This paper examines what, if anything, is morally problematic about the desire for healthy limb amputation. The paper begins with a brief survey of the empirical data concerning the desire to amputate a healthy limb, focusing on questions of characterisation and treatment. Subsequent to this, the paper focuses on two normative questions: is the amputation of a healthy limb in and of itself morally questionable if those persons requesting it are autonomous? And, are patients who (...) desire the amputation of a healthy limb autonomous? With respect to the first question, I reject two possible objections to healthy limb amputation, namely the claim that it is repugnant, and that it might cause harm to others, thus showing there is nothing inherently objectionable to healthy limb amputation. With respect to the second question, I critique two opposing views of patient autonomy from the healthy limb amputation literature, in order to show that the nature of the desire itself may inhibit a person‟s autonomy. (shrink)

PurposeThe effect of sensorimotor stripping on neuroplasticity and motor imagery capacity is unknown, and the physiological mechanisms of post-amputation phantom limb pain (PLP) illness remain to be investigated.Materials and methodsIn this study, an electroencephalogram (EEG)-based event-related (de)synchronization (ERD/ERS) analysis was conducted using a bilateral lower limb motor imagery (MI) paradigm. The differences in the execution of motor imagery tasks between left lower limb amputations and healthy controls were explored, and a correlation analysis was calculated between level (...) of phantom limb pain and ERD/ERS.ResultsThe multiple frequency bands showed a significant ERD phenomenon when the healthy control group performed the motor imagery task, whereas amputees showed significant ERS phenomena in mu band. Phantom limb pain in amputees was negatively correlated with bilateral sensorimotor areas electrode powers.ConclusionSensorimotor abnormalities reduce neural activity in the sensorimotor cortex, while the motor imagination of the intact limb is diminished. In addition, phantom limb pain may lead to over-activation of sensorimotor areas, affecting bilateral sensorimotor area remodeling. (shrink)

The ethics of medically-authorized limb amputation in individuals with Body integrity identity disorder (BIID) remains extremely controversial. One factor to consider is the putative locus of a disease process, and whether the proposed treatment--in this case, limb amputation—reasonably addresses the issue of what organ is mediating the patient’s complaint.

Lower limb major amputations are both life-saving procedures and life-changing events. Individual responses to limb loss are varied and complex, some individuals experience functional, psychological and social dysfunction, many others adjust and function well. Some patients refuse amputation for religious and/or cultural reasons. One of the greatest difficulties for a person undergoing amputation surgery is overcoming the psychological stigma that society associates with the loss of a limb. Persons who have undergone amputations are often viewed (...) as incomplete individuals. The medical and physical consequences of amputation serve as the centerpiece in acute care and are commonly at the forefront of prosthetic rehabilitation. Prosthetic prescription aims to compensate for functional and/or cosmetic losses where possible. The aims of rehabilitation following amputation are to restore acceptable levels of functioning that allow individuals to achieve their goals, to facilitate personal health, and to improve participation in society and quality of life either with or without prosthesis. Our article aims at underscoring some medical, social and religious aspects that can contribute to the wellbeing of patients who suffer a life changing event such as lower limb amputation. (shrink)

Se realiza la investigación con el objetivo de perfeccionar la obtención del consentimiento informado en las amputaciones mayores de causa vascular en el Servicio de Angiología del Hospital Universitario Manuel Ascunce Domenech. Se constató debilidades en la institucionalización del consentimiento informado y específicamente en el caso de tales amputaciones. Se utilizaron métodos y técnicas del nivel empírico: encuestas a 30 pacientes con riesgo inminente de amputación. El 64% eran mayores de 65 años, 73 % femeninos, todos escolarizados y 73% residentes (...) urbanos. Los resultados más relevantes fueron: que el 54% de los pacientes manifestaron debe existir consentimiento en la aceptación de la amputación, aunque un grupo no despreciable el 37% declinó este derecho a favor de sus familiares. A los médicos se les realizó una entrevista y aunque no hubo unanimidad de criterios, todos coincidieron en que debía legislarse este consentimiento, como parte del perfeccionamiento de los servicios de salud. Research is conducted to improve the process of obtaining informed consent for major amputations due to vascular causes in the Angiology Service of the Manuel Ascunce Domenech Teaching Hospital. Deficiencies were identified in the institutionalization of informed consent protocols, most specifically as they relate to major lower limb amputations. Empirical methods and techniques were used. Thirty patients at imminent risk of amputation were surveyed by questionnaire methods; 64% of those surveyed were of 65 years of age, 73% were female, all of them had an average educational level, and 73% were urban residents. The results indicated that 54% of patients recognized the importance of informed consent in cases of amputation, although a rather considerable group declined this right for their families. Physicians were also interviewed and, although there was no unanimity of criteria, all of them considered that this consent should be legislated as part of the improvement of health services. (shrink)

This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Dis...

