Aesth Plast Surg (2008) 32:1–10
DOI 10.1007/s00266-007-9040-7
REVIEW
Aesthetic Surgery and Religion: Islamic Law Perspective
Bishara S. Atiyeh Æ Mohamed Kadry Æ
Shady N. Hayek Æ Ramzi S. Musharafieh
Published online: 30 October 2007
Ó Springer Science+Business Media, LLC 2007
Abstract
Background Plastic surgeons are called upon to perform
aesthetic surgery on patients of every gender, race, lifestyle, and religion. Currently, it may seem natural that
cosmetic surgery should be perceived as permissible, and
in our modern liberal age, it seems strange to attempt
justifying certain surgical acts in the light of a particular
cultural or religious tradition. Yet every day, cruel realities
demonstrate that although the foremost intention of any
scripture or tradition has been mainly to promote religious
and moral values, most religions, including Christianity,
Islam, and Judaism, invariably affect human behavior and
attitude deeply, dictating some rigid positions regarding
critical health issues.
Methods A Web search was conducted, and the literature
was reviewed using the Medline search tool.
Results Islamic law closely regulates and governs the life
of every Muslim. Bioethical deliberation is inseparable
from the religion itself, which emphasizes continuities
between body and mind, between material and spiritual
realms, and between ethics and jurisprudence.
Conclusions The rule in Islam is that individuals should
be satisfied with the way Allah has created them. Islam
welcomes, however, the practice of plastic surgery as long
as it is done for the benefit of patients. Even if it clearly
considers ‘‘changing the creation of Allah’’ as unlawful,
Islamic law is ambiguous regarding cosmetic surgery. Its
objection to cosmetic surgery is not absolute. It is rather an
objection to exaggeration and extremism. It has been
mentioned that ‘‘Allah is beautiful and loves beauty.’’
This review was not supported financially by any organization,
pharmaceutical company, or research board. The authors also do not
have any financial or other interest from conducting it.
Religion is a pathway to the practices and thoughts
appropriate to the god(s) of a particular faith [1, 2]. It is not
interchangeable with spirituality, which has a broader
meaning and encompasses philosophical ideas about life,
its meaning and purpose [1, 2]. Unfortunately, its role in
health care seems to be increasing [3].
Incorporating religion with medicine necessarily raises
serious questions of medical ethics [4]. Religious and
medical perspectives are, of course, different and could
come into conflict, although in general they need not be
contradictory [5]. Throughout history, the relationship
between religion and health care has cycled between
cooperation and antagonism. Some of the most advanced
civilizations of ancient times (Assyrian, Chinese, Egyptian,
Mesopotamian, and Persian) equated physical illnesses
with evil spirits and demonic possessions, and aimed
B. S. Atiyeh (&)
Division of Plastic and Reconstructive Surgery, American
University of Beirut Medical Center, Beirut, Lebanon
e-mail: aata@terra.net.lb
M. Kadry
Department of Plastic and Reconstructive Surgery,
Cairo University, Cairo, Egypt
S. N. Hayek
Department of Plastic and Reconstructive Surgery,
University of Minnesota, Minneapolis, MN, USA
R. S. Musharafieh
Department of Hand Microvascular and Reconstructive Surgery,
St Georges University Hospital, Beirut, Lebanon
Keywords Aesthetic surgery Cosmetic surgery
Islamic law Religion
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treatment at banishing these spirits. Since then, physicians
and other health care providers have been viewed by religious groups as everything from evil sorcerers to conduits
of God’s healing powers. Similarly, the views of religion
held by physicians, scientists, and health care providers
have ranged from interest to disinterest to disdain [3].
Although the medical ethics guiding each surgeon currently remains influenced by his or her religious or cultural
background [6], the surgeon still needs to be cognizant of
the varying perceptions of health shared by people of different religious, sociocultural, and linguistic backgrounds
[7–9]. Plastic surgeons in particular are increasingly called
upon to perform surgery on patients of every gender, race,
lifestyle, and religion.
Today, it may seem natural that there should be little
opposition to cosmetic surgery [10, 11], but up to the
start of the 20th century, most religions as well as the
medical establishment were opposed to any form of
surgery for purely cosmetic reasons. Medical ills and
physical disfigurement were considered forms of divine
punishment. It was not permissible to correct what God
had decreed [10].
