Evans_Neuoethics Final Paper

Running Head: RESPECTING IDENTITY OR ENCOURAGING LUNACY?
Respecting Identity or Encouraging Lunacy?
A Review of Elective Healthy Limb Amputation and its Ethical Implications
Hailey Zie Evans
Barnard College Psychology Department

RESPECTING IDENTITY OR ENCOURAGING LUNACY? 2
Background
Case Study
A 51 year old male civil servant arrived to the emergency department of his local hospital
after attempting to sever his left hand with an ax. His medical history included obsessive urges to
physically alter his body since before puberty, when he was exposed to an amputee. At age 41,
his constant interference with the injury site of a minor wound on his right leg resulted in the
need for an above-the-knee amputation. Following this operation, he claimed he was much more
comfortable with his body. However, over time, he began to develop a desire for the amputation
of an upper limb. At first, he tried to quiet this urge by mutilating his left little finger, which
resulted in a need for amputation. He then self amputated both his right little finger, his left ring
finger, and finally, tried to remove his entire left hand. Once he was admitted to the hospital, he
asked his surgeon for a mid-forearm amputation. After the procedure was complete, he expressed
that he was content with the results and awaiting being fit for a prosthesis (Sorene, Heras-Palou,
& Burke, 2006).
Introduction
Body Identity Integrity Disorder (BIID), also referred to as apotemnophilia (Barnes,
2011; Bou Khalil & Richa, 2012; De Preester, 2013; Phillips et al., 2010) or xenomelia
(Aoyama, Krummenacher, Palla, Hilti, & Brugger, 2012; Brugger, Lenggenhager, & Giummarra,
2013; Hilti et al., 2013; McGeoch et al., 2011), is an extremely rare (First, 2005) and poorly
understood disorder that results from a inconsistency between the sufferer’s internal body image
and their actual, physical body (First & Fisher, 2012). The result is a longstanding and persistent
desire for disability (Ryan, 2008) in non-psychotic and otherwise healthy individuals (Hilti &

Brugger, 2010). BIID characteristically involves the unrelenting desire to have a healthy limb
amputated (Blom, Hennekam, & Denys, 2012), but many suggest expanding this definition to
include wish for paralysis (Blom et al., 2012; First & Fisher, 2012; First, 2005), as well as other
disabilities, such as blindness (First, 2005), deafness, and neurological dysfunction (Giummarra,
Bradshaw, Nicholls, Hilti, & Brugger, 2011). For the purposes of this review, strong craving for
healthy limb amputation will be the focus, as it seems to be the most common expression of the
disease.
Demographics
Documented cases of BIID are present majorly in the western first world, and the
disorder appears to primarily affect men (Blanke, Morgenthaler, Brugger, & Overney, 2009;
First, 2005). These cases occur in individuals whose lives seem extrinsically normal. Many of
them have a spouse or long-term partner, a high degree of education, and a stable occupation
(Blanke et al., 2009). Thus, it seems that the disorder largely occurs in financially secure, middle
class individuals (Sorene et al., 2006). A prominent study in the field found that BIID occurs in
homosexual and bisexual individuals at rates higher than chance (First, 2005), but this finding
has not been consistent across research (Blanke et al., 2009).
Common Symptomotology
Individuals who have BIID claim that they feel “over complete” with four limbs. They
insist that their physical self doesn’t fit their sense of body ownership (Hilti & Brugger, 2010)
and describe one or more of their limbs an alien annoyance (Hilti & Brugger, 2010; Müller,
2009a). Another major complaint is emotional discomfort that disrupts social life, distracts at
work, negatively affects family life, and generally interferes with daily functioning (Blom et al.,

2012; Müller, 2009a; Patrone, 2009). The disorder typically begins in early childhood or emerges
around puberty. Some individuals report feeling discomfort in respect to the target limb for as
long as they can remember, while others can pin-point a more precise date, which often includes
exposure to an amputee (Blanke et al., 2009; First, 2005).
It is much more likely for an individual suffering from BIID to desire an amputation of a
major limb (i.e. a leg or an arm) (Blanke et al., 2009). As mentioned, BIID appears to be more
prevalent in males and it seems as though many of the males with this disorder would like an
amputation of the left lower limb, specifically (Blanke et al., 2009; Hilti et al., 2013). While
there are very few female documented cases, the majority of them indicate that the female
expression of BIID is more extreme, with a frequent desire for bilateral or multiple limb
amputation (Blanke et al., 2009; Brugger et al., 2013; First, 2005). There is typically a clear
demarcation line presented by the sufferer—they can indicate exactly where the accepted area of
their body image ends and the rejected region begins (Hilti & Brugger, 2010). Despite the fact
that the limb in question feels incongruent in respect to the individual’s body image, they tend to
be completely in control of its movement and are able to recognize when it is probed with a
tactile or motor stimulus (Giummarra et al., 2011).
In general, there are few comorbidities associated with BIID. Studies related to the
disorder provide little to no evidence of presence of any sort of psychotic disorder in BIID
patients (Blom et al., 2012; Ryan, 2008), but depression seems to be a common symptom
(Blanke et al., 2009). There is a low frequency of documented physical comorbidity, but a few
cases have shown that muscle weakness, mild headaches, migraines, lumbar hernias, and type II
diabetes are at least occasionally present in BIID individuals (Blanke et al., 2009). There is a
more universal prevalence of abnormal sensory experiences, including paraesthesia and

hypoesthesia, along with the experience that the target limb differs in some way from the rest of
the body (Blanke et al., 2009). One of the most widespread documentations in BIID patients’
histories is chronic, mysteriously inflicted injury to the affected limb (Barnes, 2011). It is not
unusual for BIID sufferers to take matters into their own hands. Numerous cases have
demonstrated that in order to attempt removal of the target limb, sufferers are willing to employ
a plethora of methods, including: shooting, using tourniquets, or sawing at the desired
amputation site, and burning the limb, placing it in the path of a moving train, packing it in dry
ice, or crushing it with weights (Adams, 2007; First & Fisher, 2012; First, 2005; Patrone, 2009).
One of the most prevalent tendencies across documented BIID cases is pretending
behavior. Sufferers utilize various techniques in effort to simulate being an amputee. They will
bandage and bind their limbs, use wheelchairs and crutches, sit on their limbs, and use
tourniquets to reduce sensory perception. In addition, they often try to avoid using the target limb
whenever possible. When using a wheelchair, for example, they will try to transfer in and out of
it without using their legs (Adams, 2007; First & Fisher, 2012; First, 2005; Giummarra et al.,
2011). The fact that the target limb is used so infrequently likely attributes to the muscle
weakness that is sometimes found in BIID patients (Blom et al., 2012). Because the disease
nearly always begins in childhood, it is common for these pretending behaviors to commence at
an early age. They are often done secretively, which can make it difficult for the individuals to
have normal social lives (First & Fisher, 2012).
There is a final common component to BIID involving sexuality. Many sufferers report
being sexually aroused by the concept of becoming an amputee, or apotemnophilia. Such
individuals are often referred to as “wanabees” (De Preester, 2013; Patrone, 2009). Further,
people with the disorder claim to also be “devotees”, those who are attracted to other amputees.

