bodily autonomy Archives - The Prindle Institute for Ethics

Warning: This article contains graphic descriptions of bodily mutilation.

Early in 2022, I wrote a piece for The Prindle Post discussing the arrest of John Yalu for the suspected murder of Kalman Tal. The circumstances surrounding Tal’s death are unclear, but the initial facts appeared to indicate that he had paid Yalu to amputate his leg, despite Yalu having no medical training. Speculation was, and remains, that Tal suffered from Body Integrity Dysphoria (BID), a rare disorder which makes sufferers feel like a disabled person trapped within a non-disabled person’s body and for which there is no agreed-upon treatment.

In that article, I argue that if we are committed to the principle of do no harm, then all treatment avenues, regardless of how distasteful we may find them, must be considered. Failing to do so would abandon those with the disorder to their suffering and force them to consider dangerous, even life-threatening alternatives like black-market surgery or DIY operations.

Fast forward to May 2024 and London, where the criminal court sentenced Marius Gustavson, 46, to prison. Charged with, amongst other things, five counts of causing grievous bodily harm, Gustavson was given a life sentence, meaning he will serve no less than 22 years behind bars. The actions that warranted such a severe sentence have a Hannibal Lecter quality.

Gustavson, who called himself the “eunuch maker,” ran a highly profitable business providing body modifications to willing participants. This was despite neither Gustavson nor any of those assisting him having medical training. Additionally, these operations were carried out in non-surgical settings as seemingly innocuous as flats and hotel rooms. This, by itself, would be shocking, but it is not simply that operations were carried out by criminally unqualified individuals such as Gustavson. What elevates this into the realm of body horror is the operation’s nature, severity, and voyeurism.

As listed by the Criminal Prosecution Service, the 22 procedures in which Gustavson was involved included “the removal of the victims’ testicles, the amputation of penises, clamping of testicles with burdizzo clips (ordinarily used by vets in the castration of cattle), and the insertion of needles into genitalia.” It was not simply that these bodily parts were removed or mutilated, although that is itself horrifying, but that such tissue was then kept by Gustavson and his accomplices either as trophies, to be sold online, or in what might be the most disturbing fact of this case, to be cooked by Gustavson and ate.

To add another layer of horror to this case, Gustavson not only carried out these procedures but also ran a pay-per-view service where subscribers could watch him work. Altogether, between 2017 and 2021, Gustavson’s business earned him £223,229.43, $32,972.99 and €24,799 in profit.

What links this to the Yalu and Tal case is that Gustavson claims to have been suffering from BID. What’s more than this is that, according to his legal defense, Gustavson wanted to put “a smile on people’s faces by offering a service to those suffering, like him, from what was described as [BID].”

Now, whether Gustavson suffered from BID is a matter for debate. He had undergone surgical interventions himself to alter his physicality. This included, but is not limited to, having his penis removed in 2017 in a procedure carried out in a London flat and, in 2019, had to have his leg amputated after he deliberately submerged it in dry ice. Those who helped Gustavson in both instances also received jail sentences.

For my part, I doubt whether he had BID. His actions do not conform with the symptoms typically associated with the disorder. Most notably, those with BID rarely seek additional amputations or modifications once the part of their body which caused the initial distress has been removed. Gustavson, on the other hand, sought multiple modifications. Additionally, his desire appears to have begun to manifest after his divorce in 2016. Those with BID start experiencing symptoms in mid to late childhood. So, I suspect Gusatvson was using BID as a legal defense to lessen the likelihood or severity of his criminal sentencing. This did not work.

But, why does this matter from a philosophical and ethical standpoint?

First, it draws into question what the purpose of medicine is and what procedures fall under the umbrella of treatment. We typically accept that the amputation of a diseased limb to save someone’s life is acceptable. But is that the only circumstance? Might it be those other motivations, such as body modification or the improvement of the quality of life, could justify limb amputation?

Second, there are questions of justice and resource allocation. Who should pay for these operations and the ongoing support for the “willingly” disabled? Is it OK to amputate a limb if the individual pays out of pocket? What about access to benefits and social support? Should these be assigned to those who could have otherwise not needed them?

Third, we face questions about the limit of consent. Can you provide valid consent to such an operation, or are there certain things to which you cannot consent? Does this even matter in the case of such surgeries?

And fourth, can these interventions be legal? Is there any way that such an operation can be justified within the eyes of the law, or is the law’s very purpose to prevent such harmful acts, like these, from occurring?

