Abstract

In lieu of an abstract, here is a brief excerpt of the content:The Ethics of Surgical Interventions for Body Integrity Identity Disorder and Gender DysphoriaNicanor Pier Giorgio Austriaco, O.P.IntroductionOn May 20, 2009, Fox News featured a report that described the life of a man named "John" who had spent his life struggling with Body Integrity Identity Disorder (BIID).1 In a phone interview, John admitted that he remembers wanting to amputate his leg when he was between seven and eleven years of age, by sticking his leg under the rear wheel of a bus. He never went through with it but continued to experience an intense desire to amputate his healthy limb for the following fifty-plus years. Described for the first time in 1977 as apotemnophilia, BIID was originally thought to be a psychological disorder characterized by sexual arousal associated with the desire to be an amputee. However, it was renamed when Dr. Michael First, a professor of clinical psychiatry at Columbia University, proposed that the primary motivation behind the condition was an issue of identity rather than of sexual desire.2 This proposal is controversial.3 Despite much [End Page 1003] debate, BIID was not included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published on May 18, 2013.In this essay, we will consider the ethics of surgical interventions for BIID and Gender Dysphoria (GD).4 We begin with a discussion of the principle of totality that distinguishes ethical from unethical modifications of the body. We will refer specifically to the latter category of surgical interventions as "mutilations," though the Catholic moral tradition's use of the term is itself ambiguous.5 This is followed by an extensive moral discussion of (1) amputations of healthy limbs for patients struggling with BIID and (2) sex reassignment surgeries for those who identify themselves as transgender persons. I will propose that an ethical argument can be made to justify the former but not the latter.The Principle of TotalityBecause of the goodness of the human body, its integrity is a good that has to be protected and preserved. The ethical principle that is used to judge the morality of bodily interventions that impinge upon this bodily integrity is the principle of totality.6 It was articulated by St. Thomas Aquinas in his Summa theologiae as follows:Since a member is part of the whole human body, it is for the sake of the whole, as the imperfect for the perfect. Hence a member of the human body is to be disposed of according as it is expedient for the body.... If, however, the member be decayed and therefore a source of corruption to the whole body, then it is lawful with the consent [End Page 1004] of the owner of the member, to cut away the member for the welfare of the whole body.7Over the centuries, Catholic moral theologians appealed to the principle of totality to justify three different scenarios that involved the sacrifice of a bodily organ for the sake of the whole human organism. The first case involves a diseased organ that has to be removed to save the life of the soldier wounded on the battlefield—say a gangrenous, decaying limb as in the example of Aquinas. The second case involves the healthy foot of a man who is trapped on a railroad track that has to be amputated to save his life from a collision with a train, and the third case involves the healthy limb of an individual that has to be amputated in response to a tyrant who orders him to cut off his own hand or lose his head to the executioners instead. In these cases, the sacrifice of the part would be morally permitted as a necessary means of preserving the life of the individual. As Fr. Gerald Kelly, S.J., points out, this final case is particularly significant because it involves a healthy limb whose very presence—and not its diseased or trapped condition—becomes a source of vital harm for the organism.8How does one justify the principle of totality? In 1944, Pope Pius XII explained it this way: "Man's power over his...