Expected consequences of convenience euthanasia perceived by veterinarians in Quebec

Abstract

In companion animal practice, convenience euthanasia (euthanasia of a physically and psychologically healthy animal) is recognized as one of the most difficult situations. There is little published on veterinary perceptions of the consequences of convenience euthanasia. A qualitative study on the subject based on interviews with 14 veterinarians was undertaken. The animal’s interests in the dilemma of convenience euthanasia was taken into consideration, strictly from the point of view of the physical suffering and stress related to the procedure. The veterinarian’s goal was to respect the animal’s interests by controlling physical pain. Most often, veterinarians made their own interests and those of the owners a priority when considering the consequences of their decision to perform or refuse convenience euthanasia.

Introduction

Decisions on euthanasia are known to be ethically challenging in both human and veterinary medicine (1–3). Similar to physicians, veterinarians are trained to examine patients, diagnose diseases, and develop treatment plans. When animals are in the final stages of disease, discussion between veterinarians and owners about euthanasia is recognized as the next step (4). If discussion and request for euthanasia are raised for healthy animals (convenience euthanasia), differences in the veterinarian’s perception of the animal are seen with regard to their decision (accepting versus refusing to perform the procedure).

These perceptions were the basis for a previous study on the animal’s status in veterinary medicine as well as the moral duties of veterinarians toward animals (5). The role and consideration of each major stakeholder (veterinarian, owner, animal) in decisions to accept or refuse convenience euthanasia were identified as core elements leading to a better understanding of the convenience euthanasia dilemma. In 2013, the American Veterinary Medical Association (AVMA) (6) published euthanasia guidelines including an algorithm to help address the morality of the decision. Despite this publication, moral duties of veterinarians concerning convenience euthanasia are still not clearly defined within the profession.

Consequences resulting from either performing or refusing to perform convenience euthanasia could shed light on elements that veterinarians consider important for their choice. For example, which stakeholder (veterinarian, owner, or animal) would be considered? This type of approach is based on a method of professional dilemma analysis (7). The veterinarian would think about convenience euthanasia, taking into consideration the consequences of the procedure. The goal of this study, therefore, was to describe the veterinarian’s opinion on expected consequences of convenience euthanasia.

Materials and methods

Methodological approach

In order to obtain maximal data, an inductive approach previously described was used (5). Perceived consequences of convenience euthanasia were obtained via semi-structured interviews consisting of open-ended questions on perceived consequences of accepting or refusing convenience euthanasia. The interview ended with a scheduled period of discussion on the topic. This inductive approach allowed an understanding and knowledge of the various responses (8). The interview guide available from the corresponding author was pretested and modifications were deemed unnecessary. The research ethical committee of the Faculty of Medicine at the University of Montreal approved this study.

Consequences of convenience euthanasia

Analysis of perceived consequences following convenience euthanasia was chosen to describe the dilemma. This method is known to help professionals analyze problematic situations (9). This type of assessment is a frequent tool used to understand dilemmas in terms of different potential outcomes (7). More specifically, this approach assesses which stakeholders (veterinarian, owner, or animal) and stakeholder interests were taken into consideration, in this case by the veterinarian.

Population studied and sampling

The population of veterinarians for this research was limited to those in the province of Quebec. General practitioners and specialized veterinarians were both included in the sample to achieve data saturation. Saturation establishes when to stop data collection in order to avoid a waste of time and money and allows generalization of results for a given population (10).

Veterinarians who practiced convenience euthanasia and veterinarians who refused to practice convenience euthanasia for ethical reasons were recruited. Participating veterinarians were familiar with the topic of convenience euthanasia in their practice.

In order to target a specific population of veterinarians, a non-probabilistic sampling method was elected. Choosing the participants would likely result in a more efficient collection of in-depth information about the consequences related to the decision of accepting or refusing convenience euthanasia.

Participants were recruited using a snowball method as described in other publications (5,9). Veterinarians not practicing convenience euthanasia were initially recruited followed by veterinarians practicing convenience euthanasia.

