To obtain information on euthanasia decisions from practising veterinary surgeons, respondents were asked to estimate how often during their time in practice they had refused to euthanase a dog and how often they had wanted to refuse to euthanase a dog but not done so because of other pressures. For each, respondents were then asked to state their most common reasons for refusing/not refusing in free text. The responses of clinicians were considered in the light of established ethical concepts to produce an evidence-based ethical framework for decision making. In total, 58 practitioners responded. Common reasons given for decisions on whether to refuse euthanasia referred to the patient's interests, such as the possibility of treatment or rehoming, and the fear of other unacceptable outcomes for the dog. Other reasons were based on concern for owners' interests. Some respondents reported being pressured into euthanasia by clients and other veterinary surgeons. This gives insight into the ethical principles that explicitly underlie veterinary surgeons' euthanasia decisions and the resultant framework may be useful for discussing and teaching euthanasia.
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EUTHANASIA can be a morally complex and stressful part of veterinary practice (Rohlf and Bennett 2005, Gardner and Hini 2006) and may even be a cause of mental health issues within the profession (Rollin 1988, Bartram and Baldwin 2010). Therefore, practitioners might be expected to consider refusing some requests for euthanasia that they feel would be unethical. Understanding why practitioners refuse euthanasia or not may inform guidance documents and teaching programmes, assist policy making (Duncan and Parmelee 2006) and provide insight into issues such as the high suicide rate among veterinary professionals (Bartram and Baldwin 2008).
This study aimed to produce an evidence-based framework for decision making, informed by both actual reported decisions from practising veterinary surgeons and established ethical approaches.
Materials and methods
UK respondents were recruited through publications by the BSAVA, BVA, SPVS and issues in Companion, SPVS Bulletin, Veterinary Business Journal, Veterinary Record and Vet Times. Respondents were recruited by publicity concerning another study, so they did not know whether they would be asked about euthanasia, and they were asked to remotely access an anonymous questionnaire placed online.
Respondents were asked individually to ‘please estimate approximately how often during your time in practice you have refused to euthanase a dog’ and to ‘please estimate approximately how often during your time in practice you have wanted to refuse to euthanase a dog, but not done so because of other pressures’. Reported frequencies were selected from a range of options (Table 1).
In each case, respondents were then asked to ‘please give your most common reasons for refusing’ or ‘please give your most common reasons for not refusing’ in the free text boxes provided. Demographic data on age and sex were also collected.
The responses to the euthanasia questions were grouped into generic reasons, such as ‘young dog’ or ‘treatable’ and then categorised more generally according to the ethical position that influenced the decision, for example, ‘Lack of legitimate reason for euthanasia’ or ‘Better options available’, respectively, for the two previous examples (Tables 2, 3). These categories were related to positions described in the published literature within normative ethics, animal ethics, medical ethics and veterinary ethics, including the Guide to Professional Conduct (GTPC) of the Royal College of Veterinary Surgeons (RCVS 2010). The frequencies of responses that fell in each category were tallied and compared. In the analysis, quotations were used, with the quoted respondent's sex and year of graduation, for example ‘male, 2000’.
Statistical analyses were conducted using SPSS (PASW Statistics 17). Correlation coefficients were calculated to assess the association between frequencies of responses and the year of graduation, and Mann-Whitney U tests were conducted to assess the effect of the sex of the respondent on the frequencies of their responses. A significance threshold of P<0.05 was used for all tests of statistical significance.
The questionnaire was completed by 58 respondents, 25 of which were male and 33 female. The dates of qualification ranged from 1961 to 2008 (mean 1992) (Table 4).
Refusing and not refusing
The reported frequencies of refusing and not refusing when wanting to do so are given in Table 1. Two respondents reported refusing euthanasia ‘most months’ (one female, one male; graduation range 1970 to 2004). Eleven respondents reported never refusing euthanasia (six female, five male; graduation range 1970 to 2004). The median frequency for refusing euthanasia was ‘yearly or less’.
