The first successful face transplant was recently performed in France. A woman had lost her nose, lips, and chin after being mauled by her dog. The injuries left her grotesquely deformed, making it virtually impossible for her interact normally with others. Muscles, blood vessels, nerves, and other tissues were transplanted from a "brain dead" donor in order to fashion a "hybrid" face that neither resembled the donor nor the recipient's original face.
This surgery marked a new milestone in transplantation, raising new questions to the usual list of ethical issues involved in transplantation. Unlike, kidney, liver, lung, or other vital organ transplants, which are life-saving procedures, the recent historic surgery brings transplantation into the realm of plastic surgery.
How far may an individual go to improve his/her appearance?
From a Jewish perspective, the face transplant raises two sets of questions. There are the technical questions regarding transplant and a more fundamental set regarding the approach of Judaism to vanity and plastic surgery.
Let us leave aside the issues of cadaveric transplantation and brain death involved in the recent face transplant case for another day and ask the more basic question of how far an individual may go to improve his/her appearance? Clearly the face transplant patient's surgery was not prompted by vanity, but we must still ask if even routine plastic/cosmetic surgery is permitted at all? What might the possible concerns be that arise for one contemplating plastic surgery?
Cosmetic versus Reconstructive Surgery
Plastic surgery may be divided into cosmetic and reconstructive surgery. The former is performed for enhancement of one's physical appearance (such as rhinoplasty, liposuction, or breast augmentation). The latter is performed to correct a defect, whether congenital (from birth) or acquired (for instance suffered in a car accident). These two indications for surgery may overlap and there is not necessarily a neat line that separates deformity from normal appearance. As has often been repeated, beauty is in the eye of the beholder.
Judaism treats the subjective sense of the individual very seriously when a person feels unattractive. What about a self-perceived cosmetic defect, one that is neither a true congenital defect nor the result of an injury? How much importance does Judaism place on self-esteem and self-consciousness?
The History of Plastic Surgery
The oldest descriptions of plastic surgery date back to 2600-year-old Sanskrit texts and ancient Egyptian papyri. These documents describe nose, ear, and lip reconstructions utilizing surgical flaps and skin grafts! Nevertheless, the term "plastic surgery" to describe reconstructive surgery was not introduced until 1818.1
Despite the long history of plastic surgery, no responsa were written about surgery performed for cosmetic surgery until the latter half of the 20th century. This is hardly surprising, since prior to the mid 19th century, all surgery was limited by the inability to adequately ameliorate the pain of the surgery itself and the high morbidity and mortality of surgery in general.
This all changed due to important advances made in the second half of the 19th century. Building upon the work of Ignaz Philipp Semmelweis (who argued that handwashing would decrease hospital infections) and Louis Pasteur (who proved that bacteria cause infection), Joseph Lister introduced the concept of antiseptic surgery in the late 19th century, significantly decreasing the risk of surgical infection. Ether, the first form of general anesthesia, was publicly utilized for the first time on October 16, 1846, in an operating theater at the Massachusetts General Hospital, ushering in the age of modern anesthesia. 2 With these two breakthroughs came rapid advances in surgical techniques, and advancements in both reconstructive and cosmetic surgery, particularly between the first and second world wars.
The Earliest Responsum
As plastic surgery developed and the options for cosmetic enhancement grew, formal halachic discussion began. In 1961, Rabbi Immanuel Jakobovits, considered by many to be the father of the discipline of Jewish medical ethics, 3 addressed the American Society of Facial Plastic Surgery at a symposium entitled "Religious Views on Cosmetic Surgery." 4 Rabbi Jakobovits, later Chief Rabbi of Great Britain, discussed the parameters of plastic surgery from a Jewish legal perspective.
After explaining that no responsa had yet been written on the topic, he dealt with the question of whether one may undergo plastic surgery for the purpose of improving one's physical appearance. As Rabbi Jakobovits eloquently described in his classic work, Jewish Medical Ethics: 5
The problem was considered under four headings: the theological implications of "improving" God's work or "flying in the face of Providence"; the possible risks to life involved in any operation; the Jewish objection to any mutilation of the body; and the ethical censure of human vanity, especially among males.
