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Docs go out on a limb Sarah Wotherspoon and Janelle Miles
23 Jun 05
Quote:
SURGEONS should be allowed to cut off the healthy limbs of people who want to be amputees, a Melbourne researcher says.
Sufferers of the rare body integrity identity disorder say their limbs feel wrong on their bodies and want them amputated.
Melbourne University Centre for Applied Philosophy and Public Ethics researcher Dr Neil Levy and Sydney philosopher Dr Tim Bayne argue sane patients should not be denied the surgery.
"As long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests," the pair wrote in the Journal of Applied Philosophy.
Dr Levy said yesterday: "If it's a long-standing condition then surgery may be a reasonable option.
"One guy I've corresponded with, a New Yorker . . . he's had it for 50 years. He's in his 60s.
"He says it's had a huge impact on his life. It's made him desperately unhappy."
Dr Levy said he had corresponded with at least one Australian, a 29-year-old from Melbourne, who had told him she had always wanted to be an amputee.
To reinforce their case, Dr Levy and Dr Bayne, of Macquarie University's philosophy department, relate the example of a Scottish surgeon's patient who says his life has been transformed for the better by his amputation.
Dr Levy believes such operations are less of a problem than cosmetic surgery such as breast enlargement.
Only about 1000 people worldwide suffer from the disorder, many so severely they have resorted to self-amputation.
"People have used chainsaws or shotguns to try and amputate their limbs or deform them so badly that amputation is the only option," Dr Levy said.
Very interesting dilemma and I have a paper on the Bioethics of Toe Cutting pending publication in the UK. Apotemnophilia (desire to have an amputation) is not that rare albeit sensational when the person wants a leg or arm removed. A very much neglected aspect of podiatry is the managment of people living with psychological (and often psychosexual) challenges. The rise and popularity of cosmetic surgery has brought the bioethical issues in caring for these patients to the fore which I am sure will interest all practitioners.
If you consider body modification as an extension of cosmetic surgery then an interesting ethical and medico-legal dilemma presents itself. In the scenario where a patient presents with a request for foot modification like the young lady with the intermetatarsal studs - what should the clinician do. Whilst the first maxim of healthcare should be 'do no harm', it is worthwhile considering what the outcome might be if the patient self-administered insead. Perhaps in cases such as this a more appropriate maxim would be, 'minimise any harm'. In practice, sexual health have been upholding this principle for years when distributing conoms to under-age teens. Shouldn't podiatry do the same? Certainly there is evidence the NHS recognises and addresses these issues with the radical approach to BDS but I wonder how podiatrists would deal with such a dilemma? And the indemnity costs.
While I have no problem with the notion of surgery to alleviate psychosocial problems (losing a leg probably has effects of equal magnitute on the individual as some of the psychotropic medications, which essentially amputate personalities....) But I would not be doing surgery of that nature in my role as a Podiatrist, I would leave it to a team approach between therapist and well insured surgeon. Very well insured.....
There was a recent case where a young woman sued the medical team that performed her transgender surgery (she was originally a young man). She argued that she had not be sufficiently screened and counselled, and that she regretted the decision and wanted to go back.... Hmmm, it could be tricky glueing the limb back on (or anything else that had been cut off...)
Have these Melbourne researchers lost touch with reality? An amputation is a risky and very expensive operation, plus all the aftercare and help these people would need to continue with their lives. Who will pay for all of that?
I suppose the amputee would be considered 'disabled' and no longer be expected to work, maybe entitled to benefits as a disabled person. I wonder if that has anything to do with their 'psychological condition'?
Or am I being cynical?!
No i do not agree that these researchers have lost touch with reality. Do remember that the article appears to be written by a philosopher and ethicist.
In the 1st post from Admin it highlights that the condition is extremely rare (around 1000 people worldwide) and people with the condition are known to attempt self-amputation; chainsaws and shot-guns are referenced. If we are to focus purely on the financial aspect then i am sure that there is a balance somewhere between long-term pharmacological therapy, psychiatric intervention and managment of botched self-amputation versus amputation.
I am also sure that much ethical debate could be provoked if we were to concern ourselves with the psychological and physical torment that the condition must impose on sufferers.
I recall an episode of Law & Order on this .... the plot was based on a "back street" surgeon performing these operation to amputate limbs for those with this condition...but one of them died :(
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
>Have these Melbourne researchers lost touch with reality? An amputation is a risky and very expensive operation, plus all the aftercare and help these people would need to continue with their lives. Who will pay for all of that?
