859953

research-article20192019
SGOXXX10.1177/2158244019859953SAGE OpenHanna

Literature Review - Original Research

SAGE Open

“What Do You Want to Do With the

April-June 2019: 1­–8
© The Author(s) 2019
DOI: 10.1177/2158244019859953
https://doi.org/10.1177/2158244019859953

Leg?” A Critical Narrative Review of journals.sagepub.com/home/sgo

the Understandings and Implications

of Disposal in the Context of Limb
Amputations

Esmée Hanna1

Abstract
Amputation is seen to be a potentially distressing experience for patients and one which, for some patients, is seen as being
akin to grief. Historically, medical professionals have alluded to the relevance of considerations of disposal of amputates after
the process of amputation as being implicated in the psychological adjustment to amputation, yet limited understandings
around disposal are evident. The disruption of bodily integrity by the process of amputation also presents a disruption of
our norms around the disposal of human tissue, presenting challenges for how health care professionals can support patients
through enacting their decisions around disposal. This narrative review article then explores the existing literature around
disposal of amputates, drawing on literature from across the health and social sciences to examine what is known about
disposal. It then argues that our considerations of disposal remain lacking despite the increasing incidence of amputation
and the potential distress that not managing disposal can cause for some patients. It also examines the social implications
of disposal and how limitations around disposal can itself reinforce the overlooking of disposal within the process and
experience of amputation.

Keywords
amputation, limbs, corporeal, disposal, bodily integrity

Introduction diabetes-related lower limb amputations alone, occurring

Amputation, both emergency and planned, has significant
consequences for understandings of the body and subsequent
function of patients. Lower limbs are most commonly impli-
cated in amputation, with 90% of all amputations suggested
to involve a lower limb (Bradway, Malone, Racy, Leal, &
Poole, 1984). Common reasons for lower limb amputation
can be due to disease, such as diabetes, vascular disease, sep-
ticemia (including as a complication from acute illnesses
such as meningitis) or due to external trauma or other serious
injury to the limb. The prevalence rate for lower limb ampu-
tation in the United Kingdom is reported to be 26.3 per
1,00,000 (Ahmad, Thomas, Gill, Chan, & Torella, 2014), and
it is suggested that rates of amputation may double by the
year 2050 (Holzer et al., 2014). Amputation has been viewed
as an increasing medical practice, due in part to an aging
population and to increasing rates of diabetes and vascular
disease among the population as a whole (NCEPOD, 2014).
It is reported, for example, that there are currently over 7,000
annually within the United Kingdom (Majeed & Molokhia,
2015).
Concerns have also recently been raised in relation to the
lack of good care those undergoing lower leg amputation
receive (Mayor, 2014; NCEPOD, 2014) and the higher mor-
tality rate for U.K. amputation patients as compared with
those in the United States. There is also a North–South divide
in the United Kingdom in relation to the prevalence of ampu-
tation (Ahmad et al., 2014) in that patients in the North of
England are more likely to experience amputation. Rationale
for such divides and the reasons underlying poor care are
seen as requiring further investigation (Ahmad et al., 2014;
1
De Montfort University, Leicester, UK
Corresponding Author:
Esmée Hanna, School of Allied Health Sciences, De Montfort University,
Leicester LE1 9BH, UK.
Email: Esmee.hanna@dmu.ac.uk

