A call to action: Ameliorating moral distress among veterinarians

Abstract

Veterinarians have higher incidences of suicidal ideation and suicide attempts than the general population. In a survey, 1/6 veterinarians had contemplated suicide, with psychological distress a key predictor of suicidal ideation. Availability of lethal means, habituation to death, student loan debt, and other causes may contribute. Several studies have considered the individual agency of veterinarians, well-being initiatives, and selection biases in veterinary school admission. However, there is growing consideration of the moral distress, moral injury, and moral residue that afflict and destabilize veterinarians and may promote suicidal ideation and suicide. Moral distress, a historically elusive concept in veterinary medicine, is undergoing rapid delineation and analysis. This article discusses moral distress in human and veterinary healthcare professionals and how it is measured. Identification of emerging moral stressors may result in designation of broad veterinary moral distress categories and measurable moral distress scales, with an aim to predict and ameliorate moral distress. Finally, 2 tools are proposed to identify and address deleterious effects of moral distress in veterinarians.

INTRODUCTION

Veterinarians have higher incidences of suicidal ideation and suicide attempts than the general public; 1/6 veterinarians have contemplated suicide and the risk of death by suicide in veterinarians has ranged from 1.7 to 4 times that of the general population (1–3). Male and female veterinarians have demonstrated proportionate mortality ratios for suicide of 2.1 and 3.5, respectively — significantly greater than those for the public at large (4). Availability of and effective utilization of lethal means, potential habituation to death, student loan debt, failures in reflective functioning, frequency of euthanasia of animals, substance abuse, and other factors may be contributors, loosely stratified into contextual and individual risk factors (2,3,5–7). Much professional veterinary speculation has focused on the individual (e.g., agency of veterinarians, selection biases involved in admission to veterinary schools, personality traits common to veterinarians, implementation of coping mechanisms) rather than on profession-induced or contextual (e.g., professional, occupational trauma) etiologies and interventions (8–11).

A potential barrier to identifying and ameliorating suicidality in veterinarians has been the paucity of research examining the direct role of moral distress as a risk factor for developing psychiatric disorders and, potentially, suicidality. Moral distress is currently undergoing conceptual delineation for application in the veterinary profession and may be elicited by ethical dilemmas in companion-animal veterinary practice (8–10). Because of the ambiguous moral and legal statuses of animals, particularly in North America, companion-animal patient welfare is not ensured (12). Although much veterinary clinical decision-making is done with animal welfare as paramount, the ultimate choice lies with the proxy, or pet owner, and their willingness and ability to pay for medically indicated care. Accordingly, diminutions in animal patient welfare, lack of best interest of the animal, and potential harm are likely to constitute a substantial portion of ethically challenging situations encountered by companion-animal veterinarians (8,13).

Quantification of moral distress is difficult and there is no established methodology to measure it in veterinary medicine. Surveys have suggested associations between occurrence of veterinary moral distress and trait perfectionism, personality, age, and female gender (9,10,14,15). This article summarizes the application of moral distress in medical professionals, discusses clinical scales used to quantify it in medicine, examines the role of moral distress in veterinary suicidality, and proposes veterinary moral distress scales. Clarification of morally distressing situations and identification of potential strategies to mitigate moral distress may attenuate such dilemmas and reduce veterinary suicidality.

MORAL DISTRESS IN MEDICINE

According to Andrew Jameton’s foundational definition of moral distress, nurses experience moral distress when institutional or supervisory constraints make it impossible for them to act on moral judgments, precluding the most ethical action (16). Jameton postulated that moral uncertainty may affect diverse individuals in a nuanced space, who must accordingly exercise moral reasoning to take the most ethical action (16).

Jameton describes initial frustration, anger, and anxiety (“initial distress”) plus subsequent “reactive distress” (17). Core etiologies of moral distress in healthcare professionals have 3 pillars: internal factors (e.g., perceived powerlessness, lack of knowledge), external factors (e.g., institutional constraints, lack of support, incompetent associates), and clinical situations (e.g., unnecessary and futile treatment, aggressive treatment potentially harmful to patients, lack of informed consent, violation of patient autonomy, deception, false hope) (18). Much clinical moral distress research has been conducted in nurses, but the concept is increasingly recognized in medical students, residents, and physicians (19–25).

