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Evans_Neuoethics Final Paper

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Evans_Neuoethics Final Paper

  1. 1. Running Head: RESPECTING IDENTITY OR ENCOURAGING LUNACY? Respecting Identity or Encouraging Lunacy? A Review of Elective Healthy Limb Amputation and its Ethical Implications Hailey Zie Evans Barnard College Psychology Department
  2. 2. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 2 Background Case Study A 51 year old male civil servant arrived to the emergency department of his local hospital after attempting to sever his left hand with an ax. His medical history included obsessive urges to physically alter his body since before puberty, when he was exposed to an amputee. At age 41, his constant interference with the injury site of a minor wound on his right leg resulted in the need for an above-the-knee amputation. Following this operation, he claimed he was much more comfortable with his body. However, over time, he began to develop a desire for the amputation of an upper limb. At first, he tried to quiet this urge by mutilating his left little finger, which resulted in a need for amputation. He then self amputated both his right little finger, his left ring finger, and finally, tried to remove his entire left hand. Once he was admitted to the hospital, he asked his surgeon for a mid-forearm amputation. After the procedure was complete, he expressed that he was content with the results and awaiting being fit for a prosthesis (Sorene, Heras-Palou, & Burke, 2006). Introduction Body Identity Integrity Disorder (BIID), also referred to as apotemnophilia (Barnes, 2011; Bou Khalil & Richa, 2012; De Preester, 2013; Phillips et al., 2010) or xenomelia (Aoyama, Krummenacher, Palla, Hilti, & Brugger, 2012; Brugger, Lenggenhager, & Giummarra, 2013; Hilti et al., 2013; McGeoch et al., 2011), is an extremely rare (First, 2005) and poorly understood disorder that results from a inconsistency between the sufferer’s internal body image and their actual, physical body (First & Fisher, 2012). The result is a longstanding and persistent desire for disability (Ryan, 2008) in non-psychotic and otherwise healthy individuals (Hilti &
  3. 3. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 3 Brugger, 2010). BIID characteristically involves the unrelenting desire to have a healthy limb amputated (Blom, Hennekam, & Denys, 2012), but many suggest expanding this definition to include wish for paralysis (Blom et al., 2012; First & Fisher, 2012; First, 2005), as well as other disabilities, such as blindness (First, 2005), deafness, and neurological dysfunction (Giummarra, Bradshaw, Nicholls, Hilti, & Brugger, 2011). For the purposes of this review, strong craving for healthy limb amputation will be the focus, as it seems to be the most common expression of the disease. Demographics Documented cases of BIID are present majorly in the western first world, and the disorder appears to primarily affect men (Blanke, Morgenthaler, Brugger, & Overney, 2009; First, 2005). These cases occur in individuals whose lives seem extrinsically normal. Many of them have a spouse or long-term partner, a high degree of education, and a stable occupation (Blanke et al., 2009). Thus, it seems that the disorder largely occurs in financially secure, middle class individuals (Sorene et al., 2006). A prominent study in the field found that BIID occurs in homosexual and bisexual individuals at rates higher than chance (First, 2005), but this finding has not been consistent across research (Blanke et al., 2009). Common Symptomotology Individuals who have BIID claim that they feel “over complete” with four limbs. They insist that their physical self doesn’t fit their sense of body ownership (Hilti & Brugger, 2010) and describe one or more of their limbs an alien annoyance (Hilti & Brugger, 2010; Müller, 2009a). Another major complaint is emotional discomfort that disrupts social life, distracts at work, negatively affects family life, and generally interferes with daily functioning (Blom et al.,
  4. 4. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 4 2012; Müller, 2009a; Patrone, 2009). The disorder typically begins in early childhood or emerges around puberty. Some individuals report feeling discomfort in respect to the target limb for as long as they can remember, while others can pin-point a more precise date, which often includes exposure to an amputee (Blanke et al., 2009; First, 2005). It is much more likely for an individual suffering from BIID to desire an amputation of a major limb (i.e. a leg or an arm) (Blanke et al., 2009). As mentioned, BIID appears to be more prevalent in males and it seems as though many of the males with this disorder would like an amputation of the left lower limb, specifically (Blanke et al., 2009; Hilti et al., 2013). While there are very few female documented cases, the majority of them indicate that the female expression of BIID is more extreme, with a frequent desire for bilateral or multiple limb amputation (Blanke et al., 2009; Brugger et al., 2013; First, 2005). There is typically a clear demarcation line presented by the sufferer—they can indicate exactly where the accepted area of their body image ends and the rejected region begins (Hilti & Brugger, 2010). Despite the fact that the limb in question feels incongruent in respect to the individual’s body image, they tend to be completely in control of its movement and are able to recognize when it is probed with a tactile or motor stimulus (Giummarra et al., 2011). In general, there are few comorbidities associated with BIID. Studies related to the disorder provide little to no evidence of presence of any sort of psychotic disorder in BIID patients (Blom et al., 2012; Ryan, 2008), but depression seems to be a common symptom (Blanke et al., 2009). There is a low frequency of documented physical comorbidity, but a few cases have shown that muscle weakness, mild headaches, migraines, lumbar hernias, and type II diabetes are at least occasionally present in BIID individuals (Blanke et al., 2009). There is a more universal prevalence of abnormal sensory experiences, including paraesthesia and
  5. 5. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 5 hypoesthesia, along with the experience that the target limb differs in some way from the rest of the body (Blanke et al., 2009). One of the most widespread documentations in BIID patients’ histories is chronic, mysteriously inflicted injury to the affected limb (Barnes, 2011). It is not unusual for BIID sufferers to take matters into their own hands. Numerous cases have demonstrated that in order to attempt removal of the target limb, sufferers are willing to employ a plethora of methods, including: shooting, using tourniquets, or sawing at the desired amputation site, and burning the limb, placing it in the path of a moving train, packing it in dry ice, or crushing it with weights (Adams, 2007; First & Fisher, 2012; First, 2005; Patrone, 2009). One of the most prevalent tendencies across documented BIID cases is pretending behavior. Sufferers utilize various techniques in effort to simulate being an amputee. They will bandage and bind their limbs, use wheelchairs and crutches, sit on their limbs, and use tourniquets to reduce sensory perception. In addition, they often try to avoid using the target limb whenever possible. When using a wheelchair, for example, they will try to transfer in and out of it without using their legs (Adams, 2007; First & Fisher, 2012; First, 2005; Giummarra et al., 2011). The fact that the target limb is used so infrequently likely attributes to the muscle weakness that is sometimes found in BIID patients (Blom et al., 2012). Because the disease nearly always begins in childhood, it is common for these pretending behaviors to commence at an early age. They are often done secretively, which can make it difficult for the individuals to have normal social lives (First & Fisher, 2012). There is a final common component to BIID involving sexuality. Many sufferers report being sexually aroused by the concept of becoming an amputee, or apotemnophilia. Such individuals are often referred to as “wanabees” (De Preester, 2013; Patrone, 2009). Further, people with the disorder claim to also be “devotees”, those who are attracted to other amputees.
