Wednesday, July 06, 2005

The Ethics of Gratuitous Amputation

Suppose that a person wants one of his perfectly well-functioning limbs to be amputated, for no (other, instrumental) reason. He just has an intrinsic, inexplicable desire to be rid of it. Should surgeons accede to the request? That's the question raised in this fascinating article:
[Australian philosophers] Neil Levy and Tim Bayne argue that patients obsessed with having a limb amputated should be able to have it safely removed by a surgeon, as long as they are deemed sane.

"As long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests," the pair wrote in the Journal of Applied Philosophy.

Dr Levy, of the University of Melbourne's Centre for Applied Philosophy and Public Ethics, said some patients suffered so severely from the rare condition - known as Body Integrity Identity Disorder (BIID) - they tried to remove the limb themselves.

"There's cases of people using chainsaws or shotguns and there's been deaths, not surprisingly," Dr Levy said in an interview.
To reinforce their case, Dr Levy and Dr Bayne, of Macquarie University's philosophy department, relate the example of a Scottish surgeon's patient who said his life had been transformed for the better by his amputation.

Dr Levy said he believed such operations were less of a problem than cosmetic surgery like breast enlargement.

"Cosmetic surgery reinforces norms of appearance that are of themselves, undesirable - the idea that women have to be sexually attractive and if they're not, they're not valuable," he said. "Amputation surgery flies in the face of our norms of attractiveness. I think it's less problematic."

Well, it is less problematic in that sense, for sure. But it is more problematic in the sense that it involves deliberately disabling a person. It will make them less able to perform various actions. And that is, in general, exactly the opposite of what we ought to be aiming at. On the other hand, enabling people has predominantly instrumental value, in that it helps them achieve what they want out of life. So if what someone really, truly, wants is to lose their arm, then perhaps we ought to help them achieve that end. This conclusion is supported by the libertarian values of self-ownership and neutralism, but I wonder if the substantive autonomist might see it as self-undermining in the same way that selling oneself into slavery would be (though perhaps not quite so bad).

I think what it comes down to is how much they care about the amputation, as compared to how serious a (detrimental) impact it would have on their life. If the person does not have an accurate understanding of how severely the loss of their limb would impair them, then we have good paternalistic grounds to deny their request. But if they have made an informed decision, concluding that getting rid of the unwanted limb is more important to them, then I think we have to support that.

There are also good utilitarian reasons to allow the procedure to be done safely, as with abortion, if the alternative is that many would attempt it themselves in an unsafe environment (cf. Levy's mention of "chainsaws"). If this is reinforced with testimony from past amputees who are happy with their choice, then all the better, I suppose.

The requirement of "sanity" is a tricky one. One is tempted to think that anybody who wants to amputate a perfectly good limb is, ipso facto, irrational. "But the people I'm talking about are rational people, they're not insane in any way. They've just got this one, very strange, belief." (Quote from Dr. Levy.)

The article also quotes Dr Quinn, the Royal Australasian College of Surgeons' executive director of surgical affairs, as suggesting that "to remove a normal limb because somebody thinks it would be a good thing is unethical and we wouldn't do it." But he doesn't give any reason why it's unethical. Perhaps that was due to space constraints, I don't know. But one would hope that those who get to decide such matters have something more than blind prejudice to support their position.

Update: A better, more thorough, article on the issue is here. It offers a bit more by way of explaining the condition:
Past research has suggested this rare condition may be because they believe their body part is diseased or ugly, because the notion of becoming an amputee sexually excites them, or because of a mismatch between their body and their image of it... Levy says it's unclear exactly what causes BIID, although it may be the result of a cortical misalignment between how the brain "sees" the limb and what's really there. He says in the case of so-called "phantom limbs", people who lose a limb may experience the sensation that it's still there. This is because the way the limb is represented in the brain hasn't caught up with the physical change. But amputee wannabes may have the limb but not the cortical representation.


  1. the problem is that insane just means "thinks in a way we dont identify with". Or the trait of the people we want to control. It is just a word that classifies all sorts of people we want to control or act paternalistcally towards or whatever.

  2. I blogged on this a few months ago, in relationship to arguments for/against sexual orientation and the idea of natural kinds. I'd be interested in your thoughts...

  3. It seems to be that a doctor may of course perform this type of procedure if they desire to for payment or whatever, but that if no "medical good" is had from the procedure then a doctor cannot morally be compelled to do such a thing. So I don't think we should prevent the person from undergoing the procdure, but at the same time its up to them to find a doctor willing to do this. And if they cannot find one then so be it.

