Ethics are values or beliefs which dictate what is right or wrong. They may be categorised with respect to the field to which they pertain — be that personal, social, or professional (Morgan and McDonald, 2007). Veterinary ethics have been used in the development of the Royal College of Veterinary Surgeons (RVCS) Code of Professional Conduct for both veterinary surgeons (VSs) and registered veterinary nurses (RVNs) in order to provide guidance in their daily professional actions, set the national standards of care and act as a benchmark when dealing with ethical dilemmas (RCVS 2017a; 2017b).
In veterinary practice, ethical considerations predominantly concern the rights and welfare of animals (Busch, 2008). One ethical predicament within veterinary practice is the euthanasia of aggressive, but otherwise healthy, dogs (Tudor, 2013). Aggressive behaviour is the most common behaviour pathology seen in dogs, and one of the main reasons why they are rehomed, abandoned or euthanased (Atkinson and Riccomini, 2008; Polo et al, 2015).
In 2015, The Guardian reported a 76% increase in hospital admissions as a result of dog attacks over the last decade (Siddique, 2015). This increase in dog attack incidence can be extrapolated to deduce a corresponding increase of dogs being presented for euthanasia in veterinary practice. With RVNs and VSs having a duty of care to the client, an obligation to ensure the public health, and a responsibility to hold animal health and welfare as their primary concern (RCVS, 2017a; 2017b), this topic requires careful ethical consideration.
The One Health Initiative strives to integrate human medicine, veterinary medicine, and environmental science, to benefit the health of all species (One Health Initiative, 2017). The collaboration of medical and veterinary professionals acting to prevent dog attacks through training and education would reduce the occurrence of attacks and, by extension, the necessity for euthanasia of aggressive but otherwise healthy animals.
Ethical theories and frameworks
Utilitarianism and deontology are two classical theories which have been used to guide ethical decision making (Crowley, 2006). The former relates to achieving the greatest happiness for the greatest number of people, whereas the latter champions the following of certain rules to make a moral decision, irrespective of the consequences (Abbitt, 2010; Mann, 2013).
In human medical practice, end-of-life decision making is guided by an ethical framework (Yeates and Main, 2011). At present, owing to a lack of published studies in this area, no veterinary ethical framework exists. This necessitates the extrapolation of a human health-care ethical framework. One such framework which may be used in veterinary practice is the ‘four principles of biomedical ethics' (UK Clinical Ethics Network, 2017), which are:
- Autonomy
- Beneficence
- Non-maleficence
- Justice.
Autonomy
Autonomy considers animals as individuals, with freedom and the right to make choices. This is harmonious with a holistic approach to patient care; however, it is limited by the fact that veterinary patients may be unable to make these choices to which they are entitled. It is therefore necessary for RVNs to act as patient advocates in a way that provides for the animal's best interests.
Beneficence
Beneficence advocates the promotion of welfare and goodness, primarily via treatment options. RVNs are actively encouraged to make patient welfare a top priority in the RCVS (2017b) Code of Conduct for Veterinary Nurses. When considering beneficence in the case of euthanasia, it may be argued that euthanasia is never of benefit to a healthy animal (Welsh, 2015). It is, however, important to consider the potential quality of life of the dog if euthanasia is not carried out. For example, the dog may require constant muzzling or confinement to a kennel. There are many potential reasons for canine aggression; even if in an ideal situation, the animal could have a good quality of life, the options must be considered pragmatically (Yeates, 2010; Polo et al, 2015).
Non-maleficence
Non-maleficence dictates that animals should not be harmed unnecessarily. It is therefore essential to consider whether this harm would be outweighed by the benefits of reduced risk of attack to the public, and reduced distress for the owners (Tudor, 2013).
Justice
Justice dictates that all individuals must be treated with equality. In veterinary practice, the needs of all patients should be considered equally, with respect to individual requirements (Mullan, 2006). Concerning aggressive dogs, to be treated with equality, it is necessary for each dog to be provided with the opportunity to respond to alternative interventions before the euthanasia decision is finalised. This framework has received criticism for being too superficial and limiting, but can make a useful starting point in veterinary ethical decision making (Crowley, 2006).