  6. 6. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 6 This phenomenon is referred to as actrotomophilia (De Preester, 2013; Giummarra et al., 2011). Frequently, items associated with disability, such as crutches, wheel-chairs, and prostheses also cause sexual excitement (First, 2005; Giummarra et al., 2011). Conflicting Titles Those who argue that the disorder is first and foremost an identity disorder see Body Identity Integrity Disorder as the most appropriate title for the disease (Craimer, 2009; First & Fisher, 2012; First, 2005; Giummarra et al., 2011). They gain support from the fact that while there are typically several reported motivations for requesting healthy limb amputation, the majority of documented cases include a primary motivation of attaining true identity or feeling whole (Blom et al., 2012; First, 2005). The choice to designate the disorder as BIID in this review does not reflect a personal opinion, though BIID does seem to be the most prevalent name in the literature. For consistency and clarity’s sake, BIID will be used throughout this review, unless referring specifically to the symptom of apotemnophilia. However, it is useful to look into other names for the disorder and the justifications behind them. It has been made fairly clear that while the sexual component to the disorder is very much a common symptom, it is rarely the primary motivation for desiring amputation (First, 2005). Therefore, the original name for the disorder, apotemnophilia (meaning “love of amputation”), is generally considered outdated and not fully correct, because it only accounts for a symptom and does not encompass the disease as a whole (De Preester, 2013; First & Fisher, 2012). However, some argue that the sexual component is now under-recognized, which effectively eliminates a crucial part of the disorder from the awareness of the public eye (De Preester, 2013). Sexual gratification may not be a typical primary motivation, but it is a secondary motivation in a large
  7. 7. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 7 number of cases. While paraphilia is not necessarily required for diagnosis of BIID, some patients are purely motivated by attaining their true sense of self, it is an extremely common attribute of BIID individuals. Further, differentiating between sexual and non-sexual motivations can be challenging, because most consider sexuality to be an integral part of their identity (De Preester, 2013). It has been suggested by some that there may be two pathways for the disorder, a paraphilic one that involves a significant input from sexual motivations, and a non-paraphilic one that is purely identity-driven (First & Fisher, 2012). A final title for the disorder has emerged more recently, xenomelia, which stems from the Greek words “alien” and “limb”. This title is supported by recent data indicating that the disorder is linked to brain abnormalities, which will be discussed in more detail in the next section of this review. Because these brain discrepancies appear to involve a decreased representation of the target limb in the brain, it would make sense to designate a title that acknowledges the limb’s sense of non-belonging (Aoyama et al., 2012; Brugger et al., 2013; Hilti et al., 2013; McGeoch et al., 2011). Possible Causes There are many speculations about potential causes of BIID. However, it is crucial to acknowledge that because the disease is so rare, it is impossible to be certain about any one, universal cause. Generally, the disorder may involve an interaction between an individual’s own body image and how they perceive the bodies of those around them. Viewing a handicapped body as enviable is not normal in terms of the beliefs that the majority of society has. It would be sound to hypothesize that such an unconventional perception is related to an alteration in brain function or structure, because changes in brain mechanisms often reflect in behavior. All of this
  8. 8. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 8 is reason to believe that the disorder is, in part, brain based, but also a function of environmental influence (Brugger et al., 2013). Moreover, because of the relatively substantial evidence that the disorder begins at an early age, it is reasonable to suspect that it stems from either congenital abnormality, early brain trauma, or defective nerve development (Müller, 2009a), along with childhood experience. It has been suggested that the sexual component of BIID, when present, results from an “erotic target location error.” This hypothesis assumes that apotemnophilia, sexual arousal from the idea of being an amputee, begins with actrotomophilia, sexual attraction to other amputees. Instead of directing their love of amputation at other amputees, actrotomophiles target their own bodies with their sexual inclinations, which results in a strong wish for achieving disability (Ryan, 2008). Others suggest different environmental influences as the culprit. Some believe that the disorder reflects a reverence of amputees. Perhaps sufferers see amputees at heroes because of the obstacles they have overcome (De Preester, 2013). BIID individuals who were exposed to amputees at a young age recall feeling fascination, admiration, sexual stimulation, or excitement. Further, those who remember where this amputee was affected very often target the same limb in their own bodies (Barnes, 2011; First & Fisher, 2012; First, 2005). Additionally, a number of BIID sufferers report some kind of injury to the target limb during their childhood, such as a broken bone or a limp (First, 2005). A few studies demonstrate the presence of abnormal skin conductance in the affected region in individuals with BIID, which may indicate a sort of unhealed damage (McGeoch et al., 2011). Researchers have proposed that neural plasticity could exacerbate the disorder via pretending behaviors. If the target limb goes habitually unutilized, this could alter the neural programming of motor representations. Some pretending behaviors, such as tourniquet use, could also cause permanent peripheral nerve damage (Giummarra et al.,
  9. 9. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 9 2011). One could postulate that BIID is caused or amplified by a childhood plagued by emotional trauma or dysfunctional family relationships, which in turn result in longing for sympathy, love, and attention in adulthood (Barnes, 2011; First, 2005). However, the general consensus is that this sort of symptom would be better explained by another illness, such as Facetious Disorder (First & Fisher, 2012). Even prior to more recent research, it was thought that BIID could stem from lesions or tumors in regions of the brain that are involved in controlling awareness (Bridy, 2004). Several studies have looked into somatosensory representation of the target limb in BIID patients. There is evidence that those with BIID symptoms display reduced activation of the somatosensory cortex in response to tactile stimulation of the target limb. This activation is different from both the activation that occurs when their non-target limb is stimulated and the activation that occurs in control (non-BIID) individuals (McGeoch et al., 2011). Further, studies have attributed sensory irregularities to damage in the parietal cortex, specifically in the multisensory integration areas in the right parietal lobule and their connections with the limbic system (McGeoch et al., 2011). Abnormalities in the insula have been observed in some studies, but not others (Dijk et al., 2013.; McGeoch et al., 2011; Sedda, 2011). A more detailed investigation demonstrated that BIID individuals appear to have reduced cortical thickness in the superior parietal lobule and secondary somatosensory cortices on the right side and increased thickness of the central sulcus. They additionally demonstrated increased cortical surface area in the inferior parietal lobe and secondary somatosensory region on the left side (Hilti et al., 2013). While none of this evidence can be stated with certainty due to the rarity of BIID and thus small sample sizes, the findings of such studies are extremely relevant. It is possible that somatosensory processing deficits are involved in the alien association that BIID individuals feel