Certainly, the bioethical problems occasioned by
modern medicine have not been the exclusive concern of
one religion or culture. Patients invariably present with
diverse ethical decision-making models or religious/
spiritual preferences and may not hold Western bioethical views [12]. Moreover, studies have clearly shown
that many patients are interested in integrating religion
with their health care and consider religion to be very
important. They would like their physicians to discuss
religious issues with them [3].
The impact of religious beliefs on perceptions of health
and illness is definitely important for the development of
culturally sensitive and appropriate health care systems [7,
13]. However, it currently seems strange to attempt justifying certain surgical acts in light of a particular cultural or
religious tradition. Nevertheless, the dogmas of most religions, including Christianity and Judaism, deeply affect
human behavior and attitude [11] and dictate some rigid
positions regarding critical health issues. Muslims as well
as other religious communities today face a crisis of
knowledge, or rather, a crisis in connecting knowledge and
faith [14].
Much has been written about Jewish and Christian
medical ethics. Islamic medical ethics, on the other hand,
have not been specifically discussed widely as an independent field of ethics [6]. Paramount to this discussion
must be an understanding of the various schools of Islamic
thought and, most importantly, the mechanisms of jurisprudence and theological decision making that differ
somewhat from what is customary in the Judeo-Christian
tradition.
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Islamic Schools of Thought and Mechanisms of
Jurisprudence
Islam is one of three monotheistic religions [15] and shares
essentially the same code of morality as Judaism and
Christianity despite some doctrinal differences [16, 17].
The most striking distinguishing feature in Islam, however,
is the absence of an organized ‘‘church’’ and ordained
‘‘clergy’’ [6, 16]. In contrast to Christianity and Judaism,
for which doctrinal authority is centralized and in the hands
of one supreme figure or governing body, determination of
valid religious practice and resolution of bioethical issues
in Islam are left to qualified scholars (Ulema). These
scholars are called upon to provide rulings (Fatwa) on
whether a proposed action is forbidden, discouraged, neutral, recommended, or obligatory [6, 16] based on the four
sources of law in Islam (Usul al-Fikh) [18].
A school of thought (Madhhab) is an Islamic term
referring to the paths people follow to the Qur’an and the
Prophet [19]. It is a method of interpreting religious
material [18]. It also is a school of religious jurisprudence
(Fiqh) within Sunni Islam [20].
Over the years, Islam has witnessed several learned
Islamic scholars (Imams), but four of these became more
known, and their teachings spread in different parts of the
Islamic world [21], leading to the four currently recognized
major schools: Hanafi, Hanbali, Maliki, and Shafi’i [20].
The Hanafi School, considered to be the most open to
modern ideas [20], preserves many of the older Mesopotamian traditions, and its rulings are based largely on the
personal opinion of the particular scholar [18]. The Hanbali
School, predominant in the Arabian Peninsula, is the most
conservative of the four schools [20]. The differences
between the four schools of thought manifest in minor
practical details. However, most Sunni Muslims consider
them all fundamentally the same [20].
Currently, there is a strong growing movement against
following the classical schools (anti-madhabist). The
agenda of this movement is a return to the tradition of the
Prophet’s companions (Sahaba), relying mainly on Hadith,
which every individual can read for himself. In some
aspects, this movement appears to represent a traditionalist
new revival [18]. On the other hand, in Shi’a Islam, a fifth
school of thought may be considered: the Ja’fari jurisprudence [19].
In addition to these major schools of thought, various
sects and movements exist within each group. Wahhabism,
for example, is a puritanical and legalistic Islamic movement under the Sunni umbrella often associated with the
Hanbali school [20]. Salafis, on the other hand, advocate a
puritanical and legalistic stance in matters of faith and
religious practice. Salafism is in general opposed to Sufism
and Shi’a Islam, which they regard as heresies [20].
Aesth Plast Surg (2008) 32:1–10
Twelvers (believers in 12 Imams) represent the largest
Shi’a school of thought [20]. Usulis, for their part, are the
largest group of Twelver Shi’a, and they follow the religious jurisprudence of Ayatollahs [20], considering that it
is illegitimate to continue following the controversial rulings of a dead jurisprudent [22].
