A strange case and a doctor’s “right of conscience”
Robert says that he first became aware of his “disability” at age 10. It became a disability “that would rule [his] life.” It robbed the enthusiasm of his youth and kept him from enjoying relationships, male and female, during that time of life when he should have been playing sports, interacting with peers in common pursuits and interests and, yes, learning about the opposite sex and what it’s like to have a girlfriend and the thrill of “puppy love” that most of us fondly remember all our lives. (Robert tells his entire story here.)
Robert had a secret. That secret and the effects of keeping it led to years of depression and anxiety for which he sought help from multiple psychiatrists, all without relief. He attempted suicide on several occasions. He writes, “ I attempted suicide as the only way to peace. At twenty-five I was a failure – I couldn’t even get ‘Elementary Suicide’ right.”
Eventually Robert married and began to raise a family and he reports that during those years “All was sweetness and light. It seemed that love could cure all, and that my handicap was but a figment of my imagination, a long lost memory. This was life, and for the first time ever, things looked rosy and never better.”
But at age forty-one in what Robert believes was the result of a mid-life crisis the disability re-emerged with new ferocity; “Something inside me collapsed, suddenly my handicap became all consuming. Nothing else mattered. It was as though I had hit a brick wall, and life could not go on until I sorted out my disability; overcame my handicap. It had become the handicap from hell. I lied to my wife, I lied to my employer and took the day off to cure my handicap.”
On Thursday 21st. of June 1984 Robert left his home with a plan and all the necessary supplies to carry it out. He went to his mother’s vacant apartment and applied dry ice to the whole of his left leg from mid-thigh to foot. He endured the pain of this procedure in what he describes as “unbridled ecstasy.” At long last he knew he would soon be free from the debilitating condition that had nearly ruined his life. When he was satisfied that the leg was sufficiently damaged by frostbite he called his wife to pick him up and get him to the hospital.
Robert writes of the hospital experience: “After preliminaries and discussion about my obviously necessary amputation, I was taken to [the operating room]. Hours later, I was taken aback to waken and find my leg still in place. My initial distress was eased when it became apparent that after exploratory work, they must have thought they could save my knee, with the easier option later for a below-knee prosthesis. But I was adamant: my leg was to be amputated halfway up the thigh, so that there would be no need for plastic surgery or any other mucking about to save more of my leg than was the easiest, and desired, option.
“Next time I woke, it was as if in heaven. The leg I had despised and desired to be rid of since a small child, was gone. I didn’t care where, just so long as I had my newly bandaged stump to see me through the rest of my days. Gone in that simple operation was years of depression and sadness, gone any further thoughts of suicide, gone the hatred of myself and my inadequacies. It was the start of the rest of my life, and I was to start it the way I always knew it was meant to be.”
Robert suffers from a little-known psychiatric disorder called Body Integrity Identity Disorder or BIID. This is a condition where the individual desires the removal of a perfectly healthy limb, usually one or both legs but sometimes arms. The etiology of this condition is unclear except that those suffering it seem to have no other identifiable psychological disorder. But the desire to be rid of the unwanted limb can be all-consuming.
Suffers of BIID have historically found little help from medical professionals. Doctors are loathe to amputate normal limbs simply at the patient’s request. Consequently, many resort to self-mutilation so as to force that which they so ardently desire.
Robert explains his decision to force an amputation of a perfectly good leg thus: “It is a matter of balance. Think of it simply as elective surgery. Many surgical procedures can be had electively, and for a mere whim rather than for any surgical or psychological necessity. Almost anything goes under the label of cosmetic, be it reshaping body, breasts, nose, face, genitals etc. In some cases, and after lengthy psychological assessment, one can have gender reassignment surgery to make a man look like a woman or vice versa…But to have a limb removed to become a real amputee – not pretend or surgically simulated – to remove a desire that has become a debilitating handicap, is just not available. Maybe if I had wanted to be a one-legged woman, I may have been able to get a package deal.”
Robert was fitted with a prosthesis and this has caused some to wonder “’but doesn’t your use of a prosthesis negate your intent?’ Simply, ‘No.’ The prosthesis is only a mobility aid, and when I remove it, there is my stump, my security blanket. After a journey of forty years, visiting places of darkness and deep despair, there is peace and satisfaction in fondling the amputated remnant of my leg.”
