COSMETIC SURGERY

QUESTION:

A young, unmarried Orthodox girl wants a nose plastic operation and her face lifted. She realizes that according to Halacha she must not inflict unnecessary injury to herself. Should she have these operations? (Asked by Dr. Abraham Bernstein, San Francisco, California.)

ANSWER:

IN TRADITIONAL LAW there is ground for debate whether any operation which cuts the human body can be freely consented to. Of course if it is a question of saving an endangered person’s life, then no prohibition among the commandments is allowed to stand in the way of the necessary operation. All commandments are waived in cases of pikuach nefesh (danger to life). But suppose the operation is not one for saving a person from real danger but is for a relatively minor purpose, such as improving the shape of the nose, are such operations permitted by Jewish law?

In order to answer that question, we must first look into the question of a person giving consent to an op eration. The law is fairly clear that just as a person may not wound another (chovel, “to wound, to injure”) so he may not wound himself (or arrange for someone else to wound him—in this case, the surgeon). This law is stated clearly by Maimonides in his Code in Hilchos Chovel V, l. However, where the law is stated in the Shulchan Aruch in Choshen Mishpot 420:31, it is not stated as positively as Maimonides does. The Shulchan Aruch says: “He who injures himself is free [from punishment] although it is not permitted to do so.” The reason for this ambiguous statement of the law in the Shulchan Aruch, which seems to say you may and you may not injure yourself, is that Rabbi Akiba, who is the chief authority for this law, himself seems to have two diverse opinions. In the Mishnah (Baba Kama 8:6), he states the law just as the Shulchan Aruch quotes it, namely: “You should not injure yourself, but if you do so, you are free from punishment.” But in a boraita quoted in the Talmud (Baba Kama 91 a at the bottom), Akiba says flatly that a man is free to injure himself. Clearly this vagueness in the law of self-injury leaves room for discussion of the question asked here and of many analogous questions.

An interesting recent discussion was made by Moshe Feinstein, the prime contemporary Orthodox authority (in his Igros Moshe, Choshen Mishpot #103). The specific question with which he was dealing was the following: May a man give his blood to a blood bank for pay? On the face of it, this should be prohibited because the man is arranging for his self-injury. After a minute analysis of the two semi-contradictory state ments of Rabbi Akiba, Moses Feinstein comes to the conclusion that it is permitted, first because they used to do bloodletting in Talmudic times; second, because the injury is slight and painless; and third, because the man may, of course, need the money.

On the basis of the law, the line of our inquiry must be as follows: First, how dangerous is the cosmetic surgery as a procedure? What risks does the patient incur? Second, how important a benefit is the beautification of the woman? Is it important enough to justify whatever danger there is in the surgery?

It may be assumed that cosmetic surgery deals mostly with the outer parts of the body and does not generally involve disturbing the vital organs. As for the benefit derived by whatever risk this surgery entails, this question has a remarkable place in Jewish traditional literature. The Bible and the Talmud pay a surprising amount of attention to cosmetic matters. First of all, the various spices and lotions used in women’s beautification are mentioned many times in Scripture. In the Song of Songs 3:6 and 4:10, and in Esther 2:12, various spices are mentioned. Also in the Talmud (Baba Kama 82a) we are told that when Ezra brought the people back from Babylonian captivity, among his special ordinances was one permitting peddlers of cosmetics to travel freely throughout the country so that these ointments, etc., would be readily available.

The law permits a woman to go through extensive beauty treatment on the half-holidays (see Orah Hayyim 346:5). The husband must provide means of his wife’s beauty material (see b. Ketubos 64b). One of the most touching narratives in the Mishnah (Nedarim 9:10) concerns Rabbi Ishmael. A man had made a vow that he would not marry a certain woman on the ground that she was homely. Rabbi Ishmael then took the girl into his house and beautified her. Then he presented her to the young man who had made the vow and said to him: “Is this the girl you vowed you would not marry because you said she was homely?” The young man looked at the beautiful girl and said: “No, I would gladly marry her.” Then follows the saying: “The daughters of Israel are beautiful. It is their poverty which makes them homely.” Then we are told that when Rabbi Ishmael died, all the daughters of Israel sang a dirge for him.