Thus Islam is not monolithic, and Muslims cannot be
considered a homogeneous group because they have
diverse cultures, customs, and sects, as well as various
schools of jurisprudence. Diverse views in bioethical
matters do therefore exist [1, 7, 16, 23] depending on
whether the scholar making the ruling is a traditionalist
following only the literal meanings of the Qur’an and
Hadith (ahl al-hadith) or is basing his ruling on personal
interpretation and opinion (ahl/ashab al-ra’y) [18]. Irrespective of this apparent distinction, liberal and progressive
movements in Islam have in common a religious outlook
that depends mainly on reinterpretations of scriptures
(Ijtihad). Liberal Muslims believe in greater autonomy of
the individual in interpretation, a critical examination of
religious texts, gender equality, and a modern view of
culture, tradition, and other ritualistic practices in Islam
[20].
The Islamic point of view about any given issue can be
presented from two different perspectives: first, by analyzing the work of various Muslim thinkers, and second, by
attempting to assess the Qur’anic stance directly in the light
of both verbal instructions and practices of the Prophet
[24]. It is a misconception therefore that a Muslim should
follow any given school of thought [21]. All the great
scholars of Islam must be respected, but if any of their
rulings or teachings contradict the Qur’an, they must be
rejected without hesitation, and the Sunnah of the Prophet
should be followed [21].
It is worth noting also that modern medical Fatwas
demonstrate a clear continuity from medieval times.
Companions of the Prophet and classical legal compendia
are cited as easily and as cogently in the 20th century as in
the 10th. Moreover, the mode of argument and classical
terminology often are identical, although the specific issues
have of course changed [25].
Scholars from Islamic universities such as Al-Azhar in
Cairo often are charged with interpreting and contextualizing religious teachings for the wider community [26].
Some of the issues discussed are universal (e.g., abortions),
whereas others are typically Islamic [6]. A proliferation of
complex issues producing ethical dilemmas for health care
professionals, patients, and society has resulted from recent
scientific and technological advances requiring specialist
knowledge and necessitating the somewhat novel concept
of a ‘‘consensus edict’’ rather than classical Fatwa. For
rulings pertaining to medicine, these consensus groups
include in addition to a diverse representation of ‘‘Ulema,’’
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specialist clinicians from relevant disciplines responsible
for providing necessary background information.
The decision-making process is typically transparent,
with members of the wider community able to scrutinize
the arguments used and the textual material underpinning
these edicts. Counterarguments may be presented, and it is
not unusual for two or more seemingly contrasting opinions
to coexist [26]. Instead of defining normative positions,
broadly constructed bounds for discussion are set. The
Fatwa literature is thus characterized by a spirit of lively
debate legitimating many shades of opinion. In principle,
individuals are free to choose whichever judgment they
find most agreeable [25, 26].
Islamic Concepts of Health and Disease
The treatment of illness is difficult enough without
throwing in the added complications of religious and cultural differences [27]. Yet in any society, religion exerts
powerful influences on personal perceptions, attitudes, and
beliefs toward health care and shapes models of care that
patients receive [1, 7, 28]. In recent years, interest in
understanding the effects of religion on health has grown in
the medical and scientific communities [29]. It is no surprise that health care workers in many countries face the
problem of treating patients whose beliefs and behaviors
about health and illness may be completely different from
their own. Muslims are but one of many groups presenting
such a challenge [27].
Islam is far more than a spiritual tradition, for it also has
a societal dimension. Shari’a, or sacred law, is principally
concerned with five objectives: protecting life, safeguarding the freedom to believe, maintaining the intellect,
preserving human honor and dignity, and protecting property [30]. In Islam, all aspects of behavior are regulated by
the precepts set in the Qur’an and the Sunnah [6, 14].
Sacred law is an entity embracing all aspects of human
existence [26, 31]. Human beings are the crown of creation.
They are endowed with reason, choice, and responsibilities,
including stewardship of other creatures, the environment,
and their own health [16, 32]. God plays a major role in
health belief systems, which constitute a holistic framework meeting physical, spiritual, psychosocial, and
environmental needs of individuals and communities [1, 7,
28]. Concepts about the origins, nature, cause, consequences, and interventions of health and disease appear
heavily influenced by strong connections to Islam and its
traditional culture. These affect as well the interplay
between the surgeon and his practicing and deeply religious conservative patient [6, 7].
