Diabetic Foot Ulcer: Amputation on Request?

In 2000, a Scottish surgeon received significant publicity for amputating lower limbs from healthy patients who were thought to have a Body Integrity Identity Disorder (1). We present a type 1 diabetic patient with a recurrent foot ulcer who requested a lower-limb amputation. Although very different, this situation also created difficult ethical issues that we have attempted to address.

Peter C. Brown (aged 54 years) was diagnosed as having type 1 diabetes at age 21 years. Between early 2006 and November 2008, he had several admissions with a diabetic foot ulcer that partly resolved but never fully healed (2). By early November 2008 and after discussions with his family, he decided that he wanted a below-knee amputation. At the time of the request, he did not require surgery, and health professionals faced with a patient making such a request might conservatively refuse on the ethical grounds of “primum non nocere” (first do no harm). Professionally, doctors have an ethical and legal duty of care. The General Medical Council states that “an adult patient who has capacity may decide to refuse treatment even if refusal may result in harm to themselves or in their own death” (3). That negative right is quite different from a positive right—to insist upon an intervention that the doctor is obliged to give. Mr. Brown had capacity (4) and believed that the advantages of an amputation included removal of the discomfort, broad-spectrum antibiotic therapy, infection, and the frequent hospital visits. Mr. Brown also believed that with adequate support, he could become fully mobile again.

Within this clinical dilemma there are several ethical dimensions that need to be considered (5). The principles of beneficence (acting in the patient's best interests) and nonmaleficence (balancing risk and benefit) should be viewed as ethical obligations in all health care. The active pursuit of the patient's benefit and the avoidance of preventable harm underpin the professional code of medicine. In terms of nonmaleficence, it is imperative to balance the possible harm resulting from amputation against the possible benefits. This includes the unnecessary loss of a lower limb, the possible surgical and anesthetic risks, and the potential for the patient to regret the decision at a later stage.

Autonomy entails the patient's ability to consider, decide, and act for oneself and is a subclass of freedom: respect for Mr. Brown's wishes must at least be given appropriate regard. Lastly, the principle of justice is also fundamental to ethics in health care. The treatment option(s) preferred by a patient may place others, particularly his caregivers, in a disadvantaged position.

In accordance with good clinical practice and clinical decision making, the issue was discussed by the multidisciplinary diabetes and vascular teams as a whole. After numerous meetings and discussions involving all parties, the decision was made to set a date for an “elective amputation.” Unfortunately, Mr. Brown's foot ulcer became more infected; he deteriorated quickly and became systemically unwell. A collective decision was made to undertake an emergency amputation.