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2 SAGE Open
Mayor, 2014). However, these features can affect signifi-
cantly on the experience of those patients undergoing ampu-
tation, thus are salient to note.
Much of the existing literature relating to amputation has
explored the psychological implications of amputation, sug-
gesting that “The psychological reactions of patients after
surgical or traumatic amputation of a limb are both varied
and complex” (Bradway et al., 1984, p. 46). Impacts on body
image and self-identity are, however, seen as common in
those undergoing amputation (Armstrong-James, 2015;
Senra, Oliveira, Leal, & Vieira, 2012). Differences in experi-
ence and adjustment to amputation can be related to a num-
ber of factors, including whether the need for amputation is
directly connected to mortality (Aravind, Shauver, & Chung,
2010) and the role of the amputation within the wider health
issues of the patient. The aftereffects of amputation, includ-
ing the adjustment of the altered corporeal form including
prosthesis (Crawford, 2012; C. D. Murray, 2005), and the
incidence and experience of phantom limb syndrome
(Crawford, 2014) have also been recently explored within
the small corpus of literature.
The body has increasingly been a site of social science
interest, in that “. . . bodies or even body parts (cells, genes,
organs, limbs, etc) are objects of importance that are ‘dis-
sected’ in an effort to explore the processes underlying their
emergence as interactional effects” (Crawford, 2012, p. 436)
although the experience of amputation has itself received
limited engagement within this, particularly about the expe-
riences of limb loss (Senra et al., 2012). The literature relat-
ing to disposal remains even smaller, raising the question of
why disposal of limbs has and continues not to attract
research interest, even within the context of the renewing
and flourishing wider social science engagement with under-
standings of the body (Crawford, 2012, 2014). This review
then seeks to explore the relevance and implications of dis-
posal in the context of lower limb amputation. In doing so, it
examines the need for disposal to be situated within broader
considerations of amputation and how disposal impacts on
the decision-making process and experiences of patients and
their families during the incidence of and adaptation too, the
loss of lower limb(s).
Method
Examination of the existing social science literature demon-
strates a dearth of work directly relating to the issue of dis-
posal within the experience of amputation. Searches on key
databases, specifically ACADEMIC SEARCH COMPLETE,
CINAHL, MEDLINE, PSYCHINFO, for the terms “ampu-
tation” + “disposal” provides only 18 results, three of which
included with the others being excluded as not relevant to
the scope of this review. The remaining 18 papers included
within this article were then drawn from Google Scholar,
primarily using the search terms “amputation” + “Disposal,”
as well as papers which were followed up in a purposive
manner when key sources were found. This narrative review
then draws on literature from the fields of psychology (such
as around adaptation to amputation and psychological impli-
cations of amputation), sociology (such as texts around the
body and embodied experience), medical and social scien-
tific work around phantom limb syndrome and prosthesis as
well as case reports and comment from medical profession-
als around amputation. Although 21 papers were specifi-
cally included in the literature, the paper draws in additional
supporting information from other academic research as
well as news and authority commentaries to examine the
key issues identifiable around disposal in the context of
amputation.
The diverse body of literature drawn upon demonstrates
the lack of any significant corpus of work pertaining to dis-
posal directly and the exploratory nature of this review.
Given the challenge of finding literature relating specifically
to the topic of disposal more generous inclusion criteria
relating to date of publication has been utilized than perhaps
one may otherwise do so for a narrative review (i.e., all dates
have been included). Although some of the literature included
here is dated, and contemporary thinking around the body
and patient experiences has moved forward extensively
within the last 50 or 60 years, why disposal featured in medi-
cal cases or commentaries historically, yet, is notably absent
now remains an important rationale for inclusion of such
works here. Papers were included based on their relevance,
specifically if they were discussing amputation (lower or
upper limb specifically), practices around disposal or meth-
ods for disposal of amputates and/or contributed to under-
standings that would contextualize disposal within the patient
experience of amputation (i.e., discussions of bodily integ-
rity, prosthetic technology, etc.). Given the dearth of avail-
able literature directly on the topic of disposal, an inductive
coding approach was adopted, which is advocated as a useful
method when the body of evidence is perceived as limited at
the outset of the analysis (see Elo & Kyngäs, 2008), and key
themes were then generated from this coding using a reflex-
ive approach to thematic analysis as advocated by Braun and
