Case: Elective Amputation

The availability of high-quality artificial organs, including legs, arms, hands, eyes, and so on, creates a new ethical problem for doctors: whether to take part in elective amputations. An elective surgery, such as elective amputation, is not medically necessary, but is desired by the patient. This is already an issue with current prosthetics, and it will only get more pronounced as the technology behind body-to-computer interfaces improves.

Many surgeons refuse to participate in surgeries unless there is some clear positive health outcome for the patient. If a limb is damaged to the point that it either places the life of the patient at risk, or inflicts so much pain that it will significantly reduce the patient’s quality of life, the surgeon is probably ethically justified in participating in the amputation. But what if there is no immediate medical reason for the amputation? To explore the range of choices doctors might face, let’s consider three scenarios.

The first scenario, described by Dan O’Connor, a faculty member at the Johns Hopkins Berman Institute of Bioethics, was a real case that involved a patient with a nonfunctional hand. The patient lost the use of his hand in a motorcycle accident, but the hand was otherwise normal. It was not likely to be infected and was not giving the patient much pain. The hand did have sensation, so the patient was not likely to get an injury without knowing it (something that happens often to patients with serious nerve damage). The patient had requested that a surgeon remove his hand. He wished to get a bionic hand, but there was no way to use it without getting his original hand amputated. Should the surgeon agree to perform the procedure?

The second scenario (which is made up, but based on real cases) involves a very rare and controversial condition: body integrity identity disorder (BIID). The main symptom of this condition is the desire to have a healthy and functioning limb amputated. Most patients with this condition are not irrational about other issues, but strongly feel that their current bodies do not match their images of themselves. Some patients have described their feelings as being similar to the feelings that motivate a person to have gender reassignment surgery or to get piercings or tattoos that others never see. Overwhelmed by the desire to alter their bodies, some people who suffer from BIID will often seek the help of a surgeon. Some, if they fail to find a competent surgeon, will take matters into their own hands, often with disastrous results. Should a surgeon participate in such an operation?

Scenario three looks to the future, and is somewhere in between the other two scenarios. In this scenario a patient with a perfectly healthy and functioning limb asks a doctor to remove it so that he can use a bionic prosthesis. Should a surgeon be willing to participate in such an operation?