It is clear from Jewish tradition that the right of a woman to beautify herself is one that is honored in Scripture and in Talmud. It is not at all to be considered as a trivial matter. It is clearly the spirit of the tradition that a woman has the right to strive for beauty.

Since, therefore, the cosmetic purpose is an honored one and an important one, and since the operation is not likely to be a dangerous one, then the ambiguous law of chovel against self-injury does not apply here, and this woman is not prohibited by Jewish law from undergoing cosmetic surgery.

CCAR RESPONSA

Cosmetic Surgery

5752.7

She’elah

A woman is planning breast enlargement surgery in order, she says, to please her husband. She now wonders whether this is sufficient justification for the procedure, and she has asked my counsel. (Rabbi Jon Haddon, Richfield, CT)

T’shuvah

The question involves the advisability of surgical procedures undertaken for cosmetic (i.e., non-medical) purposes. As such, it is essential at the outset to distinguish penile implant from breast implant surgery. Penile implantation is generally directed at correcting organic impotence and would therefore be justified on medical grounds.¹ Traditional Jewish law would favor the procedure as a means for helping a husband fulfill the mitzvot of procreation² and conjugal responsibilities.³

Breast implantation, by contrast, is undertaken for either of two broad reasons: to reconstruct the breast following a mastectomy, or to enlarge the breasts for the sake of physical appearance. The former, initiated as part of a response to disease, is generally considered a medical purpose. We regard our case, in which a woman wishes to “enhance” her appearance to please her husband, as falling into the second category, that of cosmetic surgery. We are of course aware that individuals who opt for “mere” cosmetic surgery justify their choice on a variety of grounds. Our task here is to consider, from the standpoint of Jewish tradition and our own Reform perspective, whether and in which instances such procedures either violate or serve our highest religious goals.

Traditional Perspectives

We begin with the observation that, under Jewish law, it is forbidden to cause injury to one’s own body without sufficient justification. The prohibition, found in the leading codes,⁴ is based upon a statement of Rabbi Akiva in Mishnah Baba Kama 8:6. Although this ruling is somewhat controversial,⁵ it reflects mainstream halakhic thought as well as, to us, the better interpretation of the tradition, for the gratitude which we owe God for the gift of life surely demands that we treat our bodies with the utmost reverence.

Similarly, it is forbidden to endanger one’s life needlessly, a rule derived from Lev. 18:5 (“these are the mitzvot which a person shall do and live by them”)⁶ and from the exemption from the commandment to save the life of another (Lev. 19:16) when the attempt to do so endangers one’s own life.⁷ Neither of these prohibitions, however, is absolute. Rambam, for example, forbids self-injury only when it is performed for harmful or pointless ends.⁸ The rule against self-endangerment does not forbid one from flying in airplanes, driving an automobile, working in construction or engaging in other potentially dangerous but worthwhile activities. In particular, the prohibition is waived in medical situations. The whole medical enterprise is suffused with risk; “that which cures one person will kill another”.⁹ Nonetheless, we are permitted and even commanded to administer medical and surgical measures in order to save human life.¹⁰ One may submit to such measures when they serve legitimate and reasonable therapeutic purposes. With cosmetic surgery, then, as with other invasive procedures, the task is to reckon its inherent dangers against its hoped-for benefits: do the latter outweigh the former?

The current controversy over breast implant surgery indicates that, at least with respect to this procedure, the answer is “no”. The silicone-gel-filled sacs used in this operation have long been known to deteriorate, leak, and occasionally rupture. Preliminary studies suggest that gel leakage may be associated with various health risks, including arthritis, lupus, and cancer. Widespread concern over the dangers of this surgery has led the U.S. Food and Drug Administration to place restrictions on their use.¹¹ The FDA has sought to distinguish between medical and non-medical need. Women undergoing reconstructive surgery after mastectomies, as well as those disfigured due to medical trauma or birth defects, will have access to breast implants; those wanting cosmetic breast enlargement can use these devices only as part of approved clinical trial programs. In one sense our answer has been determined by these events: the risks associated with breast implant surgery convince us, along with the U.S. Government, that the procedure should be restricted to bona fide medical purposes.