Clarke (2006). Thematic analysis is seen as a useful process
for the analysis of secondary data (such as in literature
reviews) and the now established six steps set out by Braun
and Clarke (2006) for this method were utilized—with
reflexive practice embedded at each stage. Final themes were
then read by a colleague to check for coherence and final
refinement was completed by the author.
This article then provides a starting point for exploring
the landscape around disposal following amputation, starting
from the research question of “what are the implications and
understandings of disposal following amputation.” Three
main thematic areas of literature were identified, relating to
the individual experience, the social considerations of human
“waste,” and the medical experience and context, and these
aspects are explored below, before wider conclusions and
suggestions for future research are outlined.
Hanna 3
Disposal of Amputates: The Individual
Experience
Existing literature points toward the consideration of dis-
posal of the limb to be part of the adaptation process that
patients may go through during the experience of amputa-
tion. Charmaz’s (1983) reflections of the experience of
chronic illness could thus be seen as highly applicable to the
context of amputation, “Chronically ill persons frequently
experience a crumbling away of their former self-images
without simultaneous development of equally valued new
ones” (p. 168). The loss of limb also potentially entails a loss
of self through the transgression and disruption of the corpo-
real form, thus adaptation to amputation is seen as a central
focus for the process of “recovery” of the self from the loss
of limb(s). Much of the literature on amputation then focuses
around the period after the patient has undergone the ampu-
tation itself (Grech & Debono, 2014; Holzer et al., 2014; C.
D. Murray, 2005). Disposal then receives very limited explo-
ration, perhaps pointing to the act of amputation, itself
viewed as a “violent intervention” (Shildrick, 2008), as the
marker between the fixed corporeal “whole” and the new
modified body and bodily experience, with disposal being a
by-product of this and caught within the interregnum.
Early research into amputation suggested that “Grief is
the universally identified reaction in those patients being told
that they must lose a limb” (Bradway et al., 1984, p. 47).
Although psychological and social disruption is viewed as a
central feature of the experience of amputation (Armstrong-
James, 2015; Holzer et al., 2014), grief can perhaps not be
universally assumed, as understandings of the variance of
both patients and their experiences becomes more widely
understood, including evidence about elective amputations
(Bayne & Levy, 2005; Müller, 2009; Patrone, 2009), which
are sought by patients rather than being “solutions” to a
health crisis. The grief or sadness patients may experience is
seen as being focused on the loss of functions and changed
future from that which may have been perceived (Bradway
et al., 1984; Jansen & Baart, 2018; Senra et al., 2012), again
focusing on the before/after dichotomy created by the act of
amputation. Bradway et al. (1984) do, however, identify that
in the preoperative phase for those undergoing nonemer-
gency amputations that
Questions regarding the exact nature of function and use of a
prosthesis, future sexual function, and even disposal of the
amputated limb are all questions which are also prominent in the
minds of potential amputees. (p. 47)
To borrow from the work of Crawford (2012), the amputate,
can perhaps be viewed as part of the “apparent ‘residue’ of
that which is no longer ‘me’ but still definitively ‘mine’” for
patients (p. 445). One of the core reasons that patients who
opt for reconstruction rather than amputation for severe
lower limb trauma is reported to be due to the personal
attachment to the limb “I don’t want to lose my leg because
it’s mine” (Aravind et al., 2010, p. 2024). In that context,
then the desire for patients to understand how part of their
bodies will be disposed seems entirely understandable and
may form part of the process of grieving and adaptation to
the new sense of self. Auto-ethnographic work, such as that
of Sobchack (2010) offers one of the few insights into the
patient experience of disposal. Sobchack (2010) reports ask-
ing “where, indeed, was my leg?” after amputation (p. 55).
Her enquires to health care professionals regarding what had
happened to her amputated leg, were, however, met with no
reply. Qualitative explorations with patients around this issue
is then currently lacking from the literature and would be
required to enable a more comprehensive understanding of
the questions patients may have around disposal and their
choices in light of these.
Some recent contributions from medical professionals
demonstrates that some patients, in the way Sobchack (2010)
was, are indeed raising concerns around the disposal of their
amputate(s). Rudd (2014), for example, describes the con-
cern of a patient regarding the disposal of his lower leg “He
was concerned about the dignity and disposal of his leg, and
that there was no guarantee that his leg would be reunited
with his body during his eventual cremation on death” (Rudd,
