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.

A second is the prospect of doing something we consider monstrous to prevent something even more monstrous. The obvious precedent here is abortion. One of the more convincing arguments advanced for legalised abortion - even for those passionately against it in general - was harm minimisation: women were going to have terminations anyway, and it would be far better if they not run the risk of dying at the hands of a backyard abortionist.

There has been at least one death at the hands of a backyard amputationist, and there is no way of knowing if other apotemnophiles have died attempting somehow to do it unaided. Given the means to which many have already resorted, it is unlikely there have been no fatalities. And such people are harming, if anyone, only themselves.

A third reason is that while the treatment inspires involuntary shudders, it could be seen as merely a logical, if extreme, extension of, for example, a nose job. We accept the one, so why not the other? For the (presumably) very few who would want such surgery, it might be considered an act of mercy. And I doubt this particular operation would be the beginning of a slippery slope.

If, purely for argument’s sake, we concede voluntary amputation might be acceptable, what should be done with another from the catalogue of unusual physical modifications - trepanation (cutting a hole in your skull)? Adherents claim this gives them a permanently higher level of spiritual vision, through increased blood volume in the capillaries of the brain. They're also willing to engage in do-it-yourself surgery when they cannot get professional medical assistance. In fact, it is possible to buy a video guide to self-trepanation.

This is, if anything, even more problematic than voluntary amputation. The claim that drilling a hole in your skull can get you to a permanently higher state of consciousness is all very well. But it is just the sort of thing that could attract someone with severe depression, or a more florid mental disorder. It also sounds like the kind of state a great many people will take a great many drugs to attempt to reach. How many of those willing to risk addiction and death for a living nirvana might think a hole in the head worth chancing? It can be done: all you need is an electric drill, and a hell of a lot of luck.

What if, unlikely though it may seem, trepanation lived up to the claims made for it? Imagine a groundswell of support building for the fashion, little by little. Where would this be most visible? Almost certainly on the Internet.

The way the Internet is being used raises, for the liberal, some truly disturbing questions. Have we unwittingly produced an effective device for disseminating mania? (A lot more worrying, I would have thought, than most varieties of pornography.) Are we feeding the desire for self-harm by letting those who have it in an extreme form express themselves?

American bioethicist Carl Elliot suggests this might be exactly what is happening. Writing on the voluntary amputation phenomenon, Elliot describes the interest shown on the Internet as “enough to support a minor industry. One discussion list has over 1,400 subscribers.”

Elliot describes his interviews with apotemnophiles, for whom the ’net has proved a boon in a lot more ways than one. According to several of his contacts, it provides “instant validation”. Along with instructions on how to lose your legs. But the blessing can be mixed:

To discover that she was not alone was wonderful - but it also meant that a desire she had managed to push to the back of her mind now shoved its way to the front again. It occupied her conscious thoughts in a way that was uncomfortable.

This indicates the danger inherent in exposing some things to the light. Elliot floats the idea of “semantic contagion”, recounting a conversation with a professor of psychology who had been appointed to a censorship committee. Certain rather alarming sexual acts, the psychologist said, would never occur to most people in an entire lifetime of thinking about sex if they hadn’t seen them pictured. In his opinion people were better off never having conceptualised such acts.

Illiberal this opinion may be, but certainly not inarguable. The idea of having one's legs amputated might never even enter the minds of some people until it is suggested to them. Yet once suggested, and paired with imagery a person's past may have primed him or her to appreciate, that act becomes possible. It has become thinkable in a way it had not been before. I think about it, therefore I can (and should) do it.

Websites promoting these non-mainstream practices present a major dilemma for the liberal conscience. It seems abundantly clear they are promoting self-harm. One of the cornerstones of classic liberalism is that people should not be prevented from doing harmful things to themselves, so long as others are not hurt. But there are at least two questions here. The first is about empathy. Do those who deliberately maim themselves have any idea what it is like to have no choice about being, for instance, armless or not? How does the intended nirvana from trepanning compare with an intellectual disability conferred at birth? Do these people know anything about unwanted human suffering?

The second question is more difficult. Is proselytising by the converted which encourages the vulnerable to irreparably damage themselves harmful in itself - that is, precisely because it is likely to cause harm to others? While it is very tempting to think it is, along that path lies danger.

It may seem a simple matter to distinguish missionary activity on behalf of voluntary amputation from religious evangelising, for example. But what exactly is the dividing line between bliss and serenity via a hole in the head, and the same through Hare Krishna? Would a devoutly religious parent prefer her impressionable child to lose his leg or his immortal soul? The obvious answer is neither, but can we legitimately prevent people advocating a temporal harm, while continuing to allow others to try their hardest to inflict what is arguably an eternal one?

Perhaps the test case might be sites containing DIY advice. Unlike those merely glorifying apotemnophilia, drilling a hole in your head, or just plain making yourself look ridiculous, it involves something beyond incitement. Obviously it is a test case that tries the liberal conscience hard, especially when we try to distinguish between exploiting the vulnerable and providing help to those in need. And even more so when we consider the freedom of expression given other extreme sites, such as Westboro Baptist Church, or Aryan Nations.

So do we let the amputee and trepanation sites stay, while banning “how to” sites? It can be done. It’s a hard call, but when you’ve had the horror of seeing some of this stuff, Michael Jackson’s face begins to look quite attractive.