But what I think both Gustavson and Yalu’s cases raise is the vulnerability of those suffering from BID. Those with the disorder have nowhere to turn to address the significant distress that they experience, which can last for decades, even entire lifetimes.

If the purpose of medical practice is to use knowledge of science and biology to improve the quality and length of life, then it seems clear that this will involve, in some exceptional circumstances, interventions which may be ethically troubling and socially distasteful. Indeed, many of the interventions and technologies which we might today consider ethically untroublesome or even mandated, like organ donation, were once viewed as affronts to the sanctity of the body and to nature itself.

This is to be expected as new knowledge and technologies extend the sphere of medical practice into realms which, for one reason or another, had previously remained outside its control.

Resisting calls to even investigate the effectiveness of amputation in BID cases cuts off potential treatment options for those with the disorder. This, in turn, means that those with BID feel betrayed, unseen, or misunderstood by the medical profession. So, they seek out alternative treatments, making them easily exploitable by the likes of Gustavson, who conducted these “surgeries” not to provide any therapeutic benefit but to satisfy his own desires and to make money.

It may be weird. It may be unbelievable. But until a better alternative comes along, amputations conducted under proper surgical conditions may be the best way to help those with BID. After all, who is likely to cause more harm, a trained surgical professional working with the proper tools in the right environment or someone like Gustavson, selling the spectacle of quasi-surgery and eating what he takes?

In 2013, Simon Bramhall, a surgeon at the U.K.’s Queen Elizabeth Hospital Birmingham, performed a life-saving liver transplant on Patient A. Despite the surgery being a success, a few days later, the liver started failing. So, roughly a week after receiving their first liver, Patient A was back in the operating room for their second transplant, this time under the care of another surgeon. But, when this second surgeon opened up Patient A, they found something remarkable. Burned into the liver’s surface – the one that Simon Bramhall had implanted only a few days before – were two four-centimeter letters: “SB.”

Eventually, after some delay, equivocation, and the sharing of photos, it emerged that, yes, during the first operation, Bramhall had used an argon beam – used for cauterization – to sign the liver after he had transplanted it into Patient A. According to a nurse who had been present at the first surgery, when asked what he was doing, Bramhall said, “I do this.” He has since said he doesn’t recall saying this or that he must have been referencing something else if he did.

Bramhall’s rebuttal, however, is suspect. Not long after news of Bramhall’s actions emerged, a consultant anesthetist came forward and claimed that Bramhall signed his initials on another patient’s liver during a 2013 surgery, known as Patient B. Bramhall claims not to recall doing this.

Despite these revelations, Bramhall didn’t lose his job, at least not immediately. He left Queen Elizabeth Hospital Birmingham of his own accord, feeling that he was no longer welcome there, and continued to practice surgery at another institute until 2020; this is despite his 2017 admission of two counts of assault by beating concerning the liver brandings. Eventually, in 2022, the General Medical Council struck him off the medical register, arguing that his actions had undermined public trust in the medical profession.

Now, this case raises a whole host of questions, from the practical: Why did Bramhall feel the need to do this and has he done this to anyone else? to the ethical and legal: Why didn’t his colleagues immediately raise the alarm and why did it take so long for him to be charged and struck off once they did?

What I want to focus on here is not that he marked the liver unnecessarily but that he did so with a particular vision in mind. He didn’t do a squiggle, a circle, a smiley face, or something meaningless, but he used the argon beam to burn his initials into Patient A’s liver. Does this make a difference? Is it, in some sense, more harmful than if he had done another shape? Or some random letters?

First, it must be noted that the argon beam is commonly used during operation to stop bleeding, so its presence is not unusual. Also, the mark it makes is very shallow, with the beam only penetrating micrometers into the tissue. So, the amount of damage is limited. Finally, tissue can be used as a medium to test the beam’s effectiveness, meaning that the fact that the liver wasn’t pristine when Bramhall closed up Patient A isn’t an intrinsic concern.

This latter point is something which has been raised in Bramhall’s defense with Barbara Moss, a patient of Bramhall and now his co-author (they write thrillers together), arguing that:

He’s got to test the laser on the liver before he can use it – it’s a routine process. If I’m trying out a pen, I might as well just put my initial, because I can do that very quickly. The fact that he did it in a particular shape makes no difference.

