The first successful partial face transplant from a donor was performed November
in Amiens, France. The recipient 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 to 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. Since that time,
several more face transplants have been performed, including a near total face
transplant at the Cleveland Clinic in December, 2008.
These surgical procedures marked a new milestone in transplantation,
adding 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 face transplants bring
transplantation into the realm of plastic surgery.
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 cases and ask the more basic
question of how far an individual may go to improve his/her appearance? Clearly
the face transplant patients’ surgeries were not prompted by mere vanity, as
these patients were horribly disfigured. But, we must still ask if even routine
plastic/cosmetic surgery is permitted at all? What are the possible concerns
that may 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 (suffered in a
car accident, for instance). These two indications for surgery may overlap and
there is not necessarily a clean 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.
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. 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 contemporary era of plastic surgery was ushered in by War War I. Due
to the nature of trench warfare, which protected the soldier’s lower body but
exposed the head and neck to destructive new explosive devices, thousands of
soldiers returned from war with horrible facial deformities. In order to aid
these soldiers to integrate back into society, where they were finding difficulty
finding jobs and spouses, several countries, including the United States, created special medical programs and hospitals dedicated to treating these
injuries. World War II led to further advances in cosmetic surgery, largely for
the same reason.
As Max Thorek (the founder of the International College of Surgeons)
pointed out, even modern cosmetic surgery was the direct result of war:
“If soldiers whose faces had been torn away by bursting shells on the
battlefield could come back into an almost normal life with new faces created
by the wizardry of the new science of plastic surgery, why couldn’t women whose
faces had been ravaged by nothing more explosive than the hand of the years
find again the firm clear contours of youth.”
Thus was born the era of widespread “plastic” surgery.
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, addressed the American Society of Facial Plastic
Surgery at a symposium entitled "Religious Views on Cosmetic
Surgery." 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:
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.
He concluded 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
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.
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 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 verse 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 Talmud 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
Risk and harming oneself are not the only issues. There are also
philosophical considerations. Do we assert that God, as the ultimate craftsman
Who fashions 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
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 (1895-1976), 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.
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 Nezer 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. 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.
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 Pesaim Hashem, 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 it is 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 Law 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 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 unnecessarily. But, the
concept of bloodletting or amputation of a parent’s limb per se, merely
to relieve pain, despite the trauma involved, does not appear to be
The second proof is fundamental to our discussion of plastic surgery,
particularly cosmetic surgery. The Talmud states that a man may remove scabs from his body
to alleviate pain, but not to improve his appearance. At first glance, this may appear to exclude the
possibility of plastic surgery. However, Tosofos, 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
Citing the psychological pain associated with the inability to find a
spouse, Rabbi Breish ruled that the woman may have the cosmetic surgery.
That 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, 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. 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. Rabbi Klein utilizes an ingenious approach to
evaluate the question. He points out that there is ample precedent for medical
intervention to improve appearance dating back to Talmudic times.
The Mishna 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. Tosofos 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 imperfections 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 on information he received from physicians.
In a second responsum, 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 for 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. 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 responsa 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 Healer
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. 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 (1917-2006), author of Tzitz Eliezer, a multivolume set of
responsa, much of which deals with medical issues. First, Rabbi Waldenberg objects to performing surgery on someone who is
neither sick nor in pain. 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 pursued to
relieve 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 reports the opinion of Rav Shlomo Zalman Auerbach
(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 Auerbach
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 weekday "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, Rabbi Auerbach 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 Auerbach 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 and the empathy of our rabbis to their plight. 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.