This phenomenon is referred to as actrotomophilia (De Preester, 2013; Giummarra et al., 2011).
Frequently, items associated with disability, such as crutches, wheel-chairs, and prostheses also
cause sexual excitement (First, 2005; Giummarra et al., 2011).
Conflicting Titles
Those who argue that the disorder is first and foremost an identity disorder see Body
Identity Integrity Disorder as the most appropriate title for the disease (Craimer, 2009; First &
Fisher, 2012; First, 2005; Giummarra et al., 2011). They gain support from the fact that while
there are typically several reported motivations for requesting healthy limb amputation, the
majority of documented cases include a primary motivation of attaining true identity or feeling
whole (Blom et al., 2012; First, 2005). The choice to designate the disorder as BIID in this
review does not reflect a personal opinion, though BIID does seem to be the most prevalent
name in the literature. For consistency and clarity’s sake, BIID will be used throughout this
review, unless referring specifically to the symptom of apotemnophilia. However, it is useful to
look into other names for the disorder and the justifications behind them.
It has been made fairly clear that while the sexual component to the disorder is very much
a common symptom, it is rarely the primary motivation for desiring amputation (First, 2005).
Therefore, the original name for the disorder, apotemnophilia (meaning “love of amputation”), is
generally considered outdated and not fully correct, because it only accounts for a symptom and
does not encompass the disease as a whole (De Preester, 2013; First & Fisher, 2012). However,
some argue that the sexual component is now under-recognized, which effectively eliminates a
crucial part of the disorder from the awareness of the public eye (De Preester, 2013). Sexual
gratification may not be a typical primary motivation, but it is a secondary motivation in a large

number of cases. While paraphilia is not necessarily required for diagnosis of BIID, some
patients are purely motivated by attaining their true sense of self, it is an extremely common
attribute of BIID individuals. Further, differentiating between sexual and non-sexual motivations
can be challenging, because most consider sexuality to be an integral part of their identity (De
Preester, 2013). It has been suggested by some that there may be two pathways for the disorder,
a paraphilic one that involves a significant input from sexual motivations, and a non-paraphilic
one that is purely identity-driven (First & Fisher, 2012).
A final title for the disorder has emerged more recently, xenomelia, which stems from the
Greek words “alien” and “limb”. This title is supported by recent data indicating that the disorder
is linked to brain abnormalities, which will be discussed in more detail in the next section of this
review. Because these brain discrepancies appear to involve a decreased representation of the
target limb in the brain, it would make sense to designate a title that acknowledges the limb’s
sense of non-belonging (Aoyama et al., 2012; Brugger et al., 2013; Hilti et al., 2013; McGeoch et
al., 2011).
Possible Causes
There are many speculations about potential causes of BIID. However, it is crucial to
acknowledge that because the disease is so rare, it is impossible to be certain about any one,
universal cause. Generally, the disorder may involve an interaction between an individual’s own
body image and how they perceive the bodies of those around them. Viewing a handicapped
body as enviable is not normal in terms of the beliefs that the majority of society has. It would be
sound to hypothesize that such an unconventional perception is related to an alteration in brain
function or structure, because changes in brain mechanisms often reflect in behavior. All of this

is reason to believe that the disorder is, in part, brain based, but also a function of environmental
influence (Brugger et al., 2013). Moreover, because of the relatively substantial evidence that the
disorder begins at an early age, it is reasonable to suspect that it stems from either congenital
abnormality, early brain trauma, or defective nerve development (Müller, 2009a), along with
childhood experience.
It has been suggested that the sexual component of BIID, when present, results from an
“erotic target location error.” This hypothesis assumes that apotemnophilia, sexual arousal from
the idea of being an amputee, begins with actrotomophilia, sexual attraction to other amputees.
Instead of directing their love of amputation at other amputees, actrotomophiles target their own
bodies with their sexual inclinations, which results in a strong wish for achieving disability
(Ryan, 2008). Others suggest different environmental influences as the culprit. Some believe that
the disorder reflects a reverence of amputees. Perhaps sufferers see amputees at heroes because
of the obstacles they have overcome (De Preester, 2013). BIID individuals who were exposed to
amputees at a young age recall feeling fascination, admiration, sexual stimulation, or excitement.
Further, those who remember where this amputee was affected very often target the same limb in
their own bodies (Barnes, 2011; First & Fisher, 2012; First, 2005). Additionally, a number of
BIID sufferers report some kind of injury to the target limb during their childhood, such as a
broken bone or a limp (First, 2005). A few studies demonstrate the presence of abnormal skin
conductance in the affected region in individuals with BIID, which may indicate a sort of
unhealed damage (McGeoch et al., 2011). Researchers have proposed that neural plasticity could
exacerbate the disorder via pretending behaviors. If the target limb goes habitually unutilized,
this could alter the neural programming of motor representations. Some pretending behaviors,
such as tourniquet use, could also cause permanent peripheral nerve damage (Giummarra et al.,

