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...

The ethics of medically-authorized limb amputation in individuals with Body integrity identity disorder (BIID) remains extremely controversial. One factor to consider is the putative locus of a disease process, and whether the proposed treatment--in this case, limb amputation—reasonably addresses the issue of what organ is mediating the patient’s complaint.

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to his face (...) and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and “get in his way,” causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper-extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation. (shrink)

In 1997, a Scottish surgeon by the name of Robert Smith was approached by a man with an unusual request: he wanted his apparently healthy lower left leg amputated. Although details about the case are sketchy, the would-be amputee appears to have desired the amputation on the grounds that his left foot wasn’t part of him – it felt alien. After consultation with psychiatrists, Smith performed the amputation. Two and a half years later, the patient reported that his (...) life had been transformed for the better by the operation [1]. A second patient was also reported as having been satisfied with his amputation [2]. (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)

This paper examines what, if anything, is morally problematic about the desire for healthy limb amputation. The paper begins with a brief survey of the empirical data concerning the desire to amputate a healthy limb, focusing on questions of characterisation and treatment. Subsequent to this, the paper focuses on two normative questions: is the amputation of a healthy limb in and of itself morally questionable if those persons requesting it are autonomous? And, are patients who desire the (...) class='Hi'>amputation of a healthy limb autonomous? With respect to the first question, I reject two possible objections to healthy limb amputation, namely the claim that it is repugnant, and that it might cause harm to others, thus showing there is nothing inherently objectionable to healthy limb amputation. With respect to the second question, I critique two opposing views of patient autonomy from the healthy limb amputation literature, in order to show that the nature of the desire itself may inhibit a person‟s autonomy. (shrink)

The disposal of limbs remains absent from our understandings of amputation, with ‘estranged limbs’ occupying a liminal position. Despite acceptance that the appropriate disposal of human tissue matters on moral, ethical and legal grounds, limbs and their disposal is estranged from these discourses, mirroring the experience of the limbs themselves. This article then examines this absence around disposal, considering both the options which exist for the disposal of limbs after amputation, as well as why disposal itself remains sidelined (...) from our broader understandings of the body. Practices for disposal that encompass both traditional clinical approaches and more unusual patient choices will be discussed – through the discussion of these as potential ‘disposalscapes’. Utilising concepts from the work of Crawford, Shildrick and Steinberg and Slatman and Widdershoven, the potential importance of the disposal of limbs to patients and the role of disposalscapes within this are considered. (shrink)

Disabled women's issues, experiences, and embodiments have been misunderstood, if not largely ignored, by feminist as well as mainstream disability theorists. The reason for this, I argue, is embedded in the use of materialist and constructivist approaches to bodies that do not recognize the interaction between “sex” and “gender” and “impairment” and “disability” as material-semiotic. Until an interactionist paradigm is taken up, we will not be able to uncover fully the intersection between sexist and ableist biases that form disabled women's (...) oppressions. Relying on the understanding that sexuality is one such material-semiotic phenomenon, I examine the operation of interwoven biases in two disabled women's narratives. (shrink)

: Disabled women's issues, experiences, and embodiments have been misunderstood, if not largely ignored, by feminist as well as mainstream disability theorists. The reason for this, I argue, is embedded in the use of materialist and constructivist approaches to bodies that do not recognize the interaction between "sex" and "gender" and "impairment" and "disability" as material-semiotic. Until an interactionist paradigm is taken up, we will not be able to uncover fully the intersection between sexist and ableist biases (among others) that (...) form disabled women's oppressions. Relying on the understanding that sexuality is one such material-semiotic phenomenon, I examine the operation of interwoven biases in two disabled women's narratives. (shrink)

Lower limb major amputations are both life-saving procedures and life-changing events. Individual responses to limb loss are varied and complex, some individuals experience functional, psychological and social dysfunction, many others adjust and function well. Some patients refuse amputation for religious and/or cultural reasons. One of the greatest difficulties for a person undergoing amputation surgery is overcoming the psychological stigma that society associates with the loss of a limb. Persons who have undergone amputations are often viewed as incomplete individuals. (...) The medical and physical consequences of amputation serve as the centerpiece in acute care and are commonly at the forefront of prosthetic rehabilitation. Prosthetic prescription aims to compensate for functional and/or cosmetic losses where possible. The aims of rehabilitation following amputation are to restore acceptable levels of functioning that allow individuals to achieve their goals, to facilitate personal health, and to improve participation in society and quality of life either with or without prosthesis. Our article aims at underscoring some medical, social and religious aspects that can contribute to the wellbeing of patients who suffer a life changing event such as lower limb amputation. (shrink)