Upon first consideration, the desire of an individual to amputate a seemingly healthy limb is a foreign, perhaps unsettling, concept. It is, however, a reality faced by those who suffer from body integrity identity disorder (BIID). In seeking treatment, these individuals request surgery that challenges both the statutory provisions that sanction surgical operations and the limits of consent as a defence in New Zealand. In doing so, questions as to the influence of public policy and the extent of personal (...) autonomy become important. Beyond legal issues, BIID confronts dominant conceptions of bodily integrity, medical treatment, and ethical obligations. This paper seeks to identify the relevant public policy concerns raised by BIID in New Zealand and the limits of autonomy, before moving on to consider how BIID sufferers may legally seek the treatment they require and how a doctor might be protected from criminal proceedings for assault for performing this treatment. It will be argued that it is possible to legally consent to the amputation of a healthy limb as medical treatment and that public perception should not be allowed to take precedence over this right. (shrink)

The disposal of limbs remains absent from our understandings of amputation, with ‘estranged limbs’ occupying a liminal position. Despite acceptance that the appropriate disposal of human tissue matters on moral, ethical and legal grounds, limbs and their disposal is estranged from these discourses, mirroring the experience of the limbs themselves. This article then examines this absence around disposal, considering both the options which exist for the disposal of limbs after amputation, as well as why disposal itself remains sidelined (...) from our broader understandings of the body. Practices for disposal that encompass both traditional clinical approaches and more unusual patient choices will be discussed – through the discussion of these as potential ‘disposalscapes’. Utilising concepts from the work of Crawford, Shildrick and Steinberg and Slatman and Widdershoven, the potential importance of the disposal of limbs to patients and the role of disposalscapes within this are considered. (shrink)

The study aimed to identify the psychological changes that result from the amputation of a limb and the ways in which patients coordinate their daily lives. The study uses an interpretative phenomenological analysis aimed at understanding individual experiences in seven patients who have suffered limb amputation. The method used consisted of individual, semi-structured interviews, conducted approximately 4 months after surgery, to patients at home or in hospital, at the time of their regular checkup. The interviews were (...) audio recorded, transcribed and, following the qualitative analysis performed, six common themes were identified: emotional impact, negative affects, tendency toward isolation, role constraints and limitations, phantom limb, and emotional balancing. A specific theme for patients who have suffered amputations is phantom limb pain, which has received special attention from researchers. The last topic relates to the tendency toward emotional balancing and psychological calibration to return to normal life. (shrink)

Apotemnophilia is a condition that causes those who have it to not feel “correct” in their own bodies. As a result, an intense obsession develops with removing the limb; this obsession hinders tremendously the patients' social behaviour and societal integration. These patients, in some respects resembling transgendered individuals, feel that the body part (limb) in question is simply “not a part of themselves”, causing them to feel uncomfortable in their own bodies. Whether amputations should be performed on apotemnophiles (...) or not is a question that poses a significant medical ethical dilemma. It is argued that observing an apotemnophile's request for amputation is the ethical action. The major arguments opposing such amputations and supporting such amputations are examined and critically analysed with regard to ethical principles—namely, patient autonomy, beneficence, non-maleficence and justice with regard to every person's “right to happiness”. Finally, a discourse on how the accepted notion of harm does not apply to apotemnophilia is developed to justify the position that amputation is indeed medically the ethical choice. (shrink)

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for (...) amputation in analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for (...) amputation in analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

