The scale of the ethical challenges faced by veterinary surgeons and their perceived stressful consequences were investigated via a short questionnaire, completed by 58 practising veterinary surgeons. Respondents were asked to report how frequently they faced ethical dilemmas, and to rate on a simple numerical scale (zero to 10) how stressful they found three common scenarios. Fifty seven per cent of respondents reported that they faced one to two dilemmas per week, while 34 per cent stated they typically faced three to five dilemmas per week. The three scenarios provided were all rated as highly stressful with ‘client wishing to continue treatment despite poor animal welfare’ rated as the most stressful (median 9). The female veterinary surgeons gave two of the scenarios significantly higher stress ratings than the male veterinary surgeons. Stress ratings were not influenced by number of years in practice (which ranged from one to more than 25 years). The results show that veterinary surgeons regularly face ethical dilemmas and that they find these stressful. This has implications for the wellbeing of veterinary surgeons and supports the case for increased provision of training and support, especially for those who entered the profession before undergraduate ethics teaching was widely available.
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VETERINARY surgeons often find themselves faced with difficult decisions as a result of their duties towards both animals and clients, especially when the wants of the client conflict with the interests or welfare of the animal. Veterinary surgeons also face the added complication that in many cases there is a lack of clearly defined rules of what course of action is best. This leads to situations in which the best outcome is not obvious and these situations are often referred to as ethical dilemmas. These ethical dilemmas typically involve decisions regarding treatment options (eg, whether to try the most advanced treatments available), the welfare or quality of life of the animal (eg, is prolonged life the best option for the animal?), the interests of the client (eg, what is the client prepared to pay for treatment?) and the duty of care to both (Wiseman-Orr and others 2009). In her doctoral dissertation, Morgan (2009) more specifically states a number of ethical dilemmas commonly experienced in veterinary practice. These examples include various requests from clients for procedures that the vet might not agree with, such as those deemed unnecessary for health reasons (ie, cosmetic procedures), procedures that cause pain or stress to the animal (eg, dehorning in cattle), the controversial issue of healthy animal euthanasia and whether to break client confidentiality in favour of the animal.
It is quite possible that facing such difficult decisions regularly is stressful, and a recent poll in the UK reported that over 80 per cent of veterinary surgeons thought that veterinary medicine was a stressful occupation (Robinson and Hooker 2006). In support of this, a survey of recent graduates from five of the UK vet schools (Mellanby and Herrtage 2004) found that less than half of them reported that they could always rely on support from others in the practice and 78 per cent had made mistakes during treatments which had negative emotional repercussions. In a review by Platt and others (2010), 28 studies relating to stress and burnout in the veterinary profession were examined, with one study reporting that 67 per cent of the veterinary surgeons surveyed showed signs of ‘burnout syndrome’ (Elkins and Kearney 1992). Another of the studies reviewed (Meehan and Bradley 2007) reported that in Australia, longer working hours and more frequent performance of small animal euthanasia was associated with increased stress levels. Specific sources of stress reported by veterinary surgeons included working hours, workload, financial issues, client demands/expectations and euthanasia (Platt and others 2010). These high levels of stress experienced in the profession have also prompted a number of papers investigating and confirming the heightened risk of suicide in the profession (Mellanby 2005, Bartram and Baldwin 2010, Platt and others 2010).
A major challenge in veterinary decision making is the lack of a universally accepted moral worth afforded to animals. Unlike human beings, who are given equal moral value in almost all instances, the views on animals' moral worth differ considerably across groups of people. This opens up the debate on whether a situation involving an animal is ethically difficult or not. In the dilemmas outlined above, the core of the problem is often the same – should the veterinary surgeon give primary consideration to the animal or the client? This has been called ‘the fundamental problem’ in veterinary medicine (Rollin 1988). For example, so-called convenience euthanasia is where a seemingly healthy animal is presented to the vet with the request from the client that the animal be put to sleep, either for reasons of finances, lack of time or simply because they do not want it anymore. To someone who views animals as moral beings with intrinsic value, the idea of killing a companion animal for convenience is morally repugnant. However, if animals are viewed as the clients' property and responsibility, and to do with what they wish, then the decision to perform the euthanasia is not so problematic. This type of ethical dilemma is one only faced by the veterinary profession and is in some ways even more trying because most veterinary surgeons enter the profession to help animals, a goal at odds with convenience euthanasia (Rollin 2006). As has been pointed out, “Moral stress … arises out of a fundamental conflict between one's reasons for going into animal work and what one is in fact doing, or being asked to do” (Rollin 1990).
