An owner presents a litter of 15-week-old puppies and their mother. The puppies are collapsed and have severe diarrhoea. You strongly suspect this to be caused by parvovirus, as you have seen several cases in the past three months. The owner says they were vaccinated by a neighbouring practice using a homeopathic nosode vaccine, but she has now lost all faith in the practice and wants to move to your practice. What legal and ethical elements should be considered when proceeding?
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Conventional vaccines and nosode homeopathic remedies share a common philosophy: that like cures like. The difference between them, to be considered here, lies within evidence-based medicine and informed consent from the client.
Issues to consider
The RCVS Code of Professional Conduct and supporting guidance state that homeopathy is considered a treatment under the Veterinary Surgeons Act 1966. Therefore, homeopathic therapies may only be administered by veterinary surgeons.
The Veterinary Medicines Regulations 2011 seem to conflict with the RCVS' view on the need for a veterinary surgeon to administer homeopathic remedies by stating in Schedule 4, paragraph 8: ‘A registered homeopathic remedy or a homeopathic remedy prepared and supplied by a pharmacist under paragraph 10 of Schedule 3 may be administered to an animal by anyone. . .’ and that ‘A homeopathic remedy that was on the market before 1st January 1994 may be administered by anyone’. However, it is prudent to follow the RCVS' advice in this matter as it is the veterinarian's direct regulatory body. The RCVS recommends that veterinary surgeons undertaking homeopathic medicine should be adequately trained (RCVS 2012) and that it would be impermissible for a veterinary surgeon to delegate the power to diagnose and prescribe a homeopathic remedy to a non-veterinary surgeon.
In the present scenario, the veterinary surgeon in the other practice would not have been acting outside the RCVS' Code if:
The client was fully informed of the risks and benefits of the homeopathic and conventional vaccinations;
■ hey acted within their area of competence, including training in homeopathy;
■ They did not compromise the welfare of the animal; and
They followed the Veterinary Medicines Regulations 2011 Schedule 4, paragraph 8, which controls the use of homeopathic remedies.
The profession prioritises giving veterinary surgeons and their clients freedom to choose interventions (Anon 2006), but this must be matched with the veterinary surgeon's primary duty to ensure the welfare of animals in their care.
All things considered, it seems unlikely that the veterinary surgeon at the other practice was in breach of the Code.
The veterinary surgeon in this scenario should proceed by receiving the client as they would any new client. They should request permission from the client to contact the primary veterinary surgeon to obtain the patient's history and to inform them they are taking over the patients' care. If the client refuses this information, except in an emergency, the case should be declined (RCVS 2012).
The Code requests that veterinary surgeons do not speak disparagingly about other members of the profession, including when making clinical decisions. It is therefore advisable not to pass any comment or judgement to the client regarding the homeopathic veterinary surgeon, irrespective of personal views on homeopathy.
Possible way forward
While the veterinary surgeon at the other practice has acted lawfully and within the Code, some find it hard to reconcile the use of remedies with unknown efficacies, mechanisms and side effects over conventional therapies where these factors are known or demonstrable. Importantly, the risk to animal welfare is unknown when the detailed knowledge of the homeopathic remedies remains unspecified. This may compromise the veterinary surgeon's ability to inform the client sufficiently, as is required for consent. It also diminishes the veterinary surgeon's ability to robustly defend the therapeutic choice.
Evidence-based medicine must remain a foundation of veterinary work. Only with evidence can competency be measured and protocols audited to ensure that the profession's endeavour to the welfare of animals is realised. This does not negate homeopathic medicine, but rather should encourage practitioners to validate it through developing an evidence base. It cannot be the intention of any practicing veterinary surgeon to utilise an ineffective treatment, and more evidence will assist all practitioners and clients in making informed clinical choices.
Vaccinations pose a particular problem. Conventional vaccines are most effective when a high percentage of animals are protected. Veterinary surgeons are in a difficult position of upholding the client's freedom of therapeutic choice, so long as animal welfare is not compromised, and being aware of the effect of their actions on the wider population of animals not under the influence of that client.
For each animal that receives a nosode homeopathic vaccine, this must be balanced against the potential health risk to the dog population as a consequence of reducing the percentage of conventionally vaccinated dogs.
Readers with views to contribute on ‘Homeopathic vaccine’ 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, August 10. Please limit contributions to 200 words.
It is advisable for local veterinary practices to keep an open dialogue in reference to common infectious diseases such as parvovirus, thus allowing all local veterinary surgeons to include this information when providing their clients with the necessary evidence of the risks and benefits, which is needed for informed consent. The veterinary surgeons and clients can then select homeopathic remedies or conventional vaccines with knowledge of evidence-based medicine, for the betterment of animal welfare.
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, ‘Homeopathic vaccine’, was submitted by a reader and is presented and discussed by Martin Whiting. 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 ‘Offering neighbourly advice’, which was published in the June issue of In Practice, appears on page 431.
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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