What Are the Ethical Issues in Treating a Patient With Bilateral Leg Gangrene Incapable of Consenting to Amputation Secondary to Psychiatric Illness?

The case we report is unusual and complicated from patient-care and bioethical standpoints, and underlines the importance of communication, collaborative multidisciplinary care, and continuity in medical care.

After a long period of observation, diagnoses of cluster-B borderline personality traits (Axis II) and major depressive disorder (moderate to severe–Axis I) [1] were made. The severe emotional stress experienced by our patient owing to the bilateral foot gangrene caused the Axis II disorder to further manifest, substantially interfering with psychiatric and surgical treatments. The loss of her feet would lead not only to the loss of physical integrity but also to the loss of her ability to work, earn wages, maintain her career and business, and her self-esteem. According to Kohut’s theory [16], self-objects are “external objects that function as part of the ‘self machinery’ and are not experienced as separate and independent from the self and are important for emotional survival.” The patient’s body of work was the “self-object” that helped her regulate and maintain self-esteem and psychological equilibrium. Bilateral amputations would threaten her career as a personal fitness trainer and occasional circus performer, therefore the amputations were seen as a substantial threat to her self-worth. Additionally, during her lucid periods, she stated that the loss of her feet and physical integrity would lead to eventual dissolution of her 7-year relationship; our opinion is that this belief triggered unconscious and underlying fears of abandonment [1] to which the patient was prone, further adding to her cumulative stress.

The patient’s actions and behavior caused members of the healthcare team to feel helpless and stuck, a phenomenon in psychoanalytics known as counter-transference [7]. This is a trait typical of borderline personality disorder [11], and a detailed developmental patient history revealed additional traits highly indicative of borderline personality disorder, including childhood sexual assault, oppositional behavior, unstable relationships, impulsivity, chronic feeling of emptiness, legal problems, and periods of homelessness. Making others around her feel helpless, as she felt, gave our patient, at an unconscious level, emotional and psychological relief. From a psychological point of view, identifying this proved helpful in gaining a better understanding of her psychological dilemma and helping her move forward. Respecting the patient’s autonomy while giving her time to mourn the loss of her feet were important in helping her make an informed decision.

Typically, in the case of patients who are capable of making medical decisions, the objective is to enable them to make an informed choice regarding available treatment options or alternatives, such as refusal. In Canada, as in some other liberal democracies, patients who are competent are legally entitled to refuse life-preserving clinical care. A continuation of clinical care against the express wishes of a patient who is competent amounts legally to assault. The process leading to informed consent or refusal depends on the presence of various factors to be ethically valid [8]. Beauchamp and Faden [3] proposed an influential conceptual framework for informed consent involving threshold, information, and consent elements. Threshold elements include the competence to understand and decide and voluntariness. Information elements include disclosure of relevant information, recommendation of a plan of action, and demonstrable patient understanding of the information elements. Consent elements include a decision in favor of a proposed course of action and clear authorization to follow the agreed on plan [3]. Our patient would have needed to be capable of giving voluntary informed consent that meets these standards.

It was determined that the patient was not able to understand the information provided nor did she show appropriate insight, therefore she was deemed incapable and her mother was appointed the substitute decision maker. The ethical rationale for the appointment was that the patient’s next of kin was more familiar with the patient’s values and convictions and so was best suited to make decisions on her behalf. This type of appointment is meant to be an imperfect extension of patient autonomy and the justification rests on empirical assumptions regarding the next of kin’s ability to make sound decisions on behalf of family members. Mirzaei et al. [12] suggested that when a substitute decision maker is appointed after a patient is deemed incapable (rather than chosen by the patient before becoming incapable), the decisions made by the substitute decision maker frequently are at odds with the patient’s wishes. It is for reasons such as these that the decisions made by the substitute decision maker generally are thought of by medical ethicists as carrying less normative force than the actual decisions reached by patients who are competent [6].