All of this came to mind when reading an earlier post on Dakota Voice “Lesbians, Christian Fertility Doctors Settle Out of Court.” In the comments Dr. Rutledge argues that the doctors that refused to do in vitro fertilization for a lesbian couple acted unethically and that such refusal constitutes patient abandonment. He may have a case depending upon the actual facts of the case as I explained in a response to Dr. Rutledge’s comment.
My point here is to ask whether you, the reader, can see the dilemma posed for physicians when asked to do something that they feel is immoral or unethical. Can you see that we must allow physicians the “right of conscience” when we are asked by patients to do something that we cannot be a part of out of deeply held moral or religious convictions?
In the situation of BIID neurophysiologists tell us that the disorder exists in the patient’s perception of self. Sufferers do not think of the offending extremity as “self” and want beyond any rationality to be free of the parasitic appendage. Perhaps so, but I could not bring myself to amputate a fully functional limb simply on request and would rather forfeit my profession than comply with such a request. To me, and many other physicians, abortion, genital mutilation and in vitro fertilization for a lesbian couple are similarly unconscionable.
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It's a sad day in America when doctors have to defend their right to do what's right according to their conscience. Since this is the case, we absolutely must insist on “conscience clause” legislation. I know the left will fight tooth and nail against this, because they are evil to the core. Who could ever have imagined that doctors would have to fight to keep from being forced to kill unborn babies?! So much for the Hippocratic Oath.
Another thing that won't make me popular with the left and many on the right is to remind everyone of the reality of demon possession. In my opinion, this fellow, Robert, is clearly infested with demons. As you read in the Bible, demon possession was commonplace and lumped together with physical illnesses when Jesus and the disciples were ministering to the masses, healing them and casting out demons. They understood its prevalence, but Satan has managed to bury the knowledge of this fact to most in our modern world. There is a plethora of modern, doctor-treated “illnesses” that I am convinced are nothing more than demon possession (they do not spare children, either). Of course, many people will be scandalized by this assertion, but I don't care. Look at the opportunity of the enemy to create “disorders” that are then misdiagnosed and “treated” with all manner of toxins prescribed by the doctors and laughed at by the demons, as both demons and “medicine” wreak havoc on the mind and body of the person. The huge amount of prescriptions written for amphetamine-type (Ritalin, etc.), anti-psychotic and other medicines that jack with serotonin and other brain chemicals and body processes… well, we have a prescription drug epidemic that's messing people up alongside a demon possession epidemic that almost no one is aware of.
How does the conscience clause fit in here? I'm sure this also takes the patience and wisdom of the saints, and there is no easy answer.
Okay, now I expect to get pummeled with people questioning my sanity.
Gina Miller
BIID is a rare and not well understood disorder, but it clearly is a psychiatric illness and I would question whether a physician refusing to amputate a limb with a patient with BIID is the same as a physician refusing to do abortions.In other words, are they both ” right of conscience ” issues.
I think there is no doubt that the physician who refuses to perform abortions or do sex change operations can and does so for moral, religious or 'right of conscience' reasons and that is their right. The one caveat is that the physician must be completely honest with the patient as I believe essentially all are with the rare, rare exception.
I believe a physician refusing to amputate a limb in someone with BIID is simply following what is known as the standard of medical practice. It is just practicing good medicine and accepted medicine.It is not a moral issue We are all taught that psychiatric illnesses are not treated with surgery.
I am frequently faced with a different dilemma that is less clear cut than BIID or a physician who doesn't do abortions (the former is the medical standard all doctors should follow and the later is the legitimate moral right of a physician). What 'right of conscience' do I have when a patient follows none of my advice. They don't take their insulin, eat all day long, don't take their other meds and on and on, until it even causes them premature death.
Do I have a ' right of conscience' or is it morally correct to tell them I can no longer treat them and tell they need to find someone else who might help them ? Or do I continue treating them knowing that in all likelihhod, no one else will change them either. I have chosen ,of course, to continue to help as much as I can knowing it will to be of no avail.But would it be morally wrong to tell them to go eslewhere?
