- “One of my, my earliest memories … was that when I was playing with Barbies, I thought Barbie would look much more interesting if she didn't have legs, so I popped her legs off,” a woman referred to only as “Corinne” told a BBC Horizon documentary. “I mean Barbie is Barbie and you know she's an attractive woman, but she just looked so much better, so much more interesting and intriguing without legs and, and I can say that, you know, that, that's something that I want for myself.”
- Corinne's desire to have her legs amputated strikes most as a macabre symptom of an underlying mental disorder. But according to two Australian philosophers, Neil Levy of the University of Melbourne and Tim Bayne of Macquarie University, surgeons should be allowed to amputate healthy limbs in cases of would-be amputee who request it, provided they are considered sane1 and no other treatment is available.
- Corinne certainly thinks2 she's sane. “Everything about my life is ordinary, except this one aspect and it's very hard to fit that in to the rest of my life. My legs are extraneous. They shouldn't be there, they don't feel, it doesn't feel right that they extend beyond where I feel my body should end.”
- In an article for the Journal of Applied Philosophy , Levy and Bayne define this condition, known as Body Identity Integrity Disorder (BIID) or body dysmorphia, as “a mismatch between their body and their body as they experience it – what we might call their phenomenal (or subjective) body.” They suggest that this mismatch may involve a discrepancy between a person's actual body and her body image. They compare unusual cases of people like Corinne with more familiar ones, such as a person who wants breast enlargement: she knows she has small breasts, but her idealised image of herself is of a person with large breasts. “She does not feel comfortable3 – at home – in her own body.”
- Levy and Bayne are not the first to advocate going ahead with requests for amputations in such circumstances. In January 2000, Robert Smith, a surgeon at Falkirk and District Royal Infirmary in Scotland, amputated the healthy legs of two patients at their request, and was planning to do a third amputation when the trust in charge of the Infirmary stopped him. In the Horizon documentary on the subject, “Complete Obsession,” Smith said this about his decision to amputate:
- “Certainly when I was first contacted by the patients who wished an amputation of a perfectly healthy limb it struck me as being absolutely utterly weird. I was worried and concerned about whether in fact we should even consider this procedure. ... It's quite a difficult change of view on my point really, to remove a healthy limb is an anathema to a surgeon. ... The major concern with these individuals is that if they do not achieve their amputation by medical means they will try and achieve it by self-injury4. We do have a number of individuals who have deliberately injured themselves with train tracks, shot guns and have achieved amputation this way.”
- Carl Elliott, an MD-PhD who teaches at the University of Minnesota's Center for Bioethics, wrote a widely-read article for the December 2000 Atlantic that considered the phenomenon of voluntary amputation as part of a broader pattern of new pathologies arising “as if from nowhere”.
- “Like Robert Smith, I have been struck by the way wannabes use the language of identity and selfhood in describing their desire to lose a limb. ... Why do certain psychopathologies5 arise, seemingly out of nowhere, in certain societies and during certain historical periods, and then disappear just as suddenly?”
- Elliott cites the philosopher and historian of science Ian Hacking, who has written about the sudden appearance of “transient mental illnesses” such as the fugue state and multiple-personality disorder.
- “Hacking uses the term ‘semantic contagion' to describe the way in which publicly identifying and describing a condition creates the means by which that condition spreads6. ... An act has been redescribed to make it thinkable in a way it was not thinkable before.”
- Elliott argues that this possibility suggests concerns about voluntary amputation as treatment for the disorder of wanting a voluntary amputation. He told me, “one occupational hazard of philosophy is preoccupation with theoretical problems at the expense of the practical, and this is often the case with the way that some philosophers think about voluntary amputations. It may be that there are no good principled reasons for surgeons not to do them, and that the reasons surgeons give for refusing to do them can be picked apart and attacked as irrational and inconsistent. But we need to remember that the history of psychiatry does not give us good reason to be enthusiastic about surgical cures7 for psychiatric problems. Think about lobotomy. Think about the more recent practice of treating intersexed infants by surgically modifying their genitalia. Think about all the many other efforts to treat psychological problems with mechanical solutions, from insulin coma therapy to ECT. Whatever you think about these treatments (and some, it is true, have been unjustly vilified) they should give anyone pause who is about to embark on a new, untested, irreversible treatment for a psychological problem.”
- Levy and Bayne discuss this concern in their JAP article. They acknowledge that even if they are right about the force of their arguments in favour of allowing “self-demand amputation of healthy limbs,” it could still be the case that the force of these arguments is outweighed by reasons against allowing such surgery.
- “In our view, the strongest such argument concerns the possible effects of legitimising BIID as a disorder. The worry is that giving official sanction to a diagnosis of BIID makes it available as a possible identity for people. To use Ian Hacking's term, psychiatric categories have a ‘looping' effect: once in play, people use them to construct their identities, and this in turn reinforces their reality as medical conditions.”
- However they go on to say that there is reason to think such fears are unwarranted, because the preference for bodily integrity is deep-seated in normal8 human beings, and so it seems unlikely that the desire for amputation will proliferate9.
