Body Integrity Identity Disorder and Cyborgs: An Exploration of the Ethics of Elective Amputation and Enhancement Technologies A thesis submitted to the University of Manchester for the degree of Doctor of Bioethics and Medical Jurisprudence in the Faculty of Humanities 2021 Richard B. Gibson Centre for Social Ethics and Policy TABLE OF CONTENTS PRELIMINARIES ABSTRACT .................................................................................................................................... 6 DECELERATION AND COPYRIGHT STATEMENT.............................................................. 7 DECLARATION ......................................................................................................................... 7 COPYRIGHT STATEMENT....................................................................................................... 7 DEDICATION ............................................................................................................................... 8 ACKNOWLEDGEMENTS ........................................................................................................... 9 THE AUTHOR ............................................................................................................................. 10 EDUCATION ............................................................................................................................ 10 PUBLICATIONS AND CONFERENCE PAPERS .................................................................. 10 DESTINATION ........................................................................................................................... 12 TABLE OF STATUTES ............................................................................................................... 13 TABLE OF CASES ....................................................................................................................... 14 PART I INTRODUCTION CHAPTER I THE QUESTION ................................................................................................... 17 CHAPTER II BODY INTEGRITY IDENTITY DISORDER: AN OVERVIEW .................... 24 2.1 BODY INTEGRITY IDENTITY DISORDER AND GENDER DYSPHORIA ................... 32 CHAPTER III PHILOSOPHICAL AND LEGAL BACKGROUND ...................................... 34 3.1 INTRODUCTION ............................................................................................................... 34 3.2 AUTONOMY AND THE CAPACITY FOR CONSENT .................................................. 35 3.3 BENEFICENCE ................................................................................................................... 39 3.4 NONMALEFICENCE ......................................................................................................... 52 3.5 JUSTICE ............................................................................................................................... 62 3.6 THE LEGAL LANDSCAPE OF HEALTHY LIMB AMPUTATION IN CASES OF BIID .................................................................................................................................................... 65 3.7 CONCLUSIONS .................................................................................................................. 83 CHAPTER IV PHILOSOPHICAL AND LEGAL APPROACH .............................................. 91 4.1 INTRODUCTION ............................................................................................................... 91 4.2 WHY HEALTH, DISABILITY, AND NEUROPROSTHETICS? ...................................... 91 2 4.3 BACKGROUND ASSUMPTIONS AND GROUNDING PRINCIPLES .......................... 92 4.4 THE EMPIRICAL, THE SOCIAL, THE NORMAL, AND THE PATHOLOGICAL ...... 96 4.5 ETHICS, LAW, AND THE LIMITATIONS OF LEGISLATION .................................... 119 4.6 CONCLUSION .................................................................................................................. 126 PART II THE ARTICLES CHAPTER V ARTICLE ONE: THE DESIRABILITY OF DIFFERENCE: GEORGES CANGUILHEM AND BODY INTEGRITY IDENTITY DISORDER ................................. 130 5.1 ABSTRACT ........................................................................................................................ 130 5.2 INTRODUCTION ............................................................................................................. 130 5.3 BODY INTEGRITY IDENTITY DISORDER .................................................................... 134 5.4 THE NORMAL AND THE IDEAL .................................................................................. 138 5.5 BOORSE AND CANGUILHEM ...................................................................................... 141 5.6 HOW DO THESE TWO ACCOUNTS UNDERSTAND AND TACKLE DISABILITY? .................................................................................................................................................. 143 5.7 HEALTHY LIMB AMPUTATION AND CANGUILHEM ............................................ 145 5.8 CONCLUSION .................................................................................................................. 147 CHAPTER VI ARTICLE TWO: ELECTIVE IMPAIRMENT MINUS ELECTIVE DISABILITY: THE SOCIAL MODEL OF DISABILITY AND BODY INTEGRITY IDENTITY DISORDER ............................................................................................................ 149 6.1 ABSTRACT ........................................................................................................................ 149 6.2 INTRODUCTION ............................................................................................................. 149 6.3 NONMALEFICENCE AND BIID .................................................................................... 152 6.4 THE SOCIAL MODEL OF DISABILITY ......................................................................... 157 6.5 THE SOCIAL MODEL OF DISABILITY AND ELECTIVE AMPUTATIONS .............. 159 6.6 THE CREATION OF DISABILITY IN CASES OF BIID ................................................. 160 6.7 THE CREATION OF IMPAIRMENT IN CASES OF BIID ............................................. 161 6.8 CONCLUSIONS ................................................................................................................ 168 CHAPTER VII ARTICLE THREE: ELECTIVE AMPUTATION AND NEUROPROSTHETIC LIMBS ................................................................................................ 170 7.1 ABSTRACT ........................................................................................................................ 170 7.2 INTRODUCTION ............................................................................................................. 170 3 7.3 HEALTHY LIMB AMPUTATIONS AND BODY INTEGRITY IDENTITY DISORDER .................................................................................................................................................. 172 7.4 NEUROPROSTHETICS: WHERE ARE WE NOW AND WHERE ARE WE GOING? 181 7.5 ELECTIVE AMPUTATION AND NEUROPROSTHETIC LIMBS ................................ 183 7.6 CONCLUSIONS ................................................................................................................ 187 CHAPTER VIII ARTICLE FOUR: NO HARM, NO FOUL? BODY INTEGRITY IDENTITY DISORDER AND THE METAPHYSICS OF GRIEVOUS BODILY HARM ..................... 189 8.1 ABSTRACT ........................................................................................................................ 189 8.1 INTRODUCTION ............................................................................................................. 190 8.2 CURRENT ATTITUDES TO THE HARM COMPONENT OF GBH IN ENGLISH LAW .................................................................................................................................................. 192 8.3 WHY THE CLARITY OF HARM IS NEEDED ............................................................... 195 8.4 BIID AND THE SMITH AMPUTATIONS ...................................................................... 197 8.5 METAPHYSICS OF HARM IN GBH ............................................................................... 201 8.6 CONCLUSION .................................................................................................................. 215 PART III CONCLUSION CHAPTER IX CONCLUSION ................................................................................................. 219 9.1 INTRODUCTION ............................................................................................................. 219 9.2 PRINCIPAL ARGUMENTS ............................................................................................. 224 9.3 CONTRIBUTION TO THE LITERATURE ...................................................................... 230 9.4 FUTURE RESEARCH ....................................................................................................... 233 9.5 CLOSING REMARKS ....................................................................................................... 234 APPENDIX A. ............................................................................................................................ 237 APPENDIX B. ............................................................................................................................. 249 BIBLIOGRAPHY ......................................................................................................................