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Joseph OkaiHealthcare Ethics

Widow Refusing AmputationRC is a 77-year-old widow who has been somewhat confused and depressed since the deathof her husband one year ago. She is admitted to a hospital suffering from gangrene in her rightfoot and lower leg. The attending physician recommends amputation without delay. After somevacillation, she refuses to consent to the operation and still persists in that refusal.

Her relationship with her children is marked by conflict. She had lived on her own until hercurrent hospitalization. Her daughter, Grace, petitions Probate Court for appointment asguardian with authority to consent to the operation for her mother. An order and judgment to thateffect were issued by the Probate Court. The lawyer representing RC appealed and asked for amedical opinion.

Four years ago, she had an infection in her toe on her right foot, which becamegangrenous. It was discovered at the time she was diabetic and the toe was amputated. Twoyears ago, she bruised herself while getting into a bus. The bruise developed into gangrene,which resulted in an operation in which a portion of her right foot was amputated. After a six month stay in rehabilitation, itwas learned she had gangrene in the remainder of the foot. Twicein two weeks she consented to the operation after persuasion by a physician she had known formany years, but each time changed her mind and withdrew her consent on the day of theoperation.

The reasons for her change of mind were:1. She has been unhappy since the death of her husband.2. She does not want to be a burden on her children.3. She does not believe the operation will cure her.4. She does not wish to live as an invalid in a nursing home.5. She does not fear death, but welcomes it.

She is stubborn and somewhat irascible. She expresses a desire to get well, butindicates she is resigned to death and adamantly against the operation. She is lucid on somematters and confused on others. Her train of thought wanders.

A psychiatrist testified that in his opinion she was incompetent to make a rational choicewhether to consent to the operation. (She refused to discuss the issue with him.)Until she changed her original decision and withdrew her consent to the operation, hercompetence was not questioned.

I. What is/are the ethical issues, concerns, or conflicts?a. Given [ RCs persistent refusal of a life -saving amputation of her lower leg and the uncertainty

about her capacity to make this medical decision ], is the attending ethically justified in withholding

the life-saving surgery based on respect for her autonomy? If so, why? If not, why not and what stepswould be needed to ensure an ethically justifiable plan of care? 1. Whether or not the standard of patient autonomy is being upheld?2. Whether or not patient has decision-making capacity?

II. What are the facts of the case?a. Health issues:

1. 4 years ago, infection of toe Gangrene Led to amputation (Diabetes Diagnosis)2. 2 years ago, bruised right foot Gangrene Led to partial amputation of Right Foot3. Currently, found that part of her foot is still Gangrenous as well as a portion of her lower

leg ?4. If left untreated then what?

1. Bacteria can spread to other organs Fatal Outcomeb. Options for goals of treatment and probabilities of success

1. Amputate1. Aim to remove gangrenous limb and stop the bacteria from spreading as well as

prevent more damage of healthy tissue.a. Probability is pretty high if successfully performed

c. Contexti. Social dynamics and conflicts

1. Family Problemsa. Relationship with children marked with conflict

2. Possible Depressiona. Husbands deathb. Doesnt want to burden her children c. Doesnt believe operation will cure her d. Nursing homee. Welcomes death

ii. Legal issues1. Determination of competence.

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2. Daughter is lobbying for guardianship.d. What is best course of action from the medical perspective?

1. Amputation1. Remove gangrenous limb to prevent further complications and mortality.

e. What is the best course of action overall?iii. Who is the morally valid, legally valid decision-maker?

1. Does the patient have decision-making capacity?a. Competence/Incompetence Legal term that refers to an individuals

ability to make decisions about their affairs.b. Decision Making Capacity Medical term which refers to anindividuals ability to make medical decisions. Determined by medicalpersonnel.

i. Method of assessment (Practical Ethics, for Students,Interns and Residents)

1. Ability to Understand2. Ability to Evaluate3. Ability to Communicate

ii. If deemed lacking in Decision Making Capacity determinedto be de facto incompetent

c. Which term was used to describe RCs state in the courtroom ?d. Question to think about: Was our patient fairly assessed? What

next? 2. Is there a morally appropriate surrogate (or advance directive) if the patient lacks

capacity? Is there a legally valid surrogate?a. Daughter would be morally appropriate surrogate if court decision were

upheld.b. Guardianship appointment is being appealed

3. Have risks, benefits, alternatives (including non-treatment), and outcomes beenadequately conveyed?

a. Depends on evaluation of capacity.III. State the ethical arguments for and against each option:

a. Boils down to whether you treat or not.1. Amputate

1. Hinder patient autonomya. Patients moral right to decide for herself as well as physicians

obligation to respect and enhance that decision.2. Physician Determined vs. Patient Determined Beneficence

a. Acting in the best interest of the patient2. Dont Amputate

1. Uphold patient Autonomya. Hand in hand with patient determined b eneficence

IV. Decisiona. The attending is ethically justified in withholding the life- saving surgery based on respect for RCs

autonomy.1. Many patients with mental illness are still competent to make decisions about their

medical care.2. The ethically preferable treatment option can be implemented. We can choose to not

perform the amputation.1. Have to deal with family being upset.2. Have to continue to care for patient as best as we can.

V. Is conflict resolution possible? Is compromise possible without loss of moral integrity?a. Conflict resolution may be possible.

1. Eventual Surgery:1. Its important to have patients possible depression treated.2. Once depression is being actively treated patient may be more open to

discussing everything necessary in order to make a thoroughly informed decisionabout her health.

References:

Junkerman, Charles, Arthur Derse, and David L. Schiedermayer. Practical Ethics for Students, Interns, and Residents: AShort Reference Manual . Hagerstown, MD: University Pub. Group, 2008. Print.

Leo, Raphael J. "Competency and the Capacity to Make Treatment Decisions." The Primary Care Companion to TheJournal of Clinical Psychiatry 01.05 (1999): 131-41. Print.