2014, p. 28). Rudd further details the apprehension of what
would happen to the leg was causing the patient stress during
the preoperative phase and suggests that there is a “need for
local guidelines for staff, and better information for patients,
on what can be done with a limb after amputation” (Rudd,
2014, p. 28). Similarly, Marlow (2008) notes that he faced
requests from patients regarding their desire to have their
amputates cremated “After such a traumatic decision pro-
cess, they might want their ashes as a memorial or simply
consider how they would like their amputated leg treated
with dignity” (Marlow, 2008, p. 774).
Recent work by Jansen and Baart (2018) examines the
legal “ownership” of limbs and expresses the importance of
doctors ensuring patients have been given the full options
regarding disposal and sees this as an integral part of
informed consent. They also usefully note the imbalance
between knowledge around disposal after amputation
between doctor and patient and thus stress that the doctor
should ensure the patient is fully aware of their options and
choices for good patient outcomes following amputation
(Jansen and Baart, 2018). The discussion within these arti-
cles focuses around patients’ concerns around “dignity” for
their amputated limbs, again echoing Crawford’s (2012)
notion of me/mine and the desire for patients to have “clo-
sure” around the transition of their amputate from being part
of them to not becoming part of them. As Blood (1956) notes,
It has been pointed out that patients experience the loss of an
amputated part as if it were the loss of someone close to them
whom they love; and that they expect the lost part to be cared for
with due respect. (p. 122)
4 SAGE Open
Given as Sobchack (2010) describes, that they are “our
body parts- our bodies in parts” (p. 55), thus, it is perhaps
understandable that patients would seek to know of and
secure a dignified solution for the disposal of their “body
parts.”
Although for some patients the process of amputation and
the disposal of the amputate is part of the abject (Kristeva,
1982)—in that consideration of the detachment and then
detached limb may be seen as grotesque or gruesome for
some—for others the disposal of amputate(s) after their “last
moment of life” (Crawford, 2012, p. 439) remains relevant to
their psychological adjustment and adaptation to and through
a process that entails “abandonment of the notion of inte-
grated embodiment” (Shildrick, 2008, p. 34; Jansen & Baart,
2018). Riding (1976) reported that there were class differ-
ences around concerns about disposal, with those without
higher education more concerned about the issue of disposal
within the context of amputation. Solomon and Schmidt
(1978) report that awareness of concerns around disposal can
also help with the mitigation of phantom limb syndrome, a
condition in which patients continue to “feel” their absent
limb after the process of amputation, in that “The phantom
appendage represents the organized impression of a person’s
image of his body before loss of the limb” (Blood, 1956, p.
121). Solomon and Schmidt (1978) note the case of a patient
who felt “burning” sensations in the “phantom limb,” which
was ultimately attributed to the patients’ feelings of her limb
being incinerated against her wishes. Similarly, Sherman
(1996) reports of a case of water being poured on a burnt
amputate to resolve phantom sensations of “burning” for the
patient. Other historical medical cases similarly note the
relationship between phantom pain, adaptation to amputa-
tion and disposal. Blood (1956), for example, describes a
patient undergoing a second amputation, and that “It is
believed that discussion with the patient, before the second
operation, of the method of disposal of the limb and his
knowledge of disposal of the first amputated part helped to
alleviate his anxiety” (p. 116). Disposal can then for some
patients be a source of anxiety, and lack of consideration to
disposal can contribute to continued negative feelings after
amputation, as well as being implicated within phantom limb
syndrome itself. It does, however, appear that disposal itself
is receiving limited considerations both in the abstract and
practical sense, and that some health care professionals
would like to see greater guidance and patient information to
help support the process.
The Social Considerations of
Human “Waste”
Those undergoing limb amputation creates what Leder
(1990) terms “dysapperance” in that the body that is experi-
encing change or transformation is brought into the gaze
(specifically in terms of the self-awareness in the sense Leder
refers to, but such gaze could potentially encompass the
broader social gaze if we extend our considerations of the
modified body). Such processes go against the desire for
“clean and proper” corporeal selves, as Shildrick (2008)
notes,
we demand of modern biomedicine that all disruptions to the
self’s “clean and proper body” should be dealt with, that the
actual vulnerability of the embodied self and its propensity to
diverge from the normative structures of health and well-being
should be covered over. (p. 34)
Therefore, it is perhaps unsurprising within this context that
disposal of amputates has received and continues to receive
limited consideration within medical contexts and even
