Thelma S. is a 44 year old single white female admitted to the hospital 3 days ago for an emergency BKA (below the knee amputation) on her right leg, which has a gangrene infection secondary to infected leg ulcerations. Thelma is well known to the hospital social work staff, having been admitted before on several occasions for infected leg ulcers that are a consequence of poorly managed diabetes and poor hygiene. Thelma has a psychiatric diagnosis of chronic schizophrenia (paranoid type) and is homeless. Her hospital records indicate she has no known relatives, and the emergency contact listed is a case manager affiliated with the local public mental health agency. Thelma refuses psychiatric medications and, other than her occasional hospital admissions to clean up her leg ulcers, appears to keep herself in food and shelter through the use of various agencies serving the homeless. According the physicians consulting on her case, there is now no way to save her leg short of amputation, which Thelma refuses. When informed that the gangrene will spread and result in her death unless she agrees to the amputation, Thelma sometimes states would rather die whole than in parts and at other times states she believes that she will be killed during the surgery. The hospital has petitioned the court to have a guardian appointed so that consent for surgery can be pursued through that mechanism. In the meantime, the stench from the gangrene is becoming a real issue and the hospital must keep Thelma in an isolation room. The hospital is losing a lot of money on her care and the situation is adding to the hospital's already precarious financial state.

Assume you (as a group) are charged with the responsibility of making a recommendation to the court regarding emergency surgery (in real life this would likely be a guardian ad litem). What are some of the key issues you identify from both a clinical social work perspective and a bioethics perspective? Do you see any points of distinction between the role of a social work consultant and the role of a bioethicist in this case?