Surgeon defends decision to amputate healthy legs of patients

A surgeon in Scotland amputated the legs of two psychologically disturbed men who had nothing physically wrong with them but felt a "desperate" need to be amputees, it emerged this week.

Both men, one from England and one from Germany, had a rare type of body dysmorphic disorder known as apotemnophilia, in which patients are convinced from childhood that they will be normal only once a limb has been removed. The obsession is always with the removal of a specific limb, and each patient had a leg amputated above the knee.

The operations were carried out in September 1997 and April 1999 at an NHS hospital, Falkirk and District Royal Infirmary, by consultant surgeon Robert Smith. Both men had been turned away by other doctors.

The chairman and board members of Forth Valley Acute Hospitals NHS Trust, which runs the hospital, were unaware of the operations at the time. They only learnt of them last summer when Mr Smith informed the trust's new chief executive, Jim Currie, that he was involved in assessing a third patient, an American.

This week the trust announced a ban on further amputations after a report from its ethics subcommittee. Mr Smith had obtained the agreement of the then chief executive and medical director, both of whom have since changed jobs, before performing the two operations.

He also discussed the procedure with his defence body and with the ethics committee of the General Medical Council. The patients, who had failed to respond to conventional treatment, were assessed and counseled beforehand by psychiatrists and a psychologist.

Mr Smith told the BMJ that he accepted no fee for the operations, though the hospital was paid £3000 ($4800). "The money went back into the NHS."

He said that there were two groups of patients who wanted to have limbs amputated. The larger group found the concept sexually arousing. But both patients on whom he operated were a small subgroup who wanted the operation because they felt incomplete with four limbs but would feel complete with three.

Patients with the disorder often resorted to self harm - for example, by shooting their leg off or lying on a railway track, added Mr Smith. "They are a very strange group of people who have had this obsession since childhood. The more I saw these patients, the more I realised this was an extremely distressing and disabling condition."

He said that the patients' lives had been transformed by losing a limb and they were delighted with their new state. Both had had artificial limbs fitted, though they did not always wear them.

Earlier, he told a press conference at the hospital: "At the end of the day I have no doubt that what I was doing was the correct thing for those patients."

The trust's chairman, Ian Mullen, said such operations were not ruled out for the future, but a strict procedure would have to be followed.

Clare Dyer, legal correspondent, BMJ


studentBMJ 2000;08:45-88 March ISSN 0966-6494