This answer, however, does not suffice, for the scope of the case before us extends far beyond the particulars of this one surgical procedure. The question seems to have originated at an earlier time than when the specific dangers of breast implant surgery filled the news. We are not being asked whether these dangers warrant a prohibition against this operation. We are asked instead a broader question, whether such cosmetic surgery as breast implantation, undertaken in order to “please” a spouse, ought to be permitted under our conception of Jewish teaching? Would we approve of that surgery even were it not linked to grievous health risks? In other words, supposing the absence of concerns like those surrounding breast implantation, how should we measure the potential benefits of cosmetic surgery against those factors which would persuade us to caution against it?

Orthodox halakhic literature is markedly ambivalent on this subject. R. Moshe Feinstein permits cosmetic surgery to a young woman who seeks to make herself more attractive and therefore “marriageable”. The prohibition against self-injury, as we have seen, applies only when the act is done for harmful or pointless ends. Cosmetic surgery undertaken for a legitimate and beneficial purpose is hardly “harmful” or “pointless”, and Feinstein accordingly sees no reason to forbid a woman from choosing that option.¹² On the other hand, R. Eliezer Yehudah Waldenberg, in a lengthy analysis of the mitzvah of medicine,¹³ concludes that physicians are permitted to perform invasive procedures only to treat conditions generally recognized as “disease”. This leads him to condemn cosmetic surgery whose goal is to enhance a person’s physical appearance. Such surgery serves no accepted medical goal, and Waldenberg sees it as evidence of hubris (an attempt to improve upon God’s work) and misplaced values.¹⁴

Halakhah supports these contradictory conclusions because, while each authority arrives at a decision which is perfectly logical, they begin their process of reasoning from opposing points of departure. Feinstein considers cosmetic surgery under the rubric of “benefit”. Inasmuch as self-injury is permitted for a “beneficial” purpose, and since “benefits” need not be restricted to medicine, there is no reason to forbid the operation. Waldenberg, on the other hand, views the issue solely from its medical standpoint.¹⁵ The question is one of surgery, which is generally undertaken to secure refu’ah, healing. Surgery which does not contribute to refu’ah is not, properly speaking, “surgery” at all, but willful damage to and desecration of the human body. Cosmetic surgery, which has nothing to do with medicine, thus has no justification whatsoever. Further, Waldenberg bases his decision upon a value judgement which Feinstein does not mention, namely that the willful alteration of the human form is in itself frivolous and undesirable and in no way warrants the use of surgery which by its nature involves bodily injury.

Reform Considerations

Reform Jews, it seems to us, must ask similar questions and make similar value judgments. If we regard cosmetic surgery first and foremost as a technology offering attractive and legitimate benefits to an individual, then we would have no real reason to caution against it, excepting those cases such as breast implants which entail significant health risks. If, on the other hand, we presume that the proper function of surgery is to contribute to healing and that enhancement of appearance is not a truly “worthwhile” goal, then we are much more likely to reject cosmetic surgery. We would, rather, affirm with Jewish tradition the sanctity of the human body and the abhorrence of capricious manipulation of its form. True, value judgments are difficult to objectify, and in a movement such as ours, which places such a high premium on freedom of personal choice, much can be said for leaving these judgments exclusively in the hands of the individuals who must make them. Religion, however, is all about value judgments, and in this case the rabbi, as a teacher of religion, is being asked for counsel as to which value judgment reflects a better and more coherent understanding of Judaism’s message. To assist in the making of that judgment is the task before us.

