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Drug Legalization: “My Body, My Choice”?

Few slogans are as rhetorically powerful as “my body, my choice.” It captures a fundamental intuition: that individuals should have control over what happens to their own bodies. People rightly recoil at the idea of being forcibly subjected to another’s will, and the phrase is often invoked to argue for bodily autonomy in areas like abortion and end-of-life decisions. The assumption is that, as long as an individual’s actions do not harm others, they should be free to do as they please with their own bodies.

Given this, some argue that drug legalization naturally follows from the “my body, my choice” principle. If a person wants to engage in the recreational use of drugs, the reasoning goes, that is his decision alone. As long as he does not harm anyone else, the state has no business interfering. The case seems simple enough — until we examine it more carefully.

The problem is that freedom is not just about making choices; it is about making choices rationally. True autonomy is not simply the absence of external interference but the ability to govern oneself through reason. A person who deliberately impairs his rational faculties through recreational drug use is not exercising freedom. He is attacking it.

To be clear, I am not making the case for any particular drug policy. My point is simply that we need to be honest about what drugs do and not dress up something destructive to freedom in the language of liberty, even if restrictive drug laws are ultimately unjustified.

Freedom Requires Rational Self-Governance

The conceptual justification behind the “my body, my choice” argument assumes that individuals possess and retain rational self-control over their decisions. However, the problem with recreational drug use is that it directly undermines this ability.

Mind-altering substances do not just create pleasurable experiences, they chemically alter the brain in ways that impair self-governance. Recreational drug use can distort judgment, suppress self-restraint, and, in many cases, create dependency that weakens one’s ability to make future choices freely. A person under the influence of drugs is not acting as a fully rational self-governing agent but as someone whose thoughts and actions are being heavily influenced by an external chemical influence.

This is true whether the drug in question is alcohol, marijuana, psychedelics, or harder narcotics. Even substances that supposedly “enhance” mental function (such as certain stimulants) often do so at the cost of rational self-regulation, increasing impulsivity and distorting judgment. When we speak of drugs altering rational agency, we are not only referring to substances that depress cognitive function but also to those that overstimulate it. Proper cognitive function depends on homeostasis, a balanced and well-ordered state that allows the mind to perceive reality clearly and process information accurately. The purpose of our rational and cognitive faculties is to enable us to (1) perceive reality accurately so that we can (2) deliberate soundly so as to (3) act in accordance with the truth. All of these functions are distorted by recreational drug use.

If freedom is about self-rule, then a person who deliberately places himself in a state where his ability to rule himself is severely diminished is not exercising freedom. Invoking drug use as an exercise of freedom makes as much sense as touting the benefits of drinking seawater as a remedy for thirst.

This is not abstract philosophical theorizing. The law already recognizes that a person who is mentally incapacitated cannot validly consent to certain decisions. Contracts signed under severe intoxication can be voided. A person high on drugs cannot give legally binding consent to medical procedures. The state intervenes when individuals threaten suicide by placing them in involuntary psychiatric holds. Why? Because we recognize that rational self-governance is a necessary precondition for meaningful autonomy.

How Drug Use Turns You Into a Slave

The defining feature of slavery is the absence of self-governance. A slave does not act according to his own rational will but is controlled by an external force that dictates his actions. The master determines what he does, where he goes, and how he lives. That is precisely what happens when someone consumes a substance that then overrides their rational faculties. While physical slavery is imposed by another person, chemical slavery is self-imposed. For both, the end result is the same: a loss of autonomy.

A person under the influence of drugs is no longer fully acting according to rational self-direction. His will is hijacked by a foreign chemical influence that suppresses judgment, distorts perception, and overrides impulse control. At that moment, he is not truly free. His actions are dictated by the effects of the substance rather than by reasoned deliberation.

This is not a metaphor. A person in the grip of a mind-altering substance literally loses self-mastery, even if it is just temporarily. The person who becomes addicted to drugs does not simply choose to continue using; his ability to choose is progressively eroded as the drug rewires his brain and makes rational self-control more difficult. At that point, he is no longer the master of his actions — the drug is his master.

