Ethical frameworks in small animal practice.ppt

Ethical frameworks in small animal practice Dorothy McKeegan [email protected] Intended learning outcomes Relevant Phase ILO •CP3035 - Discuss the ethical considerations and legal responsibilities which underpin veterinary professional judgement Lecture ILOs •Demonstrate an understand...

Ethical frameworks in small animal practice Dorothy McKeegan [email protected] Intended learning outcomes Relevant Phase ILO •CP3035 - Discuss the ethical considerations and legal responsibilities which underpin veterinary professional judgement Lecture ILOs •Demonstrate an understanding of the ethical issues that may underpin decision making •Utilize a logical approach to decision making Animal ethics: difficult questions • Why should we care about animals? • Do animals have moral status? • What human actions towards animals are acceptable or unacceptable? • What is the value of animal life? • Is painless death a harm? Intrinsic moral value If animals have a mental life and feelings (e.g.) if they can feel pain Interests flow from these feelings (e.g.) the interest in avoiding pain Others are obliged to respect such interests Animal interests Quality of Life • Hunger & Thirst • Pleasure • Fear & Distress • Happiness • Pain, Injury & Disease • Play • Discomfort • Species behaviour • Behavioural restriction Quantity of Life • Shortened life • Extended life Three ethical frameworks • Contractarian – Only humans are morally relevant, animals have no moral status so do not create moral duties • Utilitarian – Animals deserve equal moral consideration; in deciding what to do, we must consider welfare consequences for animals as well as potential benefits (for humans or animals) and try to achieve the greatest good for the greatest number (cost-benefit) • Animal rights – Fixed ethical rules place limits on our treatment of animals; individual rights cannot be violated to benefit others Applying the frameworks Are you against hunting? • Contractarian – “No, it is a good sport and it benefits rural economies” • Utilitarian – “Not in all cases. It may be a good way of controlling a population and thus secure better welfare for wildlife. Also, it may be a way to get meat from animals that had good lives” • Animal rights – “Yes, we should not kill healthy animals” Most of us hold hybrid views containing elements of each framework (may also depend on context) These frameworks are usually the basis of our ethical principles Applying the frameworks Should we euthanise healthy pets? • Contractarian – “Yes, they are the property of their owners and we should follow the owners wishes” • Utilitarian – “It depends. We must try to balance the interests of the animal and the interests of the owner” • Animal rights – “No, animals have a right to life” Simplistic? Many factors affect individual decision making But underlying principles affect our starting point Veterinary ethics – ‘the fundamental problem’ Does the vet have primary responsibility to the client or the animal? RCVS declaration: “.. ABOVE ALL, my constant endeavour will be to ensure the health and welfare of animals committed to my care." How do you view your role as a vet? Garage mechanic model • Owner decides ‘his animal, his decision’ –Client autonomy • Do as you are asked within the law and professional boundaries and charge for your services Paediatrician model • Vet decides (with input from owner) – Animal akin to nonconsenting, non-verbal but ethically relevant child • Reject requests which are not in the animal’s interests • Joint decision making – owner has legal power • Communication, education BVA Treatment choice guide “In both human and veterinary medicine, there appears to be a trend towards patient (or client) autonomy, away from the paternalism which has characterised these professions in the past. It may be argued that since clients have legal ownership of animals they should be allowed to make decisions for their animals and should have the final say regarding treatment. However, when considering the best interests for the animal, it is reasonable to expect that a vet may attempt to influence treatment choice. Especially as, for a variety of reasons, there are occasions when some owners do not always act in the best interests of their animals” “The animal’s welfare must be the vet’s first priority” Euthanasia, killing and the value of animal life Justifications for killing animals • • • • • For food Pest control Research Hunting Euthanasia Companion animals – special status • Difficult decision – source of dilemmas • Personal decision, wide individual variation Quality or quantity of life? • • • • Wide agreement that welfare (QOL) is important No quantity of life protection in legislation Debate over the value of animal life Evidence that quantity of animal life does matter to (many) people – Moral vegetarianism – Vets unwilling to kill healthy animals – Shelters and re-homing programmes for abandoned pets – Advanced treatments of companion animals – Critical attitudes to hunting Is death a harm? • Death is distinct from dying which may involve suffering • Death itself precludes all experiences, positive or negative • Death ordinarily considered to harm humans • But does a painless death harm animals? “Death is not a welfare issue” John Webster Death is not a harm - arguments • Only quality matters Our only duty to animals is to ensure they live good lives, as long as those lives last • Nature of animal consciousness – Animals can’t perceive/anticipate death – Animals don’t have long term plans, hopes or desires that can be thwarted by death • Animals are replaceable – In a way that humans aren’t – If animals die and are replaced by others with happier lives, this adds to the total sum of welfare Death is a harm - arguments • Lost opportunities – Death forecloses valuable opportunities that continued life would give – Greater harm to kill younger animals? • Right to life – Animals have strong moral claim to continued