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, ‘Dealing with dark desires’, was submitted and is discussed by Andrew Knight. 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 ‘Pest or patient?’, which was published in the November/December issue of In Practice, appears on page 55.
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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Andrew Knight is associate professor for welfare and ethics at Ross University School of Veterinary Medicine, St Kitts, in the Caribbean. He is also a European veterinary specialist in welfare science, ethics and law. He previously practised small animal medicine in the UK.
Dealing with dark desires
You are called in the middle of the night to see what sounds like a badly injured cat following a road traffic accident. Is it wrong to hope the cat has died by the time it reaches the surgery so you can return to bed more quickly? And does it really matter what you think, if such dark thoughts remain locked inside?
Issues to consider
On the face of it, such thoughts appear quite obviously reprehensible. By contemporary standards, they would outrage a substantial proportion of society at large and they seem particularly inappropriate for members of a profession whose professed aim is to safeguard the health and welfare of animals.
However, it is worth remembering that, whatever else vets are, we are human beings first and foremost, and, therefore, subject to the same weakness and temptations as other mortals. Who in practice has never finished long days or weeks in a state of borderline exhaustion? Who has never come to dread the ringing interruption of the precious few evening hours we dare to call our own, by the on call phone?
On the other hand, one might argue that ill-intentioned thoughts do indeed matter, because they increase the likelihood that suboptimal, if not overtly malign, actions will follow, especially if such thoughts recur over time. This is because thoughts – especially when repetitive – can influence behaviour subconsciously. We are, of course, consciously aware of our thoughts, and can and should choose to fight negative impulses, but we are not always aware of their more subtle effects on our attitudes, choices and, potentially, behaviour.
So, in the case of our suffering cat, who could be affected by our thoughts and actions? If, after wishing the cat dead, most probably due to exhaustion and sleep disruption, we arrive at our clinic in the middle of the night to discover it is still alive, our exhaustion and resentment could conceivably influence clinical judgment to a greater or lesser degree, resulting in recommendations of a more limited or quicker range of diagnostic or treatment options than might be the case during daylight hours.
It is also worth remembering that we do have a duty to ourselves – which the profession's unusually high rates of suicide and mental disorders strongly suggest we neglect. And we have a duty to the patients we will see the following day, who could also receive suboptimal care, if we are tired.
Vets of course have a duty to the client as well. Exhaustion could result in a decreased willingness to spend time explaining options and prognoses, or the exercise of undue pressure on the client to accept a quicker option, even though it might be more expensive or result in suboptimal care.
We also have a duty to our practice employer. Fatigue and resentment at their failure to arrange alternate out of hours cover could possibly also increase the likelihood of recommending treatment options that are less likely to provide appropriate financial recompense for the practice, or more likely to result in subsequent malpractice liability (for which our employer might also be responsible under the principles of vicarious liability, in which an employer may be held liable for the actions of an employee).
We even have a duty to the profession at large. If exhaustion and resentment impairs our judgment, with the result that the cat subsequently dies following suboptimal treatment, and the case is critically publicised by the client or an associate, the reputation of the wider profession might suffer as a result. Cases such as these ultimately decrease public trust, which is a crucial necessity in maximising client compliance with veterinary healthcare recommendations. Without such trust, the welfare of animals could also suffer on a broader scale.
However, despite our duties to ourselves, the client, our practice and the veterinary profession at large, it is nevertheless quite clear that our primary duty remains to our patients. The RCVS Code of Professional Conduct for Veterinary Surgeons unambiguously states that veterinary surgeons must make animal health and welfare their first consideration when attending to animals (RCVS 2012). The prominence and prioritisation of this recommendation in this and previous versions of the code, as well as similar guidelines in other countries, like those of the American Veterinary Medical Association, accurately reflects the core expectations placed on our profession by society at large and our subsequent need as a profession to be clearly seen to be meeting those expectations (AVMA 2013).
Possible way forward
When faced with such cases, it can be helpful to be aware of, and consider, our own emotions and internal dialogue. That is, to perform a ‘reality check’ in order to ensure our perspective is not becoming distorted by considerations that are not clinically relevant. We should aim to ensure that neither our care nor our proffered advice is suboptimal, and that any decision to delay procedures until regular working hours is motivated by a genuine desire to maximise the health and welfare of the patient; for example, because equipment or personnel are more available for procedures that might reasonably be delayed. Of course this does not apply to procedures in which such delay could compromise health and welfare.
Longer term, it would seem wise to consider the factors that have led us to entertain such dark thoughts in the first place. Most likely, for most veterinarians, exhaustion and work-life imbalances are to blame. Given what we now know about the prevalence of suicide and stress-related mental disorders within our profession, it is no longer acceptable to dismiss these factors because ‘it's always been this way’. So in order to best care for our patients, we must not neglect to look after ourselves as well.
Readers with views to contribute on ‘Dealing with dark desires’ should e-mail them to email@example.com so that they can be considered for publication in the next issue. The deadline for receipt of comments is Friday, January 24. Please limit contributions to 200 words.
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