2011). One could postulate that BIID is caused or amplified by a childhood plagued by
emotional trauma or dysfunctional family relationships, which in turn result in longing for
sympathy, love, and attention in adulthood (Barnes, 2011; First, 2005). However, the general
consensus is that this sort of symptom would be better explained by another illness, such as
Facetious Disorder (First & Fisher, 2012).
Even prior to more recent research, it was thought that BIID could stem from lesions or
tumors in regions of the brain that are involved in controlling awareness (Bridy, 2004). Several
studies have looked into somatosensory representation of the target limb in BIID patients. There
is evidence that those with BIID symptoms display reduced activation of the somatosensory
cortex in response to tactile stimulation of the target limb. This activation is different from both
the activation that occurs when their non-target limb is stimulated and the activation that occurs
in control (non-BIID) individuals (McGeoch et al., 2011). Further, studies have attributed
sensory irregularities to damage in the parietal cortex, specifically in the multisensory integration
areas in the right parietal lobule and their connections with the limbic system (McGeoch et al.,
2011). Abnormalities in the insula have been observed in some studies, but not others (Dijk et
al., 2013.; McGeoch et al., 2011; Sedda, 2011). A more detailed investigation demonstrated that
BIID individuals appear to have reduced cortical thickness in the superior parietal lobule and
secondary somatosensory cortices on the right side and increased thickness of the central sulcus.
They additionally demonstrated increased cortical surface area in the inferior parietal lobe and
secondary somatosensory region on the left side (Hilti et al., 2013).
While none of this evidence can be stated with certainty due to the rarity of BIID and
thus small sample sizes, the findings of such studies are extremely relevant. It is possible that
somatosensory processing deficits are involved in the alien association that BIID individuals feel

in respect to one or more of their limbs. Additionally, research has found no evidence that the
somatosensory cortices are not intact, which accounts for the fact that those with the disorder are
able to perceive and utilize their target limb while it remains disjointed from their body image.
Failure to integrate the limb into the sense of self may be a result of parietal lobe deficits
(McGeoch et al., 2011). Furthermore, a very interesting tie between somatosensory input and the
sexual component of BIID has been made. Lower limb amputation desires are most common,
and the leg and foot regions of representation in the somatosensory cortex are directly adjacent to
the area that represents genitalia. Though no evidence exists, this could explain why BIID may,
in fact, be an inherently sexual disorder and why lower limbs are more common targets (Hilti et
al., 2013).
Some issues have arisen regarding the right parietal lobe hypothesis of BIID. Firstly,
there is evidence that there is occasionally a transfer in the target limb during the sufferer’s
lifetime (Blanke et al., 2009; Blom et al., 2012). However, proponents of the brain evidence
argue that this could simply be reflective of neural plasticity (McGeoch et al., 2011). Some BIID
patients who secure elective amputation report experiencing phantom limbs following the
operation (Hilti & Brugger, 2010) or plan to use prostheses (De Preester, 2013), two trends that
are inconsistent with the apparent foreignness of the target limb. The evidence of cortical
dysfunction finds strength in the fact that the bulk of documented cases present a request for a
left lower limb amputation, because the majority of the brain deficits that have been
demonstrated lie in the right hemisphere (Hilti et al., 2013). However, there are cases that
involve right limbs and upper limbs, as well as other disabilities altogether (De Preester, 2013;
First & Fisher, 2012). Moreover, it has been argued that perhaps the left leg is chosen more
frequently due to functionality. In fact, there is even documentation of a few cases where the

patient claimed to pick their non-dominant side so that they would be able to drive after
amputation (Blom et al., 2012). It is, however, notable that the right hemisphere, unlike the left,
provides a bilateral representation of the body. This could be why primarily left-sided desires are
present, but right-sided ones are possible as well (Hilti et al., 2013).
Related Disorders and Common Misdiagnoses
Because BIID is extremely rare (First, 2005) and is not recognized in the International
Statistical Classification of Diseases or the Diagnostic and Statistical Manual of Mental
Disorders (DSM) (Blom et al., 2012), it is often misdiagnosed (First & Fisher, 2012). However,
the body of disorders related to BIID may provide some ideas for potential treatment (Ryan,
2008). Additionally, understanding what BIID is not can help clarify its identifying
characteristics.
BIID is often assumed to be akin to Body Dysmorphic Disorder (BDD) and anorexia
nervosa. These are a few of the only disorders than manifest themselves through a monothematic
delusion, and it would be rational, at first glance, to assume that BIID could be classified in that
category (Patrone, 2009). However, there are several distinctions between BIID and these two
disorders that should be addressed. Firstly, in BDD a body part is seen as defective or
exceedingly ugly. Typically, patients with BDD experience extreme levels of embarrassment and
shame, as well as exceptionally low-self esteem (Bayne & Levy, 2005; First & Fisher, 2012;
Phillips et al., 2010). Contrastingly, in BIID, the perception of the target limb is no different
from that of other limbs. There is no interest in becoming more attractive, rather the focus is
becoming more congruent with one’s identity (Bridy, 2004; Phillips et al., 2010; Ryan, 2009). It
is notable that cosmetic surgery is notoriously ineffective in treating BDD and occasionally

makes it worse (Müller, 2009a). Amputation has shown to be an effective treatment in at least
some cases of BIID (First & Fisher, 2012). Both BDD and anorexia nervosa tend to appear in
mid-to-late adolescence, as opposed to BIID, which seems to stem from childhood (First &
Fisher, 2012). Furthermore, anorexia nervosa involves an irrational decision based on a false
conviction, while the beliefs surrounding BIID could be considered rational, at least be some
(Ryan, Shaw, & Harris, 2010). It has further been suggested that BIID is actually an expression
of a combination of BDD and Obsessive Compulsive Disorder (OCD) (Müller, 2009a).
However, this has been countered by arguing that the compulsions in OCD are motivated by
reducing anxiety and stress, while the behaviors exhibited by those with BIID are intended to
produce pleasure or calmness (First & Fisher, 2012).
There are several reasons one could be motivated to seek healthy limb amputation that
cannot be attributed to BIID. Firstly, the disorder has nothing to do with receiving enjoyment or
pleasure through pain (Sorene et al., 2006). Additionally, BIID individuals don’t seem to desire
care and recognition, and don’t have the strong desire to be a needy patient as those with
Facetious Disability Disorder do (First & Fisher, 2012; Müller, 2009a; Ryan, 2009). Desiring
amputation for financial or social benefits, such as insurance money or early retirement, is not a
symptom of BIID (Müller, 2009a; Sorene et al., 2006). BIID is not self-amputation or other
injury triggered by psychosis (First & Fisher, 2012). Finally, BIID cannot be considered a sort of
cosmetic or reconstructive surgery, because it has little to no relation to aesthetics and has a goal
that is opposite of reinstating function in a injured or dysfunctional limb (Bridy, 2004).
It seems that BIID is more closely related to some syndromes that result from acute
neurological crises. Somatoparaphrenia involves damage to the parietal lobe, typically on the
right side, following a stroke or other brain-lesioning event. Sufferers deny that one of their

