A Drop of Blood

DOI: 10.1200/JCO.2015.63.2828 I was a third-year internal medicine resident, rotating through the oncology service, when I was asked to perform my first circumcision. My team was rounding on Tom, a 52-yearold gentleman currently receiving third-line treatment for metastatic esophageal cancer; we were discussing at length his various options for pain management and nutrition. As we exited the room, my attending asked Tom if we could do anything else for him that day. “Yeah,” he said. “You guys got a Jewish doctor?” The interns, attending, and I looked at each other in slight surprise. “Sure,” I volunteered, raising my hand perhaps a bit too enthusiastically. “What can I do for you?” I was eager to help this man in any way I could. He was cachectic and uncomfortable and had only months, if not weeks, to live. “Well,” Tom said. “You see, I’m in the process of converting to Judaism. My wife is Jewish, and the only way that I can be buried in a Jewish cemetery— where she will be buried herself one day—is if I convert to Judaism. I have a rabbi that’s been helping me through the process, but one of the last things I need to do is to get circumcised.” Circumcision is an ancient practice, not unique to Jews, that is common in many traditions that originate in the Middle East. Even before Biblical times, Egyptians practiced circumcision to improve male hygiene. In Judaism, circumcision represents a covenant between man and God, as described in the book of Genesis: “Such shall be the covenant between Me and you and your offspring to follow which you shall keep: 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.” The procedure entails removal of the foreskin of the penis and is usually done when a child is a newborn. In Judaism, circumcision is done when a male infant is 8 days old and is called a brit milah. Performing a circumcision on a grown man is more complicated and requires a urologic specialist; it is often performed under general anesthesia. In the Bible, Abraham is said to have undergone circumcision at the ripe old age of 99, by his own hand. “Are you already circumcised?” I asked. “Oh yeah. I was circumcised as a baby. My rabbi said you just need to take a drop of blood and say some prayers. Here, I have a whole packet of information for you.” Tom reached over to the bedside table and handed me a stack of photocopied pages from there. The documents detailed the steps of his conversion as well as an article on ritual circumcision by a selfdescribed urologist and mohel (a Jew trained in the laws, ritual requirements, and act of circumcision). I would not need to perform an actual circumcision; rather, I would perform something called a brit hatafat dam, which is the drawing of a drop of blood from the remnant of the foreskin. It is quick and relatively painless, and it can be performed by a rabbi, a Jewish physician, or the patient himself. “I’d really like to do this for you. Let me just check with my attending, as your white blood count is quite low, and get in touch with the hospital rabbi to make sure I’m doing everything right,” I said. I thought, “What would my role be in this procedure? Would I be acting as a doctor or as a Jew who just happened to have some degree of medical expertise? If something went wrong, would I be held liable? Would the hospital?” I didn’t know the answers to these questions, but I did feel a deep yearning to ease the spiritual burden of this dying man. I e-mailed the rabbi, who said she had never been asked to take part in such a ceremony but would be interested in being present. I asked my attending for her permission, and I explained the procedure to her just as I had learned it. Tom was borderline neutropenic, but, given how important this was to him, my attending agreed to allow the procedure. We scheduled the brit hatafat dam for the next day. The rabbi and I met at Tom’s bedside–she with a prayer book, and I with a 23-gauge needle and an alcohol wipe. “Are you ready?” I asked. “Go for it.” Tom replied. “I want you to know how much I appreciate you guys doing this for me. My wife Janet is at work and can’t be here today, but she is really thankful as well.” I lifted up Tom’s gown and explained to him what was going to happen next. Unfortunately, his penis was so edematous that I had to stick him twice JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 33 NOVEMBER 2