Almost everyone who has a limb amputated will experience a phantom limb--the vivid impression that the limb is not only still present, but in some cases, painful. There is now a wealth of empirical evidence demonstrating changes in cortical topography in primates following deafferentation or amputation, and this review will attempt to relate these in a systematic way to the clinical phenomenology of phantom limbs. With the advent of non-invasive imaging techniques such as MEG (magnetoencephalogram) and (...) functional MRI, topographical reorganization can also be demonstrated in humans, so that it is now possible to track perceptual changes and changes in cortical topography in individual patients. We suggest, therefore, that these patients provide a valuable opportunity not only for exploring neural plasticity in the adult human brain but also for understanding the relationship between the activity of sensory neurons and conscious experience. We conclude with a theory of phantom limbs, some striking demonstrations of phantoms induced in normal subjects, and some remarks about the relevance of these phenomena to the question of how the brain constructs a 'body image.'. (shrink)

ABSTRACT Should surgeons be permitted to amputate healthy limbs if patients request such operations? We argue that if such patients are experiencing significant distress as a consequence of the rare psychological disorder named Body Integrity Identity Disorder (BIID), such operations might be permissible. We examine rival accounts of the origins of the desire for healthy limb amputations and argue that none are as plausible as the BIID hypothesis. We then turn to the moral arguments against such operations, and argue (...) that on the evidence available, none is compelling. BIID sufferers meet reasonable standards for rationality and autonomy: so as long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests. (shrink)

Interventions are medically necessary when they are vital in achieving the goal of medicine. However, with varying perspectives comes varying views on what interventions are (un)necessary and, thus, what potential treatment options are available for those suffering from the myriad of conditions, pathologies and disorders afflicting humanity. Medical necessity's teleological nature is perhaps best illustrated in cases where there is debate over using contentious medical interventions as a last resort. For example, whether it is appropriate for those suffering from body (...) integrity dysphoria to receive healthy limb amputations. This paper explores how one's perception of medicine's goal underpins whether interventions are necessary or unnecessary, using the controversial topic of therapeutic amputation as an example. By contrasting ‘classical’ amputations with their more contentious counterparts, it highlights how the idea of medical necessity influences and restrains clinical decision-making. The paper starts by giving an account of body integrity dysphoria, focusing on the debate concerning elective amputation's justifiability. It then introduces Georges Canguilhem's vitalist theory of health, paying particular attention to his emphasis on adaptability. Then, this paper uses his theory as a lens through which to evaluate the appropriateness of therapeutic amputation as a medically necessary procedure. Ultimately, the paper highlights how the label of medical necessity is withheld from potential therapeutic interventions because they fail to conform to pre-established ideas of medicine's purpose and that by doing so, potential harm befalls those who are left with no effective treatments and must look for solutions in the non-clinical world. (shrink)

Amputation of a limb can result in the persistent hallucination that the limb is still present [Ramachandran and Hirstein, 1998]. Distressingly, these socalled ‘phantom limbs’ are often quite painful. Of a friend whose arm had been amputated due to gas gangrene, W.K. Livingston writes: I once asked him why the sense of tenseness in the hand was so frequently emphasized among his complaints. He asked me to clench my fingers over my thumb, flex my wrist, and raise (...) the arm into a hammerlock position and hold it there. He kept me in this position as long as I could stand it. At the end of five minutes I was perspiring freely, my hand and arm felt unbearably cramped, and I quit. But you can take your hand down, he said. (quoted in [Melzack, 1973] 53) In addition to the obvious medical issues, phantom limb pain also presents philosophical problems. Here’s a thorny one: are phantom limb pains hallucinations of pain? (shrink)

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the (...) diagnosis and consideration of other treatment options. (shrink)

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation’s International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with (...) the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of “justice” are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor’s desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient’s desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures. (shrink)

On one view, limb transplants cross technological frontiers but not ethical ones; the only issues to be resolved concern professional competence, under the assumption of patient autonomy. Given that the benefits of limb transplant do not outweigh the risks, however, the autonomy and rationality of the patient are not necessarily self‐evident. In addition to questions of resource allocation and informed consent, limb, and particularly hand, allograft also raises important issues of personal identity and bodily integrity. We present (...) two linked schemas for exploring ethical issues in limb transplants. The first, relying on conventional concepts in biomedical ethics, asks whether the procedure is research or therapy, whether the costs outweigh the benefits, and whether it should be up to the patient to decide. The second introduces more speculative and theoretically challenging questions, including bodily integrity, the argument from unnaturalness, and the function of the hand in expressing personal identity and intimacy. We conclude that limb transplants are not ruled out a priori, unlike some procedures that are prima facie wrong to perform, such as amputation of healthy limbs to relieve body dysmorphic disorders. However, their legitimacy is not proven by appeals to the interests of scientific research, cost‐benefit, or patient autonomy. (shrink)

