Self-demand amputees are persons who need to have one or more healthy limbs or digits amputated to fit the way they see themselves. They want to rid themselves of a limb that they believe does not belong to their body identity. The obsessive desire to have appendages surgically removed to fit an alternative body-image is medically and ethically controversial.

Medically, amputating an organically healthy limb is an anathema for most surgeons as desired amputations cannot be justified on the basis of physical health, since the limb or limbs pose no imminent threat to life or health. Amputations, from this perspective clearly contravene the most memorable principle of the Hippocratic Oath – first do no harm However, while cutting off an organically healthy limb, may undermine the physical integrity of the human body, it may ironically, preserve the mental integrity of a ‘bone fide’ self-demand amputee. In short the principle of doing no harm is ambiguous, in part, because, ’ bone fide’ self-demand amputees, have a body identity disorder where their embodied sense of their able bodied self is experienced as uncanny and where they do not feel ‘at home’ in their body. In this way harm has to do with perspective. That is, seen from the outside in, objectively, if you will, removing an organically healthy limb is harmful. However, perceived from the inside-out, from the embodied subject’s life-world, it may not be harm if by amputating, one restores a sense of being ‘at home in one’s body’. The natural attitude (or unreflective common experience) of what constitutes harm must be reviewed from the perspective of the person affected. In the words of a self demand amputee:

“Inside I feel like my legs don’t belong to me... I don’t want to die, but there are times I don’t want to keep on living in a body that doesn’t feel like mine... My legs are extraneous”

Moreover this desire is specific and not generalised,

“The desire that I have for an amputation of above the knee of the right... it is still the reality that it seems like my body stops mid-thigh of my right leg. It’s the rest of not me.” (BBC2, Horizon, 2000)
Ironically then, having an amputation restores their sense of wholeness, rather than takes it away. In many ways, like transsexuals going through gender reassignment, self demand amputees (affected by genuine body identity disorder) invariably feel more whole when they are disabled through a desired amputation. Whilst in objective terms, both transsexuals and bone fide self-demand amputees, are worse off after surgery in terms of functional health, they are better off in terms of how they ‘feel in themselves,’ which has both a physical and mental health component.
Having outlined self-demand amputation in more general terms in respect to harm, I now turn to different normative positions – both professional and philosophical – to assess the legitimacy of this practise. In doing so, I test normative assumptions against the experiential sense of the condition and briefly assess the most appropriate ethical response.

The overriding professional ethical concern involves whether or not self-demand amputees are bone fide or not. That is, it is important to be sure that they are genuinely affected by a body-identity disorder, not least because amputations are irreversible, so if, post-amputation, the patient does not feel better and whole, there is nothing that can be done about it (other than suing!). The assessment of bone fide self-demand amputee affected by body-identity disorder involves a rigorous psychiatric assessment, which recognises the condition and does not confuse it with psychotic delusion, neurosis and/or sexual deviance. The crucial professional concern is to establish whether or not, the self-demand amputee has a genuine body-identity disorder and whether a requested amputation will, in all likelihood, make them feel better in themselves.

The philosophically ethical concern is whether or not such a practice can be at all justified. From a more conservative Kantian perspective the answer is probably no, because amputating an organically health limb violates a self-regarding duty towards our self and our body and its organic integrity (Kant  1997 and Rom Harre, 1987). Since a self-regarding duty involves preservation of intrinsic human worth, an amputation of this sort would be intrinsically degrading to the human worth. The problem with a more conservative reading of Kant is that integrity and human worth are traditionally and ideally defined, in terms of what this means for most human beings. Whilst, it is not beyond the whit of some neo-Kantians, if they so wish, to define integrity and worth more flexibly, Kant at least, has a normalized view of humanity as evidenced by the examples that he uses on amputation and suicide. So from a more conservative Kantian perspective cutting off a limb to suit one’s body-identity is an anathema as it flies in the face of what it is to preserve the worth and integrity of a normalized ideal of what it is to be human. Unfortunately, any normalized sense self is becoming increasingly problematic the more we know about embodied difference. As such voluntary amputation may in very special circumstances, paradoxically, lead to integrity.
A more useful approach to the problem may lay in certain consequentialist approaches to the problem, where surgery may be justified in terms of

a. Minimising overall harm. That is,  where some harm through amputation, maybe justified if it can be established that the amputation will result in an overall feeling of physical and mental wellbeing. In this respect a minor interest for physical functionality (being able bodied) may be sacrificed if it can be shown that an amputation preserves a major interest of physical and mental wellbeing in a disabled body. This is more in line with interest utilitarianism following Singer (1979) –influenced by Bentham – which involves pitting major interests over minor interests whilst assessing like interests wherever possible.

