It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. (...) It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction—a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View. (shrink)

Unter Body Integrity Identity Disorder (BIID) versteht man das sehr seltene Phänomen, dass jemand die Amputation einer oder mehrerer gesunder Gliedmaßen oder die Beibringung einer Querschnittslähmung verlangt. Manche dieser Menschen verstümmeln sich selbst; andere fordern von Chirurgen eine Amputation oder die Durchtrennung des Rückenmarks. Von Psychologen und Psychiatern gibt es unterschiedliche Erklärungsansätze für dieses Phänomen; bisher ist aber keine erfolgreiche psychotherapeutische oder pharmazeutische Therapie bekannt. Betroffenenvertreter erklären den Amputationswunsch in Analogie zu dem Verlangen von Transsexuellen nach chirurgischer Angleichung an ihr (...) Wunschgeschlecht. Unter Medizinethikern ist die Amputation gesunder Gliedmaßen höchst umstritten; einerseits wird aus dem Autonomie-Prinzip das Recht auf Körpermodifikation abgeleitet, andererseits wird angenommen, dass der Amputationswunsch aus innerem Zwang oder Wahn resultiert. Neurologische Befunde legen nahe, dass BIID wahrscheinlich eine hirnorganisch bedingte Störung des Körperbildes ist, vergleichbar mit bestimmten Schlaganfallfolgen. Wenn BIID eine neuropsychologische Störung ist, zu deren Symptomen fehlende Krankheitseinsicht und eine durch inneren Zwang eingeschränkte Fähigkeit zu vernünftigen Entscheidungen gehören, sind die von BIID-Aktivisten und einigen Medizinethikern geforderten Amputationen kontraindiziert und stellen Körperverletzungen an Menschen mit einer neuropsychologischen Störung dar. Statt des Kurierens an einem Symptom sollte eine kausale Therapie entwickelt werden, mit dem Ziel der Integration des als fremd empfundenen Körperteils in das Körperbild. (shrink)

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in (...) analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in (...) analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

Phenomenology provides a method for disability theorists to describe embodied subjectivity lacking within the social model of disability. Within the literature on body integrity identity disorder, dominant narratives of disability are influential, individual bodies are considered in isolation, and experiences of disabled people are omitted. Research on BIID tends to incorporate an individualist ontology. In this article, I argue that Merleau-Ponty's conceptualization of “being in the world,” which recognizes subjectivity as embodied and intersubjective, provides a better starting point for research (...) describing the experiences of those with BIID and amputees. (shrink)

In this article, we present an analysis of bodily integrity in hand transplants from a phenomenological narrative perspective, while drawing on two contrasting case stories. We consider bodily integrity as the subjective bodily experience of wholeness which, instead of referring to actual bodily intactness, involves a positive identification with one’s physical body. Bodily mutilations, such as the loss of a hand, may severely affect one’s bodily integrity. A possible restoration of one’s experience of wholeness requires a process of re-identification. Medical (...) interventions, such as a hand transplant, may improve the possibility of a successful re-identification. However, since the experience of wholeness does not refer simply to physical intactness or impairment, the choice for medical intervention should not be based merely upon the degree of physical mutilation. It should also be based upon the degree to which a person fails in re-identifying with his or her mutilated body. We argue that a normalizing operation is only ethically justifiable if the intervention enables the person to be the body he or she has. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

In this article, I argue that persons suffering from Body Integrity Identity Disorder (BIID) can give informed consent to surgical measures designed to treat this disorder. This is true even if the surgery seems radical or irrational to most people. The decision to have surgery made by a BIID patient is not necessarily coerced, incompetent or uninformed. If surgery for BIID is offered, there should certainly be a screening process in place to insure informed consent. It is beyond the scope (...) of this work, however, to define all the conditions that should be placed on the availability of surgery. However, I argue, given the similarities between BIID and gender dysphoria and the success of such gatekeeping measures for the surgical treatment of gender dysphoria, it is reasonable that similar conditions be in place for BIID. Once other treatment options are tried and gatekeeping measures satisfied, A BIID patient can give informed consent to radical surgery. (shrink)

