A. Collier

A. Dowie

Appelbaum

I. Malik

Lavery

P. C. Brown

S. Boom

S. Ghosh

English

PubMed

Collier, A.

Dowie, A.

Ghosh, S.

Brown, P.C.

Malik, I.

Boom, S.

Enlighten

       Collier, A., Dowie, A., Ghosh, S., Brown, P.C., Malik, I. and Boom, S. (2011) Diabetic foot ulcer: amputation on request? Diabetes Care, 34 (10). e159. ISSN 0149-5992  http://eprints.gla.ac.uk/57612  Deposited on: 18 November 2011   Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk OBSERVATIONSDiabetic Foot Ulcer:Amputation onRequest?In 2000, a Scottish surgeon received sig-niﬁcant publicity for amputating lowerlimbs from healthy patients who werethought to have a Body Integrity IdentityDisorder (1). We present a type 1 diabeticpatient with a recurrent foot ulcer who re-quested a lower-limb amputation. Al-though very different, this situation alsocreated difﬁcult ethical issues that wehave attempted to address.Peter C. Brown (aged 54 years) wasdiagnosed as having type 1 diabetes at age21 years. Between early 2006 and No-vember 2008, he had several admissionswith a diabetic foot ulcer that partly re-solved but never fully healed (2). By earlyNovember 2008 and after discussionswith his family, he decided that hewanted a below-knee amputation. At thetime of the request, he did not requiresurgery, and health professionals facedwith a patient making such a requestmight conservatively refuse on the ethicalgrounds of “primum non nocere” (ﬁrst dono harm). Professionally, doctors have anethical and legal duty of care. The GeneralMedical Council states that “an adultpatient who has capacity may decide torefuse treatment even if refusal may resultin harm to themselves or in their owndeath” (3). That negative right is quitedifferent from a positive right—to insistupon an intervention that the doctor isobliged to give. Mr. Brown had capacity(4) and believed that the advantages of anamputation included removal of the dis-comfort, broad-spectrum antibiotic ther-apy, infection, and the frequent hospitalvisits. Mr. Brown also believed that withadequate support, he could become fullymobile again.Within this clinical dilemma there areseveral ethical dimensions that need to beconsidered (5). The principles of beneﬁ-cence (acting in the patient’s best inter-ests) and nonmaleﬁcence (balancing riskand beneﬁt) should be viewed as ethicalobligations in all health care. The activepursuit of the patient’s beneﬁt and theavoidance of preventable harm underpinthe professional code ofmedicine. In termsof nonmaleﬁcence, it is imperative to bal-ance the possible harm resulting from am-putation against the possible beneﬁts. Thisincludes the unnecessary loss of a lowerlimb, the possible surgical and anestheticrisks, and the potential for the patient toregret the decision at a later stage.Autonomy entails the patient’s abilityto consider, decide, and act for oneselfand is a subclass of freedom: respect forMr. Brown’s wishes must at least be givenappropriate regard. Lastly, the principleof justice is also fundamental to ethics inhealth care. The treatment option(s) pre-ferred by a patient may place others, par-ticularly his caregivers, in a disadvantagedposition.In accordance with good clinical prac-tice and clinical decision making, the issuewas discussed by the multidisciplinarydiabetes and vascular teams as a whole.After numerous meetings and discussionsinvolving all parties, the decision wasmadeto set a date for an “elective amputation.”Unfortunately, Mr. Brown’s foot ulcer be-came more infected; he deterioratedquickly and became systemically unwell.A collective decision was made to under-take an emergency amputation.ANDREW COLLIER, FRCP1AL DOWIE, FRCGP2SUJOY GHOSH, MD1PETER C. BROWN3IQBAL MALIK, FRCP1STEVEN BOOM, FRCS4From the 1Department of Medicine, Ayr Hospital,Ayr, U.K.; the 2Faculty of Medicine, University ofGlasgow, Glasgow, U.K.; 3patient, Ayr Hospital,Ayr, U.K.; and the 4Department of Vascular Sur-gery, Ayr Hospital, Ayr, U.K.Corresponding author: Andrew Collier, andrew.collier@aaaht.scot.nhs.uk.DOI: 10.2337/dc10-2183© 2011 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor proﬁt, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ fordetails.Acknowledgments—No potential conﬂicts ofinterest relevant to this article were reported.A.C., A.D., and S.G. researched data, con-tributed to discussion, and wrote, reviewed,and edited the manuscript. P.C.B., I.M., andS.B. contributed to discussion and wrote, re-viewed, and edited the manuscript.c c c c c c c c c c c c c c c c c c c c c c c cReferences1. Elliott T. Body dysmorphic disorder, radi-cal surgery and the limits of consent. MedLaw Rev 2009;17:149–1822. Lavery LA, Armstrong DG, Wunderlich RP,Mohler MJ, Wendel CS, Lipsky BA. Risk fac-tors for foot infections in individuals withdiabetes. Diabetes Care 2006;29:1288–12933. General Medical Council. Treatment andcare towards the end of life. London, U.K.,2010;80. Available online at http://www.gmc-uk.org/static/documents/content/End_of_life.pdf4. Appelbaum PS, Grisso T. Assessing pa-tients’ capacities to consent to treatment.N Engl J Med 1988;319:1635–16385. Beauchamp TL, Childress JF. Principles ofBiomedical Ethics. 5th ed. Oxford Univ.Press, Oxford, U.K., 2001care.diabetesjournals.org DIABETES CARE, VOLUME 34, OCTOBER 2011 e159O N L I N E L E T T E R S