  10. 10. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 10 in respect to one or more of their limbs. Additionally, research has found no evidence that the somatosensory cortices are not intact, which accounts for the fact that those with the disorder are able to perceive and utilize their target limb while it remains disjointed from their body image. Failure to integrate the limb into the sense of self may be a result of parietal lobe deficits (McGeoch et al., 2011). Furthermore, a very interesting tie between somatosensory input and the sexual component of BIID has been made. Lower limb amputation desires are most common, and the leg and foot regions of representation in the somatosensory cortex are directly adjacent to the area that represents genitalia. Though no evidence exists, this could explain why BIID may, in fact, be an inherently sexual disorder and why lower limbs are more common targets (Hilti et al., 2013). Some issues have arisen regarding the right parietal lobe hypothesis of BIID. Firstly, there is evidence that there is occasionally a transfer in the target limb during the sufferer’s lifetime (Blanke et al., 2009; Blom et al., 2012). However, proponents of the brain evidence argue that this could simply be reflective of neural plasticity (McGeoch et al., 2011). Some BIID patients who secure elective amputation report experiencing phantom limbs following the operation (Hilti & Brugger, 2010) or plan to use prostheses (De Preester, 2013), two trends that are inconsistent with the apparent foreignness of the target limb. The evidence of cortical dysfunction finds strength in the fact that the bulk of documented cases present a request for a left lower limb amputation, because the majority of the brain deficits that have been demonstrated lie in the right hemisphere (Hilti et al., 2013). However, there are cases that involve right limbs and upper limbs, as well as other disabilities altogether (De Preester, 2013; First & Fisher, 2012). Moreover, it has been argued that perhaps the left leg is chosen more frequently due to functionality. In fact, there is even documentation of a few cases where the
  11. 11. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 11 patient claimed to pick their non-dominant side so that they would be able to drive after amputation (Blom et al., 2012). It is, however, notable that the right hemisphere, unlike the left, provides a bilateral representation of the body. This could be why primarily left-sided desires are present, but right-sided ones are possible as well (Hilti et al., 2013). Related Disorders and Common Misdiagnoses Because BIID is extremely rare (First, 2005) and is not recognized in the International Statistical Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Blom et al., 2012), it is often misdiagnosed (First & Fisher, 2012). However, the body of disorders related to BIID may provide some ideas for potential treatment (Ryan, 2008). Additionally, understanding what BIID is not can help clarify its identifying characteristics. BIID is often assumed to be akin to Body Dysmorphic Disorder (BDD) and anorexia nervosa. These are a few of the only disorders than manifest themselves through a monothematic delusion, and it would be rational, at first glance, to assume that BIID could be classified in that category (Patrone, 2009). However, there are several distinctions between BIID and these two disorders that should be addressed. Firstly, in BDD a body part is seen as defective or exceedingly ugly. Typically, patients with BDD experience extreme levels of embarrassment and shame, as well as exceptionally low-self esteem (Bayne & Levy, 2005; First & Fisher, 2012; Phillips et al., 2010). Contrastingly, in BIID, the perception of the target limb is no different from that of other limbs. There is no interest in becoming more attractive, rather the focus is becoming more congruent with one’s identity (Bridy, 2004; Phillips et al., 2010; Ryan, 2009). It is notable that cosmetic surgery is notoriously ineffective in treating BDD and occasionally
  12. 12. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 12 makes it worse (Müller, 2009a). Amputation has shown to be an effective treatment in at least some cases of BIID (First & Fisher, 2012). Both BDD and anorexia nervosa tend to appear in mid-to-late adolescence, as opposed to BIID, which seems to stem from childhood (First & Fisher, 2012). Furthermore, anorexia nervosa involves an irrational decision based on a false conviction, while the beliefs surrounding BIID could be considered rational, at least be some (Ryan, Shaw, & Harris, 2010). It has further been suggested that BIID is actually an expression of a combination of BDD and Obsessive Compulsive Disorder (OCD) (Müller, 2009a). However, this has been countered by arguing that the compulsions in OCD are motivated by reducing anxiety and stress, while the behaviors exhibited by those with BIID are intended to produce pleasure or calmness (First & Fisher, 2012). There are several reasons one could be motivated to seek healthy limb amputation that cannot be attributed to BIID. Firstly, the disorder has nothing to do with receiving enjoyment or pleasure through pain (Sorene et al., 2006). Additionally, BIID individuals don’t seem to desire care and recognition, and don’t have the strong desire to be a needy patient as those with Facetious Disability Disorder do (First & Fisher, 2012; Müller, 2009a; Ryan, 2009). Desiring amputation for financial or social benefits, such as insurance money or early retirement, is not a symptom of BIID (Müller, 2009a; Sorene et al., 2006). BIID is not self-amputation or other injury triggered by psychosis (First & Fisher, 2012). Finally, BIID cannot be considered a sort of cosmetic or reconstructive surgery, because it has little to no relation to aesthetics and has a goal that is opposite of reinstating function in a injured or dysfunctional limb (Bridy, 2004). It seems that BIID is more closely related to some syndromes that result from acute neurological crises. Somatoparaphrenia involves damage to the parietal lobe, typically on the right side, following a stroke or other brain-lesioning event. Sufferers deny that one of their
  13. 13. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 13 limbs belongs to them and attribute its ownership to someone else (Hilti & Brugger, 2010; Ryan, 2009). However, BIID patients do not seem to spontaneously lose their belief, as somatoparaphrenic individuals occasionally do (First, 2005; Sedda, 2011), and they don’t assign ownership of their limb to another person, they just don’t believe it belongs in their body image (Giummarra et al., 2011). Tumors and strokes result can also result in Pötzl Syndrome, a sudden ignoring of the left side of the body because it feels alien (Müller, 2009a), Alien Hand Syndrome, a disorder where the left hand feels foreign and may act against the will of the affected individual, and anosognosia, the denial that a post-injury neural dysfunction is present (First & Fisher, 2012). Asomatognosia is another seemingly similar disorder that results in a body part suddenly disappearing from conscious awareness (Hilti & Brugger, 2010). Phantom limb syndrome results in experiencing an amputated body part as present due to a persevering somatosensory representation, (First & Fisher, 2012; Hilti & Brugger, 2010) and misoplegia is characterized by hatred and aggression toward a paralyzed region of the body (Hilti & Brugger, 2010). Unlike the acquired damage that accounts for many of the discussed disorders, the brain abnormalities in those with BIID are likely congenital or due to an early developmental dysfunction (McGeoch et al., 2011). Perhaps the disorder that is most commonly connected to BIID is Gender Identity Disorder (GID), particularly in respect to cases of homosexual male to female (MtF) transsexuals. Individuals with both disorders are motivated by establishing their identity (First & Fisher, 2012). They express discomfort with a portion of their physical body, because it interferes with their sense of self. Both of the disorders seem to begin in childhood and they both involve imitating their preferred identity, either by pretending to be an amputee or by cross- dressing. Another parallel can be drawn by the fact that both homosexual MtF transsexuals and
