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, ‘Too hot to handle?’, was submitted and is discussed by Madeleine Campbell. 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 ‘A request for euthanasia: handling the client’, which was published in the July/August issue of In Practice, appears on page 415.
The series is being coordinated by Steven McCulloch, a practising vet with a PhD in the ethics of veterinary policy. It is hoped it will provide a framework that will help practitioners find solutions when facing similar dilemmas.
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Madeleine Campbell is an equine veterinary surgeon, a Diplomate of the European College of Animal Welfare and Behavioural Medicine, and the director of Equine Ethics Consultancy. She has a particular research interest in the ethics of using animals for competitive sport.
Too hot to handle?
You have recently taken on a new client for your equine practice. Not long after you start working for that client, you are asked to treat a horse's tendon injury with thermocautery. How should you respond?
Issues to consider
Thermocautery or ‘firing’ of equine tendons was once a common method of treating equine tendon injuries; it was believed to promote healing by counter-irritation, which supposedly induced an acute healing effect. According to the British Equine Veterinary Association's position statement entitled ‘Thermocautery – the firing of equine tendons’ (BEVA 2014) ‘there are a number of experienced equine practitioners and owners who claim good results post-therapy and are strong advocates of the procedure.’ However, there is a dearth of evidence to support the use of the technique. Indeed, the one peer-reviewed experimental paper which has been published (Silver and others 1983) suggested that thermocautery has no beneficial effect on tendon injuries, and causes skin to become initially inflamed and oedematous, and subsequently thinner and weaker than normal skin. The authors of an independent literature review of firing of equine tendons conducted for the Australian Veterinary Association concluded that they were ‘unable to find any evidence that firing is an effective therapy. Instead, evidence is presented that it is more likely to do harm than good. Pain and stress are caused to the fired animal for at least 24 hours’ (Hayward and Adams 2001).
Veterinarians undertaking any procedure need to be aware of primary legislation and of any secondary legislation or local regulations (for example, those of the sport's governing bodies) relating to the proposed procedure. Of most immediate relevance is the Animal Welfare Act (AWA) (2006). Firing not only causes pain, but also interferes with and permanently damages sensitive tissue. Even if local analgesia is provided at the time of treatment, and even if systemic analgesia is also provided after the treatment, given that there is no proven beneficial therapeutic effect of the treatment, firing could well be considered a cause of unnecessary suffering under the AWA (2006), for which both the veterinary surgeon and the animal owner could potentially be held responsible.
Veterinarians should also consider whether undertaking thermocautery of equine tendons may expose them to allegations of gross professional misconduct. In recent years, the Royal College of Veterinary Surgeons has made clear its view that firing is an unethical, non-therapeutic procedure (RCVS 2011, Molyneux 2012).
A veterinarian's first duty is to the welfare of the animals under his or her care (RCVS 2016). This is the case however insistent the client might be, and whatever the veterinarian's other responsibilities (for example, to run a profitable practice, or to provide for one's dependents). BEVA's position statement asserts that ‘Firing should only be performed if in the view of the attending vet it is in the best interests of the horse’ (BEVA 2014). Considered with reference to a variety of ethical frameworks, no convincing argument can be made that thermocautery of equine tendons is ever in the best interests of the horse. Undertaking a procedure for which there is no proven benefit and which is known to cause tissue damage and pain contradicts the ethical principles of beneficence and non-maleficence; is not what a virtuous agent would do; contradicts an animal's right not to be unnecessarily harmed; and is not justified by a harm/benefit analysis, since there are evident harms but no proven benefit.
It has been claimed that the welfare of a horse is better protected by a veterinarian agreeing to undertake the procedure of firing, since refusing might result in the horse being transported long distances, and possibly abroad, to someone who is prepared to undertake firing. Such a ‘lesser of two evils’ argument is not convincing. Veterinarians are meant to practice according to evidence-based principles. If all veterinarians followed the evidence on firing tendons there would be no veterinarians conducting the procedure to whom a horse could be transported. Furthermore, evidence from the farm animal world suggests that taking a stand on a welfare issue at a national level need not necessarily result in the problem being exported, but can improve welfare standards internationally. Prohibitions of veal crates, sow stalls and battery cages in the UK preceded similar bans and improvements in welfare legislation in the EU and internationally.
Possible way forward
One possible way forward is to try to persuade the client that there is no logical or ethical justification for the procedure they are requesting. This could include discussing the lack of evidence that firing has any therapeutic benefit, the evidence that it does cause harm, and explaining that any reported anecdotal benefit of firing is likely to be attributable to the enforced period of rest following firing, rather than to any therapeutic merit of the procedure itself. It would also be worth mentioning the client's and your own obligations not to cause unnecessary harm under the AWA. Alternative treatments for tendon injury, such as rest and stem cell therapy, should be explored with the client, and referral offered if appropriate.
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