The term ethics encompasses a wide variety of different topics, many of which cause conflict and debate among professionals. This article uses a case-based approach to consider the topic of euthanasia, discussing who may have the authority to decide when to perform the procedure. The author considers this dilemma from the aspect of registered veterinary nurses (RVNs), the owner and the animal.
What are ethics?
Ethics is the practical application of beliefs and values in everyday life (Busch, 2008) and each person holds their own individual beliefs. The study of ethics considers moral questions and the reasoning behind opinions on these (Mullan, 2006). Ethical decisions contemplate notions such as ‘right’ and ‘wrong’, and ‘good’ and ‘bad’, when people are presented with various ethical dilemmas throughout their lives (Mullan, 2006). Ethical dilemmas that may be encountered in veterinary practice include treatment differences between insured and non-insured patients, providing palliative care to suffering patients and many situations involving the subject of euthanasia.
What are veterinary ethics?
Veterinary ethics are specifically concerned with all aspects of animal rights and welfare and are applied to help define a code of conduct guiding professional activities (Busch, 2008). Moral opinions are continuously changing (Busch, 2008) and with new treatments and technology being introduced, which have the potential to prolong an animal's lifespan, ethical questions will continue to arise. Ethical dilemmas can also arise as a result of laboratory testing involved and the impact on laboratory animals (Mullan, 2006) and RVNs should be aware of consequences of new treatment options. Debates in veterinary ethics are essential to resolve issues that impact on a veterinary practitioner's daily performance and it is common to find ethical values conflicting with those of others involved in animal welfare (Busch, 2008).
Why should RVNs study ethics?
Since the veterinary nursing (VN) profession has become regulated and emphasis is placed on movement towards autonomy, it is imperative that RVNs are able to offer potential solutions for ethical dilemmas guided by knowledge and experience. Personal beliefs and values have an impact on the decisions reached but it is important for RVNs to consider their duty of care (DOC) to patients, clients and colleagues first (Mullan, 2006).
It has been advised by Abbitt (2010/11) that the teaching of ethics and law should be introduced to all VN syllabuses, and this is already being taught to Level 3 Diploma students and RVNs studying for the Advanced Diploma in Veterinary Nursing. These teachings are important during advancement towards autonomy because it is essential that RVNs are aware of any legal implications that take precedent over their personal moral beliefs (Abbitt, 2010/11).
Considering ethical dilemmas
Abbitt (2010/11) advised there are numerous ethical principles to be considered when contemplating an ethical dilemma but highlighted two main principles, one emphasising the ‘right and wrongs’ of an action and the other emphasising the outcome of an action. These have been described an alternative way by Mullan (2006) as either involving a requirement for certain duties to be met with certain harms to be avoided and to analyse the likely benefits and costs of an action.
The theory of deontology considers the ‘right thing to do’ (Budd, 2012) and a set of rules must be established and followed when utilising this theory, for example a specified code of conduct (Mullan, 2006). Some deontological principles, including moral absolutism, give no consideration to the consequences of the action implemented and deontological duties have sometimes been described as negative constraints by Mullan (2006).
A contrasting theory is utilitarianism which aims to achieve the greatest happiness for the greatest number of people (Budd, 2012) and this theory involves considering different approaches to the dilemma and weighing up the positives and negatives to reach an outcome (Mullan, 2006).
A third theory, described by Hursthouse (2012), is virtue ethics, considering a person's moral standing. Virtue ethics teach that an action is only the correct action if the same solution would have been implemented by a virtuous person. A potential limitation to this theory is the differing views on which virtues are of greatest importance and limited guidelines are available.
The dilemma of euthanasia occurs commonly within practice and can prove challenging for all professionals involved. There are a variety of potential scenarios and outcomes involving this dilemma but the main focus of this article is to discuss who is involved in the decision and who should be able to make the final decision.
The RVNs' aspect
Where do RVNs stand legally?