  4. I basically have to agree with Roark here - I can't figure out any compelling ethical reason for a doctor not to comply with that sort of request (given suitable constraints). On the other hand, I don't think there's any reason to imagine doctors to be compelled to perform these surgeries and more than they are compelled to perform any elective, cosmetic surgeries. So barring a good argument against them I don't really see that the issue is an ethical one at all.

    (Perhaps a religiously based ethical theory might have something to say here? That's the most I can figure out, though.)

  5. Yeah, I have no problem with that. The ethical question here is whether "surgeons ought to be allowed to accede to their requests". I don't think anyone was suggesting that we force them to do so.

    GNZ - such things are often said, but I think they're mistaken. We can identify psychological conditions that obstruct one in their life pursuits, just as we can physical impediments. If there was some way to cure BIID - i.e. removing the desire rather than the limb - without harmful side-effects, then I think that would be a more appropriate treatment. Especially if the patient consented. But possibly even if not. Successful psychological treatment would solve all the problems (of severe unhappiness, etc.) without the cost of imposing a physical disability.

    (There is indeed an element of paternalism here, but you have the causal direction backwards. We do not label someone "insane" merely because we want to control them. Rather, we act paternalistically because we do not believe that they are in a position to know what is in their own best interests.)

  6. CK's post is very interesting, by the way, comparing BIID patients to (e.g.) deaf people who refuse cochlear implants that would let them hear again. But the latter choice is more understandable, given the flourishing "deaf community" and culture which they are embedded within. Do amputees have a similar sense of community? (Honest question - I have no idea.)

    Further question: should BIID amputees qualify for taxpayer-funded disability benefits?

  7. > identify psychological conditions that obstruct one in their life pursuits

    Indeed a utilitarian definition, a good starting point however of course we are all insane because none of us act rationally.

    > Rather, we act paternalistically because we do not believe that they are in a position to know what is in their own best interests.)

    Well - you know - I would say that is true of most (even all) humans - in that they do not generally know and certainly dont always act in their own best interests and insane peopel certainly dont always act against their best interests.


  8. Richard's comment 5 is very interesting. I think that (and I don't take Richard to have challebnged this point) we can force doctors to perform a medical procedure (for here just means if you don't do you will not longer be doctor in this community.) For instance. For instance we can justly force* doctors to treat both black and white heart patients. It might be the case that when we no longer feel as if this force can be levied, then this is a good sign that the doctor is no longer doing "true medicine." The procedure in these cases is elective. No, I doubt we could force* a doctor (even in this limited sense) to give gratuitous amplications in a non-discriminatory fashion. She can give them to whomever she wants to give them to provided that they consent to the procedure. She can even solicit for the procedure if she wishes. Hell, plastic surgeons do it all the time, and this does not seem problematic. Further, it seems wrong to suggest that a doctor cannot perform an elective procedure which places their patient at a social disadvantage. People have a right to place themselves in a social disadvantage if they want to. Odd, but it is surly permissible. Why can't a doctor (provided) she gets consent perform a procedcure which places one in a comparative social disadvantage (having one leg). What's next! The barber won't be permitted to respect the wishes of the punk rocker who wants an outlandish haircut. Imagine the barber saying, "sorry son but my doing this would disadvantage you and for your own good and interests I'm not going to cut yuour hair that way. Of course he can say this, but by the same token there is nothing ethically wrong with him pulling out his barber sheers and cutting the hair.

  9. I am surprised I missed this post earlier, but there are at least two obvious similar conditions in modern society.

    The first is transsexuality, where people intensely wish to take on sex and gender characteristics of the sex and gender other than the one that society assigns them. I strongly accept and affirm that people should be allowed to do this.

    The second is male circumcision and the belief that it ought to be performed on all infants. Yes, this isn't quite the same as removing a part of YOUR OWN body, and yes, it's far short of removing an entire limb. But still, many circumcized men believe that it's the only "right" way to be, while many others wish that it had never been done. The people who are happy about being circumcized may be compared (again, with some caveats) to the people who wished to have a limb removed and who were happy about it afterward. The case is even stronger with adult males who decide to be circumcized on their own.

  10. Though I'm not sure if circumcision (or a sex change) is in any sense a disability. The dodgy thing about these amputations is that they would serve to impair the person, making them less able to perform various actions successfully. Arms and legs are useful and even crucial for many purposes. Foreskins, not so much.