Although a lack of participation in decision making is listed by Michie and Williams (2003) as a work factor related to psychological illness, making challenging decisions could also be expected to have similar effects. Research on the mental health consequences of continually facing challenging decisions in day to day practice for veterinary surgeons is limited and there is no published information on the common scenarios encountered, their frequency and whether veterinary surgeons find them stressful. It is also not clear whether factors such as sex, type of practice and level of experience are influential. For example, certain types of practice could be perceived to be giving rise to more dilemmas and level of experience might be expected to influence ability to cope with difficult ethical decisions. Sex may also be a factor because women have tended to score higher than men on standardised tests of ethical reasoning (Self and others 1995, 1996). In this survey, data on these factors are sought, with the aim of providing baseline data on the scale of the ethical challenges faced by veterinary surgeons. The authors also aimed to provide a basic insight into the perceived stressful consequences of three common ethical dilemmas.
Materials and methods
A brief postal questionnaire was sent to first-opinion veterinary surgeons practicing in the UK or was presented to veterinary surgeons attending Continuing Professional Development (CPD) sessions at the University of Glasgow's School of Veterinary Medicine. The questionnaire collected demographic information on sex, years in practice and percentage of time spent in each type of practice (small animal, large animal and equine). Respondents were then asked the frequency with which they faced ethical dilemmas in an average week (0, 1 to 2, 3 to 5, 6 to 10, >10). Three common scenarios were then briefly described which were (1) convenience euthanasia of a healthy animal, (2) financial limitations of the client restricting the treatment options and (3) the client wishing to continue treatment despite compromised animal welfare/quality of life. Respondents were asked to rate how stressful they found each of these scenarios on a simple numerical rating scale of 0 to 10, with 0 being ‘not at all stressful’ and 10 being ‘extremely stressful’. The veterinary surgeons were also asked which of the three provided ethical dilemmas that they most commonly faced (or they could provide another common scenario) and whether they felt they had received adequate training in ethics at university.
Median ratings for each dilemma were calculated and Mann-Whitney U tests were carried out to compare the median stress ratings for men and women for each dilemma. To investigate the effects of type of practice and years in practice on the ratings, Kruskal-Wallis tests were used. Type of practice was categorised into three groups: 100 per cent small animal, ≥50 per cent but <100 per cent small animal and <50 per cent small animal.
The survey was completed by 58 practicing veterinary surgeons, 43 of whom were women and 15 of whom were men. The veterinary surgeons had variable levels of experience in practice (Fig 1), ranging from one year to more than 25 years. Most of the veterinary surgeons surveyed spent the majority of their time in small animal practice, with 76 per cent of them doing entirely small animal work. The majority of respondents (57 per cent) reported that they faced one to two ethical dilemmas per week, with 34 per cent stating that they faced three to five dilemmas per week. Two respondents reported facing greater than 10 ethical dilemmas per week and three respondents stated they faced none.
The median stress ratings for each dilemma were eight (healthy animal euthanasia), seven (financial limitations) and nine (client wishing to continue treatment). Thus, client wishing to continue treatment despite poor animal welfare/quality of life was rated as the most stressful, but the other two scenarios were also rated as highly stressful. No effect of years in practice was found in relation to the stress ratings, nor was there any relation to type of practice. Although not statistically significant, the median stress rating for healthy animal euthanasia was numerically highest in those veterinary surgeons with only one to two years of experience (nine compared with eight for veterinary surgeons with more than two years' experience). A significant sex difference was observed in stress ratings for two scenarios, healthy animal euthanasia (P=0.022) and client wishing to continue treatment (P=0.014), with females rating the dilemmas more stressful than males (Fig 2). No difference in stress ratings was seen with the financial limitations scenario (n=55, P=0.497). No difference was seen in the reported number of dilemmas experienced per week between the sexes, nor in the different types of practice.
