Saturday, 1 September 2007

Body Dysmorphia (2007)

From The Philosopher, Volume LXXXXV No. 2

The Social and Ethical Challenge
By Simon Woods

We have always celebrated the grace and beauty of the human form. The notion that there is an objective ideal of the perfect human form underpins a classical aesthetic that has become a consistent motif in every artistic genre. The Elgin Marble frieze with its lithe, athletic human figures represents the human form in every possible martial and athletic pose. These classical and idealised forms of human perfection reappear and are epitomised in the Renaissance, in paint, in marble and in the written word. So when Shakespeare's Hamlet says:
What a piece of work is man! How noble in reason! how infinite in faculties! in form and moving, how express and admirable! in action how like an angel! in apprehension, how like a god! the beauty of the world! the paragon of animals! 
We have the words and a repertoire of images to conjure with. However it would be wrong to suggest that classical perfection has been the sole muse for ideas and the arts. Ugliness particularly when coupled with sin and deviance has also had its place. It appears in many of Bosch's paintings, the malign ugliness in Goya's dark paintings and the deliberate "deforming" of the human shape distinctive of the modern and post-modern explorations of the human form.

Medicine also has its place within this history of culture and ideas and has also been influenced, some might say overly influenced, by the classical ideals. The concept of health as a state of perfection as represented in the much criticised World Health Organisation's definition of health is an example of this classical idealism. Concepts of health and disease often play on ideas such as perfection of mind and physical function, and deviations from this state become the basis for defining disease and ill-health. Nor are these efforts to define and categorise disease immune to normative concepts where disease is frequently associated with corruption, deviation, even with sin and immorality. Human moral failings have been closely associated with organic disease even in the contemporary world, so syphilis, T.B, cancer and AIDS have all had morally pejorative associations. It is perhaps in the area of psychiatry and mental illness that these associations are most obvious and most controversial. The anti-psychiatry movement of the 60's and 70's was partly inspired by individuals keen to take the moral and political out of the mental health context.

The taxonomies and terminologies of medicine and psychiatry have done a good job of disguising the moral, political and socially controlling aspects of these disciplines. However the tension that exists between concepts of disease as harmful pathology and the normative notions of disease as moral deviation are still evident in contemporary health care and it is with these thoughts in mind that I now turn to consider the particular challenge of healthy limb amputation.

In the late 1990's Dr Robert Smith a surgeon in the National Health Service performed amputations of ostensibly "healthy" limbs in two individuals who had approached him with this request. His plans to amputate the limbs of a third patient were halted when the Hospital Trust in which Dr Smith was employed prevented him from doing so. How should we regard Smith's actions and the subsequent decision to prevent him from continuing with this work?

The patients who presented to Dr Smith were said to be suffering from a psychiatric illness, a disease "of the mind" that led them to believe that their otherwise healthy limbs did not belong to them and that they would be healthy and whole once the limb was removed.

There are a number of ways in which to begin thinking about this situation. Take for example the phenomenon of the phantom limb, a common experience in those who have suffered a traumatic amputation or elective surgery related to disease. Many amputees often experience this unpleasant symptom, haunted so to speak by the "ghost" of their former limb. One explanation for this phenomenon is the idea that the mental schema of the body is now mismatched, since this schema has failed, or at least partially failed to adjust to the new surgically adjusted physical territory of the body.

One can perhaps draw a parallel to the case of the person who wishes to be rid of a healthy limb because their mental schema is also mismatched with the physical territory of the body. In this instance the physical limb of flesh and blood might be said to be the "phantom" which haunts the person.

So how are we to understand this phenomenon and how ought we to respond as a society in which the health and well-being of our fellows is a shared social concern? Perhaps one way of comprehending this phenomenon is to distinguish the failure to recognise a part of the body as one's own and the desire to have a body part amputated? Therefore a first question to consider is whether there is one kind of case or more.

The neurologist, Oliver Sacks, has described several neurological cases, including his own experience following an accident in which he suffered a serious leg fracture. Sacks describes cases of patients who fail to recognise part of their body as belonging to them - a condition dubbed asomatagnosia. In such cases patients have been known to attempt to throw the alien limb out of bed and have invented all manner of bizarre stories to rationalise how an alien limb has become attached to their body. Cases of asomatagnosia are all associated with a neurological condition, a lesion in the brain or other form of physical damage. But these cases do not exhaust all possible examples of the phenomenon.

