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 cannot pay’, was submitted and is discussed by Peter Fordyce. 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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Peter Fordyce qualified from the Royal Veterinary College in 1981 and spent some time working in general practice. He currently teaches first-opinion small animal practice in the Department of Veterinary Medicine at Cambridge. He holds a PhD and the RCVS certificate in animal welfare science, ethics and law.
When the client cannot pay
Working at a clinic owned by a charity providing subsidised services to people unable to afford private veterinary fees, you see a 10-year-old Staffordshire bull terrier with a suspected closed pyometra. The bitch is unwell but stable at the time of presentation. Owners must pay in full at the time of treatment. Occasionally, the charity has surplus funds and offers the client to sign over ownership of the patient. It then pays for treatment and rehomes the animal to another person. The charity has a pro-life policy and believes that animals should not be euthanased because a client cannot afford to pay for treatment. The owners of the bitch cannot afford treatment, even at the charity's prices. While discussing case management with an EMS student, the student says they would pay for the surgery if they could keep the dog. What should you do?
Issues to consider
The legal position is clear under the Animal Welfare Act 2006 (as devolved). Owners of animals protected under the Act must ensure their animal's needs are met, and prevent them enduring unnecessary suffering (Sections 3, 4 and 9), within the parameters of the caveats in Sections 4 and 9 (‘whether the conduct concerned was in all the circumstances that of a reasonably competent and humane person’, and the extent to which the steps the owners have taken to meet the animal's needs ‘are reasonable in all the circumstances, to the extent required by good practice’). Having brought the bitch to the surgery, the owners are clearly complying with the Act. However, beyond this point, compliance becomes problematic if they cannot fund the necessary treatment to avoid a worsening welfare situation. The veterinary surgeon has a legal and professional duty (RCVS 2017a) to the animal's welfare, but like the charity, no legal obligation to provide credit to owners of animals in distress.
Possible way forward
Along with responsibility for the animal's welfare, veterinarians also have responsibilities to their clients (RCVS 2017b). In order to avoid exposing the owners to the risk of prosecution, it is important to appropriately ensure that the client is aware of the legal obligations, and explore options for resolving the problem.
Given the welfare of a bitch with a closed pyometra may deteriorate rapidly, while a precipitous decision does not have to be made immediately, it needs to be made as a matter of urgency. The owner should therefore be allowed a reasonable amount of time to find alternative sources of finance, for example, loans from family and friends, other charities, or possibly referral to a private practice that would accept a payment plan, and this should be the preferred option.
If the bitch's owners cannot meet its needs as required in law, that is, by addressing the medical condition causing its worsening welfare, then two further options might be considered in the order below, although neither are likely to be palatable to the owner:
▪ Transferring legal responsibility for the dog's welfare to a new owner (Animal Welfare Act 2006, Sections 3 and 9)
▪ Euthanasia (Animal Welfare Act 2006, Section 9).
Discussing transfer of ownership as a way forward may be problematic, although essential to avoid a charge of paternalism. Legally, it is straightforward, but significantly complicated by the nature of the companion animal-owner bond (Robertson 2015). If one accepts Rollin's ‘paediatrician model’ (Rollin 2006) of veterinarians acting as advocates for their patients, there is a duty to the patient to try and ensure they have a ‘life worth living’, by finding someone who will take financial responsibility for the dog's treatment. However, this potentially virtuous act needs to be considered in the context of harm to the feelings of the owners, and the potential misunderstanding of the motivation of the veterinarian. This would be particularly so if a person working at the clinic was seen to benefit from the situation.
For the reason above, and before discussing the student's offer with the client, it would be better to explore whether the charity was in a position to take over ownership (with fully informed consent), fund the surgery and rehome the dog; even so, the owners may find accepting why they should not have their dog back, once healed, contentious. If the charity is not in a position to help, then the student's offer ought to be discussed. However, due to the potential perception of a conflict of interest, discussion should be approached with tact and caution.
In the event that the owners are unable to afford the surgery, the charity has no funds, and they are unwilling to transfer ownership to the student, the ethical imperative underpinning the legislation to protect the animal's welfare becomes critical, that is, setting limits to suffering. Clearly, if there are no alternatives for funding treatment, not relieving the animal's suffering by euthanasia would be cruel, and illegal.
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