Moral distress has neurobiological corollaries; it impairs prefrontal cortical cognitive function (26). Reductions in prefrontal cortex self-regulation may result in even greater vulnerability to stress that contributes to clinician burnout (26), supporting susceptibility to moral distress as a predisposed inherent trait in some people (27,28).

Moral distress may be further elucidated by recognizing other related concepts, including moral injury, moral courage, moral resilience, and moral residue (29). Moral injury is a form of moral distress in which an individual may observe, perpetrate, or participate in acts that violate deeply held moral beliefs. Moral courage is the ability to practice ethical behaviors, whereas moral resilience may be characterized as an individual’s ability to sustain one’s ethical integrity in response to ethical conflict. Moral residue, akin to a chronic type of moral distress, remains after passage of a morally distressing situation. In Epstein’s construct, acute moral distress attenuates with resolution of the clinical situation, but the remaining moral residue is not completely resolved and is the baseline for future episodes of moral distress (29). Therefore, additional bouts of acute moral distress increase chronic moral residue. Subsequently, consistent increases in baseline moral residue result in a lower threshold to develop an acute episode of moral distress with each triggering situation, establishing a perpetually decreasing setpoint and reduced tolerance for morally distressing situations (29). Perhaps moral courage and moral resilience are reflective of individuals who can uphold and maintain core ethical values, suggesting that such individuals perhaps have profound coping strategies that sustain them in morally challenging situations.

Moral distress has been identified globally in veterinary professionals, including veterinary students, veterinary technicians, client-service representatives, and veterinarians, and has been significantly associated with psychological stress, burnout, and compassion fatigue (3,8–10,15,30). Diverse ethical dilemmas, ethically challenging scenarios, and disparate stressors contribute to veterinary moral distress (2,8–10,13), encompassing an undervalued contributor to veterinary well-being.

Many common clinical situations are associated with or may cause moral distress, including futile care or inappropriate/ ineffective treatment, excessive workload, aggressive treatment not in the patient’s best interest, inadequate informed consent, deception, false hope, decisions regarding utility of life-sustaining treatments, medical errors, elimination of lifesaving treatment, poor patient quality of life, and acquiescence or complicity in violation of patient rights or autonomy (31). Evaluation of factors on an original moral distress scale stratified general categories or factors into several specific categories that could incorporate most ethically distressing situations, including individual responsibility that may be discordant with external directive, facets not in the patient’s best interest, and deception; all 3 of these in aggregate contribute to understanding moral distress (32).

CONSEQUENCES OF MORAL DISTRESS

Greater qualitative moral distress and quantitative moral distress are associated with many deleterious sequelae, including anxiety, guilt, depression, intent to leave specific professions/career attrition, lower job satisfaction, job turnover, early retirement, secondary post-traumatic stress, compassion fatigue, reduced quality of patient care, medical error and potential diminution in positive patient outcomes, depersonalization, and negative career identity (33,34). Moral distress can have major long-term psychopathologic consequences in many populations, and moral injury or morally injurious events have been associated with significant debilitation, including post-traumatic stress disorder and suicidal ideation in general and healthcare populations (35–37).

A potentially important sequela of moral distress is burnout, a psychological phenomenon secondary to chronic job-associated stressors that results in personal exhaustion, job cynicism and detachment, job inefficacy, lack of accomplishment, or emotional detachment and dehumanization (38). Burnout may be quantified by multiple tools of variable validity, of which the most commonly used is the Maslach Burnout Inventory (30,38,39).

Psychological capital (e.g., resilience, hope, optimism, self-efficacy) may be compromised by burnout in clinicians and harbors the risk for progressing to significant psychological distress, including anxiety, depression, and suicidal ideation (40). Burnout has been characterized as either an established sequela of, or an entity related to, moral distress in many clinical populations (19,20,34,41) and can be a damaging consequence of moral distress. Presumably, moral distress is a core cause of burnout in medicine (27). Perhaps there is an association between clinician burnout and suicidal ideation (19,20,22,25,42); this suggests that amelioration of moral distress is a critical endeavor.