Recent criticisms of medicine converge on fundamental questions about the aim of medicine. The main task of this paper is to propose an account of the aim of medicine. Discussing and rejecting the initially plausible proposal according to which medicine is pathocentric, the paper presents and defends the Autonomy Thesis, which holds that medicine is not pathocentric, but sanocentric, aiming to promote health with the final aim to enhance autonomy. The paper closes by considering the objection that the Autonomy Thesis (...) is overly permissive and allows many highly controversial procedures as legitimate parts of medicine. (shrink)

In this paper, I explore the meaning of bodily integrity in disfiguring breast cancer. Bodily integrity is a normative principle precisely because it does not simply refer to actual physical or functional intactness. It rather indicates what should be regarded and respected as inviolable in vulnerable and damageable bodies. I will argue that this normative inviolability or wholeness can be based upon a person's embodied experience of wholeness. This phenomenological stance differs from the liberal view that identifies respect for integrity (...) with respect for autonomy (resulting in an invalidation of bodily integrity's proper normative meaning), as well as from the view that bodily integrity is based upon ideologies of wholeness (which runs the risk of being disadvantageous to women). I propose that bodily integrity involves a process of identification between the experience of one's body as “Leib” and the experience of one's body as “Körper.” If identification fails or is not possible, one's integrity is threatened. This idea of bodily integrity can support breast cancer patients and survivors in making decisions about possible corrective interventions. To implement this idea in oncology care, empirical-phenomenological research needs to establish how breast cancer patients express their embodied self-experiences. (shrink)

ABSTRACT In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of (...) duties to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of duties (...) to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

In this paper, we offer a new account of disability. According to our account, some state of a person's biology or psychology is a disability if that state makes it more likely that a person's life will get worse, in terms of his or her own wellbeing, in a given set of social and environmental circumstances. Unlike the medical model of disability, our welfarist approach does not tie disability to deviation from normal species’ functioning, nor does it understand disability in (...) essentialist terms. Like the social model of disability, the welfarist approach sees disability as a harmful state that results from the interaction between a person's biology and psychology and his or her surrounding environment. However, unlike the social model, it denies that the harm associated with disability is entirely due to social prejudice or injustice. In this paper, we outline and clarify the welfarist approach, answer common objections and illustrate its usefulness in addressing a range of difficult ethical questions involving disability. (shrink)

The prelims comprise: Introduction Controversial Choices Kinds of Normative Reasons for Action Limits on Respect for Autonomy Children and Controversial Choice Controversial Choices and the Duty to Strive Toward Perfection and Full Autonomy Acknowledgments Notes References.

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the diagnosis and consideration of (...) other treatment options. (shrink)

Body integrity identity disorder is a very rare condition in which people experience long-standing anguish because there is a mismatch between their bodies and their internal image of how their bodies should be. Most typically, these people are deeply distressed by the presence of what they openly acknowledge as a perfectly normal leg. Some with the condition request that their limb be amputated. 1 We and others have argued that such requests should be acceded to in carefully selected patients.1–4 Consistent (...) with this view, a group at the University of Sydney is developing a programme to better understand and treat BIID and to offer amputation if appropriate. In a recent paper, Patrone argues that such amputations should be prohibited.5 He suggests that authors supporting amputation in BIID depend on analogies with more familiar conditions and then claim that the ‘the desires, choices and requests of BIID patients should be held to exactly the same standards and treated with exactly the same respect as the desires, choices and requests of any more conventional patient’.5 He believes that these analogies are invalid and that therefore the arguments for amputation are invalid.Patrone concentrates a great deal upon whether a decision to have a particular medical intervention is to be regarded as ‘rational’. Unfortunately, he makes no attempt to define what he …. (shrink)

In light of the variety of uses of the term autonomy in recent bioethics literature, in this paper, I suggest that competence, not being as contested, is better placed to play the anti-paternalistic role currently assigned to autonomy. The demonstration of competence, I will argue, can provide individuals with robust spheres of non-interference in which they can pursue their lives in accordance with their own values. This protection from paternalism is achieved by granting individuals rights to non-interference upon demonstration of (...) competence. In this paper, I present a risk-sensitive account of competence as a means of grounding rights to non-interference. On a risk-sensitive account of competence individuals demonstrate their competence by exercising three capacities to the extent necessary to meet a threshold determined by the riskiness of the decision. These three capacities are the capacity to acquire knowledge, use instrumental rationality, and form and revise a life plan. (shrink)