  14. 14. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 14 BIID suffers are sexually attracted to what they wish to become, females and amputees, respectively, and this sexual arousal is related to wanting to express a true identity. In both disorders, surgery is not the focus of the desire, but it is something that needs to be completed in order to achieve one’s true self (De Preester, 2013; First & Fisher, 2012; First, 2005). An Ethical Dilemma BIID presents an immense ethical dilemma. Experiencing the body as part of the self is a critical part of consciousness, and having normal interactions with our surrounding environment is reliant, at least in part, on our experience of body ownership (Berti, 2013). Because there is a lack of recognition and awareness regarding BIID, it is possible that when medical professionals encounter patients with the disorder, they assume that psychosis is the culprit. This ultimately would lead to a treatment path that would be ineffective in alleviating the symptoms of the underlying disease (First & Fisher, 2012). However, even when knowledgeable healthcare givers are presented with a case of BIID, they are faced with a challenging decision. It is understandable to have a repulsed visceral reaction to the idea of elective healthy limb amputation, but this in and of itself cannot be used as grounds to deem something immoral (Bayne & Levy, 2005). Approaching cases of BIID in an ethical manner raises many demanding questions regarding the limits of a patient’s autonomy, the Hippocratic Oath, economic concerns, societal impact, and the like. Taking all of these factors into account, medical professionals have to judge whether healthy limb amputation is a moral or immoral action. This review will look briefly at several ethical perspectives: a principle based argument consisting of autonomy, beneficence and non-maleficence, and justice, a Utilitarian point of view, and a Kantian interpretation.
  15. 15. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 15 Ethical Analysis Principle-Based Argument Autonomy. An autonomous action is one that has both intention and insight and is not directed by outside influences (Müller, 2009a). One’s first reaction to a BIID case may be that the individual in question is highly mentally troubled, indicating that their request for amputation should be ignored. Delusional individuals are universally not considered autonomous, and therefore cannot be trusted to make rational decisions (Ryan, 2009). However, there is evidence against the fact that BIID sufferers are delusional. The abnormal feelings sufferers have in respect to their limbs are typically the only unusual thing about them (Ryan, 2008). On the other hand, while monothematic delusions are rare, they do occur in some instances, such as in BDD and anorexia nervosa, two disorders that are considered highly akin to BIID by some (Müller, 2009a; Patrone, 2009). According to the DSM requirements for diagnosing someone as delusional, the affected person’s beliefs must be false. Due to the fact that some individuals with the disorder have obtained amputation and thereafter reported relief implies that their original belief about their target limb was not artificial. Additionally, many BIID patients are willing to recognize that amputation might not necessarily be a cure, and are still willing to try it as a possible treatment (First & Fisher, 2012). They seem to simply be reporting their mental state, and some would argue that there is no obvious reason not to regard this as true. Furthermore, they are often hesitant to confess their strange beliefs to others, because they recognize them as abnormal, which further separates them from delusional individuals (Ryan, 2008). Although, there is another consideration to take into account—whether or not the desire for amputation is an obsession. Obsessions are external, coercive influences on a person and should not be considered makers of rational decisions. There is little evidence that favors obsession as a
  16. 16. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 16 component of BIID. Instead, the wishes characteristic to the disorder are widely considered a intrinsic part of identity (Craimer, 2009). Many who are proponents of BIID as an identity disorder find grounds for supporting elective amputation in the way GID is managed. They question why GID patients are allowed to alter their bodies, while BIID sufferers’ pleas to achieve their true identity are ignored (Loeb, 2008). Thus, they see requests for elective amputation as analogous to appeals for gender reassignment surgery and think both cases should be approached in a similar manner (Ryan et al., 2010). It is notable that those who have non-normative sexual preferences often consider their sexuality to be even more a part of their identity than those who have a sexual inclination in accord with their societal and cultural norms. More simply, a homosexual may consider their sexuality to be deeply engrained in their identity, while a heterosexual individual may feel less strongly (De Preester, 2013). Given that the primary motivation behind the desire for amputation in most BIID cases is to restore identity (Blanke et al., 2009; First & Fisher, 2012), one could draw a similar parallel to being an amputee. Someone with BIID might consider being an amputee to be a critical part of their identity, while someone without the disorder probably doesn’t consider not being an amputee as central to their sense of self. On a similar note, even if a BIID sufferer’s desires were motivated by their identity, one could attest that their proposed solution to their incongruent body image, amputation, is irrational. Instead of changing the structure of their body, it would be more cogent to modify their experience of body image (Bayne & Levy, 2005). Contrarily, the desire for amputation derives from the fact that sufferers feel unable to alter their body image to fit their physical body. Further, their strange sense of self has been a part of them since childhood, so asking them to change this body image would be no different from asking them to change who they are (Bayne
  17. 17. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 17 & Levy, 2005). One could certainly further this point by suggesting that such a request would vary little from asking someone with GID that they should simply change the way that they experience their body. Still, the differences between GID and BIID could also be raised. Firstly, surgical treatment of GID strives to produce a non-disabled product. In addition, while GID is much more prevalent than BIID, the brain abnormalities that are present in those with GID are unknown. Finally, even if the brain discrepancies could be targeted and fixed, developing a medical treatment would be much more complex, not to mention more controversial, than one to integrate alien limbs (Müller, 2009b). Some dispute these claims and even go as far as condemning the search for a neurological treatment for BIID, because they believe that this would disrespect identity and rid of an integral aspect of one’s personhood (Craimer, 2009). Even if BIID shouldn’t be considered an identity disorder, one could still argue in favor of allowing elective amputation. Those who request cosmetic surgeries don’t necessarily consider the alterations they receive to be central to their identity. However, society as a whole doesn’t look scornfully upon such operations. Many ask why elective healthy limb amputation should be thought of any differently (Loeb, 2008). It could be argued that the risks and costs that stem from cosmetic surgery differ from those that correspond with amputation. Nevertheless, it should be considered that sometimes plastic surgeons comply with very strange and expensive requests regarding bodily alteration that may have many significant risks (Ryan et al., 2010). Some insist that it is a human right to be able to design one’s own body (Bridy, 2004), but there are also opponents to this ideal. Several religious groups are adamant that we have no right to change our natural bodies, because the human body is sacred. For example, the Jewish tradition forbids physicians from disrupting the natural manifestations of the body. Further, purposeful maiming is regarded as sinful by Hinduism and several other Eastern religions, Christianity,