MORAL DISTRESS SCALES

A challenge in identifying and developing targeted strategies for moral distress is measuring it. The first Moral Distress Scale (MDS) was produced in 2001 (32) and attempted to measure distress in a cogent and objective manner. It was tested in 214 nurses; higher scores predicted greater moral distress with validity and reliability and yielded 3 primary factors, including individual responsibility that may be discordant with others’ directive, things not in the patient’s best interest, and deception (32). The original MDS scale has been revised and adapted, mainly for nurses and physicians (28,43), implying its potential broad utility. Rigorous detection of moral distress in myriad clinical settings, including veterinary medicine, requires robust creation and implementation of scientific instruments. The diversity of scales with varying validity and accuracy implies flexibility in measuring moral distress, enabling modification of preexisting scales.

MORAL DISTRESS IN THE VETERINARY PROFESSION: UNIQUE CHALLENGES

Unique characteristics of veterinary moral distress (e.g., workload, client issues, financial concerns, emotional demands, student loans) delineate it from moral distress in other healthcare professions. Although these issues are common to other healthcare professions (e.g., physicians), there is a central difference: the moral status, or the “personhood,” of the patient. What is distinctive about the moral status of the patient in veterinary medicine is the often unprotected legal or moral status and near total dependence on the pet owner of the companion animal, described as “chattel” or “child” in legal and social approaches (12). Accordingly, without consistent legal or moral protection, the animal’s moral status is wholly defined by the pet owner. Pallotta suggests that, for companion animals, “…dual definitions of family and property are competing for cultural ascendancy,” and there are profound consequences of such an ambiguous cultural, social, emotional, and legal lack of clarity — particularly for providers of medical care to animals (12). The ensuing moral distress of companion-animal caregivers is unique in veterinary medicine. The legal fiduciary duty of the veterinarian is to the patient proxy, or pet owner, yet the moral obligation may be to the welfare of the animal, creating an ethical conflict that generates a unique form of moral distress. Perhaps companion-animal veterinary ethics are most frequently driven by external factors (e.g., financial capability of the owner or their social or emotional desires) rather than by a virtue-based standard ethical framework. Therefore, “best care” of individual animals cannot be consistently prioritized, and veterinary moral distress has a deeper basis.

The ambiguous patient moral status results in both unintended and deliberate violations of animal welfare. Animal welfare is measured by evidence-based, objective physiologic data and behavior markers to provide the most robust, objective, and non-proxy-driven sense of “the state” of an animal: its biological function, emotional and affective states, and ability to engage in species-specific behaviors (44). Considerations of quality of life, best interest, and minimization of harm commonly used for human patients may not be adequate measurables as they are highly subjective and self-reported. The need to constantly define patient welfare and a fluid and tenuous patient moral status often causes moral distress for veterinarians.

The United States’ Veterinarian’s Oath, in contract to physicians’ oaths, is not patient-centric. How is the fiduciary duty to the patient asserted when the patient has no autonomy, agency, or personhood? How is decision-making a shared endeavor when decisions are wholly left to the proxy (pet owner) in the patient/pet owner/veterinary triad? Is the virtuous veterinarian the one who intercedes in the animal’s best interest even if doing so will bankrupt a bereft pet owner? The divergent and fluid moral statuses of animals, dependent on so many external factors and modified by the proxies, confound the ethical model of the doctor and patient.

Veterinarians may have more clinical duty responsibility than decision-making authority. In the triad of the veterinarian, the patient who is a pet animal, and the pet-owner proxy, the best interest or minimizer of harm is almost solely secondary to pet-owner decisions, and the pet owner might be considered the “authoritative decision-maker” who can supersede the most stringent veterinary recommendation without legal or moral risk.

If professional autonomy is represented by the balance between professional authority and professional responsibility, the professional autonomy of veterinarians is, conversely, always limited by the choices of the pet owner. Veterinarians might believe that they are participating in shared decision-making and exercising clinical autonomy when they may be yielding to limitations of the pet owner. This may be a deterrent to the enforcement of evidence-based approaches in the veterinary profession, since this ideally prioritizes a fiduciary duty to the animal, assumes no variability in patient moral status, and does not include economic consideration as the determinative aspect of the care calculus. Implementation and maintenance of best clinical evidence may be difficult to describe in veterinary medicine due to the heterogeneity of the financial means and personal desires of pet owners, as finances are often the controlling interest in veterinary medicine.