b. Discriminating between perceived and actual harms on the grounds of a liberal notion of duty by which different categories of moral obligation towards’ subjects can be worked out. This is particularly useful in professional decision-making where psychiatrists and surgeons have to assess between perceived and actual harms when confronted by patient’s requesting voluntary amputation. For example, in assessing the difference between self demand amputees or voluntary amputees with a genuine need and wannabee’s who may not be genuine. Also, it helps prioritise actual needs in the minds of professionals. For example, the acceptability of bilateral amputations versus the difficulties this poses for the severity of disability. This is more in line with liberal utilitarianism espoused by Hayry (1994) – influenced by Mill.

While consequential, as opposed to deontological theories, fare better in justifying self-demand amputation, both are mired in the problem of recognition.  That is recognising both the intelligibility and legitimacy of the request for voluntary amputation is an antecedent problem to that of moral legitimisation or justification.  Neither approach, by itself, provides an adequate solution to the problem of recognition, since most traditional normative theories are underpinned by assessing intelligibility and legitimacy on a symmetry of likeness. In other words, likeness extends to strangers on the rational basis to treat them in the way we would like to be treated. This presupposes symmetry of likeness.  This is because we immediately recognise a fundamental commonality in our experience of being-in-the-world. The problem arises, when people and their requests to satisfy their sense of themselves are radically different from us and our experience of being-in-the-world. To do justice to the intelligibility and legitimacy of such claims I would like to suggest three attitudes:

1. To take an objective view of subjectivity that is different from us. In other words, to take seriously self-demand amputee claims of what it is like to be in the wrong body and what this feels like. In other words, in the first instance, to do a phenomenology, of being a voluntary amputee before applying any censorious ethical judgement. What is interesting about this is that embodied difference is rarely ever totally other, but predicated on a sense of the other that throws into stark relief the demands of the same (see Levinas 1995)

2. To take an inter-subjective view of the problem, reflecting back what it is like, for oneself, as a professional, to meet the demands that such patients place on one. That is, there is a difference between taking a self-demand amputee seriously in their request for amputation and coming to some sort of decision in helping them achieve their desire for amputation. For example, while one may be able to understand the request one may refuse to grant that request on the grounds that it undermines ones sense of being a virtuous professional. Moreover, even if one is willing to risk ones professional reputation, some requests may simply be too much e.g. while one might be able to approve the removal of one limb, a bilateral amputation may be too extreme, when balanced with its disabling effect.
3. To prioritise perceived and actual harms in a rational way – discriminating between genuine and non-genuine cases of self-demand amputee’s as well as assessing what one can, in all good conscience, justify as professional psychiatrist/surgeon.

The difficulty with confronting the demands of those with radical embodied difference and who need surgery to satisfy their sense of embodied identity is recognising both the intelligibility and moral legitimacy of such a claim. Although a phenomenological approach may reveal the intelligibility of their demand for a surgical request, it can never be a moral demand on professionals to satisfy this request when it proves to be alien them – alien in the sense of their perception of what bodily integrity is and/or alien in the sense of remaining true to the integrity of their professional role in preserving it. At best acting on the demands of voluntary amputees for professionals can never be regarded as a morally obligatory act. However, such requests may be perceived as morally permissible and, at best, as morally heroic acts, when participating in such surgeries risks a professional career and censure.

Note on style – academically orientated polemic

References: 

Harre R ((1987) Body Obligations Cogito 15-19

Hayry M (1994) Liberal Utilitarianism London and NewYork: Routledge

Horizon Documentary, Complete Obsession Transcript BBC2 9.30pm Thursday 17 Feb 2000 

Kant, I (1997) Lectures on Ethics ed. Heath & Schneewind, trans. Heath: Cambridge: Cambridge University Press.

Levinas I (1995) Totality and Infinity Pittsbury USA: Duquesne Press

Singer P (1979) Practical Ethics Cambridge: Cambridge University Press

Adapted from :
Tomasini F., (2006) Exploring Ethical justification for Self-Demand Amputation Ethics & Medicine vol. 22 No.2: Bioethics Press, Chicago, USA

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	Ethical Justification for Self-Demand Amputation