Should people who have a desire for the amputation of a healthy limb receive that treatment? In this paper Tim Bayne argues yes.
What causes the desire? Bayne distinguishes Body Dysmorphic Disorder from Bodily Integrity Identity Disorder: in BDD, the “wannabe” believes the limb is diseased or ugly, and in BIID the person’s identity does not include the limb. In both the wannabe knows the limb is part of their body, unlike in deafferentation, where people rationally recognise the limb is theirs but only know where it is from visual clues, so that learning to walk again is difficult. Some amputees have phantom limbs, even trying to use those limbs eg to answer the telephone.
A wannabe might have apotemnophilia or acrotomophilia, the sexual desire to have an amputation or attraction to amputees. The attraction may be a projection: few apotemnophiles form permanent relationships with amputees, as it is never the right amputation. There is overlap between devotees, those who pretend to have an amputation, and wannabes. In a survey of only 52 subjects, 87% admitted sexual arousal. Bayne suggests that some wannabes might have BIID, some BDD, even some both, and if there was a sexual component this does not invalidate the desire: Perhaps the sexual element is better conceived of as common, though not inevitable. Sexuality is an essential ingredient in most people’s sense of identity. Like Gender Identity Disorder, BIID might be importantly sexual without ceasing to be essentially concerned with identity.
What could justify a surgeon amputating? Harm minimisation: many will damage their limbs in a dangerous way. Autonomy: an individual’s conception of their good should be respected. Jehovah’s Witnesses are not forced to have blood transfusions. Whether it is morally relevant is that amputation is an act rather than an omission is questionable, especially where doctors have an obligation to promote health. Arguably wannabes are not competent to give informed consent, as they are deluded; but it is a specific individual delusion, they are otherwise rational, and given the delusion amputation is a rational response.
Some say an attempt to change the belief is an attempt to change their identity, who they are. Perhaps they have tried and failed: there is little evidence, but it is unclear another cure would work. There are feminist arguments against cosmetic surgery, that the desire for a different body is false consciousness, but people are allowed to seek it.
Incidentally Bayne argues that transsexual surgery is less acceptable, because trans women conform to stereotypes- weak, helpless and obsessed by appearance. Here I wonder if he is motivated by empathy or perceived kudos for putting an unattractive argument convincingly.
The operation will have a therapeutic effect if (i) wannabes endure serious suffering as a result of their condition; (ii) amputation will – or is likely to – secure relief from this suffering; (iii) this relief cannot be secured by less drastic means; (iv) securing relief from this suffering is worth the cost of amputation.
One writer claimed the desire for amputation has its origins in attention seeking sparked by the deprivation of parental love. I find I am able to appear needy, and attract those who like helping, by less drastic means; and this disbelieves the subject. Why do you want the amputation? Simply for itself. “It is who I am.”
Many will feel repugnance, as shown by my initial choice of title, a poor joke to cover my embarrassment- “Off with their Legs!” That is not a ground for refusing the operation. Disgust is no reliable indicator of moral objectionability.