within the academic exploration of the meanings and experi-
ences of bodily transgressions. Although amputation can be
seen in some instances as a means for forestalling permanent
bodily disruption, that is, death, it does as Shildrick (2008)
suggests, reduce “the corpus to its component part” (p. 34)
and in doing so creates a paradox of expired bodily part yet a
living body. In doing so, this then creates a challenge to our
socially normative approaches to the disposal of the deceased.
The amputate is then not a “proper body” (Shildrick, 2008, p.
32) but a “component part” and seen as “waste” rather than
as deceased. As Marlow (2008) points out,
A crematorium cannot cremate any human tissue or organs from
a living person. Paradoxically, patients are within their rights to
sign for their leg and take it away with them; they may bury it
themselves or burn it on a bonfire. (p. 774)
Thus, for the patient options for disposal are seemingly
unconventional, in that they would require or involve the
patient themselves undertaking or arranging the direct dis-
posal of their own limb, and taking the notion of “a man [sic]
is the master of his own body” (P. M. Murray, 1990, p. 109)
to a new dimension.
Rudd (2014) also details the challenges of disposal within
the clinical setting:
a hospital’s waste management service can incinerate a limb and
return the ashes to the patient. Patients’ can personally dispose
of their amputated limbs as long as this is done in accordance
with the Human Tissue Act 2004 and the Cremation Regulation
2008, but crematoria cannot cremate human tissue or organs
from a living person as certification of death is require to do this.
(p. 28)
This further demonstrates the “otherness” of the amputate,
neither living nor deceased, but rather a by-product of the
necessary modification and maintenance of bodies to prevent
their further discord. Patients may also struggle with know-
ing whether discussions around disposal are deemed “appro-
priate” as Blood (1956) notes of one case;
Hanna 5
When asked if he knew what disposal had been made of the
amputated limb, the man became panicky and said that he did
not want to know. Then he quieted and said that he had wanted
to ask but was afraid he “would be laughed at.” (p. 117)
Therefore, in the process of amputation and consideration of
disposal not only do we see the desecration of the corporeal
form, but we see a transgression of social norms regarding
both our conversations around and the actual disposal of
human tissue. This sense of transgression occurs due to
amputation sitting at this liminal space, constructed from the
power relationship of doctor and patient—in which patients,
such as the one quoted in Bloods’s (1956) case study above,
do not want to raise questions about the amputate, but also
due to our norms around whole bodies and their disposal—
something that society often struggles to discuss despite its
regularity of occurrence. Social cues around disposal, there-
fore, appear to be lacking, and these are further reinforced by
a lack of straightforward options for patients to make regard-
ing their wishes for the disposal of amputates. Recent news
reporting of the issue of disposal of amputates included com-
ment from amputation patients, one of whom noted the pos-
sible need for patients to say “goodbye” to their limbs in the
same way people may do after a death; “Whether or not it
causes problems it is a part of you, and I understand the need
to say goodbye” (Rowswell, 2016, cited in Parkes, 2016).
To deal with the need for options regarding the disposal of
amputates, a chaplain from Sheffield Teaching Hospital has
set up a burial space for limbs (Parkes, 2016). This is reported
to be the first of its kind in the United Kingdom and its role
or use in the management of disposal and possibilities it
holds for helping patients in the adjustment to amputation is
as yet uninvestigated. Such settings may, however, provide a
social solution to the disposal of amputation, allowing for
conventional practices for the bereaved to lay to rest the
departed human, or limb, within the instance of amputation.
Given that there is seen to be a broad-ranging experience of
social disruption for amputees (Holzer et al., 2014) provid-
ing more normative solutions for those who wish to say
“goodbye” to their former appendage may be fruitful as well
as ethical position for medical professionals to offer (Jansen
& Baart, 2018) as part of rehabilitation process for those
adapting to amputation.
The Medical Experience and
Context of Disposal
As noted earlier within this article, there is seen to be a lack
of good care around amputation and it has been suggested
that there should be “development of a ‘best practice’ clinical
care pathway covering all aspects of the management of
patients who need an amputation” (Mayor, 2014, p. 1). This
pathway could usefully, given the role that questions of dis-
posal may place in adaption and psychological well-being
after amputation, also include consideration of disposal.
Early work around amputation encouraged such consider-
ations (primarily to help avoid phantom limb syndrome)
“Discussing the methods of disposal of amputated parts with
the patient before amputation and allowing the patient his
choice of burial, cremation, or preservation of the part in
