Informed choice: the ethical dimensions — and dilemmas — of surgical procedures

By: Madeline Martelles

Have you ever thought about how you would live if you lost your right leg due to infection? What if, on top of that, you were 87 years old and had advanced diabetes? Most people don’t think they will ever have to confront such a scenario. However, working as a surgical services assistant (basically a nurse’s assistant in surgery), I recently witnessed a similar situation that resulted in a right-sided below-the-knee amputation.

I was ecstatic to see this surgery performed, as it was one of the first surgeries I got to witness at my new job at a local hospital. But the excitement wore off quickly in the pre-op area, where the nurse and I both noticed that our patient, whom I will call Mrs. Kay, was very quiet. Instead, Mrs. Kay’s daughter was doing most of the talking, answering the nurse’s questions before her mother had a chance to respond. The daughter claimed that her mother was “too old” and “out of it” to understand our conversation, yet there was no record of dementia, Alzheimer’s disease or delirium in her medical chart. It was alarming to me that Mrs. Kay’s daughter wasn’t giving her mother an opportunity to speak up about her wishes.

While the surgery was taking place, the surgical scrub tech argued there was no point in doing the surgery. He based his contention on Mrs. Kay’s age and her likely diminished quality of life after the amputation (Mrs. Kay was very frail and would not be able to be fitted into a prosthetic leg after the surgery).

Is surgery always the right option?

The tech’s comment made me wonder whether, had I been the patient, I would have elected to have the amputation or not, due to the negative consequences that come with the procedure. After all, following the surgery, we knew that Mrs. Kay would most likely need help getting in and out of her wheelchair to go to bed, getting onto a toilet and even pushing herself in a wheelchair. As the surgery continued on, I asked myself whether Mrs. Kay should have been allowed a voice in whether to let the infection naturally lead to her death?

Ethical questions

This particular case is difficult due to the ethical questions it raises. How, for instance, was the surgeon supposed to become aware of Mrs. Kay’s wishes? Could this procedure lead to unintended harm? Was the health system truly honoring Mrs. Kay’s ability to make autonomous decisions, especially without informing her of the risks, benefits and alternatives to performing the amputation in the first place?

If I had been the patient or if it had been my mother on the operating table, I would have asked many questions of the health care team. Moreover, if I had been the surgeon, I hope I would have tried my best to explain the options of performing vs. not performing the amputation. I would have wanted to assess the daughter’s understanding of the demands she will face at home while caring for her mother.

Choosing among several approaches

When most people first hear the diagnosis “life-threatening infection,” curative surgery seems like an attractive option. However, pausing to learn the associated risks and outcomes of surgery is essential. For example, even if a cure is not possible without an operation, in Mrs. Kay’s case a course of antibiotics could have mitigated the infection, which might have added both quantity and quality to her life. Another option would have been to defer antibiotics, treat just the associated pain, make Mrs. Kay comfortable and let nature take its course.

My main point here is that patients – and their family members – should have a chance to review all potential options and select the approaches that are most consistent with their goals and values.

Our patients, their decisions

From the very beginning, we in health care are taught to do what’s best for our patients. But in fast-paced fields, such as surgery and emergency medicine, it is easy to forget about the long-term effects of invasive procedures, especially once patients leave our care.

In the case of Mrs. Kay, I believe the surgeon should have considered the ramifications of a below-the-knee amputation and allowed both the patient and her daughter to make an informed decision together. Across all specialties of medicine, it is important to remember how our actions ultimately affect our patients’ lives – especially once they disappear from our care.


Madeline MartellesMadeline Martelles is a Tulsa native and a sophomore at The University of Tulsa. She is majoring in chemistry pre-med, with a minor in English.