PurposeThe effect of sensorimotor stripping on neuroplasticity and motor imagery capacity is unknown, and the physiological mechanisms of post-amputation phantom limb pain (PLP) illness remain to be investigated.Materials and methodsIn this study, an electroencephalogram (EEG)-based event-related (de)synchronization (ERD/ERS) analysis was conducted using a bilateral lower limb motor imagery (MI) paradigm. The differences in the execution of motor imagery tasks between left lower limb amputations and healthy controls were explored, and a correlation analysis was calculated between level of phantom limb (...) pain and ERD/ERS.ResultsThe multiple frequency bands showed a significant ERD phenomenon when the healthy control group performed the motor imagery task, whereas amputees showed significant ERS phenomena in mu band. Phantom limb pain in amputees was negatively correlated with bilateral sensorimotor areas electrode powers.ConclusionSensorimotor abnormalities reduce neural activity in the sensorimotor cortex, while the motor imagination of the intact limb is diminished. In addition, phantom limb pain may lead to over-activation of sensorimotor areas, affecting bilateral sensorimotor area remodeling. (shrink)

ABSTRACT Should surgeons be permitted to amputate healthy limbs if patients request such operations? We argue that if such patients are experiencing significant distress as a consequence of the rare psychological disorder named Body Integrity Identity Disorder (BIID), such operations might be permissible. We examine rival accounts of the origins of the desire for healthy limb amputations and argue that none are as plausible as the BIID hypothesis. We then turn to the moral arguments against such operations, and argue that (...) on the evidence available, none is compelling. BIID sufferers meet reasonable standards for rationality and autonomy: so as long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests. (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)

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)

IntroductionResearch indicates that body image disturbance is associated with poorer psychosocial outcomes for individuals with physical health conditions, with poorest body image reported for individuals with visible bodily changes. Using White’s theoretical model of body image the present paper aimed to examine the nature of these relationships in two distinct groups: individuals with an amputation and individuals with diabetes. It was hypothesized that body image disturbance would be associated with psychosocial outcomes and would mediate the relationships between self-ideal discrepancy (...) and personal investment in psychosocial outcomes.MethodsIndividuals with diabetes and individuals with an amputation provided details regarding their medical condition, and completed measures assessing body image, investment, self-ideal discrepancy, depression, anxiety, and quality of life. Structural equation and invariance modeling were used to test the model paths and the invariance of the model.ResultsAs hypothesized, body image disturbance was found to mediate the relationships between personal investment and psychosocial outcome, and between self-ideal discrepancy and psychosocial outcome. The predicted paths were invariant across groups, although the model accounted for more variance in people with an amputation than people with diabetes.ConclusionBody image disturbance, personal investment, and self-ideal discrepancy are important factors contributing to psychosocial outcome for individuals with diabetes and individuals with an amputation. These findings not only confirm the validity of the model in these two groups, but they emphasize the importance of targeting body image in future psychological interventions for individuals with a health condition. (shrink)

This paper explores ethical considerations for active studies of circumcision, i.e., the amputation of the foreskin, in the form of a case study of three major trials performed in African countries in the early 2000s. The paper outlines the function of the foreskin and method and history of its amputation as well as its current use in attempting to combat the global AIDS crisis. These trials are then interrogated in accordance with the Declaration of Helsinki. In particular, the (...) irreversible nature of amputation is given great consideration. The case studies are found to have serious failures in terms of the modern iteration of the Declaration of Helsinki. This paper calls for extreme scrutiny in accordance with international norms relating to the ethical treatment of human subjects in a research context of studies of circumcision if and when they are proposed again. (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)

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)

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 study aimed to identify the psychological changes that result from the amputation of a limb and the ways in which patients coordinate their daily lives. The study uses an interpretative phenomenological analysis aimed at understanding individual experiences in seven patients who have suffered limb amputation. The method used consisted of individual, semi-structured interviews, conducted approximately 4 months after surgery, to patients at home or in hospital, at the time of their regular checkup. The interviews were audio recorded, (...) transcribed and, following the qualitative analysis performed, six common themes were identified: emotional impact, negative affects, tendency toward isolation, role constraints and limitations, phantom limb, and emotional balancing. A specific theme for patients who have suffered amputations is phantom limb pain, which has received special attention from researchers. The last topic relates to the tendency toward emotional balancing and psychological calibration to return to normal life. (shrink)

This paper examines Johann Ulrich Bilguer’s 1761 dissertation on the inutility of amputation practices, examining reasons for its influence despite its nonconformance to genre expectations. I argue that Bilguer’s narratives of patient suffering, his rhetorical likening of surgeons to soldiers, and his attention to the horrific experiences of war surgeons all contribute to the dissertation’s wide impact. Ultimately, the dissertation offers an example of affective rhetorics employed during the Enlightenment, demonstrating how bodies and environments—those “ambient rhetorics” made visible in (...) a text—can contribute to an analysis of genre deviations and widen the scope of genre studies. (shrink)