One respondent reported wanting to refuse euthanasia but not doing so most weeks (female, graduation 2006). Five respondents reported wanting to refuse euthanasia but not doing so most months (one female, four male; graduation range 1983 to 2004). Seventeen respondents reported never wanting to refuse euthanasia but not doing so (10 female, seven male; graduation range 1961 to 2007). The median frequency of this occurrence overall was also ‘yearly or less’ (Table 1).
Three respondents reported both never refusing to euthanase a dog and never wanting to euthanase a dog but not doing so (two female, one male; graduation range 1990 to 2004). Of the six respondents who reported wanting to refuse but did not do so most weeks or months, five reported refusing ‘yearly or less’, one reported ‘never’ refusing and one reported refusing ‘most months’. Sex and year of graduation did not correlate significantly with either the frequency of refusal or the frequency of wanting to refuse but not doing so (P>0.05).
Ethical analysis of reasons
Of the 47 respondents, 44 (26 female, 18 male) who reported refusing euthanasia at some point gave a total of 109 reasons for this decision. Three respondents did not give any reason. Most responses were general, although one applied to specific cases. The reasons for refusing euthanasia were categorised and are shown in Table 2.
Of the 40 respondents who reported wanting to refuse euthanasia but not doing so, 33 (18 female, 15 male) gave 52 reasons. Seven respondents did not give any reason. The reasons for not refusing were categorised and are presented in Table 3.
The ethical analysis of the reasons was considered in more detail, within the classifications of ‘animal-based’ reasons, ‘owner-based’ reasons and ‘social pressures’.
Many decisions on whether or not to euthanase were based on the interests of the respondents' patients. For example, one respondent cited the patient's ‘best interests’ as a reason for refusing euthanasia (female, graduation 1998). Another asserted that ‘We are the animal's advocate’ (male, graduation 1981).
A large number of respondents gave a dog being ‘young’ or ‘healthy’ as a reason against euthanasia. Other respondents said that the animal should not be euthanased because it was ‘not suffering’.
An explicit reason for refusing euthanasia that was given by several respondents was because the euthanasia was requested by the owner ‘for convenience’. Such refusals may be to encourage more responsible pet ownership. Another reason for not euthanasing was that a young, healthy dog could have a worthwhile quality of life (QOL). One respondent (female, graduated 1979) said ‘good QOL’ as a reason for refusing euthanasia and another (male, graduated 2004) said ‘positive prospects’. Many respondents reported refusing euthanasia when alternatives were available. One (female, graduated 1980) refused it when a dog's problems were ‘surmountable’. Another (female, graduated 2000) said it was ‘very difficult [to euthanase a dog] if [there was a] behavioural problem we think could be treated’. Another (female, graduated 2002) referred to a case where ‘from careful history taking, and with examination of the animal, a retraining or rehoming programme seems appropriate’.
There were also many animal-based arguments for not refusing to euthanase, with a lack of alternative options being mentioned. Several respondents recalled not refusing in cases where rehoming was impossible or inappropriate. One respondent (male, graduated 2004) said that rehoming may be ‘limited by [the] dog's health or age’. Another (male, graduated 1981) said that ‘stable DM [diabetes mellitus] may be very difficult to rehome, both from practical considerations and also financial considerations for the new owner’. A female respondent who graduated in 1998 said that aggression may also be a reason why a veterinary surgeon ‘can't take the risk of rehoming’, which was reinforced by a female graduate from 1986, who said: ‘Staffies and bull breeds are hard to home, especially if there is any history of aggression’. In addition, one respondent (male, graduated 1981) raised a general concern that rehoming to charities may simply ‘abrogate our responsibility for the situation, as these homes have finite space and financial resources and it must be accepted that the “difficult” dogs will end up being euthanased’.
Other respondents suggested that treatment options might be limited by owners' finances. For example, one said that they had fulfilled requests for euthanasia when ‘clients’ financial circumstances prevent treatment' (female, graduated 2006). In some cases, respondents suggested that alternative financial arrangements may be possible, such as ‘part-payment options’ or ‘help from charities’ (female, graduated 1998), although one respondent noted that there are ‘often very limited options from charities’ (female, graduated 2000), presumably due to restricted resources.
