Veterinary Medical Ethics

Ethical question of the month — August 2012

A 14-year-old Labrador retriever is owned by a young professional couple. They obtained this dog as a puppy and have been regular clients since the first puppy appointment. This dog is self-described as their “only child.” The dog has osteoarthritis (managed successfully with daily oral NSAID administration), and is hypothyroid (managed well with daily oral levothyroxine). This past weekend, the dog collapsed and was taken to a very well-respected emergency and referral hospital. A diagnosis of hemangiosarcoma was made, with tumors identified on the right atrium, the spleen, and the lungs. The treatment plan proposed by the referral surgeon is to stabilize the dog and perform a thoracotomy to resect the tumor on the atrium. Following recovery from the thoracotomy, a splenectomy would be performed, followed by chemotherapy. The owners are advised that survival time with this treatment plan is, at best, 6 months. The owners are understandably distraught when they advise you of the recent events. They wish to pursue any and all options to extend the life of their pet. Cost is not a concern. What advice should you give?

Responses to the case presented are welcome. Please limit your reply to approximately 50 words and forward along with your name and address to: Ethical Choices, c/o Dr. Tim Blackwell, Veterinary Science, Ontario Ministry of Agriculture, Food and Rural Affairs, 6484 Wellington Road 7, Unit 10, Elora, Ontario N0B 1S0; telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: tim.blackwell@ontario.ca

Suggested ethical questions of the month are also welcome! All ethical questions or scenarios in the ethics column are based on actual events, which are changed, including names, locations, species, etc., to protect the confidentiality of the parties involved.

Ethical question of the month — May 2012

You are a mixed animal practitioner and an accomplished surgeon with 12 years of experience. You are also a member of the local volunteer fire service in your community and trained in advanced first aid. You are the first responder to a scene where an injured person is in severe respiratory distress. You suspect a tracheal obstruction due to trauma. Your training as a medical first responder does not include invasive procedures and the operating procedures for the fire and paramedic service in your region do not include them either. You receive notice that an ambulance will arrive in 10 to 15 minutes. The patient is turning blue and can hardly breathe. Based on your veterinary training, experience with respiratory emergencies, and your diagnostic skills you have confidence that a simple surgical procedure you are capable of performing would alleviate the respiratory distress of the patient. You also suspect that neither your veterinary practice insurance nor the fire department would cover you if something untoward happened. How should you respond? Should you act as a veterinarian using all your skills, or should you act as a basic first-aider, as per your role as first responder?

Submitted by Dr. Martin Appelt, Ottawa, Ontario

Comment

I feel strongly about this question, as I was faced with the same scenario when my 2-year-old son drank disinfectant. After poison control was contacted I was asked, “Is his airway starting to close up yet?”

This question provides fundamental revelation in the difficulty of exercising ethical judgment. There is the threat of litigation, inquiry, or whatever other system against the veterinarian who acted outside of the accepted domain of conduct. Licensing, permits, and accreditation will not save the life of the person with the obstructed airway, but action will. To do nothing will guarantee the veterinarian freedom from speculation, and the person will probably die. I support the veterinarian who would take action. Whether it be 15 minutes before an ambulance arrives or 2 hours in the wilderness, each situation warrants urgency. If someone did not have training or accreditation to pull another person away from a speeding car, should the person be left to die? Sounds absurd. Of course, it does not warrant performing brain surgery on a sidewalk, but that is the gray zone that out of fear none of us want to touch. There is no risk in pondering ethical questions; however, those who have the courage to act AND face scrutiny against opposing opinions because they put themselves out of the realm of accredited and insured conduct, need to be supported.

Dr. Tom Picherack, Carstairs, Alberta

An ethicist’s commentary on the veterinarian facing a human respiratory emergency

This case dramatically points up one of the paramount problems in our society; the fear of interceding even in emergencies lest one be sued. It is bad enough that one can be sued for writing a letter of reference expressing the opinion that a candidate is something less than a cross between Einstein and Hercules, thereby rendering the entire recommendation process irrelevant because of “evaluation inflation.” In this case, we face the possibility, if not probability, that someone competent to intervene in a life-and-death emergency must think twice for fear of legal action should something, however improbable, go wrong. It is, of course, this litigious mindset that contributes to escalating health-care costs. In fact, one of my students, who was a board-certified human obstetrician in New York City, was driven out of practice and back to school because her malpractice insurance costs exceeded her income!

In the ancient Jewish tradition, the strict laws preventing any work on the Sabbath could be superseded in the pursuit of saving a life, even the life of a domestic animal. It is absurd that fear of liability should provide a greater disincentive to helping a person in dire straits than sacred religious rules do.

In this case, the victim is severely compromised as regards the ability to breathe, and, we are told, is in fact turning blue. The longer this situation persists, the greater the danger of heart attack or stroke, and even of brain damage. The veterinarian in question, we are told, is “an accomplished surgeon with 12 years of experience.” Further, the veterinarian justifiably suspects a tracheal obstruction caused by trauma. Let us recall that a human trachea is not markedly different from a canine one. Tissue is tissue, and the surgical procedures required to repair such an injury are significantly similar. In fact, it is an open secret among ranchers in very rural areas that such accidents as lacerations and fractures are very well managed by veterinarians willing to risk the legal system.

When my son was a little boy, he often accompanied me on dirt bike rides sitting on the back. On one occasion, the trail went straight up. As I prepared to attempt the climb, he said, “Daddy, could we not do it — I’m afraid.” “So am I,” I replied. “But courage is not about not being afraid. It is about conquering fear. Superman is not brave, because he knows nothing can hurt him.” He understood.

In a nutshell, then, all courage is about acting in spite of fear and risk. As Plato and Aristotle point out, courage is the mean between cowardice and foolhardiness. In this situation, there is indeed some risk to the veterinarian, including legal action and loss of licensure. But, to me, the benefit — possibly saving a life or a person’s quality of life — far outweigh the risk. If the veterinarian is reasonably confident of his own abilities in this domain, he should forge ahead. As a society, we have experienced far too many cases of fear leading to paralysis, as in the famous case of Kitty Genovese who was stabbed to death in New York in the 1960s while hundreds watched from their patios, and no one raised a finger to help.