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Comments on the dilemma in the March issue: When the client cannot pay
  1. Steven McCulloch

Abstract

In the dilemma discussed in the March issue of In Practice, you worked in a clinic owned by a charity that provided subsidised treatment. A 10-year-old bitch presents with a suspected closed pyometra. The owner cannot pay for the treatment, even at the charity's prices. While discussing the case, an EMS student offers to pay if they can keep the dog. What should you do? (IP, March 2017, vol 39, pp 142-143). Peter Fordyce suggested that there were two options if the bitch's owner could not meet the costs of treatment: transferring the legal responsibilty of the bitch to a new owner, or euthanasia. Both of these may not be palatable to the owner. Before discussing the student's offer, it might be better to explore if the charity is in a position to take over ownership of the bitch, fund the treatment and rehome it. If it is not, then the student's offer could be discussed with tact. If there are no options for rehoming and no options for payment of the treatment, euthanasia would be the only way to relieve the dog's suffering.

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IN the poll, 50 per cent of respondents voted to communicate and facilitate change of ownership; 44 per cent voted to offer medical management; and 6 per cent voted to recommend euthanasia, as other options are unsatisfactory. Perhaps more than others, this poll reveals interesting results. First, this is not the place for a review of the efficacy of medicines for the treatment of pyometra, but studies have shown that there are options here (Ros and others 2014). Given that veterinary surgeons are obliged to offer all reasonable treatment options (RCVS 2012), based on such evidence, it seems problematic to not offer medical management, at least as one option.

However, let's focus on the student's offer, where the following two points can be made. First, from a moral point of view, it seems better for all relevant parties to avoid the euthanasia option: the patient continues to live, the owner feels less guilt/remorse and the vet doesn't experience moral stress due to unnecessary euthanasia. Even the student presumably desires to have the dog, and, to boot, the charity's pro-life ethos is not tarnished. So let's assume that the vet is at least minded to discuss all options with the owner. The interesting questions are now whether the vet should communicate the student's offer, and, if so, whether the vet should recommend medical management or effective rehoming.

Personally, despite the obvious benefits of rehoming in some cases, I have always considered there to be something problematic about it. It's not hard to see where the problem lies. Generally, in rehoming scenarios, the vet's position is that they cannot provide treatment as the client cannot pay. However, they can provide the treatment if the patient is signed over. So, despite the patient winning out, there is something problematic in the vet's position that they both can and cannot provide the treatment, depending on who owns the patient. In our case, the EMS student has offered to pay for treatment. While this seems at first sight to avoid the problem described above, it carries its own problems that are very similar. Whether it is the vet or the vet student who offers to fund treatment in return for taking over the dog, they are effectively using their more fortunate financial position as tool of power to take ownership of the dog. In such cases, the client (rightly) consents not because it is their genuinely held desire, but because it is all they can do for their beloved pet in the dire circumstances that they face.

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