Some Modern Responsa on
Plastic Surgery on Down’s Syndrome Children*
Lord Immanuel Jakobovits
By new methods of plastic surgery, it is now possible to give the faces of Down’s Syndrome children an almost normal appearance. The ethical issues involved were discussed at a conference of medical experts and social workers held at Ravenswood Village on June 26, 1983. Among the participants was Professor Gottfried Lemperie, of the Clinic for Plastic and Reconstructive Surgery, Frankfurt, the pioneer of the operation. The text below, an abridged transcript of my contribution, is taken from the Report of the Conference edited by Professor Stanley Segal, O.B.E.
… While in America, in 1961, I was invited by the American Society of Facial Plastic Surgery to contribute to a symposium by representatives of the three major denominations – Protestant, Catholic and myself – on the attitudes of their respective religious beliefs and teachings to cosmetic surgery. In defining our Jewish response to the moral and ethical problems thrown up by the skills we now command in performing such operations, there are, I stated, four major considerations. These then have to be related to the specific issue of performing such operations in Down’s Syndrome cases.
These four are the possible objections that can be raised in the light of Jewish law. First, there is the risk factor. Every operation involves a degree of risk, especially the anesthetic and its effects. Under normal conditions we are not permitted to set our lives at risk, even if the risk is remote, because we are meant to be guardians of our health. For us it is a religious duty to protect our health and to prevent any threat to life. Second, there is our extremely insistent objection to any mutilation of the human body. We regard it as a grave religious offense to inflict an injury not only on others, but equally on ourself. The human body is Divine property. As such we must not violate its integrity. That objection can only be overcome on urgent medical grounds or other overriding reasons. Third, there is the theological argument that by any recourse to medicine we defy the Will of God. This argument has led some to oppose applying Jenner’s discovery of vaccination and others to object to the use of chloroform to ease the pain of childbirth as acts “flying in the face of Providence.” We have never accepted this. We recognize the validity of the argument, but we answer it by claiming that in the Bible itself – after all, the source of all rights as well as their restriction – there is an express sanction given to us to apply medical skills in an effort to overcome suffering. Since in connection with the infliction of injuries the second Book of Moses states: “You shall surely cause him to be healed,” this provides divine sanction for us to interfere with nature in order to overcome the disabilities created by nature. Therefore we have not been troubled with this problem.
Finally, a factor which also carries considerable weight in connection with plastic surgery would be the aversion of Judaism to any form of vanity. Anything done purely to promote one’s vanity, especially by males, is frowned upon. In fact there is an early rabbinic source which speaks of two men whose beauty is especially mentioned in the Bible – Joseph and later Absalom, son of David – and both came to grief on account of their vanity.
Bearing in mind, then, these four considerations, and relating them to cosmetic surgery, I came to the conclusion that such operations could probably, according to Jewish law and principles, be sanctioned only under two major condition: to facilitate mat- rimonial prospects or maintaining the happiness of a marriage, if a disfigurement would be an impediment. That would then be a consideration overriding the objections which I have listed to plastic surgery. Secondly, if otherwise suffering from this disability a person would be prevented from playing a constructive role in society, and in particular from being employed and earning a living to maintain himself and his family in decent comfort.
Above all, of course, if the operation is carried out on purely medical grounds as a therapeutic means to undo an injury inflicted, say, in a car accident, and you therefore apply plastic surgery not to improve nature as it is, but in order to correct a damage done to nature, then it would be an act of healing, and as such it comes under the general sanction mentioned earlier.
The same consideration would, broadly speaking, have to be transferred to our specific area of Down’s Syndrome. One would presumably have to analyse and define very carefully who is to be the main beneficiary of such operations. Is it the patient himself, the afflicted child? Do we improve the child’s opportunity for living a normal existence, relating better to those around him, his family and society? Or is the objective primarily not the child at all but others, the family who will feel it easier to cope, or his environment who would feel more at ease by the patient having certain de- formities corrected through plastic surgery?
