Euthanasia's moral stress: a high psychological price

Dr. Karen Reamsnyder remembers the day well.

Her client was an angry middle-aged man requesting euthanasia for hisdog, a healthy looking small mixed breed.

"I remember telling him, 'This dog is healthy, and I don't feelcomfortable putting this animal to sleep. Have you tried to place it?' "

"I don't have time for that," he replied. "I'll be honestwith you. If you refuse to do it now, I'm driving down the street and goingto open up the door and kick the dog out on the road."

"I was absolutely shocked," says Reamsnyder, who at the time,was just starting her career. "This guy was angry, and I just keptthinking about the possible abuse situation to this animal."

She performed the euthanasia with the client, who demanded to be present.

A practitioner now for 26 years and owner of the Raynham Veterinary Hospitalin Raynham, Mass., Reamsnyder says she still regrets doing it.

The incident, however, helped shape her attitude on euthanasia. Today,she refuses to perform convenience euthanasia. Instead, her hospital attemptsto find other alternatives rather than put them down. In fact, when a clientcalls to request euthanasia, her receptionist gathers information on theage of the animal, condition and informs the client that the doctor willdo a physical examination first and may or may not perform the euthanasia.

"I never forgot that incident," she adds, but experiences likeit were important for her to create the policy she now puts into practice.

Euthanasia inherently causes veterinarians moral stress.

Bernard E. Rollin, Ph.D., veterinary ethicist at Colorado State University,says that this moral stress is the single largest source of job dissatisfaction.

It's no wonder, Rollin says. Veterinarians are trained to heal, but theyare routinely confronted with ending life rather than saving it. In manycases, veterinarians are asked to kill healthy animals out of convenienceto the owner or because they can't afford treatment, he says.

The ethics of euthanasia is an extremely complicated issue because itcuts right to a person's core beliefs which often conflict with a client'sbeliefs.

"You can't devote your life to one purpose and flagrantly violatethat on demand without paying a high psychological price," he says."Can you imagine, four years earlier a dog was hit by a car? It wasbrought into the clinic, you did surgery and actually saved the animal.Now, the same client brings it in lame and ask to have it euthanized becauseit can no longer jog with the owner."

Scenarios like that cause moral stress.

According to Dr. Marsha L. Heinke, a DVM Newsmagazine contributor andpresident of Marsha L. Heinke, CPA Inc., euthanasia is an emotional, psychologicaland economic issue that every veterinarian must come to grips with. "Iwas recently reminded that veterinary medicine is one of the toughest professionsbecause it is the only one that deals with elective killing. And it's awake up call on why depression, anxiety, turnover, substance abuse and sometimes,in really extreme cases, suicide, is present in the veterinary profession."

How do you create a situation to obviate moral stress? Provide optionsto clients and do everything you can, within reason, to help extend an animal'slife, Rollin says. He adds that practitioners choose either the role ofgarage mechanic or one of a pediatrician for each case. The garage mechanicdoes exactly what a client demands, while a pediatrician only does whatis in the best interest of the child. "In any given case, you haveto ask yourself what model are you working from."

Of all the ethical dilemmas practitioners regularly face, the decisionto euthanize an animal can be one of the hardest. That decision becomeseven more complicated when the animal requires an expensive procedure thatits owner cannot afford or because of a behavior problem.

Dr. Douglas K. Wyler, DVM, of the Animal Medical Hospital and Bird Clinicin Hempstead, N.Y., agrees. "We try to let them know what they're infor in a best-case scenario and a worst-case scenario," he says. "Becauseeven in a best-case scenario, the animal may require a lifetime of care.We present them the facts and give them their options."

Those options can include euthanasia, which brings a core ethical issueinto focus: life vs. livelihood.

In some cases, pet owners want to put the animal down rather than spendmoney on proper pet care and "they're not willing to make the changein their lifestyle to accommodate their pet's behaviors," says JohnSnyder of the Humane Society of the United States.

In cases like these - where the animal is relatively healthy and thebehaviors can be corrected - many practitioners offer to place the animalelsewhere and sometimes provide basic medical treatment.

"If someone comes in with a perfectly healthy animal," Wylersays, "and they want to euthanize for economic reasons, we'll do ourbest to help them find a home."

The situation becomes more difficult when dealing with a severely sickanimal. Due to recent advances in medicine and nutrition, more pets reachthe geriatric age, says Dr. Thomas Lane, DVM, professor emeritus at theUniversity of Florida's College of Veterinary Medicine. That means morecases of cancer, kidney failure and other diseases associated with olderanimals.