Body integrity identity disorder (BIID), formerly also known as apotemnophilia, is characterized by a desire for amputation of a healthy limb and is claimed to straddle or to even blur the boundary between psychiatry and neurology. The neurological line of approach, however, is a recent one, and is accompanied or preceded by psychodynamical, behavioural, philosophical, and psychiatric approaches and hypotheses. Next to its confusing history in which the disorder itself has no fixed identity and could not be classified under a (...) specific discipline, its sexual component has been an issue of unclarity and controversy, and its assessment a criterion for distinguishing BIID from apotemnophilia, a paraphilia. Scholars referring to the lived body—a phenomenon primarily discussed in the phenomenological tradition in philosophy—seem willing to exclude the sexual component as inessential, whereas other authors notice important similarities with gender identity disorder or transsexualism, and thus precisely focus attention on the sexual component. This contribution outlines the history of BIID highlighting the vicissitudes of its sexual component, and questions the justification for distinguishing BIID from apotemnophilia and thus for omitting the sexual component as essential. Second, we explain a hardly discussed concept from Maurice Merleau-Ponty’s Phenomenology of Perception (1945a), the sexual schema, and investigate how the sexual schema could function in interaction with the body image in an interpretation of BIID which starts from the lived body while giving the sexual component its due. (shrink)

Some 14 years ago, I published an article in which I identified a prime site for bioethicists to ply their trade: medical responses to requests for hormonal and surgical interventions aimed at facilitating transgendered people’s transition to their desired genders. Deep issues about the impact of biotechnologies and health care practices on central aspects of our conceptual system, I argued, were raised by how doctors understood and responded to people seeking medical assistance in changing their gender, and there were obviously (...) significant issues of regulation involved as well. Yet mainstream bioethics was conspicuous by its relative absence from the discussion. Here, I return to the matter and find that, while the conceptual issues are just as profound and their connection to health care practice and policy just as intimate, even as transgender issues have become much more socially visible, bioethical engagement with gender reassignment has increased only slightly. I set the little movement that has occurred against the backdrop of the situation as I saw it in 1998 and conclude, once again, by trying to make the bait for bioethicists inviting. (shrink)

In this paper, we argue that promoting patient values is a legitimate goal of medicine. Our view offers a justification for certain current practices, including birth control and living organ donation, that are widely accepted but do not fit neatly within the most common extant accounts of the goals of medicine. Moreover, we argue that recognising value promotion as a goal of medicine will expand the scope of medical practice by including some procedures that are sometimes rejected as being outside (...) the scope of acceptable medical practice, such as certain forms of physician-assisted death. We then rebut some common and possible objections to this view. Our aim is not to argue that other accounts are mistaken—except when they argue for a single goal that does not include patient values—but rather to show that value promotion should play a more central role in discussions about the goals of medicine. (shrink)

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation’s International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with (...) the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of “justice” are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor’s desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient’s desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures. (shrink)

The Problem of Overlappers is a puzzle about what makes it the case, and how we can know, that we have the parts we intuitively think we have. In this paper, I develop and motivate an overlooked solution to this puzzle. According to what I call the self-making view it is within our power to decide what we refer to with the personal pronoun ‘I’, so the truth of most of our beliefs about our parts is ensured by the very (...) mechanism of self-reference. Other than providing an elegant solution to the Problem of Overlappers, the view can be motivated on independent grounds. It also has wide-ranging consequences for how we should be thinking about persons. Among other things, it can help undermine an influential line of argument against the permissibility of elective amputation. After a detailed discussion and defence of the self-making view, I consider some objections to it. I conclude that none of these objections is persuasive and we should at the very least take seriously the idea that we are to some extent self-made. (shrink)

This paper explores the possibility that some cases of criminal paternalism might include among their justifying reasons an appeal to human dignity.

Supporters of paternalistic policies argue that interference with risky or dangerous choices for citizens’ own good is permissible, as long as those choices are caused by cognitive irrationality or ignorance. Yet, some liberal thinkers argue that despite human irrationality, paternalistic policies are still wrong because they fail to respect citizens as moral equals. I argue that actually both views are mistaken about what respect for citizens requires, because they conceptualize the citizens’ interests from the wrong standpoint. In order for citizens (...) to be respected as equals, I argue that citizens’ interests must be defined from a joint (second-person) standpoint which is constructed through a dialogical process between policymakers and citizens oriented towards mutual understanding. Furthermore, I argue that engaging citizens in such a dialogue is a distinctive paternalistic intervention in its own right, which unlike other kinds of paternalistic intervention, is compatible with respect for citizens as equals. (shrink)