The world, including any advantages presented by nature or science, belongs to the bounties of God, which must
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be shared so that no one goes hungry, no one suffers illness
when there is a cure, and no one abuses the gifts that have
been entrusted to us [1]. Historically, Islam teaches that
God has decreed all things, good and evil, from eternity, all
that happens, whether obedience or disobedience, faith or
infidelity, sickness or health, riches or poverty, life or death
[33]. Belief in predestination gives Muslims great courage
in times of terrible hardship [33]. However, it is a crucial
problem not only in Islam but also in Christianity. There
has been a long and continuing discussion by theologians
on both sides about whether man has power to act and free
will to choose his action [34].
The conclusion that God has predetermined all things is
what most Muslim theologians believe today [33]. Nevertheless, there are two opposing concepts in Islam: the
concept of predestination and the concept of testing, which
involves a notion concerning some sort of free will that
essentially nullifies the former concept [35].
Muslims understand that illness, suffering, and dying are
part of life and a test from God. A major illness is considered God’s will, and birth defects are regarded as a test
of one’s patience and faith in him. It is a cleansing ordeal,
not a curse or punishment or expression of God’s wrath [1,
15, 16, 32, 36]. With Islam, it is important to understand
that opposites do not negate one another. Both concepts of
predestination and free will are considered equally true
[35]. Although the concept of ‘‘testing’’ is present, God’s
will is never subservient to human will [35]. Thus the
‘‘testing’’ of the believer is reduced to a test of conformity
to the creed rather than a test of the ability to discover what
is right and true by oneself [35]. This explains why the
Muslim so easily says, ‘‘Insha Allah,’’ meaning ‘‘if God
wills.’’ It is the reason also why the illness, accident, death,
or good fortune is said to be from God [33].
Educated Muslims who are trained in modern sciences,
on the other hand, place more emphasis on human
responsibility. They often believe that sickness or poverty
is a simple result of man’s ignorance or laziness. They
prefer to believe that it is God’s will for man to fight disease rather than simply accept it as one’s fate [37].
Although most Muslims appreciate modern medicine and
seek health care, the belief in predestination may lead some
patients not to follow treatment or not even to seek health
care [23]. Moreover, older people, in particular, who have
strong religious and sociocultural health beliefs, might be
relatively resistant to acclimatizing to the ‘‘new’’ modern
universal values and culture [7].
Muslims are expected to be moderate and balanced in all
matters, including health. Health and illness are seen as
part of the continuum of being. Illness is regarded as an
event, a mechanism to purify and balance the person
physically, emotionally, mentally, and spiritually. It is
received with patience and prayers. Death is viewed as a
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journey to meet the creator [1, 16, 23, 31, 32]. Anger,
therefore, is an inappropriate response [31]. However
patients must avoid being fatalistic and are strongly
encouraged, if not obliged, to seek treatment, which should
not be regarded as a sign of conflict with reliance on God
for cure [1, 16, 23, 32]. ‘‘Indeed, Allah has created the
illness and its cure. So treat yourselves O Allah’s worshippers, but do not treat yourselves with something
forbidden.’’ Medications therefore are permissible provided unlawful (haram) prohibited products (alcohol, pork)
are not used [1]. Reported sayings of the Prophet are categorical in that regard [38].
However, for the exempted case of necessity, Islamic
law has a different ruling [38–41]. Necessities overrule
prohibitions [41]. Unlawful ingredients are allowed if they
are lifesaving or prescribed by a trustworthy Muslim
physician, and if lawful alternatives are not available [39,
40]. Others have even ruled that unlawful products may be
allowed parenterally or for topical application [41].
Moreover, ‘‘transformation,’’ causing a material to change
into another, with totally different properties and characteristics, turns prohibited substances into products
permissible by law [41].
The Holy Qur’an achieves its healing and health-promoting effect by legal legislations prohibiting hazardous
lifestyle and behavior, stressing behaviors that promote
health (moderate eating; abstinence from consumption of
alcohol, tobacco, and other psychoactive substances; regular exercise; prayers; fasting; ablution and bathing;
breastfeeding; and many other injunctions). It provides
general rules and regulations to guide individuals in conducting their daily lives. It also has direct healing powers;
‘‘a healing and a mercy to those who believe.’’ Anyway,
prayer remains the salvation in both health and sickness
[1].