  18. 18. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 18 Islam, and Judaism (Jotkowitz & Zivotofsky, 2009). It is therefore quite likely that some BIID patient’s desires are in conflict with their religious beliefs, which may coerce their decision. It is also mentionable that strong religious influences are in disagreement with several issues in medical ethics that involve a controversy surrounding the right to bodily integrity. In all of such cases, religious opposition can’t in and of itself be used as reason to judge something as unethical (Loeb, 2008). In order to make an autonomous medical choice, one must be able to provide informed consent. Some argue that BIID sufferers can’t possibly know what it is like to be an amputee until the operation is complete. On these grounds, elective limb amputation would be regarded as unethical simply because it would not be feasible to fully convey the ramifications of the procedure. This has been contested by claims that those with the disorder spend such a high percentage of their time pretending to be amputees that they understand, at least partially, what having a disability is like (Bayne & Levy, 2005). Thus, a BIID patient’s informed notion of their own good should be valued (Bayne & Levy, 2005). Yet, autonomy can’t be taken as an absolute property; it depends on several prerequisites. Therefore, when a patient asks for a detrimental procedure, this request should be evaluated cautiously by the medical professionals involved. Autonomy should encompass a decision between alternatives that are medically reasonable, and there is great debate regarding whether or not elective limb amputation is a sensible option. Further, one could assert that while everyone possesses the right to harm their own body if they so wish, no one has the right to request harm via physicians (Müller, 2009b). Ethical decisions must allow every party involved to act autonomously. This means that physicians should not feel coerced one way or another by extrinsic forces when considering whether or not to perform an elective amputation. Hence, physicians should not feel obligated to perform this operation under
  19. 19. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 19 any circumstance, but it has been stated that doctors should be responsible for referring BIID patients to a surgeon who will operate if they cannot do so themselves (Ryan, 2009). Beneficence & Non-maleficence. It is a moral objective to obtain more benefits that harms, for all parties involved in a decision. BIID has been defended as an identity disorder by many researchers and medical ethicists. The good that comes from respecting identity and allowing elective limb amputation is the patient’s self-acceptance. While this may not be considered an ultimate good, it can certainly be considered a kind of good, perhaps even a fundamental good. Recognizing acquiescence of the self as such would require elective limb amputation to be complied with, if the true goal is actually to achieve one’s real identity (Craimer, 2009). There are several other medical cases where preserving identity is favored over the typical course of action. Consider a Jehovah’s Witness who refuses blood transfusion. This choice is always respected because in the mind of the patient, there is more harm done by disturbing their identity to receive a blood transfusion than in undergoing the bodily damage inflicted by the lack of one (Patrone, 2009). Another example is a congenitally blind elderly person who refuses corrective eye surgery because she finds her lack of sight, something she’s lived with for her entire life, to be central to her identity (Bayne & Levy, 2005). Gaining support from such instances, some argue that acting upon a request for healthy limb amputation is no different. Even though it is an atypical course of medical action, it should be completed in order to value one’s identity (Bayne & Levy, 2005). Nevertheless, there are a few problematic aspects of this assertion. Firstly, both the case of the Jehovah’s Witness and the congenitally blind individual involve an omission of action, withholding a blood transfusion and not performing corrective eye surgery, respectively. In contrast, complying with elective limb amputation involves performing an action. This quality makes it difficult to seamlessly compare these
  20. 20. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 20 situations in the same context. In addition, while BIID may indeed be an expression of identity, it is also an expression of disease, whereas refusal of a blood transfusion by a Jehovah’s witness is not (Patrone, 2009). It is probable that a wide body of doctors would consider performing an elective healthy limb amputation to be a violation of the Hippocratic oath (Adams, 2007). Particularly if it was decided that the patient in question was not autonomous, performing such a surgery would be an obvious infringement upon a physician’s duty to “do no harm” (Müller, 2009a). The operation itself poses a great number of risks, including infection, thrombosis, paralysis, and necrosis. Following the surgery, amputees are left with a disability and often phantom limb pain (Müller, 2009a; Slatman & Widdershoven, 2009). Nonetheless, it is important to consider that BIID patients aren’t suffering from the loss of a limb—they are being freed from an everyday hindrance. The harm that comes from amputation is minimal when compared to the chronic harm that BIID suffers experience when living with an alien limb (Ryan, 2008). One might urge physicians to err on the side of caution and not take part in radical and irreversible treatments. However, there are no breakthroughs in BIID treatment on the horizon—the disorder is simply too rare (Ryan, 2008). It is also mentionable that there are several cases in which a healthy body part might be removed in order to benefit a patient. People often donate one of their kidneys to those in need, because they can function with one. Those who are at high risk for cancer may elect to remove their currently non-diseased breasts or ovaries, and sexual reassignment surgery also involves the removal of fully functional body parts (Ryan, 2008). There are numerous ways in which performing elective amputations can help minimize harm. Internet sites run by BIID sufferers have forums for individuals to discuss “safe” and “pain-free” ways to either self-amputate limbs or inflict enough damage upon them to make
  21. 21. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 21 amputation a necessity (Bayne & Levy, 2005). Furthermore, it has previously been discussed the painful, dangerous, and even fatal lengths at which individuals with the disorder will go in order to rid of one of their limbs, with or without online encouragement (Adams, 2007; Bayne & Levy, 2005; Loeb, 2008; Müller, 2009a). Patients might also choose to obtain a surgery from an unqualified surgeon in the third world, which could result in immense complications and permanent damage (Bayne & Levy, 2005; Ryan, 2008). Not obtaining amputation can cause psychological harm, as well, through depression, anxiety, and even suicidality (Sorene et al., 2006). Therapy for BIID should focus on restoring an individual’s wholeness and helping them identify with their body (Slatman & Widdershoven, 2009). Many suggest that the degree of suffering that those with the disorder undergo cannot be alleviated by a means of treatment other than amputation (Bayne & Levy, 2005). All of this evidence suggests that amputation may be the least of all evils (Bayne & Levy, 2005), but it is clear that amputation doesn’t always guarantee a resolution. It appears that, at least occasionally, the desire can migrate to a second limb after amputation is secured (Sorene et al., 2006). Some argue that a treatment as radical as amputation can only be justified if it has lifesaving and remarkably curing results. It is debatable whether or not amputation reaps such benefits, and it certainly causes irreversible disability. Additionally, it is difficult to not to wonder how patients who obtain amputations might feel if a revolutionary treatment is developed. There also aren’t enough cases to discern that it is impossible for BIID patients to spontaneously heal (Müller, 2009a). In all, treatments must be effective and have sustainable results in order to be pursued, and there must be no evidence of a less noxious option (Müller, 2009a). Because there is evidence of successive mutilations and desire for amputation following
