The Virginian-Pilot
                             THE VIRGINIAN-PILOT 
              Copyright (c) 1996, Landmark Communications, Inc.

DATE: Monday, May 13, 1996                   TAG: 9605130030
SECTION: LOCAL                    PAGE: B1   EDITION: FINAL 
SOURCE: BY MARC DAVIS, STAFF WRITER 
DATELINE: NORFOLK                            LENGTH: Long  :  138 lines

SELF-MUTILATION LAWSUIT RAISES QUESTIONS OF MEDICAL ETHICS, LAW

A construction worker who intentionally cut off his hand, thinking it was possessed by the devil, and then refused to let doctors reattach it, is now suing the hospital and doctors for loss of the hand.

The catch: The construction worker claims he was psychotic that day in 1994, and therefore incompetent to make his own medical decisions.

His lawyers claim that the doctors at Sentara Norfolk General Hospital should have contacted the patient's parents or sister to provide consent for the reattachment.

The construction worker wants $3 million compensation, plus $350,000 in punitive damages.

The bizarre self-mutilation case was filed April 22 in Norfolk Circuit Court, but the lawsuit has not been served on the defendants. The patient's lawyers have one year to do do. If they do not, the case will be dropped.

While there has been no action on the case yet, it raises important issues of medical ethics and law. Among the questions:

Can a man who hallucinates and sees demonic signs on his body be held responsible for his own self-destructive actions?

Can the hospital be faulted ifit consulted a local judge before abandoning the hand reattachment surgery?

And how much did the judge know before advising the doctors to scuttle the surgery?

Both the hospital and the lead surgeon refused to discuss the case while it is pending in court. The worker, who is anonymous in this story because he is mentally ill, also declined to comment.

But his lawyers, Robert E. Brown and Michael Wayne Price, and the lawsuit itself describe in detail why and how the worker cut off his own hand, and why it was not reattached.

The worker - a 32-year-old computer specialist who was working construction temporarily - does not feel guilty about amputating his hand, but blames the doctors for faulty medical care, the lawyers say.

``He's angry and disturbed that he doesn't have a hand, that he is this diminished person,'' Brown said. ``It affects not only his earning capacity but his whole mental outlook. . .

``He does not blame himself because he knows he was not acting of free will. He knows it was not his fault that he cut his hand off. But he does know it's the fault of the doctors that he doesn't have the hand now,'' he said.

While this particular situation may be odd, the underlying issue is not, says John Fletcher, a medical ethicist at the University of Virginia, who is not involved with the case.

``About 10 percent of patients in hospitals are refusing something,'' said Fletcher, director of the Center for Biomedical Ethics. ``It's one of the most frequent medical issues.''

In this instance, Fletcher said, the patient may have a case.

``If you don't have a competent decision-maker'' on whether to conduct surgery, Fletcher said, ``you go and look for the next of kin. It's not too complicated.''

The amputation occurred in Kill Devil Hills on April 27, 1994. According to the lawsuit and the lawyers, it happened this way:

At a construction site, a worker with a history of mental illness had a hallucination. The right-handed man saw the number ``666'' on his right hand and believed it was a demonic sign.

Obeying the Biblical instruction ``If thy right hand offend thee, cut it off and cast it from thee,'' the worker cut off his hand at the wrist with a circular saw.

He was rushed to Norfolk General with the hand packed in ice. Doctors had about 12 hours to reattach the hand.

In the emergency room, a plastic surgeon examined the patient. The doctor told the patient that the hand could be successfully reattached with 80 to 85 percent chance of success.

During the exam, the patient said he had a history of psychiatric disorders and had used Lithium for a manic-depressive disorder.

A psychiatric resident was called in to examine the man. In her notes, she wrote that the man amputated his hand because ``he thought he would feel better if he cut it off. He feels he must be evil because, despite blood loss, he is all right.''

The patient told the doctor he had made an appointment at the local mental health center later that week, had a history of alcoholism, had two past psychiatric hospitalizations, and had had little sleep, little food and racing thoughts for the past week.

The resident recorded her clinical diagnosis as ``bi-polar disorder with psychotic features. Alcohol dependence.'' She prescribed anti-anxiety and anti-psychotic medication.

At that point, the lawyers say, the doctors should have asked the patient for a relative's name and phone number, so someone else could make the medical decisions. The man's parents live out of state; his sister lives out of town.

``It's hard to imagine a situation where someone cut off their hand and would be considered competent to make a decision'' on surgery, Brown said.

Fletcher, the medical ethicist, agrees. ``On the face of it, if the psychiatrist had examined him, asking him to sign a consent form (for surgery) raises a lot of questions,'' he said.

According to the lawsuit, doctors asked the patient for permission to reattach the hand, and he signed a consent form. Just before surgery, however, the patient changed his mind. He thought he would go to hell if the hand were reattached ``because it was inhabited by the devil,'' the lawsuit says.

Confused as to what to do next, the surgeon called in the hospital's risk manager. She, in turn, called Circuit Judge William F. Rutherford for help.

According to the lawsuit, the surgeon and the hospital did not tell Rutherford that the patient was incompetent. As a result, Rutherford advised the hospital to heed the patient's wishes. The hand was not reattached.

Price said the judge did not take notes of the conversation and does not remember it.

The next day, when the patient awoke, he immediately regretted his decision, the lawyers said. ``He was very upset right away,'' Price said. By then, however, it was too late.

Brown compares the construction worker to a 3-year-old who innocently puts her hand into a spinning fan blade. Doctors wouldn't dream of asking the girl if she agreed to surgery, Brown said; they would ask her parents' permission, or would just do it.

``He's no more competent than the 3-year-old,'' Brown said.

State law says a doctor should seek authorization from a patient's relatives or guardian if the patient is ``incapable of making an informed decision'' about his own care.

State law also says a doctor or hospital cannot be held liable for withholding treatment if a judge approves that action and the patient is ``capable of making and communicating an informed decision.'' ILLUSTRATION: WHAT THE LAW SAYS

Virginia Health Care Decisions Act: When the attending physician

of an adult patient has determined after personal examination that

such patient because of mental illness . . . is incapable of making

an informed decision about providing, withholding or withdrawing a

specific treatment . . . the attending physician may . . . provide

to, withhold or withdraw from such patient medical or surgical care

or treatment, . . . upon the authorization of any of the following

persons, in the specified order of priority. . .

1. A guardian

2. A spouse.

3. An adult child.

4. A parent.

5. An adult brother or sister.

6. Any other relative in descending order of blood relationship.

KEYWORDS: LAWSUIT MENTAL ILLNESS MEDICAL ETHICS SELF-MUTILATION by CNB