Islamic Bioethics
Ethics can be described as a subbranch of applied philosophy that seeks what is the right and the wrong, the good
and the bad set of behaviors in a given circumstance.
Bioethics, however, is a quasi-social science that offers
solutions to the moral conflicts arising in medical and
biological science practice [42]. The four ethical principles,
namely, ‘‘respect to autonomy,’’ ‘‘justice,’’ ‘‘beneficence,’’
and ‘‘nonmaleficence,’’ have almost always existed and
govern the ethical behavior of human societies. They are
universal age-old commonsense principles applicable to
any culture and society including Islamic traditional societies [42].
Irrespective of this generalization, appreciation of
beliefs, perspectives, and conceptual frameworks are of
Aesth Plast Surg (2008) 32:1–10
paramount importance and central to discussions concerning medical ethics. If secular Western bioethics has been
described by some authors as rights based, with a strong
emphasis on individual rights, Islamic bioethics is based on
a combination of principles, duties, obligations, and rights
as well as on virtue to a certain extent [6, 16, 26]. In Islam,
Ijtihad (law of deductive logic) governs bioethical decision
making carried out within a framework of values derived
from revelation and tradition. Islamic bioethics is an
extension of Islamic law (Sharia), which is based on the
Qur’an (holy book) and the Hadith and Sunnah (Prophet’s
words and acts) [16, 23, 26, 43]. The holy book is believed
to be the eternal word of God revealed to the Prophet. The
Hadith and Sunna also are accepted as truth [23]. The Shi’a
branch of Islam has in some cases developed its own
interpretations, methodology, and authority systems, but on
the whole, its bioethical rulings do not differ fundamentally
from the Sunni positions [16].
Bioethical deliberation is inseparable from the religion
itself, emphasizing continuities between body and mind,
material and spiritual, and ethics and jurisprudence [16].
The Qur’an, Hadith, and Sunnah have laid down detailed
and specific ethical guidelines regarding various medical
issues [16]. Islamic bioethics emphasizes prevention.
However, when prevention fails, it provides guidance not
only for the practicing physician, but also for the patient. It
teaches also that the patient must be treated with respect
and compassion and that the physical, mental, and spiritual
dimensions of the illness experience must be taken into
account [6, 16]. On the other hand, physicians must
understand the duty to heal, acknowledging at the same
time that God is the ultimate healer [16].
Islam recognizes that there is nothing in the creation that
was created for naught. ‘‘And know that We have not
created the heavens and the earth and all that in between
them in mere idle play’’ (21:16) [14].
Moreover, one of the central emphases in the Qur’an is
that God had faith in Adam and trusted that humankind can
and will achieve goodness on earth. Furthermore, God gave
man knowledge not imparted to other creatures to benefit
humankind as a whole, regardless of race, color, or social
status. The knowledge we acquire comes with God’s ‘‘help,
guidance and will’’ [14]. God ‘‘knows all that lies open
before men and all that is hidden from them, whereas they
cannot attain any knowledge except that which He wills
them to attain’’ (2:255).
5
‘‘Verily, we did offer the trust to the heavens, and the
earth, and the mountain; but they refused to bear it because
they were afraid of it. Yet man took it up’’ (33:72) [14].
Thus there exists no conflict between science and Islam
[14]. Anyway, a scientific medical approach does not
preclude a religious perspective [5]. However, when science operates in an ethical vacuum, when it fails to assess
whether its achievements are detrimental to the many or
beneficial only to the few, a serious situation ensues [14].
Moreover, social organizations in general negate scientific
and technological achievements by restricting their benefits
to selected sectors of the community [14]. Anyway, Islam
considers acquired scientific knowledge as a responsibility
and a trust, given and accepted by the human, to be applied
to the betterment of mankind, for doing good deeds, preventing evil, and addressing the misery and suffering of all
[14]. Yet it must be accompanied by compassion, kindness,
and generosity [14].
Attempting philosophical and theological justifications
for certain surgical decisions, such as extensive skin
grafting for severe burns, is one thing, but it is quite
another thing to justify elective procedures [11]. Islam,
however, has the flexibility to respond to new biomedical
technologies, and because it shares many foundational
values with Judaism and Christianity, the informed physician of Judeo-Christian background will find Islamic
bioethics quite familiar [16].