Assessing patients’ capacities to consent to treatment.

Body dysmorphic disorder, radical surgery and the limits of consent.

Principles of Biomedical Ethics.5 t he d .O x f o r dU n i v .

Risk factors for foot infections in individuals with diabetes.DiabetesCare2006;29:1288–1293

Treatment and care towards the end of life.

Diabetic foot ulcer: amputation on request?

Enlighten: Publications

 
 
 
 
 
 
 
Collier, A., Dowie, A., Ghosh, S., Brown, P.C., Malik, I. and Boom, S. 
(2011) Diabetic foot ulcer: amputation on request? Diabetes Care, 34 
(10). e159. ISSN 0149-5992 
 
http://eprints.gla.ac.uk/57612 
 
Deposited on: 18 November 2011 
 
 
Enlighten – Research publications by members of the University of Glasgow 
http://eprints.gla.ac.uk 
OBSERVATIONS
Diabetic Foot Ulcer:
Amputation on
Request?
In 2000, a Scottish surgeon received sig-nificant publicity for amputating lowerlimbs 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 re-
quested a lower-limb amputation. Al-
though 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 No-
vember 2008, he had several admissions
with a diabetic foot ulcer that partly re-
solved 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 dis-
comfort, broad-spectrum antibiotic ther-
apy, 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 benefi-
cence (acting in the patient’s best inter-
ests) 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 ofmedicine. In terms
of nonmaleficence, it is imperative to bal-
ance the possible harm resulting from am-
putation 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) pre-
ferred by a patient may place others, par-
ticularly his caregivers, in a disadvantaged
position.
In accordance with good clinical prac-
tice 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 wasmade
to set a date for an “elective amputation.”
Unfortunately, Mr. Brown’s foot ulcer be-
came more infected; he deteriorated
quickly and became systemically unwell.
A collective decision was made to under-
take an emergency amputation.
ANDREW COLLIER, FRCP1
AL DOWIE, FRCGP2
SUJOY GHOSH, MD1
PETER C. BROWN3
IQBAL MALIK, FRCP1
STEVEN BOOM, FRCS4
From the 1Department of Medicine, Ayr Hospital,
Ayr, U.K.; the 2Faculty of Medicine, University of
Glasgow, Glasgow, U.K.; 3patient, Ayr Hospital,
Ayr, U.K.; and the 4Department of Vascular Sur-
gery, Ayr Hospital, Ayr, U.K.
Corresponding author: Andrew Collier, andrew.
collier@aaaht.scot.nhs.uk.
DOI: 10.2337/dc10-2183
© 2011 by the American Diabetes Association.
Readers may use this article as long as the work
is properly cited, the use is educational and not
for profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0/ for
details.
Acknowledgments—No potential conflicts of
interest relevant to this article were reported.
A.C., A.D., and S.G. researched data, con-
tributed to discussion, and wrote, reviewed,
and edited the manuscript. P.C.B., I.M., and
S.B. contributed to discussion and wrote, re-
viewed, and edited the manuscript.
c c c c c c c c c c c c c c c c c c c c c c c c
References
1. Elliott T. Body dysmorphic disorder, radi-
cal surgery and the limits of consent. Med
Law Rev 2009;17:149–182
2. Lavery LA, Armstrong DG, Wunderlich RP,
Mohler MJ, Wendel CS, Lipsky BA. Risk fac-
tors for foot infections in individuals with
diabetes. Diabetes Care 2006;29:1288–1293
3. General Medical Council. Treatment and
care towards the end of life. London, U.K.,
2010;80. Available online at http://www.
gmc-uk.org/static/documents/content/
End_of_life.pdf
4. Appelbaum PS, Grisso T. Assessing pa-
tients’ capacities to consent to treatment.
N Engl J Med 1988;319:1635–1638
5. Beauchamp TL, Childress JF. Principles of
Biomedical Ethics. 5th ed. Oxford Univ.
Press, Oxford, U.K., 2001
care.diabetesjournals.org DIABETES CARE, VOLUME 34, OCTOBER 2011 e159
O N L I N E L E T T E R S


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