  22. 22. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 22 initial surgery, it must be assumed that the early success of amputation does not promise a lifetime of relief for every patient (Müller, 2009a; Sorene et al., 2006). Justice. It is crucial to consider whether or not elective healthy limb amputation is ethically just. Those who obtain amputation will have to undergo treatment and rehabilitation, which will be costly to society (Müller, 2009a; Slatman & Widdershoven, 2009). However, one could also argue that public financing should only be recruited if the amputations are needed to cure a life-threatening disease. Amputations for aesthetic, economic, sexual, or other less dire interests should be paid for by the individual (Müller, 2009a). Still, one might counter that this makes elective limb amputation unfair, because BIID patients will have to be of a certain economic standing to pay for the operation. Finally, there is a cost to society that cannot be ameliorated using money. Disabled individuals typically are limited in the occupations they can take on or must retire early (Müller, 2009a). Still, since BIID is so rare, there would likely be very little effect on the quality of the international workforce as a whole. Furthermore, because many sufferers report that the disorder distracts them at work (Blom et al., 2012), it is possible that they aren’t contributing sufficiently to their career, anyway. A Utilitarian Perspective It is clear that amputation has both costs and benefits, and the sum of these factors may vary from individual to individual (Ryan et al., 2010). It is quite possible that for many with BIID, being in accord with their sense of personal identity outweighs the costs of disability (Blom et al., 2012). It is also plausible that society is more cynical about the lives of the disabled than it ought to be (Bayne & Levy, 2005). Still, amputation is costly in terms of the operation itself, as well as the rehabilitation expenses and loss of productivity in society (Ryan, 2008).
  23. 23. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 23 Financial and social costs will depend both on the social and financial standing of the individual and the sort of amputation performed (Bayne & Levy, 2005). Other costs to the patient’s family and friends should be considered (Patrone, 2009). Having to care for someone with a disability may come with financial and emotional harms. Additionally, costs to other patients must be taken into account (Patrone, 2009). Time and resources would be taken away from other patients in need, for something that is by and large, not considered a life-threatening disease. It is, however, mentionable that it may be possible to use amputated limbs for transplantation, which could benefit other patients. Prosthetics, particularly for hands, far from replicate the appendages they are meant to replace (Ryan, 2008). Elective amputations could change that for some individuals, but BIID probably isn’t common enough to make a substantial impact. Another relevant aspect to this cost-benefit analysis is the effect on the medical community. Acting to disable someone else’s body has been considered a crime for centuries, but there is reason to assert that surgical alterations of the body, whether they be therapeutic or not, should not be categorized as acts of criminal mayhem (Bridy, 2004). Nevertheless, costs to a physician who chooses to perform an elective amputation may be high due to the public’s interpretation (First & Fisher, 2012; Ryan, 2008). Because the medical profession is committed to patient health and strives to avoid public criticism, hospital administrators will likely have a difficult time accepting and allowing such an unconventional procedure to occur (Bridy, 2004; First & Fisher, 2012). It would be reasonable to think that if these amputations were to occur anywhere, it would be at university hospitals where experimental procedures are more common (Bridy, 2004). However, there are currently no academic medical centers with research protocols for elective surgeries of this variety (First & Fisher, 2012).
  24. 24. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 24 Finally, it is worth considering that a formal recognition of BIID might result in an increased prevalence. This occurred after official acknowledgment of both GID and Dissociative Identity Disorder (DID), because more sufferers felt like they could admit their condition to their family, friends, and physicians (Ryan, 2008). It is hard to say whether such a pattern would be a cost or a benefit if it were to occur. On one hand, it would allow for more individuals to feel comfortable sharing something they once kept private, which would alleviate a great deal of distress. However, if increased prevalence resulted in more amputations, this would require more resources and would inflict a greater cost on society, due to financial burdens and loss of occupational productivity. Overall, no matter if BIID remains rare or becomes more widespread, it doesn’t seem as though the benefits of elective amputation would outweigh the costs for society as a whole. They may, however, result in a net benefit for the individual sufferer, depending on the case. A Kantian Interpretation The Kantian perspective takes on a stance similar to the principle of autonomy, that choices should only be respected when made rationally. Additionally, decisions that are made in this manner should be respected if they improve the individual’s overall well-being, even if they appear to cause harm to their health (Ryan, 2008). On the other hand, self-maiming opposes self- preservation, which is an indispensable component to Kantian morality. Just as suicide is a moral crime, self-mutilation, whether it be performed by oneself or a proxy (i.e. in this case, a surgeon), is an ethical offense and could be considered a type of partial-suicide. Impairing one’s functionality goes against the moral responsibility to acquire, sustain, and better bodily capabilities. However, it seems as though elective limb amputation shouldn’t be considered self- maiming. While one could claim that voluntarily harming one’s body via elective amputation
  25. 25. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 25 violates autonomy and demeans moral personhood, such assertions are generally regarded as outdated and conservative (Schramme, 2008). The motive behind elective limb amputation is far from hurting oneself. In fact, one with BIID would consider limb amputation as a way to live more fully. Because acting morally requires one to lay out a set of rational goals, if a lucid being makes a decision to comply with something that could be potentially regarded as self-mutilation, they should be permitted to carry out this aim, because it will allow for their completion of moral action in the future (Schramme, 2008). Another component to the Kantian argument involves freedom of will, which is considered a prerequisite for making rational, autonomous decisions. One is considered free if their first order volitions, which refer directly to particular items or situations, agree with their second order volitions, which refer to first order volitions. For example, if one’s first order volition was wish for amputation, their second order volition would be to want to have no amputation craving. In this case, the second order volition could be fulfilled by either acquiring amputation or ridding of the desire for amputation. If the patient in question believes that only amputation could eliminate his amputation desire, his first and second order volitions are in accord, and he should seek amputation. However, if he senses that the amputation desire could be alleviated without amputation, his first and second order volitions are in conflict and he does not possess freedom of will. In this case, amputation should not be sought, but instead, a treatment to remove the amputation desire should be the objective. While it is mentionable that many patients strongly believe that their amputation desire can only be quelled by obtaining amputation (First, 2005), some are unsure (Blanke et al., 2009). It is also true that amputation desire is incompatible with many desires that most humans have, including good health, avoidance of pain, mobility, and social acceptance (Müller, 2009a).