Supporters of paternalistic policies argue that interference with risky or dangerous choices for citizens’ own good is permissible, as long as those choices are caused by cognitive irrationality or ignorance. Yet, some liberal thinkers argue that despite human irrationality, paternalistic policies are still wrong because they fail to respect citizens as moral equals. I argue that actually both views are mistaken about what respect for citizens requires, because they conceptualize the citizens’ interests from the wrong standpoint. In order for citizens (...) to be respected as equals, I argue that citizens’ interests must be defined from a joint (second-person) standpoint which is constructed through a dialogical process between policymakers and citizens oriented towards mutual understanding. Furthermore, I argue that engaging citizens in such a dialogue is a distinctive paternalistic intervention in its own right, which unlike other kinds of paternalistic intervention, is compatible with respect for citizens as equals. (shrink)

Supporters of paternalistic policies argue that interference with risky or dangerous choices for citizens’ own good is permissible, as long as those choices are caused by cognitive irrationality or ignorance. Yet, some liberal thinkers argue that despite human irrationality, paternalistic policies are still wrong because they fail to respect citizens as moral equals. I argue that actually both views are mistaken about what respect for citizens requires, because they conceptualize the citizens’ interests from the wrong standpoint. In order for citizens (...) to be respected as equals, I argue that citizens’ interests must be defined from a joint (second-person) standpoint which is constructed through a dialogical process between policymakers and citizens oriented towards mutual understanding. Furthermore, I argue that engaging citizens in such a dialogue is a distinctive paternalistic intervention in its own right, which unlike other kinds of paternalistic intervention, is compatible with respect for citizens as equals. (shrink)

Supporters of paternalistic policies argue that interference with risky or dangerous choices for citizens’ own good is permissible, as long as those choices are caused by cognitive irrationality or ignorance. Yet, some liberal thinkers argue that despite human irrationality, paternalistic policies are still wrong because they fail to respect citizens as moral equals. I argue that actually both views are mistaken about what respect for citizens requires, because they conceptualize the citizens’ interests from the wrong standpoint. In order for citizens (...) to be respected as equals, I argue that citizens’ interests must be defined from a joint (second-person) standpoint which is constructed through a dialogical process between policymakers and citizens oriented towards mutual understanding. Furthermore, I argue that engaging citizens in such a dialogue is a distinctive paternalistic intervention in its own right, which unlike other kinds of paternalistic intervention, is compatible with respect for citizens as equals. (shrink)

Moral agential neuroenhancement can transform us into better people. However, critics of MB raise four central objections to MANEs use: It destroys moral freedom; it kills one moral agent and replaces them with another, better agent; it carries significant risk of infection and illness; it benefits society but not the enhanced person; and it’s wrong to experiment on nonconsenting persons. Herein, I defend MANE’s use for prisoners of war fighting unjustly. First, the permissibility of killing unjust combatants entails that, in (...) cases where MANE is equally or more likely as termination to reduce moral recidivism in unjust combatants, then MANE is morally justified. Second, the relevant infections and illnesses caused by MANE are less bad than death, so MANE leaves unjust POWs better off than the alternative. Third, just as incarceration is often permissible despite benefitting society but not the incarcerated, the same holds for unjust POWs. Fourth, we should accept a broader construal of “benefit” that includes moral benefits. Thus, 3 and 4 are false when applied to unjust POWs. Fifth, medical experimentation likely to help nonconsenting persons is sometimes permissible. Because MANE is likely to help unjust POWs irrespective of their consent or lack thereof, its use is permissible. Sixth, basic principles of proper medical care support the use of MANE on unjust POWs as pro tanto morally obligatory. I conclude that militaries should therefore begin to employ MANE for unjust POWs. (shrink)

Medical ethics would be better if people were taught to think more clearly about well-being or the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the “theory-without-theories approach” to welfare in practical contexts. The first element of this approach is a (...) focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as “the mild objectivity framework.” I conclude with illustrations of the way in which the “theory without theories approach” can improve thinking in medicine. (shrink)

