Hi all, I registered here on a whim long ago - but have since not returned. Just now finding my interest again - so, to start myself off slowly (and maybe to familarise you all with me) I’ll post an essay.
It was written for a Bioethics course I took this semester - and deals with the the problems associated with a peculiar psychology known as apotemnophilia, and the ethics of its treatment. It has liberal dollops of the “yuck factor” in the conclusion I draw. Comments, disagreement, argument are all welcome.
The Ethics of Removing an Healthy Limb
The question of whether voluntary amputations should be performed is a difficult one. Within this essay, I will argue that, given certain conditions, satisfying an apotemnophile’s desire for surgery is ethical. I will first examine the issue of patient autonomy, both doctor and patient initiated, and how it informs the apotemnophilia debate. In discussing the second type of patient autonomy, I will explore the trend towards a service oriented commercialism within medicine and why this should be avoided. Concurrently, I will also explore the nature of “harm” and how traditional notions of it cannot be used to evaluate the apotemnophile case. I will attempt to show that the removal of an apotemnophile’s limbs “given certain conditions” is an ethical medical treatment.
Late in 1999, Robert Smith - a surgeon at a public hospital in Falkirk, Scotland - amputated the legs of two people. Both legs were healthy, yet the patients insisted that the operation be performed. The patients were suffering from a psychological disorder known as apotemnophilia - or the desire to become an amputee. After careful consideration of their mental state, Smith concluded that they were able to give informed consent and that the operation was medically sound. Yet, when a third apotemnophile approached him, the surgeon made the case public, and the hospital refused to allow the operation to be performed.
One of the most frequent objections raised to the operation, in the press and within the wider community, was that the patients could never have given informed consent to such a procedure. While the issue of what constitutes informed consent is something into which I will not delve in this essay, there is a fundamental caveat upon which much of this essay predicates. That is - the question of patient autonomy when faced with cases of questionable competency. Patients may be deemed non-competent for a variety of reasons and are then considered ill at ease to make rational decisions. Consciousness (or lack thereof, as in coma) and the inability to think rationally (such as in cases of extreme physical pain) are key criteria. It is this last category to which many opponents of radical elective surgery would deign to place potential amputees. As the title (though perhaps not the content) of Carl Elliot’s article, A New Way to be Mad, suggests, the prejudice in such cases is that anyone who would wish a functioning part of their anatomy to be removed must necessarily be irrational. While this is an interesting argument from a psychological perspective, the debate is somewhat muted by the opinion of psychologists who have analysed the apotemnophiles. They found that while suffering from a body dysmorphic disorder, the patients were competent and rational (Elliot, 2000). Therefore, within this essay I will not deal with competency issues, but will assume that the patients are competent for the purposes of such choices.
So, we return to autonomy. At what point do the ethical and moral persuasions of the surgeon have an impact on whether the operation should be performed? At first glance, this may seem difficult. Should a doctor wish to perform surgery, or some other procedure, on a patient, that patient must give consent for the operation, regardless of whether the physician feels withholding such treatment would lead to the death of the patient. This is what I would term “doctor initiated autonomy”, given that the doctor is suggesting treatment regimes. This was examined by the Bartling v. Superior Court ruling in the United States, which stated that “adult persons have the fundamental right to control the decisions relating to the rendering of their own medical care, including the decision to have life sustaining procedures withheld or withdrawn” (Bartling v. Superior Court). This is premised upon a Millsian perspective of autonomy which holds that “over himself, over his own body and mind, the individual is sovereign” (Mill JS, On Liberty [1859] quoted in Pence, 2004:21). Cases where patients (such as Jehovah’s Witnesses) refuse blood transfusions, aware that this will lead to death, are prime examples of such autonomy in action. The difficulty arises when a doctor finds it unethical to not administer treatment, knowing that the patient’s life can be saved, yet they ultimately respect the wishes of people to refuse such treatments. In fact, under common law, disrespecting the wishes of the patient in these cases is actionable battery.
