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, ‘Blocked cats and limited finances: an ethical obstruction?’, was submitted and is discussed by David Williams. 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, senior lecturer in human animal studies at 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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David Williams qualified from the University of Cambridge in 1988. He teaches veterinary ophthalmology at Cambridge veterinary school and is director of studies in veterinary medicine at St John’s College, Cambridge. He is also involved in animal ethics and welfare teaching and research at both undergraduate and postgraduate levels, and is a diplomate of the European College of Animal Welfare and Behavioural Medicine.
Blocked cats and limited finances: an ethical obstruction?
It’s 18:45 on a Friday just before the end of your evening surgery and you find a long-standing client at your door with one of her numerous cats. Maximillian is an eight-year-old male domestic short-haired moggie with a urinary obstruction. The practice has recently been taken over by a corporate company, and you know that there is now a standard operating procedure for such cases – a blood workup to check for renal function, a radiograph to localise the obstruction and a urine sample to evaluate what crystals are present. Following this, catheter placement under general anaesthesia should be performed to flush out the sediment and stone. The trouble is that the client doesn't have the money for such workup and treatment. What do you do?
Issues to consider
You remember from an extramural studies (EMS) placement with an older vet that she used to attempt localisation of such blockages by rectal examination and then easing the obstruction out by massage. However, this clearly isn’t the gold standard treatment you were taught at vet school nor is it the operating procedure expected by the practice. As the client doesn't have the money to pay for the necessary workup and treatment, euthanasia is another option, but that seems rather drastic.
Readers with views to contribute on ‘Blocked cats and limited finances: an ethical obstruction?’ should e-mail them to email@example.com so that they can be considered for publication in the next issue. The deadline for receipt of comments is March 15, 2019. Please limit contributions to 200 words.
You are the vet and the decision should be yours, guided, but not prescribed, by practice policy. An evidence base is key in making your decision. We tend to condemn 'Dr Google', but in the right circumstance it can be really useful. A quick browse of Google Scholar takes you to the article ‘A protocol for managing urethral obstruction in male cats without urethral catheterization’, where 11 out of 15 cats were successfully treated for urethral obstruction without catheterisation at Ohio State veterinary college at a cost of $350, rather than the $1200 to $1800 a standard workup and treatment regime would cost (Cooper and others 2010).
In the study, cats were sedated with acepromazine and given the analgesic buprenorphine, which also minimised stress. The penis was gently massaged to dislodge any obstructions and a single attempt to gently express the bladder was made, with cystocentesis being performed in cases in which this was unsuccessful. You are sure you could perform this procedure within the client’s budget.
Possible way forward
In my opinion it would be unethical not to attempt this, even though it may be against practice policy, as not doing so could lead to euthanasia of the cat.
However, this is not the only concern. The client also needs to be informed of the influence of stress on urinary obstruction in cats. Is keeping that many cats in a small house really conducive to their wellbeing?
But, maybe those sort of conversations are not to be had in the heat of the moment on a Friday evening and are best saved for another time. Indeed, the key to avoiding these situations is not to leave decisions on emergency cases with limited finance until 18:45 on a Friday evening. How to deal with cases where sufficient financial cover to pay for the gold standard treatment is not available should be discussed in a meeting with all vets, nurses and support staff present so that everyone is singing from the same hymn sheet!
My concern is that all too often students today are taught the gold standard treatment, which is most often an expensive one, without being taught or told about the silver and bronze options, which are certainly possible to undertake at a lower cost albeit not providing quite such optimal results. Where finances are an issue surely a silver or bronze procedure is preferable to euthanasia, as long as they do not compromise the welfare of the animal, which should always be our prime focus.
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