Se realiza la investigación con el objetivo de perfeccionar la obtención del consentimiento informado en las amputaciones mayores de causa vascular en el Servicio de Angiología del Hospital Universitario Manuel Ascunce Domenech. Se constató debilidades en la institucionalización del consentimiento informado y específicamente en el caso de tales amputaciones. Se utilizaron métodos y técnicas del nivel empírico: encuestas a 30 pacientes con riesgo inminente de amputación. El 64% eran mayores de 65 años, 73 % femeninos, todos escolarizados y 73% residentes (...) urbanos. Los resultados más relevantes fueron: que el 54% de los pacientes manifestaron debe existir consentimiento en la aceptación de la amputación, aunque un grupo no despreciable el 37% declinó este derecho a favor de sus familiares. A los médicos se les realizó una entrevista y aunque no hubo unanimidad de criterios, todos coincidieron en que debía legislarse este consentimiento, como parte del perfeccionamiento de los servicios de salud. Research is conducted to improve the process of obtaining informed consent for major amputations due to vascular causes in the Angiology Service of the Manuel Ascunce Domenech Teaching Hospital. Deficiencies were identified in the institutionalization of informed consent protocols, most specifically as they relate to major lower limb amputations. Empirical methods and techniques were used. Thirty patients at imminent risk of amputation were surveyed by questionnaire methods; 64% of those surveyed were of 65 years of age, 73% were female, all of them had an average educational level, and 73% were urban residents. The results indicated that 54% of patients recognized the importance of informed consent in cases of amputation, although a rather considerable group declined this right for their families. Physicians were also interviewed and, although there was no unanimity of criteria, all of them considered that this consent should be legislated as part of the improvement of health services. (shrink)

Upon first consideration, the desire of an individual to amputate a seemingly healthy limb is a foreign, perhaps unsettling, concept. It is, however, a reality faced by those who suffer from body integrity identity disorder (BIID). In seeking treatment, these individuals request surgery that challenges both the statutory provisions that sanction surgical operations and the limits of consent as a defence in New Zealand. In doing so, questions as to the influence of public policy and the extent of personal autonomy (...) become important. Beyond legal issues, BIID confronts dominant conceptions of bodily integrity, medical treatment, and ethical obligations. This paper seeks to identify the relevant public policy concerns raised by BIID in New Zealand and the limits of autonomy, before moving on to consider how BIID sufferers may legally seek the treatment they require and how a doctor might be protected from criminal proceedings for assault for performing this treatment. It will be argued that it is possible to legally consent to the amputation of a healthy limb as medical treatment and that public perception should not be allowed to take precedence over this right. (shrink)

Previous studies on body ownership illusions have shown that under certain multimodal conditions, healthy people can experience artificial body-parts as if they were part of their own body, with direct physiological consequences for the real limb that gets ‘substituted’. In this study we wanted to assess (a) whether healthy people can experience ‘missing’ a body-part through illusory ownership of an amputated virtual body, and (b) whether this would cause corticospinal excitability changes in muscles associated with the ‘missing’ body-part. Forty right-handed (...) participants saw a virtual body from a first person perspective but for half of them the virtual body was missing a part of its right arm. Single pulse transcranial magnetic stimulation was applied before and after the experiment to left and right motor cortices. Motor evoked potentials (MEPs) were recorded from the first dorsal interosseous (FDI) and the extensor digitorum communis (EDC) of each hand. We found that the stronger the illusion of amputation and arm ownership, the more the reduction of MEP amplitudes of the EDC muscle for the contralateral sensorimotor cortex. In contrast, no association was found for the EDC amplitudes in the ipsilateral cortex and for the FDI amplitudes in both contralateral and ipsilateral cortices. Our study provides evidence that a short-term illusory perception of missing a body-part can trigger inhibitory effects on corticospinal pathways and importantly in the absence of any limb deafferentation or disuse. (shrink)

Sufferers of body integrity identity disorder (BIID) experience a severe, non-delusional mismatch between their physical body and their internalised bodily image. For some, healthy limb amputation is the only alleviation for their significant suffering. Those who achieved an amputation, either self-inflicted or via surgery, often describe the procedure as resulting in relief. However, in England, surgeons who provide ‘elective amputations’ could face prosecution for causing grievous bodily harm (GBH) under section 18 of the Offences Against the Persons Act (...) 1861. Whether such a therapeutic intervention should be classified as GBH depends on the presence of harm, as, without harm, it is hard to argue that GBH has occurred. However, there is no agreed-upon definition of what constitutes harm. Such a definitional absence then begs the question, what is harm? It is this question which this article addresses, using the provision of healthy limb amputation in cases of BIID as an example. Drawing on metaphysics, this article will seek to clarify three separate contemporary models of harm: the counter-temporal, the counterfactual, and the non-comparative. Each model will be applied to the scenario of a surgeon carrying out a BIID-induced, therapeutic, healthy limb amputation, and in each, how harm may, or may not, be understood to have been caused will be explored. It concludes that an unexamined conception of harm is ill-equipped for employment in suspected cases of GBH when it is unclear whether harm has been caused and that a better-informed understanding of harm is required in cases where there is potential disagreement, be that in instances of BIID or a myriad of other borderline scenarios. (shrink)

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)