Some ethical dilemmas can result in professionals being involved in legal issues and these can be categorised under either criminal or civil law. Criminal law involves punishment of violations by the state (Abbitt, 2010/11) and this would apply if the RVN were to breach legislative acts, for example the Veterinary Surgeons Act, 1966. In comparison, civil law considers personal losses and this may be a result of failure to fulfil obligations, for example negligence by the RVN (Abbitt, 2010/11).
RVNs are unlikely to incur any criminal consequences as a result of assisting with consented euthanasia because as stated in the Guide to Professional Conduct for Veterinary Nurses (Royal College of Veterinary Surgeons, 2010: 27) ‘euthanasia is not, in law, an act of veterinary surgery, and may be carried out by anyone provided that it is carried out humanely’. However, if they assist the veterinary surgeon (VS) in performing euthanasia against a client's wishes there is potential for them to be involved in disciplinary action or civil law proceedings and Yeates (2010) explains there is a risk of prosecution for litigation and personal loss.
RVNs should have established values guiding their decisions and in some situations, such as euthanasia, these values may cause conflict (Crowley, 2006). Would the RVN face disciplinary action for abiding by these values if they disagreed with the VS? Does their refusal to play a part affect the duty of care to patient, client and colleagues? The Guide to Professional Conduct for Veterinary Nurses (Royal College of Veterinary Surgeons, 2010) indicates that RVNs must act in the best interests for colleague, patient and owner (Budd, 2012) and disagreement over the need for euthanasia is a difficult situation for the RVN to be involved in due to the potentially conflicting opinions of the owner, the VS and themselves.
Who should RVNs DOC be to?
As mentioned previously the RVN holds a DOC to clients, patients and colleagues but Earle (2006) explains that in legal terms there is no DOC to the animal. Even if RVNs hold strong moral obligations the DOC is owed to the owner. A test that can be used to establish if a DOC exists comes from Donaghue v Stevenson and the test advises that the DOC is owed to any person likely to be affected by their acts (Abbitt, 2010/11). Applying this test to the scenario of elected euthanasia, which the RVN may disagree with, the result shows that the RVN is required to fulfil their DOC to the owner primarily by providing reassurance.
A standard used to establish if DOC has been breached is the Bolam Test (Abbitt, 2010/11). The affected client is required to prove the service provided has fallen below reasonable standards (Earle, 2006) and if DOC is called into question it is likely that the RVN would be judged against the Guide to Professional Conduct for Veterinary Nurses (Abbitt, 2010/11; Royal College of Veterinary Surgeons, 2010). Relating this to the scenario of euthanasia, if the RVN refuses to assist they are not satisfying the DOC and the service provided may be judged as below reasonable standard. Their refusal to assist may result in prolonged suffering of the patient and the Guide to Professional Conduct for Veterinary Nurses explains: ‘a veterinary nurse must not cause any patient to suffer by failing to assist with the maintenance of adequate pain control and relief of suffering’ (RCVS, 2010: 6).
What tools can be utilised to assist RVNs?
Reaching a decision during an ethical debate is difficult and Busch (2008) comments that consideration of ethical values may be easier in human medicine than veterinary medicine because all human life is considered equal. In human medicine many ethical issues are guided by laws informing what is accepted culturally (Busch, 2008).
Ethical frameworks have been developed providing an appropriate route of action for RVNs to take when considering ethical issues. Mullan (2006) explains that frameworks are beneficial because they ensure all important points involved in resolving an ethical debate are considered. A suggested ethical framework may involve the following steps:
- Identification of all potential treatment courses
- Establishing interests of affected parties
- Proposing an ethical decision
- Assessment and minimisation of impact of this decision (Mullan, 2006).
Crowley (2006) suggests a similar path of thought to reach an ethical decision and explains that the nursing process can be utilised in this route. The nursing process involves four stages: assessment; planning; implementation; and evaluation (Main, 2011). Assessment involves consideration of all issues at stake and allows the RVN to establish the facts of the situation, including recognition of the ethical values that may be compromised (Crowley, 2006). Planning involves suggestion of actions that can be implemented (Jeffery, 2008) and Crowley (2006) advises that short and long-term goals should be defined at this stage taking into account staff members' experiences. Implementation is execution of the actions (Davis, 2007) and during this period it is important that the actions decided on are understood by all involved and communication is essential for this stage to be efficient (Crowley, 2006). Finally, the evaluative stage involves considering the consequences of the decisions made during the planning stage and appraising the situation, deciding whether an alternative decision would be beneficial in the future (Crowley, 2006).