  26. 26. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 26 Ethical Resolution Potential Treatments In order to devise an ethical treatment route, several possible options, including amputation, must be considered. Those who suffer from BIID often report that their amputation desire is amplified when they see an amputee or feel lonely or stressed (Blanke et al., 2009). Some indicate that pretending behaviors provide temporary relief, but this is not a beneficial means of treatment as it may also amplify symptoms (Giummarra et al., 2011). A more promising route would be to encourage involvement in distractions that could help reduce loneliness and stress, such as physical activity, a rewarding occupation, or social engagements (Adams, 2007; Blanke et al., 2009). It is notable, however, that these distractions only seem to provide temporary relief, if any. They also may no longer be feasible after retirement or with increasing age (Adams, 2007). Unfortunately, there is very little evidence of psychotherapy being an effective treatment of BIID. At best, the therapy seems to help alleviate some of the symptoms of BIID, such as stress and depression, or facilitates patients’ understanding of their relationship to the disorder. In no cases has psychotherapy eliminated or reduced the amputation desire (Blom et al., 2012). Although, it is also mentionable that many BIID patients who reported attending therapy sessions also admitted that they never told their therapist about their strange beliefs and urges (Ryan, 2008). Perhaps if the therapists had been more knowledgeable about their patients’ conditions, they could have tailored the sessions more towards their needs. There are many treatments that could be effective in treating BIID, but haven’t been extensively utilized. SSRIs and clomipramine, which are effective in related disorders such as BDD and OCD, seem to be ineffective. However, there has been at least one case where
  27. 27. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 27 alleviation of BIID symptoms was observed on an abnormally high dose of flouxetine, an SSRI (Ryan, 2008). While there seems to be significant evidence against BIID involving delusions, it is possible that it consists of a monothematic delusion, in which case antipsychotics would be worth trying (Ryan, 2008). Other non-pharmaceutical options also exist. Vestibular caloric stimulation, flushing the ear canal with cold water, temporarily relieves the symptoms of somatoparaphrenia, and should be attempted as treatment for BIID (McGeoch et al., 2011; Ryan, 2008). Additionally, repetitive magnetic stimulation (rTMS), which can improve tactile discrimination by enlarging corresponding somatosensory maps, has not yet been tried as treatment for BIID. Deep brain stimulation (DBS) of the proposed affected area could also be tested. It is possible that small, benign brain tumors or artereovascular abnormalities may cause BIID symptoms, and in this case, microsurgery might be an effective cure (Müller, 2009a). It is, of course, possible that all of these proposed treatment ideas will only be effective in a handful of patients or will fail completely. Thus, amputation might be the only option for some BIID individuals. There are some who are very strong supporters of amputation as the best, or even the only possible cure (Loeb, 2008). The removal of a healthy limb might be unconventional and strange, but this alone doesn’t give one ground to judge it as unethical (Ryan, 2008). It is crucial, however, that the fact that the evidence surrounding amputation being a positive treatment is scarce. Furthermore, this support is from patients who sought out researchers because they were content with their elective amputations. Therefore, the only backing to the claim that elective amputation in BIID individuals yields beneficial results is anecdotal, not scientific or systematic, and may be biased towards success stories. Still, it is, at present, the best evidence, and one must base their judgments on what is known to be true (First, 2005; Giummarra et al., 2011; Müller, 2009a; Patrone, 2009).