Law in veterinary nursing ethics
Although an RVN's actions must always be considered ethical, it is vital that they are also legal. The regulatory body, the RVCS, published the Code of Professional Practice for RVNs, which provides guidelines for professional actions in order to protect the public and their animals (RCVS, 2017b). In addition to legal accountability to the profession, RVNs have professional accountability in three other areas (Dimond, 1995):
- To society through criminal courts. Criminal law concerns the punishment of acts which are deemed as offences of the state, to protect society and individuals from harm. Criminal law legislation applicable to the euthanasia of aggressive dogs includes, but is not limited to, The Dangerous Dogs Act 1991; Anti-social Behaviour Crime and Policing Act (ASBCP) 2014; The Veterinary Surgeons Act 1966; and The Animals Act 1971
- To the client through civil courts. Civil law is differentiated from criminal law in that it concerns disputes regarding individual losses. Legally, animals are considered the owner's property; therefore, there may be civil consequences should euthanasia be performed without the owner's consent (Dye, 2006)
- To their employer through contracts of employment, which detail responsibilities of employers and employees to one another (Dimond, 1995; Orpet and Welsh, 2011). RVNs would be unlikely to be contractually obliged to assist with a procedure which they felt was not ethically justifiable. However, when polled, 6% of VSs who had not refused euthanasia when they had wished to, stated this was a result of pressure from their employer (Yeates and Main, 2011).
In law, RVNs have a duty not to cause harm or loss to clients; as animals are considered property, any harm to them resulting in loss to the client would result in potential charges of negligence. RVNs also owe a duty of care to clients, colleagues, and their employer (Earle, 2006).
The Dangerous Dogs Act 1991
The Dangerous Dogs Act 1991 was originally put into place to protect the public from certain breeds of dogs which were deemed dangerous, making it an offence to own or be in charge of such a dog (Tudor, 2013). Despite its presence, dog attack statistics continued to rise, attesting to its ineffectiveness as a preventive measure (Laurence, 2011). Amendments to the Dangerous Dogs Act 1991 came into effect in May 2014, making it an offence for any dog to be out of control anywhere in England or Wales, including the owner's property (Lacey, 2014). It is now considered an ‘aggravated offence’ should an individual or assistance dog be injured, be that directly or indirectly, by a dog that is out of control. It is also an offence if somebody feels threatened or fears injury by the dog. Consequences for the owner of a dog that has committed an offence have also greatly increased, with the maximum prison sentence for an aggravated offence being 14 years (Lacey, 2014). The dog may be subject to a destruction order and, in these cases, in accordance with the RCVS Code of Professional Conduct for Veterinary Surgeons, the VS asked to destroy the dog should obtain a written and signed order from one of the appropriate statutory authorities (RCVS, 2017a).
Dogs are often presented for euthanasia in veterinary practice at the request of their owners following an attack on an individual. In these cases, the VS's decision to euthanase the animal or not should be based on the severity of the incident, the animal's temperament, the owner's ability to control the dog responsibly in future, and whether it is possible to implement preventive measures (Lacey, 2014; Welsh, 2015).
Legalities and ethics of euthanasia
Euthanasia is not an act of veterinary surgery, and can therefore legally be carried out by anybody — not just VSs — provided it is performed humanely. VSs are commonly approached to perform euthanasia, however, as a result of their professional expertise and access to appropriate medications and materials. Crump (2013) stated that RVNs are unlikely to incur any legal charges from assisting with consented euthanasia.
Although RVNs have a duty of care to their clients and colleagues, there is no legal duty of care to the animal (Earle, 2006). Should an RVN refuse to assist with an elected euthanasia of an aggressive dog, they are not fulfilling their duty of care to the client. The service provided would be deemed wanting when judged against what would be considered reasonable action for an RVN to take in this situation (Earle, 2006).
Also, RVNs may bring about prolonged suffering in the patient by their refusal to assist in the euthanasia, which is prohibited in the RCVS Code of Professional Conduct for Veterinary Nurses (RCVS, 2017b). In cases of aggressive dogs, such suffering may include abandonment or unsuitable rehoming of the dog, lack of mental and physical stimulation as a result of the owner's reluctance to take the dog out, and being muzzled or tied up for prolonged periods (Figure 1).
