What to do?

The original article appears on Overground. Reproduced here for the ease of our readers.

[edit] What Ought We To Do About Wannabes?

by J.

Of the people who have an interest in amputees there are a few whose identification with amputees is so strong that they desire to become amputees themselves. The reasons for this desire are not well-understood. As there are such people we can ask the questions:

  1. Why should someone want to become an amputee?
  2. What must it be like to have such a desire?
  3. How should society respond to this desire?

The only other group of people who desire to make such radical changes in their bodies through surgery are the people who wish to change sex and it may shed light on the problem of determining the motives for such desires to compare both groups.

People seeking transsexual surgery commonly justify their desire by asserting that they feel inside that they belong to the sex they seek to emulate. The fact that the notion is commonly expressed should not necessarily lead one to infer that it truly reflects what the aspirant transsexual feels. It may be that this kind of statement is perceived by the aspirant transsexual as being an acceptable pretext for seeking what the majority would regard as mutilating surgery. One thing that is certain is that surgery will not achieve the ostensible goal of making the gender of the identity and the sex of the body coincide. All that surgery can do is to convert the exterior of the person to a simulacrum of the body of someone belonging to the opposite sex. Do people seeking to become transsexuals understand this? They must, because the reproductive functions cannot be transformed, indeed they cannot be retained at all by the transsexual person. So knowing that the desired transformation cannot be achieved, they must know that the reason offered for seeking the surgery must be just a pretext: men cannot become women and women cannot become men. You don't release the gender inside by modifying your outside to make it easier to impersonate a member of the other sex, and there's nothing you can do to change the intervening meat. So what is the real motivation? I suggest that it is not to change sex at all, but to become the beloved, to incorporate the beloved into oneself, that the desire is not to become a member of the other sex, but to become the androgyne, self and beloved, fused and inseparable.

One piece of evidence in support of this speculation is that transsexuals do not, on the whole, settle down in long-term relationships as apparently conventional couples, by which I mean transsexual female with a male partner, transsexual male with a female partner or transsexual male with transsexual female. This may in part be due to the fact that such couples are unable to produce children, and are unlikely to be acceptable as foster-parents. Also the aspects of femininity apparently most valued by transsexual females are not those associated with maternity or domesticity, and this suggests that aspirant transsexuals do not want, really, to become members of the opposite sex, they want to acquire only a sub-set of the attributes of the sex, the glamourous ones, the sexually provocative ones. Their behaviour indicates that their desires are quite different from the desires of conventional members of either sex. If they were really aspiring to be members of the desired sex their behaviour would be likely to correspond with that expected of the the most conventional members of the sex they wished to belong to. Of course the failure to achieve a conventional style of living might not be entirely due to the fault of the transsexual. It is possible, even likely, that a person involved with a transsexual would be somewhat unusual, and it may be that such people are not predisposed to get themselves involved in long-term relationships. It may also be true that social disapproval of relationships between transsexuals and members of the opposite sex may cause such relationships to be very unstable. The stereotype of the typical fate of the transsexual is of a period of unbridled promiscuity leading to prostitution, alcoholism or drug addiction, and early death. Does this mean that the desire to become a transsexual is a suicidal one? Not really. Suicide can be achieved quite easily without the expense, difficulty, and pain involved with transsexual surgery.

As a justification for seeking the amputation of a limb, the statement that one feels oneself to be an amputee inside, would be very unconvincing. How could you feel yourself to be an amputee inside when you aren't in fact an amputee? The answer is, of course, that you couldn't. The pretext would simply not be available to you. However there may be parallels between this desire and the interpretation of the motives for transsexual modification. The differences are profound and will be discussed first. The primary difference is that it is possible for anybody to become an amputee. The goal state is completely achievable in a way that the explicit goal state of the transsexual is not, because the transsexual can never become a real member of the desired sex but there is nothing in principle to prevent a person from becoming a real amputee. Perhaps there is some similarity in the desires of the aspirant amputee and the aspirant transsexual: perhaps he too wants to incorporate into himself some aspect of the ideal; but in his case, if he succeeds in his aspiration, then there is no incorporation, rather the transformation is complete, the original is completely lost, there is no underlying survivor, and he has in fact achieved the alteration ostensibly sought by the transsexual.

