Background to the Illness: In the Emergency Ward pp. 369-376
Authors: (Virginie Vautier, Toulon, France)
Abstract: 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.