But can the same sort of respect for a patient’s wishes apply to; not refusing treatment - but requesting it? That is the ethical dilemma which presents itself to us - the morality of “patient initiated autonomy”. For the patient is not refusing a proffered treatment; they are requesting (and in some cases demanding) a course of action. There are two factors to be considered here.
Firstly, this questioning ties into the debate over the position of medicine and medical practitioners within our society. Doctors, have long held (at least within the last 200 years) a certain prestige and extra-professional responsibility within the community. Medical practice was, and some would argue still is, regarded not as a business enterprise but a profession, a special calling. This has, in some respects been eroded by the introduction of economics into medical practice. Litigation, the internet, the shift away from public healthcare - all have been cited as factors in the commercialisation of medicine. Yet the most disturbing aspect to some doctors is the possibility that health care will become “a commodity relying on cultivation of desires instead of satisfaction of needs, even as many basic needs go unmet” (Dougherty, Dec 1990:275). Dougherty is correct in denouncing the hypocrisy of a doctor-patient culture where expensive plastic surgery to satisfy superficial desires is encouraged – while patients die in hospital waiting rooms of simple maladies. Yet, more than that, the increasing shift towards viewing the profession as a profit making exercise is something to be avoided, lest necessary, but unprofitable, specialties are abandoned. Thus criteria for deciding which treatments are necessary, and not merely desired, must be established.
Secondly, the fundamental maxims of medicine are sometimes opposed by such notions of extreme patient autonomy. Foremost among every physician’s mind is that whatever action they take “the health and life of my patient will be my first consideration” (SGAWMA, 1948). This sentiment, quite rightly followed as a general rule, is traditionally understood in terms of relieving disease, pain and restoring the body to “normalcy”. Furthermore, it is not my intention to challenge it, the basic premise of the declaration. What is required is a re-evaluation of what constitutes harm and what a physician’s duty is too prevent it.
The increasingly chemical nature of medicine - owing to the increasingly molecular state of biological science - has been ongoing for the past ten years. That “the number of prescriptions in the United States has already increased from 2.0 billion in 1994 to 2.5 billion in 1998 and is projected to reach 2.9 billion in 2000”, is itself a telling statistic (Foote and Etheredge, Jul 2000:165). Moreover, this can be traced back to a fundamental shift in biological science to a deterministic outlook on many diseases, preordained by our own genetic code. This has many implications for medicine.
The body, and its care, have become the primary focus for many young medical graduates. Indeed, “traditionally, physicians have been trained to understand illness and death biologically, but they lack education regarding the spiritual and psychological aspects” (Leland S, 2001). This becomes a major problem when we examine the issue of harm. Specifically - what is more harmful, biological or psychological damage?
To me, the most informative prism to view this dilemma through is that of the utilitarian. Utilitarianism, as an ethical code, is founded on the maximisation of happiness (among the greatest number of beings) rather than the stricter Kantian ethic of “right” (Pence, 2004:19). It seems to me that medical harm relates specifically to what would limit our happiness, and not what would limit our ability to do “right”. Thus, the utilitarian ethic is especially useful when exploring the principle of “harm”.
There are two key questions that a doctor must ask himself when exploring these principles from such a perspective. Firstly, what would raise the patient’s happiness in the long term future?
In the case of the rational apotemnophile, the answer is clearly that his leg must be removed. Most apotemnophiles are supremely happy after the operation. One apotemnophile, when asked if he enjoyed having one leg replied: “it improve (sic) my life quite a bit 'cos that’s the way I wanted to be, that’s the way it is so I’m quite happy about that” (BBC, 2000). Apotemnophiles wish to have their legs removed and, once achieved, the operation does them inordinate psychological good, with respect to their happiness. Of corollary importance is that, as psychiatrist Russell Reid points out, “psychotherapy talking treatment doesn’t make a scrap of difference in these people” (BBC, 2000). Thus the only option, if we are beholden to act, is to amputate the limb.
