While working as a short-term locum, a client asks for a repeat prescription for acepromazine tablets for a dog in the run up to bonfire night. You know that it is not the ideal treatment from a behavioural point of view, but other clients' records show that acepromazine is widely prescribed by the practice for firework phobias. It would be difficult to refuse the repeat prescription without upsetting the client and the practice, and it seems unfair to cause problems for this particular client when she could come in a week later and be given the tablets without any hassle. As a short-term locum, you feel that it is important to fit in with normal practice procedures as much as possible, and the RCVS requires you not to criticise colleagues. However, your client is likely to know other clients who are being prescribed acepromazine tablets by the practice at the same time as you are refusing to prescribe them. With this in mind, if you refuse to prescribe the tablets, how should you explain to the client that they're not an appropriate treatment?
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Richard Green qualified in 1989 from Bristol, and has worked in companion animal practice in the UK and abroad. He is currently chief veterinary surgeon at the Blue Cross animal hospital in Hammersmith, which provides care for animals whose owners are unable to afford private veterinary services. He holds the RCVS certificate in animal welfare science, ethics and law.
Issues to consider
As a locum vet, you have obligations to a number of different ‘stakeholders’ – to the animal, to the client, to the practice and your colleagues, and to yourself – although the RCVS makes it clear that as a vet your overriding obligation must be to the animals under your care. It can be useful to use an ethical matrix (see further reading) to allow due consideration of each of these stakeholders' interests, including their welfare, autonomy, and justice or fairness.
In this case, the dilemma occurs as a result of the apparent mismatch between doing the right thing by the animal and not upsetting either the client or the practice. The ramifications of either course of action for yourself are slightly more complicated. Refusing to dispense acepromazine might reduce the potential moral stress caused by acting in a manner you are not comfortable with, but it could also cause stress as a result of disapproval on the part of the client or practice. It might even reduce your future employment prospects.
While an ethical matrix provides a tool for the analysis of the ethical impacts of the different options available, it is limited by not providing an objective evaluation of them. This will still fall to an individual's subjective weighting. However, the matrix may help to identify and clarify some of the contradictory issues and aid decisions on whether the potential welfare compromise to the animal is large or small, and how the this compares with the impacts on other stakeholders.
Possible way forward
Fitting in with the practice is a very important part of being a locum, but it is inevitable that your way and the practice way of doing things will differ sometimes. For the most part, the differences will be unimportant to both parties and will have no consequences for the welfare of the patients. However, instances such as this occur, where it is clear that a practice is falling short of what is considered best practice and that animal welfare will be affected to some degree. Fitting in should not extend to perpetuating poor practice.
This is not the place to argue whether giving acepromazine as a remedy for firework phobias constitutes a large or small compromise to welfare. However, if we accept that it represents some compromise to welfare and that there are better ways of doing things, it would seem that trying to use your influence to change things for the better would be the correct course of action.
Many practices are willing to change but don't, either because of inertia or a lack of awareness. Most clients would like the best care for their pets. Best practice changes all the time, and it should be possible to discuss tactfully alternative treatments to the customary ones without overtly criticising colleagues. This is a vital skill for all recent graduates as well as locums. If you elect to pursue this course of action, it would be both fair and sensible to alert your colleagues in the practice that this is what you are doing.
If it is unlikely that you can avoid a difficult situation with the client on this particular occasion, perhaps it would be acceptable to prescribe the tablets but then to use this as a springboard to instigate a practice discussion on treatments for firework phobias. One might allow a small compromise to an individual patient's welfare if it promotes a change that will bring benefits to a greater number of animals in the future.
If you feel that prescribing the acepromazine is unavoidable but will significantly compromise your personal ethics and therefore feel unable to do so, you might consider referring the client to another vet in the same practice, either immediately or at the next available opportunity. Again, while not directly improving the welfare of the individual animal, it is hoped that this would provoke discussion that might lead to future improvement for a greater number of patients.
If, in your judgement, the practice you are working in is unlikely to welcome any new ideas or discussion of their policies, you might wish to question if it is a practice you want to continue working for in future. It is unlikely that the dispensing of acepromazine in this way will be the only issue you find you disagree with.
Readers with views to contribute on ‘Shortcomings in locum practice procedures’ should e-mail them toso 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, February 17. 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, ‘Shortcomings in locum practice procedures’, was submitted by a reader and is presented and discussed by Richard Green. 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 ‘Promoting personal views in practice’, which was published in the January issue of In Practice, appears on page 111.
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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