As recommended for qualitative research, no initial limit on number of participants was established. Recruiting and interviews were discontinued when data analysis indicated saturation of information. Data analysis was performed throughout the period of data collection. Fourteen participants were interviewed for 30 to 45 min. Although the number of participants may seem low, the sample size matched information in the published literature on the average number of interviews required for saturation of information in non-probabilistic studies (11).

Data analysis

The primary researcher audio recorded all interviews and then transcribed the data using a word processing system (MSWord; Microsoft, Redmond, Washington, USA). A manual coding of verbatim established the preliminary list of codes (10,12). The researcher created codes to represent the main ideas of the discourse sections. Similar ideas from different participants were then grouped together. The first 4 interviews allowed completion of the manual coding. Next, a software analysis program (QDA MINER; Provalis Research, Montréal, Québec) was used to complete coding of all interviews. The coding list was continously adjusted to reflect any new idea identified throughout the data analysis process. Internal validity and accuracy of the coding technique were assessed using counter-coding and inverse coding procedures (5,10). First, coding done by an independant research assistant was compared to the researcher’s coding (counter-coding). Consistency level (percentage on agreement) was 89% (10,12). Next, inverse coding was performed to ensure that all interview excerpts represented by a code were appropriately categorized. Coding results were shown to be accurate. Analysis of the results was then undertaken.

Results

Veterinarians’ evaluation of expected consequences of convenience euthanasia

Veterinarians were invited by direct questioning to describe their perceived consequences of convenience euthanasia. Veterinarians were asked about both the possibility of accepting and refusing convenience euthanasia regardless of their choice in private practice. Veterinarians identified 3 major stakeholders: the animal, the owner, and the veterinarian. Their perceptions were classified in different categories depending on whether they resulted in positive (desirable) or negative (undesirable) consequences. Categories were not mutually exclusive. All 14 veterinarians answered. The results are shown in Table 1.

Table 1.

Perceptions of veterinarians who agree or refuse to proceed with convenience euthanasia^a

Negative perceptions when veterinarians agree to proceed with convenience euthanasia	Negative psychological impact (n = 8) Contribute to dilemma/vicious cycle (n = 4)
Positive perceptions when veterinarians agree to proceed with convenience euthanasia	Profitability for veterinary business (n = 6) Control of the situation by veterinarians (n = 3) Good relationship with the owner/trust (n = 3)
Negative perceptions when veterinarians refuse to proceed with convenience euthanasia	Does not change the end result for the animal (n = 13) Judgment and lack of respect from the owner (n = 6) Contributes to the animal overpopulation (n = 4) Uncertainty about the future of the animal (n = 3) Transfers the problem to other sources (n = 3) Pressure related to the profitability of veterinary business (n = 3)
Positive perceptions when veterinarians refuse to proceed with convenience euthanasia	Influence on the public and social education (n = 7) Influence during the choice of employment (n = 5)

^aThe number in brackets indicates the number of veterinarians with that perception. Categories were not mutually exclusive.

Impact of convenience euthanasia decisions on animal overpopulation

Most veterinarians (n = 13) thought that their decision on convenience euthanasia in private practice did not change the end result for the animal (Table 1). An owner faced with refusal of convenience euthanasia would find the service at another facility or could arrange for the death of the animal in some other way.

“I am thinking about what would happen if we refused to euthanize the animal. What will the owner do? The owner will go to the SPCA and the animal will stay there. He will not be adopted by another family and we as veterinarians think that we saved the animal’s life.”

Three veterinarians shared this opinion and considered not only that the end result for the animal would not change, but that the refusal to proceed with convenience euthanasia would also transfer the dilemma to another facility (category “Transfers the problem to other sources” in Table 1).

Opinions were divided concerning the impact of the refusal to proceed with convenience euthanasia on pet overpopulation. Four veterinarians thought that refusal would contribute to increase the overpopulation in animal shelters (Table 1). For others, decisions of convenience euthanasia made in private practice would have no impact on the overpopulation problem in shelters.

“Here we participate in the spaying program for stray animals of our town. It has been proven that when a town traps and kills every stray animal in its territory, the population of stray animals just comes back to what it was in a short period of time.”

