This essay follows up on yesterday’s essay, Orbiting Planet Madness: Consenting to Puberty and Other Absurdities.
Polydactyly is a congenital condition where a human or other animal is born with extra fingers or toes. The extra digits can be fully formed, but are often only partially formed. It can be genetic or the result of a syndrome. Polydactyly is one of the most common congenital limb malformations. It occurs in approximately 1 in 500 to 1,000 live births worldwide, which means that a lot of extra digits are surgically removed in childhood. Polydactyly can result from mutations in several genes involved in limb development, particularly those affecting the Sonic Hedgehog (SHH) signaling pathway, which is crucial for digit patterning during embryonic development. Yep, you read that right: it’s called the Sonic Hedgehog signaling pathway (I didn’t believe it, either). When an extra digit has bone, joints, or tendons, doctors typically recommend surgical removal and reconstruction to improve appearance and function.
Perhaps we must adjust our language: Most humans have ten fingers, though variations exist due to genetic and developmental factors. That’s fine with me (as long as we don’t then suggest that the number of digits on the human hand is “on a spectrum”). However, beyond physical differences, some individuals experience a mismatch between their perceived and actual number of fingers. This is a situation where a person’s internal sense of their body (body schema) doesn’t match their physical anatomy, leading some to seek surgical alteration. (I have written about this before with respect to limb amputation; see The Exploitative Act of Removing Healthy Body Parts.) In rare cases, a person may feel they have six fingers on each hand when they don’t and may seek the removal of a digit to match their internal body perception, leaving them with only four digits per hand.
This phenomenon provides us with a scenario with which to check the integrity of medical ethics. What if, after surgery, the person looks at his hands and now sees only four digits on each? He can’t have his fingers back since the surgery is quite involved and irreversible. Was it ethical for a doctor to remove the patient’s imagined sixth digit? The man was clearly delusional, seeing six fingers where there were only five, and now, confronted with only four, discovers he not only deceived himself, but that the doctor affirmed his deception and mutilated his hands. Even if he now sees five digits, was it ethical? The surgeon knows what he did. He never had extra digits either way. Whether he immediately, later, or never sees that he now has only four digits, we are confronted with a problem: a doctor affirming a delusion and mutilating a man’s hands.
In a philosophy class, a teacher might ask his students to ponder the ethics of such a case, which hinges on the principles of autonomy, beneficence/non-maleficence, and informed consent. He might note that, on the one hand, medical ethics generally uphold a person’s right to bodily autonomy. If an individual experiences deep distress due to a perceived mismatch between their body and their internal perception of it, some might argue that removing the “extra” digit is an act of compassion, akin to “gender-affirming surgeries” or procedures for body integrity dysphoria (BID). Put to one side for the moment the problematic character of these supposed acts of compassion. It will only be a moment because what I say next blows up the acts of compassion claim in both the cases of gender dysphoria and BID. Indeed, the other hand would likely result in a student going to the professor’s chair or dean and complain about a class that problematized the core premise of gender ideology, specifically the pseudoscientific notion of “gender identity.”
The professor might ask the students to suppose that the case of a man who imagines polydactyly differs from a BID case in a crucial way: the perception of extra fingers was a delusion rather than a physical or neurological variation. The patient did not, in reality, have six fingers, yet a doctor, rather than addressing the underlying cognitive or psychological condition that led the patient to believe an observable falsehood, affirmed the false perception by surgically altering the body to match it. But how would the doctor know? What medical test allows a doctor to tell the difference between a man who falsely believes he has extra digits and a man who truly believes he has an extra digit? I might now move on from what the reader may perceive as an analogy, except it is not an analogy—it’s the thing itself. The professor may ask the students to ponder whether this scenario raises serious ethical concerns about non-maleficence (“do no harm”)—that the doctor is complicit in harming the patient by enabling a delusion instead of treating its root cause—but since a man cannot be a woman, then his internal sense of gender must always be delusional. SO why the double standard?
