TFN no.5750.3 283-288

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)

 

 

Teshuvah

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 the M. Baba Kama 8:5. 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 gratitudewhich 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 andlive 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”.9Nonetheless, 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 distinguishbetween 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 Feisntein accordingly sees no reason to forbid a woman from choosing that option.12 On the other hand, R. EliezerYehudah 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 ofthat 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 onpsychological 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

  • 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.
  • Gen. 1:28; BT. Yeb. 65b; Yad, Ishut 15:2
  • Ex. 21:10; BT. Ketubot 61b; Yad, Ishut 14:1 ff.).
  • Yad, Chovel 5:1; Sh. A. HM 420:31.
  • The Talmud (Baba Kamma 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.
  • BT Yoma 85b; Isserles, Sh. A., YD 116:5.
  • See SA Sh. A., HM 426 and commentaries.
  • See note 4.
  • R. Moshe b. Nachman, Torat Ha’adam, she`ar hasakanah (Chavel ed., p. 43).
  • Sh. A., YD 336:1.
  • Indeed, as of this writing, the leading manufacturer of silicone-gel breast implants has announced its intention to cease producing them.
  • Resp. Iggerot Moshe, HM II, # 66)
  • Resp. Tzitz Eliezer, v. 11, # 41, end.
  • He cites Prov. 31:30–“grace is deceitful and beauty is vain”.
  • 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.
  • According to current estimates, for example, 120,000 American women per year seek cosmetic breast enlargement (Newsweek, March 2, 1992, p. 75).
  • “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.