Plastic surgery for aesthetic enhancement is a form of arrogance and vanity and is forbidden unless the patient meets certain criteria.
He concluded6 definitively that plastic surgery for aesthetic enhancement is a form of arrogance and vanity (particularly for men) and is forbidden unless the patient meets certain criteria. He later wrote as part of an overview of the Jewish approach to medicine:
In the sparse rabbinic writings on the subject, these reservations could be discounted, provided the danger is minimal; and especially 1) if the operation is medically indicated, e.g. following an accident, or for grave psychological reasons; 2) if the correction of the deformity is designed to facilitate or maintain a happy marriage; or 3) if it will enable a person to play a constructive role in Society and to earn a decent livelihood. 7
The four ethical concerns of Rabbi Jakobovits remained the pivotal issues in all future responsa and therefore bear further elucidation, as subsequent poskim have approached them in different ways.
The first potential practical objection to plastic surgery is the Torah obligation to guard health (See: "Taking a Risk") which might limit the surgical risks that one may accept as part of plastic surgery. In addition to the hazards associated with the surgery itself, anesthesia, particularly general anesthesia, presents a very small but real risk of death or incapacitation.
Beyond the blanket obligation to guard health, there is the particular prohibition of self-mutilation. Just as one may not injure someone else, one may not cause injury to oneself. The prohibition of injuring someone else is called chavala and is derived directly from the Biblical verse8 that warns the court not to give a convicted criminal more lashes than legally mandated. The verse is interpreted to mean that if the court must not strike a criminal without justification, surely an ordinary individual may not strike or otherwise injure his neighbor.
The Talmud9 discusses whether this prohibition applies to harming oneself, concluding that "one who injures himself even though it is forbidden, pays no damages. But if someone else injures him, they pay damages." Injuring oneself without a valid reason is called chovel b'atzmo. This proscription has limitations however. We are only barred from causing unnecessary injury to ourselves. The key question is what is considered necessary.
Risk and harming oneself are not the only issues. There are also philosophical considerations. Do we assert that God, as the ultimate craftsman and molder of human beings, makes each person exactly as they should be and that our "remodeling" of ourselves is an affront to His judgment? That is, does the divine mandate to heal and obligation to seek medical treatment extend to plastic surgery?
The fourth issue applies predominantly to men. The Torah commands that a man not wear the clothing of a woman and that a woman not wear the clothing of a man. This prohibition extends beyond mere clothing, but includes actions and activities that are characteristic of one of the sexes. For instance, in most situations a man may not dye his white hairs back to black for purposes of improving his appearance since this is considered to be a feminine activity. Is plastic surgery also considered a "feminine" activity?
A Variety of Approaches
In 1964, Rabbi Mordechai Yaakov Breish, Rabbi Menasheh Klein, and Rabbi Moshe Feinstein were each asked to rule on questions of cosmetic surgery for enhancement of appearance.
Rabbi Mordechai Yaakov Breish, author of the Chelkas Yaakov and a prominent posek [authority in Jewish law] in Switzerland, discussed the issues of risk and chavala (self-injury) when asked whether a woman may undergo cosmetic surgery to straighten and decrease the size of her nose in order to improve her chance of finding a suitable husband. 10
He used a previous ruling of Rabbi Abraham of Sochachev, the 19th century author of the Avnei Nezer, as a starting point for his discussion of why it is permitted to enter into surgery or other dangerous situations, even when not absolutely necessary. The Avnei Nezer11 had forbidden a child to have surgery to straighten a crooked leg due to the risk of the operation. Rabbi Breish points out several objections to this ruling.