Some respondents mentioned the lack of consent for other options as a reason for euthanasia. When other options are available to the owner, but the owner declines to give consent, the veterinary surgeon cannot legally take these other options (eg, rehoming the dog could constitute stealing). In such cases, euthanasia may become the best available option for the veterinary surgeon, even though better options were available to the owner.
Several respondents reported animal-based reasons against refusing to euthanase a dog because they were concerned about what would otherwise happen to it. One had worried that refusal might lead to ‘unnecessary suffering of [the] patient in question because of abandonment/non-compliance with treatment/possible drastic measures taken by [the] owners’ (female, graduated 2004). Other respondents said that they were ‘doubtful as to whether they [the owner] might let the dog loose to fend for itself’ (male, graduated 1965) or that the owner might ‘throw [the animal] on [a] motorway’ (male, graduated 1970). Some respondents had specifically feared that refusals would lead to owners destroying their dog by an inhumane method such as drowning (male, graduated 1970). One respondent also raised a reason against refusing euthanasia based on its possible effects on other animals, because ‘if we start to refuse, unless the prognosis is, in the opinion of the vet concerned, hopeless, then folk will cease coming to us at all, meaning other more deserving cases won't be brought in either’ (male, graduated 1981).
Several respondents gave reasons for and against refusing euthanasia that related to owners' interests. One stated: ‘I rarely disagree with an owner's request for euthanasia … where the animal's behaviour is causing serious problems at home’ (male, graduated 1981). Others said aggression was a reason against refusing; for example, they would refuse destruction only if the animal was ‘not a danger’ (male, graduated 2005) or if there was ‘no evidence of aggression’ (female, graduated 2000). Another respondent reported not refusing euthanasia because of the ‘fragile mental state of owner’ (female, graduated 1980).
Not all human interests appeared to justify humane destruction. Several respondents reported refusing requests for euthanasia from owners whose dog ‘does not fit their life any more’ (female, graduated 1975) or who ‘can't be bothered to look after it’ (female, graduated 1999), or where destruction ‘was for [the] owners’ convenience' (male, graduated 1965). One respondent described a case where they ‘euthanased one animal for health reasons and the owner then requested [they] euthanase [an]other animal, “while you're here,” as it was inconvenient to look after’ (male, graduated 1991). The owner's death was mentioned by several as being a reason to refuse euthanasia; in each case, this appeared to be because euthanasia was then requested for the convenience of the benefactors, despite any potential arguments from the heirs that an animal whose owner has died may consequently have a decreased QOL.
Opinions seemed divided on whether financial costs were a legitimate reason for not refusing euthanasia. In contrast to the respondent who reported not refusing due to clients' financial circumstances (female, graduated 2006), three other respondents said that they would refuse if the euthanasia had been requested on financial grounds. However, the same three respondents all said that there had been the possibility of alternative financial arrangements. In addition, they appeared to be motivated to refuse euthanasia only when owners would not pay ‘reasonable’ costs. One (male, graduated 2007) said he would refuse euthanasia in a case where the cost of a ‘daily NSAID tablet for mild-moderate arthritis’ had been implied as a reason why euthanasia was necessary. Another implied that he would perform euthanasia instead of ‘some of the radical extremes offered by oncology, “blockectomy” surgery and extended chemotherapy to keep an animal alive for 3 to 6 months’ (male, graduated 1981), although this may have been due to the welfare impact of these interventions.
Some respondents cited confusion, disagreement or incompetence on the part of the owner as reasons to refuse euthanasia. One recalled a ‘confused owner that seemed to be quite attached to [the] animal but requested euthanasia in spite of no apparent reason’ (female, graduated 2004). Another disagreed with the owner's assessment that a blind dog was suffering (female, graduated 1986). Others reported refusing euthanasia where owners had been ‘not prepared’ (female, graduated 2001) or ‘where there was dispute between owners over euthanasia’ (female, graduated 1988). Some of these refusals may have been due to concerns that the owners would regret their decisions. Another described a case in which they refused euthanasia because they ‘suspect[ed] the owner had health/mental health problems’ and was ‘very upset’. In this case, the owner ‘had changed her mind by [the] next day and apologised for her behaviour’, thereby justifying the judgement that her original request was ill-founded (male, graduated 1984).