Quality of life (QOL) assessment is important when considering the ethical dilemma of euthanasia and Warland (2012) explains that previous QOL decisions were based on survival statistics whereas preference nowadays is to assess impact of the disease on individual patients. Wojciechowska and Hewson (2005) designed a QOL assessment tool specifically for dogs and suggested considering age, breed and temperament, however they advise that QOL assessment may be unreliable in sick animals. Mullan (2007) offers use of a questionnaire for owners to complete involving consideration of the ‘happiness and health’ of the pet in comparison to their normal behaviour and how the disease affects their demeanour.
It is clear that various tools can be utilised to aid RVNs with consideration of ethical dilemmas, however DOC is an essential consideration alongside any framework used.
The owner's aspect
How they can decide ‘right or wrong’?
As established previously, euthanasia is not an easy decision to reach and even the RVN with existing knowledge and a wealth of evidence-based research can have difficulties in solving this ethical dilemma, so can the owners be expected to decide whether euthanasia is the right path to take or not? Paternalism is an ethical theory in human medicine that involves the idea of the doctor and nurse knowing best (Kennedy, 2004) and it may be possible that some owners apply this to veterinary medicine. If this is the case the owner may rely heavily on the opinion of the VS and there may be potential for the VS to apply their personal moral beliefs to the situation.
An alternative reaction to the situation is disagreement with the VS. Once a diagnosis of their pet's condition is made and the VS provides treatment options, there is a possibility for owners to search the internet for alternative opportunities; this includes researching human treatments for similar conditions. An extreme example of this would be an animal in organ failure, human counterparts have opportunities for organ transplants to prolong their life, there is potential for pet owners to cling on to the hope that these advancements may be achieved in veterinary medicine, which may cause them to prolong decision making.
As discussed previously QOL assessments are tools that can be utilised and they may be beneficial not only in assisting RVNs but also owners. Unfortunately these assessments are subjective and results vary dependent on each individual's observations; if an owner is bias towards either euthanasia or continuing treatment this would compromise the test making the results unreliable.
Can RVNs support the owner?
Supporting the owner is an essential duty of RVNs and they need to ensure they do not force their personal beliefs onto the owners, pressurising them into making decisions. The Guide to Professional Conduct for Veterinary Nurses (RCVS, 2010) advises that the RVN must realise the owner has freedom of choice, and they must consider the client's concerns and wishes unless they compromise welfare. An owner may be struggling to accept the prognosis and Yeates (2010) explains that grief may be an affecting factor in the decision-making process. The various stages of grief involve shock, disbelief, anger, guilt, bargaining, depression and lastly acceptance (Yeates, 2010) and the RVN may have to deal with the owner at any of these stages. It is important for RVNs to have patience and compassion with the owner to ensure they are not being pressurised into a decision.
If there are concerns that the welfare of the patient is compromised it is essential to consider whether the owner is in breach of the law. The Animal Welfare Act states five needs that any person responsible for an animal must fulfil, these are (Defra, 2006):
- A suitable place to live
- Suitable food and water
- To be able to behave normally
- To be with other animals or alone
- To be protected from pain, suffering, injury and disease.
If an RVN suspects an owner is failing to comply with this legislation, for example failing to protect the animal from suffering, they can report their concerns to the VS. The VS should explain to the owner about the DOC they owe to their pet as they may not understand they are in breach of the Animal Welfare Act. In extreme circumstances, where the animal is suffering and the owner refuses to consider euthanasia, the Animal Welfare Act (2006) allows police officers to instruct a VS to perform euthanasia. This situation should arise only in extreme situations and the RVN and VS should do everything in their power to educate and guide the owner before implementing this action.
