Ethics and shared decision-making in major amputation for the diabetic foot

Major lower-extremity amputation for diabetic foot disease is a decision with lasting physical and existential consequences, and it is frequently reached under prognostic uncertainty and without fully shared deliberation. This narrative review synthesizes the evidence on the ethical considerations and shared decision-making processes that surround the choice between limb salvage and major amputation in people with diabetes-related foot disease. The synthesis shows that long-term mortality after diabetic foot disease exceeds that of several cancers, that prognostic and frailty tools inform but do not resolve the decision, and that the four principles of biomedical ethics remain in recurring tension. Shared decision-making is inconsistently achieved: patients, surgeons and care teams describe communication gaps, decisional conflict is mediated by anxiety and depression, and patients weight amputation-level outcomes differently from providers. Decision aids exist but remain under-implemented, and ethnic, insurance, income and social vulnerability gradients modify who is amputated and who receives limb preservation. The review concludes that the amputation decision should be reframed as an ethical and preference-sensitive process supported by equity-informed decision tools and structured communication, and it identifies the outcome gaps that future studies should address.