- Neil Levy told me, “BIID is very persistent; indeed, apparently lifelong. So, so far as we know, amputation is the only effective treatment. But research is in its early days: if psychotherapy or psychopharmacological treatment turns out to be effective, then it is obviously preferable. And it does not seem to impair rationality in any detectable manner. So the request seems autonomous, and even reasonable (it is reasonable to want a source of persistent and significant suffering removed, even if you know that the costs of removal are high; so long as the benefits outweigh the costs and there is no other way to secure the benefits) ... And what cases we have available (including an Australian man who contacted me, and who damaged his limb himself, to force surgeons to remove it) suggest that the desire disappears once the limb is removed. This man had his leg amputated 25 years ago, and reports that he is very satisfied with the result.”
- Nevertheless it is hard not to conclude that a weekend spent in a wheelchair pretending to be a legless amputee is an inadequate test for being an actual and irreversible legless amputee. The worries Carl Elliott mentions seem cogent. He put it this way: “Re looping effects: I warned about this in 2001, and while it is hard to come up with reliable data, the numbers of amputee wannabes do seem to be rising. The listservs are growing – there are more of them, and more people on them.”
- Ophelia Benson is co-author of The Dictionary of Fashionable Nonsense (Souvenir Press). .
- See Link. The onward link to the full text is now broken, so I've included the full text in my abstract.
- Voluntary amputations: Body Identity Integrity Disorder (BIID) or body dysmorphia.
Footnote 1: Surely, this should read “otherwise sane”? How can one be completely sane if one desires extreme bodily mutilation and dysfunction?
Footnote 2: Well, how does she react to reason on this issue – that her body does indeed extend to the end of her legs, and that it’s some sort of psychological issue that persuades her that it does not?
- I reject this analogy. What this person seeks is something that is (for good or ill) perceived by many as a bodily improvement – so this desire is for an objective good. This is not the case for amputation.
- Even if the analogy were successful, there is a case to be made for one being happy with the body one has, or for improving it by natural and healthy means (dieting, exercise). Wanting surgical improvements is itself a psychological problem unless there is no natural alternative and the problem is important enough.
- This is a sound consequentialist argument as far as it goes – but only if a robust counselling attempt fails. Again, it must not be lost sight of that the desire is indeed “utterly weird” and is fundamentally mistaken. Somehow, the patient needs to be convinced of this fact.
- I’m convinced that a root of this problem has to do with the “diversity” arguments. No-one is willing to say that the physically disabled would be better off were they able-bodied. There is a confusion between two claims:-
The first statement is clearly true (it seems to me) while the latter is clearly false (because however the able-bodied might benefit, if at all, the loss to the disabled would be total).
- That we would all be better off if there were no disabled people in existence, and
- We would all be better off if the currently-existing disabled people did not exist.
- The reason it is true that cateris paribus we would all be better off were there no disabled people is that disablement is – as the terms suggests – a disability. Non-disabled bodies are as they are because they are best fitted to life on this planet. Having no legs means you can’t do various things you could otherwise do. Also, there is an emotional and practical impact on others. People will naturally think you in distress, or disadvantaged. They will also be called upon to help when they might not have needed to.
- There is also an aesthetic aspect. We’re not indifferent to whether animals are perfectly formed or not. A lion with its normal complement of limbs looks the part, whereas a lion with a limb missing – however much we might empathise with it – doesn’t. It’s not as nature designed it. And the same goes for human animals.
- Again, it is true to say that the disabled are a burden on society, and in an ideal world there would be no such burden. While this doesn’t not imply that in the actual world we should eliminate the disabled, it does imply that we should not add to their number.
- Finally, acting in a way that makes oneself a burden when there is no objective need to do so is immoral in most ethical systems.
- I agree. It has become (to a greater or lesser degree) socially acceptable to be disruptive, or dreadful at spelling or innumerate because you are “suffering” from one or other of the popular “conditions”.
- I’ve no doubt that such people need help, but that doesn’t take away the fact that such states of affairs are “bad things” and should be corrected – by self-help where possible, rather than just accepted and worked around (however much this might be the last resort).
- But, the point here is that such “conditions” can become popular. No one is proud of being bad at spelling, but if you have dyslexia you can join a club.
Footnote 8: This seems to imply correctly – that those without this desire aren’t “normal”; but, I suppose, this does not in itself imply that they are insane.
- Much as I agree with this argument, the parallel isn’t exact. Lots of these “cures” were rather wild and speculative. Others are more focussed and better understood.
- Take commissurotomy as a cure for epilepsy. If it works, there might be a case for it despite the cognitive impairments that accompany the treatment. That said, the commissures are not there for no reason, and this has to be a last resort.
- A parallel exists between and commissurotomy and amputation – both are focussed and “last resort” solutions to particular problems. This is not quite the same with lobotomy or ECT.
- Well, it’ll hardly catch on; but it may persuade some attracted to the idea that the idea isn’t as outlandish as might be thought.
- Also, it’s amazing what can catch on. After Louis XIV was surgically cured of his anal fistula, it became all the rage for court toadies to have the problem, real or simulated, and have it cured (without anaesthetic): see Link.
Text Colour Conventions (see disclaimer)
- Blue: Text by me; © Theo Todman, 2019
- Mauve: Text by correspondent(s) or other author(s); © the author(s)