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Judging Jaundice: Medical Wisdom and Halacha

Dear Rabbi Lawrence,

When you did my son’s bris, you communicated with his pediatrician about jaundice. Is that something that could have delayed the bris?

Hope you are doing well!

Yael F.

Dear Yael,

Great question! As I tell all the families I serve, from a Torah perspective, the health of the baby is top priority. The Mishnah in Shabbos 137a states explicitly that “a child who is sick is not circumcised until he becomes healthy.” Implicit in such a mandate, however, are questions around definitions; what is the definition of “sick” and who defines it?

One of my fondest memories from my milah training was accompanying one of my beloved teachers to “inspect yellow babies”; that is, we were checking to see the bilirubin levels of babies who had jaundice but were cleared by their doctors to have their bris. Since jaundice is the excess of bilirubin in the bloodstream, the physiological manifestation of the condition is that a baby’s skin generally appears to have a yellow undertone. While there are a number of modern ways to assess precise bilirubin levels, including blood tests and the use of a bilirubinometer (a portable non-invasive device), we instead assessed using the old fashioned method of holding the babies up to the sunlight and gently pressing on their skin to reveal the undertone.

Why the old-fashioned method? From a medical perspective, there are two types of jaundice: physiological and pathological. Physiological jaundice is extremely common and not indicative of any systemic issue, and pathological jaundice is rare, more severe and could point to an issue with the baby’s red blood cells or liver. As long as the bilirubin levels, however high, are on a downward trend from the peak, which is usually the fourth day post birth, it would be considered physiological. Since in these cases bilirubin levels either resolve themselves or are helped to resolve through phototherapy, the medical consensus is that babies with physiological jaundice are considered healthy.

With this in mind, the enterprise of “checking” medically healthy babies is a little funny; if the doctors did not consider him to be sick and cleared him for the bris, what are we checking for?

The Gemara in Shabbos (134a) gives us our first insight into the subject of jaundice and its medically transcendent status in halacha. Abeye, an orphan, shares a series of medical tidbits that he learned from his wetnurse: “My [adoptive] mother told me: … ‘if a baby is yarok (what many understand to be the color spectrum that included yellow), his blood has not yet entered him; let them wait until his blood enters him and then circumcise him’.” This meimra, like many, can be read through either a prescriptive or descriptive lens; is its inclusion in the Gemara reflective of an eternal truth about “yellow babies,” or is it a description of what medical professionals at the time, like Abeye’s wetnurse, understood about the world around them? This dichotomy ends up influencing the various competing piskei halacha determining whether or not to delay a bris of a baby with jaundice and for how long.

Some poskim like the Tzitz Eliezer and R. Elyashiv take the prescriptivist approach and hold that any yellow is too yellow. Other mohalim have a mesorah for the level of bilirubin that halacha permits to perform a bris; since the “normal” range of bilirubin is 1 mg per dL, some say nothing above 5; others say 10 or 12.

On the other hand, many poskim, like R. Shlomo Zalman Aurbach, take the descriptivist approach in understanding Abye’s meimra. R. Moshe Dovid Tendler, for example, writes: “If a pediatrician confirms that there is no concern of illness, he should be circumcised on the eighth day, accordingly.” That is, if a medical professional determines that a child is not sick, there is no halachic need to delay the bris. Aderaba, according to R. Tendler, delaying the bris in such a circumstance would be denying the opportunity to fulfill the mitzvah bizmanah, at the halachically prescribed time.

Almost every milah sefer has a different bilirubin number that is acceptable for a bris, a different stance on how long to delay a bris if that number is exceeded, and a different opinion on whether a downward trend is enough to be considered “healed.” In such a contested sphere, every mohel will determine how to handle physiological jaundice based on his own mesorah and kabbalah. All approaches are most certainly from a place of emunas chachamim, belief in the wisdom of our sages. In our case, it is just a matter of interpretation of what the sage Abaye was trying to teach us—the wisdom of the medical professionals of his time, or a timeless endorsement of evolving medical wisdom.

Wishing you well!

Rabbi Lawrence


Rabbi Eliezer Lawrence is a doubly certified, highly rated mohel serving the NY, NJ and CT region and beyond. If you or someone you know is expecting or want to learn more about his practice, visit www.FamilyMohel.com. He can also be reached at [email protected] or at (212) 518-7334. Questions for the column can be submitted to
[email protected].

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