Prosthetic devices that replace a lost limb have become increasingly performant in recent years. Recent advances in both software and hardware allow for the decoding of electroencephalogram signals to improve the control of active prostheses with brain-computer interfaces. Most BCI research is focused on the upper body. Although BCI research for the lower extremities has increased in recent years, there are still gaps in our knowledge of the neural patterns associated with lower limb movement. Therefore, the main objective (...) of this study is to show the feasibility of decoding lower limb movements from EEG data recordings. The second aim is to investigate whether well-known neuroplastic adaptations in individuals with an amputation have an influence on decoding performance. To address this, we collected data from multiple individuals with lower limb amputation and a matched able-bodied control group. Using these data, we trained and evaluated common BCI methods that have already been proven effective for upper limb BCI. With an average test decoding accuracy of 84% for both groups, our results show that it is possible to discriminate different lower extremity movements using EEG data with good accuracy. There are no significant differences in the decoding performance of these movements between healthy subjects and subjects with lower extremity amputation. These results show the feasibility of using BCI for lower limb prosthesis control and indicate that decoding performance is not influenced by neuroplasticity-induced differences between the two groups. (shrink)

Prosthetic devices that replace a lost limb have become increasingly performant in recent years. Recent advances in both software and hardware allow for the decoding of electroencephalogram signals to improve the control of active prostheses with brain-computer interfaces. Most BCI research is focused on the upper body. Although BCI research for the lower extremities has increased in recent years, there are still gaps in our knowledge of the neural patterns associated with lower limb movement. Therefore, the main objective (...) of this study is to show the feasibility of decoding lower limb movements from EEG data recordings. The second aim is to investigate whether well-known neuroplastic adaptations in individuals with an amputation have an influence on decoding performance. To address this, we collected data from multiple individuals with lower limb amputation and a matched able-bodied control group. Using these data, we trained and evaluated common BCI methods that have already been proven effective for upper limb BCI. With an average test decoding accuracy of 84% for both groups, our results show that it is possible to discriminate different lower extremity movements using EEG data with good accuracy. There are no significant differences in the decoding performance of these movements between healthy subjects and subjects with lower extremity amputation. These results show the feasibility of using BCI for lower limb prosthesis control and indicate that decoding performance is not influenced by neuroplasticity-induced differences between the two groups. (shrink)

This article is a phenomenological exploration and description of certain selected aspects of living the specificities and conundrums posed by what is usually, if problematically, called a ‘phantom limb’. Using my own body as an ‘intimate laboratory’, I attend to the dynamics and mutability of the supposed ‘phantom’, both during the post-operative period of the above-the-knee amputation of my left leg as well as after I began to use and incorporate my prosthetic leg. Throughout, I explore the reversible (...) aspects of my two legs as ‘phantom’ and ‘real’, present and absent, and visible and invisible — paying attention, as well, to the lived and linguistic sense we make of our bodies in ‘parts’ and our bodies as ‘whole’. (shrink)

We draw on the concept of dignity to consider the ethics of the disposal of amputated limbs. The ethics of the management and disposal of human tissue has been subject to greater scrutiny and discussion in recent years, although the disposal of the limbs often remains absent from such discourses. In light of the recent UK controversy regarding failures in the medical waste disposal and the stockpiling of waste, the appropriate handling of human tissue has been subject to further scrutiny. (...) Although this scandal has evoked concern regarding procurement and supply chain issues, as well as possible health and safety risks from such a ‘stockpile’, the dignity of those patients’ implicated in this controversy has been less widely discussed. Drawing at Foster’s work, we argue that a dignity framework provides a useful lens to frame consideration of the disposal of limbs after amputation. Such a framework may be difficult to reconcile with the logic of business and the ‘biovalue’ of the medical waste, but would we argue afford more patient-centred approaches towards disposal. It may also facilitate better practices to help mitigate future stockpiling incidences. (shrink)

