For most people, it is a perfectly normal notion that their body belongs to them. However, there are cases in which persons feel that a specific body part is superfluous or alien. Such is the case in stroke patients who have suffered a hemorrhage in the insula and request the nurse to remove “that strange leg” from their bed. Patients with body integrity identity disorder (BIID) experience this sensation from early childhood on.Reference First 1 This feeling results in a strong desire for amputation of a certain body part. To date, there is no effective treatment available for BIID patients. Consequently, patients resort to self-amputation, which often leads to complications and sometimes death.Reference Blom, Hennekam and Denys 2 We offer arguments in favor of elective amputation as an alternative.Reference Dyer 3
BIID patients are often dismissed when they share their wish for amputation with surgeons. Every physician is to comply with the Hippocratic principle of primum non nocere (“first do not harm”). Surgeons are cautious not to override this oath. In addition, they fear a patient may regret the procedure. Furthermore, one may argue that electively disabled people place an unnecessary financial burden on society. In this discussion, it is important to note that BIID patients are otherwise healthy individuals. Their wish for amputation is not a product of psychosis, imagined flaws, or factitious disorder. Nor are there any physical abnormalities of this particular body part.Reference Blom, Hennekam and Denys 2 Case reports and studies reporting on BIID patients who performed self-amputation reveal a 100% satisfaction rate.Reference Noll and Kasten 4 , Reference Blom, Braam, de Boer-Kreeft and Sonnen 5 Patients report better quality of life; they do not desire any additional amputations, nor do they regret their decision.Reference Blom, Hennekam and Denys 2 , Reference Noll and Kasten 4 The only regret they have is the fact they did not go through with amputation sooner in life.Reference Blom, Braam, de Boer-Kreeft and Sonnen 5 Furthermore, one must consider that the costs of an operation and recovery are less than long-term treatment of depression as a result of BIID.Reference Druss, Marcus, Olfson and Pincus 6
Etiology of BIID presumably lies in a fronto-parietal lobe anomaly.Reference van Dijk, van Wingen and Van Lammeren 7 , Reference Hilti, Hänggi and Vitacco 8 BIID patients do not consider intracranial interventions such as deep brain stimulation an option. Such procedures are regarded as a modification of their identity. Patients with gender dysphoria express similar arguments. Despite associations with brain abnormalities in both cases, in most countries the prevailing treatment for gender dysphoria is an external operation, although not every insurance company or plan will pay for it.Reference Roehr 9 A second analogy can be made with euthanasia. In some countries it is legal for physicians to perform euthanasia on physically healthy patients who experience unbearable and lasting mental suffering. If one allows termination of life, why not amputation? The real question is whether BIID is accompanied by unbearable and lasting suffering. It is goes without saying that less definitive measures for the alleviation of suffering would have preference.
Elective amputation can prevent complications and death in BIID patients who are contemplating self-amputation. It is crucial that physicians comply with several criteria that ensure due care, just as with transgender operations and euthanasia. The desire for amputation must be lasting, constantly present, and irresponsive to treatment. The patient must be conscious of the risks. It must be evident that the patient is not in a state of psychosis. If these criteria are met, one can make arguments to override primum non nocere in the BIID patient treatment dilemma.
Disclosures
The authors have nothing to disclose.