  28. 28. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 28 Others believe it is completely nonsensical to treat using amputation when there is evidence that the underlying disease process is mediated by the brain (Pies, 2009). They see amputation as a cure of a symptom, rather than the disorder as a whole and recommend seeking a casual therapy that targets the brain abnormalities to integrate the alien limb into the sufferer’s sense of self (Müller, 2009a). Still, there may be no feasible way to ameliorate the brain dysfunction (Ryan, 2009). Some cases involve the recurrence of amputation desire after amputation has been secured, indicating that this “cure” may be far from lasting in its effects (Sorene et al., 2006). Furthermore, there is ample evidence that two related disorders respond very differently to surgery. GID responds incredibly well to surgical intervention, while BDD responds quite poorly (Barnes, 2011). While it seems that GID is more akin to BIID than BDD, these relationships to other disorders can’t be known for sure. Because there are no systematic, long-term studies that followed BIID patients post-amputation, there is no way to be certain about what the true enduring effects of amputation might be. How to Choose Treatment In order to approach BIID in the most ethical way possible, it has been suggested that treatment should be chosen using the following parameters: probability that the treatment will reduce suffering and the magnitude of reduction, probability that the treatment will cause damage and the magnitude of damage, cost to society, and the patient’s personal preferences (Ryan, 2008). Furthermore, reversible treatments should be applied before non-reversible treatments in an increasingly invasive manner. First, vestibular caloric stimulation should be employed; it is reversible, inexpensive, and its effects are apparent immediately (McGeoch et al., 2011; Ryan, 2008). Next, a high dose of a SSRIs, another low-cost option, should be trialed for six to twelve weeks, after which the effects will be present or absent (Ryan, 2008). Similarly, a
  29. 29. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 29 trial of antipsychotics, which are also relatively cheap, could be trialed for a similar amount of time if the antidepressants appear to be ineffective (Ryan, 2008). Throughout all of these trials, psychotherapy sessions should be instituted as well, in which the patient tells their therapist about their amputation desires. Therapists should also encourage their patient’s participation in physical activity and other involvements that may distract from the amputation craving. This route of treatment is more costly and its effects may take months or years to manifest, but nevertheless, both the patient and the therapist should be as persistent as possible in their efforts (Ryan, 2008). Following this time period, if none of the trialed treatments have been successful, the patient’s preferences should be consulted more deeply. At this point, rTMS, DBS, or other more invasive brain procedures, such as microsurgery, could be attempted, if the patient was willing and if finances were in order (Müller, 2009a; Ryan, 2008). Another option would be to wait for a future development. In this treatment plan, there is nothing more invasive than amputation, and it should therefore be used as a last-resort option (Ryan, 2008). If no other treatment is effective and the patient is unwilling to wait for a possible advancement, amputation could be considered. It is notable that in GID, a persistent desire of minimally two years in length is requisite before surgery is considered (Ryan, 2008). It would make sense to institute a similar, or perhaps even longer, requirement for BIID patients, so that they could fully attempt other treatment options. Establishing Recognition In order for medical professionals to ethically approach cases of BIID, awareness of the disorder needs to be more widespread. It is not currently listed in the DSM, but a few sets of diagnostic criteria have been suggested (see Appendix). Some believe that until diagnostic criteria are established, a valid epidemiological study on the disorder is out of reach (Giummarra
  30. 30. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 30 et al., 2011). One could also attest that currently, BIID is much too rare to be investigated using a properly controlled clinical intervention trial, even if published diagnostic criteria were present (Ryan, 2008). Still, given that patients with the disorder rarely confide in their physicians, it is likely that we have a distorted perception of the disease’s prevalence (First & Fisher, 2012). Those who do embark upon treatment strategies must report the results they observe to the medical community, while still striving to protect patient confidentiality (Ryan, 2008). It is critical to institute some reliable resources for BIID patients to turn to so that they stop relying on self-help websites designed by sufferers. These sites encourage disordered individuals to take matters into their own hands by suggesting methods of self-amputation. They also imply that consulting a physician will not yield desired results (Bridy, 2004). Patients with BIID need to feel comfortable telling medical professionals about their beliefs without worrying about being sent to a mental institution (First & Fisher, 2012). Furthermore, because it is an emerging, poorly understood disorder, past BIID cases have resulted in media sensationalism, which prevents cases from being taken seriously (Bridy, 2004). Formal recognition of the disorder could change that. Conclusion It is worth mentioning that cosmetic surgery used to be a laughing stock of the surgical field, but is now a thriving specialty. Establishing BIID as an official disorder in the DSM, along with time, may allow the idea of elective amputation to become more acceptable. While it is unlikely it will ever be as prominent as cosmetic surgery, due to its rarity, healthy limb removal may gain a different reputation as time progresses (Bridy, 2004). However, it is critical that BIID is treated on a case-by-case basis, until the disorder is more fully understood. Taking into account the patient’s preferences, the benefits and harms a treatment has the potential to cause,
  31. 31. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 31 as well as the cost to society is necessary in making the most ethical decisions possible. There are various treatment possibilities that should be thoroughly explored before amputation is considered as an option. Nevertheless, it may be possible that all of these alternatives fail to cure, or even ameliorate the amputation desire. If the patient is considered autonomous in the case at hand, their request for amputation should be taken as a medically rational and plausible alternative for treatment.
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  34. 34. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 34 Patrone, D. (2009). Disfigured anatomies and imperfect analogies: body integrity identity disorder and the supposed right to self-demanded amputation of healthy body parts. Journal of medical ethics, 35(9), 541–5. doi:10.1136/jme.2009.029256 Phillips, K. A., Wilhelm, S., Koran, L. M., Didie, E. R., Fallon, B. A., Feusner, J., & Stein, D. J. (2010). Body dysmorphic disorder: some key issues for DSM-V. Depression and anxiety, 27(6), 573–91. doi:10.1002/da.20709 Pies, R. (2009). The Ethics of Limb Amputation and Locus of Disease. Neuroethics, 2(3), 179– 180. doi:10.1007/s12152-009-9044-x Ryan, C. J. (2008). Out on a Limb: The Ethical Management of Body Integrity Identity Disorder. Neuroethics, 2(1), 21–33. doi:10.1007/s12152-008-9026-4 Ryan, C. J. (2009). The Ethical Management of Body Integrity Identity Disorder: Reply to Pies. Neuroethics, 2(3), 181–181. doi:10.1007/s12152-009-9045-9 Ryan, C. J., Shaw, T., & Harris, A. W. F. (2010). Body integrity identity disorder: response to Patrone. Journal of medical ethics, 36(3), 189–90. doi:10.1136/jme.2009.033175 Schramme, T. (2008). Should we prevent non-therapeutic mutilation and extreme body modification? Bioethics, 22(1), 8–15. doi:10.1111/j.1467-8519.2007.00566.x Sedda, A. (2011). Body integrity identity disorder: from a psychological to a neurological syndrome. Neuropsychology review, 21(4), 334–6. doi:10.1007/s11065-011-9186-6 Slatman, J., & Widdershoven, G. (2009). Being whole after amputation. The American journal of bioethics : AJOB  , 9(1), 48–9. doi:10.1080/15265160802626994 Sorene, E. D., Heras-Palou, C., & Burke, F. D. (2006). Self-amputation of a healthy hand: a case of body integrity identity disorder. Journal of hand surgery (Edinburgh, Scotland), 31(6), 593–5. doi:10.1016/j.jhsb.2006.05.022
  35. 35. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 35 Appendix Table 1 Proposed Diagnostic Criteria for BIID (First & Fisher, 2012)
  36. 36. RESPECTING IDENTITY OR ENCOURAGING LUNACY? 36 Table 2 Proposed Diagnostic Criteria for BIID (Ryan, 2008) A. A strong persistent desire for the amputation of a limb. B. The primary motivation for the desire is the feeling that being an amputee is one’s true and proper identity. C. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disorder is not better explained by another medical or psychiatric syndrome such as somatoparaphrenia, a psychotic disorder or body dysmorphic disorder.

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