This argument seems slightly odd given that, as another surgeon has noted, such tests normally consist of a couple of dots or a small wiggle, which happens before bleeding occurs, not after as, obviously, you’d test the laser before you have need of it. However, Moss’s argument got me thinking: does the shape matter?

One could make a case for the negative. Whether it’s someone’s initials, a circle, or a couple of dots, the damage done to the liver itself is minimal at most. Any mark is confined to the organ’s surface and doesn’t impact functioning. Indeed, if it hadn’t been for Patient A’s replacement liver failing, the liver may have never been seen again, and they would have never known about the mark’s existence. So, from a rather restrictive point of view, if one is concerned with the potential for physical harm that Bramhall’s actions might have caused, then it seems that it doesn’t matter what shape he etched into the organ as any shape would have the same impact – nothing at all.

However, this would indeed be a very limited conceptualization of harm. It is now common for us to understand harm not only in a purely physical sense (getting hit with a hammer, being run over by a car) but also in a mental and cognitive sense (seeing someone get hit with a hammer, accidentally running someone over with a car). This understanding of harm emerged and became a central factor in Bramhall’s trial as, after seeing images of their branded organ, Patient A began experiencing symptoms of PTSD. This instigating factor led the Criminal Prosecution Service to charge Bramhall in the first place. It was not what he had done to the liver but what his actions had done to Patient A that mattered. So, with a broader understanding of harm, it can become easy to see how Bramhall’s actions might be considered uniquely wrong.

Yet, I am unconvinced that this gets to the nub of the issue. The idea of someone branding their initials into your internal organs is unquestionably horrifying, and I do not doubt that this could lead to PTSD, but I don’t think this fully captures the uniqueness of Bramhall’s offense. The fact that, above all other options, he chose to brand his initials into Patient A means there is something horrifyingly unique, even personable, in his actions.

To illustrate this, imagine that, to relieve the stress, two surgeons play a game of noughts and crosses (aka tic-tac-toe) on a patient’s liver, branding the game into the organ with an argon beam much like Bramhall did his initials. It’s not unreasonable to think that, upon finding out that their innards would forever carry the remnants of such a game, they would experience similar distress and symptoms as Patient A (for context, Bramhall says he knows someone who has done this very thing). The game’s presence would represent the reckless attitude such surgeons would have towards their patients and their jobs. Indeed, it would have to be someone holding an awfully cavalier attitude toward their profession to even consider such a thing. Yet, this lacks a certain degree at the core of the Bramhall case: the unabashed egotistical arrogance.

This is not to say that a surgeon who played a child’s game in the tissue of a patient’s organ wouldn’t have this critical flaw – I’m almost certain they would. Nevertheless, the imprinting of the game itself would be separate, to some degree, from the person playing it. It could have been anyone doing that. Bramhall’s initials, however, are an entirely different story. They are tied to him in a very personable way. And, yes, anyone could have put the letters SB into the patient, but someone with those initials did. If the liver hadn’t been rejected, Patient A would have spent the rest of their life walking around with a mark that intimately tied them to Bramhall; not an ambiguous game of noughts and crosses, but one of the very things that Bramhall uses to self-identify.

To emphasize this point further, imagine he branded his entire name into Patient A’s liver. The more personable and unique the mark signifying Bramhall’s actions, the worse it is (at least, that’s how it seems to me).

I suspect we will never really know why Bramhall did what he did (at least twice). He’s claimed that extreme stress led him to make the markings, but I find this doubtful. He has said that he thinks the backlash and subsequent punishment he’s received was over the top and that the GMC sought to make an example out of him. To use him as a way of warning other reckless medical professionals. This might be true. But, given the extreme power doctors hold over us – especially surgeons, who violate our bodies with our permission and are responsible for us when we are at our most vulnerable – might the example be worth making? Is it not better to make an example out of someone who did something terrible, than slap them on the wrists and potentially encourage such behavior in others?

It costs millions of pounds to train a surgeon of Bramhall’s caliber, and if nothing else, he was reportedly a technically sound surgeon. But if the cost of protecting the medical profession is his removal from it, the subsequent loss of his expertise, and all the time spent cultivating his skill, then it strikes me as a price worth paying.

I want to have faith that those who care for me will do just that, and this is fundamentally compromised if I must worry about those professionals using my flesh as an Etch A Sketch when I’m under the knife.

bodily autonomy

Body Integrity Dysphoria and the Gustavson Case

The Unique Harm of Bramhall’s Liver Branding