The principle of autonomy is widely recognized to be of utmost importance in bioethics; however, we argue that this principle is often misapplied when one fails to distinguish two different contexts in medicine. When a particular patient is offered treatment options, she has the ultimate say in whether to proceed with any of those treatments. However, when deciding whether a particular intervention should be regarded as a form of medical treatment in the first place, it is the medical community who (...) has the ultimate say. Some argue that particular interventions should be allowed by virtue of the fact that they are autonomously requested. But making such an argument fails to distinguish between these two contexts and misapplies the principle of autonomy, ultimately having the potential to instigate problematic changes in the practice of medicine. (shrink)

Value and responsibility are two central concepts in philosophy and bioethics. The articles that comprise this issue of The Journal of Medicine and Philosophy engage topics of moral injury, madness, transhumanism, cognitive enhancement, and the woman’s responsibility to assist her fetus. Clearly diverse in matter, these subject articles univocally present fruitful ground for engagement with contemporary questions that impact society today. The ability to cure or to enhance, to treat or to terminate through advances in medical technology are all actions (...) that come with personal and social responsibility for their consequences. By approaching each article through the dual lens of value and responsibility, the reader is challenged to think seriously about the values we hold as human persons and the responsibility we take to pursue and protect these values. (shrink)

During the past few months, the discussion over the physicians' “Right of Conscience” has been on the rise. The intervention of politics in this issue shifts the discussion to a very specific and narrow area, namely the “reproductive health laws” which bear well-known predisposing attitudes.In this article, the physician's ROC is discussed in the context in which it naturally belongs: the Patient Physician Relationship . I suggest that the physicians' rights demand is a comprehensible, predictable, and even inevitable step as (...) part of the “evolution” of the PPR. Thus, the most appropriate way to comprehend and tackle the demand for physicians' ROC is within the context of medical professionalism. While searching for practical solutions to the “reproductive health” problems, there is a need to recognize the ethical and practical implications of the change in the PPR and balance between patient and physician rights. (shrink)

Recently, the discussion regarding the physicians’ “Right of Conscience” has been on the rise. This issue is often confined to the “reproductive health” arena within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. The involvement of the political system automatically shifts the discussion regarding physicians’ ROC into the narrow area of “reproductive (...) health laws.” Indeed, the immediate association that comes to mind when thinking about the practical implications of this dispute is related to the reproductive health arena. This is partly because of the historical context of the first “conscience clauses,” initially enacted by Congress and state legislatures in the mid-1970s; in fact, most of these clauses provided specific exemptions for abortion and few exempted sterilization as well. (shrink)

Physician-assisted death (PAD) of patients whose suffering does not stem from terminal conditions has become more prevalent during the last few decades. This paper is focused on decision-making competence for PAD, specifically in situations in which PAD is related solely to psychiatric illness. First, a theoretical analysis presents the premises for the argument that competence for physician-assisted death for psychiatric patients (PADPP) should be determined based on a higher threshold in comparison to the required competence for conventional medical interventions. Second, (...) the higher threshold for decision-making competence for PADPP is illustrated. Third, several real PADPP cases are critically discussed, as an illustration to decision-making competence evaluations that would not have met the higher standard. Finally, a short summary of practical suggestions regarding the assessment of decision-making competence for PADPP is presented. Psychiatrists are called to address the ethical, legal, societal and clinical challenges related to PADPP and should be prepared for its probable expansion. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of (...) health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of (...) health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of (...) health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of (...) health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Dis...

Opponents of the provision of therapeutic, healthy limb amputation in Body Integrity Identity Disorder cases argue that such surgeries stand in contrast to the goal of medical practice – that of health restoration and maintenance. This paper refutes such a conclusion via an appeal to the nuanced and reflective model of health proposed by Georges Canguilhem. The paper examines the conceptual entanglement of the statistically common with the normatively desirable, arguing that a healthy body can take multiple forms, including that (...) of an amputee, provided that such a form enables the continuing ability to initiate new norms of existence. It concludes that the practice of healthy limb amputation in cases of Body Integrity Identity Disorder is not only compatible with the goal of medicine but is potentially the only method of achieving this goal in the face of a complex and often mischaracterized disorder. (shrink)

