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Background to the Illness: In the Emergency Ward pp. 369-376 $100.00
Authors:  (Virginie Vautier, Toulon, France)
An apparently psychically normal woman with no medical background comes to the
emergency room after willingly exposing her leg to severe burns. She clearly explains
that she wants to have both her legs amputated. She has never felt like those legs actually
belonged to her physical integrity even though she clearly perceives their being attached
to her body. This feeling appeared back when she was six years old. She has already
repeatedly consulted surgeons and submitted to various psychiatric evaluations that did
not discern any clear psychiatric pathology. The paradox here is that of a forty-year-old,
socially well-adapted mother asking surgeons to perform an abnormal procedure
consisting in removing a healthy part of her body. To grant such a demand is mostly
unorthodox nowadays even though some surgeons do publicly comply. Scientific
publications on the subject are still scarce since the phenomenon itself is rather recent.
However, a community of patients acknowledging the same challenge – which consists in
not accepting a healthy part of their body – and making the same demand – which is to
have such part of their body removed – has developed through the modern medium of the
Internet. Outside of the medical and academic field, a rather elaborate discourse on the
subject has thus appeared. A new and precise vocabulary was created so as to distinguish
between various clinical situations, involving patients diagnosed with a pathology now
known as “Body Identity Integrity Disorder”. The specific case of the aforementioned
patient resembles other Internet compiled cases and raises pathogenic, therapeutic,
medico-legal and ethical issues. From the pathogenic point of view, and after positively
ruling out any psychotic pathology, these clinical cases could be compared to the case of
transsexuals since they both involve acknowledging one's anatomical reality while failing
to identify with it. In such cases, despite the lack of clear medical explanations of such
confusion, therapeutic procedures have been established, eventually allowing surgical,
therefore mutilating, rectifications. From the therapeutic point of view, it may all be
about choosing the lesser of two evils: rather an operation by a competent surgeon than
death from self-inflicted injury. On the other hand, nothing proves that amputation is the
best answer and care; thus it seems important to offer a necessarily long psychological
undertaking previous to any surgical decision. From the medico-legal point of view, the
law states that one's body integrity can only be impaired in case of medical necessity,
which leads to ponder on the definition of such “necessity”, since its limits seem to vary
according to place, time and cultural values. At that point, the ethical debate finally rises.
It exceeds the simple issue of freedom and the right of any mentally healthy person to
dispose of one's body; it also involves a debate between practitioners, psychiatrists and
surgeons on the enigma of an up-to-now unheard-of symptom requiring enlightened
therapeutic answers. 

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Background to the Illness: In the Emergency Ward pp. 369-376