Don't try this at home: extreme body make-overs

Michael Jackson is not alone. His is merely the most famous case of excessive plastic surgery. One American woman is well on the way to realising her ambition: becoming a life-size facsimile of a Barbie doll. Another, known as “the Bride of Wildenstein” to the gossip press, had facial surgery to emphasise her cat-like features. Then she had more, followed by more. Her skin is stretched so taut that her face is both grotesque and motionless. She can no longer close her eyes.

Repellent and risible though we might think such behaviour, it would be most illiberal to think she should be prevented from disfiguring herself if she so wishes. We may wonder about surgeons who perform such operations; but, in general, a person’s right to self-disfigurement is just that.

Other people want to remake themselves in other ways. Gender reassignment surgery is rather more contentious than plastic surgery, but broadly, if squeamishly, is accepted. I suspect most people, if they think about transgender surgery, tend to apply a variant of the Golden Rule, asking what they would want if they believed themselves trapped inside the wrong body. To most people, such a thing is all but incomprehensible, yet not quite beyond our capacity to imagine. Thus we are inclined towards compassion, sometimes mixed with horror and disgust.

But what of those who wish to change their bodies in other ways? Not with tattooing and exotic piercings, although this can involve far more radical modifications than most people realise, (EXTREME GRAPHICS WARNING) but truly arcane physical transformations.

Excessive facial surgery and gender reassignment have been categorised by some psychiatrists as a form of Body Dysmorphic Disorder (BBD): a syndrome in which a person becomes obsessed with the ugliness of an aspect of their appearance - usually invisible to others - and will go to extraordinary and bizarre lengths to change it. Another, less common form is apotemnophilia: the desire to be an amputee. It is rare, but perhaps not rare enough. And it raises serious questions of medical ethics.

In January 2000, Scottish surgeon Robert Smith removed healthy legs from two of his patients. This was not a tragic surgical error: Smith described it as “the most satisfying operation I have ever performed … I have no doubt that what I was doing was the correct thing for those patients”.

This may seem a drastic form of patient care, but let us consider why Smith might have thought it right. One of the few psychiatrists with experience of apotemnophiles says:

When a person wanting an amputation comes to a psychiatrist, the options are fairly limited … You could give them drugs. They're not [depressed or] psychotic so that's not going to be any use. Counselling, psychotherapy, help them focus on the positive things in life and get away and forget wanting to have an amputation.

Unfortunately, talking treatment doesn't make a scrap of difference. You can talk till the cows come home. It doesn't make any difference. They're still going to want their amputation.

Not just want it, but be determined to get it. The most compelling argument for performing such surgery is the prevention of far greater harm. The cost of not amputating a healthy limb may be greater than mere unhappiness.

In 1998 a 79-year-old man travelled to Mexico and paid $10,000 for a black-market leg amputation. He died of gangrene in a motel. In 1999, a mentally competent man in Milwaukee severed his arm with a homemade guillotine, and threatened to sever it again if surgeons re-attached it. A Californian woman, refused a hospital amputation, tied her legs with tourniquets and packed them in ice, hoping gangrene would set in. She passed out and eventually gave up. Afterwards, she said she would probably have to lie under a train or blow her legs off with a shotgun.

Though rare, these cases are problematic. One reason is that we have trouble understanding why anyone would feel “incomplete” because they don’t have a missing limb. The mental leap necessary to comprehend wholeness as a disability is a hard one to make.