Amputee Wannabes: the Data About the Desire to Lose Limbs

In large part as a result of the oft cited article by Carl

Elliot entitled "A New Way to be Mad" from Atlantic Monthly, there is considerable debate these days about a condition called body integrity identity disorder or BIID. Those with the condition seek, to put it simply, to have part of their body removed, most typically a limb. Reviewing a philosophy article today, Australian Broadcasting Corporation discusses a study that hasn't even been accepted for publication but which is interesting fodder for conversation:

The first person to use the term BIID was US psychiatrist Associate Professor Michael First from Columbia University, who interviewed 52 wannabes as part of a recent study which has been submitted for publication.
He found that 15% of wannabes identified sexual arousal as a reason for amputation, 63% wanted to be restored to their "true identity" and 37% said the limb "felt different".

Thirteen percent said the limb didn't feel like their own and six people had tried to perform their own amputation, including using a chainsaw.

The authors of the philosophical article make the claim that clinical amputations are not morally problematic. The ~~nub~~ root of their claim is that persons with BIID are not by definition irrational, and are thus capable of giving informed consent for removal. Given the damage that those who want amputation can do to themselves while waiting for surgical help, this gives enough moral weight in the minds of Bayne and Levy (the authors of the article, published in The Journal of Applied Philosophy), neglect to make any kind of argument as to why it is incumbent on physicians to offer the treatment (as opposed to the more ordinary sense of "autonomy", in which physicians are obliged only to acquiese to a patient's request to forego a treatment).

posted Jun 21, 2005 | link | jump to the comments (9)

comments

It is only appropriate that our blogger requires an "argument as to why it is incumbent on physicians to offer the treatment (as opposed to the more ordinary sense of "autonomy", in which physicians are obliged only to acquiese to a patient's request to forego a treatment)." After all, it's generally assumed in law, politics and ethics that refusing assistance is not the same as imposing one's will. The surgeon who demurs from the wannabe's request is not violating the latter's autonomy.
If this is so in the case of BIID, though, then by parity of reasoning it should apply to the provision of "elective" procedures generally. Imagine, conscientious objectors might actually have a conceptual leg to stand on!

- by Bob Koepp on Jun 22, 2005 at 3:22 AM | link

For those of us who are not 'wannabes" it borders on inconceivable that one would choose to amputate a healthy limb. Do no harm would weigh heavily into the argument, even when the harm might be viewed differently by the pt. The MD clearly has his/her own personal/professional integrity to maintain and should not be bound to amputate in the name of autonomy. Somehow taking a chainsaw to one's limb just doesn't cut it as a logical choice.

- by sotto on Jun 27, 2005 at 12:47 PM | link

But having surgery to make one's breasts larger does seem to count as a logical choice in our society. In a manner of thinking about it, though, how is cutting off an a body part that interferes with your sense of self any different? Sure, there are differences in functioning, etc., but I have a hard time buying that it would be consistent to argue that a physician's "integrity" prevents her from removing an unwanted leg but not performing cosmetic (non-reconstructive) surgery. Maybe our single-minded emphasis on autonomy is coming home to roost. . .

- by Sue on Jun 29, 2005 at 5:45 PM | link

Yet again it is being suggested that the "emphasis on autonomy" is leading bioethics astray. But the notion of "autonomy" being criticized is severely misshapen. Autonomy is not the same as "getting whatever you want" -- and especially and most emphatically, not the same as being able to compel others to help you exercise your liberty. Not providing assistance to a wannabe, whether a would be amputee or a would be super model, is not an infringement of the wannabe's autonomy.

- by Bob Koepp on Jun 30, 2005 at 11:23 AM | link

I absolutely don't mean to say that I believe autonomy entails the right to compel others to do your will; rather, it seems to me that our respect for autonomy has led us into situations in which whatever somebody wants to do to him or herself is perfectly ok, so long as it doesn't hurt anybody else. Seems to me this makes it easier for us to stand by and watch people harm themselves who for whatever reason may not be able to make decisions that are in their best interests. For example, allowing an older adult--who, while legally competent but clearly confused--decline treatment, without any discussion or counseling, is happening a lot in nursing homes. . . and being touted as a good, b/c, after all, "it's what they want."
And I still wonder, why don't surgeons have the same sense of moral hazard around cosmetic surgery that they do around amputation?

- by Sue on Jun 30, 2005 at 3:31 PM | link

If, though legally competent, these elders are "clearly confused," about what declining treatment involves, on what basis could anybody calim that "it's what they want?" This makes a mockery of the notion of autonomy. To what extent are bioethicists responsible for the misinformation and misunderstanding evidenced here?

- by Bob Koepp on Jun 30, 2005 at 6:25 PM | link

This is exactly my point! I have talked with many families who have elders "in care" who are "confused" in the eyes of those who know them best, but whose decisions are nonetheless "respected" by medical staff. Example: a 95-yearold bedridden diabetic woman with a high fever resulting from a UTI refuses insulin. The nurses tell her daughter, "She refused her shot today, there's nothing we can do." What the patient actually understands or doesn't understand, or whether she is in fact delirious, does not enter into the equation. THIS is the kind of "respect for autonomy" I am worried about--because (and here I think we agree), it's not really respect for autonomy at all. . . frighteningly, it's being used as something more like window-dressing for laziness, or for system-level problems that make better care impractical in that setting.

- by Sue on Jun 30, 2005 at 9:57 PM | link

As one of the authors of the article that's being discussed here, I'm writing to correct a misunderstanding of our paper. We do not argue that it is incumbent on physicians to offer amputations to persons with BIID who seek them. Rather, our claim is that there is a prima facie case for thinking that physicians should be *permitted* to perform such operations should they be willing to. This is a *very* different claim, and one that we do support with arguments.

- by Tim Bayne on Jul 8, 2005 at 6:06 AM | link

I'm the other author of the article. Tim's quite right that we don't argue that physicians should be required to offered amputations. But who would think they were? The question that all the literature has focused on "is it wrong to amputate?", not, "are we required to amputate?" Think of change operations: does anyone seriously think that physicians are *required* to offer them? But many of us think they are permitted to offer them.

- by Neil Levy on Jul 8, 2005 at 6:53 AM | link