Nov 16 2012

The Ethics of Amputating a Perfectly Healthy Leg

Published by at 7:58 pm under Healthcare Reform

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..


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?

6 responses so far

6 Responses to “The Ethics of Amputating a Perfectly Healthy Leg”

  1. Davidon 16 Nov 2012 at 8:12 pm

    Composite Tissue Allotransplantation is alive and well. Offer a living donor status to the patients with the BIID condition.
    Review work by Warren C Breidenbach III MD
    Limb transplantation is a reality.

  2. Jsternon 16 Nov 2012 at 11:06 pm

    Good luck getting BCBS to pay for this one!

  3. Gardneron 17 Nov 2012 at 10:10 am

    …”functional MR studies have identified imaging signatures suggesting reasons why patients experience a limb as alien.”

    Any explanations as to what this means?

  4. Bigorthoon 17 Nov 2012 at 10:35 am

    I had a patient with a body dysmorphic syndrome who thought his hips were too wide and wanted me to narrow them. He had done research on pelvic and femoral osteotomies and came with many different diagrams so we could design the best operation. I did present him at an indications conference where we had a serous discussion about the feasibility and technique of such surgery, but no would actually do the surgery.

  5. Medical Justiceon 17 Nov 2012 at 11:06 am

    To Gardner…My bad. Should have read MEG signature and not functional MR.

    Apotemnophilia – the Neurological Basis of a ‘Psychological’ Disorder

    Paul D. McGeoch, David J. Brang, Tao Song2, Roland R. Lee2, Mingxiong Huang & Vilayanur S. Ramachandran

    Nature Precedings npre.2009.2954.1

    Here we show using functional brain imaging – magnetoencephalography (MEG) – that the condition is characterized by an absence of activity in the right superior parietal lobule (SPL) when the affected limb is touched. When this discovery is combined with our earlier finding of a simultaneous increase in skin conductance response (SCR) on touching the affected limb , which reflects increased sympathetic nervous system activity relating to the limb , we conclude that what has been regarded as a purely psychological condition, actually has a neurological basis and is caused by a failure to represent one or more limbs in the right SPL. This has the bizarre consequence that although sufferers can feel the affected limb being touched, it does not actually integrate into their body image – a mismatch that results in a desire for the affected limb to be amputated.

  6. Stephenon 17 Nov 2012 at 4:00 pm

    Certainly a bioethical challenge. It reminds me of the deeply held controversies about sex-change surgery, especially the castration and penectomy involved–which are now accepted as part of the culture.