Financial impact of clinical decisions with regard to convenience euthanasia

Some veterinarians (n = 6) reported that euthanasia was a profitable activity for veterinary enterprises (Table 1). When veterinarians agree to perform convenience euthanasia, it creates a substantial income for their veterinary clinic

“The owners are business men. They are very good veterinarians, but they also are business men. Their philosophy about convenience euthanasia is if we do not perform it here, the client will go somewhere else and he will pay elsewhere, so it is better if he pays here.”

During the interviews, 3 veterinarians declared being pressured by their employer to accept every request for convenience euthanasia (category “Pressure related to the profitability of veterinary enterprises” in Table 1). These 3 veterinarians believed that they did not have a choice, even if they did not share the position of their facility on the subject:

“(…) I didn’t think that I would be obliged to do an act that I didn’t agree with. I didn’t think that they would impose this on me. I think that now, the only thing that I do control in those situations is to insist that every animal be adequately sedated before euthanasia, so that the animals do not feel the stress related to the act…. But aside from the sedation, my boss does not let me refuse euthanasia of a patient.… They want consistency of decisions made within their clinic. They even met with me once because I had been asking clients questions about the reason why they wanted their animal euthanized and I was offering other solutions.”

Some veterinary facilities have a policy in place declining all cases of convenience euthanasia. Five veterinarians interviewed chose to work in those facilities partly because of the existence of such a policy (category “Influence during the choice of employment” in Table 1). Those veterinarians liked the fact that they would not be pressured from their employer to proceed with convenience euthanasia. Responses showed that a practice policy of consistently refusing requests of convenience euthanasia was very important for some veterinarians when choosing a workplace.

Psychological impact of clinical decisions on convenience euthanasia

Eight veterinarians reported on the negative psychological impact of the decision to proceed with convenience euthanasia (Table 1).

Some veterinarians (n = 3) proceeded with convenience euthanasia because they stayed in control of the situation, particularly on the outcome for the animals (Table 1). These veterinarians would therefore not feel the discomfort associated with abandonment or cruel killing of the animal elsewhere. One veterinarian performed euthanasia to ensure that the animal would be put down humanely. Three veterinarians described their discomfort with the uncertainty of the animal’s safety if convenience euthanasia was refused (Table 1). Refusing convenience euthanasia could have consequences for the animal (potential tragic outcome elsewhere) and the veterinarian’s psychological health (guilt as a result of potential tragic outcome elsewhere for the animal). These veterinarians felt that if they proceeded with convenience euthanasia, they were able to control the situation and the future of these animals. From that perspective, convenience euthanasia was partly beneficial for the veterinarian’s psychological health.

Concept of shirking responsibilities

Four veterinarians stated that they were in a vicious cycle created by convenience euthanasia (Table 1). These veterinarians thought that the practice of convenience euthanasia did not include any element that would discourage current or future use of this service by the animal’s owner. The ease of access for convenience euthanasia could even lead owners to repeat the experience every time they chose to get rid of an undesirable animal.

The indirect influence of convenience euthanasia on the veterinarian’s perception of moral responsibility was also highlighted. In fact, some veterinarians felt that when they proceeded with convenience euthanasia, they encouraged owners to consider euthanasia as an acceptable method to get rid of their animal. These veterinarians also made a link between convenience euthanasia and the fact that owners were transferring responsibility for their animals to the professional. They believed that owners were not aware of the amount and importance of responsibilities associated with adopting a companion animal. Veterinarians felt that owners asking for convenience euthanasia were choosing the least complicated option to “get rid of the animal” and associated responsibilities. They did not research other options to resolve the problem.

“Euthanasia shows a degree of cowardice because the owner asks someone else to take responsibility for the healthy animal. It is the only method that he has found.”

Some veterinarians took charge of the animal even when they refused to euthanize. In other words, refusal of convenience euthanasia did not force the owner to take any responsibility. Therefore, in both situations, there was a shift of responsibility for the animal from the owner to the veterinarian.

“(…) I remember one case; it was a couple with a young child. They decided to adopt a great Dane puppy. Before adopting the dog, they should have gotten information about great Danes. It is a big dog and he will grow faster than the child. They came for convenience euthanasia when the dog was 6 months old, because he was playing too roughly with the child…. A great Dane is not just great, he is going to eat a lot and he will need to play a lot also. It is not a delicate breed; he will wag his tail and whip everything around. We did find a new home for this puppy, because I refused to euthanize him. But once again, who was stuck with the problem? We were! This is what pisses me off and in the long-term it is burdensome. People do not take their responsibilities. They unload their responsibilities onto someone else.”

