People with a form of Body Dysmorphia called Body Integrity Identity Disorder (BIID) who have voluntary amputations cause a dissonance with our concept of normal which we, the observers of those with BIID, use to determine what is or is not good. This results in either labeling of the condition as a mental illness or a questioning of our concept of normal. I believe that voluntary amputees deserve the second option. To demonstrate this, I am placing those who want to voluntarily amputate themselves in the gray area between transsexuals who justifiably go through Sex Reassignment Surgery (SRS) and anorexics who wrongfully damage their bodies. From there, I wish to argue that an understanding of the kind of body dysmorphia voluntary amputees have is like that of transsexuals rather than like that of anorexics. This would give the basis of suggesting that this form of body dysmorphia's solution belongs to the category 'normal' where normal is to be understood as healthy, morally permissible, and not irrational. I will end by addressing some objections to the amputation procedure on healthy limbs for voluntary amputees.
There are two conditions related to Body Integrity Identity Disorder. One is Body Dysmorphic Disorder (BDD), which Tim Bayne and Neil Levy describe well in their article Amputees By Choice: Body Integrity Identity Disorder and the Ethics of Amputation. They define BDD as the following:
Body Dysmorphic Disorder is a condition in which the individual believes, incorrectly, that a part of their body is diseased or exceedingly ugly. This belief can be a matter of intense concern for the individual, and is resistant to evidence against it. BDD appears closely akin to anorexia nervosa, in hat both appear to be monothematic delusions that sustained by misperceptions of one's body. (Baynes 75-76)
The other is Gender Identity Disorder (GID) which transsexuals have. The A.D.A.M. Medical Encyclopedia defines GID as:
Gender identity disorder is a conflict between a person's actual physical gender and the gender that person identifies himself or herself as. For example, a person identified as a boy may actually feel and act like a girl. The person experiences significant discomfort with the biological sex they were born. (A.D.A.M.)
Both conditions can lead to current-body-averse behavior. For instance, young male transsexuals are known to self-amputate their external genitalia as a way of handling the discomfort of feeling like they are in the wrong body in regards to biological sex.
Voluntary Amputees with BIID feel that internal body image does not fit their actual body. This is different significantly different from BDD because people with BIID do not have the delusion that the undesired body part is diseased or ugly. BIID is a feeling of mismatched mind-body identity that strikingly similar to that of GID.
Mismatched body identity is not uncommon1 because the reverse of the BIID occurs with amputees often. This reversal of the condition is phantom limbs for which a person's mental image of his or her body contains a limb that they no longer have. The feeling of phantom limbs is so strong that phantom pains occur in the mind despite the nerve endings no longer being there. In the case of people with BIID, the feeling is that the healthy limb is not really part of their body. This feeling is the cementing factor that when understood as being in this relation to GID and phantom limbs, voluntary amputation become normal for people with BIID.
Normal, as I said earlier, is the concept of being healthy, morally permissible, and not irrational. Normal is often devalued as being a social construct that has caused great harm to the 'different'. Unlike those who hold this understanding of normal, I will defend it as being central to our species project towards a better understanding of health, other minds, and the world in general.
In regards to health, normal acts as a inductive conclusion that certain qualities indicate illness. The qualia valances associated with beauty and ugliness are so ingrained with our species that most humans are born with the same instinctive perception of beauty and ugliness. This helps explain why health is often associated with beauty and illness is often associated with ugliness. The grossness of sickness acts as a deterrent in our species away from things which may cause us to become ill ourselves and to take recognition of something being 'wrong' in the other we perceive.
In the case of voluntary amputees, our misunderstanding-based response is to think that the person has a self-destructive mental sickness. As with the evolution with our views on transsexuality, I believe that given the similarities, our investigation into BIID will lead to a general understanding of the normalcy of the condition. The issue concerning whether or not amputation is harm will be addressed in the next section.
The second aspect of normal is that it is morally permissible. Society, in part, makes the abnormal by both de facto and de jure attitudes towards acts, beliefs, conditions, etc. In one society, being homosexual is taboo so homosexuality appears to those in the society generally as abnormal. In another, homosexuality included into the mainstream and the fact there are homosexuals is part of the normal for those in that society.