Many upper limb amputees experience an incessant, post-amputation “phantom limb pain” and report that their missing limbs feel paralyzed in an uncomfortable posture. One hypothesis is that efferent commands no longer generate expected afferent signals, such as proprioceptive feedback from changes in limb configuration, and that the mismatch of motor commands and visual feedback is interpreted as pain. Non-invasive therapeutic techniques for treating phantom limb pain, such as mirror visual feedback (MVF), rely on visualizations of (...) postural changes. Advances in neural interfaces for artificial sensory feedback now make it possible to combine MVF with a high-tech “rubber hand” illusion, in which subjects develop a sense of embodiment with a fake hand when subjected to congruent visual and somatosensory feedback. We discuss clinical benefits that could arise from the confluence of known concepts such as MVF and the rubber hand illusion, and new technologies such as neural interfaces for sensory feedback and highly sensorized robot hand testbeds, such as the “BairClaw” presented here. Our multi-articulating, anthropomorphic robot testbed can be used to study proprioceptive and tactile sensory stimuli during physical finger-object interactions. Conceived for artificial grasp, manipulation, and haptic exploration, the BairClaw could also be used for future studies on the neurorehabilitation of somatosensory disorders due to upper limb impairment or loss. A remote actuation system enables the modular control of tendon-driven hands. The artificial proprioception system enables direct measurement of joint angles and tendon tensions while temperature, vibration, and skin deformation are provided by a multimodal tactile sensor. The provision of multimodal sensory feedback that is spatiotemporally consistent with commanded actions could lead to benefits such as reduced phantom limb pain, and increased prosthesis use due to improved functionality and reduced cognitive burden. (shrink)

The goals of vascular composite allotransplantation for hand are to maximize functional status and psychosocial wellbeing and to improve quality of life. Candidates are carefully vetted by transplant programs through an extensive evaluation process to exclude those patients with contraindications and to select those that are most likely to attain functional or quality of life benefit from transplant. Patient choice for any treatment, however, requires that candidates be able to understand the risks, benefits, and alternatives before choosing to proceed. This (...) study aimed to understand patients’ knowledge and perceptions about treatment options for hand loss, including hand transplant. This study will be used to inform a standardized education approach and develop conversation aids for use by clinicians and patients throughout the treatment decision process. Ten individuals who had experienced hand amputation or had congenital limb loss were interviewed to better understand previous and current decisions about treatment, experiences in adjusting to their treatment, and perceptions about hand VCA. From this qualitative interview data, four findings emerged: knowledge and education around VCA as a treatment option; adaptation of individuals with limb loss; fear of risk associated with transplantation; issues of aging and overuse injuries to existing limbs. Results suggests that there is opportunity for expanding education about all treatment options for patients with new loss, long-term loss, and congenital limb loss. Establishing a baseline of knowledge about all options–prosthetics, rehabilitative strategies, and VCA—can help patients evaluate their values and goals of treatment. Issues associated with aging, including overuse and injury, and adaptability over the life course should be included in considerations about treatment choices. Data indicate the need for routinely assessing patient preferences about treatment choice so patients can plan for their future as they adapt and age and as technology for treatments change. To assure that thorough information is provided for current and future decision-making, education about treatment choices and selection procedures for VCA should be standardized. (shrink)

Over recent years, brain-computer interface (BCI) has emerged as an alternative communication system between the human brain and an output device. Deciphered intents, after detecting electrical signals from the human scalp, are translated into control commands used to operate external devices, computer displays and virtual objects in the real-time. BCI provides an augmentative communication by creating a muscle-free channel between the brain and the output devices, primarily for subjects having neuromotor disorders, or trauma to nervous system, notably spinal cord injuries (...) (SCI), and subjects with unaffected sensorimotor functions but disarticulated or amputated residual limbs. This review identifies the potentials of electroencephalography (EEG) based BCI applications for locomotion and mobility rehabilitation. Patients could benefit from its advancements such as wearable lower-limb (LL) exoskeletons, orthosis, prosthesis, wheelchairs, and assistive-robot devices. The EEG communication signals employed by the aforementioned applications that also provide feasibility for future development in the field are sensorimotor rhythms (SMR), event-related potentials (ERP) and visual evoked potentials (VEP). The review is an effort to progress the development of user’s mental task related to LL for BCI reliability and confidence measures. As a novel contribution, the reviewed BCI control paradigms for wearable LL and assistive-robots are presented by a general control framework fitting in hierarchical layers. It reflects informatic interactions, between the user, the BCI operator, the shared controller, the robotic device and the environment. Each sub layer of the BCI operator is discussed in detail, highlighting the feature extraction, classification and execution methods employed by the various systems. All applications’ key features and their interaction with the environment are reviewed for the EEG-based activity mode recognition, and presented in form of a table. It is suggested to structure EEG-BCI controlled LL assistive devices within the presented framework, for future generation of intent-basedmultifunctional controllers. Despite the development of controllers, for BCI-based wearable or assistive devices that can seamlessly integrate user intent, practical challenges associated with such systems exist and have been discerned, which can be constructive for future developments in the field. (shrink)