Despite family meetings attended by psychiatry, orthopaedic surgery, social work, and nursing, the substitute decision maker and family showed a lack of understanding of the facts and issues and continued to fixate on the need to amputate immediately. The psychiatric service stressed that an urgent amputation would not improve the patient’s psychiatric condition and the orthopaedic service reiterated that an urgent amputation without the patient’s participation was not indicated and likely would compromise her rehabilitation and lead to clinical deterioration. Whether dealing with a patient or a substitute decision maker, the surgeon reserves the right to refuse to perform a procedure as long as this refusal is not done based on moral or religious prejudice [14]. Furthermore, patients and families cannot demand procedures that are not indicated, contraindicated, or go against sound ethical principles [4]. In the considered view of the care team, the lack of understanding and appreciation of medical facts by the substitute decision maker prevented her from making a decision that was in the patient’s best interest. Disagreements between substitute decision makers and healthcare providers are not uncommon [13], and when disagreements arise, both parties are expected to collaborate to come to a decision that is in the patient’s best interest [18]. However, in Ontario, cases in which a consensus cannot be reached in a reasonable time can be appealed to the Consent and Capacity Board. In the current case, the family eventually agreed to a plan involving psychiatric treatment with daily orthopaedic followup for the patient, and therefore the surgical treatment was delayed.

In circumstances where patients are unable to make their own choices, and where they have left no advance directives, physicians are professionally obliged to adhere to the primum non nocere principle, one of the foundations of medical ethics. A version of the principle reported by Beauchamp and Childress [2] more frequently is referred to as do-no-harm-principle, or the principle of nonmaleficence. In the context of health care, harm typically refers to pain, disability, and death. Early amputation at the behest of the substitute decision maker and without the patient’s informed consent would have addressed the gangrene, established the ideal amputation level, and prevented immediate complications such as sepsis and death. The medical ethics principle of beneficence would prima facie support this course of action. However, the course of action also would have further immobilized the patient, and without her participation in postoperative rehabilitation, an increased risk of pressure sores, joint contractures, wound complications, and deep vein thrombosis would have occurred. The alluded to principle of nonmaleficence offers countervailing normative reasons to persons who called (prima facie, at least) for immediate surgery. Surgery brought with it serious risk of further complications. In the absence of autonomous choice-based informed consent, balancing the foreseeable risks and benefits of the available different courses of action, as far as they would affect the patient’s future quality of life, was what was needed. The team’s other rationale for taking this course of action consisted of attempting to restore the patient’s capacity to enable her to make an autonomous informed choice that was her own.

The patient was capable of interacting with staff on some days. During those periods she clearly communicated her desire to wait before undergoing amputation because she was not ready to make a decision. Her reluctance did not appear unreasonable considering her careers as a personal trainer and an occasional circus performer. In the views of psychiatry and orthopaedics, her feet had substantial emotional and professional values for her. Lower-limb amputation in a young, physically and mentally healthy patient is associated with substantial psychological burden [15]. Considering the stability and painlessness of the gangrene, the close surgical monitoring of her condition, and her history of psychological recovery, the surgical team concluded after careful evaluation that the benefits of surgical intervention without the patient’s participation in consent did not outweigh the risks of psychological harm to her prospects of recovery.

Subsequent developments confirmed the assessment reached by the multidisciplinary care team. The patient’s psychological condition improved sufficiently to permit her to make an informed, autonomous choice regarding her preferred course of action which was to undergo amputation and begin the process of prosthesis fitting, physical rehabilitation, and eventual recovery.

The presented case is difficult and complex, one which underlines the difficulty in providing high-quality and timely care to a surgical patient with severe, preexisting mental illness. However, it also underlines the effectiveness of the multidisciplinary approach when dealing with such complex medical and social issues. Although her prognosis from surgical and psychiatric points of view was guarded, at 8 months after the amputations, the patient has undergone prosthetic fitting and is participating in physical therapy and psychiatric followup. The outcome is attributable to collaboration among the surgical and psychiatric teams, nursing staff, social workers, family members, and hospital ethicists.