The most common dilemma faced was financial limitations restricting treatment options (Fig 3). As well as healthy animal euthanasia and client wishing to continue treatment, other scenarios reported as common were ‘all euthanasia’ and senior staff recommending treatments that the respondent did not agree with. Of 55 respondents, 78 per cent reported that they felt they had inadequate training on ethics during their veterinary degree.
The results of this relatively small scale survey show that veterinary surgeons regularly face ethical dilemmas and that they find these dilemmas stressful. Most of the veterinary surgeons reported that they dealt with one or two ethical dilemmas weekly, and a substantial proportion (a third) stated that they faced three to five per week and very few (3) stated that they encountered none. Worryingly, two respondents reported facing more than 10 dilemmas per week. This part of the survey (aiming to determine frequency of dilemmas encountered) depended on the assumption that veterinary surgeons were able to recognise ethical dilemmas. The ability to recognise ethical issues within a problem is known as ethical sensitivity. Instruments using practice-specific dilemmas have been created in other professions to measure ethical sensitivity (such as dentistry, science, engineering; Bebeau and others 1985, Clarkeburn 2002, Borenstein and others 2008) but there is neither a veterinary tool nor data on this attribute in veterinary surgeons. Therefore, as well as recording actual differences in encountered dilemma frequency, the results of this study may have been affected by the differences in the number of dilemmas reported due to differing levels of ethical sensitivity. In addition, it is clear that there are differences of opinion on what constitutes a moral problem in veterinary medicine. Veterinary surgeons differ in their ethical views and some will oppose actions that others would happily carry out. Rollin (2006) described two different approaches that veterinary surgeons may take to their role and responsibilities using metaphors relating to service or care. He refers to the ‘mechanic model’ (where the vet is essentially a service provider to the client) or the ‘paediatrician model’ (where the vet is primarily an advocate and care provider for the patient). Thus, such differences in outlook would also affect whether or not veterinary surgeons consider the situations they face to be ethically problematic.
Repeatedly dealing with stressful situations is likely to contribute to anxiety disorders, erosion of morale and dissatisfaction with the profession. Fogle and Abrahamson (1990) even proposed that it could lead to ‘learned helplessness’, due to the lack of control or forewarning veterinary surgeons receive in these situations. The authors suspected that repeated exposure to dilemmas (as assumed by increased years of experience) might have been related to reduction in the stress caused by these situations but this was not the case. It would appear, therefore, that coping with ethically challenging situations is not necessarily self-taught or improved by repetition.
In the survey, the authors put three common scenarios (all of which were assumed to be ethically problematic) to veterinary surgeons. Of these, situations in which clients wish to continue treatment despite poor animal welfare/quality of life was rated as the most stressful. However, the other two scenarios (healthy animal euthanasia and financial limitations on treatment) were also rated as highly stressful. This relates well to previous work; Herzog and others (1989) found that a quarter of veterinary students found euthanasia distressing and the students were most often upset by what they felt was prolonged suffering of animals due to the owners' failure to recognise that there was no cure. Clearly, veterinary surgeons are concerned both with the quality and quantity of animal life and situations in which these are compromised are potentially very stressful.
Interestingly, although the scenario of financial limitations on treatment was reported as the most common dilemma, it was rated as less stressful than the other two. The authors can only speculate the reason for this, but it might be related to the acceptance of an unpleasant but common reality, availability of methods to work around this (eg, doing an operation at a reduced fee) or possibly that financial constraints are seen as the client's responsibility and are as a result of their actions (as opposed to the other scenarios that were more directly related to the veterinary surgeons' actions). Higher stress ratings for clients wishing to continue treatment despite poor animal welfare/quality of life and convenience euthanasia may also be related to the fact that these are both situations in which the veterinary surgeons may be at odds with the clients and may be seen to go against their wishes (Yeates and Main 2011). The greater stress associated with clients wishing to continue treatment despite poor animal welfare may be a result of the difficulty of communicating to a well-meaning owner that animals ‘live in the now’ and that the primary interests relate to quality not quantity of life (Rollin 2003).
