Should humans be allowed to alter their body in any way they see fit? Is there a point in which a patient’s request is too extreme for the medical profession to perform? What if fulfilling this request would relieve the patient’s mental suffering? Mental health has become a widespread topic in our society today, as doctors investigate how it can severely affect one’s sense of self. This issue is especially prevalent for patients with Body Integrity Identity Disorder (BIID) who feel as a though one or more of their limbs is a foreign object. In a delusion, patients with BIID obsessively think about amputating the limb. They feel over-complete with the limb and see it as hindrance. In consequence, patients with BIID seek out doctors to perform this procedure for them. The question is thus raised: Should these requests be honored? So far, doctors have tried several different treatment options; however, the most effective one has proven to be surgery. Therefore: Should elective amputation be an acceptable treatment? Would this procedure do more harm than good? These questions will be explored through the lenses of patient’s autonomy versus nonmaleficence.
A respected surgeon meets with a prospective patient who has a seemingly outrageous request to remove a perfectly healthy limb. After some questioning, this surgeon comes to learn that the patient has Body Integrity Identity Disorder (BIID), a rare psychiatric condition. The mental body image of one with BIID does not match their physical body, causing them to feel as though one or more of their limbs is a foreign object, one that they want to remove. A person with BIID has such an intense desire to remove the limb(s) that they will seek to amputate it by consulting a doctor. Some even resort to amputating it themselves. Doctors are still trying to determine the cause and best treatments for BIID, but they are not fully in agreement. A question that has created a debate among ethicists is: Should a doctor perform this extreme elective surgery for BIID patients in order to rid them of their psychological burden, or would following through with the request be a violation of their professional oath to do no harm?
Doctors who value a patient’s autonomy above all else have compassion for individuals with BIID. They argue that this procedure is allowable because by granting the patient’s wish, they are relieving genuine psychological suffering. Other medical practitioners argue that if they perform this elective procedure, they will also have to take responsibility for giving someone a disability. Additionally, there exists the fear within these same doctors that by removing healthy limbs, they are doing more harm than good (nonmaleficence); and by disobeying the hippocratic oath their actions could be classified as criminal. Throughout this paper, I will focus on whether amputation surgeries on healthy limbs should be considered a medically appropriate or acceptable treatment for BIID patients, specifically delving into a patient’s autonomy vs. a doctor’s oath to do no harm.
My first goal of this paper is to inform. I will do this through a presentation of background information and facts about BIID. Additionally, I will establish what I see the goals of the medical profession are. This explanatory section of the paper will serve as a foundation for what follows. The second goal of my paper is to present ethical arguments on both sides of the elective amputation dilemma. To do so, I have separated the values autonomy and nonmaleficence into two different sections in which I will pose a multitude of arguments and parallels. My last goal of this paper is to pose my opinion on the subject- that elective amputation should be seen as acceptable for those suffering from BIID- and spark ideas for the future.
Patients diagnosed with BIID have obsessive compulsive thoughts about and a longing for amputation. They are in a state where their physical anatomy does not match their mental body image or sense of their true self causing them to feel over complete. Another way to conceptualize BIID is that it is, “an extremely unusual dysfunction in the development of one’s fundamental sense of who (physically) one is” (First). Likewise, is critical to understand that BIID patients, “don’t see the concerned limb as ugly, they just have the feeling it is not truly belonging to their body” which distinguishes BIID from Body Dysmorphic Disorder (Noll). The diagnosis of BIID has changed over time, as it has been recognized by several names and researched by many people. It was first referred to in 1977 as “Apotemnophilia” by Dr. John Money who considered the condition to be a form of paraphilia. Then, Richard Bruno, a doctor at Englewood Hospital in New Jersey, categorized people with BIID into three groups: “people who are sexually aroused by amputees (‘devotees’), those who use wheelchairs and crutches to make it seem as if they are amputees (‘pretenders’) and those who want to get amputations themselves (‘wannabes’).” Later, Dr Gregg Furth wrote a book which named the disease Amputee Identity Disorder. The current name was established by Dr. Michael B. First who published a study in Psychological Medicine in 2004 (Henig). Dr. First proposed Body Integrity Identity Disorder as an alternative name to Apotemnophilia because he associated the diagnosis as more of an identity issue than one of paraphilia as only a small minority of patients experienced sexual