John Stuart Mill, who first articulated the “harm principle,” recognized the problem posed by enslaving oneself. In On Liberty, Mill wrote that “The principle of freedom cannot require that [one] should be free not to be free.” In other words, freedom does not include the right to permanently destroy one’s own ability to be free. A person who permanently sells himself into slavery is not exercising freedom but abolishing it. The same logic applies to someone who places himself under the control of a substance that strips away his ability for self-rule. A person who willingly puts himself under the influence of something that systematically erodes rational control is doing the opposite of exercising freedom. Although Mill was talking about political slavery, his points apply just as equally to chemical slavery.

The Paradox of “My Body, My Choice”

The deeper irony of the “my body, my choice” argument is that the more a person engages in self-destructive drug use, the less able he is to make meaningful choices at all. A person addicted to meth, heroin, or even high-potency marijuana is not exercising greater autonomy; he is increasingly at the mercy of chemical dependency, impaired judgment, and distorted perception. His decisions are no longer fully his own. Instead, they are shaped and dictated by the drug.

If we reject political slavery because it violates autonomy, then we should likewise reject chemical slavery, because it produces the very same result: a person who is ruled by something other than his own rational will. A society that tolerates and normalizes widespread chemical enslavement is not a society that is maximizing freedom.

What About Alcohol?

Even alcohol is not immune from this critique. Alcohol, like any substance that affects the mind, can be used in ways that compromise rational self-governance. A person who drinks to the point of intoxication is, in that moment, undermining his own ability to think clearly and act rationally. A blackout drunk, a reckless binge drinker, or a person who routinely drinks to escape reality is no different, in principle, from the drug user who deliberately seeks intoxication. The problem arises when consumption crosses the line from responsible use to rational impairment.

However, the key difference between alcohol and hard drugs is that alcohol can be used in moderation without necessarily leading to impairment. A person can have a glass of wine with dinner, a beer at a social gathering, or a whiskey while unwinding after a long day without losing rational control. Unlike recreational drugs, which are taken precisely for their intoxicating effects, alcohol is unique in that it allows for consumption without cognitive dysfunction.

This is why alcohol is tolerated in a way that drugs like cocaine, methamphetamine, heroin, or hallucinogens are not. There is no responsible way to use these substances recreationally — their entire purpose in being used is to override rational agency. Unlike alcohol, which can be incorporated into normal life without necessitating impairment, the defining feature of recreational drug use is that impairment is the goal.

That said, alcohol abuse is clearly subject to the same concerns as other forms of intoxication. Alcohol, like any substance that affects the mind, can become a means of self-imposed enslavement when it is used to evade reason rather than complement normal, responsible living.

So while moderate alcohol consumption does not necessarily violate the principles of rational self-governance, its misuse certainly can. The fact that alcohol allows for some responsible use does not mean it is exempt from the general principle that true freedom requires rational control.

Freedom Requires More Than Just Choice

Recreational drug use is incompatible with freedom. The more a society tolerates and encourages such behavior, the less free that society becomes, not because the government is restricting choice, but because its citizens are actively degrading the very faculties necessary for responsible self-rule.

So does “my body, my choice” work as a defense of recreational drug use? No. It is logically incoherent and self-defeating. If we care about autonomy, we should reject the idea that freedom includes the right to systematically destroy the very conditions that make freedom possible.

Whatever we think about drug legalization, we should at least be honest about what drugs do. Freedom is not a magic word that turns self-destruction into autonomy.

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In the Eye of the Beholder?: Puberty Blockers & the Concept of Harm

Treatment for gender dysphoria in children has come under increased scrutiny in recent years. As of January 2021, no states in the U.S. prohibited youth gender-affirming care. Since then, however, 26 states have passed bans. In December 2024, Wes Streeting, the current Health Secretary of the United Kingdom announced that a previous emergency measure prohibiting new prescriptions of puberty blockers to underage patients would now become an indefinite ban. On Tuesday, January 28th, the White House announced an executive order directing federal agencies to cease supporting gender affirming care for anyone younger than 19. Now, the United States Supreme Court is considering Tennessee’s ban on gender affirming care for minors, including puberty blockers and other hormone therapy.