Education of the owner and relationship between the owner and the veterinarian

Seven veterinarians believed that their decision to refuse convenience euthanasia made a difference in the way owners saw the dilemma even if ultimately the animal would be put down one way or another (category “Influence on the public and social education” in Table 1). By refusing euthanasia, these veterinarians were creating an opportunity to talk with the owner about the dilemma and to explain the situation as experienced by the veterinarian. The owner was then more aware of the dilemma and this discussion brought about a reflection related to the issue. However, other veterinarians (n = 6) did not share this opinion about provoking a discussion with the owner on convenience euthanasia. They believed that by doing so, the veterinarian was showing judgment and a lack of respect for the owner’s moral values (Table 1). The only respectful decision for them was to accept convenience euthanasia. This decision was the only one that respected the owner’s autonomy. It did not judge the depth of the owner’s reflection nor the quality of motivations related to the demand. Agreeing to euthanasia was the only option if they wanted to maintain a good relationship with their clients. Three veterinarians saw their decision to agree to convenience euthanasia as an opportunity to create trust and a strong relationship with their clients (Table 1). They could not conceive of a situation in which the owner would show up at the practice and ask for convenience euthanasia without having previously analyzed the situation. They also saw this situation as an opportunity to create a good reputation with regard to the quality of service.

Discussion

Each consequence listed by interviewed veterinarians was classified to represent the defended interest (Table 1). In a utilitarian approach the assessment of the morality of an action is done by evaluating consequences for all stakeholders. An action is deemed moral if the outcomes are more positive than negative for all stakeholders (13). The minor role and consideration given to the animal in the convenience euthanasia dilemma (5) made some veterinarians consider the procedure as a service that is not necessarily contrary to the animal’s interest. In fact, management of the animal’s suffering for the [Ordre des médecins vétérinaires du Québec (OMVQ), Quebec veterinary licensing body] is an essential criterion of good veterinary practice.

Veterinarians are expected to take all possible measures to reduce an animal’s physical suffering (the only regulated aspect of the dilemma). The OMVQ does not recognize convenience euthanasia as an action against the best interest of healthy animals. Death is not a welfare factor taken into consideration (trustee of the OMVQ, personal communication, February 4th, 2010). Yeates (11) disagrees and states that welfare assessment of an animal takes into consideration all of the animal’s interests. Presence and absence of positive and negative elements and their repercussions in the animal’s life are necessary for welfare assessment. Death of an animal removes positive elements from the animal’s life and should therefore be considered when assessing animal welfare (11). Lack of discussion on recognition of the animal’s inherent value of life in the veterinary profession was noted during this analysis. Veterinarians interviewed raised concerns about physical suffering and stress related to the euthanasia procedure but did not discuss any other concern regarding the animal’s interests. For most veterinarians, an evaluation of animal welfare that would take into consideration the animal’s interests other than those related to physical suffering was difficult. As reported by Fraser (14), there is no accepted scale for animal welfare. Many criteria could be judged as essential by one evaluator and not by another. The animal’s welfare could therefore be judged as poor by one person and good by another. Even if the evaluators are members of the same profession, evaluation could differ greatly from one to another. It is therefore conceivable that veterinarians were less inclined to evaluate other aspects of the animal’s interest due to a lack of guidelines. The interests of all major stakeholders (veterinarian, owner, or animal) were considered at the time of decision. Convenience euthanasia seemed the best solution for the majority of veterinarians interviewed.

It is important to highlight that even if this vision of convenience euthanasia is shared by most of the veterinarians interviewed, cases of convenience euthanasia are still considered difficult situations to manage mostly as a result of the discrepancy between personal and professional perceptions of the animal. Because veterinarians are pet owners themselves, they may be uncomfortable with convenience euthanasia which may arise from the value they perceive of animals in general (4).The discomfort also seemed to lead veterinarians to question themselves about the dilemma. Veterinarians showed a willingness to change their way to evaluate the animal’s interest within the profession.