limbs belongs to them and attribute its ownership to someone else (Hilti & Brugger, 2010; Ryan,
2009). However, BIID patients do not seem to spontaneously lose their belief, as
somatoparaphrenic individuals occasionally do (First, 2005; Sedda, 2011), and they don’t assign
ownership of their limb to another person, they just don’t believe it belongs in their body image
(Giummarra et al., 2011). Tumors and strokes result can also result in Pötzl Syndrome, a sudden
ignoring of the left side of the body because it feels alien (Müller, 2009a), Alien Hand
Syndrome, a disorder where the left hand feels foreign and may act against the will of the
affected individual, and anosognosia, the denial that a post-injury neural dysfunction is present
(First & Fisher, 2012). Asomatognosia is another seemingly similar disorder that results in a
body part suddenly disappearing from conscious awareness (Hilti & Brugger, 2010). Phantom
limb syndrome results in experiencing an amputated body part as present due to a persevering
somatosensory representation, (First & Fisher, 2012; Hilti & Brugger, 2010) and misoplegia is
characterized by hatred and aggression toward a paralyzed region of the body (Hilti & Brugger,
2010). Unlike the acquired damage that accounts for many of the discussed disorders, the brain
abnormalities in those with BIID are likely congenital or due to an early developmental
dysfunction (McGeoch et al., 2011).
Perhaps the disorder that is most commonly connected to BIID is Gender Identity
Disorder (GID), particularly in respect to cases of homosexual male to female (MtF)
transsexuals. Individuals with both disorders are motivated by establishing their identity (First &
Fisher, 2012). They express discomfort with a portion of their physical body, because it
interferes with their sense of self. Both of the disorders seem to begin in childhood and they both
involve imitating their preferred identity, either by pretending to be an amputee or by cross-
dressing. Another parallel can be drawn by the fact that both homosexual MtF transsexuals and

BIID suffers are sexually attracted to what they wish to become, females and amputees,
respectively, and this sexual arousal is related to wanting to express a true identity. In both
disorders, surgery is not the focus of the desire, but it is something that needs to be completed in
order to achieve one’s true self (De Preester, 2013; First & Fisher, 2012; First, 2005).
An Ethical Dilemma
BIID presents an immense ethical dilemma. Experiencing the body as part of the self is a
critical part of consciousness, and having normal interactions with our surrounding environment
is reliant, at least in part, on our experience of body ownership (Berti, 2013). Because there is a
lack of recognition and awareness regarding BIID, it is possible that when medical professionals
encounter patients with the disorder, they assume that psychosis is the culprit. This ultimately
would lead to a treatment path that would be ineffective in alleviating the symptoms of the
underlying disease (First & Fisher, 2012). However, even when knowledgeable healthcare givers
are presented with a case of BIID, they are faced with a challenging decision. It is
understandable to have a repulsed visceral reaction to the idea of elective healthy limb
amputation, but this in and of itself cannot be used as grounds to deem something immoral
(Bayne & Levy, 2005). Approaching cases of BIID in an ethical manner raises many demanding
questions regarding the limits of a patient’s autonomy, the Hippocratic Oath, economic concerns,
societal impact, and the like. Taking all of these factors into account, medical professionals have
to judge whether healthy limb amputation is a moral or immoral action. This review will look
briefly at several ethical perspectives: a principle based argument consisting of autonomy,
beneficence and non-maleficence, and justice, a Utilitarian point of view, and a Kantian
interpretation.

Ethical Analysis
Principle-Based Argument
Autonomy. An autonomous action is one that has both intention and insight and is not
directed by outside influences (Müller, 2009a). One’s first reaction to a BIID case may be that
the individual in question is highly mentally troubled, indicating that their request for amputation
should be ignored. Delusional individuals are universally not considered autonomous, and
therefore cannot be trusted to make rational decisions (Ryan, 2009). However, there is evidence
against the fact that BIID sufferers are delusional. The abnormal feelings sufferers have in
respect to their limbs are typically the only unusual thing about them (Ryan, 2008). On the other
hand, while monothematic delusions are rare, they do occur in some instances, such as in BDD
and anorexia nervosa, two disorders that are considered highly akin to BIID by some (Müller,
2009a; Patrone, 2009). According to the DSM requirements for diagnosing someone as
delusional, the affected person’s beliefs must be false. Due to the fact that some individuals with
the disorder have obtained amputation and thereafter reported relief implies that their original
belief about their target limb was not artificial. Additionally, many BIID patients are willing to
recognize that amputation might not necessarily be a cure, and are still willing to try it as a
possible treatment (First & Fisher, 2012). They seem to simply be reporting their mental state,
and some would argue that there is no obvious reason not to regard this as true. Furthermore,
they are often hesitant to confess their strange beliefs to others, because they recognize them as
abnormal, which further separates them from delusional individuals (Ryan, 2008). Although,
there is another consideration to take into account—whether or not the desire for amputation is
an obsession. Obsessions are external, coercive influences on a person and should not be
considered makers of rational decisions. There is little evidence that favors obsession as a

component of BIID. Instead, the wishes characteristic to the disorder are widely considered a
intrinsic part of identity (Craimer, 2009).
Many who are proponents of BIID as an identity disorder find grounds for supporting
elective amputation in the way GID is managed. They question why GID patients are allowed to
alter their bodies, while BIID sufferers’ pleas to achieve their true identity are ignored (Loeb,
2008). Thus, they see requests for elective amputation as analogous to appeals for gender
reassignment surgery and think both cases should be approached in a similar manner (Ryan et
al., 2010). It is notable that those who have non-normative sexual preferences often consider
their sexuality to be even more a part of their identity than those who have a sexual inclination in
accord with their societal and cultural norms. More simply, a homosexual may consider their
sexuality to be deeply engrained in their identity, while a heterosexual individual may feel less
strongly (De Preester, 2013). Given that the primary motivation behind the desire for amputation
in most BIID cases is to restore identity (Blanke et al., 2009; First & Fisher, 2012), one could
draw a similar parallel to being an amputee. Someone with BIID might consider being an
amputee to be a critical part of their identity, while someone without the disorder probably
doesn’t consider not being an amputee as central to their sense of self.
On a similar note, even if a BIID sufferer’s desires were motivated by their identity, one
could attest that their proposed solution to their incongruent body image, amputation, is
irrational. Instead of changing the structure of their body, it would be more cogent to modify
their experience of body image (Bayne & Levy, 2005). Contrarily, the desire for amputation
derives from the fact that sufferers feel unable to alter their body image to fit their physical body.
Further, their strange sense of self has been a part of them since childhood, so asking them to
change this body image would be no different from asking them to change who they are (Bayne