While dreaming amputees often experience a normal body image and the phantom limb may not be present. However, dreaming experiences in amputees have mainly been collected by questionnaires. We analysed the dream reports of amputated patients with phantom limb collected after awakening from REM sleep during overnight videopolysomnography . Six amputated patients underwent overnight VPSG study. Patients were awakened during REM sleep and asked to report their dreams. Three patients were able to deliver an account of a dream. (...) In all dreaming recalls, patients reported that the amputated limbs were intact and completely functional and they no longer experienced phantom limb sensations. Phantom limb experiences, that during wake result from a conflict between a pre-existing body scheme and the sensory information on the missing limb, were suppressed during sleep in our patients in favour of the image of an intact body accessed during dream. (shrink)

Patients with the controversial diagnosis of body integrity identity disorder report an emotional discomfort with having a body part that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. Although patient requests to receive the best available treatment are generally respected, BIID demands for amputation, at present, are not. However, what little has been (...) said in the ethics literature on the subject tends to favour doing so in cases of BIID. The general argument is that BIID demands should be respected, first, because of the importance that is already placed on respecting autonomy in medical decision-making contexts and second, because of the potential harm of not providing amputation coupled with the fact that no alternative means of relieving suffering exists. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. This paper criticises the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation. (shrink)

The concept of positional information is applied to a large amount of data obtained previously in experiments on developing and regenerating amphibian limbs. Only the proximo-distal axis of the limb is considered. It is shown that the concept provides a simple, unitary hypothesis which satisfactorily accounts for the experimental data, and may moreover suggest meaningful new approaches. It is suggested that the boundaries of the bipolar limb system lie in the girdle skeleton and at the distal end of (...) the limb, respectively, and that it is the apical epidermis of the growing or regenerating limb which defines the distal boundary conditions. A relatively stable gradient of positional information is assumed to be set up in the mesoderm . It is further shown that the differentiated limb retains its positional information and upon amputation imparts it to the base of the blastema. To explain an apparent discrepancy between the developing and the regenerating limb, it is proposed that dedifferentiation of mesodermal limb tissues upon amputation entails a change of positional value in the mesenchyme. Consequently, the amputation level does not once and for all specify the positional value at the proximal end of a mass of blastemal mesenchyme, particularly when the mesenchyme is transplanted in such a way that its linear size decreases or increases. (shrink)

Sufferers of body integrity identity disorder (BIID) experience a severe, non-delusional mismatch between their physical body and their internalised bodily image. For some, healthy limb amputation is the only alleviation for their significant suffering. Those who achieved an amputation, either self-inflicted or via surgery, often describe the procedure as resulting in relief. However, in England, surgeons who provide ‘elective amputations’ could face prosecution for causing grievous bodily harm (GBH) under section 18 of the Offences Against the Persons (...) Act 1861. Whether such a therapeutic intervention should be classified as GBH depends on the presence of harm, as, without harm, it is hard to argue that GBH has occurred. However, there is no agreed-upon definition of what constitutes harm. Such a definitional absence then begs the question, what is harm? It is this question which this article addresses, using the provision of healthy limb amputation in cases of BIID as an example. Drawing on metaphysics, this article will seek to clarify three separate contemporary models of harm: the counter-temporal, the counterfactual, and the non-comparative. Each model will be applied to the scenario of a surgeon carrying out a BIID-induced, therapeutic, healthy limb amputation, and in each, how harm may, or may not, be understood to have been caused will be explored. It concludes that an unexamined conception of harm is ill-equipped for employment in suspected cases of GBH when it is unclear whether harm has been caused and that a better-informed understanding of harm is required in cases where there is potential disagreement, be that in instances of BIID or a myriad of other borderline scenarios. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative (...) biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative (...) biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative (...) biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative (...) biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

