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Patients with the controversial diagnosis of body integrity identity disorder (BIID) report an emotional discomfort with having a body part (usually a limb) that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. 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 sufficiently such that surgeons have no choice but to remove them.
Although patients' individual preferences regarding their own care are given great weight in determining appropriate treatment, BIID demands for amputation, at present, are considered to be requests for unethical treatment and are not honoured by any surgeon or hospital in the west. However, what little has been said in the ethics literature on the subject tends to favour adopting a policy of respecting such requests in cases of BIID. 1 2 3 4 The general line of thinking is that if it can be shown that respecting BIID requests for amputation is in no relevant sense different from already established and widely accepted medical practices and norms, then the thought that these patients request unethical or unprofessional treatment ought to be dismissed and the requests should be given the same weight in medical decision-making as putatively non-problematical patient preferences. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. In this paper, I criticise the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argue that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation. i
Not so strange after all
Drawing on the study by Michael First 5 of 52 people "self-described as having had a desire for amputation" ("wannabes", as they call themselves), there is indeed a prima facie case that can be made on behalf of respecting the self-demand for amputation. I will call this the...