Why the push to halt the use of these drugs in gender-affirming care? Advocates of the bans cite worries about the potential for long-term harm. The brain undergoes significant development during puberty and it is not clear what role sex hormones play. Unfortunately, the data are just not there – long-term studies of human patients observing the effects of puberty blockers on their development are only just underway and it will take literal decades to determine life-long effects, if there are any. As a result, there is a plausible mechanism by which puberty blockers and other hormonal treatments could produce harm, but the data are insufficient to firmly establish this.

That said, some data suggest that those who take puberty blockers experience changes in body composition, are shorter and have slower rates of growth than their peers. Research in animal models suggest that puberty blockers may produce cognitive deficits – male sheep treated with puberty blockers were significantly slower to progress through a familiar maze, even after treatment ceased.

There are two things worth noting, though. First, reactions in animal models, particularly in pharmacology studies, are not always reliable indicators of human reactions. Second, some of the currently available data on hormone replacement therapy complicates the picture of potential long-term consequences. Animal models provide data suggesting that some consequences of puberty blockers, including infertility, may be reversible with future hormone therapy.

Of course, negative consequences are just one part of the picture. We must also look at the reasons why underage patients seek prescriptions for hormonal treatment. Undergoing puberty causes numerous changes to one’s body. For individuals suffering from gender dysphoria, these changes may produce significant distress. The data show that gender non-conforming youth are significantly more likely to experience symptoms of anxiety and depression, to confront suicidal thoughts, and to attempt suicide. But those who seek and receive gender affirming treatment, including puberty blockers experience positive psychological outcomes, including greater life satisfaction and fewer symptoms of depression and anxiety, after beginning treatment.

As of now, the data suggest these treatments are a mixed bag. There are potential negative consequences associated with puberty blockers and other hormonal treatments, specifically, interference with growth. Negative cognitive consequences are possible, but the data are, at best, suggestive. More research is necessary. But casting a further cloud over the possibility of clarity is that gender dysphoric individuals are more likely to experience comorbid conditions such as depression and anxiety than members of the general population. Troublingly, these conditions correlate with worse performance on cognitive assessment measures.

So, what does this mean for hormonal treatments? If we take it for granted that there are potential long-term negative consequences, then it seems like they offer a trade-off. Specifically, a trade-off between physical health, cognitive function, and mental health.

But just because we regard some initial consequences as negative does not mean that they will prove harmful in the long run. Consider the following case. Imagine that, while crossing the street one day, I am hit by a car and break several bones. The recovery requires surgery along with many months of physical therapy and rehab. While I regain independence, I never quite reach my prior physical capability. Further, having suffered a head injury after hitting the ground, I now have permanent deficits in my long-term memory recall. Nonetheless, I find that the perseverance I developed during rehab serves me well throughout my life; I feel that I am more resilient, better able to regulate my emotions during trying times, and work harder through adversity.

Imagine now that a time traveler offers to travel back in time and push me out of the way of the car, preventing my accident. Should I accept her offer? It seems that either choice would be reasonable. One could hardly blame me for wanting to avoid the suffering, the surgery and the recovery (along with the medical bills), and to undo the deficits which now affect me. Yet, simultaneously, it seems like a rational person may still accept the offer. Perhaps I think my newfound character is worth the negative consequences of the accident.

What does this example show us? It displays the complexity of the idea of harm. This is revealed in two interlinked ways. First, establishing a negative consequence is not by itself enough to demonstrate that something is harmful. It may be the case that something’s positive aspects outweigh its negative aspects. Second, whether the positives do outweigh the negatives may sometimes be best determined by the individual who experiences it. Outright bans on gender affirming care seem to set aside both of these facts. They view the potential for negative consequences as sufficient grounds to eliminate the treatments entirely, not taking seriously the potential positives, nor the possibility that one receiving the treatment might think the risk is worth taking.

Of course, detractors may point out that the bans target these treatments for children only. Perhaps, even if a reasonable adult could judge these treatments as beneficial, a child is not yet a competent enough decision maker for that choice.

