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, ‘Clients who cannot afford to pay’, was submitted and is discussed by Anne Fawcett and Myles Chadwick. 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 Dr Steven McCulloch, acting director of the Centre for Animal Welfare, University of Winchester. It aims to provide a framework that will help practising veterinarians find solutions when facing similar dilemmas.
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Anne Fawcett teaches professional practice and veterinary ethics at the University of Sydney. She works in companion animal practice and is completing a doctorate in animal welfare and ethics. She is a diplomate of the European College of Animal Welfare and Behaviour Medicine in Animal Welfare Science, Ethics and Law. She is also a co-author of Veterinary Ethics: Navigating Tough Cases.
Myles Chadwick is the vice president of Emancipet New School, Austin, Texas. Before working with Emancipet, Myles was with the American Society for the Prevention of Cruelty to Animals, working with the National Spay/Neuter Project, and Berg Memorial Animal Hospital.
Clients who cannot afford to pay
You work in a veterinary shelter that provides a private service. A young man presents a four-month-old puppy that is clearly suffering from parvovirus. The practice policy is that every client must pay a deposit of at least 50 per cent of the fee estimate at the time of admission. If they cannot afford to pay they have the option of seeking treatment elsewhere, euthanasing the animal, or surrendering the animal to the shelter. In this case, the owner is adamant that the puppy is treated now. You overhear colleagues talking about the ‘irresponsible owner’. ‘
Couldn’t afford to vaccinate?’ one says. ‘He really shouldn’t have a dog.’ The other replies: ‘Just make sure you include everything possible in that estimate to get the maximum deposit. At least then we have our costs covered if he surrenders the dog.’
On paper this means that the client will have to consent to paying almost double the actual cost of treatment, which may prompt them to surrender the animal.
What should you do?
Readers with views to contribute on ‘Clients who cannot afford to pay’ should e-mail them to vet. firstname.lastname@example.org so that they can be considered for publication in the next issue. The deadline for receipt of comments is February 16, 2018. Please limit contributions to 200 words.
Issues to consider
The stakeholders in this scenario include the puppy, the owner, the veterinary team, the practice and the affiliated shelter that would accept animals surrendered to its hospital. If the puppy is surrendered, factors that determine its fate include shelter policy and capacity, as well as previous socialisation and training that the puppy has undergone.
It is increasingly common for veterinary practices to require a deposit to minimise losses and bad debts. An estimate of fees enables clients to understand and agree to pay estimated expenses, and plan financially.
In this case it is being misused to influence the client’s behaviour, and potentially to ‘punish’ the client for being an ‘irresponsible owner’. This is not what we might consider a virtuous member of the veterinary team would do. There are potentially negative consequences. Social scientist Patricia Morris (2012) observed that ‘a veterinarian’s ability to accurately estimate the cost of a patient’s treatment can have life-and-death consequences for animals in their care … underestimating the cost of treatment can cause mistrust between the veterinarian and owner as prices gradually rise, while overestimating may lead the owner to choose euthanasia rather than pay to treat’.
According to Yeates and Main (2010), doctoring an estimate with a view to ensuring a particular outcome constitutes a strong method of influence which is ethically indefensible because it does not respect the client’s wishes and the animal’s welfare. Such behaviour risks undermining trust in the veterinary profession, which may compromise the care of future animals. Furthermore, in branding the client irresponsible, the team dismiss the developing bond that the owner has with the patient, and its long-term future if treatment is successful.
If surrendered, the patient will enter a shelter and be subjected to a number of stressors including: an unfamiliar environment, exposure to unfamiliar people, noise, potential social conflict, confinement, social deprivation, fear and reduced ability to engage in behaviours such as regular exercise and socialisation, which promote wellbeing (Stephen and Ledger 2005, Newbury and others 2010).
If the patient enters the shelter, it will require resources, including cage space, food, exercise, behaviour assessment and training that might otherwise go to another homeless dog.
Possible way forward
On a utilitarian cost-benefit analysis, the consequences of inflating the estimate may enable the clinic to cover costs in the short term, but may have dire costs for the client as well as for the animal.
Given the possible expense of veterinar y treatment, not ever y owner will be able to access funds for a large deposit. A recent study reported that Danish small animal veterinar y practices encountered clients with limited finances commonly – 34 per cent saw such clients three to four times a month, while 25 per cent saw such clients five to 10 times per month. Yet only 9 per cent had a written policy on handling financially limited clients (Kondrup and others 2016). Clinics can consider third-party credit, payment plans, payment of a lower estimate or discounted ser vices for persons in financial hardship.
A US study found that 77 per cent of people noted cost as a reason for relinquishing their dog to a shelter, yet the majority of owners reported being emotionally attached to their dogs. Eighty-one per cent of owners said they were not aware of any services or assistance available to them (Dolan and others 2015). Another study found that many surrenders could have been avoided with some assistance, with 40 per cent of owners who had surrendered or rehomed pets reporting that free or low-cost veterinary care might have allowed them to retain their pet (Weiss and others 2015).
A virtue ethics approach is based on cultivating morally valuable character traits, such as trustworthiness, discernment and compassion (Beauchamp and Childress 2013). The veterinary team should provide an accurate estimate, discuss potential variation and disclose all payment options to the client.
Blaming owners for being ‘irresponsible’ may function as a way of reducing moral stress. Scotney and others (2015) describe a ‘moral shift’ in shelter workers, involving ‘shifting the responsibility of having to kill animals away from themselves to people outside the shelter, (ie, those who are seen to create the necessity for euthanasia, neglectful owners and irresponsible owners for pet overpopulation).
Instead of judging clients, the virtuous veterinary team would address the system in which surrenders occur. Implementing programmes and policies to help those clients experiencing a financial shortfall, when a sick or injured animal is presented, helps more animals stay with their owners. It may also begin to change the mindset of veterinarians about what ‘responsible’ pet ownership looks like.
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