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, ‘Fate of a severely lame cow ’, was submitted and is discussed by Gwen Rees. 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 ‘Euthanasia in a no-kill shelter’, which was published in the October issue of In Practice, appears on page 527.
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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Gwen Rees qualified from the University of Liverpool in 2009 and worked in a mixed, rural practice in Wales, before spending a year as a dairy veterinarian in New Zealand. She is currently a teaching fellow in farm animal population medicine at the University of Bristol.
Fate of a severely lame cow
You attend to a severely lame cow with deep digital sepsis. The cow is 10/10 lame, has lost a lot of condition (BCS condition score of 1.5 out of 5) and has practically dried off, despite having calved only three months previously. You feel the best decision for the cow is euthanasia but the farmer is adamant that a digit amputation will ‘put her right’ so that he can fatten her up for slaughter. How do you proceed?
Issues to consider
This is a very common and difficult scenario to deal with out on farm. There are multiple factors that might influence decision-making with a case such as this.
Of primary concern should be the welfare of the animal. The RCVS Code of Professional Conduct states, ‘(1.1) Veterinary surgeons must make animal health and welfare their first consideration when attending to animals.’ This should make the situation simple shouldn't it? However, this is directly followed by, (1.2)' Veterinary surgeons must communicate effectively with clients and ensure informed consent is obtained before treatments or procedures are carried out.' When informed consent is not being given, what are our options?
Deep sepsis leading to 10/10 lameness is inherently very painful and a cow in these circumstances is suffering. The fact that the cow has dropped in condition and almost dried off suggests that this pain has been ongoing for some time and that the animal should probably have been presented and treated sooner. Amputation of the digit can be done with minimal pain and discomfort provided adequate anaesthesia and analgesia are used, but prolonged analgesia while the stump heals is unlikely to be carried out, and, even if analgesia is regularly administered, there will still be an element of pain during healing.
Is amputating the digit really so wrong? There are several studies to suggest that digit amputation reduces survival rates in the herd and is associated with early culling, but as we're only hoping to achieve a short term resolution, in order to fatten and transport the cow for slaughter, it may be a valid option. There are many instances in which digit amputation is the treatment method of choice for digital sepsis. This is where the decision comes down to clinical judgement. How far has the sepsis spread? What condition are the other three feet and remaining claw in? What is the general health of the animal? In this case, in order to fatten this cow, there could be a period of weeks or months in which the cow is pain-free, not being milked and just eating to her heart's content. The crux of this scenario is weighing up the value of this extra length of life and its higher quality, against the immediate period of amputation and recovery at a lower quality of life. If the balance appears to be favourable it would be acceptable to perform the amputation.
However, this decision involves an element of clinical judgement about the length of the recovery period and the cow's welfare during it, as well as an assessment, probably through discussion with the farmer, of her life after recovery. When it comes to clinical judgement, it must be assumed that the veterinary surgeon's opinion, unless overly affected by personal biases, is more valid than the farmer's, which is possibly biased by financial reasons and does not have the benefit of medical training.
Possible way forward
In situations such as this, open and frank communication is always the first step. Explaining exactly why you do not believe digit amputation is in the best interests of this animal might be enough to gain consent and should always be tried in the first instance. Failing this, if you are certain that digit amputation should not be carried out, the next step would be to offer a second opinion on the case. This places the onus on the farmer to arrange and pay for a second opinion, and the offer could be enough to change his mind. However, if this offer is taken up it is important to ensure it happens in a timely fashion, as the animal is continuing to suffer while the decision is ongoing.
Involving the RSPCA or the police would generally be a last resort, with serious consequences likely for the farmer. Sometimes just the possible mention of contacting either organisation can be enough to sway the farmer; however, if the welfare of this cow is being seriously compromised, vets should have enough confidence in their own clinical judgement, as it relates to the RCVS Code of Professional Conduct, so that when all other methods of gaining consent are exhausted, they are able to report these cases without doubt.
If we do refuse to amputate the digit, we must be certain that the animal will be euthanased, otherwise it will just continue to suffer as it is. Involvement of the RSPCA or the police would doubtless be of tremendous concern to the farmer, who is extremely unlikely to remain a client after that point. In fact, given the nature of farm/vet relationships, you are likely to very quickly gain a reputation as a troublemaker, which is unlikely to win you any favours or clients.
Whether consent is gained or not, it is important in this case to note that this animal should have been presented for treatment sooner and there is likely to be a deeper lameness/welfare issue at the farm. If relations remain good, it would be advisable to offer some health planning in order to avoid this kind of situation in the future.
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