Of course, societal consensus is not enough to establish what is actually morally permissible, but societies invested in morality ought to invest in understanding the world in which we actually live in. This is because generally taboos about things like homosexuality come with genuine beliefs about the nature of homosexuality and what kind of entities exist in this world that act as moral law-givers. If those beliefs are not true, this can and often does lead to harming people despite the good intentions of the law or taboo.
This relates to BIID in that the desire to be amputated was believed to be a psycho-sexual condition (Bayne 76). It was believed by psychologists that this desire to be an amputated was the desire to be the receivers of apotemnophilia, or the sexual attraction for amputees (Bayne 76). The taboos against deviant sexual desires and acts underlies the labeling this desire negatively, or as abnormal.
Abnormal is often associated with irrationality. For instance, if I wanted to eat it would be irrational or abnormal for me to refuse food to which I am not averse. I say normal is being not irrational because normal can be either rational or nonrational. It would be rational for me to eat when I am hungry, but my tastes and my desire to eat are nonrational. The foundational desires that I have no grounds on which to be in themselves rational. There is no reason to live but through of the desires to live or the desires which are satisfied through living. This is why euthanasia is morally permissible when all the conditions that make life of the one to be euthanized desirable are gone for both the person suffering and the invested party like dependents. This understood allows for making an extremely important distinction between illness-driven behavior like that of anorexics and justifiable behavior like that of transsexuals receiving SRS.
This understanding leads to that distinction because mental illness leads to undesirable outcomes like death. Neither the anorexic nor his or her relatives want the anorexic to die. The desire to lose weight that the anorexic has is conditioned by a false representation of reality, particularly that they are overweight. The desire would cease when their beliefs change to more healthily reflect reality. The transsexual and the voluntary amputee, all things equal, have correct beliefs about their bodies but the desire stems from their very understanding of self, which is not conditioned by false beliefs about the physical body they have.2 The truism that captures the general idea here is 'who I am is not what I am'.3
In this section, I will address three objections to voluntary amputation of healthy limbs that challenge the moral status of the very idea of voluntary amputation, BIID aside. If successful, these objections override the desire satisfaction that voluntary amputation achieves, all things equal, desires being a good enough reason to do something.
- When we contemplate whether or not being amputate someone, we always desire not to amputate because amputation should only be done as a necessary evil to save someone's life. Losing a limb, in other words, is a serious harm, and even if a person wants to lose a limb, it is wrong to seriously harm someone even if they want us to.
The understanding that amputation is necessarily harmful is such a strong intuition that it characterizes our medical practice, which avoids amputation unless risk is high enough to the person's life, as this objection alludes. If amputation was a serious harm necessarily, then even a person with BIID would not justifiably be able to get a voluntary amputation. This intuition that amputation is necessarily harmful is false.
Harm must be put into context with human experience and threat to self because we are after all trying to have a moral landscape that reflects the world we live in. Those without experience of BIID would induce from their limited understanding of human desires that it is universally undesirable to be an amputee. This is an easy move because there are so few with BIID, so an ethicist can feel comfortable with the informal sampling of human population she has in her life of moral science.
A thought experiment might help here. It is a common assumption that the default is not to amputate, but this would be assuming that a neutral body would be harmed by amputation. A doctor is deciding on a procedure to take on a patient. This patient is, however, completely neutral, meaning he has neither any aversions nor any attractions. The doctor could cut of the patients arm, and the patient would not care. Nothing the doctor can change the patient's true condition which is neutrality. If the doctor were to cure this neutrality, perhaps by reading him Albert Camus's Myth of Sisyphus, the doctor cannot assume that the patient will necessarily not have right arm aversion.
