The Ethics of Limb Amputation and Locus of Disease
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LETTER TO THE EDITOR
The Ethics of Limb Amputation and Locus of Disease Ronald Pies
Received: 31 May 2009 / Accepted: 9 June 2009 / Published online: 23 June 2009 # Springer Science + Business Media B.V. 2009
Abstract The ethics of medically-authorized limb amputation in individuals with Body integrity identity disorder (BIID) remains extremely controversial. One factor to consider is the putative locus of a disease process, and whether the proposed treatment–in this case, limb amputation—reasonably addresses the issue of what organ is mediating the patient’s complaint. Keywords Body integrity identity disorder . BIID . Apotemnophilia . Amputation
The author reports no conflicts of interest relevant to this submission R. Pies Department Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, NY 13210, USA R. Pies (*) Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, MA 02111, USA e-mail: [email protected] Present Address: R. Pies Box 332, Bedford, MA 01730, USA
Introduction Dear Editor: The paper by Dr. C.J. Ryan on apotemnophilia (Body integrity identity disorder, BIID) is wellreasoned and thoughtful, and makes a compelling case for avoiding a reflexive decision when faced with a patient’s request for amputation of a “disowned” limb. Dr. Ryan discusses the issue from a variety of ethical, legal, and medical perspectives, and concludes that medically-authorized limb amputation for BIID sufferers may be justified under certain carefully-defined circumstances. Perhaps so; however, I want to suggest that our medical ethics must also be informed by our models of disease processes, and by whether a proposed corrective procedure “makes sense” in light of that model. Consider a patient who insists that he wants his right shoulder operated upon, because he is experiencing significant pain there. Let’s posit that his discomfort is actually referred pain, owing to known liver cancer (a well-described pattern in the medical literature) [1]. Let’s further posit that the pain has not been relieved with any conventional analgesic treatment, including nerve block procedures. Would it therefore “make sense” to operate on the patient’s shoulder, knowing that the disease process of referred pain is actually mediated by sensitization of dorsal horn neurons sharing input from both visceral (liver) and somatic (right shoulder) sites? [1] I would argue
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that such a procedure would probably not be justifiable on either medical or ethical grounds. Now, by analogy: let’s posit that whatever the nature of BIID—i.e., whether a delusional disorder, an obsessive compulsive disorder, or a disorder related to abnormal brain circuitry—the disease process is mediated by the brain. If we have good grounds (as I believe we do) for making this claim, then we must raise both scientific and ethical questions regarding surgical removal of the “offending” limb, in patients with BIID. One might argue that “the proof of the pudding is in the eating” and that if the patient is “happier” after such surgery
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