arousal. However, BIID is not formerly recognized in the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) because of its rarity. As First states, “Adding rare disorders to the DSM may compromise its clinical utility by increasing its complexity.” Doctors rely on the DSM as a manual of diagnosis (hence where it gets its name) which increases the importance of including BIID within the DSM as a way of codifying its legitimacy. While BIID is rare, it is a disease that can cause distress, impairment, and risk of death. Most of First’s study subjects were proponents of adding BIID with the hope that it will precipitate doctors to develop treatments. However, before there can be more consideration of including BIID in the DSM, further research needs to be done (First). Further research areas include investigating whether improving psychotherapy would make it more effective or developing new therapies (Noll). Additionally, Tim Bayne and Neil Levy think there is a need for research, “about the nature and aetiology of the desire for amputation of a healthy limb” (Bayne). An article published in 2012 stated that:
There have been approximately 300 documented cases of BIID. Most of these are male, almost all of whom desire amputation of a limb on the left side of the body. More often, it is the arm that is affected rather than the leg. All of these so-called ‘wannabe amputees’ know exactly where they want the limb to be cut off, to the millimetre, and almost all of them remember seeing an amputee at a very young age and thinking that they should have been born like that themselves (Costandi).
The definite causes are unknown but some researchers have proposed that BIID is caused by a malfunction in the right parietal lobe area of the brain. A similar study in stroke patients has linked damage in this region to a person not being able to recognize the affected limb as part of their body image. Doctors Paul McGeoch and David Brang suggest that patients with BIID have something cognitively wrong with their right parietal lobe. To test their hypothesis, McGeoch and Brang examined four male subject with BIID “using a non-invasive brain imaging technology called magnetoencephalography (MEG), which measures the tiny magnetic fields created when neurons fire.” They found that the right parietal lobe responded when they touched limbs that were perceived as normal by the individual, however activity in the lobe didn’t change if they touched the limb wanted gone by the individual. Despite this research, Michael First remains unconvinced that a problem in the right parietal lobe causes BIID because, “The limb that patients want amputated can change throughout their lifetime… ‘That can’t be explained by a cognitive mismapping [of the limb]’” (Callaway). I suggest that further research should be done to see if McGeoch and Brang’s inquires about the right parietal lobe are accurate. If research is done in this area and their findings are reinforced, it could be a breakthrough for finding the cause of BIID.
There are currently debates over what the most effective treatment would be. As defined by Oxford English Dictionary, “treatment” is, “Management in the application of remedies; medical or surgical application or service” (“Treatment”). Elective amputation surgeries have been performed, under the logic that patients have the right to do what they want to do with their body. One doctor, famously known for removing legs from two men and about to perform the same surgery on another until the hospital forced him to stop, is Scottish surgeon Dr Robert Smith (Henig). Patients who received elective surgery as a treatment had positive results, claiming it cured their disorder and relieved their suffering. In a study conducted by Sarah Noll and Erich Kasten, BIID patients who had achieved the handicap they were yearning for were asked a multitude of questions to get insight into their experience. When asked what their motives were, one participant responded:
Since my early childhood I have had an appetence and yearning to live as an leg- and arm-amputee. Lifelong this desire was very strong. Always I imagined to have an amputation beginning from my left thigh and I’ve had this body scheme before my inner view. The yearning for this ideal body image grew with increased age; at last so much, that—in regard to my age—I decided to look for a solution… I only wanted to shake off the pressure and the suffering from BIID and to have a liberate, released and sufficient life in the future. Out of my view, instead of other causes for an amputation (e.g. diabetes, tumor and so on), I was suffering from BIID, which I haven’t had in my grip and which hampered me to live a good life. To get healthy, the amputation was necessary. Already as a child I had seen several amputees, especially in the open air bath, and instantly admired, how they handle their handicap. I was absolutely fascinated and wished to be like these people. I felt drawn to them and felt always well, when I watched them.
Another participant asked the same question answered, “I have no idea how, why or where my wish/need to be an amputee came from and I don’t know the cause either. I believe the desire/wish/need comes from some genetic mix up in my brain. It’s not something I wanted to have to deal with for most of my life (Noll).” Many, including me, sympathize with BIID patients considering that surgery is the only effective treatment in existence.