In other words, it is not because amputation is universally harmful, but only in the experience of the majority who do not have BIID is it wrong to amputate because they do not desire as a block to live a life as amputees. Because harm must be understood in terms of how people experience world, being an experience itself, and because amputation is not universally a harmful experience, amputation cannot be as a rule be necessarily harmful, despite that being usually the case.4
- Humans seek to reach certain ends like living independently. Amputations decrease the utility of the body which a person uses to achieve ends. A person who voluntarily amputates when confronted with something they could have only done with the limb he had amputated will feel regret. Since the loss of utility is great when one is amputated, voluntary amputation of healthy limbs cannot be justified.
This regret is a serious problem which is the purpose psychological exams of those with BIID and GID have before their life-changing surgeries. Like male-to-female-to-male transsexuals, there is the risk that someone who voluntarily amputates will find him- or herself desiring to reverse the procedure. Despite this serious risk, the risk is justifiable.
Every time a human makes a decision, some utility is expended, and regret over what could have been is made possible. This is the human condition to always be under the threat of regret. The psychological exams before the voluntary amputation are necessary to reduce this risk to a reasonable level.
- The good life is a project of growth. We extend our lives, strengthen our bodies, and rid ourselves from disease. Just like it is irrational to not to be death-averse, it is irrational to weaken the body when the virtuous goal is to be a greater being. In other words, the virtuous person ought to overcome the desire to amputate in order to continue on the path of self-betterment.
I am most sympathetic to this objection. Though the utility argument could have been construed this way, this transhumanist argument hits the nail on the head. The best counter I can provide is that better can be achieved without ones limbs. It takes a certain creativity to imagine what it is like to be without ones limbs. Just like those who are blind whose hearing becomes stronger to compensate, without limbs a new strength can be sought.
Anyways, this new strength has been sought ever since people started dedicating themselves to academics. The body became a tool to carry the head to classes. We have constantly replaced the body with intellectual pursuits which in many ways made us more powerful than our bodies could have ever been. Since the body is merely a tool to achieve these goals of virtues, new better tools can replace the body's traditional purpose, making the body only important in-so-far as having a long, comfortable, mentally aware life is concerned. The car is faster than any person who has ever lived; the computer is faster than any brain that ever existed. Those with amputations can live virtuous lives in this day and age precisely because the body with which people are born is becoming less and less essential to achieving virtue.
While this does not cover all the objections, this outlines how something seemingly abnormal like voluntary amputations may in fact be normal after investigation. Any objection to the risk of amputations will have to refer to the way the world is because risk is not an a priori concept. Any declaration of wrongness must avoid merely projecting ones own feelings onto people who do not have them. Even if BIID ends up being an illness rather that should be cured by treatment of the mind rather than treatment of the body, amputees can live fulfilling lives more and more, making the moral consequences of amputating someone who should not have been amputated less and less.
Bayne, Tim. Levy, Neil. “Amputees By Choice: Body Integrity Identity Disorder and the Ethics of Amputation.” Journal of Applied Philosophy. Vol. 1, No. 1, 2005. Society of Applied Philosophy. Blackwell Publishing, Oxford: 2005.
A.D.A.M. Gender Identity Disorder. U.S. National Library of Medicine. ncbi.nlm.nih.gov. A.D.A.M., Inc. 2012. Date Accesses: April 18, 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002495/ >
1Being common is closely associated with our concept of 'normal', which I will flesh out in the next section.
2This is only part of the story of distinguish the irrational from the not irrational. There are distinctions like that for fear-desires. What makes a fear-desire irrational (phobias) rather than nonrational might require more nuance than the story of rationality that I am providing here because fear-desires can run very deep yet retain a semblance of irrationality.
3I only sort of believe this. I would say that you are still a what but you can change what you are and remain you because identity is a set of whats and these whats do not necessarily essentialize everything about ones body. I avoid the debate around identity here and simply go with something I merely admit as a truism.
4It might be helpful here that I am not saying just any perception of the world overrules whether or not something is harmful. For instance, a person might perceive, incorrectly, that water is harmful. With the understanding that the person's fear stems from instincts that tends towards survival, it would doing the person a favor to help them over their life-threatening fear. Again, I am going to avoid addressing phobias directly in the body of this paper because of the problems they provide for the story of desire-based ethics I am pushing here.