I have a problem with plastic surgeons performing surgery on a patient whose problem is insecurity and poor self esteem and not a bump on the nose. The promises often made or implied that this will make them feel better, rarely come true.Unfortuneately, money frequently wins over morality.
If the day ever comes when a physician can't follow his or her 'right of conscience', then the whole of medicine will have lost it's soul.
Gina Have no intention of pummeling you as you are free to believe what you want. Would just like to remind you that Christians ( and others) were once 100% convinced that epilepsy was due to demon possession.We of course know now that it is caused by a irritative focus of nerves in the brain, similiar to irritative nerve fibers in the heart that cause heart irregularities.. Just something to ponder.
Thank you, Dr. Rutledge.
Another thing to ponder: Do you think demons don't have the ability to cause an “irritative focus of nerves” and effect other physical symptoms? Autism, epilepsy and various psychiatric “disorders” in a person's body can easily be brought about by a demonic presence in a person's spirit. Examples of this are prevalent in the Bible, mostly the New Testament.
Just a thought…
Gina
One thing I do find 'demonic', if you will, is the terrible abusive treatment of young children with so called illnesses like ADD an ADHD. We are treating the parents and teachers, not the kids, in 99.99% of the cases. A real American tragedy in my view.
Ah, there's a point.
However, doctors have been giving at least fifteen to twenty years worth of kids Adderall, Ritalin, and various SSRIs. We are seeing the results in young people, including soldiers, who are now suseptible to suicidal and homicidal tendencies. These kids are hooked on these amphetamine-like drugs.
Are you familiar with Dr. Peter Breggin (http://breggin.com/)? I admit his teachings ring very true with me.
Gina
“What 'right of conscience' do I have when a patient follows none of my advice. They don't take their insulin, eat all day long, don't take their other meds and on and on, until it even causes them premature death.”
From what I understand, many patients don't adhere to their regimens because they are in denial and constantly having to take pills, test their blood, and watch what they eat are depressingly frequent reminders that they are “sick.”
I would think that any doctor with a conscience who notices symptoms of denial in a patient would recommend counseling or a support group, not sit idly by and watch them die or tell them to go somewhere else.
It is apparent in your comment that you are a compassionate and thoughtful student, but very naive. Of course patients are counseled and instructed on their disease but many decide that they would rather live a lifestyle of excess and depend on their doctor to bail them out when they get in trouble.
Changing people's behavior is very difficult. Counseling and therapy have a dismal record of actually helping people to do so. What does help sometimes is reality. When patients are forced to accept that they alone are responsible for their behavior they often make the right choices.
I think it is unethical to continue to see a patient that habitually refuses to follow the regimen laid out by his physician. In such cases there clearly is no therapeutic relationship and the patient should be asked to find another doctor in whom they have greater confidence and respect. In doing so some patients will come to realize that the problem is one in which they alone have the power to change.
Additionally, I believe that as a mortal human I have only so much energy, talent and compassion to give my patients and when some patients use up much more that their share to no benefit they are taking from my other patients who actually could benefit from my ministrations.
(I might add that I am a patient that has to take eight different meds a day and follow fairly strict dietary and exercise regimens ordered by my doctor.)
You and I are in agreement on most aspects of this issue, but I would argue that the distinction between physical and psychiatric is arbitrary. The 19 year old woman that wants fuller lips and a boob job is likely suffering a psychological problem, yet they go under the knife with disturbing regularity. Need I bring up sex change operations? The promiscuous woman that has no regard for herself or for the life that she conceives seeks an abortion to rid herself of the consequences of her behavior. Does that not represent a psychological problem?
The lines are not clear unless one has a firm moral grounding, in which case a doctor will come into conflict with society on a regular basis. From what I know of you through our many exchanges, I think you'll agree, Dr. Rutledge.
dr theo I would have to agree that a promiscuous women who has no regard for herself or for life in general and shows this disregard by engaging in frequent sex, gets pregnant and then resorts to abortion to negate her actions, does have a psychologic or emotional problem.