Scientists who have studied the disease found that amputated patients felt good about their decision: “‘I have never heard of them regretting it,’ McGeoch says. ‘They’re always delighted’” (Callaway). For example, in a survey conducted by Michael First, six patients who had undergone amputation surgery claimed that, “the procedure abolished their yearning to cut off a limb and brought them great happiness” (Mueller). However, critics convey that there is a “looping effect” in which the compulsive thoughts recur with regards to a different limb. Noll and Kasten investigated whether BIID patients who had achieved amputation were satisfied and thought it as a sufficient longer term solution. When asked whether they desired further surgeries, “seventeen out of 20 persons stated that they do not feel a desire for any other surgery” leaving three that wished for another. Although the three participants who did wish for further surgeries “all claimed to have has these desires before their first operation” (Noll).
Additionally, it is essential for doctors to take caution and make sure, “the reasons BIID patients have for demanding amputation are normative rather than merely motivational” (Patrone). In others words, doctors should be careful in checking that their patients’ desire to amputate is derived from their thoughts as opposed to other motives like the hope for attention or disability payments. Furthermore, patients who have tried to treat their disorder with “traditional psychotherapy and medication, such as antidepressants,” said it had little or no effect on the desire for amputation (Mueller). People in First’s study who received these treatments saw little change or influence on their symptoms and desire for amputation. However, it is important to note First’s admittance that subjects in his study, “had not received ‘psychotherapy tailored to this disorder’ or ‘high sustained doses’ of medications that were used to treat related conditions like obsessive-compulsive disorder” (Henig). Moreover, First proposes that an area of future research is to examine the effectiveness of tailored psychotherapy and mediation on a BIID patients suffering (First). Similarly, Dr Spiegel pushes for response-prevention and thought-stopping psychotherapy as he thinks they will be effective treatments; however, unlike First, Spiegel doesn’t think elective amputation surgery should be accepted. (Henig).
Although individuals with BIID may be suffering on the inside, they may appear to be “normal” to the outside world. According to Dr. First, patients are highly functioning: they have families and are able to hold jobs, so it is hard to detect that they have this delusion. Dr Spiegel adds, “‘It’s often the case that people with this kind of delusion would pass a mental status screen’” (qtd. in Henig). With this being said, distressing thoughts of these individuals can “disrupt their social life and distract them at work” (Müller). Besides the difficulty with detecting BIID using tests, it is often the case that individuals with BIID hide their desire from family and society. It is rare for a BIID patients to open up about their struggles because of they fear they will be judged. Even though BIID patients, “do not show any psychotic symptoms”, there still exists a stigma that those with this disorder are psychotic (Noll). Because BIID is associated with shame and disapproval, the desire “is almost always kept secret, even from close relatives, because most people simply can’t empathize with the desire to be an amputee. A shocked response to a childhood confession often leads one to go silent for the rest of their lives” (Tsoulis-Reay). According to Dr. First, individuals who have opened up to relatives or friends often don’t get the response they need to feel supported and understood (Sulim). Not sharing is a defense mechanism.
Lastly, in desperate efforts to force surgical amputation, individuals with BIID have attempted self mutilation through the use of homemade guillotines, dry ice, chain saws and guns. The insatiable urge to remove a limb has also caused individuals to seek out amputation abroad (Henig). In Noll and Kasten’s study, ten had surgery (for most, this was done in a foreign country), eight created a deliberate accident, and one had a real accident to get rid of their unwanted limb. Yet, all participants first tried to avoid surgery and resist the temptation through other means including psychotherapy, medication, or relaxation techniques. They were conflicted about whether amputation would cause harm which is consistent with how doctors feel about this subject.
Goals of Medical Profession
One ethical principle, adopted by the medical profession when the hippocratic oath was written, is that of nonmaleficence. The hippocratic oath is a pledge taken by medical professionals, where they state their obligations and responsibilities to their patients and medicine. Perfectly summarized by Britannica “In the oath, the physician pledges to prescribe only beneficial treatments, according to his abilities and judgment; to refrain from causing harm or hurt” (The Editors of Encyclopaedia Britannica). A doctor’s first responsibility is to do no harm to their patients. Before continuing, it is important that I define “doing harm” because the phrase has different meanings for different people. Harmful care is where the pain or suffering endured is higher than the potential reward. This puts a lot of responsibility on the doctor to decipher whether a treatment is helping their patients more than it’s hurting them.