& Levy, 2005). One could certainly further this point by suggesting that such a request would
vary little from asking someone with GID that they should simply change the way that they
experience their body. Still, the differences between GID and BIID could also be raised. Firstly,
surgical treatment of GID strives to produce a non-disabled product. In addition, while GID is
much more prevalent than BIID, the brain abnormalities that are present in those with GID are
unknown. Finally, even if the brain discrepancies could be targeted and fixed, developing a
medical treatment would be much more complex, not to mention more controversial, than one to
integrate alien limbs (Müller, 2009b). Some dispute these claims and even go as far as
condemning the search for a neurological treatment for BIID, because they believe that this
would disrespect identity and rid of an integral aspect of one’s personhood (Craimer, 2009).
Even if BIID shouldn’t be considered an identity disorder, one could still argue in favor
of allowing elective amputation. Those who request cosmetic surgeries don’t necessarily
consider the alterations they receive to be central to their identity. However, society as a whole
doesn’t look scornfully upon such operations. Many ask why elective healthy limb amputation
should be thought of any differently (Loeb, 2008). It could be argued that the risks and costs that
stem from cosmetic surgery differ from those that correspond with amputation. Nevertheless, it
should be considered that sometimes plastic surgeons comply with very strange and expensive
requests regarding bodily alteration that may have many significant risks (Ryan et al., 2010).
Some insist that it is a human right to be able to design one’s own body (Bridy, 2004), but there
are also opponents to this ideal. Several religious groups are adamant that we have no right to
change our natural bodies, because the human body is sacred. For example, the Jewish tradition
forbids physicians from disrupting the natural manifestations of the body. Further, purposeful
maiming is regarded as sinful by Hinduism and several other Eastern religions, Christianity,

Islam, and Judaism (Jotkowitz & Zivotofsky, 2009). It is therefore quite likely that some BIID
patient’s desires are in conflict with their religious beliefs, which may coerce their decision. It is
also mentionable that strong religious influences are in disagreement with several issues in
medical ethics that involve a controversy surrounding the right to bodily integrity. In all of such
cases, religious opposition can’t in and of itself be used as reason to judge something as
unethical (Loeb, 2008).
In order to make an autonomous medical choice, one must be able to provide informed
consent. Some argue that BIID sufferers can’t possibly know what it is like to be an amputee
until the operation is complete. On these grounds, elective limb amputation would be regarded as
unethical simply because it would not be feasible to fully convey the ramifications of the
procedure. This has been contested by claims that those with the disorder spend such a high
percentage of their time pretending to be amputees that they understand, at least partially, what
having a disability is like (Bayne & Levy, 2005). Thus, a BIID patient’s informed notion of their
own good should be valued (Bayne & Levy, 2005). Yet, autonomy can’t be taken as an absolute
property; it depends on several prerequisites. Therefore, when a patient asks for a detrimental
procedure, this request should be evaluated cautiously by the medical professionals involved.
Autonomy should encompass a decision between alternatives that are medically reasonable, and
there is great debate regarding whether or not elective limb amputation is a sensible option.
Further, one could assert that while everyone possesses the right to harm their own body if they
so wish, no one has the right to request harm via physicians (Müller, 2009b). Ethical decisions
must allow every party involved to act autonomously. This means that physicians should not feel
coerced one way or another by extrinsic forces when considering whether or not to perform an
elective amputation. Hence, physicians should not feel obligated to perform this operation under

any circumstance, but it has been stated that doctors should be responsible for referring BIID
patients to a surgeon who will operate if they cannot do so themselves (Ryan, 2009).
Beneficence & Non-maleficence. It is a moral objective to obtain more benefits that
harms, for all parties involved in a decision. BIID has been defended as an identity disorder by
many researchers and medical ethicists. The good that comes from respecting identity and
allowing elective limb amputation is the patient’s self-acceptance. While this may not be
considered an ultimate good, it can certainly be considered a kind of good, perhaps even a
fundamental good. Recognizing acquiescence of the self as such would require elective limb
amputation to be complied with, if the true goal is actually to achieve one’s real identity
(Craimer, 2009). There are several other medical cases where preserving identity is favored over
the typical course of action. Consider a Jehovah’s Witness who refuses blood transfusion. This
choice is always respected because in the mind of the patient, there is more harm done by
disturbing their identity to receive a blood transfusion than in undergoing the bodily damage
inflicted by the lack of one (Patrone, 2009). Another example is a congenitally blind elderly
person who refuses corrective eye surgery because she finds her lack of sight, something she’s
lived with for her entire life, to be central to her identity (Bayne & Levy, 2005). Gaining support
from such instances, some argue that acting upon a request for healthy limb amputation is no
different. Even though it is an atypical course of medical action, it should be completed in order
to value one’s identity (Bayne & Levy, 2005). Nevertheless, there are a few problematic aspects
of this assertion. Firstly, both the case of the Jehovah’s Witness and the congenitally blind
individual involve an omission of action, withholding a blood transfusion and not performing
corrective eye surgery, respectively. In contrast, complying with elective limb amputation
involves performing an action. This quality makes it difficult to seamlessly compare these