I believe that the core of these desires is the desire literally to incorporate, to embody, the beloved; but as well as this central need, other reasons are likely to add their their own force to the desire and amplify it. The social reasons may be determined by the person's relationships with others. For aspirant transsexuals the decision about gender may have been reinforced through observing that members of the sex they wish to join may wear different clothes, have different social relationships, from members of the sex to which they belong, interactions which are perhaps less aggressive, more nurturing than the interactions between the unmodified self and others. I find the sexual reasons unconvincing: It does not seem plausible to argue that the aspirant transsexual male, attracted to men, might feel the attraction less guilty after he had become a transsexual female: in our society homosexual behaviour is much more acceptable than transsexual bodily modification. Other reasons might play a part: the transsexual female joins a group of people with a different role in society from the original sex: women are still expected to be less competitive and less committed to careers than men.

Are there parallel social reasons that would amplify the desire to become an amputee? I suppose that there might be a parallel in feelings of attraction, not only to the state of being an amputee, but towards the accessories that the state makes necessary, so just as a transsexual woman might get pleasure from wearing feminine clothes, so the aspirant amputee could justify fetishes for crutches or prosthetics, by seeking a state in which such objects become necessary adjuncts to his daily living. Perhaps another parallel reason is that by becoming an amputee he would be joining the class of disabled people of whom society expects less performance than it does of the able-bodied. Whatever the reasons may be for people seeking to become amputees some seek this transformation and this fact leads to the second of the questions I raised: What must it feel like to have this desire?

It is obvious that sexuality and identity are intimately interwoven. Some of the most insistent of human hungers are focussed on particular aspects of sexual activity, yet after the desired behaviour has been instantiated, the desires may be completely dissipated; and they can be regarded with such detachment that it seems impossible for the subject of them to recall emotionally the ferocity of the hunger that led to the behaviour that satisfied them. The behaviour itself may be recollected, the fact that the behaviour was motivated by irresistable desire may be understood, but the emotional force that drove the behaviour is expended, and all that is left is detachment. Almost everybody who has shared a sexual relationship has experienced post-coital melancholy, or detachment at least. People who feel themselves to be driven to taboo sexual behaviour have described the emotional vacuum that follows the satisfaction of their desires, and the gradual filling of that vacuum with feelings of self-disgust. Some people who have felt themselves driven to have, and have had, sexual relations with children, have felt so ashamed of themselves in the aftermath that they have mutilated themselves in the hope of making it impossible to repeat the behaviour. I suspect that the feelings are those involved with normal sexual behaviour: appetite, action taken to satisfy it, and detachment, intensified by the fact that the behaviour that satisfies the appetite, being taboo, is resisted until the hunger becomes unendurable, the desired activity is undertaken, satiation follows, and with it self-disgust. It is a tragic dilemma because both action and inaction lead to misery. (This is one of the rare occasions where the rational responses may be to seek therapy or to commit suicide.) I conjecture that such an emotional pattern would be likely to follow the satisfaction of the desire of the aspirant amputee. What, before the event, seemed to be entrancingly desirable, the amputation of the chosen limb or limbs, would lead in the short-term to orgasmic euphoria that would be replaced, all too soon, with feelings of detachment (!) followed by self-disgust and despair, and that what had been so strenuously desired would in retrospect be seen to have resulted in an absolute catastrophic disaster. So I foresee that the satisfaction of the desire to become an amputee would be likely, in the long term, to be perceived by the subject as an enormous mistake. Other people may disagree with me. My sympathy with the desire is limited by the fact that sexy though it might become an amputee the practical drawbacks make the option unacceptable. (This is coming to sound like the trial of Oscar Wilde: 'Why did you not kiss the boy?' 'Because he was so ugly.' says Wilde, and the gates of Reading Gaol begin to gape.) It seems to me that the desire to become an amputee would be a dangerous one to satisfy for oneself, and a dangerous one to be an accessory in the satisfying of for someone else, who would almost certainly become resentful and perhaps even vindictive.