Our answer must distinguish between the particular instance and the general rule. It is conceivable that, for some persons, “mere” cosmetic surgery may serve a useful and legitimate purpose. It may be determined, for example, that an enhanced appearance is vital to an individual’s psychological and emotional well-being. This is a judgement that must be made carefully in each individual case; when it is made, these persons should not be dissuaded from this alternative. In general, however, we think this argument is too frequently raised and too easily exaggerated. We would argue the opposite: that so many people are willing to subject themselves to damaging and potentially dangerous procedures for no other reason than better looks¹⁶ is clear evidence of the overemphasis which our materialistic culture places upon superficialities. Rabbis customarily and justly critique this distortion of values. Indeed, if Judaism means anything to us, it admonishes us to look below the surface, to concentrate upon the development of deeper and more lasting measurements of self-worth and satisfaction. When even breast reconstruction, which we tend to view as “medical” rather than “cosmetic”, is not always indicated on psychological grounds,¹⁷ the notion that purely cosmetic surgery is beneficial to mental health must as a general rule be resisted. We would therefore urge that rabbis advise against cosmetic surgery undertaken solely for the improvement of personal appearance.

Notes

1. See Jan K. Meyer in A.M. Harvey et al., eds., The Principles and Practices of Medicine(Norwalk, CT, 1984), p. 1404; L. Vliet and J. Meyer, “Erectile Dysfunction: Progress in Evaluation and Treatment”, The Johns Hopkins Medical Journal 151:246-258, 1982.
2. Gen. 1:28; BT. Yeb. 65b; Yad, Ishut 15:2
3. Ex. 21:10; BT. Ketubot 61b; Yad, Ishut 14:1 ff.).
4. Yad, Chovel 5:1; Sh. A. CM 420:31.
5. The Talmud (Baba Kama 91a-b) records a baraita quoting R. Akiva to the opposite effect: one is permitted to injure oneself. According to the 13th-century Spanish sage R. Meir Halevy Abulafia, the law follows the baraita (Shitah Mekubetset, Baba Kama 91b). Since Rav Hisda, the latest authority found in the Talmudic discussion, seems to accept the baraita as authoritative, Abulafia invokes the rule hilkheta kevatra’ei, “the law is decided according to the latest authorities”. All other poskim reject this ruling, inasmuch as the Talmudic sugya concludes by upholding the Mishnah’s version of R. Akiva’s view.
6. BT Yoma 85b; Isserles, Sh. A., YD 116:5.
7. See Sh. A., CM 426 and commentaries.
8. See note 4.
9. R. Moshe b. Nachman, Torat Ha’adam, she`ar hasakanah (Chavel ed.), p. 43.
10. Sh. A., YD 336:1.
11. Indeed, as of this writing, the leading manufacturer of silicone-gel breast implants has announced its intention to cease producing them.
12. Resp. Iggerot Moshe, CM II, # 66)
13. Resp. Tzitz Eliezer, v. 11, # 41, end.
14. He cites Prov. 31:30–“grace is deceitful and beauty is vain”.
15. He brands as “ridiculous” attempts to justify cosmetic surgery by various midrashim which speak in praise of feminine beauty. In so doing, he teaches an important lesson: traditional sources, when quoted out of context, can be made to support virtually any position.
16. According to current estimates, for example, 120,000 American women per year seek cosmetic breast enlargement (Newsweek, March 2, 1992, p. 75).
17. “It is rare for a husband to urge reconstruction…I can attest to the stability of married relationships after a mastectomy. I have seen only one that was significantly worse than before mastectomy, and that one was significantly bad to begin with”; T.K. Hunt, MD, in T. Gant and L. Vasconez, eds., Post-Mastectomy Reconstruction, Baltimore, 1981, pp. 3-4.

If needed, please consult Abbreviations used in CCAR Responsa.