The apotemnophiles pay for there hospital expenses and prosthesis by themselves. hat is ofen a stimpualtion and one which overtakes criticism of fairness for all.
I suppose the amputee would be considered 'disabled' and no longer be expected to work, maybe entitled to benefits as a disabled person.
That is not what the person wants and they have live for two years as an amputee and exhaust all forms of other treatment before surgery is even contemplated. These are people living with a preoccupation to have three limbs instead of four. It is not for sympathy nor to become dependent, is it because their ideal body is minus one limb.
I wonder if that has anything to do with their 'psychological condition’.
Or am I being cynical?!
The psychological condition is real and there are no other therapies available. The preoccupation is oppressive and leads apotemnophiles in desperation to cut their limbs off to the danger of their lives.
Stewart wrote
>If we are to focus purely on the financial aspect then I am sure that there is a balance somewhere between long-term pharmacological therapy, psychiatric intervention and management of botched self-amputation versus amputation.
In the treatment of apotemnophilia no pharmaceutical or psychiatric intervention has shown to improve the condition. These folks have a life long obsession relieved only by amputation.
>I am also sure that much ethical debate could be provoked if we were to concern ourselves with the psychological and physical torment that the condition must impose on sufferers.
That is certainly part of the debate.
The key to the bioethical issue is the patient’s right to make the request for “amputation on demand.”, and the physician’s autonomy to grant it or otherwise.
The same debate is related to cosmetic toe surgery, where despite the obvious inclusion of patients with body dimorphic disorders, there is a pattern of “normals” demanding body sculpting which presents the same bioethical dilemmas to podiatrists.
Craig Wrote
>I recall an episode of Law & Order on this .... the plot was based on a "back street" surgeon performing these operation to amputate limbs for those with this condition...but one of them died
The psychological condition is real and there are no other therapies available. The preoccupation is oppressive and leads apotemnophiles in desperation to cut their limbs off to the danger of their lives.
Is there much difference to someone with Anorexia whose desperation leads them to starve themselves to the danger of lives?? I'm sure many anorexics would attest the the preoccupation with being thin is oppressive and rules their lives...
However they're "treated"...not allowed to indulge the self-image that their skeletal frames are "fat".
How does this differ?
Why should one be accommodated and the other be treated?
However they're "treated"...not allowed to indulge the self-image that their skeletal frames are "fat".
The therapies used in the intervention of eating disorders are much the same as body dysmorphic disorders. The goals are to address underlying psychodynamic issues while instituting behavioural and cognitive changes. In addition, there are a range of medications (mainly the SSRI's) which may have benefit.
However, the use of phrases such as 'indulge the self-image' might not be entirely helpful. The person with an eating/body image disorder has a genuine psychiatric illness, and the notion of 'indulgence' sounds a bit like telling some-one with depression to 'pull up their socks'. The sad fact is that with some body image disorders, it is not possible to achieve the state where the individual can reconcile their internal image with the external reality. The mortality rate for anorexia/bulimia is disturbingly high.
If a person has a psychiatric condition whereby their existence is untenable unless a limb is removed, then ultimately amputation might save their life. Psychiatric treatment is not 100% effective (our suicide rates attest to that), so surgical intervention might be the only option.
cheers,
Felicity
Last edited by Felicity Prentice : 11th July 2005 at 06:58 PM.
However, the use of phrases such as 'indulge the self-image' might not be entirely helpful. The person with an eating/body image disorder has a genuine psychiatric illness, and the notion of 'indulgence' sounds a bit like telling some-one with depression to 'pull up their socks'.
Fully aware of that...just couldn't think of the right word (still can't!) to use instead of "indulge". I'll consult my trusty thesaurus next time!!
>If a person has a psychiatric condition whereby their existence is untenable unless a limb is removed, then ultimately amputation might save their life. Psychiatric treatment is not 100% effective (our suicide rates attest to that), so surgical intervention might be the only option.
In apotemnophilia psychiatric treatment ( pharmaceutical and otherwise) has been shown to be completely ineffective. Before surgical treatment is undertaken however the person must first exhaust all other forms of care.
The condition apotemnophilia describes people with a fixation to have a limb amputation (usually healthy). This of course has caused much concern to many in the medial fraternity but a University of Sydney academic has recently brought the subject up again with a call for better understanding
Apotemnophilia is a condition where sufferers wish to be an amputee. Currently, belief in the medical profession is that it is part of the spectrum of body dysmorphic disorder and as such patients are denied surgical correction. This can lead sufferers to extreme lengths. Proponents seek to have the disorder reclassified to a body identity integrity disorder such as gender identity disorder. In this way treatment modalities could be reassessed.