So long as a doctor practices in an acceptable way, it is a mitzvah for a physician to treat even non-life-threatening illnesses even though he may injure or kill patients inadvertently. 12 That is the nature of the mandate to heal. Additionally, the Talmud allowed bloodletting as a preventative health mechanism, even though it was known to be somewhat dangerous. We also clearly see that one is not prohibited from entering into a dangerous situation voluntarily since we do not prohibit women from having babies, despite the risks associated with pregnancy and childbirth. 13
Rabbi Breish also points out that the general population undergoes surgery for non-life-threatening conditions with a very low complication rate. He therefore invokes the concept of Shomer Pasaim Hashem, 14 that God watches over the simple, to defend low risk surgeries. He rules that from the perspective of risk, one may pursue plastic surgery as one of the activities that the general population finds to be acceptably safe. To support his contention that one may injure oneself (independent of any associated risk) for treatment of a non-life-threatening malady, he brings two proofs. The Code of Jewish Law15 warns a child not to remove a thorn, bloodlet, or amputate a limb from a parent, even for medical reasons, lest he transgress the capital offense of (unnecessarily) injuring a parent. Rabbi Moshe Isserles, in his gloss to the Code of Jewish Law, states that the child should only refrain if there is someone else present who can help the parent, for otherwise, the child should even amputate the limb if the parent is in pain. It seems clear that the prohibition is only to injure one's parent, but the concept of bloodletting or amputation merely for pain, despite the trauma involved, does not appear to be problematic!
The second proof is fundamental to our discussion of plastic surgery, particularly cosmetic surgery. The Talmud16 states that a man may remove scabs from his body to alleviate pain, but not to improve his appearance. 17 At first glance, this may appear to exclude the possibility of plastic surgery. However, Tosofos, 18 commenting on this statement, promulgates a concept that demonstrates a very sensitive understanding of human nature and psychology. He writes: "If the only pain that he suffers is that he is embarrassed to walk among people then it is permissible, because there is no greater pain than this." Tosofos recognizes that there is no greater suffering than psychological pain and that it is very difficult to judge for someone else the degree of suffering they are experiencing as a result of a self-perceived defect.
Citing the psychological pain associated with the inability to find a spouse, Rabbi Breish ruled that the woman may have the cosmetic surgery.
The same year, Rabbi Moshe Feinstein (1895-1986) was asked the same question. His responsa first examines the parameters of the prohibition of chavala. He points out that in his Mishneh Torah, 19 Maimonides clearly describes chavala as injury with malice. Rabbi Feinstein brings several examples of injury without the intention to do harm that Jewish religious literature finds acceptable. 20 His final ruling permits surgery when it is in the best interests of the patient, even if they are not sick and it does not treat an illness. As a result, he permitted the woman to have cosmetic surgery since it was to her advantage and not being done to harm her.
Also in 1964, Rabbi Menasheh Klein, author of Mishneh Halachos, dealt with the question of the permissibility of cosmetic surgery to correct various facial imperfections that mar a woman's appearance, such as a very long nose which makes it difficult for her to marry and which she feels makes her very unattractive. 21 Rabbi Klein utilizes an ingenious approach to evaluate the question. He points out that there is ample precedent for medical intervention to improve appearance in dating back to Talmudic times.
The Mishna22 discusses the case of a man who betroths a woman on the condition that she has no defect (mum) where a "mum" is defined as any defect that would bar a Cohen (Jewish priest) from serving in the Temple. Tosofos23 states that if the woman had her blemish corrected by a physician before her engagement, the marriage is valid. Since many of the blemishes that would apply to a Cohen include cosmetic imperfections24 of the face for which people today would desire elective plastic surgery and Tosofos permits these blemishes to be corrected by a physician, Rabbi Klein states that it appears that a man or woman may go to a doctor to correct a cosmetic defect merely for enhancement of their appearance. Rabbi Klein rejects the argument that plastic surgery entails any danger whatsoever based the information which he received from physicians.
In a second responsum, 25 printed immediately following the previously discussed one, Rabbi Klein discusses plastic surgery and chemical peels in men with respect to the prohibition of a man performing female behaviors. He reiterates his previous ruling and adds that (minor) cosmetic procedures are forbidden to men if done strictly for aesthetic enhancement, but that the prohibition does not apply if the blemish causes the man enough embarrassment that he shuns social interaction. Rabbi Klein wisely points out that such a distinction requires a great deal of intellectual honesty.
