Where a best interests assessment weighs on amputation

The Court of Protection (CoP) has authorised a hospital trust to perform life-changing amputations, ruling that, despite her consistent opposition, the surgery was in her best interests to prevent imminent death from sepsis.

Facts:

LE is a 46-year-old woman who has a long-standing history of schizophrenia and Type 2 diabetes. She was admitted to hospital in July 2025 as an emergency case after being found confused and in a state of diabetic ketoacidosis. During her admission, she was discovered to have a strangulated hernia, which required a laparotomy.

Following this surgery, LE suffered a cardiac arrest and was transferred to the intensive care unit. To save her life and preserve her major organs during the cardiac crisis, clinicians administered vasopressor medication, specifically noradrenaline.

While this treatment was successful in maintaining her organ function, it caused a severe restriction of blood flow to her extremities, resulting in ischaemia and the eventual development of dry gangrene.

On her left hand, the gangrene affected all four fingers and her thumb, rendering the hand completely non-functional and immobile. On her right hand, which is her dominant hand, the necrotic tissue affected the tips of her fingers and thumb.

Additionally, the toes on both of her feet were affected to varying degrees. The medical team determined that the only viable clinical path to prevent life-threatening sepsis was the surgical removal of the dead tissue, which involved amputating the affected digits on both hands and feet, followed by reconstruction surgery using local tissue and skin grafts to cover exposed bone.

Despite the severity of her condition, LE consistently refused the surgery over a period of several months. Her refusal was rooted in a belief that the black, necrotic skin was actually a “dirty plaster cast” that the doctors had placed on her. She maintained that if the areas were simply cleaned and washed, the infection would clear up and her fingers would return to normal. Due to her diagnosis of schizophrenia, she was unable to accept the medical explanation that the tissue was dead and posed a fatal risk. This led the Trust to seek a declaration from the CoP, as LE was found to lack the mental capacity to “use or weigh” the information necessary to decide on her treatment.

Decision:

The CoP granted the Trust’s application, authorising the medical team to proceed with the amputations and reconstructive surgery, despite LE’s consistent refusal. The Court’s reasoning centred on the “best interests” test under Section 4 of the Mental Capacity Act (MCA) 2005. Because LE was found to lack the capacity to make such a decision for herself, the Judge had to step into her shoes and evaluate her welfare in the widest possible sense—encompassing her medical, social, and psychological needs.

The most persuasive factor in the Judge’s reasoning was the clinical evidence regarding the severity of the gangrene. The Court accepted that without surgery, the risk of sepsis and death was not just a possibility but a “very high” probability, one that could occur within days. The Judge carefully weighed LE’s consistent refusal against the reasons behind it. Under the law, a patient’s wishes must be given significant weight, especially when they are held consistently. However, the Judge found that LE’s wishes were based on an irrational and delusional foundation—specifically her belief that the gangrene was merely “dirt”.

Implications:

This case reinforces the principle established in Aintree v James that a patient’s “best interests” are not purely medical. The Court demonstrated that it will look beyond the clinical necessity of surgery to the patient’s social and emotional landscape. By linking the surgery to LE’s desire to see her daughter, the Court shifted the narrative from “forcing an amputation” to “enabling a mother’s survival,” showing how judges use a patient’s own values to justify a decision the patient is vocally opposing.

A major implication of this ruling is the clarification of how much weight is given to a patient’s wishes when those wishes are rooted in a mental health condition. The Court sent a clear signal that while a “borderline” capacity patient’s views carry great weight, views founded on a total denial of physical reality will be significantly discounted.