Apotemnophilia or body integrity identity disorder (BIID) denotes a syndrome in which a person is preoccupied with the desire to amputate a healthy limb. In this report, we review the available case reports in the literature in order to enhance psychiatrists’ and physicians’ comprehension of this disorder. A search for the case reports available via MEDLINE was done since the first case report published by Money et al in 1977 till May 2011, using the following terms: apotemnophilia, self-demand amputation, body integrity identity disorder, and BIID. In all, 14 case reports were found relevant to our search. The desire to amputate one’s healthy limb seems to be related to a major disturbance in the person’s perception of one’s own identity, where limb amputation can relieve temporarily the patient’s feeling of distress without necessarily and uniformly adjusting the patient’s own identity misperception. More investigations are needed in this domain in order to develop noninvasive treatment strategies that approach this aspect of the patient’s distress within a globalist perspective. In addition, the health professionals’ awareness regarding this disorder is required to ensure professional management of patients’ suffering.
I submitted an article on apotmenophilia and BMD to the UK podiatry journal and it took nearly three year to have it published. I was very pleased to see the editorial committee eventually had the courage to do so.
Apotemnophilia or body integrity identity disorder (BIID) denotes a syndrome in which a person is preoccupied with the desire to amputate a healthy limb. In this report, we review the available case reports in the literature in order to enhance psychiatrists’ and physicians’ comprehension of this disorder. A search for the case reports available via MEDLINE was done since the first case report published by Money et al in 1977 till May 2011, using the following terms: apotemnophilia, self-demand amputation, body integrity identity disorder, and BIID. In all, 14 case reports were found relevant to our search. The desire to amputate one’s healthy limb seems to be related to a major disturbance in the person’s perception of one’s own identity, where limb amputation can relieve temporarily the patient’s feeling of distress without necessarily and uniformly adjusting the patient’s own identity misperception. More investigations are needed in this domain in order to develop noninvasive treatment strategies that approach this aspect of the patient’s distress within a globalist perspective. In addition, the health professionals’ awareness regarding this disorder is required to ensure professional management of patients’ suffering.
The desire for healthy limb amputation: structural brain correlates and clinical features of xenomelia
Leonie Maria Hilti, Jürgen Hänggi, Deborah Ann Vitacco, Bernd Kraemer, Antonella Palla, Roger Luechinger, Lutz Jäncke, Peter Brugger Brain (2012) doi: 10.1093/brain/aws316 First published online
Quote:
Xenomelia is the oppressive feeling that one or more limbs of one’s body do not belong to one’s self. We present the results of a thorough examination of the characteristics of the disorder in 15 males with a strong desire for amputation of one or both legs. The feeling of estrangement had been present since early childhood and was limited to a precisely demarcated part of the leg in all individuals. Neurological status examination and neuropsychological testing were normal in all participants, and psychiatric evaluation ruled out the presence of a psychotic disorder. In 13 individuals and in 13 pair-matched control participants, magnetic resonance imaging was performed, and surface-based morphometry revealed significant group differences in cortical architecture. In the right hemisphere, participants with xenomelia showed reduced cortical thickness in the superior parietal lobule and reduced cortical surface area in the primary and secondary somatosensory cortices, in the inferior parietal lobule, as well as in the anterior insular cortex. A cluster of increased thickness was located in the central sulcus. In the left hemisphere, affected individuals evinced a larger cortical surface area in the inferior parietal lobule and secondary somatosensory cortex. Although of modest size, these structural correlates of xenomelia appear meaningful when discussed against the background of some key clinical features of the disorder. Thus, the predominantly right-sided cortical abnormalities are in line with a strong bias for left-sided limbs as the target of the amputation desire, evident both in our sample and in previously described populations with xenomelia. We also propose that the higher incidence of lower compared with upper limbs (∼80% according to previous investigations) may explain the erotic connotations typically associated with xenomelia, also in the present sample. These may have their roots in the proximity of primary somatosensory cortex for leg representation, whose surface area was reduced in the participants with xenomelia, with that of the genitals. Alternatively, the spatial adjacency of secondary somatosensory cortex for leg representation and the anterior insula, the latter known to mediate sexual arousal beyond that induced by direct tactile stimulation of the genital area, might play a role. Although the right hemisphere regions of significant neuroarchitectural correlates of xenomelia are part of a network reportedly subserving body ownership, it remains unclear whether the structural alterations are the cause or rather the consequence of the long-standing and pervasive mismatch between body and self.
Amputate healthy limb? (Apotemnophilia)
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