Opponents of the provision of therapeutic, healthy limb amputation in Body Integrity Identity Disorder cases argue that such surgeries stand in contrast to the goal of medical practice – that of health restoration and maintenance. This paper refutes such a conclusion via an appeal to the nuanced and reflective model of health proposed by Georges Canguilhem. The paper examines the conceptual entanglement of the statistically common with the normatively desirable, arguing that a healthy body can take multiple forms, (...) including that of an amputee, provided that such a form enables the continuing ability to initiate new norms of existence. It concludes that the practice of healthy limb amputation in cases of Body Integrity Identity Disorder is not only compatible with the goal of medicine but is potentially the only method of achieving this goal in the face of a complex and often mischaracterized disorder. (shrink)

A 72-year-old widowed woman known to have an organic brain syndrome was hospitalised owing to gangrene of her lower limbs. The gangrene had been caused by an adduction contracture of her hip resulting in pressure on the medial surface of her left leg. In addition she had pressure sores over both trochanters and the sacrum. The smell of putrefication could be sensed from a distance and on examination large white worms could be seen slithering in the decomposing tissue. The patient (...) was pyrexial, oblivious of her surroundings, and without pain. Surgery--limb amputations--would not restore the patient to a cognitive state nor improve here quality of life, but abstinence posed an inherent threat of sepsis, and revulsion to the attendants. The sacral pressure sore was so large that surgical closure was impossible. The question of surgical intervention is discussed. (shrink)

Body identity integrity disorder is experienced by a small percentage of the population, whose idea of how they should look does not match their actual physical form. The most common manifestation of BIID is the desire to have a specific limb amputated. In a small number of cases, the desire is not for the removal of a limb, but to be blind or paralyzed. There has been a lot of discussion regarding the possible physiological, neurological, or psychological etiologies (...) of BIID. This paper examines the ethical implications of the different approaches to help those with BIID. These approaches and the dilemma that doctors face in cases of BIID are the subject of the final section, which offers some tentative ethical conclusions regarding this disturbing disorder. (shrink)

This abstract presents a novel brain-computer interface (BCI) framework to control a prosthetic leg, for the rehabilitation of patients suffering from locomotive disorders, using functional near-infrared spectroscopy (fNIRS). fNIRS signals corresponding to walking intention and rest are used to initiate and stop the gait cycle and a nonlinear proportional derivative computed torque controller (PD-CTC) with gravity compensation is used to control torques of hip and knee joints for minimization of position error. The brain signals of walking intention and rest tasks (...) are acquired from primary motor cortex in the left hemisphere for nine subjects. After acquiring brain signals, in order to remove motion artifacts and physiological noises, the performance of six different filters i.e. Kalman, Wiener, Gaussian, hemodynamic response filter (hrf), Band-pass and finite impulse response, is evaluated. Afterwards, six different features are extracted from oxygenated hemoglobin signals and their different combinations were used for classification. The classification performance of five different classifiers i.e. artificial neural network, quadratic discriminant analysis, linear discriminant analysis (LDA), Naïve Bayes and support vector machine (SVM) is used. The classification accuracies obtained from SVM using hrf filter are significantly higher (p < 0.005) than the other combinations of classifier and filters. These accuracies are 77.5%, 72.5%, 68.3%, 74.2%, 73.3%, 80.8%, 65%, 76.7%, and 86.7% for all nine subjects. The control commands generated using classifier initiate and stop the gait cycle of the prosthetic leg whose knee and hip torques are controlled using PD-CTC to minimize position error. The proposed scheme can be effectively used for neurofeedback training and rehabilitation of lower limb amputation of paralyzed patients. (shrink)

In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there (...) is a growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients’ knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption. (shrink)

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. (...) hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics. (shrink)

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. (...) hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics. (shrink)