A few respondents reported refusing euthanasia because the problem was caused by the owner's actions (ie, the owner did something that lead to the problem) or failure to act (ie, the owner failed or refused to rectify an existing problem). One stated that their refusals had been when a dog had a problem ‘that had been present for a long period and [the] owner had sought no advice’ (male, graduated 2005). Another cited ‘Animals presented for behavioural issues which are clearly the result of inappropriate training and exercise’ (female, graduated 2002). Another said that they would refuse euthanasia when it was requested ‘for behavioural reasons when no behaviourist consulted/alternatives [had been] attempted’ (female, graduated 2007). Conversely, one respondent reported not refusing when ‘at least the owners have done the responsible thing and not just turfed the dog out’ (female, graduated 1983).
Some respondents reported not refusing when faced with ‘client pressure’ (female, graduated 2006), ‘(stubborn) insistence’ (two males, graduated 1981 and 2007) or an ‘abusive/ignorant client’ (female, graduated 2004). Others appeared to be more resistant: one specifically reported that they ‘have never been “bullied” into doing [euthanasia]’ (male, graduated 1984) and another described themselves as ‘quite happy to risk alienating [the] client’ (male, graduated 1981).
Several respondents suggested that pressure from bosses might stop them refusing. One respondent stated that ‘When I started out nearly seven years ago, the pressure to do what the boss wanted was much stronger and I knew little else’ (female, graduated 2002).
The respondent who reported abstaining from refusal ‘most weeks’, said that their ‘personal belief is that suffering is not worse than death, but general consensus forces me to act otherwise’ (female, graduated 2006). Other respondents cited concern that if they refused euthanasia the owner would simply go to another veterinary practice. ‘If I don't do it they will just go elsewhere’, said one (female, graduated 1983).
Refusing euthanasia was reported as an uncommon issue for most of the respondents. Previous reports have suggested that euthanasia decisions are common. For example, Hart and others (1990) found that Californian veterinarians performed euthanasia an average of eight times a month, and Sanders (1995) reported that northeastern US veterinarians performed euthanasia just over 11 times a month. If the respondents of this study had similar frequencies of decisions to make on euthanasia, they were motivated to refuse only a small proportion of requests.
Several respondents effectively reported always euthanasing a dog whenever it was requested. Never refusing a request to destroy a dog is legal in the UK, because owners have property rights over their dogs and the humane destruction of animals is allowed under the RCVS GTPC and UK law (Animal Welfare Act 2006, Scottish Animal Health and Welfare Act 2006). It is also possible that these respondents had been motivated to refuse but had always managed to find ways to avoid destroying the dog without a flat refusal; for example, by persuading the owner not to want euthanasia.
However, most respondents reported both that they had occasionally refused a request for euthanasia and that they had occasionally wanted to refuse such a request but did not do so. For some respondents, these situations occurred more often. The female recent graduate who reported wanting to refuse but not doing so ‘most weeks’, might have worked in a rehoming centre, where euthanasia is reported to be a major issue (Rogelberg and others 2007). Refusing euthanasia is also legal, and the RCVS guidance states that ‘No veterinary surgeon is obliged to kill a healthy animal unless required to do so under statutory powers as part of their conditions of employment’ (RCVS 2010).
A large number of respondents said that they did not euthanase because the animal was ‘young’ or ‘healthy’, or because it was ‘not suffering’. Studies indicate that the rationale for most euthanasia decisions (approximately 70 to 80 per cent) is the age or illness of the animal (McCulloch and Bustad 1983), and suffering has been suggested previously as a reason for euthanasia (Webster 2005). It might therefore be argued that there is no basis for euthanasing a young, healthy dog with no untreatable illness. However, these factors do not provide an explicit reason for refusing (just as the lack of a contraindication to a medicine does not mean that medicine should be administered). An explicit reason for refusing must explain why practitioners refuse to destroy young and healthy/treatable dogs, not simply why they do not euthanase them.