Two points are worth raising in response. First, legal adulthood is an arbitrary threshold. The frontal lobe, the portion of the brain that deals with complex decision making and problem solving, does not finish developing until the mid-20’s at the earliest. Yet children in the U.S. may be competent enough to drive at 16, to vote at 18, to buy alcohol at 21, etc. We seem to view competent decision-making as a spectrum, not a binary. It is not immediately obvious why 18 is the appropriate threshold for when one has become competent enough to consent to gender-affirming treatment. Second, legal guardians already serve as the surrogate decision-makers in this context. If they cannot make competent informed decisions regarding gender-affirming care, then this implies that no one can. If the worry is that the many unknowns eliminate the possibility of informed consent, this view would call into question much of currently acceptable medical practice. Few treatments, if any, have their lifetime consequences known before approval. From 2001 to 2010, about one-third of all drugs approved by the FDA were found to have unexpected side-effects, some of which were life threatening. A purely precautionary approach would require a radical revision of how we think about medicine.

In closing, some perspective is warranted. Proponents of bans on gender-affirming care for underage patients, such as Tennessee’s Attorney General Jonathan Skrmetti, often cite European nations like Finland, Sweden, and the Netherlands beginning to walk back the use of hormonal treatments for minors seeking gender-affirming therapy as evidence supporting bans. Yet this willfully misrepresents the situation. These nations are ensuring that their current treatments more carefully adhere to the “Dutch Protocol,” not altogether banning the treatments. With a matter as intimate as a patient’s relationship to their own body, any universal approach seems like wielding a machete when a scalpel is required. Given the complexity of the issues involved, including the tradeoffs regarding uncertain consequences, decisions about these treatments seem best left to the particular parties involved – parents, patients, and medical providers – not the government.

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Pathologizing Values: When Should Patients Be Treated Against Their Will?

Many sufferers of anorexia nervosa — and similar eating disorders — intensely value thinness. They believe that thinness is of the utmost importance, more so than school, work, personal relationships, and their own physical health. Valuing thinness so strongly is harmful not only because of the malnutrition that follows but also because of how it undermines treatment. Treatment for anorexia leads (one way or another) to weight gain. Just as valuing thinness causes people with anorexia to lose weight, it can also cause them to refuse treatment that leads to weight gain.

How should clinicians respond when their patients refuse treatment? One possibility is to treat them against their will. In the case of anorexia, this involves detainment in in-patient facilities, which enforce strict protocols around feeding. In severe cases, it can also involve force-feeding through a tube. But is this ethical? On the one hand, such treatments can help sufferers to improve and prolong their lives. On the other hand, clinicians have a duty to respect their patients’ decision-making autonomy. This means respecting their decisions about what (if any) treatment they will receive — even decisions that seem irrational or harmful.

An illustrative example of the principle of decisional autonomy involves religion. Jehovah’s Witnesses often refuse blood transfusions due to their religious beliefs. That can result in death and could seem unreasonable from the perspective of those outside their faith. Nevertheless, such decisions are generally respected.

To exercise their decision-making autonomy, patients must be able to understand and appreciate the relevant medical facts. Many conditions, like psychosis or dementia, undermine this capacity. In such cases, patients are judged to lack decision-making competence, and coercive treatment is generally seen as warranted. Anorexia is a particularly perplexing case because those who suffer from the disorder often maintain their ability to understand and comprehend their treatment options. They are simply opposed to treatments that undermine their desire to be thin.

The philosopher and clinician Dr. Jacinta Tan advocates for one approach to justifying coercive treatment in the context of anorexia. She argues that the thinness values associated with anorexia are pathological — they belong to the disorder, not the individual. Because they are pathological, they can (and should) be distinguished from the agent’s authentic values, i.e. those that are genuinely her own. So, while someone with anorexia may be able to weigh their options and understand the relevant medical facts, they cannot freely decide on treatment because these (inauthentic) values get in the way.

The history of psychiatry suggests that we should tread carefully when it comes to pathologizing values. In the 1800s, drapetomonia was a supposed mental illness afflicting enslaved Africans. The central symptom was a strong desire to escape from captivity, leading to escape attempts. In trying to escape, these slaves were pursuing something they valued: freedom. But this value (according to certain psychiatrists from the Southern states) was pathological. The case of drapetomania illustrates an important principle: labeling values as pathological has serious consequences. We ought to, therefore, have a strong justification for the label.