The veterinary establishment, a fee for service, still urges a strong economic foundation, partially to support and maintain a potentially higher standard of care. However, more flexible contextualized care, reflective of a continuum of acceptable care, is more likely to drive factors that influence care delivery. Veterinarians must integrate clinical care delivery in a model that is thus rarely consistent for most or all animals. Accordingly, these unique types of moral distress and ethical dilemma elicited from non-patient-centric models are important among veterinary practitioners (8,9,10,13).

Marcia Angell described the doctor as a “double agent” — reconciling patient needs with costs to society, endangering the patient-centric ethos of medicine, and compromising one’s fiduciary duty to the patient (45). Veterinarians may be considered “quadruple agents” — reconciling the needs of the pet animal with those of society, the financial needs of the pet owner, and the psychosocial preferences of the pet owner. Clear acknowledgement of this, with greater articulation of ethical dilemmas, potential solutions, and integrated ethics education, may attenuate moral distress (8). Subsequently, if contextualized care deviates from optimal care, this might enable veterinarians to use active intellection, rather than passive acceptance, to preserve the priority of the animal.

Although veterinary moral distress factors may mirror those seen in other areas of clinical medicine, veterinary medicine elicits unique stressors. Euthanasia of companion animals contributes to veterinary moral distress, and likely moral injury and moral residue, among practitioners (8,13,46). Certain groups may become habituated to death or inured to circumstances that might elicit pain through repeated exposure to painful events, essentially acquiring the capability to lose the natural fear of death (47). There may be an acquired vulnerability or habituation to suicide due to chronic exposure to painful events or to death (47).

Perhaps this applies to veterinarians’ repeated exposure to death via euthanasia, characterizing death by suicide as a solution for severe psychological distress (48). Furthermore, because euthanasia is a positive clinical outcome in their patients, some veterinarians might consider suicide a form of “self-euthanasia” in difficult situations (49,50). In national surveys of companion-animal veterinarians, euthanizing animals ≥ 5 times weekly was significantly associated with meaningful suicidal thoughts (5), whereas euthanasia frequency was weakly associated with depression (51). Depression, anxiety, emotional exhaustion, cynicism, lack of professional efficacy, and burnout were identified or normalized in many global veterinary professional populations and may contribute to suicidal ideation and suicide (11,49–55); and burnout may be independently associated with suicidal ideation in veterinarians (56). Preventing suicidal ideation is paramount in veterinarians because of their ease of acting on suicidal thoughts due to access to lethal means (54).

Client factors, such as lack of finances, client noncompliance, and unrealistic expectations may contribute to distress, and this may be amplified because there is no legal protection to provide recommended care to veterinary patients (8). The pet owner/clinician dyad may be affected by clinical state of the animal. Sick animals may be associated by pet owners with greater caregiver burden, more depression and anxiety, poorer psychosocial functioning, poor quality of life, greater veterinary utilization, and more nonbillable contact hours that may increase stress on the clinician, reducing clinician well-being (i.e., “burden transfer”) (57). The burden transfer inventory scale had a correlation between encountering burden transfer inventory items and stress and burnout (57), a potential site of intervention.

Potentially injurious moral events (common in veterinary medicine), moral injury, moral distress, and moral residue may occur in veterinary medicine secondary to owner-directed treatment restriction due to finances or inability to prioritize the pet’s best interest, refusal of lifesaving care, insistence on futile care, lack of institutional infrastructure to support standards of ethical care, lack of veterinary decisional authority, reporting of animal abuse, breeding and purely cosmetic procedures, surgical and other procedures conducted on animals by non-veterinarians, and aspects of euthanasia (36,37,49,50). In addition, some veterinarians respond to such encounters with an amorphous and uncharacterized sadness that appears to be an unspoken and accepted part of the profession (8,36,37). The responses and the associated emotional detritus are likely passive coping behaviors that are negative rather than adaptive (8).

