Patrick Knight and Rashad Rehman argue that surgery to treat bodily identity integrity disorder should be reconsidered, despite its apparent success.

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Bodily Identity Integrity Disorder (BIID) is an understudied, complex psychological disorder in which a person desires to remove or amputate or, in the technical sense, “mutilate” or “dismember” an otherwise healthy limb. What is the ethical treatment of BIID? Two studies provide relevant information required for ethical assessment.

The first is a 2012 study involving people with BIID. Of the 54 surveyed, nearly ninety percent (48 of 54) said they experienced dissonant feelings about their limb constantly, with only brief periods when these feelings were diminished, and with virtually no concurrent physical issues linked to BIID. Twenty-four percent (13 of 54) experienced some type of mood disorder, but only one of the 54 had been diagnosed with any other kind of psychotic disorder.

Image Description: An AI generated photo of a classical marble statue of a male figure with a missing arm.

The second is a study from 2014 in which 21 individuals with BIID who had limb amputation were interviewed. Only 2 of the 21 individuals achieved any success in decreasing their desire for limb amputation through the use of psychotherapy, psychopharmacologicals, or relaxation techniques. Some non-surgical treatment recommendations were actually reported to decrease mental wellness.

Remarkably, every person with BIID who had their limb removed, even years after their procedures, proclaimed drastic positive changes in every examined metric: general life situation, job satisfaction, private life, health status, sexual satisfaction, body identification, happiness, extraversion, courage, calmness and peacefulness, enthusiasm about life, and self-confidence. These results are echoed in the 2012 study above – 7 of the 54 individuals had become amputated, all of which agreed that it had helped alleviate their suffering.

Why is this significant? When surgery is performed, there is high success and satisfaction rates despite not knowing the exact aetiology of BIID. The tradeoff is that it requires the intentional dismemberment of an otherwise healthy limb (hereafter abbreviated to “bodily mutilation”). There are a series of interrelated reasons that, despite the apparent surgical success, we should be apprehensive about treating BIID by means of bodily mutilation.

Treating BIID by means of bodily mutilation appears morally justified if we assume that the consequences of surgery are the only relevant moral metric. This is to espouse the ethical theory consequentialism, which requires weighing the relative weight of the consequences in the form of a utility calculus or risk/benefit or benefits/harms analysis. This is an assumption not without serious conceptual, philosophical, and practical problems. The deficiencies of applying a consequentialist approach to this question become apparent when we consider two other moral issues that are unaddressed by these research studies.

First, performing surgery on individuals with BIID without knowing the aetiology disincentivizes mental health and medical research concerning the origin of BIID, stifling the possibility of the ideal scenario in which we can care for those suffering from BIID by increasing their quality of life without bodily mutilation and ensure adequate mental and medical diagnosis. Moreover, this highlights the tacit assumption that talk of “success” by means of bodily mutilation could or should be defined outside of a mental and medical diagnosis. A worst-case-scenario treatment for BIID which requires irreversible bodily damage does not plausibly constitute “success,” but one in which bodily mutilation is absent and in which a diagnosis is causally connected to prognosis. Consequently, moving towards or normalizing treatment for BIID by bodily mutilation disincentivizes mental health and medical research, threatening more optimal care for those suffering with BIID.

Second, we should worry that despite individuals seeming to consent to bodily mutilation to treat their BIID, they may not be fully autonomous. To put the point succinctly: desires or persistent desires to have otherwise healthy body parts removed are formally, psychopathologically abnormal. In fact, it is not simply abnormal in a generalized sense, but indicative of mental illness.

Despite the DSM-5’s formal diagnostic criteria not categorizing BIID as a mental illness, BIID unambiguously meets each criteria. Moreover, the crucially distinct feature of BIID is that the choice-structure for surgery is entirely determined by the mental disorder. The determination of capacity is specific to the decision to be made, and in this case the decision to amputate seems influenced by a mental disorder. This feature casts doubt that those with BIID autonomously consent to bodily mutilation.

In sum, treating BIID should be reconsidered, despite its apparent success – for what constitutes “success” is not only a matter of controversy chock-full of implicit moral assumptions, but should ultimately aim at optimal, not merely concessionary, interventions.

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Patrick Knight is a graduate student in the M.A. Philosophy program at Franciscan University of Steubenville, Ohio.

Rashad Rehman is Assistant Professor of Philosophy and Assistant Director of the Center for Bioethics at Franciscan University of Steubenville, Ohio.