A client whose pet is under treatment with you asks you to perform a radical surgical intervention that may extend its life. You are highly competent at this procedure, but unsure whether it would be over-treatment for this case. If you do not perform the treatment, the owner has made it clear they will go to another local practitioner.
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James Yeates is the BSAVA Petsavers/RSPCA resident at Bristol in animal welfare, ethics and law and a first-opinion practitioner in Gloucester. He is a member of the BVA's Ethics and Welfare Group and its Member Services Group, SPVS council and the committee of the Animal Welfare Science, Ethics and Law Veterinary Association. His main interests are in veterinary ethics, quality of life and animal welfare jurisprudence.
Issues to consider
Veterinary treatment choices must be based on the interests of the animal. The owner's wants may act as a constraint on what can be done, by legally preventing certain options, but veterinarians should not do whatever the owner wants.
The decision on whether to perform this surgery involves assessing the animal's interests. Overtreatment can be defined as treatment that is against the patient's interests compared to non-treatment or euthanasia.
First, compare treatment to euthanasia. The question here is whether the animal is better off dead. This is not simply a matter of whether the surgery is overtreatment per se, but of what it would bring to the individual animal. Nor is this a question of giving the animal ‘a chance’, but of whether it is a chance worth having. Consider whether the pain of surgery is worth the pleasure of future life.
If treatment is worse than being dead, euthanasia should be suggested and advised. If the owner refuses euthanasia, the relevant comparison is between treatment and non-treatment. These can be compared by evaluating the expected outcomes of each in terms of ‘quality-adjusted life years’. For each, the expected length of life is multiplied by the predicted quality of life, graded between -1 and 1. On this scale, two years with a quality of life of 0·3 (score 0·6) are worse than one year with a quality of life of 1 (score 1). When options have several different possible outcomes, the score of each must be multiplied by its probability to give an overall score. One can then compare the scores of treatment and non-treatment, and select and encourage the option with the best score. Consensus figures for animals have not been worked out yet, and individual vets would have to use their own opinions to estimate potential length and quality of life. Nevertheless, it does provide a useful way of thinking about the issues and helps avoid errors such as focusing on small probabilities or a single issue.
Since euthanasia would lead to no life, its score is 0, and so this method can be used to compare treatment and euthanasia – a treatment with a positive score is worthwhile, but a treatment with a negative score is overtreatment.
In this case, non-treatment would involve the animal going to another veterinarian. So the comparison is not really between treatment and no treatment, but between you versus the other vet performing the operation.
It is not acceptable to do something merely because another vet would do it otherwise. There has to be some other justification for you to do it. It should go without saying that your own profit is not a morally acceptable reason.
This justification should be in terms of the animal. This might be justified in terms of your greater competence; non-treatment would involve the animal going to another vet who may be less competent. Furthermore, if the other veterinarian is keen to overtreat, you may question their judgement, and so keeping the patient under your care means you can control future treatment choices, including euthanasia.
However, thinking away from the patient, this argument has two major disadvantages. First, providing the overtreatment may lack integrity – another practitioner's failings should not make you overtreat. Secondly, this position will not progress the profession's moral standards. For the profession to improve, each practitioner should maintain their ‘moral integrity’, and appeal to local practices and professional bodies to coordinate actions.
Possible way forward
You should advise euthanasia and give your reasons for it; it may be that the owner will change their mind. If this is unsuccessful, you should try to speak to the other vet if possible. A discussion may reveal that they are not actually keen to perform the surgery, or that they were going to carry it out only because they thought that you would do so otherwise. A frank discussion (and some subtle moral censure) may discourage the other veterinarian from performing the operation. If nobody is willing to conduct the operation, the owner's legal duty can be invoked to encourage euthanasia.
If both the owner and the other vet are immovable, then performing the operation is legitimate, so long as you ensure that you really are motivated by this concern, and not merely justifying your capitulation. However, it might be better to maintain your moral integrity – if the client and the other practitioner proceed nonetheless, the stain is on their consciences and you have done your best.
Readers with views to contribute on ‘To treat or not?’ should e-mail them to firstname.lastname@example.org so that they can be considered for publication in the next issue, or fax comments to 020 7383 6418. The deadline for receipt of comments is Friday, November 19. Please limit contributions to 200 words.
THIS series gives readers the opportunity to consider and contribute to discussion of some of the ethical dilemmas that can arise in veterinary practice. Each month, a case scenario is presented, followed by discussion of some of the issues involved. In addition, a possible way forward is suggested; however, there is rarely a cut-and-dried answer in such cases, and readers may wish to suggest an alternative approach. This month's dilemma, ‘To treat or not?’, is presented and discussed by James Yeates. Readers with comments to contribute are invited to send them as soon as possible, so that they can be considered for publication in the next issue. Discussion of the dilemma ‘Can’t pay, won't pay?', which was published in the September issue of In Practice, appears on page 459.
The series is being coordinated by Siobhan Mullan, of the University of Bristol. It is hoped it will provide a framework that will help practices find solutions when facing similar dilemmas.
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