The Guide to Professional Conduct for Veterinary Nurses (2010) explains that RVNs are required to educate the public in responsible animal ownership, this includes aspects of animal welfare. It is essential however that they do not inflict their personal opinions on owners and they should ensure they do not compromise their professional courtesies to the public.
It is unlikely that an owner is able to reach a fully justified decision about their animal's condition without some guidance from the veterinary team; however it is important that the RVN and VS do not force their personal views onto the owner.
The animal's aspect
Does the animal have rights?
The difficulty surrounding veterinary ethics is the VS' inability to communicate with the animal and ask how the disease is affecting them; this is a stark contrast to human medicine where, for example, a ‘do not resuscitate’ order can be signed by the patient prior to any procedures being undertaken. Mullan (2007) makes a valid argument when considering euthanasia; it is assumed the animal wants to be free from suffering; however they may not wish this at the expense of their life. This opinion is supported by Busch (2008: 14) who poses the question: ‘is it better to have a painful life or no life at all?’
When approaching this dilemma, Yeates (2010) recommends the evaluation should be of the expected future welfare of the animal and not necessarily the state of that animal at that time. It is suggested to approach the evaluation anthropomorphically; this means considering if you were the animal would you opt for euthanasia or would you rather continue but implement further measures to relieve suffering and re-evaluate after a period of time (Yeates, 2010)?
There has been development of tools to assist in the decision of euthanasia, assessing whether it is in the animal's best interests (Yeates, 2010). An informal checklist of questions has been suggested by Edney (1989); this involves working through seven questions:
- Is the animal in pain, distress or discomfort?
- Can the animal walk and balance?
- Can the animal eat and drink?
- Does the animal have inoperable tumours that can cause pain, distress and discomfort?
- Can the animal breathe without difficulty?
- Can the animal urinate and defecate normally?
- Can the owner cope physically and emotionally with nursing?
Although this list was published over 20 years ago and there have been great developments of treatments in veterinary medicine, this list still holds great relevance when assessing QOL. A bold statement by Yeates (2010) is that euthanasia of an animal when it is not in their best interest is not true euthanasia but is killing of the animal, therefore everything should be done to accurately assess if euthanasia is in the interest of the animal.
Should the concept of ‘personhood’ be applied to animals?
The concept of ‘personhood’ was developed through medical ethics to assist in determining which patient should receive treatment and which should be allowed to die (Pierce, 2011). Criteria have been established to indicate ‘personhood’ including self control, minimum intelligence, self awareness and a sense of time (Pierce, 2011). Animals are able to fulfil some of these criteria whereas other criteria cannot be measured, for example intelligence. The author feels there is a valid argument surrounding the issue of ‘personhood’; it is the animal that is affected most by the decision of euthanasia and there may be the option of considering the criteria already detailed to assist in deciding if euthanasia is appropriate at that time, for example if the patient still has self control and self awareness then treatment may be a viable option. However, the issue of personhood is a detailed subject area and is beyond the scope of this article.
Conclusion
Having considered the dilemma of euthanasia from various perspectives, it is easy to see where difficulties can arise during the decision-making process. All people involved have an interest in the animal's QOL and are usually only acting on what they perceive to achieve most benefit for the animal.
It is important for RVNs to educate owners of their responsibilities to their animals and ensure they are clear on any legal implications they may attract if they fail to fulfil their duties. It is essential however that the Guide to Professional Conduct for Veterinary Nurses (Royal College of Veterinary Surgeons, 2010) is used to educate the RVN during this process, ensuring they do not breach the guiding principles and they maintain their professional courtesy.
To conclude, there is no definite answer to the initial question of who can decide when euthanasia is justified, and rarely can there be a single person making the decision of when to euthanise. The RVN plays an important role in delivering palliative care to the animal and supporting the owner and VS during the process of deciding on euthanasia and providing assistance when the decision has been made. The RVN is essential to provide a voice for their patient and the welfare of the animal is paramount in any situation. The RVN should feel confident in relaying any concerns to the VS in charge of the individual case.