Evaluation of the convenience euthanasia dilemma revealed the importance of multiple allegiances for veterinarians. On one hand, the importance of the owner’s motivations to justify their request of convenience euthanasia was raised (5). Veterinarians during their education learn to analyze and choose the treatment to obtain the best outcome for animals. It is thus understandable that veterinarians for different reasons will agree to euthanize the animal rather than refuse in a particular medical situation (15). However, by definition, cases of convenience euthanasia are unique in that the best interests of the animal are not taken into consideration. At first glance, the decision concerning convenience euthanasia creates a situation in which the animal’s interests are not respected. This fact creates a stressful situation and a negative psychological impact on veterinarians. The second component deals with psychological stress within the field of veterinary medicine. Publications show that the act of euthanasia is not an element causing stress for veterinarians (16,17). The origin of the psychological stress surrounding the convenience euthanasia dilemma seems to arise from the conflict between the prioritization of the animal’s interests and the willingness to satisfy the owner (18). Results from our study confirm this evaluation of the psychological impact of convenience euthanasia. Stress surrounding the decision was also amplified by the pressure of profitability coming from the owner of the veterinary facility (19).

The evaluation of negative and positive perceptions of accepting or refusing to perform convenience euthanasia adds another perspective. Many outlined consequences were emotional states experienced by veterinarians such as psychological stress, importance to feel in control of the situation, and discomfort regarding the animal’s future. Those emotional states would be interpreted as favorable to the veterinarian’s interests. The negative psychological impact also suggested that veterinarians worried about the animal’s interests (absence of physical suffering). Owner interests prevailed when evaluating the financial aspect and the data concerning the client-veterinarian relationship. Little information was collected on the animal’s interests except for stress control during euthanasia and appropriate pain management for physical suffering. No one talked about the healthy animal’s interests to live. The animal’s welfare presented in this analysis of consequences did not include any aspect other than those related to stress, and physical pain and suffering. All others (e.g., the animal’s desire to live) were missing from their evaluation of consequences. These results are partly in accordance with Yeates’ and Main’s publication on the topic (20). They concluded that the veterinarian’s opinions on refusing euthanasia were based mainly on justifications related to the animal. In other words, veterinarians who were refusing euthanasia justified their decisions on animal-based reasons primarily. The concerns related to owners were also important, but they were taken into consideration secondarily. In this study most veterinarians interviewed were practicing convenience euthanasia, so the main decision scheme was reversed.

For some veterinarians, convenience euthanasia is a humane method to stabilize the situation of companion animal over-abundance. In this study, description of the veterinarian’s moral responsibility toward animals was only possible in terms of management of the animal’s physical suffering and stress control during the procedure. Veterinarians were thus respecting their oath and commitment toward animals when they performed convenience euthanasia. As concluded in the previous article related to this study (5), veterinarians decided about convenience euthanasia based on their analysis of the owner-animal bond. As most owner-animal bonds seen in private practice were from the anthropocentric point of view, the animal’s interests were barely taken into consideration. From that perspective, most veterinarians believed that they were not active participants in the dilemma of convenience euthanasia. In fact, with their pain management, they felt that their ethical duties toward animals were met.

This study provides a description of the consequences of convenience euthanasia, but does not assess the prevalence of the reported facts within the entire population of veterinarians in Quebec. Fourteen Quebec veterinarians expressed their opinions and therefore these cannot be extrapolated to the entire Quebec veterinary population or any other veterinary population in Canada. Information on similarities and differences within Canadian veterinary practices is lacking. Evaluation of expected convenience euthanasia consequences on a larger scale in Quebec requires a quantitative evaluation of the concepts described in this article. A quantitative study is currently underway.

The goal of this study was to describe the veterinarian’s perception of consequences related to the decision of accepting or refusing convenience euthanasia, as experienced in their day-to-day practice. Analysis of the veterinarians’ responses brought to light many components of the dilemma and led to a better understanding of this issue. Decisions on convenience euthanasia in practice are taken by evaluating the consequences and interests of the veterinarian and the client/owner. The animal’s interests are evaluated strictly from a physical suffering point of view. Therefore, veterinarians are accomplishing their duty toward animals with regards to convenience euthanasia.