In addressing the goals of medicine, the Hastings Center Goals of Medicine project came up with four goals of medicine. One goal of relevance is, “the relief of pain and suffering caused by maladies” and another is for, “the care and cure of those with a malady and the care of those who cannot be cured” (Anderson). Suffering is another word that has multiple interpretations. According to the Oxford English dictionary suffering is defined as “The bearing or undergoing of pain, distress, or tribulation” (“Suffering”). Suffering can be both physical and/or mental and creates hardship for a person to function. The reason why doctors aim to relieve their patients’ suffering is because they have compassion for the patient and they have taken an oath to do so. Relieving suffering creates more comfort for the patient. Currently, there is a big focus on the quality of care and comfortability of the patient.
Another debate among ethicists that is relevant to the practices of the medical profession is the differentiation between a necessary and unnecessary procedures and the true definition of health. While I will not be engaging in this debate for my argument, it’s important to establish that many, including doctors, see amputation surgery on BIID patients as unnecessary because it is elective. Unnecessary defined by the Oxford English dictionary means “without construction” (“Unnecessary”). Many of those who hold this opinion disregard elective amputation as an acceptable request. They argue that refusing the surgery does not cause any life or death risks to the patient; however, some refute that this argument as inaccurate. By preventing BIID patients from getting the amputation safely, doctors increase the risk for patients to look for sometimes fatal alternatives. A claim to consider is that those with BIID are not truly healthy prior to amputation because of their unstable mental health. Health doesn’t have a straightforward definition at the moment as doctors discover that individuals may be physically healthy but not mentally healthy. While health is a complex topic, it is important to emphasize that physical health is not necessarily more important than mental health. As a society, we put a great deal of emphasis on physical health and often discredit the importance of mental health. In some cases, mental health issues can cause more suffering than the lack of physical health, which is why prioritizing physical over mental health is a slippery slope.
The first ethical principle I want to consider is autonomy, which prioritizes an individual’s values, independence and freedom against medical authorities (Müller). To begin, the reason why individuals are allowed to make autonomous medical decisions is because:
A corollary to the basic foundation established by the Bill of Rights is the common-law principle of self-determination that guarantees the individual’s right to privacy and protection against the actions of others that may threaten bodily integrity. [In the medical context, self determination grants individuals] the right to exercise control over one’s body, for example, the right to accept or refuse medical treatment. It is expected that when one freely accepts or refuses treatment, he or she is competent to do so, and is, therefore, accountable for the choices made (Leo).
When arguing whether a BIID patient’s request should be respected as an autonomous decision it is important to defend that they still have decision-making capacities, that is, they have been judged to be competent, and “in spite of possible appearances, no different from conventional, unproblematical candidates for surgery” (Patrone). BIID patients are often mistaken as being delusional because of their belief that amputation will correct their identity problem. However, First debunks this myth as he concluded in his study, “Strictly speaking they are not [delusional], as the individuals always understood that such thoughts were abnormal and they never had a delusional explanation” (First). Similarly, Bayne and Levy agree that wannabes are not delusional given that they recognize the unwanted limb as their own and don’t identify it as someone else’s (Bayne). The request that BIID patients makes for amputation cannot be deemed as unreasonable simply because it asks surgeons to perform a drastic procedure; it can only be called unreasonable if those who ask for it have irrational motives (Patrone). In my opinion, people view the request as unreasonable because of the bias that it is better to address the inappropriate body image rather than to perform surgery on the mismatched body. While ideally it would be great to address the disconnect between the mind and body through treating the inappropriate body image, it is unknown whether this treatment is possible. Another reason why people view BIID patients’ demands for surgery unworthy of respect or consideration is because they claim asking for surgery is an irrational response to their suffering. This argument doesn’t have any basis to it either because as it is understood in the medical context, irrationality is not a reason to deny that a patient is capable of autonomous decision-making. If doctors regarded all irrational requests as non-autonomous requests, cosmetic surgery wouldn’t be able to exist (Patrone).
