Amputation Ethics and Autonomy

Aniket Dhariwal.

Autonomy, or self determination, is a concept that is held in high regard in medicine; it is supremely valued and there exists a rich history of literature that endorses the view that medical professionals must uphold autonomy. This enduring belief in this principal value is the driving force behind many medical practices and policies, for example, informed consent. The significance our society places in autonomy is further illustrated by the way we, as a country, view end of life decisions and euthanasia. According to a Gallup poll published in June of 2017, most Americans view euthanasia positively. Issues like this one raise notable questions: Should the individual have total control over their own fate? What role should those who determine and establish health policy play and how much legislative power should they have over decisions such as these? What role do medical professionals play in advising those in these positions, and to what extent should we respect all individuals’ autonomy?

One relatively rare but illustrative condition may illuminate our understanding of autonomy and the role it plays in medicine. This condition is Body Identity Integrity Disorder (BIID). Those who have BIID have an intense desire to amputate of one of their healthy limbs, although BIID also encompasses those who want to paralyze themselves or lose the ability to see or hear. There is a severe dissociation between the mental image those suffering from BIID possess of themselves and the physical body they really have. It may seem that those who want to amputate their healthy limbs are delusional or irrational, but they have been evaluated to be quite the opposite and reasonable in all respects. This condition is relatively rare and the demographics of BIID are not precisely known, due to the generally secretive nature of the condition and the lack of information researchers have. Some people successfully mutilate themselves (see one woman who successfully blinded herself and another who self amputated a leg), others seek out surgeons who will perform the amputation or debilitating procedure for them. There is currently no known cure or therapy available to those with BIID, and the condition causes those who suffer from it great emotional pain and discomfort. The question a condition such as BIID raises is one that presides over the scope of autonomy. Should we respect the autonomy of those with BIID and, furthermore, do we have any reason to doubt it? Is the elective amputation of healthy limbs ethically justified and what or where are the boundaries of self determination?

Considering that medications and psychotherapies have been proven useless in treating the condition and that those with BIID are willing to go to extremes to amputate, we could argue that it is ethically obligatory for surgeons to provide amputations. Many of those suffering from BIID compare their condition to transsexuals desiring surgical reassignment. They argue that amputation is a form of body modification, and if we do not view those who desire to change sex in order to relieve emotional strife as irrational, we cannot view those with BIID any differently. It is also widely acknowledged that there are those who take plastic surgery too far, some even removing perfectly healthy ribs. Although some doctors refuse to remove healthy ribs, others do, citing autonomy. Some modify their breasts and end up having incapacitating back pain as well as limited mobility. It seems in the case of BIID, there is an even stronger reason, then, to provide amputations. We can argue that those with BIID are suffering from severe emotional pain, perhaps more so than those who desire to modify their breasts. If we respect the autonomy of those who desire sex reassignment surgery or of those who modify their bodies in other extreme ways and our intuition is that we should not respect autonomy in the case of BIID, we must discern what distinguishes these cases. Otherwise, we must bite the bullet and respect the autonomy of and grant amputation of perfectly healthy limbs to those with BIID. I am inclined to endorse the latter view until we find another way to cure this condition or relieve those suffering from the emotional turmoil BIID begets.