Patient–Physician Relationship in Islam
In this age of globalization, more and more members of
different religions and cultures live in the same society.
This situation tends to create many conflicts in different
areas of life and not least in the health care system, a fact
that raises a number of bioethical issues. The cultural and
religious differences between patient and physician can be
a cause of bioethical conflicts and therefore can represent a
challenge for biomedical ethics [44].
Health professionals have a dual responsibility to their
patients: to ‘‘do no harm’’ (nonmaleficence) and to act
according to the best interests of each patient (beneficence)
[4]. In an ethical conflict between two individuals who are
members of different cultures, it is necessary to make sure
that the ethical concept to be used for resolving the problem
is relevant. In this particular case, both the Islamic legal
responses (fatwa) and the classical theories of biomedical
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ethics are often insufficient [44]. A minimum level of cultural awareness is a necessary prerequisite for the delivery of
care that is culturally sensitive [45]. The long-standing
aspect of modern medicine requires that health care professionals distance themselves from any purely religious issues
that may arise in the context of their duties. This certainly
demands that such professionals forbear from promoting or
challenging religious beliefs, whatever their patients may
want in the way of medicospiritual counseling [4].
The continuous developments in medicine and, consequently, in medical ethics, create new questions for Muslim
physicians, medical jurists, and religious authorities [46].
At the center of medical morality is the healing relationship.
In today’s pluralistic society, universal agreement on moral
issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics
based on a new appreciation of what makes for a true
healing relationship between patient and physician is both
possible and necessary [47]. Health care practitioners must
actively support their patients’ diverse religious beliefs and
practices without hypocrisy, without offending patients who
do not subscribe to certain of such beliefs, and without
offending atheists, agnostics, and religious nonaffiliates [4].
Muslim jurists over the ages have adopted a somewhat
enlightened opinion with regard to the patient–physician
relationship. They have acknowledged that religiously
concealable body parts of both men and women should be
concealed from men and women alike, a statute that is
waived, however, only for the purpose of medical treatment. Therefore, medical examination entailing inspection
of the body of the opposite sex is legitimate in Islam
whenever it is considered a necessity [48]. Exceptions are
rare, abnormal, and minimized still by the rules of Islamic
medical ethics that make the presence of a third party (e.g.,
nurse) mandatory when a doctor examines a patient of the
opposite sex [48]. Some, however, argue that a male physician may inspect the religiously coverable parts of a
woman’s body that medical examination warrants, as long
as no one else but a man is available to treat her, even if he
has to look at her genital area. The same is true if a man is
ill and only a female physician is available [48]. In the
modern resurgence of Islam, some hardliners, however,
still may feel uneasy even with the permissible exception
on account of the ‘‘necessity’’ status of medical practice
and seem to linger too much at phrases such as ‘‘only if
necessary’’ or ‘‘if only a male doctor is available’’ [48].
Individuals who embrace the Islamic faith are likely to
define a good physician as one who addresses issues of
faith and spirituality as well as biologic needs in the clinical encounter [5, 49]. Not infrequently, a female patient
may express her desire to be examined only by a female
physician. It is understandable that every effort should be
made to satisfy her wish, not because it is religiously
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forbidden for her to be examined by a man, but because it
is a duty to respect patients’ personal beliefs and cater to
their psychologic comfort [48].
Islam and Aesthetic Surgery
There is a balance and perfection in the creation and in
nature that must not be ignored: ‘‘He Who created the
seven heavens one above another: No want of proportion
wilt thou see in the Creation of Allah Most Gracious. So
turn thy vision again, do you see any flaw?’’ (67:3) [14].
‘‘We created Man in the most perfect form’’ (95:4) [26].
These dictums stress that each human life has its own
inherent value and goodness but may theoretically render
any further improvement in one’s appearance rather
unconceivable. Not denying the capacity for autonomy and
self-determination, in cases of absolute necessity wherein
religiously lawful alternatives do not exist, Islamic teachings, as presented earlier, allow even for sacred law to be
suspended, temporarily: ‘‘But if one is compelled by
necessity, neither craving nor transgressing, there is on him
no sin, for indeed Allah is Clement, Merciful’’ (2:173) [26].