In giving informed consent, BIID patients must realize that life as an amputee will not be easy. It is necessary that they have an adequate understanding of what the procedure entails, what the likely consequences will be, and how they will have to adapt their life accordingly. Many doctors believe that BIID patients have already checked that box. For example, Carl Elliott, a professor in the Center for Bioethics and the Departments of Pediatrics and Philosophy at The University of Minnesota, who once expressed doubt about allowing elective amputation to take place wrote after speaking to BIID patients, “They realise that life as an amputee will not be easy… [but] they are willing to pay their own way. Their bodies belong to them, they tell me. The choice should be theirs… And to be honest, haven’t surgeons made the human body fair game?” (Patrone). Elliot expresses how his opinion changed based on the argument that if humans have the right to alter their body through cosmetic surgery, then BIID should be allowed to amputate. In this, it is important to address Elective Amputation Surgeries’ relation to Cosmetic Surgery and how doctors treat the cases differently. For cosmetic surgery, patients are allowed to make body modifications based on their desires, even if that desire is coerced. As Bayne and Levy argue:
We allow individuals to mould their body to an idealised body type, even when we recognise that his body image has been formed under the pressure of non-rational considerations, such as advertising, gender-norms and the like. If this holds for the individual seeking cosmetic surgery, what reason is there to resist a parallel line of argument that those seeking amputation? (qtd. in Patrone).
Furthermore, BIID patients criticize the stigma against elective amputation by displaying the inconsistencies that exist in the medical field:
Surgeons commonly accept demands to have what are often extensive procedures for reasons that are often socially questionable and probably irrational, as evidenced by the popularity of cosmetic surgery. In cases of cosmetic surgery, however, whether or not the patient’s motivations are rational is taken to be irrelevant to their ability to make this decision. To deny BIID patients’ self demands for amputation, then, is seen as simply inconsistent with how we treat other similar demands for surgical alteration to the human body (Patrone).
It is important to question what a doctors motives are if they don’t inquire whether a patient’s request for cosmetic surgery is rational or not. Although the American Society of Plastic Surgeons claims, “70 percent of survey respondents said they would refuse to perform cosmetic procedures in a patient they suspected of having BDD,” that still leaves 30 percent up to chance (“Body Dysmorphic”). It is often the case that cosmetic surgery is encouraged by society. For example, in a book published by the BIID advocacy group Ampulove, a self-described “ex-wannabe” recounts her cosmetic surgery experience where she was empowered to undergo a variety of surgeries some of which she wrote:
[C]ould have serious effects on my life while others are intended to alter my appearance in ways I hope to find pleasing, but what all have in common is availability on demand. If I can pay for them, I can have them. The medical community’s position on this is, it is my body, and I am entitled to alter it in accordance with my notions of how it ought to look.
By treating cosmetic surgery different from elective amputation, medical practitioners are being unfair. However, this parallel lacks to include the point that cosmetic surgery does not guarantee permanent disability. While some consider cosmetic surgery a harmful surgery, they argue this doesn’t justify encouraging surgeries that are even more harmful. This argument objectively sees elective amputation as more harmful than cosmetic surgery. Therefore, this parallel can only establish that the medical field shouldn’t consider all irrational requests as non-autonomous requests; it can not institute that the medical field respect irrational and seriously harmful demands as acceptable treatment (Patrone).
One important viewpoint to consider is empathy and compassion for BIID patients. While we do know that these individuals internally suffer, it is impossible for us to judge if the suffering is bearable or not. The degree of suffering and degree of pain toleration is different for everyone. Suffering is a subjective subject; it is difficult for anyone other than the subject to decide how much suffering has been endured. Therefore, we can not base our decision of whether amputation is acceptable or not based on suffering. Many who dispute amputation as an acceptable treatment, insist that a patient’s quality of life will be diminished post-amputation and that they will suffer more with a disability. However, patients with BIID feel quite the opposite as they state amputation would allow them to be, “‘able-bodied and more fully functioning, more whole and more complete’” (First). By denying amputation, doctors are not taking into consideration that patients with BIID are arguably living with another disability in the form of an emotional and/or intellectual barrier.