    So that's a weakness in the analogies. But they are helpful in highlighting our commitment to bodily self-ownership, I suppose.

  11. Further question: should BIID amputees qualify for taxpayer-funded disability benefits?

    How about people who smoke, drink, do drug abuse?
    If they become disabled for example: trombosis from smoking causing amputations, car accidents for drunken or doped drivers that causes the to be disabled, would anybody ask the same question? Would these people qualify for taxpayer-funded disability benefits?

    How many people become disabled by smoking, drinking, drug abuse and even radical sports?

    Hom many people want to have a limb amputated?

    I don´t have these numbers, but I think that the number of BIID patients are very smaller.

  12. The numbers of BIID/AID sufferers is currently unknown (but is estimated worldwide to be at least several thousand) as the kind of brash stigma illustrated in the comments above needlessly prevents people from being honest with physicians and therapists out of deep shame and embarrassment. But of those known, many are already on disablity because of the clinical depression that often accompanies theie BIID symptoms. Those who do have amputation, however, have been clinically demonstrated to go on to lead very productive lives after resolution of their issue.

    As to whether elective amputation of limbs is a "medical good", who can tell me what medical good breast implants are for a woman who already has ample cleavage, but still wants (and gets)them. Or lipo-suction for a person who is average weight and height? Rhinoplasty on a person whose nose has no real defect?

    As long a surgeons can engage in these practises for profit, then there is no legitimate ethical two-way to prevent voluntary amputation on persons who need and want them. The "alternative" is have people endangering their lives to mutilate unwanted limbs to necessitate surgical intervention--that's not a very ethical option, as I reason it.

  13. What about Drs. in Thailand? Even though most would surely expouse negativity to the idea of removeing a good limb ( going back to Buddhist
    religion ), Thailand has fast become the sex change capital of the world. And Im sure with THAT, there are certainly some items "removed".
    ...just passing through and thought I'd drop off a thought.

  14. MT, the point of the earlier "medical good" comments was precisely that voluntary amputation is on a par with cosmetic surgery, i.e. doctors should be allowed, but not required, to carry it out.

    But while I agree with your conclusions, I don't think your reasoning suffices. In particular, the analogy with cosmetic surgery is not good enough. Voluntary amputations leave people with a significant physical impairment, as explained earlier in the comments thread. This is a significant difference. Now, I actually agree with you that the surgery should be allowed all the same, in part because the alternative consequences can be so terrible. But we can't just ignore the difference; it needs to be addressed.

  15. BTW, what "brash stigma" are you talking about?

  16. My apologies--I posted a link with my previous comment that did not attach. The comments I speak of are those from other blogs, articles, etc, which decry any person who would seek such a thing as "nuts", "crazy", "lunatic", "demented", etc, with no qualifiers as to why this is the case.

    One of the primary reasons that permission to procede with elective amputations at Falkirk's Imfirmary was withdrawn was because of the violent criticisms and protests that resulted from the media coverage of such treatment--not because of any rational objections to cease the programme. Public outrage/opinion is too often a determining factor the treatment of individuals.

    Regardless, what constitutes "a significant physical impairment"? Unless we live with a missing limb ourselves, do we really have any right to bring any judgement to bear on how this might/will/could affect the life of an individual? How many times have we been witness to the adamant proclaimations of physicians who tell patient's families that their loved one will never be able to do a, b and c, because of a traumatic injury or disease only to be proven dreadfully wrong?

    All too often, the limitations of any physical "impairment" are determined by the attitude of the affected person and those around them. Isn't imposing disability on a person by our preconcieved ideas of what a disability "is" even more debilitating than the actual injury itself?

    So, too, with the assumption that a person who seeks out and recieves elective amputation of one or more limbs is going to depend on disability benefits. Why do we automatically expect that this will be the case? The reseach up to this point has demonstrated that the exact opposite is true--that those patients who *were* recieving benefits before amputation go on to lead fulfilling, productive lives. So, is it fair to say that the idea that we might create a societal burden by allowing such a treatment be, more realistically, an issue of projection and stigma, in and of itself?

  17. Yeah, some good points. I certainly share your exasperation at unreasoned public "outrage" (as should be clear from the main post). The empirical evidence sounds very surprising, and not what people would intuitively expect. So perhaps education is part of the problem. Once people understood that amputation would actually make the BIID sufferer's life go better, it would seem awfully perverse to continue opposing it. (Assuming that no psychological cure will be forthcoming in the near future, as that would surely be the best option, if possible.)