It is imperative, however, that any alteration of creation
be addressed with the utmost care. Moreover, one must
remain vigilant so that the market for ‘‘altered creation,’’ be
it genetically modified crops or aesthetic surgery, may
remain mercy driven, not profit driven [14].
Aesthetic surgery is spreading fast in Muslim countries.
Is it to be condemned as a futile luxury, or is it answering to
a real physical and psychological need [50]? Well-informed
scholars divide plastic surgery into two categories:
1.
2.
Essential surgery genuinely needed to correct congenital or acquired defects. Such surgery is permissible
because it is not meant to change the creation of God
[51–53]. Many hold the opinion, however, that this
provision allows the improvement of an ugly appearance causing physical and psychological suffering [52].
Surgery performed for beautification. Such surgery is
unnecessary and is therefore unlawful (haram) and not
permissible. The body given to us is a trust and ‘‘changing
Aesth Plast Surg (2008) 32:1–10
the nature created by Allah’’ is a sin inspired by Satan
(Shaytan) [51, 52, 54]. Moreover, when a person follows
Islam both in letter and in spirit, he must thank God for
what he has been blessed to receive and must not
complain about what he does not have. More recently, it
has been ruled that beautification used to reshape a
deformed part of the body is generally recommended in
Islam, as long as it is used for a valid reason [51]. Some
scholars, on the other hand, report that surgeries for
beautification are the result of the materialistic pattern
followed by Western civilization, whose main focus is
the body and its desires. Standards set by Hollywood,
sports stars, and the media are the main driving force
behind their increasing popularity. Men and women
more preoccupied with form than with substance, with
body than with soul, indulge in excessive beautification
and reshaping of their bodies, unnecessarily changing
what God has created and subjecting themselves to
torture, pain, and waste of money [50, 51, 55].
Mutilation of one’s body also is clearly prohibited in Islam.
Cosmetic surgery may be considered as deliberate selfmutilation, which indeed some failed cosmetic surgeries
may be. It also may be considered a form of oppression that
can be damaging to women’s freedom and potential for
development [52, 55, 56]. Conservative scholars have even
ruled that medical students are allowed to learn cosmetic
surgery, but that they should not perform it in unlawful
cases. They should rather advise patients against it. Perhaps
their advice may have a stronger effect [51]. Moreover,
surgeries meant to disguise criminals are impermissible.
Sex change operations and giving in to stray whims also
are definitely prohibited. However, operations to decide the
sex in cases of pseudohermaphroditism are allowed [54].
On the other hand, it has been ruled that because there is
no explicit directive forbidding plastic or cosmetic surgery,
nobody has the right to forbid what God (and his Prophet) has
not forbidden. It has been ruled as well that in the case of an
unusual physical defect attracting the attention of others and
causing physical and psychological pain, a person may seek
treatment to alleviate his embarrassment. ‘‘Allah, the Most
Merciful, has imposed no hardship on us in religion . . . .’’
If the surgery is needed to eliminate pain or distress or offers
a better quality of life, it cannot be considered unlawful and
must be allowed [5]. It is reported as well that the Prophet has
said that ‘‘Allah is beautiful and loves beauty’’ although
theological interpretation of this saying may give it a different meaning than what is apparent [57].
Conclusion
Many health care providers and many hospitals have an
overtly religious perspective or mission, yet they deliver
7
evidence-based medical care [5] irrespective of their
patients’ religious affiliation. Nevertheless, many physicians seem to agree that spiritual well-being is an important
component of health and that it should be addressed with
patients. However, only a minority do so with any regularity [58, 59]. Surveyed physicians blame lack of time,
inadequate training, discomfort in addressing the topics,
and difficulty in identifying patients who want to discuss
spiritual issues for this discrepancy [3, 60]. Moreover, there
is considerable debate over how religion should be integrated with health care and who should be responsible,
especially when health care providers are atheists or belong
to a different religious group [3, 61].
Achieving cultural competence in caring for a patient
who is a member of a different religious, ethnic, or racial
minority is a multifaceted project involving specific cultural knowledge as well as more general skills and attitude
adjustments to advance cross-cultural communication in
the clinical encounter [5]. One approach to improving the
cultural competence of physicians focuses on general,
attitudinal, and organizational shifts as well as on the
application of general methods for communicating across
different cultures [5, 62, 63]. However, establishing an
understanding and acceptance of each patient as an individual helps to create an environment in which the patient
can receive culturally acceptable care and treatment [64,
65].
