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When the client is away
  1. Simon Coghlan

Abstract

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, ‘When the client is away’, was submitted and is discussed by Simon Coghlan. 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.

The series is being coordinated by Steven McCulloch, a practising vet with a PhD in the ethics of veterinary policy. It aims to provide a framework that will help practitioners find solutions when facing similar dilemmas.

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Simon Coghlan is a veterinarian and has a PhD in philosophy. He works as a vet in a Melbourne practice, and as a part-time lecturer in philosophy at the Australian Catholic University. He writes on veterinary ethics, animal ethics and applied ethics..

When the client is away

A 12-year-old German shepherd dog (Jasper) presents with vomiting and diarrhoea. A dog minder has Jasper while the client is overseas and the dog has longstanding degenerative myelopathy. In a consultation before the client went away, they expressed concern that the dog, with whom she shares a close bond, might at some stage require euthanasia. Jasper now has additional medical problems. Furthermore, the client is not contactable. The dog minder is uncertain and upset. As Jasper's veterinarian, what should you do? Advise euthanasia, or wait until the client returns in two weeks?

Issues to consider

As people travel more frequently, this scenario becomes increasingly common in veterinary practice. Even in a highly connected world, travellers are not always contactable. Also, important medical decisions must sometimes be made relatively quickly. A practical question is the dog minder's readiness to manage a patient that needs higher care. Often there is inadequate communication between the client and the dog minder about the patient's possible medical needs. If the dog minder cannot assist, alternative arrangements might be explored. Assume, however, the dog minder is both willing and capable.

Degenerative myelopathy is a progressive, incurable loss of limb function. It can cause painful pressure sores and skin ulceration. Jasper has now developed vomiting and diarrhoea, creating medical uncertainty. What is causing the new signs? What is Jasper's prognosis for recovery? If we had more information, we could better predict Jasper's quality of life. Even then, decisions can be difficult, because judgements about quality of life are not only based on scientific information, but also on ethical reflection about the nature of a life worth living.

In our scenario, both client and patient interests should be considered. The client has a close bond with her dog. Many people regard being present with their dying companion animal as important. Some think it good for the animal to have the family present, and simultaneously beneficial to the family's emotional needs. The client has an interest in making decisions about Jasper's wellbeing. To adopt medical ethics language, the autonomy of the client matters (Beauchamp and Childress 2001). Respecting the client's autonomy involves not only acting in accordance with her known or presumed wishes, but having her actively involved in decision making. Deontological, that is, rules-based, approaches regard moral autonomy as a fundamental moral consideration. A person's autonomy, because it involves preferences and wishes, is also something a utilitarian moral theory can respect at a practical level. So, both rules-based and consequentialist (eg, utilitarian) moral theories would stress proper consideration of the client's active involvement and input.

Yet in our scenario, respecting client autonomy could conflict with respecting and safeguarding Jasper's welfare. Most moral theories now regard sentient animal interests as morally significant. Thus, if Jasper deteriorates and suffers badly, it may be wrong to wait for the client to arrive. But must it be selfish or unfair to wait? The answer is surely not always. Moral judgement must sometimes be sensitive to circumstances. A virtue ethics approach to moral judgement, for example, appreciates that applying fundamental character-based terms, like ‘selfish’ and ‘unfair’, to a decision to defer euthanasia depends on the details of the clinical situation. And at a practical level, deontological and utilitarian approaches would almost certainly agree.

In human medicine, the law recognises advance medical directives (Stanford Encyclopaedia of Philosophy [2016]). Advance directives allow people to specify the medical treatment they would prefer to receive, or to not receive, should they irreversibly lose their autonomy. For example, a patient might elect in advance not to be medicated or, instead, to be given all reasonable treatment when they fall seriously ill and their dementia is severe. Plainly, a dog cannot issue advance directives as a person can. But, in our scenario, it may be advantageous for the client to give some indication of Jasper's medical management before travelling. Indeed, the veterinarian might have initiated that earlier conversation. Taking that step would also recognise client autonomy. True, the discussion would not have been decisive for all possible scenarios: there are too many fine-grained possibilities to permit clear-cut ‘advance directives’ across the board. Furthermore, some autonomous decisions are selfish and unfair on the patient. Still, such prior exploration of the client's thoughts may have assisted decision making.

Possible way forward

If Jasper can be kept relatively comfortable, it may be reasonable to treat him and to run some medical tests, until the client can participate actively in decision making under your professional guidance. Jasper might rally and subsequently have a worthwhile life, even with limited mobility, or he might deteriorate further. Allowing some time to assess his response to treatment may be wise. As noted, many people (though not all) dearly want to say goodbye and be present at their animal's death. Respecting client autonomy – at least when choices are not selfish or unjust – and respecting the patient's life and wellbeing, are both ethically important in such cases.

With Jasper's health problems declining while his owner is abroad, what should the vet suggest?

References

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