Monday, February 15, 2010

Doctors "Do No Harm?"

In order to ethically practice medicine physicians are required by law to take the Hippocratic Oath. But what happens when these ethical standards are questioned?

In last weeks discussion on transgender Dr. Johnson juxtaposed two medical conditions: Transexuality and Apotemnophilia. Both of the disorders are recognized as psychiatric disorders however only one of these disorders can seek “ethical” medical treatment.

As defined in the text, “Medical descriptions of transexuality throughout the last forty years have been preoccupied with a discourse of ‘the wrong body’ that describes transsexual embodiment in terms of an error of nature whereby gender identity and biological sex are not only discontinuous but catastrophically at odds. The technological availabilities of surgeries to reassign gender have made the option of gender transition available to those who understand themselves to be tragically and severely at odds with their bodies…” Those suffering from transsexualism identify with a physical sex that is different from their biological one. Sexual reassignment surgeries are available to alleviate the distress caused by this condition.

Apotemnophilia, a form of Body Integrity Identity Disorder (BIID), presents as a psychological mental disorder in which one feels the desire to amputate a healthy limb in order to feel whole. No surgeon will operate on a patient suffering from apotemnophilia, seeing it as an ethical controversy to amputate a healthy limb. Patients who suffer from the disease are instead offered psychotherapy or medication. The uses of crutches or wheelchairs are examples of methods patients may practice in order to pretend they’re an amputee. Extreme cases result in self-amputation.

Both disorders are psychological. They stem from discordance with ones biological identity. Why then is surgery only available to one condition? Those in support of amputation for patients suffering from apotemnophilia believe that medication and therapy are not sufficient treatment. Those against amputation argue the implications and irreversibility of amputating a healthy limb. Female to male transsexuals terminate their ability to conceive. Irreversibility is therefore a flawed argument.

The popular drama Nip/Tuck focuses on a plastic surgery practice with each episode surrounding a unique case. The third season’s seventh episode “Ben White” (link provided below) presents a successful white middle aged,(most common sufferers of BIID), architect. He suffers from BIID and seeks medical amputation from the plastic surgeons. In the opening scene Mr. White poses the question that, “you have built your practice on body modification and I am no different than somebody who’d come to you for a sex change, would you turn him away?” The surgeons refuse to perform the surgery and the episode climaxes in Mr. White shooting himself in the leg, consequently his leg must be amputated.


It seems unethical to allow for patients suffering from a recognized disorder to remain untreated. Self-amputation and methods that these patients resort to are unsafe and preventable. Yes, it is a healthy limb but it is also a healthy life. One must consider the implications in refusing treatment.

I asked my father who has been a practicing physician for over twenty five years his perspective on the issue...

One has to also consider the Hippocratic Oath that states clearly: First, do no harm. Changing one’s identity from male to female may not necessarilty result in harm. Sterilization is performed routinely in both men and women (tubal ligations and vasectomies). One can live a full life whether a male or female. Other cosmetic “changing” surgery seems ethical when no harm is done.

However, amputation of an otherwise healthy extremity would certainly be viewed by many physicians as “doing harm.” Physicians are not obligated to do something that they view as harmful. Having said that, a physician who recognizes apotemnophilia as a disease (like transexuality or alcoholism) can ethically treat the disorder. Of course, treatment should be conducted in the best interest of the patient. It would seem logical to first send the patient for counseling, therapy to make sure this is in their best interest from a health perspective. Patients undergoing sex-change surgeries should probably undergo similar counseling prior to making this decision. Other (psychological) factors are often in play that may be severely regretted at a later date.

A similar argument (for physicians) can be held for abortion. Abortions in many places are legal. Some physicians feel that abortions are the ultimate “harm” and therefore won’t perform them. Others believe differently.

At the end of the day it should be remembered that both patients and physicians have rights. Patients have the right to refuse care of a physician. This has been tested at extreme levels such as refusing to accept blood transfusions from a doctor knowing that the blood would save their life and refusing it means death. Physicians similarly have the right to refuse treatment to a patient. No one can “force” a physician to care for patients in ways that he ethically finds objectionable. Treatment of transexuality and apotemnophilia should be handled in an individual way as a contract between patients and their physician.

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