Previous studies on body ownership illusions have shown that under certain multimodal conditions, healthy people can experience artificial body-parts as if they were part of their own body, with direct physiological consequences for the real limb that gets ‘substituted’. In this study we wanted to assess (a) whether healthy people can experience ‘missing’ a body-part through illusory ownership of an amputated virtual body, and (b) whether this would cause corticospinal excitability changes in muscles associated with the ‘missing’ body-part. Forty (...) right-handed participants saw a virtual body from a first person perspective but for half of them the virtual body was missing a part of its right arm. Single pulse transcranial magnetic stimulation was applied before and after the experiment to left and right motor cortices. Motor evoked potentials (MEPs) were recorded from the first dorsal interosseous (FDI) and the extensor digitorum communis (EDC) of each hand. We found that the stronger the illusion of amputation and arm ownership, the more the reduction of MEP amplitudes of the EDC muscle for the contralateral sensorimotor cortex. In contrast, no association was found for the EDC amplitudes in the ipsilateral cortex and for the FDI amplitudes in both contralateral and ipsilateral cortices. Our study provides evidence that a short-term illusory perception of missing a body-part can trigger inhibitory effects on corticospinal pathways and importantly in the absence of any limb deafferentation or disuse. (shrink)

In 1977 John Money published the first modern case histories of what he called ‘apotemnophilia’, literally meaning ‘amputation love’ [Money et al., The Journal of Sex Research, 13(2):115–12523, 1977], thus from its inception as a clinically authorized phenomenon, the desire for the amputation of a healthy limb or limbs was constituted as a sexual perversion conceptually related to other so-called paraphilias. This paper engages with sex-based accounts of amputation-related desires and practices, not in order to substantiate (...) the paraphilic model, but rather, because the conception of these (no doubt) heterogeneous desires and practices as symptoms of a paraphilic condition (or conditions) highlights some interesting cultural assumptions about ‘disability’ and ‘normalcy’, their seemingly inherent (un)desirability, and their relation to sexuality. In critically interrogating the socio-political conditions that structure particular desires and practices such that they are lived as improper, distressing and/or disabling, the paper constitutes an exercise in what Margrit Shildrick [Beyond the body of bioethics: Challenging the conventions. In M. Shildrick and R. Mykitiuk (Eds.), Ethics of the body: Postconventional challenges (pp. 1–26). New York: MIT Press, 2005] refers to as “postconventional ethics”. (shrink)

Analogies of grief to amputation and phantom limb are common in memoirs and literary accounts of loss.1 Consider, for example, C. S. Lewis's response to the suggestion that he will "get over" the loss of his wife, in A Grief Observed: Getting over it so soon? But the words are ambiguous. To say the patient is getting over it after an operation for appendicitis is one thing; after he's had his leg off it is quite another. … There (...) will be hardly any moment when he forgets it. … His whole way of life will be changed. … At present I am learning to get about on crutches. Perhaps I shall presently be given a wooden leg. But I shall never be a biped again.2 As Matthew Ratcliffe has argued, though such references may... (shrink)

The sense of embodiment is vital for self recognition. An examination of anosognosia for hemiplegia—the inability to recognise that one is paralysed down one side of one’s body—suggests the existence of ‘online’ and ‘offline’ representations of the body. Online representations of the body are representations of the body as it is currently, are newly constructed moment by moment and are directly “plugged into” current perception of the body. In contrast, offline representations of the body are representations of what the body (...) is usually like, are relatively stable and are constructed from online representations. This distinction is supported by an analysis of phantom limb—the feeling that an amputated limb is still present—phenomena. Initially it seems that the sense of embodiment may arise from either of these types of representation; however, an integrated representation of the body seems to be required. It is suggested information from vision and emotions is involved in generating these representations. A lack of access to online representations of the body does not necessarily lead to a loss in the sense of embodiment. An integrated offline representation of the body could account for the sense of embodiment and perform the functions attributed to this sense. (shrink)

Body Integrity Identity Disorder (BIID) is a very rare condition describing those with an intense desire or need to move from a state of ability to relative impairment, typically through the amputation of one or more limbs. In this paper, I draw upon research in critical disability studies and philosophy of disability to critique arguments based upon the principle of nonmaleficence against such surgery. I demonstrate how the action-relative concept of harm in such arguments relies upon suspect notions of (...) biological and statistical normality, and I contend that each fail to provide normative guidance. I then propose a critical theory of harm, one marked by substantive engagement with both empirical and reflective inquiry across the sciences, social sciences, and humanities. I conclude by discussing the implications of this theory and how it might enrich ongoing debates in bioethics, philosophy of disability, and the health humanities. (shrink)