This passive coping is wholly inadequate in addressing the real problem — the lack of acknowledgement and acceptance of the moral dilemmas that result in a simmering distress, constant influx of potentially morally injurious events, ever-accumulating moral residue, and a professional population unable to recognize the effects of moral injury on its caregiving model and unaware of the need to foster moral resilience. The veterinary population may be uniquely vulnerable to psychological distress because of specific shared psychological characteristics, including anxiety, greater comfort with nonhuman animals, introverted personality, compassion, empathy, and perfectionism (15). Anecdotally, veterinarians may be uncomfortable with human interactions; lack aptitude for financial discussions; not always be respected by the public; and have limited training in ethics, business, or psychology. Veterinarians may lose to death more patients than do physicians.

Moral distress in the veterinary profession and its association with psychopathology, including suicidality, is still an amorphous concept. Ultimately, identification of moral stressors might result in designation of broad moral distress categories and measurable moral distress scales, with an aim to predict and ameliorate stressors emerging from ethical dilemmas. The goal of classifying distress-inducing ethical dilemmas for the small-animal veterinarian is to ameliorate associated adverse events and their deleterious effects on the psychological health and well-being of the veterinary workforce. This is necessary to promote and enhance development of therapeutic tools to combat such effects. Although public awareness of veterinary workforce health is important, the prioritized primary audience for this survey includes practicing small-animal veterinarians and leaders in veterinary education, professional societies, and industry.

SOLUTIONS: MORAL DISTRESS SCALE — VETERINARY (MDS-V) AND SUBJECTIVE, OBJECTIVE, ASSESSMENT, AND PLAN (SOAP)-PLUS

The author proposes the following theoretical equation to potentially elucidate the current moral emergency of veterinary suicide, suggesting that reductions in access to lethal means and in moral distress would contribute to potential reductions in suicidality. Although complex etiologic factors contribute to suicidality, these factors may be contributory.

$$Access\hspace{0.17em}to\hspace{0.17em}lethal\hspace{0.17em}means+Moral\hspace{0.17em}distress=Elevated\hspace{0.17em}risk\hspace{0.17em}for\hspace{0.17em}veterinary\hspace{0.17em}suicidality$$

Veterinary moral distress may be an “ethical biomarker” of suicidality in veterinary professionals. Accordingly, ready and rapid recognition of pervasive moral distress in veterinary populations, appropriate treatment to ameliorate the slide into psychological distress and burnout, and reduction in access to lethal means may reduce suicide in the veterinary profession, which is a real probability in individuals with suicidal ideation and access to lethal means.

Current proposed institutional responses to this emergency are largely anecdotal and include wellness, financial planning, and fortification of personal agency (49,50). Limiting access to lethal means is a legal and policy-based restriction beyond the scope and expertise of this paper, but is critical, especially for veterinarians at risk. However, early identification of moral distress in broad veterinary populations may enable identification and amelioration of such distress, resulting in potential attenuation of suicidality in veterinary professionals.

Therefore, the use of 2 instruments to facilitate early recognition and intervention for pervasive moral distress among veterinary professionals is proposed. The first is the Moral Distress Scale adapted to Veterinary populations — the MDS-V. If such a scale is based on factors and appropriately validated, it could be readily applied to broad veterinary populations and used as a screening tool for suicide risk. A scale has been conceived to measure moral judgment and reasoning in veterinary students, but to our knowledge, there is no MDS adapted to veterinarians (58). The second tool is the SOAP-Plus, a tool integrated into the medical Subjective, Objective, Assessment, and Plan (SOAP) note to screen each clinical encounter for ethically challenging clinical situations that could elicit moral distress or moral injury in the practitioner, decide what they are by integrating various contributing factors, and determine ethical dilemmas.