Some argue that because there is a lack of alternative effective treatments, combined with the potential that elective amputation does alleviate internal suffering, doctors have a moral obligation to perform such surgery. Throughout this section, I have argued that BIID requests should be respected as autonomous choices because these requests are for the relief of suffering and should be “regarded as based on good normative reasons”. Others disregard autonomy and argue that “it is obligatory to provide the amputation to BIID patients simply on the grounds that this is the only effective treatment for the alleviation of suffering” (Patrone). We have to recognize that a BIID patients suffering is real; even if they are repeatedly refused treatment, many will persist in achieving amputation by taking matters into their own hands. Those who support harm minimization like medical ethicist Tim Bayne state that, “If the desire for amputation is long-standing, the patient is not psychotic, and he is well aware of the risks and consequences, surgery is ethically permissible because it will prevent many BIID patients from injuring or killing themselves” (Müller 2009). Additionally it is argued that, “Offering a clean surgical amputation to those BIID sufferers who really want it would therefore minimize the harm that they might cause to themselves by taking matters into their own hands” (Costandi 2012).
A similar surgery that recently has been accepted more broadly is gender reassignment surgery for those with Gender Identity Disorder (GID). There are many similarities between the two disorders. The most prominent is that patients with both conditions report “feeling uncomfortable with an aspect of their anatomical identity”. For those with GID they feel they were not born with the biological sex that matches their gender, for individuals with BIID they feel one or more of their limbs does not belong to them. This uncomfortability can lead one to bear an internal struggle in which they don’t feel a connection or attachment to their body. Other similarities include that both conditions are onset in childhood or early adolescence; subjects in both cases have stated the most successful treatment is surgery and sometimes people with the disorder try to mimic the desired identity people. For patients with Gender Identity Disorder, expression of the desired identity is done through cross-dressing whereas people with BIID pretend to be an amputee (First). A major difference between the two surgeries is that removal of a limb involves disability. Arguably, because BIID affects a patient’s ability to function daily, they are already living with a disability (an intellectual barriers rather than a physical one). However, I feel many people disregard this fact when differentiating the two. A possible reason why it’s easier to accept sex reassignment than it is to accept an elective amputation surgery is because with sex reassignment one is going from male to female or vice versa, objectively looked at as two normal states; however, with elective amputation one is starting as a healthy four limbed person and becoming an amputee by choice. Currently, people have a hard time not stigmatizing a BIID person’s choice to remove a limb.
Firstly, it is important to emphasize that autonomy has its limits. Autonomy means that, “patients have the right to choose between different medical therapy options regarding their different chance and risks as well as their personal situation and individual values.” Often people misinterpret autonomy to mean patients have the right to request any treatment they want; however, according to Beauchamp and Childress, “Patients do not have a demand to receive therapies by physicians that contradict medical principles.” A physician’s main responsibility is to evaluate a medical situation, use their expertise, and subsequently advise their patient what their best treatment options are. Beauchamp and Childress believe that limits on autonomy include if a patient is “immature, incapacitated, ignorant, coerced, or exploited” (qtd. in Müller). If a patient is in such a circumstance, they need not be regarded as competent. I agree that these limits should be maintained in all cases because to diminish the possibility of doctors promoting self harm or causing harm themselves. Moreover, if these limits were not upheld, there would be a greater possibility that patient’s would make decisions there are not truly autonomous. Therefore, two ideas emerge from this argument: first, patients autonomy does not extend to requesting treatments that violate the hippocratic oath and second, there must exist an established trust between patients and doctors. Doctors don’t necessarily know what’s best for the patient as an individual, but they do know what the legitimate treatment options are.
Another question that arises is which is the worse of two evils: operating on the patient to ensure they have the procedure done in a safe environment or refusal to do so which escalates the possibility of a patient venturing out to get the operation done through other means?