situations in the same context. In addition, while BIID may indeed be an expression of identity, it
is also an expression of disease, whereas refusal of a blood transfusion by a Jehovah’s witness is
not (Patrone, 2009).
It is probable that a wide body of doctors would consider performing an elective healthy
limb amputation to be a violation of the Hippocratic oath (Adams, 2007). Particularly if it was
decided that the patient in question was not autonomous, performing such a surgery would be an
obvious infringement upon a physician’s duty to “do no harm” (Müller, 2009a). The operation
itself poses a great number of risks, including infection, thrombosis, paralysis, and necrosis.
Following the surgery, amputees are left with a disability and often phantom limb pain (Müller,
2009a; Slatman & Widdershoven, 2009). Nonetheless, it is important to consider that BIID
patients aren’t suffering from the loss of a limb—they are being freed from an everyday
hindrance. The harm that comes from amputation is minimal when compared to the chronic harm
that BIID suffers experience when living with an alien limb (Ryan, 2008). One might urge
physicians to err on the side of caution and not take part in radical and irreversible treatments.
However, there are no breakthroughs in BIID treatment on the horizon—the disorder is simply
too rare (Ryan, 2008). It is also mentionable that there are several cases in which a healthy body
part might be removed in order to benefit a patient. People often donate one of their kidneys to
those in need, because they can function with one. Those who are at high risk for cancer may
elect to remove their currently non-diseased breasts or ovaries, and sexual reassignment surgery
also involves the removal of fully functional body parts (Ryan, 2008).
There are numerous ways in which performing elective amputations can help minimize
harm. Internet sites run by BIID sufferers have forums for individuals to discuss “safe” and
“pain-free” ways to either self-amputate limbs or inflict enough damage upon them to make

amputation a necessity (Bayne & Levy, 2005). Furthermore, it has previously been discussed the
painful, dangerous, and even fatal lengths at which individuals with the disorder will go in order
to rid of one of their limbs, with or without online encouragement (Adams, 2007; Bayne & Levy,
2005; Loeb, 2008; Müller, 2009a). Patients might also choose to obtain a surgery from an
unqualified surgeon in the third world, which could result in immense complications and
permanent damage (Bayne & Levy, 2005; Ryan, 2008). Not obtaining amputation can cause
psychological harm, as well, through depression, anxiety, and even suicidality (Sorene et al.,
2006). Therapy for BIID should focus on restoring an individual’s wholeness and helping them
identify with their body (Slatman & Widdershoven, 2009). Many suggest that the degree of
suffering that those with the disorder undergo cannot be alleviated by a means of treatment other
than amputation (Bayne & Levy, 2005).
All of this evidence suggests that amputation may be the least of all evils (Bayne & Levy,
2005), but it is clear that amputation doesn’t always guarantee a resolution. It appears that, at
least occasionally, the desire can migrate to a second limb after amputation is secured (Sorene et
al., 2006). Some argue that a treatment as radical as amputation can only be justified if it has
lifesaving and remarkably curing results. It is debatable whether or not amputation reaps such
benefits, and it certainly causes irreversible disability. Additionally, it is difficult to not to
wonder how patients who obtain amputations might feel if a revolutionary treatment is
developed. There also aren’t enough cases to discern that it is impossible for BIID patients to
spontaneously heal (Müller, 2009a). In all, treatments must be effective and have sustainable
results in order to be pursued, and there must be no evidence of a less noxious option (Müller,
2009a). Because there is evidence of successive mutilations and desire for amputation following

initial surgery, it must be assumed that the early success of amputation does not promise a
lifetime of relief for every patient (Müller, 2009a; Sorene et al., 2006).
Justice. It is crucial to consider whether or not elective healthy limb amputation is
ethically just. Those who obtain amputation will have to undergo treatment and rehabilitation,
which will be costly to society (Müller, 2009a; Slatman & Widdershoven, 2009). However, one
could also argue that public financing should only be recruited if the amputations are needed to
cure a life-threatening disease. Amputations for aesthetic, economic, sexual, or other less dire
interests should be paid for by the individual (Müller, 2009a). Still, one might counter that this
makes elective limb amputation unfair, because BIID patients will have to be of a certain
economic standing to pay for the operation. Finally, there is a cost to society that cannot be
ameliorated using money. Disabled individuals typically are limited in the occupations they can
take on or must retire early (Müller, 2009a). Still, since BIID is so rare, there would likely be
very little effect on the quality of the international workforce as a whole. Furthermore, because
many sufferers report that the disorder distracts them at work (Blom et al., 2012), it is possible
that they aren’t contributing sufficiently to their career, anyway.
A Utilitarian Perspective
It is clear that amputation has both costs and benefits, and the sum of these factors may
vary from individual to individual (Ryan et al., 2010). It is quite possible that for many with
BIID, being in accord with their sense of personal identity outweighs the costs of disability
(Blom et al., 2012). It is also plausible that society is more cynical about the lives of the disabled
than it ought to be (Bayne & Levy, 2005). Still, amputation is costly in terms of the operation
itself, as well as the rehabilitation expenses and loss of productivity in society (Ryan, 2008).

Financial and social costs will depend both on the social and financial standing of the individual
and the sort of amputation performed (Bayne & Levy, 2005). Other costs to the patient’s family
and friends should be considered (Patrone, 2009). Having to care for someone with a disability
may come with financial and emotional harms. Additionally, costs to other patients must be
taken into account (Patrone, 2009). Time and resources would be taken away from other patients
in need, for something that is by and large, not considered a life-threatening disease. It is,
however, mentionable that it may be possible to use amputated limbs for transplantation, which
could benefit other patients. Prosthetics, particularly for hands, far from replicate the appendages
they are meant to replace (Ryan, 2008). Elective amputations could change that for some
individuals, but BIID probably isn’t common enough to make a substantial impact.
Another relevant aspect to this cost-benefit analysis is the effect on the medical
community. Acting to disable someone else’s body has been considered a crime for centuries,
but there is reason to assert that surgical alterations of the body, whether they be therapeutic or
not, should not be categorized as acts of criminal mayhem (Bridy, 2004). Nevertheless, costs to a
physician who chooses to perform an elective amputation may be high due to the public’s
interpretation (First & Fisher, 2012; Ryan, 2008). Because the medical profession is committed
to patient health and strives to avoid public criticism, hospital administrators will likely have a
difficult time accepting and allowing such an unconventional procedure to occur (Bridy, 2004;
First & Fisher, 2012). It would be reasonable to think that if these amputations were to occur
anywhere, it would be at university hospitals where experimental procedures are more common
(Bridy, 2004). However, there are currently no academic medical centers with research protocols
for elective surgeries of this variety (First & Fisher, 2012).