CCAR RESPONSA

American Reform Responsa

172. Cosmetic Surgery

(Vol. LXXVI, 1976, pp. 94-96)QUESTION: A young unmarried Orthodox girl wants a plastic surgery on her nose and her face lifted. She realizes that according to Halacha she must not inflict unnecessary injury to herself. Should she have a facial plastic surgery? (Dr. Abraham Bernstein, San Francisco, California)ANSWER: In traditional law there is ground for debate whether any operation which cuts the human body can be freely consented to. Of course, if it is a question of saving an endangered person’s life, then no prohibition among the commandments is allowed to stand in the way of the necessary operation. All commandments are waived in cases of Pikuach Nefesh (danger to life). But suppose the operation is not one for saving a person from real danger, but is for a relatively minor purpose, such as improving the shape of the nose. Are such operations permitted by Jewish law? In order to answer that question, we must first look into the question of a person’s giving consent to an operation. The law is fairly clear that just as a person may not wound another (Chovel, “wounds or injures”), so he may not wound himself (or arrange for someone else to wound him; in this case, the surgeon). This law is stated clearly by Maimonides in his Code in Hilchot Chovel V.l. However, where the law is stated in the Shulchan Aruch, Choshen Mishpat 420.31, it is not stated as positively as in Maimonides. The Shulchan Aruch says, “He who injures himself is free [from punishment], although it is not permitted to do so.” The reason for this ambiguous statement of the law in the Shulchan Aruch (which seems to say you may and you may not injure yourself) is that Rabbi Akiva, who is the chief authority for this law himself, seems to have two diverse opinions. In the Mishna Bava Kama 8.6, he states the law just as the Shulchan Aruch quotes it, namely, “You should not injure yourself, but if you do so, you are free from punishment.” But in a baraita quoted in the Talmud (in Bava Kama 91a, at the bottom), Akiva says flatly that a man is free to injure himself. Clearly this vagueness in the law of self-injury leaves room for discussion of the question asked here and of many analogous questions. An interesting recent discussion was given by Moshe Feinstein, the prime contemporary Orthodox authority (in his Igerot Mosheh, Choshen Mishpat #103). The specific question with which he was dealing was the following: May a man give his blood to the blood bank for pay? On the face of it this should be prohibited because the man is arranging for his self-injury. After a minute analysis of the two semi-contradictory statements of Rabbi Akiva, Moses Feinstein comes to the conclusion that it is permitted–first, because they used to do bloodletting in Talmudic times; secondly, the injury is slight and painless; and thirdly, the man may, of course, need the money. On the basis of the law, the line of our inquiry must be as follows. First: How dangerous is the cosmetic surgery as a procedure? What risks does the patient incur? Secondly: How important a benefit is the beautification of the woman? Is it important enough to justify whatever danger there is in the surgery? It may be assumed that cosmetic surgery deals mostly with the outer parts of the body and does not generally involve disturbing the vital organs. As for the benefit derived by whatever risk this surgery entails, this question has a remarkable place in Jewish traditional literature. The Bible and the Talmud pay a surprising amount of attention to cosmetic matters. First of all, the various spices and lotions used in women’s beautification are mentioned many times in Scripture. In Song of Songs 3:6 and 4:10 and in Esther 2:12, various spices are mentioned. Also in the Talmud (Bava Kama 82a) we are told that when Ezra brought the people back from Babylonian captivity, among his special ordinances was one permitting peddlers of cosmetics to travel freely throughout the country so that these ointments, etc., would be readily available. The law permits a woman to go through extensive beauty treatment on the half-holidays (see Orach Chayim 346.5). The husband must provide means for his wife’s beauty material (see B. Ketubot 64b). One of the most touching narratives in the Mishna (Nedarim 9.10) concerns Rabbi Ishmael. A man had made a vow that he would not marry a certain woman on the ground that she was homely. Rabbi Ishmael then took the girl into his house and beautified her. Then he presented her to the young man who had made the vow and said to the young man, “Is this the girl you vowed you would not marry because you said she was homely?” The young man looked at this beautiful girl and said, “No, I would gladly marry her.” Then follows the saying, “The daughters of Israel are beautiful. It is their poverty which makes them homely.” Then we are told that when Rabbi Ishmael died, all the daughters of Israel sang a dirge for him. It is clear from Jewish tradition that the right of a woman to beautify herself is one that is honored in Scripture and in Talmud. It is not at all to be considered a trivial matter. It is clearly the spirit of the tradition that a woman has the right to strive for beauty. Since, therefore, the cosmetic purpose is an honored one and an important one, and since the operation is not likely to be a dangerous one, then the ambiguous law of Chovel against self-injury does not apply here, and this woman is not prohibited by Jewish law to undergo cosmetic surgery.Solomon B. Freehof

If needed, please consult Abbreviations used in CCAR Responsa.