fluid have been suggested” (Blood, 1956, p. 122). Recent
work too calls for further exploration of this aspect as part of
the care of those undergoing amputation;
Though this unusual experience, I also identified the need for
local guidelines for staff, and better information for patients, on
what can be done with a limb after amputation. Standard policies
and procedures would help raise awareness of this issue and
signpost patients and staff to the appropriate services. A person’s
remains could then be dealt with in a way that respects their
beliefs and end-of life decisions. (Rudd, 2014, p. 28)
Within the medical context of amputation, the outcome for
the “lost” parts (Shildrick, 2010) seems often absent from the
discourses, focusing more on the before and after, rather than
the act and by-products (i.e., amputates) of “desecration” of
the body. The existing literature on amputation displays a
strong narrative around rehabilitation, seeing the aftercare
for amputees as central to the avoidance of further psycho-
logical and social issues (Armstrong-James, 2015). The
importance placed on the need for patients to access and
adapt to a prosthesis, for example, is common within the lit-
erature, with the prosthesis noted as being an important
means for maintaining body schema (Holzer et al., 2014).
Prosthetics are, therefore, seen to have a social as well as
pragmatic role, enabling amputees to maintain their presen-
tation of the self (C. D. Murray, 2005). Although the need to
“look forward” in terms of rehabilitation is not to be deni-
grated, it may, however, further serve to cast aside the pro-
cess of amputation and the possible need for considerations
in patient care around disposal. If, however, we take Bradway
et al.’s (1984) contention that “with better understanding of
an amputees’ psychological and physical needs, they need
not become more disabled than necessary by the loss of their
limb alone” (p. 50) then integration of considerations of dis-
posal into patient care may be an important feature of the
care pathway and best practice for those undergoing lower
limb amputations. Although work such as Bradway et al.’s
(1984) is now dated, the ideas within around the importance
of patient-centered care that aligns to their beliefs seems as
relevant now, particularly in the time of increasing patient-
focused agendas around health care and self-management.
Discussion
Considerations of disposal are notable by its absence from
literature around amputation and the medically necessitated
alteration of the corporeal form. Although considerations of
the psychosocial experience of amputation (Holzer et al.,
2014; Armstrong-James, 2015; Grech & Debono, 2014;
6 SAGE Open
Senra et al., 2012), the use of prosthesis (Holzer et al., 2014;
Crawford, 2014; C. D. Murray, 2005) and the embodied
experience of incidences of phantom limb syndrome
(Crawford, 2012, 2014) are evident within the literature that
encompasses amputation, disposal remains underexamined.
From the limited evidence, disposal is suggested to be a fea-
ture of preoperative anxiety for some patients (see Marlow,
2008; Rudd, 2014), and consideration of and assurances of
dignity can be important to some patients in their acclimati-
zation and subsequent adaption to amputation. More sus-
tained and detailed exploration of this is, however, required
to fully understand the individual experience and implica-
tions of disposal within the patient experience. Reflections
on disposal could in turn shed light onto important elements
of corporality, the embodied experience of amputation and
our societal considerations of human “waste” and how we
categorize and manage limbs that ultimately become
amputates.
This review then also details how very early medical
commentaries suggested that those who have unmet con-
cerns around disposal are more likely to experience psycho-
logical distress from amputation or phantom limb syndrome
(Blood, 1956; Bradway et al., 1984; Solomon & Schmidt,
1978), which will require subsequent management. Some
medical professionals are also calling for more discussion
around disposal of amputates (Jansen & Baart, 2018; Marlow,
2008; Rudd, 2014) and for better guidelines and practices.
The founding of a burial space for amputates also demon-
strates a perceived demand and need for means to address
dignified disposal of amputates (Parkes, 2016).
Simultaneously, evidence suggests that care for those receiv-
ing amputations is often not meeting best practice (Mayor,
2014; NCEPOD, 2014) and consent by doctors does not cur-
rently meet the legal and ethical situation relating to who
“owns” amputated limbs (Jansen & Baart, 2018), thus a more
patient-centered pathway for amputation could potentially
usefully expand to include disposal. Given the rising rates of
diabetes and other vascular diseases, it is time to consider
disposal of amputates given that the incidence of amputation
will increasingly affect more people (Holzer et al., 2014).
Our conceptualization and understandings of the body has
within the social sciences become more nuanced and sophis-
ticated in recent years, as Shildrick (2010) notes “What we
are belatedly realizing is that the body, far from being a fairly
standardized and self-contained entity, is highly plastic and
