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BVA Congress
Where do you draw the line on treatment?

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With euthanasia a legitimate treatment option in veterinary medicine, at what point does treatment become overtreatment? The issues were discussed in a ‘contentious issues’ debate at the BVA Congress, which was held in Glasgow from September 23 to 25. Suzanne Jarvis reports

‘THOSE of us who work in practice are facing decisions many times a day on how long should we continue to treat an animal before we decide euthanasia is the best treatment option,’ said Harvey Locke, the then BVA president-elect, who chaired the debate. Increased client expectations, developments in technology, and the drive from new graduates to develop their diagnostic and treatment skills were all pushing back the boundaries of when this decision was made. The debate considered what was the right choice for the patient and how vets could weigh up the options.

‘Heroic’ treatment

Dorothy McKeegan, a lecturer in animal welfare at the University of Glasgow, set out the ethical basis for concerns about ‘more extreme’ forms of clinical treatment, and also presented what she thought were ‘defensible ethical criteria’ to help decide on an appropriate treatment in these situations.

Advances were always being made, particularly in companion animal medicine, leading to so-called ‘extreme’ or ‘heroic’ treatments. For some people, the idea that animals could be given almost as advanced treatment as humans was entirely positive, especially as many owners saw their pet as a member of the family. However, because animals could not give consent to a procedure, this could give rise to ethical concerns. ‘Vets have responsibilities to animals, owners and themselves, which leads to conflicts of interest in these situations,’ she said.

There were a variety of approaches under which the issue of heroic treatment might be assessed. First was the ‘only humans matter’ approach. Here, as long as the owner was happy with the decision then that was all a vet would need to consider. Second was the view that was concerned only with the individual ill animal and its treatment. Third was the ‘greater good’ approach, where the needs of the animal and its welfare were balanced with those of the owner and even other animals that may benefit. ‘This seems like an excellent approach,’ she said, ‘but we have to be careful because, in this approach, the individual ill animal may not be protected if it is deemed any harm done to it is outweighed by other benefits.’

Another approach considered the main ethical driving factor to be the nurturing of the unique relationship between humans and animals, particularly in relation to companion animal treatment.

However, Dr McKeegan said, in practical terms there were only three real approaches: ‘Do what the owner wants; do what the animal wants; or do what the vet wants. In my view, the most important of these is do what the animal wants.’

Quality or quantity of life?

When considering an animal's interests, should quality or quantity of life take priority? Dr McKeegan believed quality of life was more important, and pointed out that this was supported by animal welfare legislation, which considered only quality of life.

When considering quantity of life and welfare, it could be argued that a painless death ended an animal's suffering and that it had no concept of death and no ‘explicit desire to stay alive, and therefore, there is no harm’. Others would argue there was a harm as death took away the animal's potential for more life. However valid these arguments, Dr McKeegan was clear that they should not take precedence over quality of life concerns.

With heroic treatments there was often a trade-off between short-term harm to give long-term benefit. To be ethical, the longer the harm, the greater the benefits had to be to warrant the treatment. With novel treatments this could not always be assessed, but ‘it's not good enough to say “We don't know what is going to happen, but we are hoping for the best”,’ she said, because this was entering the realms of animal experimentation.

Noel Fitzpatrick and Dorothy McKeegan, speakers in a debate entitled ‘Treatment too far?’

To determine what was acceptable with treatments, quality of life needed to be assessed. This was commonly done through clinical judgement, but Dr McKeegan argued this was ‘too focused on pain and health-related issues’ and that behaviours the animal might express, for example as a result of being isolated or having its behaviour restricted, should also be considered.

She described criteria that could help vets when making a decision on extreme treatments. For the animal, the outcome should be reasonably predicted; the quality of life provided should be based on recognised criteria; pain and suffering should be controlled; and short-term harm should give a realistic long-term benefit. Owners should understand that quality of life should be the main interest; they should be informed of all consequences, including reaching a humane end point; and they should be willing and able to take on the post-treatment care of the animal. Vets should have the necessary skill required and not be pursuing the treatment solely for the technical or intellectual challenge.

If these criteria were met then the decision made could be justified from an ethical standpoint as ‘being done in the animal's best interests’.

When looking at ethical priorities, Dr McKeegan suggested they should be considered in order of decreasing importance as: to maintain and improve the quality of the animal's life; to extend the quantity of life; to serve owners; to help to contribute to a profitable business or build on a vet's own interests; and to develop new treatments.

Innovative treatments

Noel Fitzpatrick, principal of Fitzpatrick Referrals and visiting professor at the University of Surrey, has developed a number of innovative surgical techniques which he has applied to his patients.

The ‘only interest is the patient’, said Professor Fitzpatrick, so ‘why might you think that an act of clinical veterinary practice is a treatment too far?’

‘Remember what may be a treatment too far for one may be a treatment not far enough for another.’

He suggested there were two extremes: ‘Nothing can be done, or everything can be done, and we need to find a path between these two extremes.’

When looking to the future, it was the profession's choice whether to control change or have change controlled for it by the media, owners and other people. He believed the profession needed to be in control.

There were rapid advances being made in the human medical field – should vets take advantage of these? ‘Is it ethically and morally right to use those techniques in veterinary patients for the first time? These are huge moral and ethical dilemmas which we must embrace or it will be done for us,’ he said. With the internet opening up global veterinary access, clients would also ask for the latest techniques from other countries: ‘Shall we decide what is a treatment too far, or shall we be complacent and recalcitrant?’