Now, under no circumstances would we ever sanction such a procedure unless the primary beneficiary would be the patient himself. You cannot carry out an operation on one person to make life easier for others. So let us assume that it is done primarily with focus on the patient. Now again we must very carefully define here what are the objectives in relation to that child to make sure that what we hope to achieve is to “correct” nature, by facilitating his integration, his acceptance by society, or perhaps even his use- fulness in terms of the contributions to others he might more easily make due to plastic surgery. If however, these objectives are not served, then we would be hesitant to countenance the operation. I have not had the chance to read the professional literature on the subject or to hear the argument in favor of it. I am merely analysing here the pros and cons as they strike me. If it transpires that this is not related to easing that child’s life, as expressed in its relation- ships, its acceptance and possibly its usefulness within the family and society around him, then it would be highly questionable whether the operation is justified in being imposed on the child for the sake of the benefits achieved.
I gather that as of now marriages in Down’s Syndrome children have not taken place or are certainly not the norm. But if it were scientifically feasible to contemplate removing such a disability, by making possible the establishment of unions which under existing conditions are partly ruled out by physical appearance, then again this would be a very major consideration in favor, just as it is in the application of cosmetic surgery in general. On the other hand, it may well be that as a result of carrying out such an operation the temptation to marry or to be married, will be so increased as to make the tensions greater rather than smaller in not being able afterwards to fulfil the desire for marriage. In other words, you may only add to the agony, if in fact marriages could not be con- templated for other reasons, and plastic surgery would only increase the natural urge for sexual intimacies.
So these are the pros and cons which have to be weighed very carefully to make quite sure that, far from benefiting the patient, one would not aggravate the condition of the patient by creating circumstances in which a resistance to temptation is rendered harder.
Let me conclude by setting forth the moral criteria to be considered in a broader perspective. As you may know, certain genetic conditions are found particularly acutely among members of the Jewish community. For instance, Tay-Sachs is a hundred times more prevalent among Ashkenazi Jews than among others. Some time ago, I appeared on a BBC television symposium on the subject of Tay-Sachs and genetic counseling generally. In the course of the discussion, I also related to some wider implications of the issues raised. I mentioned that certainly from my limited experi- ence, my pastoral experience as a Rabbi, I find that if we speak about the quality of life in terms of contributions a person can make towards society, then no one should say that those who are helpless and merely passively receive the care and attention of others, do not thereby make a contribution to the betterment of society. Indeed they may well contribute more to human ennoble- ment than any other so-called normal person. Maybe that having tenderly to care for such a child, the parents, the family or the professional staff, not to mention institutions as magnificent as Ravenswood and others are immensely enriched. Maybe that such children contribute an element of nobility to refinement of the human heart, to the cultivation of compassion that would not otherwise exist. Therefore, who is going to tell that such children do not make an enormous contribution, enriching the human exper- ience, helping to bring out the recesses of our hearts, qualities of virtues that would otherwise remain locked and undiscovered in the human psyche? We cannot simply use, say, industrial output as the gauge by which to assess the value of a human being, in that he happens to be productive by occupying some important position, either on the factory floor, or, for that matter, in the professions, by using his brain power, or whatever.
Following that remark on television there was a radio “phone-in” program on what I had said, and I will say that the reactions were widely diverse. Some parents of afflicted children under no circumstances were prepared to accept that there was a redeeming feature, a contribution by way of ennoblement in the immense suffering inflicted by the existence of such a child. But the majority of parents went along and said, yes, we discovered something in ourselves by having to take care of such a child, that we did not know we had in us. They agreed that this was a legitimate argument that they themselves could testify to having become finer, nobler, morally more sensitive than they would have been without these children.
Therefore, to the extent that by using all the ingenuity of man, all the skills of modern medicine and surgery in order to ease the lot of those affected, but above all the patients themselves, there could be no objection to plastic surgery on Down’s Syndrome children, provided every reasonable precaution is taken obviously to ensure that the risk factor is reduced to a minimum. But the moment that we find that the anticipated benefits do not mater- ialize then our real concern transcends the consideration men- tioned. We would have the gravest hesitation in sanctioning any intervention with nature which, far from reducing the actual suffering of the patient concerned, might add to it, whether in psychological or physical terms.
Source: ASSIA – Jewish Medical Ethics,
Vol. I, No. 1, May 1988, pp. 12-13
* Introduction by Lord Jakobovitz on p. 77 above.