Articles in this series give 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, ‘A corneal cat-astrophe?’, is presented and discussed by David Williams. 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 ‘Are you positive? The fate of a shelter cat’, which was published in the November/December 2012 issue of In Practice, appears on page 47.
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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David Williams teaches veterinary ophthalmology at the University of Cambridge veterinary school and is director of studies in veterinary medicine at St John's College, Cambridge. He is also involved in animal ethics and welfare teaching and research at both undergraduate and postgraduate levels.
A cat is presented to your practice with a laceration of the cornea and subsequent protrusion of iris tissue through the corneal wound. Surprisingly, the cat does not seem in particular discomfort. The new graduate you have recently employed has told the owner that the animal needs immediate surgery to either repair the cornea or to enucleate the eye. The owner has insufficient funds to cover the costs of any surgery. Your colleague, having studied animal welfare, ethics and law at vet-school – courses you never had – tells you that, under the Animal Welfare Act 2006, the only other option is euthanasia, although this has not yet been broached with the client. What should your next step be?
Issues to consider
The Animal Welfare Act 2006 requires that an owner prevent unnecessary suffering (section 4) to his/her animal and protects it from pain, suffering, injury and disease (section 9.2). There is certainly injury here, but one might ask whether there is unnecessary suffering, given that the cat does not seem to be unduly affected by the trauma. Having said that, the evaluation of pain in cats can be a complex undertaking (Cambridge and others 2000). It may be that the cat is indeed experiencing high levels of ocular pain but without making this evident to an untrained observer.
One might also ask whether surgical repair or enucleation are the only therapeutic options. The ‘gold standard’ therapeutic approach may well be referral to a specialist centre for surgery under an operating microscope but, if this is not financially possible, are the only other options enucleation or euthanasia? I would argue that this is not the case, and that sometimes considering the ‘gold standard’ option to be the only one worth following may not actually be in the animal's best interests. Indeed, the definition of what is ‘gold standard’ treatment may well differ depending on the person making the assessment. A referral ophthalmologist might define it as treatment with the best possible likelihood of resulting in a pain-free, visual eye regardless of cost. Yet, the owner may define it as treatment that results in a pain-free cat within his/her financial capabilities. And what would the ‘gold standard’ treatment be from the cat's perspective? One that gives it a continued comfortable life, I guess.
Possible way forward
The prescription of an oral, non-steroidal anti-inflammatory analgesic and the use of a topical antibiotic might resolve any immediate pain and possible infection, leaving the laceration, now sealed by the iris adhered to the corneal wound edges, to heal by itself. This is of course by no means ideal and there is always the possibility that the eye might develop a painful glaucoma, but given that the other option is to end the animal's life, a conservative approach would seem to be preferable from an ethical stance, as long as the cat remains pain free.
Extending life at any cost is not an option that fits well with the animal's welfare, and so if there were continuing issues of pain and blindness one might agree that euthanasia was the appropriate option. However, if the quality of life seemed good – without pain or obvious distress – then conservative measures allowing the cat a continued existence would seem appropriate. Clearly the situation would need to be kept under review and if pain did supervene at any point in the future, more drastic steps might need to be taken.
The question then arises: what is the best way of dealing with the client and the veterinary surgeon? The new graduate has said that repair or enucleation are the only options. Thankfully, the owner has not been told about the third possible course of action, euthanasia, should the first two options not be financially viable. To breeze in and inform the owner that you disagreed with your colleague would do nothing for the confidence of either the client or the new graduate. A quiet word of advice in the latter's ear might allow them to go back to the owner and say that, having discussed the case with colleagues, they consider that a ‘watch and wait’ option might be the best for the animal and owner as long as the cat remains apparently pain free.
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