4 principles to guide your ethical steps
Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, CVA, MS in Clinical Bioethics, is a founder and past-president of the International Veterinary Academy of Pain Management. She owns Windsor Veterinary Clinic and The Downing Center for Animal Pain Management in Windsor, Colorado.
As veterinary technology soars ahead, pet owners are left with a lot of choices about diagnostics and treatment to sort through. And what if even we as veterinarians arent quite sure what the right thing to do is? Thats where four basic principles of clinical bioethics pioneered in human medicine can come to the rescue.
Veterinary medical decision-making involves a sequence of weighing and balancing. Clinical bioethics offers a framework within which we can frame these important weighing and balancing questions, allowing us a path toward doing the right things for the right reasons. (travelview/stock.adobe.com)For generations, care for pets has been driven by what the humans want-what the humans deem necessary. The veterinarian, for instance, would outline what should be done to “save” the pet from a particular crisis. If there was an infection, then an antibiotic would be prescribed. If there was a fracture, then surgery to stabilize the fracture would be the next step. Dehydration and acute renal compromise led to hospitalization and intravenous fluid therapy plus whatever supportive care was needed. It all seemed so straightforward.
The veterinarian would make a diagnosis, then craft a treatment or intervention plan, present that plan to the client and the client would either accept or decline based on available resources (e.g., money) and/or personal preferences. It all seemed so straightforward.
Do we ‘do everything' and ‘spare no expense' if that's what our clients want, no matter how poor the prognosis? Do we make crucial decisions on behalf of our patients by the seat of our pants?
Were the veterinary Nostradamuses right?
You're not the only one coming to terms with today's technology. See what your colleagues and experts predicted for the future of this profession in this special dvm360 Leadership Challenge.
Then technology exploded. Suddenly, veterinarians and healthcare teams had more advanced and sophisticated techniques, technologies and interventions. Pet owners could choose from a much more sophisticated palette of options for advanced care. This dramatic advance in options for both veterinarians and pet owners opened a Pandora's box of both options and challenges. So many choices! Suddenly, not all of our medical decisions were black and white. What to do? How to choose? Should we simply forge ahead with anything and everything? Should we withhold information about advanced or invasive techniques and technologies, hoping our clients will never know the difference? Do we “do everything” and “spare no expense” if that's what our clients want, no matter how poor the prognosis? Do we make crucial decisions on behalf of our patients by the seat of our pants?
As in human medicine, treatment options in veterinary medicine, particularly at the end of life, have exploded. We can make sophisticated diagnoses with advanced imaging like computed tomography (CT) and magnetic resonance imaging (MRI). It's nearly routine in some parts of the country to perform spinal decompressive surgery. Both academic and private specialty practices may offer brain surgery. There's even an option available for kidney transplantation as a treatment for chronic end-stage renal failure in cats.
Where-and how-do we draw the line between what we can do and what we should do?
Fortunately for the veterinary profession, human medicine has paved a path that we may follow: clinical bioethics, the discipline of facilitating ethical decision-making at the table side.
Where medical decision-making gets “sticky” is whenever a case presents a cascade of decision-making that's murky or unclear. The traditional medical model reflected a paternalistic/parental model of “doctor knows best.” The patient-and in our case the client-did what the doctor said needed to be done. The paradigm has shifted, thanks to the advent of clinical bioethics, to one of shared decision-making.
Medical professionals are distinguished from the general population by training, knowledge and the ability to deliver important and special services, so we have special obligations to our clients, who are also better informed than ever. In addition, we need to remember that even with the guidance of clinical bioethical principles and practices, we will still face moral dilemmas that defy easy black-and-white answers.
Clinical bioethics offers a framework [for] doing the right things for the right reasons.
Veterinary medical decision-making involves a sequence of weighing and balancing. Our target question is, “What is best for the patient?” An ancillary question that must be asked is, “What is best for the client?” Clinical bioethics offers a framework within which we can frame these important weighing and balancing questions, allowing us a path toward doing the right things for the right reasons.
There are four foundational principles of clinical bioethics. In a traditional veterinary paradigm, these principles were applied, if at all, only to clients. It's now time to apply these same principles to our animal patients. Having a basic understanding of these principles is step one to leveraging them during a difficult case. Let's look at each of these principles in turn and consider how to apply them both to our interactions with both clients and patients.