rich in the possibilities of intercorporeality” (p. 12). Yet, the
question of amputation, in raising the issue of something
being “mine,” but no longer part of “me” (Crawford, 2012)
demonstrates the liminal space that the amputate as anatomy/
object occupies. The body is alive, but the limb is no longer
part of it, and thus ceases to be part of the corporeal form.
This is then echoed in the challenge of how to handle the
wishes of patients around their former limbs—ready access to
cremation or burial of amputates is restricted, being seen as
the preserve of death of the “entire” body, rather than of parts.
Cremation can be facilitated through medical incineration,
but does, however, create connotations of amputates as
“waste” rather than something that is mourned and grieved by
the owner of those once functional limbs. Social practices for
the dealing with the intact remains of humans, therefore, do
not appear to be yielding to encompass the remains of those
who have faced and mourned their limb(s) amputation.
We then need to know more about the experiences of dis-
posal in the amputation experiences of patients, to establish
its importance or relevance to them and to consider the deci-
sion-making process they may or may not have engaged
with. Much of the literature detailing case encounters around
the problems that the lack of consideration or discussion of
disposal can cause is now significantly dated and requires
updating. Religious principles have been indicated as being a
component in why patients may state preferences around dis-
posal, due to beliefs about how the body should be handled
in death, and cultural differences around the practice of
amputate disposal could also usefully be explored within
this. The voices of those who have made decisions around
disposal is, therefore, lacking from the literature around
amputation, and only through further investigation with
those to whom this directly impacts, patients, their families,
and health care professionals can have better understandings
of what guidance and support those groups may need in rela-
tion to decisions around disposal. Key avenues for explora-
tion could include the following:
1. Why are considerations of disposal so lacking from
our understandings around amputation, the body and
how we manage human tissue?
2. Patient and family preparedness around disposal—
how and in what form are conversations taking place
around the disposal of amputates? Do these meet the
needs of patients and their families (who may be
decision makers in the instance of emergency ampu-
tations), what other information, if any, would they
like around disposal?
3. How is disposal being discussed and offered across
different health care settings? Mapping of the infor-
mation and options offered to patients to gain and
insight into the landscape around disposal and the
consistency of this between geographic locations and
across cultural groups.
4. For patients who choose to take their amputates
home, or seek individual incineration and possession
of the ashes, or who utilize burial facilities (where
available)—how did they find the process and deci-
sion making around this? And what impact did their
choices have on their experience of adaptation too
and grieving for their lost limb.
5. For those whose wishes around disposal were not
able to be enacted, how did this impact on their
patient experience and subsequent feelings around
their amputation?
Hanna 7
6. The relationship between phantom limb syndrome
and disposal—how does considerations around how
their limb was disposed of feature within the phan-
tom symptoms patients describe?
7. How do we as a society define and then “manage”
medical waste, specifically drawing on Crawfords’s
notions of “me/mine” and contemporary theorizing
around the body, such as new materialism—how can
we extend our understandings of amputates within
contemporary society and explore the relationship
between human tissue and “waste”?
8. Considerations of how we theorize the topic is needed
so that coherent theorization of the importance of dis-
posal can be made. Drawing on approaches from
(social) phenomenology, neuroscience, theories of
affect, or psychoanalysis may be useful, but will
require exploration to understand the contribution
they could make to our understandings of disposal.
Understanding disposal in the context of amputation, there-
fore, offers potential, both in terms of understanding and
potentially improving patient care and experience around
amputation, particularly in the context of rising rates of
amputation due to diabetes and questions about the adequacy
of existing care, but also in terms of extending our under-
standings of the corporeal and specifically of how we con-
sider body parts in the aftermath of their amputation from the
embodied “whole” and the dichotomy of amputates belong-
ing to patients but no longer physically being part of them.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Esmée Hanna https://orcid.org/0000-0002-0649-6620
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Author Biography
Esmée Hanna is lecturer in Health, Wellbeing and Society at De
Montfort University, Leicester. With a background in Sociology,
her work uses qualitative approaches to explore health in relation to
the body, gender and reproduction.