  18. I am most happy I ran into this post. There are many fine points expressed. Productivity of the amputee and the result of amputation as opposed to the result of suffering with BIID, untreated successfully, is a point too. BIID is debilitating and does not give the person with it the ability to be as productive, if at all. There is no question that the amputee candidate should not be given all the pros and cons and the high possibility of Phantom pain which in some cses continues for life, to the one desiring amputation so that they can intelligently make a choice.
    I hope this type of forum or subject continues to provide food for thought on this subject.

  19. Where do people get the idea that someone who wants a limb amputated wants to do it only to get disability payments?

  20. I have searched the web and ran into countless forums such as these.
    The one point that seems to be sidestepped is those that seek voluntary amputation to alleviate physical pain.

    I am a 30yo. Male that has suffered a hip condition since I was 5. I had an operation when I was 14 to help "Prolong the inevitable" of being in a wheelchair. For 10 years after the surgery everything was great I was not inhibited by the condition anymore.

    The condition I had is called Legg-Calve perthese and is a childhood form of Osteonecrosis (Bone death). Only 1 in 5,000 children contract this disorder which results in a malformed neck/ball of the hip.

    Out of these children 5% carry it into adulthood which turns into Osteonecrosis. Now the 2 treatments I have found for the disorder are Hip replacements or a wheelchair.

    Hip replacements last 10 years and can only be done 3 times. That puts me at age 50 and having my 3rd hip replacement not counting the medical bills I will have accumulated from the procedures.

    A wheelchair would keep me from the pain of walking on it, but not stop the decay of the bone, which would lead to more pain.

    I have said for years "I Wish I could just have it amputated" that would still put me in a wheelchair but without the pain of the decaying bone.

    As it stands now, I can get 4-5 hours of sleep at a stretch before I wake up with pains in my hip, I use a wheelchair at work because the walking through the rather large building kills my leg.

    I have never had the desire to be pitied, nor felt my leg was evil, or harbored the fantasy of self mutilation. My desired is purely to escape the 24/7 pain I have experienced for the past 5 years.

    Now Ethically speaking a doctor would not amputate because there are other methods of treatment, but unfortunately they seem to think that everyone makes the same type of money they do. And I personally do not enjoy the thought of spending thousands of dollars just so I can walk a few more years.

    I was told 15 years ago that I would be chair bound by the time I was 40, and have mentally come to accept that.

    Do I not deserve the right to make my life more enjoyable a more pain-free.

    I know this topic is addressing the people that have no Physical impairment that are seeking amputation. But their are virtually no discussions on those that desire amputation for medical purposes.

  21. I imagine that most people would have no objection to amputations for medical purposes. (Your desire sounds entirely reasonable, and it's a puzzle why doctors won't allow it.) The other cases are more difficult, philosophically.

  22. When you watch your child go through pain daily since toddler to adult and it continues endlessly day after day then this seems a reasonable request. Dentists will extract a tooth that is giving a patient pain. Doctors will remove your appendix or tonsils because it causes pain, infection etc. Many internal organs can be removed or replaced when it poses a physical threat. Well if an individual has researched all alternatives and has consciously considered amputation by choice to relieve pain that is hindering his lifestyle i. e. work, child rearing etc everyday life skills that i believe that individual should be listened to. If a person can not function due to extreme pain, and an amputation would relieve that ongoing pain than i believe he has that right to choose. Once the pain is gone as in this case a leg amputation the person can move forward. People can do many things in wheelchairs. People hold down jobs IN wheelchairs. If a person can not work due to pain, We (tax dollars so to speak) pay. If they can alleviate the pain and go back to work, there goes another person off disability. Ok i will get off my soap box now LOL

  23. Interesting post, Richard. It reminds me of an article in Body Modification Ezine in which two bodymod practitioners made their relationship commitment by
    mutually biting off the first section of their ring fingers.

    "I’m dating flesh, and I want flesh to make a commitment to me ... You can take a ring off your ring finger, but you can never put your ring finger back on once you take it off ... I’m going to skin them and make a pair of amulets so we can each wear each other’s ring finger bones as necklaces."

    They plan to repeat the procedure with the next segment on their ten year anniversary, and the whole finger on their twentieth.


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