One can argue that if the doctor decides to be passive and not remove the limb, the patient taking it upon themselves to self mutilate is not the doctors responsibility. A way to put this in perspective is by asking the question: Can a doctor be held responsible for everything a patient does outside of their office? My opinion is no, because it is unfair to put such an extensive amount of blame on a doctor. Once again, it is important that society has trust in the medical profession. A doctor may choose to decline performing surgery because they don’t think it is the right treatment option, not because they have mal intent in refusing treatment. An example is when a doctor declines to use chemotherapy to treat a cancer patient because they think it will do more harm to a patient than good. Similarly, doctors who refuse elective amputation surgery don’t think it’s the most optimal treatment option. A consideration that this parallel doesn’t account for is that BIID patients have constant compulsive thoughts which increases their chances of taking further action. One can say a doctor does have the responsibility to suggest other treatment options like psychiatry because their patient’s action are influenced by their thoughts; however, a doctor cannot always offer a patient what they want.
If the doctor decides the best course of action to take is to remove the limb, they have to argue that they are relieving suffering instead of doing harm. A fact in the matter is that amputation is irreversible; once the surgery is done, the patient has to live the rest of their life with that handicap. One main claim often made against amputation is, “Physicians must not perform amputations without a medical indication because amputations bear great risks and often have severe consequences besides the disability… for example, infections, thromboses, paralyses, necrosis, or phantom pain” (Müller). Nevertheless, I am compelled to wonder whether these consequences are necessarily worse than the mental anguish someone with BIID already undergoes. Again, which is the worse of two evils: physical pain or mental pain? In the film Whole, Dr. Smith argues that the real harm is refusal to treat a BIID patients because it is, “‘leaving them in a state of permanent mental torment’” (Henig).
Another facet of the hippocratic oath is that doctors have to be accountable for their actions. Doctors may be liable for the consequences or after effects of their treatment. A proponent against elective amputation surgery Arthur Caplan who is director of the Center for Bioethics at the University of Pennsylvania states that, “from a psychiatric perspective, the desire of a BIID patient to amputate a limb is just as delusional as the desire of an anorexic to continue losing weight. In such cases, the person must be protected by the doctor from his or her own irrational desires” (Mueller). Some psychiatrists hypothesize that patients with BIID suffer from a monothematic (highly specific and singularly focused) delusion similar to anorexics (Müller). Anorexics as well as BIID patients have a disparity between their body image and body type. Additionally in both cases, if the patient’s wishes are honored, serious physical harm would follow. Doctors have the obligation to defend their patient from delusions. The request for amputation, “is not merely a response to the patient’s experience or an attempt to maintain identity”, but rather, “an expression of the disorder itself.” Because a BIID patient’s demand “is directly connected to the underlying disorder that generates that experience,” that demand cannot be seen as an expression of rational agency. The individual is incapable of making coherent decisions for themself therefore a doctor must use their best judgement. Yet it is important to address that the parallel between anorexia and BIID falls short because anorexics wishes can not be relieved by treatment as BIID wishes can. By not eating, anorexics do not gain any long term satisfaction. Their obsession about weight and food intake persists, therefore starving does not alleviate internal suffering (Patrone).
Lastly, after performing this drastic procedure, the physician will have to take accountability for giving their patient a disability. In accepting their patients’ request, they have agreed to use surgery as a means of treatment. This doesn’t settle well with many because of the quality of life concerns for those who are disabled. The Oxford English dictionary defines a disabled person as “having a physical or mental condition which limits activity, movement, sensation, etc. Also occasionally of a part of the body” (“Disabled”). In addressing quality of life concerns one must ask the question: “Is securing relief from this suffering worth the cost of amputation?” (Bayne). Do the ends justify the means when it is unknown whether the benefits will offset the costs? As an amputee, BIID patients will have to adapt to the lifestyle of being handicapped. This lifestyle introduces new limitations and challenges into one’s life including lack of mobility and a financial burden. Furthermore, Sabine Müller presents that, “The amputation desire is conflicting with other desires, especially those for health, painlessness, mobility, and social acceptance” (Müller). There is a possibility that psychosocially an amputee with be received with negative reactions. The reason for this hostility Bayne and Levy suspect, “derives from the sense of repugnance that is evoked by the idea that a person might wish to rid themselves of an apparently healthy limb” (Bayne). Individuals with BIID have to decide what desire they value above all else. Another significant area of impact is the both individuals’ family and society.
