Ethics – A Right to Autonomy

by markryanmayo


In a world where we are taught to be grateful in regards to having all of our bodily functions, it is hard to comprehend the idea that someone would electively desire to remove a limb.  One morning in 2001, after eighteen years of suffering with Body Integrity Identity Disorder (BIID), George Boyer decided to take matters into his own hands.  Sitting in his backyard, Boyer cocked his gun, aimed and blasted a hole just above his left knee.  He had planned every thing down to the last detail.  However, his cordless phone was out of range, had he not been found by his landlady, Boyer would have bled to death. While in the Emergency Room, Boyer became very combative with the doctors when they decided to restore his knee, demanding that his leg be removed (Ellison, 2009).  By exercising his right to electing his own treatment, the doctors were forced to amputate.

Boyer’s case raises many questions about the ethical issues concerning the medical decision-making process in regards to self-elective amputation.  This blog addresses the issues about the medical approach regarding elective amputation, in the hopes to reduce the drive for self-injuring behavior or even suicide.  Without an established method of treatment for BIID sufferers, performing an amputation on an otherwise healthy limb will continue to be considered an unethical act (Muller, 2009).  However, BIID is not the only disorder that commonly seeks out self-elective surgery.  Those with Body Dysmorphic Disorder (BDD) and Gender Identity Disorder (GID), like BIID, usually result in a desire to change or modify ones body to reduce anxiety (Patrone, 2009).  GID commonly results in sex reassignment surgery, while those with BDD will seek plastic surgery to change a preoccupation with ugliness.  Often these surgeries are preformed regardless of the underlying psychiatric conditions, where little consideration is given to the ethical issues involved.  Unlike GID and BDD surgeries, BIID amputation results in a disability, which is considered unethical in accordance to the Hippocratic oath, “First do no harm” (Ryan, 2008, p. 27).  Yet, it is argued that this disability caused by the loss of a limb is a reasonable therapeutic trade-off, given the significant relief that it provides (First, 2005).  With no safe means to relief suffering, individuals who cannot find or afford a willing surgeon may turn to self-mutilation, causing far more damage than intended.  

While it is clear that BIID, GID, and BDD share a condition where obsessive desires can lead to suicide, it is not clear that amputation of a limb conflicts with the goals of medicine.  In an article by Tim Bayne and Neil Levy (2005) on medical ethics, they stated “if the desire for amputation is long-standing, the patient is not psychotic, and he is well aware of the risks and consequences, surgery is ethically permissible because it will prevent many BIID patients from injuring or killing themselves.” (p. 39)  Furthermore, surgeons and the medical industry have established criterions for elective removal of healthy body parts (i.e., cosmetic surgery, living-donor organ transplantation, and sex reassignment surgery) (Patrone, 2008).  It has also been suggested that Body Integrity Identity Disorder could be considered an extreme body modification, a tool used to exercise the right of control over one’s body (Muller, 2009), but this concept appears more benign than BIID really is.

Concerning the principle of autonomy, Muller states that the “patients have the right to choose between different medical therapy options regarding their different chances and risks as well as their personal situation and individual values.” (p. 40)  In other words, should the sufferer choose, elective amputation would be a suitable method of therapy.  According to the medical industry, when diagnosis with a psychiatric disorder the lost of autonomy occurs, because the concern becomes an ethical issue between one’s freedom of choose or obsessive desires (Ryan, 2009).  In term of analytical thinking, this argument directly addresses to the right to modify one’s body as desired, putting elective amputation in the gamut as liposuction, nose and breast augmentation.  It is important to note, BIID amputees do not wish to be identified as being disabled while using prosthetics to hide the amputation area.  They want the impairment, however they do not socially identify as disabled, nor are they looking to inflict additional cost to society (Bayne & Levy, 2005).

Throughout history, humans have gone to great lengths to alter their appearance at the risk or self-harm and even death.  Augmenting one’s appearance in many cultures was and is still heal in high regard.  Yet until medical professional are able to conduct further research, the public and medical acceptance of elective amputation will remain misunderstood, and sufferers will be left with very little methods for dealing with their anxiety and impulsiveness.  Currently, BIID sufferers are left with no outlet other than the Internet to find effective ways to self amputate, with the ‘dry ice method’ being number one means of treatment.  The disorder is being considered for the DSM-V, which should widen the understanding and acceptance of BIID. 


Bayne, T., Levy, N. (2005). Amputees by choice: Body integrity identity disorder and the ethics of amputation. Journal of Applied Philosophy, 1(22).

Ellison, J (2009). Cutting desire. Newsweek (  /cutting-desire.html#sthash.gUAsfCCk.dpuf). 2009 May 05.

First MB (2005). Desire for Amputation of a Limb: Paraphilia, psychosis, or a new type of identity disorder. Psychological medicine, 2005, 35:919-928. PMID 15997612.

Khalil, B. R., Richa, S. (2012).  Apotemnophilia or body integrity identity disorder: A case report review.  The International Journal of Lower Extremity Wounds, 1-7.

Muller, S. (2009).  Body integrity identity disorder (biid) – is the amputation of healthy limbs ethically justified?. American Journal of Bioethics, 9(1): 36-43, 2009. doi: 10/1080/15265160802588194.

Patrone, D. (2009).  Disfigured anatomies and imperfect analogies: Body integrity identity disorder and the supposed right to self-demanded amputation of healthy body part. Journal of Medical Ethics, 35(9), 541-545. 2009, May 15.