A number of respondents said that they had not euthanased because it was likely that the dog in question could be treated successfully, retrained or rehomed, suggesting that, for some respondents, euthanasia is seen as acceptable only after certain other options have been exhausted.
Contextual justifications for and against refusing euthanasia suggest that practitioners consider the specific circumstances of each individual case, rather than applying inflexible moral rules. This pragmatism is also evident from comparing some individuals' reasons for refusing and not refusing. For example, one respondent reported refusing in one case when the owners were not willing to treat, but not refusing in another case when the owners were unwilling to treat and there was concern regarding the welfare of the dog (female, graduated 1976).
In the case of practitioners' refusal to euthanase based on the owners' mental health or a disagreement between the owners, this may reflect self-interested concerns over the validity of any consent gained. If informed consent is not valid, clinicians may not be protected against later action.
Pressure from a superior was given as a reason for agreeing to perform euthanasia. It may be that bosses are more concerned that refusals could damage public relations, leading to differences of opinion when it comes to deciding whether or not euthanasia is appropriate. Alternatively, it may represent an ethical disagreement; for example, where a more experienced boss considers the employee to be overly naive or overly keen to insist on ‘excessive’ treatment or rehoming unsuitable dogs. Notably, there were no reports of respondents being pressured into refusing, so it appears that this is a one-way pressure towards euthanasia.
Towards an ethical framework
In general, practitioners' opinions seem to be based on whether they perceive the reasons for euthanasia to be legitimate. Many legitimate reasons for refusing or for performing euthanasia referred to the patient's interests. This concern for animals' interests fits with the positions described by some veterinary ethicists (Tannenbaum 1995, Rollin 2006) and the GTPC – that animal welfare should be a veterinary surgeon's ‘constant endeavour’ (RCVS 2010). Although one respondent suggested a wider concern, most practitioners appeared to focus specifically on the welfare of their patient. This fits with the view that practitioners have overriding duties to their patients (Yeates 2009a).
Many respondents seemed to consider that death might be against an animal's interests. Conversely, several respondents either did not give an animal-based reason for refusing, or reported ‘never’ refusing, suggesting that the view that death may be contrary to a dog's interests is not shared by all respondents. This may reflect academic debate over whether death may be undesirable when it deprives an animal of an enjoyable QOL (Yeates 2009b) or ‘is not a welfare issue’ (Webster 1994). There was no evidence in the study for any support of ‘animal rights’ views, which tend to prohibit killing, although not necessarily euthanasia, for the reason that it is not in the animal's interests (Rollin 1981, Regan 1983).
Several respondents feared that owners might destroy their animal inhumanely, and the destruction of an animal is not an ‘act of veterinary surgery’ under the Veterinary Surgeons Act 1966. Others considered the likelihood of rehoming for the individual case. In such cases, humane destruction may be ‘contextually justified’ by being better than risking these other outcomes (Yeates 2010). Such responses imply that many respondents have a pragmatic concern for patients' interests. De Graaf (2005) found evidence of similar pragmatism in a subgroup of vets. Such pragmatism may be good for the patient's welfare, but Gauthier (2001) suggested that veterinarians use such thinking to justify behaviours that outsiders might think morally questionable.
Some reasons for and against euthanasia were based on owners' interests. For example, the concern for an owner's ‘fragile mental state of owner’ (female, graduated 1980) is in agreement with the GTPC's statement that refusing an owner's request for euthanasia ‘may add to the owner’s distress' (RCVS 2010). Lesser interests such as convenience did not appear to be seen as legitimate reasons for euthanasia. This concurs with the findings from a single practice (Sanders 1995) that convenience was ‘the least justifiable reason for euthanizing an animal’. In addition, animal-based reasons were given more frequently than owner-based reasons by the sample of respondents in the present study. In general, these findings suggest that a concern for the patient has more influence on the decision of whether or not to euthanase than a concern for the owner. This contradicts previous reports that veterinary practice is client-oriented rather than patient-oriented (Sanders 1995, Dickinson and others 2010). This difference may be geographical, as the reports of Sanders (1995) and Dickinson and others (2010) were conducted in the USA. UK veterinarians are required to comply with RCVS guidance, which, in different sections, dictates that animal welfare should be a veterinary surgeon's ‘first consideration’, ‘primary consideration’ and ‘primary obligation’, although it adds that ‘account must be taken not only of the animal’s condition but also the owner's wishes and circumstances' (RCVS 2010).