A person, aware of all the dangers, may, nevertheless, feel certain in his own particular case that his only hope of happiness lies in becoming an amputee, and this raises the question: How ought we to respond to his desire? Before attempting to make a reasoned response a number of technical issues have to be addressed, the most important of which is to assert that any discussion of ethics must depend on a number of primitive terms and a set of axioms. Axioms are not amenable to logical examination, their truth is merely asserted. This is to suggest that 'We hold these truths to be self-evident ...' is not a statement amenable to logical analysis. It could be argued that a modern interpretation of that magical phrase is 'We take as axioms the following propositions ...' and this paraphrase makes it quite clear that the statements cannot be analysed in logical terms. An example of an axiom that will be useful in the following discussion is the axiom: A person has a right to pursue happiness. The primitive terms in this axiom are 'right' and 'happiness'. To seek to define these terms is to engage in a futile activity: either the task of definition leads to an infinite regress because to define the term completely the terms of any definition need themselves to be defined, and the terms of these further definitions need also to be defined ad infinitum; or the terms collapse into a tautology. What I shall do is to make sure that common words are used to represent the primitive terms and that the meaning of the common terms corresponds to a possible interpretation in common language of the results of manipulating the axioms.

There are different conceptions of ethics and these conceptions depend on different axioms and consequently the desire of the aspirant amputee may be legitimate and acceptable in one system of ethics but unacceptable in another. The perception of the nature of society is greatly influenced by the ethical assumptions of the percipient, and there is a reciprocal influence, perceptions of ethics informing definitions of the nature of society and perceptions of the nature of society informing the systems of ethics adhered to by its members. Taking a not very persuasive example, it can be argued that in our society different people have the right to different amounts of power, some have a lot, some a little, and the unit of power is essentially money. An aspirant amputee who was rich would be able to pay agents to seek out a surgeon prepared to operate upon him, and to pay the surgeon to do so. The simple fact that the aspirant has the money, power sanctioned by the society in which he lives, to pay someone to satisfy his desires, gives him the right to satisfy those desires, and it is good that he should be able to do so. Some people would feel uncomfortable with this argument and this discomfort arises partly from the sense that there is more to society than relationships based only on power. More sophisticated conceptions of society depend on the relationship between good and happiness. The teleological approach to ethics is concerned with goals. It argues that society exists to enable its members to pursue some end, perhaps happiness, and the good emerges as a result of the pursuit: the deontological approach is concerned with duties and argues that society exists to pursue good and that happiness emerges as a result of this pursuit. In other words the teleologists are saying: 'We are good because we are seeking happiness', while the deontologists are saying 'We are happy because we are seeking goodness.'

My own preference is to seek happiness, I am a teleologist at heart, as well as all the other -ists. Most of us have a fairly good idea about the kinds of things that make us happy. Far fewer of us know what we ought to do: religious people believe they do, but our society is becoming increasingly secular, and consequently the deontological conception of ethics is less relevant to most people's behaviour than it was in the past. For this reason I shall make no further reference to it.

Teleological ethics can be subdivided into classes, the most important of which are egoism and the utilitarianism. Egoism holds that it is right that a person seek his or her own happiness. Utilitarianism holds that society as a whole should seek the greatest happiness for the greatest number. Lest the egoists be condemned for total selfishness it has to be recognized that egoists believe that everybody has the right to seek happiness, and a consequence of this is that social sanctions ought to operate to restrain someone who is maximising his or her happiness at the expense of others. Egoism therefore implies that one can expect to have to modify one's own pursuit of happiness in order not to encroach excessively on someone else's. Utilitarianism, in contrast, denies the right to pursue happiness to the individual. If the happiness of many people might be enhanced by my unremitting misery, for a utilitarian my misery may be desirable.

The acts of an individual can be divided in any system of ethics into those that are good, those that are bad, and those that are neutral. I suggest that marginally bad acts and marginally good acts exist that are indistinguishable in practical terms from neutral acts. If it were the case that an individual had perpetrated an action that could be shown, in principle, to have been marginally bad, if I could not detect the effect of the action on my happiness the effect of this marginal wrong-doing is indistinguishable from the effect of a neutral action, and for this reason I can see no practical reason for forbidding it. This is not to argue that a murder in New York, having no impact directly on my happiness, is to be condoned because New York is a long way away from Edinburgh, because in both egoistic and utilitarian systems of ethics the murder is evil; but I don't feel the same about a parking offence in Aberdeen. Wrong it may be to break the law, but in this case it is difficult to feel very concerned about the matter.