I am not sure it is correct to say that every woman who has an abortion has a psychologic problem. My own adopted daughter's biologic mother got pregnant at age 15 and delivered our daughter at age 16. We have had the good fortune of getting to know 'Sara', now age 42, who is happily married, with two children and is an active Christian.
I have had some very honest talks with her and she says she was undecided whether to abort or deliver at age 15, but thankfully made the choice she did. The pregnancy had such an enormous effect on her, that it affected her views on premarital sex. She also says she wasn't promiscuous at 15, but made mistakes.
Irregardless, had she chosen abortion, would this have been a psychologic problem or the immature, undeveloped , unable to think long term mind of a fifteen year old who maybe even received bad advice from peers. So, while I remain anti-abortion, I would hesitate to say that all females who have abortions have psychologic problems
Your point is well-taken, but additionally reinforces the point that I made that the distinction is arbitrary.
Thank God that Sara made the right decision for you, your daughter and herself.
I recently had a leg amputed by choice, because of BIID. I fought it for a long time without result. I feel I have a right to live part of my life happily. I feel better now than ever before in my life.
I believe it is wrong to force a physician to do anything against his (or her) beliefs. It is also wrong to prohibit him from doing what he believes is best for the patient.
This applies to abortion as well to BIID. I personally believe that abortion is much more morally problematical than amputation for BIID.
It's interesting that the “spiritual” component of treatment is so casually dismissed on this of all sites…
I pursued psychological, spiritual, and pharmacological treatment for BIID for years. They all had one thing in common: nothing made it easier to live with.
A Christian counselor considered it as a satanic attack. Trying to treat it that way did not help either. I think the satanic attack model of BIID is plausible, but the attack was in early childhood and the damage was done at that time.
Dan Glad you are doing well and there is evidence that BIID is completely a physical defect in the 'mapping' area of the brain. The one thing I have learned in medicine is the more I think I am right about something, the more likely I am wrong about it. Guess we all need to keep an open mind.The last thing a physican should do is to assume that something is psychologic or due to a fallen world and refuse to alter from that path.
“The last thing a physican should do is to assume that something is psychologic or due to a fallen world and refuse to alter from that path.”
That sounds a little like moral relativism, Dr. Rutledge. I agree that an open mind is wise in some cases, but having a firm moral grounding is an ethical imperative when we are given the responsibility of doing the right thing for patients. The claim of an open mind can be carried to absurd lengths once we surrender our judgement to social expedience. Many physicians did just that in the name of eugenics not so long ago.
dr theo Believe me, I am no Jean-Paul Sartre. Was trying to communicate that too much rigidity( or absolute refusal to alter from) in any methodological approach, could lead to harm.
I am not sure BIID is a completely a physical defect in the mapping area of the brain, although I was one of the subjects in a study that seems to point in that direction. The bottom line for me is that it doesn't matter what the cause is. What counts is relief from suffering. I am fully aware that amputation of a limb for a problem in the brain is symptomatic treatment only. No other treatment has been known to help. The disability of amputation is very small compared to the torment of BIID.
Dan, I am glad that you found some relief from your anguish by finally freeing yourself from the obsessive desire to have a part of your body removed. I also appreciate the fact that you can see the situation from a physician's perspective. Robert actually makes a pretty good case that elective cosmetic surgeries are not far removed from his desire to have his leg amputated. I can see this point of view.
None the less, I ultimately must do what I think is the proper and moral thing when considering a treatment regimen for a patient. I have a responsibility to use my best judgement even when the issue is not absolutely clear.
I wish you the best, Dan. I hope you enjoy a happy and productive life.
Dan, I am glad that you found some relief from your anguish by finally freeing yourself from the obsessive desire to have a part of your body removed. I also appreciate the fact that you can see the situation from a physician's perspective. Robert actually makes a pretty good case that elective cosmetic surgeries are not far removed from his desire to have his leg amputated. I can see this point of view.
None the less, I ultimately must do what I think is the proper and moral thing when considering a treatment regimen for a patient. I have a responsibility to use my best judgement even when the issue is not absolutely clear.
I wish you the best, Dan. I hope you enjoy a happy and productive life.