In general, it should not be difficult for physicians and
other care providers to show courtesy to patients’ religious
beliefs without compromising evidence-based health care.
In rare circumstances of extreme belief, there may be direct
conflict between evidence-based medicine and religious
belief, and this should be approached with tact and with
community resources [5].
Religious and moral consensus, however, even within
the same culture, is neither easily achievable nor applicable
[11]. Furthermore, religious belief and practices may vary
widely among individuals, even within the same religion or
specific denomination [5]. Highly organized religions or
beliefs with a centralized governing body can collectively
express their stance on any arising issue whenever it is
required. For Muslims, however, there can be no collective
unified stance, other than a few declarations issued by Ulamas of certain countries. These are simple ‘‘prohibited’’
or ‘‘allowed’’ (haram or halal) declarations for given
products or technologies without explicit information or
justification.
Muslims’ attitudes toward ethical issues, contrary to
what may be assumed, are pragmatic, seeking a compromise between Islamic heritage and achievements of
modern medicine, as long as basic Islamic dogma is not
violated [6]. Whatever the tradition and its specific and
implied teachings, the basic questions remain what it
123
8
means to be human and to perform surgically moral acts.
Various religious traditions definitely rate physical
appearance differently, affecting perceptions about the
moral rightness or wrongness of types of surgical procedures. However, it is very clear from developments in
technology and its global expansion that we cannot survive
the 21st century with 20th-century ethics [65, 66].
Islam welcomes plastic surgery as long as it is performed for the patient’s benefit. Unfortunately, certain
scholars consider some forms of cosmetic surgery as performed for luxurious purposes and not for sound legitimate
reasons [51]. In Islam, instead of being preoccupied with
the body, the individual should be satisfied with the way
God has created him or her and should give time to worshipping and doing righteous and charitable acts [55].
Islamic law regarding cosmetic surgery, however, is
ambiguous. Objection is not absolute. It is rather objection
to exaggeration and extremism. Whenever there is genuine
need, there may be a dispensation of permissibility. In the
opinion of many, not more than 5% to 10% of cosmetic
surgery is irrevocably unlawful [51, 52].
We have personally operated on a large number of
Muslim patients, some very conservative, even royalties in
countries with strict Islamic laws. Their wishes, desires,
and requirements did not differ in any way from those of
non-Muslims. As long as the patient is willingly, rightfully,
and legitimately requesting cosmetic surgery, it is the duty
of the surgeon to fulfill this request to the best of his or her
abilities. Naturally, the surgeon must be aware of certain
cultural restrictions. Moreover, because women generally
make up the majority of any cosmetic surgery practice,
plastic surgeons need to be overly cautious when examining a Muslim woman. The issue of women in Muslim
culture is a complex one, and it is important that health care
professionals be nonjudgmental and respectful of their
traditions and customs [67].
A physician’s comfort level with his or her spiritual
beliefs should not dictate competency of knowledge on
various spiritual and religious practices. With very little
effort, families’ and patients’ wishes, culture, and customs
may be respected at all times, and one may be supportive
by respecting culturally or religiously motivated rights and
rituals [12]. Several ethical dilemmas regarding case
selection, allocation within the law, medical problems, and
economic sources must be confronted [68]. The basic
question remains, however, how to enforce international,
universal human rights standards while protecting cultural
diversity and respecting and supporting cultural, spiritual,
or religious preferences [12, 69].
On the whole, 21st-century biomedical issues are very
complex. It is hence important to understand fully the
technological, economical, political, and spiritual issues
surrounding the life science controversies instead of issuing
123
Aesth Plast Surg (2008) 32:1–10
mere statements of ‘‘halal’’ or ‘‘haram’’ [53]. Anyway, one
cultural tradition cannot be said to be better than another.
With further education and knowledge, cultural and religious smoke screens around the real reasons for maintaining
certain positions or practices can be overcome in all societies no matter what their cultural background [70].
In Islam, there is a duty to work for decisions that can
ease the suffering in the world without harming humankind
and the world humans inhabit [14]. Moreover, a comforting
aspect of Islam is its general respect for logic providing the
framework for the notion that there is a range of logical
approaches available to different people, each of which is
appropriate to different levels of society [71].
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