Finally, it is worth considering that a formal recognition of BIID might result in an
increased prevalence. This occurred after official acknowledgment of both GID and Dissociative
Identity Disorder (DID), because more sufferers felt like they could admit their condition to their
family, friends, and physicians (Ryan, 2008). It is hard to say whether such a pattern would be a
cost or a benefit if it were to occur. On one hand, it would allow for more individuals to feel
comfortable sharing something they once kept private, which would alleviate a great deal of
distress. However, if increased prevalence resulted in more amputations, this would require more
resources and would inflict a greater cost on society, due to financial burdens and loss of
occupational productivity. Overall, no matter if BIID remains rare or becomes more widespread,
it doesn’t seem as though the benefits of elective amputation would outweigh the costs for
society as a whole. They may, however, result in a net benefit for the individual sufferer,
depending on the case.
A Kantian Interpretation
The Kantian perspective takes on a stance similar to the principle of autonomy, that
choices should only be respected when made rationally. Additionally, decisions that are made in
this manner should be respected if they improve the individual’s overall well-being, even if they
appear to cause harm to their health (Ryan, 2008). On the other hand, self-maiming opposes self-
preservation, which is an indispensable component to Kantian morality. Just as suicide is a moral
crime, self-mutilation, whether it be performed by oneself or a proxy (i.e. in this case, a surgeon),
is an ethical offense and could be considered a type of partial-suicide. Impairing one’s
functionality goes against the moral responsibility to acquire, sustain, and better bodily
capabilities. However, it seems as though elective limb amputation shouldn’t be considered self-
maiming. While one could claim that voluntarily harming one’s body via elective amputation

violates autonomy and demeans moral personhood, such assertions are generally regarded as
outdated and conservative (Schramme, 2008). The motive behind elective limb amputation is far
from hurting oneself. In fact, one with BIID would consider limb amputation as a way to live
more fully. Because acting morally requires one to lay out a set of rational goals, if a lucid being
makes a decision to comply with something that could be potentially regarded as self-mutilation,
they should be permitted to carry out this aim, because it will allow for their completion of moral
action in the future (Schramme, 2008).
Another component to the Kantian argument involves freedom of will, which is
considered a prerequisite for making rational, autonomous decisions. One is considered free if
their first order volitions, which refer directly to particular items or situations, agree with their
second order volitions, which refer to first order volitions. For example, if one’s first order
volition was wish for amputation, their second order volition would be to want to have no
amputation craving. In this case, the second order volition could be fulfilled by either acquiring
amputation or ridding of the desire for amputation. If the patient in question believes that only
amputation could eliminate his amputation desire, his first and second order volitions are in
accord, and he should seek amputation. However, if he senses that the amputation desire could
be alleviated without amputation, his first and second order volitions are in conflict and he does
not possess freedom of will. In this case, amputation should not be sought, but instead, a
treatment to remove the amputation desire should be the objective. While it is mentionable that
many patients strongly believe that their amputation desire can only be quelled by obtaining
amputation (First, 2005), some are unsure (Blanke et al., 2009). It is also true that amputation
desire is incompatible with many desires that most humans have, including good health,
avoidance of pain, mobility, and social acceptance (Müller, 2009a).

Ethical Resolution
Potential Treatments
In order to devise an ethical treatment route, several possible options, including
amputation, must be considered. Those who suffer from BIID often report that their amputation
desire is amplified when they see an amputee or feel lonely or stressed (Blanke et al., 2009).
Some indicate that pretending behaviors provide temporary relief, but this is not a beneficial
means of treatment as it may also amplify symptoms (Giummarra et al., 2011). A more
promising route would be to encourage involvement in distractions that could help reduce
loneliness and stress, such as physical activity, a rewarding occupation, or social engagements
(Adams, 2007; Blanke et al., 2009). It is notable, however, that these distractions only seem to
provide temporary relief, if any. They also may no longer be feasible after retirement or with
increasing age (Adams, 2007). Unfortunately, there is very little evidence of psychotherapy
being an effective treatment of BIID. At best, the therapy seems to help alleviate some of the
symptoms of BIID, such as stress and depression, or facilitates patients’ understanding of their
relationship to the disorder. In no cases has psychotherapy eliminated or reduced the amputation
desire (Blom et al., 2012). Although, it is also mentionable that many BIID patients who reported
attending therapy sessions also admitted that they never told their therapist about their strange
beliefs and urges (Ryan, 2008). Perhaps if the therapists had been more knowledgeable about
their patients’ conditions, they could have tailored the sessions more towards their needs.
There are many treatments that could be effective in treating BIID, but haven’t been
extensively utilized. SSRIs and clomipramine, which are effective in related disorders such as
BDD and OCD, seem to be ineffective. However, there has been at least one case where

alleviation of BIID symptoms was observed on an abnormally high dose of flouxetine, an SSRI
(Ryan, 2008). While there seems to be significant evidence against BIID involving delusions, it
is possible that it consists of a monothematic delusion, in which case antipsychotics would be
worth trying (Ryan, 2008). Other non-pharmaceutical options also exist. Vestibular caloric
stimulation, flushing the ear canal with cold water, temporarily relieves the symptoms of
somatoparaphrenia, and should be attempted as treatment for BIID (McGeoch et al., 2011; Ryan,
2008). Additionally, repetitive magnetic stimulation (rTMS), which can improve tactile
discrimination by enlarging corresponding somatosensory maps, has not yet been tried as
treatment for BIID. Deep brain stimulation (DBS) of the proposed affected area could also be
tested. It is possible that small, benign brain tumors or artereovascular abnormalities may cause
BIID symptoms, and in this case, microsurgery might be an effective cure (Müller, 2009a).
It is, of course, possible that all of these proposed treatment ideas will only be effective in
a handful of patients or will fail completely. Thus, amputation might be the only option for some
BIID individuals. There are some who are very strong supporters of amputation as the best, or
even the only possible cure (Loeb, 2008). The removal of a healthy limb might be
unconventional and strange, but this alone doesn’t give one ground to judge it as unethical
(Ryan, 2008). It is crucial, however, that the fact that the evidence surrounding amputation being
a positive treatment is scarce. Furthermore, this support is from patients who sought out
researchers because they were content with their elective amputations. Therefore, the only
backing to the claim that elective amputation in BIID individuals yields beneficial results is
anecdotal, not scientific or systematic, and may be biased towards success stories. Still, it is, at
present, the best evidence, and one must base their judgments on what is known to be true (First,
2005; Giummarra et al., 2011; Müller, 2009a; Patrone, 2009).