Finally, I shall address the issues rationally; and will come to a conclusion where it is rational to do so. By insisting on rational analysis based upon explicitly stated axioms I am developing arguments that are quite separate from the deontological arguments of religious moralists. Religious moralists may have as much right to their opinions on ethics as anybody else, however they tend to claim, despite the fact that it is impossible to support the clain rationally, without, perhaps, feeling that lack of rational support is a serious shortcoming in their point of view, that certain axioms are privileged, true, and that the conclusions that they draw from their axioms are superior to the conclusions drawn from other sets of axioms. There is no logical method of distinguishing between sets of axioms so the best that can be said about conclusions derived from different sets is that valid conclusions derived from different sets of axioms are as right as each other, even though they might be antithetical. Notice that the truth of falsity of axioms concerning matters of fact can in principle be discovered empirically through experiment since theorems derived from true axioms will predict events that occur while false ones will not; but the truth of axioms to do with ethics cannot be determined empirically.

The question to be explored is: How should society respond to a person who desires to have a healthy limb amputated? From a strictly utilitarian viewpoint it should be clear that, in principle, society should not satisfy this desire. However, I believe that the desire to become an amputee is, in effect, a neutral one, wrong in principle, but having so little effect on society as a whole that there is no good reason to deny its satisfaction. The individual has an unconventional desire: there is nothing to be said about the desire, except that it is rare, and that even if it were satisfied for all who possessed it, the numbers of people involved would be very small. The satisfaction of the desire for all who possess it is not likely therefore to make a radical change in society as a whole, and someone not belonging to family and friends would be unable to detect a consequent deterioration in the quality of his or her life should the desires of all the aspirants be satisfied, and there is the possibility that the satisfaction of their desires would make the aspirants very happy. What this means is, I think, that there is no conflict between the right of the individual aspirant to pursue happiness and the right of society at large to do so, no reason for society at large to deny the aspirant the satisfaction of his desire even though the satisfaction will entail some costs. There would be the immediate cost of the surgical procedure, and the chronic cost following from the aspirant's permanent physical impairment. From one point of view it is immoral in principle to propose that the aspirant should be allowed to impose these costs on society, costs that would be difficult for most individuals to pay for themselves; but shared among all the individuals in the society the costs are insignificant. There are other much commoner desires that lead to self-destructive behaviour and significant social costs to society. Smoking for example leads in very many cases to irreversible physical impairment requiring treatment for acute conditions and for long term care. The same considerations that apply to smokers should also apply to aspirant amputees. It is noticeable that the social response to the cost of smoking is extremely limited, and is not usually couched in the currency of money but in the currency of physical fitness or health. Voluntarily having a limb amputated may well be no worse for your health than a lifetime smoking cigarettes.

In conclusion it seems that there is no justification from a utilitarian point of view for society to deny the aspirant his desire.

Although it might be argued that all interactions take place between individuals, traditionally the individuals with whom one interacts are assigned to certain social categories. In this case the categories that are relevant in the context of western society are the individual, the family and friends, and society at large. The relationship between the aspirant amputee and society at large has been dealt with in the context of utilitarianism. The relationship between the aspirant and the people he knows individually is the province of egoistic ethics.

Of the aspirant there is, in fact, little to say. He has an unconventional irrational desire the satisfaction of which he expects will make him happy. Without bothering with the sort of analysis I have sketched, the majority of people would regard the desire as ipso facto evidence of mental disturbance. The effects of the satisfaction of the aspirant's desire on the inner circle of people, those personally acquainted with him, are likely to be complex. To analyse these in detail, the inner circle has to be subdivided into people who are dependent upon the aspirant, and people upon whom the aspirant depends. The satisfaction of the aspirant's desire will directly affect the abilities of both groups to pursue happiness. Suppose the aspirant works physically to support his family: the amputation of one or more limbs is likely to reduce the aspirant's ability to work and therefore the income of the family. To determine what constitutes fair action in this case is difficult as the happiness is assessable only in terms of equating psychic satisfaction gained by the aspirant through obtaining the desired amputation against the costs in terms of a reduction of earning power and its consequent reduction of the abilities of the dependents to pursue their own happiness. Where the costs and benefits are measured in different currencies it becomes impossible to make a rational equation. If an index of quality of life could be agreed by those involved with the aspirant they could come to an equitable decision about whether or not it would be fair to allow the aspirant to satisfy his desire. In his theory of justice as fairness Rawls proposes a conceptual mechanism that could be used by the people involved to come to an equitable conclusion. Rawls argues that a just decision in the dispute could be obtained if the people involved came to an agreement under the 'veil of ignorance', so that each person, including the aspirant, participating in the debate was ignorant of his or her relationship to the aspirant, each exploring the costs and benefits of alternative courses of action, and coming to a generally agreed binding conclusion about the just course of action. It is possible to see how such a discussion would lead to a fair outcome in principle; but it is impossible to engage the participants in the debate under the veil of ignorance, and even under the veil of ignorance it is likely that some participants would be more eloquent than other people and more likely to persuade other people of the rightness of their opinions. If Rawls's method is the only way of obtaining a just resolution to the conflict of desires it has to be concluded that there is no practical way that the conflict of interests can be fairly resolved.