Moral Distress Scale — Veterinary (MDS-V)

Measurement of moral distress in the veterinary setting will establish 2 goals: characterization of the concept in veterinary medicine and, therefore, opportunities for intervention against its deleterious effects. Although the methodology to evaluate the MDS-V will be established upon construction, it will need to include certain salient questions that might contribute to the accurate and valid assessment of contributory moral distress in screened individuals if it is to demonstrate psychometric validity and reliability. Clinical situations, internal constraints, and external constraints, adapted from a prior clinical scale, could be used for possible characterization of the scale (15). However, a broad and robust factor analysis will enable more faithful characterization of moral distress categories and root causes with the MDS-V. Creation of the MDS-V may be further enhanced using qualitative interviews by a veterinary professional functioning as an ethnographer. This could generate rich and solid qualitative and quantitative data to inform the creation of MDS-V scale questions, identifying and categorizing common situations that elicit moral distress in small-animal veterinarians. Common questions would be adapted from previous surveys incorporating discussion of ethical dilemmas in the veterinary profession (8–10,13) and the scale may include questions with clinical situations (CS), internal constraints (IC), and external constraints (EC) incorporated into the scale (Box 1).

BOX 1. Possible Moral Distress Scale — Veterinary (MDS-V) questions.

Have you ever performed a convenience euthanasia? (CS) Have you ever euthanized a dog or cat with highly treatable disease? (CS) Have you ever needed to withhold treatment because of pet-owner finances? (CS) Do pet owners frequently become upset at the cost of primary-care services (vaccination, deworming, spay/neuter, wellness examinations)? (IC) Do pet owners frequently become upset at the cost of diagnostic or surgical services (complete blood count, serum chemistry testing, radiographs, anesthesia/sedation, surgical services)? (IC) Have you been accused by pet owners of being only motivated by profits? (IC) Have pet owners been angry if you have not had appointment space to evaluate their pets and have needed to refer, especially post-pandemic? (IC) How long, on average, do your clients leave their pets alone during the day? (EC) Have you been injured at work by a patient? (EC) Do you know a colleague who has committed suicide? (IC) Do you always follow standard-of-care recommendations if they are in the patient’s best interest? (CS) Do pet owners with pets with chronic disease engage in excessive overutilization of your clinical support without clear management endpoints? (CS) Do pet owners often appear unable to understand the gravity of a medical situation after you have described it? (CS) Even when the pet owner is financially restricted from seeking appropriate care, do they demand that you resolve their pet’s complex medical problem? (CS) How often do you feel pressure to provide inadequate or lack of lifesaving care in situations because the pet owner lacks the financial ability or the desire to appropriately treat the patient? (CS) How often do you feel pressure to provide futile care due to pet owner requests? (CS) How often are you asked to perform cosmetic procedures (e.g., tail docking, declawing, ear cropping) that are painful and not in the patient’s best interest? (EC)

How often are you asked to euthanize a patient with a treatable disease? (CS) How often are you asked to provide excessive treatment to a patient that is having trouble tolerating it? (CS) How often do you observe patients with serious welfare compromises (e.g., lack of food and water, lack of ability to use nutrients due to disease, presence of fear or distress, presence of untreated pain/injury/illness, presence of clinical or emotional discomfort, lack of opportunity to perform natural species-specific behaviors)? (CS) How often do you observe patients with mild, moderate, or severe clinical disease due to breed status and selective breeding? (CS) Do you ever feel guilty about caring for patients whose breeds put them at profound risk for poor welfare (e.g., brachycephalic dogs)? (CS) Do pet owners complain about the cost of veterinary medical services and does this make you feel doubt or guilt? (IC) Do pet owners assume that you did not attend veterinary medical school? (IC) Have you been asked to euthanize a healthy patient or have felt pressured to do so? By a pet owner? By a supervisor or colleague? (EC) Have you witnessed animal cruelty or abuse and felt powerless to intervene? (EC) Do you feel that presence of psychiatric disease and burnout are normalized in the veterinary profession? (EC) Do you feel distressed about the lack of acceptable gold-standard or evidence-based protocols? (CS) Are you distressed by the heterogeneity of patient treatment offerings among your colleagues? (CS) How often have you seen a family pet relinquished because a family cannot appropriately care for them? (EC) Do you often see compromised welfare of the patient in the home? (EC) Do you feel anxious during the workday? (IC) How do you alleviate feelings of hopelessness and stress? (IC)

CS — Clinical situations; EC — External constraints; IC — Internal constraints.

Although public awareness of the MDS-V will be important, it is essential that the MDS-V is carefully evaluated and deemed psychometrically valid and reliable. A strengthening of the workforce must be institutional in nature and can only occur with aggregate investment in psychosocial health of veterinarians. The goal of identifying and categorizing situations that elicit moral distress is the creation and implementation of tools to ameliorate it, thereby fortifying resilience and positive health in the veterinary workforce.