life, regardless of their ability to perceive death • Indirect consequences – If animals are thought of as replaceable this may negatively affect the way they are treated BVA Euthanasia guide • Absolutely justified euthanasia – No better option for the animal • Contextually justified euthanasia – There is at least one better option but the circumstances are such that it could not be taken – euthanasia is the best available option • Non-justified euthanasia – Better alternatives are available Ethical decision making • Vets face complex situations – leading to daunting dilemmas • We do ethical reasoning every day – balancing interests • Reasoning behind our decisions is sometimes hidden • Actions based on ‘gut feeling’ • Easier to think of ‘influences on my decision’ rather than ‘ethical arguments’ Ethical decision making – 10 steps • Prepare (think about it in advance) • Describe the options genuinely available • Identify factual influences • Identify ethical influences – (Apply any relevant ethical rules/principles) – Who’s interests do they represent? • Weight the influences – Who’s interests are strongest? • Identify the best option • Satisfy prerequisites • Act • Reflect on the decision and outcomes • Prepare for next time Prepare Preparation, at unpressured times, can reduce stress, and improve later decisions. This may involve: – Identifying potential dilemmas you might face – Identifying overarching principles you endorse/wish to follow – Communicating your position to others – Identifying other stakeholders’ ethical views – Acknowledging any biases you may experience Describe the options genuinely available • Ethics is about deciding what to do – from a range of options in a given situation • It is not helpful to merely lament about the situation or feel guilty for doing your best in an unfortunate context – For example, when presented with an animal who is aggressive through lack of training, we cannot avoid the situation by going back in time to improve its prior socialisation, but have to decide what to do now • All possible options should be considered, including doing nothing. Describe the options in “morally neutral” ways to avoid predetermining the decision. For example, “I could subsidise an undeserving client” might prejudice the outcome • Impossible options should be discounted, so that you do not feel guilty for not achieving the impossible Identify influences (factual and ethical) • Ethics is about the real world – every decision is made in a particular context • Consider all the relevant information, including both clinical data, and all pressures on the decision-maker (e.g. laws, owners’/keepers’ wishes, charity policies and practice protocols) • Ethical influences might be rules or principles that apply to everyone, such as ‘We should avoid killing healthy animals’ or relate to your role, such as ‘An owner’s refusals should be respected.’ • Dissect the problem to its basic facts and influences to help to grasp the elements of a complex situation, and reduce the risk of feeling overwhelmed by large numbers of considerations Identify interests and weight the influences • Since many dilemmas arise from a conflict of interest, consider to whom each influence relates (e.g. animal, vet, owner, organisation, society). • Evaluate how important each of the influences should be in this case (e.g. scored out of 10) • Influences should be scored as zero if they are unimportant in the case or should be ignored (e.g. inappropriate pressures from bosses or clients) • Influences should be scored as 10 if they should absolutely never be breached (e.g. “I should never torture an animal”) • Other influences should be scored in between, depending on the severity of the effects (e.g. the painfulness of an operation), the importance of the rule (e.g. not lying is a major ethical tenet) or the stakeholder (e.g. that animals should always have priority) Identify the best option • If the weighting of any influence or principle is absolute then rule that option out completely • In some cases, ruling out multiple options may leave only one option left • In other cases, identify the overall score for each interested party – by combining the scores – this will tell you who has the strongest interests which usually points to an option. • If multiple options appear equally acceptable, you could use an additional decision-making process (e.g. allowing the owner to choose) • This step can be quite ‘organic’ and may come naturally once you have dissected the problem (or it may simply be that you can now justify what you wanted to do all along!). Satisfy prerequisites • Certain options may only be achievable, or morally acceptable, under certain criteria, e.g. that informed consent has been obtained and medicines legislation or health and safety requirements are met • Other prerequisites might be your assumptions on details of the options, for example that the surgery will involve the highest level of analgesia or that no other animals are put at risk • Before acting, it is important to ensure that these prerequisites are in place – otherwise the justification for your decision will not hold Act • The actual act is often the hardest bit, and we may fail to fulfil our decisions because of human error, moral weakness, self-interest or pressure from others • For example, it is easier to decide to kill an animal in its absence than when the animal is front of you in the consulting room • Such feelings are natural and they should not make you feel guilty or embarrassed • Ensuring decisions are achieved can be helped by good communication and reminding yourself that the decision is well made • Owners face this problem as well, so you may need to help them to carry out their decisions Reflect (and prepare for next time) • • • • – – – – – One of the most important steps is to think back over a decision. When decisions go well, reflection is enjoyable and motivating, and can identify why they went well. When decisions go badly, reflection