Others believe it is completely nonsensical to treat using amputation when there is
evidence that the underlying disease process is mediated by the brain (Pies, 2009). They see
amputation as a cure of a symptom, rather than the disorder as a whole and recommend seeking a
casual therapy that targets the brain abnormalities to integrate the alien limb into the sufferer’s
sense of self (Müller, 2009a). Still, there may be no feasible way to ameliorate the brain
dysfunction (Ryan, 2009). Some cases involve the recurrence of amputation desire after
amputation has been secured, indicating that this “cure” may be far from lasting in its effects
(Sorene et al., 2006). Furthermore, there is ample evidence that two related disorders respond
very differently to surgery. GID responds incredibly well to surgical intervention, while BDD
responds quite poorly (Barnes, 2011). While it seems that GID is more akin to BIID than BDD,
these relationships to other disorders can’t be known for sure. Because there are no systematic,
long-term studies that followed BIID patients post-amputation, there is no way to be certain
about what the true enduring effects of amputation might be.
How to Choose Treatment
In order to approach BIID in the most ethical way possible, it has been suggested that
treatment should be chosen using the following parameters: probability that the treatment will
reduce suffering and the magnitude of reduction, probability that the treatment will cause
damage and the magnitude of damage, cost to society, and the patient’s personal preferences
(Ryan, 2008). Furthermore, reversible treatments should be applied before non-reversible
treatments in an increasingly invasive manner. First, vestibular caloric stimulation should be
employed; it is reversible, inexpensive, and its effects are apparent immediately (McGeoch et al.,
2011; Ryan, 2008). Next, a high dose of a SSRIs, another low-cost option, should be trialed for
six to twelve weeks, after which the effects will be present or absent (Ryan, 2008). Similarly, a

trial of antipsychotics, which are also relatively cheap, could be trialed for a similar amount of
time if the antidepressants appear to be ineffective (Ryan, 2008). Throughout all of these trials,
psychotherapy sessions should be instituted as well, in which the patient tells their therapist
about their amputation desires. Therapists should also encourage their patient’s participation in
physical activity and other involvements that may distract from the amputation craving. This
route of treatment is more costly and its effects may take months or years to manifest, but
nevertheless, both the patient and the therapist should be as persistent as possible in their efforts
(Ryan, 2008). Following this time period, if none of the trialed treatments have been successful,
the patient’s preferences should be consulted more deeply. At this point, rTMS, DBS, or other
more invasive brain procedures, such as microsurgery, could be attempted, if the patient was
willing and if finances were in order (Müller, 2009a; Ryan, 2008). Another option would be to
wait for a future development. In this treatment plan, there is nothing more invasive than
amputation, and it should therefore be used as a last-resort option (Ryan, 2008). If no other
treatment is effective and the patient is unwilling to wait for a possible advancement, amputation
could be considered. It is notable that in GID, a persistent desire of minimally two years in
length is requisite before surgery is considered (Ryan, 2008). It would make sense to institute a
similar, or perhaps even longer, requirement for BIID patients, so that they could fully attempt
other treatment options.
Establishing Recognition
In order for medical professionals to ethically approach cases of BIID, awareness of the
disorder needs to be more widespread. It is not currently listed in the DSM, but a few sets of
diagnostic criteria have been suggested (see Appendix). Some believe that until diagnostic
criteria are established, a valid epidemiological study on the disorder is out of reach (Giummarra

et al., 2011). One could also attest that currently, BIID is much too rare to be investigated using a
properly controlled clinical intervention trial, even if published diagnostic criteria were present
(Ryan, 2008). Still, given that patients with the disorder rarely confide in their physicians, it is
likely that we have a distorted perception of the disease’s prevalence (First & Fisher, 2012).
Those who do embark upon treatment strategies must report the results they observe to the
medical community, while still striving to protect patient confidentiality (Ryan, 2008). It is
critical to institute some reliable resources for BIID patients to turn to so that they stop relying
on self-help websites designed by sufferers. These sites encourage disordered individuals to take
matters into their own hands by suggesting methods of self-amputation. They also imply that
consulting a physician will not yield desired results (Bridy, 2004). Patients with BIID need to
feel comfortable telling medical professionals about their beliefs without worrying about being
sent to a mental institution (First & Fisher, 2012). Furthermore, because it is an emerging, poorly
understood disorder, past BIID cases have resulted in media sensationalism, which prevents
cases from being taken seriously (Bridy, 2004). Formal recognition of the disorder could change
that.
Conclusion
It is worth mentioning that cosmetic surgery used to be a laughing stock of the surgical
field, but is now a thriving specialty. Establishing BIID as an official disorder in the DSM, along
with time, may allow the idea of elective amputation to become more acceptable. While it is
unlikely it will ever be as prominent as cosmetic surgery, due to its rarity, healthy limb removal
may gain a different reputation as time progresses (Bridy, 2004). However, it is critical that BIID
is treated on a case-by-case basis, until the disorder is more fully understood. Taking into
account the patient’s preferences, the benefits and harms a treatment has the potential to cause,

as well as the cost to society is necessary in making the most ethical decisions possible. There
are various treatment possibilities that should be thoroughly explored before amputation is
considered as an option. Nevertheless, it may be possible that all of these alternatives fail to cure,
or even ameliorate the amputation desire. If the patient is considered autonomous in the case at
hand, their request for amputation should be taken as a medically rational and plausible
alternative for treatment.

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Sorene, E. D., Heras-Palou, C., & Burke, F. D. (2006). Self-amputation of a healthy hand: a case
of body integrity identity disorder. Journal of hand surgery (Edinburgh, Scotland), 31(6),
593–5. doi:10.1016/j.jhsb.2006.05.022

Appendix
Table 1
Proposed Diagnostic Criteria for BIID (First & Fisher, 2012)

Table 2
Proposed Diagnostic Criteria for BIID (Ryan, 2008)
A. A strong persistent desire for the amputation of a limb.
B. The primary motivation for the desire is the feeling that being an amputee is one’s
true and proper identity.
C. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The disorder is not better explained by another medical or psychiatric syndrome
such as somatoparaphrenia, a psychotic disorder or body dysmorphic disorder.

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