Discussing a cat for which he had successfully provided two hindlimb protheses as an example, he noted that ‘If you can provide a quality of life that is sustainable, then there may be a role for some of these more advanced techniques,’ he said – but just because you could do it didn't necessarily mean it was the right thing to do. ‘If you can't provide a reasonable quality of life, why are you starting?’

Asking the right questions

In making decisions on treatments, there were a number of questions vets should ask themselves, Professor Fitzpatrick said. These included: Do you have a robust moral and ethical argument? Are you afraid of change, are you complacent? Will change happen with or without you? Is what you are doing in the best interest of the patient? Is your motivation pure, that is, not for ego, money or science? Finally, is your thought process rational?

He also discussed a number of arguments that could be used to build a case against a treatment. He believed that considering these points could help vets judge if a treatment was ‘a treatment too far’.

  • We're fine as we are – why change? New ideas and the evolution of treatment were inevitable. ‘People will always think of new ideas,’ he said, and if a better treatment had been developed, ‘why are we doing something that is causing pain and suffering by doing the conventional thing?’ If a better treatment was available, why not use it?

  • Cost-benefit – putting the patient through too much with too little gain. Here, it was important to assess what was ‘too much’. Then a vet should guide and support the owner, giving them all the options. ‘There is a time and a place for treatment, and a time and a place to call it a day.’ Again, vets had to ensure they were doing something because they should, rather than because they could, and they had to be realistic with the owner about what might go wrong.

  • It's too expensive. This was not a decision for the vet. As long as the costs were transparent and reasonable, it was up to owners to decide if they could afford it.

  • Euthanasia and amputation are preferable to treatment. Why? ‘Euthanasia has a role, but may not be the role all the time, it may just be the easy way out.’ For amputation, this might very well be the best course of action, but in cases where it was not clear-cut, vets had to give the owner the options honestly and allow them to make the decision.

  • Treatment ‘too far’ causes suffering. Is the vet acting in the patient's best interest? ‘You need to ask this question again, and again, and again,’ said Professor Fitzpatrick. Was there a reasonable expectation of quality of life, with a short period of ‘cost’ and a long period of benefit? Many ‘heroic’ or ‘advanced’ procedures did not have a longer recovery time, say four to six weeks, than many commonly accepted procedures, such as cruciate repair, and the ethical concerns should apply to both the common and the advanced procedure in equal measure. It was also necessary to consider whether what was being attempted was an act of clinical veterinary practice or whether it would be classed an act of experimentation.

  • It's only a cat, it's only a dog. Here, he said, it was important to assess the individual animal, and also remember the owner's perspective. From the animal's perspective, could the vet provide a pain-free and satisfactory quality of life? As far as the owner was concerned, it was up to the vet to give all the options, advise and guide, but then allow the owner to decide. Professor Fitzpatrick cited some comments from dog owners that had been polled in his area. One said: ‘Creating an environment where a vet takes that choice away will lead to owners travelling long distances to find a vet who will treat their animal as they wish.’

  • Dogs and cats don't deserve the care level afforded to humans. It was inevitable that the care level for companion animals would increase, Professor Fitzpatrick said, but he asked ‘is what you do currently ethical and optimal? … It might be ethical but is it optimal? If it is, do not change. If it is not optimal, why not change?’

  • Treatment requires evidence – we don't have it. He believed that veterinarians were obliged to advance veterinary medical knowledge and that evidence-based medicine required evidence. Vets needed to be able to apply a set of rules: is it of direct benefit to the animal or its immediate peer group; is the primary purpose to benefit the individual animal; and is it possible that you might cause pain, suffering, distress or lasting harm?

Doing the right thing

‘The public expects us to have an ethically and morally sound profession, with integrity, honesty and collegiality and solidarity of purpose,’ Professor Fitzpatrick said. ‘They expect us not to take away freedom of choice. They expect us to guide and support them. They expect us to do our best for each and every animal.’

But what was the right thing to do? He thought it could be judged as ‘It is not enough to be able to do something; it must be the right thing to do. Power does not reside in the possession of knowledge but in what we do with that knowledge. The best thing for the animal is always the best thing for you. The public don’t care how much you know until they know how much you care – fact. The thoughts of today will be the path of tomorrow. If we do not build this path, people will find paths themselves and may get lost in the forest or kill lots of trees doing it. We will not be measured by the magnitude of our success but by the magnitude of our response to our failures. If we fail right now, we will realise that everything is impossible – until it happens.'

Medical overtreatment?

Following the presentations, John Bower, a retired vet, made the point that surgical ‘overtreatment’ was not, in his view, the main problem, but medical overtreatment of the ‘older, ill, not-very-likely-to-survive animal undergoing masses of diagnostic tests’.

Both speakers agreed that this could be a problem, with Professor Fitzpatrick commenting that too many diagnostic tests on older, ill animals could not be justified: ‘I agree with you entirely that we are ethically and morally destitute if we are doing MRIs for the wrong reasons, blood samples, etc, ad infinitum; because our moral and ethical responsibility remains and will always remain with the animal. It is to guide the owner but our responsibility still stays with the animal,’ he said.

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