can make us feel guilty, but can help to analyse this guilt and ensure it provides learning for future decisions. Reflection can also allow you to consider the “big” animal ethics issues. Analyse the decision-making process and not the outcome. Ask not “Did it turn out right?” because a decision may have been the right one at the time, even if it turned out badly through bad luck. Useful questions for reflection: Did I engage in enough discussion? Did I consider all relevant influences and stakeholders? Was my animal welfare assessment accurate? Did I stand by my principles? Did I give myself enough time? Case example - Jasper • • • • • • Staffordshire bull terrier, 4 years old, friendly to adults, in shelter (with space pressure) for 7 months Jasper is very aggressive towards other dogs After many appeals, finally a man puts in a request of interest to rehome Jasper Due to potential aggression, the shelter is very careful about who adopts him, yet the interested party seems ideal; a single man in his thirties, who has previous experience with Staffordshire terriers The man has a 6 year old daughter who does not live with him but often stays over A meeting is arranged between Jasper and the daughter and it does not go well. Jasper shows very obvious signs of aggression and it is clear the adoption cannot go ahead • Should Jasper be euthanised? Example influences on the decision For euthanasia Against euthanasia • Jasper presents a danger to children (and other dogs) • Painless death will not harm Jasper • Jasper’s QOL in kennels may be suboptimal • The shelter has limited resources and his place could be taken by another dog likely to be rehomed • The shelter’s reputation needs to be protected • Jasper has a right to life • Jasper is young • Jasper could be rehomed and have a good life • A vet will have to do the euthanasia • The kennel staff are very attached to Jasper • The shelter’s reputation needs to be protected Whose interests? For euthanasia Against euthanasia • Jasper presents a danger to children (and other dogs) S • Painless death will not harm Jasper A • Jasper’s QOL in kennels may be suboptimal A • The shelter has limited resources and his place could be taken by another dog likely to be rehomed O • The shelter’s reputation needs to be protected O • Jasper has a right to life A • Jasper is only four A • Jasper could be rehomed and have a good life A • A vet will have to do the euthanasia V • The kennel staff are very attached to Jasper O • The shelter’s reputation needs to be protected O Ranking of interests Animal (5 influences) Organisation (4 influences) Society and Individual vet (1 influence each) • But these influences provide arguments on both sides and may some are probably more important than others • We need to weight the influences, or at least identify the most important ones Example of weighting influences For euthanasia Against euthanasia • Jasper presents a danger to children (and other dogs) 10 • Painless death will not harm Jasper 6 • Jasper’s QOL in kennels may be suboptimal 8 • The shelter has limited resources and his place could be taken by another dog likely to be rehomed 6 • The shelter’s reputation needs to be protected 8 • Jasper has a right to life 5 • Jasper young and healthy 5 • Jasper could be rehomed and have a good life 8 • A vet will have to do the euthanasia 6 • The kennel staff are very attached to Jasper 8 • The shelter’s reputation needs to be protected 10 0-10 where 10 is most important Ranking of interests with weighting Society Organisation Animal Individual vet Influences and weighting will differ between individuals • Quality and quantity of life • Whether death is considered a harm • Whether animals have a right to life (Jasper was euthanised) The ‘big 3’ Common dilemmas •‘Convenience’ euthanasia •Financial limitations on treatment •Clients wishing to ‘over-treat’ •Colleague conduct •Suspected neglect/abuse •Treating wildlife •Many more!!! Moral (di)stress • Moral distress has been defined as painful feelings and/or psychological disequilibrium resulting from recognising an ethically appropriate action, yet not taking it because of obstacles such as lack of time, supervisory reluctance, workplace policy, or legal considerations. • Moral stress is associated with conflict between your personal ethical position and what you are actually doing. In this situation stress arises from the guilt-inducing mismatch between your behaviour and your moral convictions. • Moral distress could also result from being unable to decide on the most morally appropriate action. • Moral stress is profound and non-trivial and is not easily dealt with by standard methods for ‘stress management’. In conclusion… • Awareness of ethical frameworks, concept and arguments provides a strong starting point for decision making in veterinary practice • Ethical reasoning is a skill which can be learned and improved – practice! • Reasoning through ethical decisions eliminates guilt – better decisions and happier vets • Some ethically problematic outcomes are beyond your control – you can only choose from available options • If possible, think about your ethical position in advance • Respect the ethical perspectives and decisions of others (if they are defensible!) Further reading Useful papers • • • • • • Mullan, S and Main, D C J. (2001) ‘Principles of ethical decision-making in veterinary practice’, In Practice 23, 394–401 Rollin, B E. (2003) ‘Oncology and ethics’ Reproduction in Domestic Animals 38, 50– 53 Main, D C J. (2005) ‘Offering the best to patients: ethical issues associated with the provision of veterinary services’, Veterinary Record 158, 62 Rollin, B E. (2005) ‘Ethics and critical care’. Journal of Veterinary Emergency and Critical Care, 15, 233–239 Yeates J.W. (2010) Ethical aspects of euthanasia in owned animals. In Practice 30(2): 70-73 Yeates J.W. (2011) Is 'a life worth living' a concept worth having? Animal Welfare 20(3): 397-406 • In Practice – Everyday Ethics column