In their study, Noll and Kasten asked BIID patients who had achieved their desired handicap what disadvantages emerged. The responses included a variety of positive and negative feedback. Those with problems responded, “Now I need more power and more time. My body changes (I put on weight!), living is more expensive (orthotic-device, wheel-chair, fitting my house and my car to the handicap etc.),” and, “I need the double of time for my personal toilet. I’m sweating more on hot days, especially in the prostheses. Sometimes people found me ugly when I’m without prostheses.” One individual with mixed emotions said:
Rather few. I can’t walk as far (yet) without getting tired and have to use a ‘scooter’ for longer walks. I have had some problems on and off with my prosthesis. I find it harder to walk on a floor that is cluttered (as floors are often by my young grandchildren) or on uneven terrain. But actually my amputation has resulted in only rather minor difficulties and adjustments. And I have enjoyed working to find ways to overcome these minor difficulties.
Positive responses included, “Absolutely nothing. Things I can’t do now without problems are secondary and I’m missing nothing,” and, “Absolutely no disadvantages. With my ‘wheeli’ I can reach every point and can do what I want.” Despite there being some complaints, none of the subjects answered “yes” when asked if they regretted the procedure. According to the Noll and Kasten, “All participants judged their situation as better after the surgery and we found significant improvements in every field.” The fields included general life situation, job satisfaction, private life, health status, sexual satisfaction, and body identification.
Initially, my thoughts on elective amputation surgery were preoccupied with quality of life concerns. In my mind, a handicap would create challenges and struggles that were more unbearable that the mental anguish itself. However, this is a faulty way of thinking because it makes an assumption about the severity of a BIID patients condition without experience to back the assumption. In a similar way, it seems that society portrays the disadvantages of elective amputation to be more harmful than they are for BIID patients. Interestingly enough, Bayne and Levy saw the same pattern as introducing the argument that:
[T]hose of us who are able bodied have an overly pessimistic image of the lives of the disabled. As able-bodied individuals, we might be tempted to dwell on the harm that accompanies amputation and minimize what is gained by way of identification. Perhaps we are tempted to think that the effects of surgery are worse than they are.
This escalation may be to protect people from glorifying amputation, a procedure that has serious consequences. It is important that BIID patients don’t become accustomed to overlooking these consequences because, “One can argue that wannabes have an overly rosy image of what life as an amputee involves” (Bayne). A major question doctors have to consider is whether legitimizing amputation would romanticize it. Would it be harder to distinguish between those who persistently have had the desire and those who may be transient? What slippery slope could develop if we accept elective amputation surgery as permissible?
In my opinion, amputation should be legalized under strict conditions because there is evidence that it has relieved the suffering of those with BIID. In other words, amputation should be permissible as a treatment for those with BIID when no other treatment is seen to help and it is established that the patient has a full understanding of their actions. The reason why I have come to this conclusion is empathy for those who suffer from BIID and my belief that the medical profession’s duty is to relieve their patients of distress and suffering. One point of view that significantly influenced my opinion was presented by Bayne and Levy who stated:
The limb in question is not as healthy as it might appear; in an important sense, a limb that is not experienced as one’s own is not in fact one’s own. Disorder of depersonalisation are invisible to the outside world: they are not observable from the third-person perspective in the way that most other disorders are. But the fact that they are inaccessible should not lead us to dismiss the suffering they might cause.
While I may not be suffering from BIID, I feel it is important to help those who are. However, if scientists or researchers discover that there is an alternative and effective therapy to treat BIID, I don’t think amputation should be an authorized option because as Müller expresses perfectly, “it would be reprehensible to amputate healthy body parts when there is an efficient alternative therapy” (qtd. in Noll). All in all, I believe that elective amputation surgery for BIID patients is an acceptable treatment because as long as no other treatment exists, it does more good than harm by ridding BIID patients of their psychological burden.
An area of research to explore in the future is the possibility of transplantation. Given that the amputated limbs are healthy, they could be a great benefit to people who are without them including those who were not born with a limb or who lost their limb. While alleviating their own suffering, BIID patients would be helping others by becoming living limb donors. According to a paper written by Christopher James Ryan, “Live donors allow timely matching of donor to recipient and the possibility of extremely healthy body parts” (Ryan). The silver lining is that transplantation would be the solution to both hardships.