In 1967, Rabbi Yitzchak Yaakov Weiss (1902-1989), head of the Eida Chareidis rabbinical court in Jerusalem and author of Minchas Yitzchak, dealt briefly with the issues of chavala and risk with respect to plastic surgery. 26 He takes the same approach to self-injury as Rabbi Feinstein, arguing that the prohibition of chavala only applies when the wound is inflicted with the intention of causing harm or degradation. He feels that cosmetic surgery would be permitted if not for the risk of surgery, which he believes to be a serious concern. He refers to one of his earlier responsa27 which was directed to his in-law, Rabbi Breish, in which he forbids surgery for non-life-threatening conditions. While admitting that the line of reasoning of Rabbi Breish has merit, he disagrees, arguing that the permission of the Code of Jewish law to allow amputation of a limb is only in a life-threatening situation. He also agrees with Rabbi Breish that people desiring plastic surgery may be ill, but states that they are not endangered, and therefore is hesitant to allow elective plastic surgery, ending his 1967 responsa by saying the question requires further study.
Despite the generally strong support among halachic experts for the permissibility of reconstructive surgery for congenital defects and traumatic injuries, one dissenting opinion stands out with regard to cosmetic surgery merely to enhance one's appearance.
I am the Lord Your Healer28
There is an inherent tension in Judaism regarding the philosophical underpinnings of the mandate to heal. While the Torah clearly empowers the physician to treat illness, there is controversy regarding how far the permission extends (See "Mandate to Heal"). While most Biblical commentators and Jewish legal scholars interpret the Torah to grant a very broad license to heal, there is a consensus that the patient must be ill to allow the physician to treat the patient, particularly if the treatment is dangerous or requires injuring the patient in the process of healing.
This is one of the major concerns voiced by Rabbi Eliezer Yehuda Waldenberg, author of Tzitz Eliezer, a multivolume set of responsa, much of which deals with medical issues. First, Rabbi Waldenberg29 objects to performing surgery on someone who is neither sick nor in pain. 30 He argues that such activities are outside the boundaries of the physician's mandate to heal (since he questions whether cosmetic surgery is truly included in the category of healing). He further asserts that the patient has no right to ask the physician to wound him or her for the purposes of merely enhancing beauty. Rabbi Waldenberg then makes the theological argument that as the ultimate artisan, God creates each person in His image, exactly as he or she should be, with nothing extra nor anything lacking. He therefore posits that cosmetic surgery that is not for pain or true illness is an affront to God and is forbidden.
A Final Argument
The last major posek to voice an opinion is a fitting conclusion to our discussion of the various approaches of Jewish legal authorities to plastic surgery. Dr. Abraham Abraham reports31 the opinion of Rav Shlomo Zalman Aurbach (1910-1995), the great Israeli posek, on the question of a person whose arm or finger had been traumatically amputated.
In response to those who forbid plastic surgery, Rabbi Aurbach discussed the question of whether an amputated limb could be reattached by surgery requiring general anesthesia, even if the patient had already been treated so that he was no longer in danger his life. He ruled that the surgery would certainly be permitted on a weekday32 "since the surgery would not be considered an injury but a repair and treatment to save the limb. Why then should it be forbidden for someone to undergo plastic surgery in order to look normal?" In a published responsa, 33 Rabbi Aurbach writes:
if the plastic surgery is done to prevent suffering and shame caused by a defect in his looks (for instance a nose which is very abnormal) this would be permitted based on the Tosafot and the Gemara, since the purpose is to remove a blemish. However if the only reason is for beauty, this is not permitted.
Rabbi Aurbach sums up the consensus of most legal experts in ruling that plastic surgery to allow someone to appear normal, and more importantly to view themselves as appearing normal is permitted. It is only when such surgery is performed merely for vanity that the rabbis have serious reservations. Clearly however, true reconstructive surgery and even surgery for an appearance that makes one feel embarrassed is not an issue of vanity. Such was clearly the case with the French face transplant recipient.
This leaves us with a very potent human message. We must always appreciate the self-constructed prisons in which some of our friends and acquaintances live. Whether it is the torture of feeling unattractive or the feeling of hopelessness of a single friend who is losing hope that he/she will ever have a wife/husband and family, we must always look for ways to ease their pain.