Disfigured anatomies and imperfect analogies: body integrity identity disorder and the supposed right to self-demanded amputation of healthy body parts - What is BIID? emotional discomfort with having a body part (usually a limb) that they feel should not be there Why is BIID a problem? Strong discomfort that interferes with routine functioning and wanna do amputation - Generally respected to allow patient requests General argument that BIID demands should be respected (1) Respect of autonomy (medical decision-making context) (2) Potential harm of not providing amputation (do amputation themselves) and no alternative that relieve suffering exists Often, support the right with analogies with other cases Showing that denial of BIID patient demands is inconsistent with conventional medical norms and practices argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation Intro - failing to find willing surgeons, it is not uncommon for BIID patients to attempt to remove the disowned limbs themselves or to attempt to damage them Problem = although individual preferences regarding own care are given weight in determing the treatment, requests for amputation is considered unethical treatment and not honoured in the west Not so strange after all - Michael First’s 52 people (wannabes) = prima facie case that can be made on behalf of respecting the self-demand for amputation = master argument - Why? (1) BIID patients experience serious suffering (2) they report lasting relief from suffering after amputation (3) no effective alternatives for alleviating that suffering except amputation (4) the desires, choices and requests of BIID patients should be held to exactly the same standards and treated with exactly the same respect as other patients - This common strategy for justifying BIID amputation is to show that although the demand is seemingly strange, there is nothing about these cases that falls outside of the conventional practices and ethical standards governing seemingly less problematical cases - Problem in this case (1) not all wannabes identified as BIID (there are alternative conditions that can motivate the desire for amputation; can be due to severe mood disorders and psychiatric disorders; thus unlikely to identify themselves as “wannabes” - Some identify themselves as wannabes due to apotemnophilia - sexually aroused by the idea of being an amputee - Some can be body dysmorphic disorder (BDD), or somatoform disorder or dysmorphophobia - characterised by a persistent and delusional belief that some part of the body is deformed or excessively ugly - Overall, some might not solely because of (feeling that the part simply ought not to be there) - Also, often a sexual aspect to BIID patient attitudes regarding amputation, but not universally present, also rarely the primary motivation for the desire to amputate, also no delusional beliefs about the body parts to be removed - Thus, this supports that BIID can be distingusied ,tho still possible to be a combination # it is meant to apply only to cases of self-demanded amputation motivated exclusively by some form of BIID. The problems of distinguishing in practice BIID patients from other wannabes, and questions about the appropriate response to non-BIID requests for amputation, are beyond the present scope (no clear cut) - Secondly, even assume clear cut for pure BIID, each of the presmises of master argument requires further research (1) unclear whether that suffering can be managed only by amputation Seemingly, amputation provides lasting relief, no supporting systematic long-term studies, also possible that the evidence we do have for this is self-selected from among the “success” stories - evidence suggesting that amputation is the only effective treatment is provided by the few cases - Whether there are effective non-surgical treatments is not yet known, but there is some early work in this direction - Cant prove master argument wrong, but reminds us that we should be careful of concluding too much as long as the empirical questions are not yet answered satisfactorily - Thirdly, the focus should be “ BIID demands are not relevantly different from conventional and relatively non-problematical cases in which patient choice is regarded as either morally permissible or obligatory” (BIID is not so special) - (Autonomy argument) it is sometimes morally permissible to agree to a demand for amputation - Doctors are permitted to agree amputation in these casese even thought serious physical harm flows, because the patient demands it - (Patient-need argument) surgeons are obligated to agree to the selfdemand to amputate in BIID cases given the fact that these demands are in response to genuine suffering and further possible harms that cannot be alleviated or avoided by any less radical means - Ref paper BIID demands as irrational but autonomous - some BIID patients are not autonomous or not competent to make a decision about amputation while others may be - Determining autonomy and competency = requires attention to the particular facts, values and histories of individual patients - But this is odd about the BIID guys as we know enough about them as a type to make this determination without requiring more individual attention - In terms of decisional capacity of BIID, supporters of amputation must defend the claim that BIID patients are no different from conventional, unproblematical candidates for surgery