Interventions are medically necessary when they are vital in achieving the goal of medicine. However, with varying perspectives comes varying views on what interventions are (un)necessary and, thus, what potential treatment options are available for those suffering from the myriad of conditions, pathologies and disorders afflicting humanity. Medical necessity's teleological nature is perhaps best illustrated in cases where there is debate over using contentious medical interventions as a last resort. For example, whether it is appropriate for those suffering from body (...) integrity dysphoria to receive healthy limb amputations. This paper explores how one's perception of medicine's goal underpins whether interventions are necessary or unnecessary, using the controversial topic of therapeutic amputation as an example. By contrasting ‘classical’ amputations with their more contentious counterparts, it highlights how the idea of medical necessity influences and restrains clinical decision-making. The paper starts by giving an account of body integrity dysphoria, focusing on the debate concerning elective amputation's justifiability. It then introduces Georges Canguilhem's vitalist theory of health, paying particular attention to his emphasis on adaptability. Then, this paper uses his theory as a lens through which to evaluate the appropriateness of therapeutic amputation as a medically necessary procedure. Ultimately, the paper highlights how the label of medical necessity is withheld from potential therapeutic interventions because they fail to conform to pre-established ideas of medicine's purpose and that by doing so, potential harm befalls those who are left with no effective treatments and must look for solutions in the non-clinical world. (shrink)

Apotemnophilia is a condition that causes those who have it to not feel “correct” in their own bodies. As a result, an intense obsession develops with removing the limb; this obsession hinders tremendously the patients' social behaviour and societal integration. These patients, in some respects resembling transgendered individuals, feel that the body part (limb) in question is simply “not a part of themselves”, causing them to feel uncomfortable in their own bodies. Whether amputations should be performed on apotemnophiles or not (...) is a question that poses a significant medical ethical dilemma. It is argued that observing an apotemnophile's request for amputation is the ethical action. The major arguments opposing such amputations and supporting such amputations are examined and critically analysed with regard to ethical principles—namely, patient autonomy, beneficence, non-maleficence and justice with regard to every person's “right to happiness”. Finally, a discourse on how the accepted notion of harm does not apply to apotemnophilia is developed to justify the position that amputation is indeed medically the ethical choice. (shrink)

Pain is unpleasant. It is something that one avoids as much as possible. One might then claim that one wants to avoid pain because one cares about one's body. On this view, individuals who do not experience pain as unpleasant and to be avoided, like patients with pain asymbolia, do not care about their body. This conception of pain has been recently defended by Bain [2014] and Klein [forthcoming]. In their view, one needs to care about one's body for pain (...) to have motivational force. But does one need to care about one's body qua one's own? Or does one merely need to care about the body that happens to be one's own? In this paper, I will consider various interpretations of the notion of bodily care, in light of a series of pathological cases in which patients report pain in a body part that they do not experience as their own. These cases are problematic if one adopts a first-personal interpretation of bodily care, according to which pain requires one to care about what is represented as one's own body. Th.. (shrink)

What grounds my experience of my body as my own? The body that one experiences is always one’s own, but it does not follow that one always experiences it as one’s own. One might even feel that a body part does not belong to oneself despite feeling sensations in it, like in asomatognosia. The article aims at understanding the link between bodily sensations and the sense of ownership by investigating the role played by the body schema.

Abstract: What grounds the experience of our body as our own? Can we rationally doubt that this is our own body when we feel sensations in it? This article shows how recent empirical evidence can shed light on issues on the body and the self, such as the grounds of the sense of body ownership and the immunity to error through misidentification of bodily self-ascriptions. In particular, it discusses how bodily illusions (e.g., the Rubber Hand Illusion), bodily disruptions (e.g., somatoparaphrenia), (...) and the multimodal nature of bodily self-knowledge challenge a classic view of ownership and immunity that puts bodily sensations at its core. (shrink)

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition, or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of (...) the common objections to an Autonomy Only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law, and therefore poses an important challenge to this widely accepted view on justified PAD. (shrink)

The Bad-Difference View of disability says, roughly, that disability makes one worse off. The Mere-Difference View of disability says, roughly, that it doesn’t. In recent work, Barnes – a MDV proponent – offers a detailed exposition of the MDV. No BDV proponent has done the same. While many thinkers make it clear that they endorse a BDV, they don’t carefully articulate their view. In this paper, I clarify the nature of the BDV. I argue that its best interpretation is probabilistic (...) and comparative: it is the view that a person is likely to be, all things considered, worse off with a disability than without. As such, Barnes – who criticises the version of the BDV that disability by itself, intrinsically or automatically makes a person worse off – misses an opportunity to attack the most plausible and relevant version of the BDV, and the best version remains unchallenged. (shrink)