In 1997, Dr. Robert Smith, a Scottish surgeon saw a patient with an atypical request. He wanted the surgeon to amputate his perfectly healthy left leg. Why the request? The patient argued his left foot wasn’t part of him. “It felt alien.” Dr. Smith had the patient see a psychiatrist. The patient was diagnosed with Body Integrity Identity Disorder (BIID). Smith performed the operation. At follow-up a couple of years later, the patient reported his life was positively transformed by the operation. Word got out. Smith saw another such patient and performed a similar amputation. And the second patient also reported a positive result.

Then, the story hit the media. The public reacted. Smith was ordered by his hospital to cease and desist.

Some BIID patients will try the back-door route toward amputation. They’ll injure their leg – then visit the surgeon – leaving the surgeon little choice.

From an article authored by a BIID patient in The Guardian:

First I needed to freeze and kill the leg so that surgeons would amputate it afterwards. I ordered dry ice pellets from a company near Edinburgh (the same stuff that is used in discos for the smoke effect). Nobody asked what it was for. I bought 40kg – it evaporates very quickly, so you have to buy a great deal. I put on layers of pantyhose, because you do not want it sticking to you, spread it in the back of the car and sat with my leg immersed in it for one hour. The pain was indescribable: it hurt so much I passed out a few times. I was scared, but more so of failure. I am that kind of person – I never fail.

I had not damaged the leg enough to have it amputated in hospital, so the following September I made a second attempt..

(source: http://boingboing.net/2007/02/01/elective-amputee-tel.html)

In an article in Journal Applied Philosophy (Vol. 22, No. 1, 2005), the authors tackled the following: (1) What would motivate someone to have an apparently healthy limb amputated?; and (b) under what conditions is it reasonable for doctor to accede to such requests?

The authors noted that patients with BIID are suffering; and the condition does not respond to more conservative measures – including psychotherapy. In addition, functional MR studies have identified imaging signatures suggesting reasons why patients experience a limb as alien.

The authors then continued:

In a world in which many are born without limbs, or lose their limbs to poisons, landmines, and other acts of man and God, it might seem obscene to legitimize the desire for the amputation of healthy limbs. But we have argued that, in the case of at least some [of these patients], the limb in question is not as healthy as it might appear: in an important sense, a limb that is not experienced as one’s own is not in fact one’s own.

Disorders of depersonalization are invisible to the outside world: they are not observable from the third-person perspective in the way that most other disorders are. But the fact that they are inaccessible should not lead us to dismiss the suffering they might cause. Whether amputation is an appropriate response to this suffering is a difficult question, but we believe that in some cases it might be.

The authors supported their arguments with a formal ethical analysis; respect for autonomy, minimize harm; and beneficence. So, for patients with established BIID resistant to other treatment, on balance, it is morally permissible to amputate an “ostensibly” healthy limb. The mismatch between the patient’s subjective experience of their body and what third parties “objectively observe” makes this a challenging conundrum.

What do you think? Any analogous situations in your practices?