Subjective, Objective, Assessment, and Plan (SOAP)-Plus

More than 25 years ago, the bioethicist Renee Fox actualized a medical educational framework that stratified nonmedical and medical teachings into separate entities, suggesting that ethical training has been enrobed in poorly differentiated disciplines that do not encompass nuances in bioethics, as a polestar to clinical bioethics (59). The medical educational approach had been crudely split into 2 roads: the biomedical and scientific versus the nonmedical and nonscientific. Fox asserted that the soft aspects of education have traditionally been relegated to a discrete, peripheral, and less important part of the curriculum, typically in preclinical years, whereas they should be incorporated into the active clinical curriculum (59). Medical students in clinical clerkships described ethical dilemmas involving inadequate care and issues with informed consent, with students and patients as frequent targets of ethical conflict (60). Moral sensitivity and moral judgment were frequently present, but moral motivation and moral courage were infrequently present, suggesting that stronger preclinical ethics education could be highly beneficial in the eventual reduction of moral distress and moral residue (60). Ethics education should be attuned to each medical educational stage, ensuring a growing adeptness in the practice of clinical ethics as the student transforms into a clinician.

Although there has been marked progress and awareness in integration from these very early observations, practical veterinary medical ethics is arguably still in its infancy as it attempts to converge and reconcile broader animal ethics with principles of medical ethics and clinical ethics (61,62). Perhaps there is a need for full integration of bioethics into the curriculum at each step of medical, and even premedical, education, to allow for a seamless absorption of ethical analysis concepts. Such integration of medicine and ethics would be highly valuable and not compressed into preclinical didactic lectures. This type of level-specific and clinical-case-driven, real-time ethical assessment could strongly inform professional identity, conferring moral resilience and humanity to the caregiver.

In veterinary medical education, the SOAP note is universally recognized as a cognitive structural clinical heuristic to assess, diagnose, and treat a patient. If one is trying to integrate ethical consideration concomitantly with clinical consideration, it is reasonable to consider inclusion of ethical tools for decision-making in the SOAP note. The SOAP-note approach has been proposed as a tool for ethical education in clinical workup (63). Although this may be time- and labor-intensive and cumbersome, a model that is somehow automated and adept at decision-making might be able to assign “ethical dilemma scores” quickly and efficiently, calculated and maintained in a digital format. Undertaking more concrete identification and articulation of ethical dilemmas implicit in a single clinical case might aid in early identification of potential moral injury and moral distress and reduce moral residue in the clinical setting. Establishing a concrete ethical tool as an immersive part of clinical workflow could also serve to make clinicians more ethically fluent.

The analytic hierarchy process (AHP), a math- and psychology-based technique, is used in many diverse industries for making and elucidating decisions that may range from very simple to very complex and may have utility in both clinical and ethical decision-making. It may rank appropriate choices for various situations, analyzing multiple factors. The AHP has also been used to augment shared decision-making between doctor and patient, treatment selection, and policy evaluation (64). Resolving such ethical discordance may allow for further training in management and resolution of ethical dilemmas without associated moral distress, while also increasing moral resilience. Potential creation of an “ethics-focused AHP calculus,” applied to the SOAP note as a 5th separate section, might circumvent the cumbersome and subjective ethical assessment required for entry into each portion of the SOAP note, and might also circumvent the lack of consideration of ethical dilemmas and resulting emotional repercussions. Automated application of the AHP might allow for ethical conclusions with many disparate patient and pet-owner inputs.

CONCLUSION

Urgent intervention is required to contain the moral emergency of veterinary suicide. Elucidation of veterinary moral distress and the resulting burnout is essential to limit downstream psychopathological consequences. Novel tools in veterinary medical practice, including MDS-V and SOAP-Plus, might help reduce moral distress, confer moral resilience, decrease moral residue, and imbue clinical veterinary practitioners with ethical clarity and fluency. Further study is required to solidify moral connections to suicidal ideation in the profession. This may accordingly decrease the risk for suicidal ideation and suicidality.