performed by other means? R. Meir Arak (Imrei Yosher 2:14:3) questions whether circumcision might be performed by applying a caustic substance to "burn" the foreskin. Although he determines that there is no problem using a chemical in place of a knife, he insists that circumcision must be performed by a human act, known as "koach gavra." He derives this requirement from the obligation to pierce the ear of an eved ivri (an indentured Jewish servant) who refuses to be freed. Rashi (Kiddushin 21b, s.v. mi'eit) explains a chemical may not be used to pierce the ear of the slave, as the hole must be performed with "koach adam," and not on its own (mei-eilav).
The Acharonim raise a number of objections to performing a brit mila with a laser.
Some note that a knife is traditionally used for the brit mila, and therefore, aside from extenuating circumstances, any other method should not be used. Some suggest that just as the Acharonim objected to the use of certain clamps, as "dam berit" should be drawn during the brit, a laser procedure, which similarly precludes the drawing of blood, should not be performed. However, again, it would seem that in these extenuating circumstances, even those who generally require the drawing of blood would be lenient. In addition, apparently even during a laser procedure a bit of blood is drawn (see Dr. Yossi Walfish, Berit Mila Be-Laser, Assia 56).
R. Yitzchak Yaakov Weiss (Minchat Yitzchak 8:89) suggests that since the circumcision is not performed by the mohel's hand, it may not be valid. Furthermore, he expresses concern that the procedure may still be considered to be dangerous, and therefore prohibited. Dr. Abraham (vol. 5, p. 86) relates that R. Shlomo Zalman Auerbach also opposed using a laser for circumcision, as it is not performed by direct human action. 
R. Shmuel Wosner (Shevet Ha-Levi 9:212) concludes that in extenuating circumstances, such as a case of hemophilia, a laser may be used. He rules that the birkat ha-mitzva should not be recited, but the blessing of "le-hakhniso be-verito" may be recited, as the child is no longer considered to be an arel.
Finally, some note that when the circumcision is performed by laser, or even with a clamp, the mila and peria (the removal of the prepuce and the membrane) are performed in one stage and not two. As we noted in a previous shiur, although many prefer to perform the circumcision in two steps, removing the foreskin and membrane in one act is well rooted and supported in halakhic literature. That said, R. Avraham David Horowitz, in his Kinyan Torah (3:46) warns that when a circumcision is performed by laser, the peri'a must also be performed, in accordance with the principle "mal ve-lo para ke'ilu lo mal."
Laser Circumcision for a Convert
Although a Jewish child who cannot be circumcised due to safety concerns is not circumcised, he is still considered to be Jewish, although the Rishonim disagree regarding whether he may partake of the korban pesach and teruma. However, may a non-Jewish male who cannot be circumcised convert?
Theoretically, we might suggest that whether or not one who cannot be circumcised can convert through tevila alone should depend upon the debate between Rashi and Rabbeinu Tam cited above. According to Rabbeinu Tam, one who cannot be circumcised due to health concerns (meitu machamat mila) is not considered to be an arel, and therefore may eat from the korban pesach and teruma. Perhaps this means that such a person can convert without a brit mila. Furthermore, the Shulchan Arukh (268:1) rules that a man whose penis was severed may convert through tevila alone.
In the early 20th century, R. Yechiel Yaakov Weinberg sent this question to a number of leading rabbis in Eastern Europe and the Land of Israel. R. Avraham Yitzchak Ha-Kohen Kook (Da'at Kohen YD 150), Chief Rabbi of the Land of Israel, as well as R. Chaim Ozer Grodzinski, a leading posek in Vilna, responded. They both ruled that a non-Jew who cannot be circumcised may not be converted. In his own response (Seridei Esh 2:67–68), R. Weinberg insists that one who cannot be circumcised should not be equated with one whose penis was severed. R. Tzvi Pesach Frank (Har Tzvi 2:220) and the Tzitz Eliezer (14:92) concur.
R. Zalman Sorotzkin (1881-1966), in his Oznaim La-Torah (Parashat Yitro), relates that R. Chaim Ozer Grodzinski showed him the ruling of a scholar who permitted such a person to convert through tevila alone, and he rejected that ruling. Interestingly, R. Eliezer Waldenberg (Tzitz Eliezer 15:1:12) cites R. Mordechai Dov Eidelberg (1880–1941), who related that he originally suggested that a non-Jew who cannot be circumcised may be converted through tevila alone, but after consulting with R. Chaim Ozer Grodzinski, he concluded that such a conversion cannot be performed. Apparently, it was this source that R. Chaim Ozer Grodzinski had shown to R. Sorotzkin. 
However, R. David Zvi Zehman (Minchat Solet 2:6) suggests that a non-Jew who is unable to be circumcised may convert with tevila alone. He notes that when a pregnant women converts, her newborn male child is considered to have converted even without being circumcised.
R. Asher Weiss suggests that this question may depend upon whether mila is a necessary component of conversion for a male or just a preparation for the tevila. According to the second understanding, when a circumcision cannot be performed, it does not undermine the tevila as the act of conversion. He notes that he is inclined to accept this view.
Next week, we will begin our discussion of brit mila on Shabbat.