Tan and her colleagues suggest basing such judgments on the co-occurrence between mental disorders and values. In the case of anorexia, intense thinness values occur (almost exclusively) in those diagnosed with the disorder, aren’t held before the disorder or after recovery, and their strength correlates with the strength of the disorder. According to Tan and colleagues, this strong co-occurrence between values and disorder justifies attributing thinness values to the disorder, not the person.

The cause of drapetomania illustrates the risk of this approach to pathologizing values. Escaping slaves who risked their lives to escape captivity did so because of their values — they valued freedom over a continued life in captivity, even one that brought (comparable) safety. However, having such a value system (and engaging in the escape behavior that follows from it) is precisely what attracted the ‘drapetomania’ label. Those values occur with drapetomania because having them is partly what it means to have drapetomania.

The same problem applies to anorexia. Intensely valuing thinness (and the resulting weight loss behavior) is deeply intertwined with diagnosis. Anyone who valued thinness with the intensity that anorexia sufferers do would engage in the same weight loss behaviors, therefore meeting the criteria for diagnosis. Co-occurrence tells us something about diagnostic categories but nothing about the authenticity of someone’s values. To dismiss thinness values as inauthentic, we cannot rely on co-occurrence alone.

One way to make progress on this issue is by better understanding the psychological factors that drive thinness values and how such factors relate to decision-making competence. Alternatively, ethicists might turn their attention to a different factor associated with anorexia.

Many sufferers of anorexia hold false beliefs about their body size. Experiments requiring patients to indicate their current size show that they consistently indicate body sizes much larger than their own. Indeed, sufferers of anorexia are often convinced that their bodies are larger than clinicians, family members, and friends insist.

Research suggests that these false beliefs are caused by misleading experiences of body size. Sufferers of anorexia genuinely perceive their bodies as larger than reality due to disturbances in the way their brain represents their body size. Their false beliefs are a natural response to these misleading experiences.

These false beliefs can, in some cases, undermine patients’ decisional competence. Consider an excerpt from an interview with a patient, recorded by Tan and colleagues:

Has the risk of death been mentioned? “Yeah.”

Do you believe these things you’ve been told? “No.”

About the risk of death, do you think it could happen? “Not to me.”

That’s the opinion of doctors, and I wonder why you don’t think it can happen to you. “Because you have to be really thin to die, and I’m fat, so it won’t happen to me.”

In this excerpt, the interviewee cannot understand that the relevant risks apply to them because of their beliefs about their own body size. This relates to an integral feature of decision-making competence. It isn’t enough that patients understand the relevant medical facts; they must also be able to appreciate how those facts apply to them. Some sufferers of anorexia are unable to do so because they don’t believe they are thin.

This illustrates how false beliefs about body size can undermine patients’ ability to reason about treatment, through a different route than what was proposed for thinness values. Tan and colleagues suggested that because thinness values are inauthentic, any treatment decisions that follow from them are similarly inauthentic. Body size beliefs, however, undermine decision-making competence not because they are inauthentic but because they distort sufferers’ reality. In doing so, they rob patients of the capacity to appreciate how medical risks apply to their situation.

It remains to be seen whether the thinness values associated with anorexia undermine sufferers’ decision-making competence and, if so, why. To solve that puzzle, we must understand more about the psychological factors that drive those values. But an equally important feature of anorexia related to decision-making competence is the body size beliefs involved. Such beliefs do not necessarily forfeit a patient’s right to choose their treatment. A clinician would need to probe the extent to which the beliefs are resistant to change and whether they are driving their patient’s treatment refusal. There is still much work needed to understand the relationship between body size beliefs and decision-making competence, but it represents a fruitful topic for future research.

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Body Integrity Dysphoria and the Gustavson Case

image of xrays of multiple body parts

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?

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The Unique Harm of Bramhall’s Liver Branding

photograph of surgeon in operating room putting on gloves

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.