Secondly, is the risk to the patient’s happiness great enough to necessitate action? The apotemnophile will frequently turn to drastic measures in order to satisfy their desire. As Robert Smith himself stated:
The major concern with these individuals is that if they do not achieve their amputation by medical means they will try and achieve it by self-injury. We do have a number of individuals who have deliberately injured themselves with train tracks, shot guns and have achieved amputation this way. (BBC, 2000)
There have also been cases in which apotemnophiles have threatened to suicide, if medical practitioners did not remove their limbs (McGee, 2000). In short, without the operation (which appears to be the only medical solution) the apotemnophile will do irreparable harm to himself. No matter that his body may now be physically impaired, that is immaterial to the apotemnophile’s happiness. His future happiness is significantly imperilled by inaction. Thus, these two questions having been satisfied, the actions of the surgeon in removing the limb would be ethical, given a rigorous assessment of the patient’s rationality and a review of the range of treatments.
Of course, there is a very strong objection to such reasoning. If we allow people to determine what would constitute their own happiness and then follow through on their wish, what prevents their every whim from being satisfied by the medical profession? The answer is that it is not the chance of future happiness that dictates whether a procedure should be performed. Rather, it is whether their happiness is imperilled by inaction. In essence, the first question deals with the “how” of any procedure and the second deals with the much more important “should we”. When dealing with the second question, we must make careful calculations of the motives, understanding and competency of the individual, as well as the risk to their happiness. While there are no universal demarcations as too what constitutes a threat to future happiness, general standards can be applied. Cancer patients are obviously at significant risk, while performance artists who enhance their bodies with silicone are not. This may act as a safeguard against abuse of the medical community by individuals merely trying to satisfy a desire, rather than alleviate a serious threat to their happiness.
Thus, when the Falkirk hospital intervened in the continuation of Smith’s amputation regime, were they acting ethically? It can almost certainly be said that no, they were not. The threat to the patient’s happiness far outweighed the potential harm to his physical condition. Of course, objections may arise from such operations. Chief among them the issues of harm to the patient and the commercialisation of medical practice. Yet, a strict set of guidelines, based on the two key questions, safeguard the medical fraternity from continuing down a path too closely allied with commercialisation while allowing doctors to assess what actually constitutes harm in a more holistic manner. Thus, to allow the procedure would have been ethical.
Bartling v. Superior Court [1984] 163 Cal. App. 3d 186, 194-95, 209
BBC. 2000. Complete Obsession. [bbc.co.uk/science/horizon/1999/obsession_script.shtml]. Accessed 4 April 2004.
Dougherty, Charles J. 1990. “The Costs of Commercial Medicine”. Theoretical Medicine Dec 1990: 275-286.
Elliot, Carl. 2000. A New Way to Be Mad. [theatlantic.com/issues/2000/12/elliott.htm]. Accessed 31 March 2004.
Foote, Sandra M. and Etheredge, Lynn. 2000. “Increasing Use Of New Prescription Drugs: A Case Study”. Health Affairs July 2000: 165-170.
Leland, Sara. 2001. Death and Dying: Medical Education and Training. [rockethics.psu.edu/bioethics/major_issues/death/toc.asp]. Accessed 4 April 2004.
McGee, Glenn. 2000. Breaking Bioethics on Questionable Surgeries. [bioethics.net/msnbc/msnbc.php?task=view&articleID=17]. Accessed 28 March 2004.
Pence, Gregory E. 2004. Classic Cases in Medical Ethics (4ed). Boston: McGraw Hill.
The Second General Assembly of the World Medical Association (SGAWMA). 1948. Declaration of Geneva - The Medical Code of Ethics. [donoharm.org.uk/gendecl.htm]. Accessed 4 April 2004.