The professor might ask whether the patient in the scenario, post-surgery, realizes that he has made a grave mistake, which makes the ethical implications even starker. The procedure was irreversible, and the doctor, rather than alleviating suffering, may have contributed to permanent physical and psychological damage. This raises questions about informed consent—was the patient capable of making a truly informed decision while operating under a false belief? Should the medical profession have safeguards in place to prevent such surgeries in cases where the patient’s perception is demonstrably false? If we say yes to both, then where do we draw the line between respecting autonomy and preventing harm? If we say no, are we not endorsing the medicalization of delusions and self-destructive choices? Again, since the patient’s perception of gender in cases of gender dysphoria is demonstrably false, we are objectively medicalizing delusions and self-destructive choices. While we may say that an individual is free to wish to permanently alter his body, we cannot say that gives a doctor a license to permanently alter the body of a delusional person.
The professor would tell students that the scenario highlights the ethical tension between respecting individual autonomy and ensuring that medical interventions truly serve a patient’s well-being. But is there really any ethical tension here? If medical professionals knowingly affirm (validate) and act on a delusion rather than addressing its psychological roots, they cross the line from healers to enablers of harm. The ethical course of action would have been to refuse the surgery and instead offer psychiatric care. The question of whether there should be clearer medical guidelines preventing such procedures in cases of misperception already has its answer. The line is clear: any doctor—or anybody else, for that matter—who removes a delusional man’s fifth digit has committed an atrocity. The scenario forces rational minds to reconsider their view that autonomy should extend to cases of irreversible medical decisions where there is no objective underlying medical condition.
As readers ponder this matter, they might also ponder whether it is ethical for parents to remove the sixth digit on their child’s hand who suffers from polydactyly. The parents could wait until the child is old enough to decide for themselves (as a guitarist, I might have an advantage with an actual functional sixth digit, which might be worth the grief I’d experience at the teasing of other children or other guitarists accusing me of an unfair advantage). But there is no ethical problem with surgically removing a sixth digit since this condition is not normative for digital patterning.
In the case of correcting the problem of a micropenis (which I discussed in my last essay), parents must treat this condition because of the critical window of genital development. If the micropenis is due to low testosterone levels, a doctor prescribes a short course of testosterone therapy, usually in the form of intramuscular injections or topical gel, to stimulate penile growth during early childhood or puberty. In cases where hormone treatment is ineffective, or if there’s a developmental or genetic disorder, the doctor may refer the child to a pediatric endocrinologist or urologist. In rare cases, surgical options such as phalloplasty may be considered later in life if the condition significantly affects function or self-esteem. Psychological support and counseling may also be recommended to help with emotional and social concerns. None of this is gender-affirming care in the industry sense, but ethical medical intervention to address an anomaly—that is, actual gender-affirming care. To hell with the parents who love their son just the way he is. It’s not their life. It’s his.
I’m not a philosophy professor. If I were, I would hesitate before using the scenario in an ethics class because of the chill put in the air by trans activists. I would likely get in trouble for broaching the subject. Indeed, having such a discussion is not beyond the boundaries of my discipline of sociology, yet I dare not interrogate such a problematic, whatever its value in interrogating matters of social power. To illustrate the problem, I conclude with a case of a teacher who dared to broach the subject of gender critically and an op-ed by a student that confronts the climate of self-policing and the impact that has on the promise of higher education. (See my recent essay Identity-Based Academic Programming and the Scourge of Heterodoxy.)
Kathleen Stock, a philosophy professor at the University of Sussex, UK, argued against gender self-identification and supported gender-critical feminism. Students and activists—even her colleagues—accused her of transphobia, leading to protests and calls for her resignation. Stock resigned in 2021, citing a hostile work environment. She described the climate as “medieval” ostracism. Of course, the accusation of transphobia (like Islamophobia) presumes the validity of the concept; it’s a propaganda term to harass those who criticize or question what is—anthropologically and sociologically—effectively a religious system. Perhaps that’s why it remains an effective rhetorical weapon in policing speech; once an ideology is wrapped in religious symbology, its congregation becomes a protected class.
This climate has impacted students, as well. Emma Camp, a student at the University of Virginia, wrote an op-ed in The New York Times criticizing the university’s handling of gender identity issues, including policies related to transgender students. She argued that the emphasis on gender identity in academia stifled free speech and that professors were reluctant to engage in debates over gender. Professors who shared her viewpoint on gender identity faced criticism, with some calling for policies that would restrict public discussions or certain types of discourse around gender identity. No professors were formally disciplined, but the controversy was enough to chill the air. Camp’s op-ed is worth a read: “I Came to College Eager to Debate. I Found Self-Censorship Instead.”
freedom and reason 