Gary Patronek, VMD, Ph.D. and director of the Center for Animals andPublic Policy at Tufts University, adds that veterinary medicine has becomeso sophisticated, life-saving procedures can extend an animal's life. Sincetechnology will only improve, veterinarians will be confronted with theethical question of when enough medical intervention is enough. "Wehave tools now that can extend life pretty heroically," he says.

The whole issue of evaluating the quality of life for an animal is "onthe agenda for the 21st century," Patronek adds. "What is an appropriatequality of life for a companion animal, whether it is in the home or whetherit is in an institutional setting? How do you begin to gauge these things?"he asks.

Euthanasia approaches

Mary Garrett, a pet owner living in Phoenix, faced this dilemma lastSeptember, when her 18-year-old cat's liver and kidneys began to shut down.She says her veterinarian presented her with the option of trying bloodtransfusions or choosing euthanasia, and Garrett selected the latter. "Myfirst thought was for the cat and her quality of life, the second part wasa financial issue," Garrett says. "If it didn't improve her life,it would have been a huge financial burden to undertake."

Nearly every practitioner has faced situations like Garrett's, in whichthey must advise clients of their options. The animal's chances for survivaland its quality of life often can ease the decision to euthanize.

Lane cites the example of a horse that fractured its leg to the elbowafter being hit by a car.

"It's entirely feasible that if this animal was put in a sling,over the course of the year the animal could begin to heal," he says."But it could never be ridden again and any pressure on the leg wouldcreate a great deal of pain."

Practitioners must often weigh these odds, trying to intersect what canbe done for an animal with whether a client is willing to follow through.

"My approach is very consistent with survivability," says Dr.Don J. Harris, DVM, of the Avian and Exotic Animal Medical Center in Miami."If it's better than 50-50, it's worth trying. If there's a reasonablechance the animal is going to survive, I don't want a lack of funds to preventthat.

"I try to establish whether they really want to do everything possibleand whether they are sincere about paying for the care," Harris says."In very rare cases, I will allow them to make payments."

Strength of the bond

When determining a client's sincerity, practitioners must judge the strengthof the human-animal bond and the sentimental value the client attaches tothe pet. "I've seen people come in with Parakeets who they bought for$9.99 at a Wards store who will think nothing of spending hundreds of dollarson them," Wyler says.

"I'm shocked and surprised when some people who will come in andlook like they don't have their next meal paid for, but they'll reach intotheir pocket and pull out a wad of $100 bills for their animal."

Laurel Lagoni, director of the Argus Institute for Families and VeterinaryMedicine at Colorado State University, attributes this phenomenon to a changein the way pets are perceived. As people move more frequently, pets oftenfill the void created by leaving family and friends. "There's a higherdivorce rate now than before," Lagoni says. "People are waitinglonger to have children, so they might have animals instead of children."

Because clients feel such attachment to their pets, practitioners shouldexplain all the options thoroughly, but let them make the final decision.Wyler says he helps his clients find resources to pay for care, "askingthem to go through their mind as far as who can offer them financial aid"and suggesting family and friends as potential loan sources.

While Harris and Wyler have allowed trusted longtime clients to makepayments, they keep such cases to a minimum. Most practitioners requirepayment upfront, with rare exception. "We support and understand thatthey have to charge for their services," says Snyder of the HumaneSociety, citing the potential snowball of too much pro-bono work. "Becauseif they did, every good Samaritan would be bringing in animals and the vetwouldn't be able to stay in business."

Many practitioners try heading off economic euthanasia by suggestingpet insurance as soon as they see a new animal. "We recommend thatright from day one," Wyler says. "Every client that I have everhad has a tremendous sense of security from having that insurance."Policies usually require the client to pay the practitioner initially andlater reimburse payment based on the coverage. Another option is CareCredit,which lets pet owners apply for credit in participating practitioners' offices.

Human nature

In situations where euthanasia becomes inevitable, Lagoni says veterinariansmust relate to clients on a human level when discussing the decision. Sherecommends "comfort rooms" where owners can say goodbye to theirpet before the anesthesia is administered.

"I think veterinarians recognize very readily that when there isno cure, euthanasia is going to be the end result," Lane says. "Sothere's a real opportunity in veterinary medicine to counsel, to serve ina compassionate form and help the owners deal with the situation."

And euthanasia is humane, experts say. Rollin adds, "The time thateuthanasia is good is when you have a lingering debilitating illness thatis going to cause much suffering. It turns out that in human medicine, peoplewant euthanasia not because they worry about death, but they worry aboutmuch suffering."

Rollin adds, "I think the bottom line is that a responsible veterinarianwill not stand around and let the animal experience perennial moments ofagony. Frank McMillan wrote, 'euthanasia is not a treatment, it is a substituteuntil we have a treatment.' "