Those involved professionally would be presented with ethical dilemmas of their own. Central to the practice of medicine and surgery is the axiom: Do no harm. Nobody could deny that the amputation of a sound limb would be harmful to the patient. It would be unethical for a surgeon to amputate a sound limb, and a surgeon would be perfectly justified in refusing to do it. Likewise it would be unethical for someone to behead another person who was in good health. Ritual suicide as practised by the samurai class in Japan involved self-inflicted disembowelling. The disembowelling having been inflicted, the suicide would inevitably die, sometimes quickly, sometimes slowly, but always in desperate agony. It became the practice that ritual suicide was carried out in the company of a second armed with a sword, and it was the duty of the second to decapitate the suicide immediately after the lethal stroke had been self-administered. Nothing could save the suicide, and the second was simply acting to minimise the final agony, and in doing so, it could be argued, was acting entirely honourably. Equally, the aspirant, if he could present the surgeon with a self-administered injury that would lead to death if it were not treated by amputation, could not ethically be denied the treatment he required any more than a person, attempting to commit suicide, discovered before death, could ethically be allowed to die without attempts being made to resuscitate him.

The individual's relationship to himself must be considered finally. The ethical considerations are those involved with all elective surgery. The physical modification is irreversible, so the aspirant has to be convinced that the chosen course is really the desired one. The aspirant ought to be make himself aware of the physical consequences to be expected as a result of the amputation, for example phantom limb effects and the possibility of chronic pain, in order that the choice may be made with as much information as is available, and finally the aspirant would need information about how to engineer as safely as possible, the self- administered injury which, if not treated by amputation, would lead to death. It is a difficult question to decide if the provision of such information to the aspirant by his medical adviser would be unethical, or whether the witholding would be.

The conclusion that follows from all the argument is this: Society at large would be insignificantly affected if it paid the costs of allowing the aspirant to become an amputee, so under a utilitarian conception of ethics there would be no obstacle to the satisfying of the desire. From an egoistic perspective there is no simple solution: From the point of view of the aspirant effect of satisfying his desire would have to be assessed in terms of the psychic satisfaction he obtained as a result of the amputation. The impact on his immediate circle would be measurable both in the unhappiness consequent upon his having voluntarily undergone mutilation, and the practical consequences of reducing his physical fitness. There is no rational solution to this equation and egoistic ethics must therefore be silent about whether the desires of the aspirant are right or wrong.

Since indulging the desires of the wannabes costs us all so little, while at the same time satisfying an yearning that can be completely disabling in its intensity, I conclude that we ought to accept their desires and help them to achieve the bodily modifications they desire.

The arguments I have discussed and the conclusions I have come to are all derived from a set of axioms. It may be that other people choose different axioms and come to quite contrary conclusions. In such a debate it is important therefore that the axioms are explicitly stated so the foundations of the arguments are available to be questioned. Notes

[edit] fetishes for crutches or prosthetics

There is at least one documented case of a man impersonating an amputee by strapping up a leg and going on crutches in public. (described, with some venom by a woman who is an amputee in a letter to Forum (1984) 17(5): 69--70. Perhaps there are parallels between such behaviour and that of male transvestites. This may have affinities to classical fetishism, where the sexually arousing stimulus is not the changed physical state of the subject, but the accoutrements, feminine clothes in the case of the transvestite, crutches, or prosthesis for the amputee-impersonator. This seems to be a different phenomenon from the desires of the aspirant transsexual or the aspirant amputee. In the first case the accoutrements may be the primary arousing stimulus while in the second they seem to be secondary to the desired alterations of the body.

Ethics and theories of justice, including Rawls's, are discussed in many textbooks of philosophy. One of the most accessible is:

An introduction to philosophical analysis (4th. ed.) John Hospers (1990) Routledge, London.

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