The present study also identified some respondents who made decisions based on pressure from others. Whether this pressure is acceptable will depend on one's viewpoint, but it may add to the practitioners' stress. Of note is the pressure from knowing that a refusal will only mean that the dog will be destroyed by a different surgeon. This concern cannot provide a reason for ‘contextually justified euthanasia’, because this justification applies only when refusal would harm the patient. Unless going to the other practice would cause welfare harms to the patient, the likelihood that another vet will perform euthanasia does not mean a refusal would be harmful. However, this reason does neutralise any concern for the patient's interests, since the animal's life will end either way. Because individual veterinary surgeons do feel this pressure, and cannot easily affect what colleagues do, tackling this problem would require professional coordination. Further work would be useful to see if such a change is widely desired.
Other work might further investigate other possible factors that affect attitudes and behaviours. The sex and age of the practitioner have been found to affect attitudes (Robertson and others 2004, Herzog 2007). In this study, these did not appear to be determinants of the frequency of refusing or not refusing euthanasia, although this may have been due to the small sample size. The species of the animal in question can also affect people's attitudes (Driscoll 1992, Knight and Barnett 2008), and similar work might be done with farm animal practitioners, and compared with other stakeholders' attitudes (Heleski and others 2006). A practitioner's clinical role (Guedj and others 2005) and cultural differences (Fogle and Abrahamson 1990, Kogure and Yamazaki 1990) may affect their attitudes to euthanasia, so further studies might survey veterinary nurses or other groups. Further work could also investigate hypotheses generated by these results to explore veterinarian's opinions in more depth; for example, by using the reasons given in the present study as prompts or hypotheses.
For end-of-life decision making within human medical practice, there are popular ethical guidelines based on prevalent opinions of practising physicians. The most famous example is that of Beauchamp and Childress (1979), which explains the principles of respect for autonomy, beneficence, non-maleficence and justice. However, these well-established approaches are not easily applied to veterinary work for several reasons (Dickinson and others 2010). Veterinary surgeons have to consider a greater range of ethical concerns (Knight 1983) and interact with both patient and client (Tannenbaum 1985, Arkow 1998). Veterinary surgeons may also see more deaths because animals live shorter lives (Hart and Hart 1987). Furthermore, human and animal euthanasia have different legal statuses.
Therefore, it is important for the veterinary profession to develop its own ethical frameworks. Recently, Yeates (2010) and the BVA (2009) produced guidance on euthanasia, but such guidance has been based on the opinions of its authors, rather than the opinions of practising veterinary surgeons. There may also be a benefit to educational efforts to improve ethical decision making (Porter-Williamson and others 2004). Undergraduate or postgraduate students may benefit from workshops (Cohen-Salter and others 2004), ethics teaching (Rollin 2006) or greater awareness of their own values (Rosenbaum and others 2005). Recent years have consequently seen a significant inclusion of euthanasia within the majority of veterinary curricula, although specific sessions on end-of-life decision making have been designed by only four per cent of US veterinary schools (Dickinson and others 2010). The results of the present study might be useful for developing further guidance and teaching materials.
This paper has provided guidance for an evidence-based framework to address euthanasia decisions. Animal-based reasons appear to be central, but owner-based concerns are also considered to be important. Practitioners should also recognise that there are other social pressures that can influence one's reasoning and actions.
The authors thank members of the SPVS council, Siobhan Mullan and Ed Hall, for advice on the original design; the BSAVA, BVA, SPVS and the editors of Companion, SPVS Bulletin, Veterinary Business Journal, Veterinary Record and Vet Times for publicity; all of the respondents; and two anonymous referees for useful comments on the paper.
Provenance not commissioned; externally peer reviewed
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