How far may an individual go to improve his/her appearance?

From a Jewish perspective, how far can an individual go to improve his/her appearance? Is routine plastic/cosmetic surgery permitted at all? What halachic concerns might arise for one contemplating plastic surgery?

Cosmetic Versus Reconstructive Surgery

Plastic surgery may be divided into two categories: cosmetic and reconstructive surgery. The former is performed for enhancement of one’s physical appearance (such as rhinoplasty and liposuction), whereas the latter is performed to correct a defect, whether congenital (from birth) or acquired (for instance, as a result of a car accident). These two indications for surgery may overlap, and the line that separates deformity from normal appearance is not always perfectly clear. As the old cliché goes, beauty is in the eye of the beholder.

But 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? Do these uneasy feelings justify voluntarily going under the surgeon’s knife, from the perspective of Jewish law and values?

The Earliest Responsum

In 1961, Rabbi Immanuel Jakobovits, considered by many to be the father of modern Jewish medical ethics, addressed the American Society of Facial Plastic Surgery at a symposium entitled, “Religious Views on Cosmetic Surgery.” Rabbi Jakobovits, who later became 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” Gd’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 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 summarized this position 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.

These four ethical concerns mentioned by Rabbi Jakobovits remained the pivotal issues in all future responsa and therefore bear further elucidation, as subsequent poskim have approached them in different ways.

Ethical Concerns

The first potential objection to plastic surgery is the Torah obligation to maintain good health and avoid unnecessary medical risks. Seemingly, this should forbid elective cosmetic surgery, whereby one voluntarily exposes himself or herself to the risks posed by surgical procedures. 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 havalah and is derived directly from the Biblical verse that warns the court not to give a convicted criminal more lashes than legally mandated. The sages deduced 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 hovel b’atzmo, and is forbidden unless there is some necessity. The key question, then, is what is considered “necessary.”

But endangering and harming oneself are not the only issues. There are also philosophical considerations. Do we assert that Gd, as the ultimate craftsman and molder of human beings, makes each person exactly as he or she should be, and that our “remodeling” of ourselves is an affront to His judgment? That is, do the divine mandate to heal and the obligation to seek medical treatment extend to plastic surgery?

The fourth issue applies predominantly to men. The Torah forbids men from wearing women’s clothing, and women from wearing men’s clothing. This prohibition extends beyond mere clothing, but includes actions and activities that are characteristic of the other gender. 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?

Rabbi Breish’s Approach

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 Helkat Yaakov and a prominent posek in Switzerland, discussed the issues of risk and havalah (self-injury) in reference to the case of a woman who wished to 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, but Rabbi Breish noted several objections to this ruling. First, so long as a doctor practices medicine in an acceptable way, it is a mitzvah to treat even non-life-threatening illnesses, despite the risk of inadvertently injuring or killing a patient in the process. 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. Moreover, we certainly 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. As such, we may invoke the concept of “shomer peta’im Hashem” (literally, “Gd watches over the simple”) to defend low-risk surgeries. And thus from the perspective of risk, he rules, one may pursue plastic surgery as something that the general population finds to be acceptably safe.

As for the prohibition against self-inflicted injury, Rabbi Breish cites two proofs to support his contention that one may injure oneself for treatment of a non-life-threatening malady. The Shulhan Aruch forbids performing certain medical procedures on one’s parents, such as removing a thorn, bloodletting, and amputating a limb, lest he transgress the capital offense of (unnecessarily) injuring a parent. Rabbi Moshe Isserles, in his glosses to the Shulhan Aruch, states that one should only refrain only if there is someone else present who can help the parent, but 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 act of bloodletting or amputation is permissible, even if this is done merely to relieve pain. When it comes to oneself, too, it stands to reason that medical procedures are permissible, and do not fall under the prohibition of self-inflicted injury.

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, Tosafot, 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.” Tosafot 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 he is 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 undergo cosmetic surgery.

Rabbi Feinstein’s Approach

The same year, Rabbi Moshe Feinstein (1895-1986) was asked the same question. His responsum on the subject first examines the parameters of the prohibition of havalah. He points out that the Rambam, in his Mishneh Torah, clearly defines havalah as injury with malice. Rabbi Feinstein brings several examples of injury without the intention to do harm that Jewish religious literature finds acceptable. He thus permits surgery when it is in the best interests of the patient, even if the patient is not sick and the procedure is not necessary to treat an illness. In the case of a woman seeking a marriage partner, then, Rabbi Feinstein allowed her to undergo cosmetic surgery since it was to her advantage and not being done to harm her.

Rabbi Klein’s Approach

Also in 1964, Rabbi Menasheh Klein, author of Mishneh Halachot, 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 makes her feel very unattractive. Rabbi Klein utilizes an ingenious approach to evaluate the question, pointing out that there is ample precedent for medical intervention to improve appearance, dating back to Talmudic times.

The Mishnah discusses the case of a man who betroths a woman on the condition that she has no “mum” (defect), and the term “mum” is defined as any defect that would bar a kohen from serving in the Temple. Tosafot states that if the woman had her blemish corrected by a physician before her engagement, the marriage is valid.It is clear from Tosafot’s comments that blemishes which disqualify a kohen – many of which are cosmetic imperfections of the face for which people today would desire elective plastic surgery – may be surgically corrected. Rabbi Klein thus concludes that a man or woman may go to a doctor to correct a cosmetic defect merely for enhancement of his or her appearance. Rabbi Klein rejects the argument that plastic surgery entails some sort of danger, based on the information he received from physicians.

Rabbi Weiss’ Approach

In 1967, Rabbi Yitzchak Yaakov Weiss (1902-1989), head of the Eidah Haredit rabbinical court in Jerusalem and author of Minhat Yitzhak, dealt briefly with the issues of havalah and risk with respect to plastic surgery.  He takes the same approach to self-inflicted injury as Rabbi Feinstein, arguing that the prohibition of havalah only applies when the wound is inflicted with the intention of causing harm or degradation. However, he feels that the risks posed by surgery are 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 granted to amputate a limb applies 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. He concludes his 1967 responsa by saying the question requires further study.

“I am the Lord Your Healer”

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 which is desired for the sole purpose of enhancing one’s appearance.

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 some controversy regarding how far the permission extends. While most Biblical commentators and Jewish legal scholars interpret the Torah as granting 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 expressed by Rabbi Eliezer Yehuda Waldenberg, 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 (and 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, Gd creates each person in His image, exactly as he or she should be, with nothing extra or lacking. He therefore posits that cosmetic surgery that is not necessary for treating pain or true illness is an affront to Gd and is forbidden.

A Final Argument

As a fitting conclusion to this discussion, we present the ruling of the last major posek to voice an opinion on the subject of plastic surgery. Dr. Abraham Abraham reports the opinion of Rav Shlomo Zalman Aurbach (1910-1995), the great Israeli posek, on the question of whether a person whose arm or finger had been traumatically amputated may have it surgically reattached. This procedure would require general anesthesia, and the patient had already been treated and no longer faced any medical risk. Rabbi Auerbach ruled that the surgery would certainly be permitted (on a weekday, but not on Shabbat), “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 one his published responsa, 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 undergone to allow someone to appear normal, and, more importantly, to view himself or herself 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 to correct an appearance that causes embarrassment, is not an issue of vanity.

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine.