14. autonomy and amputation

Body Dysmorphic Disorder (BDD)

• Person believes their body or a body part is diseased or ugly

• Monothematic delusion; comparable to anorexia

Psychosexual disorder ('apotemnophiles')

Person is sexually excited by amputees and the idea they might become one

Bodily Integrity Identity Disorder (BIID)

Person experiences a mismatch between their experience of their body and the actual structure of their body

Authors think BIID explains most cases best

• Mostly not BDD: People tend to feel alienated from the limbs in question, not to think that they are diseased or ugly.

• Mostly not psychosexual: Only a small minority are sexually aroused by amputation.

• BIID has some clinical precedents and seems a better fit.

• Note that these three explanations aren't meant to be mutually exclusive. There can be multiple bases for the desire to remove a healthy limb within the same individual.

Arguments for providing the amputations

• Harm minimization

• Autonomy

• Best available therapy

Argument 1: Harm minimization

• AKA 'harm reduction'.

• "[M]any patients will go ahead with amputations in any case, and risk extensive injury or death in doing so."

Argument 2: Autonomy

• Principle of respect for autonomy.

• "It is well-entrenched maxim of medical ethics that informed, autonomous desires ought to be given serious weight. An individual's conception of his or her good should be respected inmedical decision-making contexts. Where a wannabe has a long-standing and informed request for amputation, it therefore seems permissible for a surgeon to act on this request."

• Jehovah's Witness blood transfusion refusals: if it is permissible to respect refusals of life-saving treatment (like in JW cases), then why not also respect informed requests for amputation?

Objection: act/omission distinction

• Many bioethicists think that, other things equal, causing harm through an action (act) is morally different from (& often worse than) allowing harm by inaction (omission).

• Not giving life-saving blood transfusion = omission (doctor does nothing).

• Performing amputation = act (doctor intervenes and does something).

• So you might think that the principle of respect for autonomy might support omissions that are requested by the patient (like in the JW cases), but not acts (like in the amputation cases)?

• Bayne & Levy respect that the act/omission distinction matters

sometimes, but, in this case, they don't think that it cancels out the autonomy-based reasons we have perform these amputations.

Objection: These patients aren't rational

These patients are suffering from a delusion and their requests for amputation are therefore irrational.

• This argument is perhaps most compelling for patients with BDD

(which is a delusional disorder).

• But even in these cases, those patients are not globally irrational...

• "One might argue that despite the fact that their beliefs about the affected limb

have been arrived at irrationally, their deliberations concerning what to do in the light of these beliefs are rational, and hence ought to be respected".

• Furthermore, the authors have already argued that what these patients are going through is usually more like BIID than BDD.

• They are motivated by a desire to achieve a fit between body and body image.

• Not typically delusional.

• For example: "Although [they] seem not to experience parts of their body as their

own, they do not go on to form the corresponding belief that it is alien."

Objection: These patients can't consent

• Can you give informed consent to becoming an amputee?

• The idea here is that these patients can't know what it will be like to become amputees, and thus cannot consent to amputation.

• The authors (rightly) point out that this objection is weak.

• (You could give a similar objection to many surgeries... and to lots of other things, like the decision to lose your virginity or to become a parent).

Argument 3: Amputation is therapeutic

• These patients' suffering really is serious:

• Lifelong alienation; 44% report disruption to work, social life, leisure. Some attempt dangerous self-amputation

• Amputation really does secure relief:

• Post-surgery patients report lasting satisfaction. No evidence of escalating demands or phantom limb issues

• There really aren't many other good options:

• Psychotherapy and drugs largely ineffective. Desire persists despite treatment attempts

• Benefits arguably outweigh the costs:

• There are some legitimate costs borne by patient, family, society.

• But for many, the extent of the relief and identity-fit they experience seem to

justify the procedure.

Argument 3: Amputation is therapeutic (Conclusion)

1. 'Wannabes' endure serious suffering as a result of their condition

2. Amputation will — or is likely to — secure relief from this suffering

3. This relief cannot be secured by less drastic means

4. Therefore, securing relief from this suffering is worth the cost of amputation.

Does it depend on how disabled the procedure will make the patient?

• We should be somewhat cautious in our estimates of the impact these interventions are likely to have on quality of life.

• Physicians tend to systematically under-estimate disabled quality of life.

• Even so, is there some sort of reasonable limit here?

• We are going to reason differently about a patient who just wants a thumb removed vs a patient who wants all four limbs removed.

• Certain desired interventions wouldn't just mean losing body parts, but also losing access to sensory modalities. Is blinding someone more radical than removing someone's leg?

Will legitimizing BIID cause more BIID?

• Psychiatric categories can have a

looping effect.

• Once a psychiatric category exists,

people begin to interpret their

experiences through it, reinforcing the

category.

• Individuals with other disorders might

gravitate toward BIID as an available

identity or explanation.

• Think also of the phenomenon of

suicide contagion, where knowledge of a suicide causes more suicides to occur

in the community.