In this brief survey, the authors did not ask the veterinary surgeons whether they resolved common dilemmas or their methods for doing so. One of the reasons that veterinary surgeons may find these situations highly stressful is that they have not been given any guidance on how to make difficult ethical decisions. This is supported by the finding that 78 per cent of respondents felt that they were not given enough (or in many cases any) ethics tuition during their training. This probably reflects the age range of the responding veterinary surgeons, given that formal tuition in ethics is still a relatively new addition to veterinary undergraduate curricula. This training usually takes a pluralistic approach and includes introduction of ethical frameworks and specific tools to aid decision making (Mepham 2005, Morgan 2009). It should be noted, however, that assessment of these skills is problematic (Wiseman-Orr and others 2009) and the effectiveness of the teaching once students enter practice is unproven although improved moral reasoning ability via educational interventions has been demonstrated (Penn 1990, Self and others 1993 1998). Studies examining the moral reasoning abilities of vet students in the USA found that their reasoning ability did not increase as they progressed via the course (Self and others 1996), and even suggested that the veterinary course retarded ethical development. The authors are currently investigating ethical development in UK vet students exposed to a curriculum with formal ethics tuition. In any case, the high stress ratings reported here support the idea that there is a need for ongoing training in ethical decision making for veterinary surgeons, especially those who graduated before undergraduate ethics teaching was widely available.
In two of the presented scenarios (clients wishing to continue treatment and healthy animal euthanasia), women reported the situations to be more stressful than did men. Previous studies have discovered similar differences in sex; Elkins and Kearney (1992) found that in the USA more female veterinary surgeons show signs of early burnout than male veterinary surgeons and Gardner and Hini (2006) found that female veterinary surgeons were more at risk of stress. Platt and others (2010) reported that females were more likely to report suicidal ideation. An obvious question is whether women might have poorer moral reasoning ability than men, which could result in more problematic decision making and more stress. In the few studies that have looked at the moral reasoning ability of vet students this has not been the case, as women have tended to score higher than men on standardised tests (Self and others 1995, 1996). Nevertheless, these tests use general social issues rather than issues involving veterinary treatment, so they may not give an accurate reflection of veterinary decision making. More plausible reasons for the differences are that women are more empathetic, so are more susceptible to emotional stress (Paul and Podberscek 2000), or because they rate the human-animal bond as more important than men (Martin and Taunton 2005). Fogle and Abrahamson (1990) found that double the proportion of female veterinary surgeons compared with male veterinary surgeons cried after subjecting a pet that they were trying to save to euthanasia, and this increased to four times as many when they could do nothing to save the animal. Capner and others (1999) reported that female veterinary surgeons provide more analgesia for surgical procedures than male veterinary surgeons, but this result is potentially confounded by year of graduation (as more women graduated in later years than men, and this is related to increasing recent emphasis on pain in veterinary undergraduate curricula). It is worth noting in this context that the proportion of women entering the veterinary profession is now around three times that of men and this may have implications for future vet wellbeing.
This relatively small scale survey provides the first data on the scale of the ethical challenge faced by first-opinion veterinary surgeons in the UK. It has revealed that veterinary surgeons experience difficult ethical dilemmas regularly, that some situations with which they are confronted are more stressful and/or common than others and that years of experience do not necessarily make these situations any easier to handle. These data provide a starting point, but more research examining ethical sensitivity and moral reasoning abilities of veterinary surgeons is needed. On a practical level, these findings suggest that there is an urgent need for ethics educational tools and approaches specifically designed with veterinary surgeons in mind. Such training should help to reduce the stress experienced by veterinary surgeons as they negotiate these complex situations and should also facilitate sound decision making, which forms the basis of morally justifiable animal and client care.
The authors thank a group of undergraduate vet students and Mrs Valerie Small for their assistance in data collection.
Provenance not commissioned; externally peer reviewed
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