Respect for the autonomy of both veterinary client and patient
Respect for autonomy implies self-rule free from coercion by others. Medical decision-making happens in the wake of our delivery of medical information to our client in a way and at a level of translation that the client can understand. This also implies that we have adequately communicated the medical details effectively enough that clients appreciate the consequences of the decisions they make.
Respecting the client's autonomy means recognizing that difficult medical situations, particularly those that occur as the end of life approaches, are disempowering. Providing clients with knowledge about their pet's situation honors their ability to make the best decisions they can for their pets. We must respect our client's confidentiality and obtain consent before performing any procedures. We must also be ready to assist with and to direct decision-making when we're asked.
Companion animals can and do express their preferences much like prelinguistic children.
So, what about respecting the patient's autonomy? This has not traditionally been a concern, but the ethical literature supports a thought shift. In 2011, Rosalind Hursthouse wrote, “… our love for our pets should be shaped and informed by our recognition of the ways in which their needs and their lives are their own, peculiar to the sorts of animals they are … ”1 Human medicine recognizes that children can and do express preferences and that they can and should participate in their own care to the level of their cognitive development. Companion animals can and do express their preferences much like prelinguistic children.2 Our patients can and do express their preferences about the delivery, and their acceptance, of treatments they may need.
The passive principle of nonmaleficence to avoid inflicting harm
Nonmaleficence is the obligation not to inflict harm, which is distinct from an obligation to actively help others. For veterinarians, nonmaleficence for clients means preventing harm to their pets from negligence. For our patients, nonnmaleficence implies preventing negligence as well as preventing a situation in which appropriate care is withheld, including withholding euthanasia when it would relieve suffering. It also means avoiding the imposition of undue risks of harm without an expectation of an appropriately beneficial outcome.
The active principle of beneficence to demand positive action for another
Nonmaleficence is a passive principle, but beneficence is an active principle that demands positive action on behalf of another, and it implies that a relationship is present. Under the umbrella of beneficence, we weigh and balance benefits, risks and costs to produce the best overall result. Applying beneficence to our patients means creating a low-stress experience for them by viewing our procedures and treatments from their perspective. It means allowing them to feel safe and protected by their owners and by us.
Issues of pet pain and death
The entire dvm360 family of publications-dvm360, Firstline and Vetted-focused on many angles on end-of-life issues in this special package. If you want to explore more of what your colleagues are doing and what experts say are best practices, click here.
Justice for people is fairness for animals
The bioethical principle of justice is best expressed in veterinary medicine as “fairness.” This means approaching and advising about “like” patients alike. Clients whose pets are facing an illness or a specific condition will receive the same delivery of information about the condition. It means we have an obligation to avoid prejudices toward either the client or the patient.
Justice and fairness take into account what the patient wants and will tolerate.
Fairness to the patient means balancing our recommendations in order to accommodate both the patient's preferences and ability to withstand what's needed. While the humans in the equation are the decision-makers, and we ultimately must choose the care that will be provided, justice and fairness take into account what the patient wants and will tolerate.
When we're faced with decision-making as the end of life approaches, the most important question that surfaces is, “When is enough enough?” These principles, when leveraged on our patients' behalf and applied in an end-of-life context provide an opportunity to reinvigorate veterinary medical decision-making. Clinical bioethical principles are in absolute alignment with the veterinary oath: “ … I will practice my profession conscientiously with dignity and in keeping with the principles of veterinary medical ethics. I accept as a lifelong obligation the continued improvement of my professional knowledge and competence … ”
Do you think Dr. Downing's lens for judging tough cases could help you in your day-to-day work? Comment below and join a discussion for the future of veterinary ethics …
1. Hursthouse R. Virtue ethics and the treatment of animals. In: Beauchamp TL, Frey RG, eds. The Oxford handbook of animal ethics. New York: Oxford University Press, 2011.
2. Andrews K. 2011. Beyond anthropomorphism: Attributing psychological properties to animals. Also in above.
Dr. Robin Downing, who holds a master's degree in clinical bioethics, is a diplomate of the Academy of Integrative Pain Management, a diplomate of the American College of Veterinary Sports Medicine and Rehabilitation, a Fear Free Certified Professional, a certified veterinary pain practitioner, a certified canine rehabilitation practitioner, and hospital director at The Downing Center for Animal Pain Management in Windsor, Colorado.