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Comments on the dilemma in the September issue: Too hot to handle?
  1. Steven McCulloch

Abstract

In the dilemma discussed in the September issue of In Practice, a new client at your equine practice asks you to treat a horse's tendon injury with thermocautery, or firing. How should you respond? (IP, September 2016, vol 38, pp 414-415). Madeleine Campbell suggested one possible way forward was to try to persuade the client that there was no logical or ethical justification for the procedure that they were requesting. This could include discussing the lack of evidence that firing had any therapeutic effect and the evidence that it caused harm, and explaining that any anecdotally reported benefit was likely to be done in the enforced period of rest following firing, rather than the procedure itself. It could be worth mentioning the client's and the vet's obligation not to cause unnecessary harm under the Animal Welfare Act. Alternative therapies should be explored with the client, and referral offered if appropriate.

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A MAJOR ethical framework in the human medical profession is that practitioners should respect the four principles of non-maleficence (don't harm), beneficence (benefit), autonomy (permit patient to choose) and justice (treat patients fairly). These principles should not be considered as absolute, as they can conflict, and the practitioner must balance them in the context of the clinical case.

In veterinary medicine, attributing greatest weight to respecting autonomy would likely translate as following the owner's wishes. This is problematic as there is a disconnect between the chooser (the client) and the patient (the animal). In effect, when a client and vet are in disagreement about the best course of treatment (eg, tendon firing), they are effectively disputing what is in the best interests for that patient.

If we reject the priority of respect for autonomy, we must look to non-maleficence and beneficence. Here, the supporter of tendon firing must argue that although there is short-term pain, it is justified for the greater long-term benefit. Campbell argues that the situation in firing is clear cut: there is evidence of its harm but no evidence of its benefit, so it is straightforwardly wrong to perform it. Indeed, from the perspective of a non-equine vet, Campbell's article is persuasive and it looks like the practice is slowly dying out although it still has its supporters. What is interesting from a broader point of view though is the relation between non-maleficence and beneficence.

We balance these principles everyday when making treatment decisions. Intuitively, the pres-cription ‘first, do no harm’ is persuasive. There is something wrong when a patient is presented to a healer and the healer's actions actually make things worse. This makes us think that we should give non-maleficence greater weight than beneficence.

However, respect for non-maleficence cannot be absolute. There is some risk in all medical interventions and an absolute principle would cause us to be in a state of paralysis about treatment. Another approach would be to go for a simple utilitarian harm/benefit approach: if a treatment has greater chance of benefiting rather than harming, we should prescribe that treatment. Although this simple utilitarian approach seems sensible, I'm not sure that there shouldn't be some kind of primacy given to non-maleficence. Perhaps it's in these difficult cases that we can revisit the principle of respect for autonomy, advise the client of the options, and ask them what is their considered choice.

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