Within the taxonomy of disorders recognised by psychiatry there are a number of groups of conditions. These groups share, to a lesser or greater extent, the elements of recognition and desire. The first group is known as the paraphilias in which sexual arousal is derived from non-sexual or inappropriate objects and states. So the infamous examples of shoe, leather and rubber fetishism are examples of paraphilias. The more disturbing phenomenon of paedophilia is also included within this group. Of interest to this discussion are the conditions known as apotemnophilia and acrotemnophilia. The first is a condition in which the individual achieves sexual arousal from the state of being an amputee and includes people who have become amputees and those who strongly desire to become an amputee, the so called "wannabes". The second term is applied to those who achieve sexual arousal from being in close proximity to amputees, known colloquially as "devotees". There is a thriving sub-culture of such individuals within complex virtual and real communities enabling them to indulge in their own particular "paraphilia" or life-style choice.

Again within psychiatric taxonomy there is Body Dysmorphic Disorder (BDD) in which individuals believe that their body is diseased or extremely and offensively ugly causing them to become reclusive and often seeking multiple cosmetic surgeries. There is a view within psychiatry that such disorders are related to conditions such as anorexia nervosa and bulimia sharing in common a "monothematic" delusion, a powerful but false belief that the individual is too fat or diseased or ugly.

The third group is known as Body Integrity Identity Disorder (BIID) sometimes referred to as Amputee Identity Disorder. In psychiatry there is a view that such conditions are related to Gender Identity Disorder in which individuals seek male to female sex-change surgery. It is argued that these cases are similar because the motive is not associated with a sexual desire and therefore not a paraphilia but with the belief that one's physical body is at odds with the mental schema of the body, giving the person a strong sense of alienation from the physical body which is often the cause of severe distress. This distress can be so profound that it often drives people to take extreme measures to seek relief including engineering their own amputations.

All of the conditions discussed here raise issues both for society at large and for medicine in particular. The moral goods with which medicine is concerned, relief of pain and suffering, amelioration and cure of disease, are also strongly endorsed by society. However this does not mean that these goals lack ambiguity. Medicine does raise controversial issues and conflicting intuitions. So how ought we to respond to the apparently "healthy" person who requests the amputation of one or more of their limbs?

One radical and perhaps controversial response would be to argue that this is not a matter for medicine, or indeed for society, but is rather a private matter, a personal choice of lifestyle. On this view, it ought to be a given that people are free to shape and re-shape their physical bodies in the same way that they change fashion or have a new hairstyle. This would require a liberal society in which the "wannabes" and "devotees" are free to pursue their interests within their own sub-culture so long as the costs are met mainly by themselves and not the rest of society. This sort of move would place most of the issues outside of the concern of medicine, except insofar as individuals may wish to buy the services of the cosmetic surgeon to aid in the reshaping of their bodies. This solution, of course, raises quite different questions about repugnance and social norms and the power a society may have to insist upon certain standards of behaviour as a condition of enjoying its membership.

A more troubling case is that of those individuals who are not driven by a sexual impulse or a radical view of lifestyle choice. For some individuals their life is severely impaired by the mere fact that, whilst appearing to be healthy, they are tortured by the existence of an unwanted and, in their view, additional limb. Tim Bayne and Neil Levy, two philosophers interested in this phenomenon, have argued that in the particular case of Body Integrity Identity Disorder (BIID) the medical model, involving surgical amputation, is appropriate and justified. They argue that the suffering of the person is real and significant enough, with a high risk of associated self-harming. The belief is rational enough and there is no other therapeutic alternative since the condition has proven resistant to psychiatric treatments. Bayne and Levy also argue that the outcome of the intervention is good in the small number of cases where amputation has taken place either surgically or through self-harm. Following such interventions the individuals do not request subsequent amputations and appear content with their reformed bodies. However, as convincing as these cases may seem, there are some complications that must be addressed. For example, in order to show that the outcomes of amputation are indeed good there is a need to conduct research on a sufficient number of interventions that are rigorously assessed and followed up.

There is, of course, the methodological problem of designing such a study. For example to what form of intervention would this be compared? There is also the further problem of whether such a research project could be sanctioned by a research ethics committee. However, a failure to make this enquiry or to provide these clinical services means that people will go on suffering; they may take drastic self-harming action forcing medicine to respond and pick up the pieces, or they may die in the process. All of which are serious harms worthy of medicine's and society's concern.

This essay has raised a number of intriguing questions in the context of healthy limb amputation that span several fields from philosophical questions about the nature of mind and the mind/body interface, questions in the philosophy of medicine about the nature of disease and impairment, social and political questions about the freedom to pursue life-style choices and the hard practical questions of medical ethics. There is not an easy solution to any of the questions raised here, but the issues are sufficiently complex to demand further enquiry - the main aim of this essay is to contribute to that enquiry.

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