Importance of informed consent
As pets are considered an owner's property, should euthanasia be performed without informed consent, there would be a loss to the client which may result in civil charges for the VS and the RVN assisting with the euthanasia (Crump, 2013). Informed consent requires the owner to be provided with sufficient information, and have any queries answered, to allow them to make an informed decision (Dye, 2006). The RCVS Code of Professional Conduct for Veterinary Surgeons detailed that informed consent cannot be achieved if the owner is not given a list of viable treatment options, along with the risks associated with each, and costs involved (RCVS, 2017a). It is part of the RCVS Code of Professional Conduct for Veterinary Surgeons and Veterinary Nurses to ensure that the owner has all this information (RCVS, 2017a; 2017b). In aggressive patients, owners often feel that euthanasia is the only option; therefore, it is necessary to discuss alternative treatment options and associated costs before the decision is finalised. Provided it is safe to do so, the VS should initially perform a thorough clinical examination, and any indicated diagnostic tests, prior to a euthanasia decision being made, with referral to a certified behavioural counsellor if required.
Behavioural management strategies
As RVNs are bound by their Code of Professional Conduct to effectively communicate with clients to ensure that they can make an informed decision (RCVS, 2017b), RVNs must have up-to-date knowledge of appropriate management strategies of canine aggression. Should behavioural management be sought as an alternative to euthanasia, initially, investigation of the triggers for the dog's aggression must be carried out, owing to the fact that it may be augmented by a physical condition, pain, fear, stress, or a behavioural problem (Seymour, 2008; Greenfield, 2013; Polo et al, 2015). VSs have traditionally been taught a sparing amount of behavioural medicine, with most behavioural therapy out-sourced to specialised behaviourists (Loftus, 2014). The Animal Behaviour and Training Council serves as a regulatory body for the behaviour and training industry, regulating professional standards. It is advised that the Council is consulted to source a reputable behaviour counsellor (Loftus, 2014).
Role of the RVN in public education
All RVNs take a professional declaration on registration with the RCVS, in which they promise to make the health and welfare of animals under their care their primary endeavour (RCVS, 2017b). They therefore play a significant role in owner and public education, as a means of preventing potential health and welfare problems. This education should include children, parents, dog owners, and dogs themselves, via education of dog trainers and breeders (McBride, 2014).
RVNs are perfectly placed to advise on various issues with dog and puppy owners in practice (McBride, 2014). It is vital that the information given to owners is correct, as inaccurate information can potentially be detrimental (Hargrave, 2013). Relevant continuing professional development (CPD) should therefore be undertaken by both RVNs and VSs to ensure provision of the most accurate and relevant knowledge based on best current evidence. Owners must understand their legal obligations of dog ownership as regards both civil and criminal law. McBride (2015) reiterated the importance of applying this to all dogs, not just those of a stereotypically aggressive breed.
RVNs should also be able to point owners towards relevant resources, such as training schools, and information and guidance on training. RVNs could also talk to schools and other groups about the importance of educating both children and parents about how to behave around dogs, and that children should always be supervised when around dogs, irrespective of how well behaved either party may be deemed to be (McBride, 2014). Owners of dogs which display aggressive, anxious or fearful behaviour in the veterinary practice can be given advice on how to remedy this behaviour, and how suitable precautions such as muzzling and indoor kennels can reduce the risk of an incident (McBride, 2014).
Resolution
In order to ensure the provision of best advice to owners of aggressive dogs, both RVNs and VSs should ensure that their knowledge in this area is up to date, by undertaking relevant CPD. Veterinary professionals should also be prepared to refer the patient to a certified behaviourist if necessary, before any decision is made, provided there is no serious risk to the general public.
Dog owners must be made aware of the Dangerous Dogs Act 1991, and their responsibility regarding their pet's behaviour towards people and other animals. Owners with children should be advised to educate their children on how to behave around dogs to reduce the risk of incidents.
Veterinary professionals and dog owners must work together to recognise early warning signs of problem behaviours and communicate well with one another to establish appropriate measures to manage the behaviour. The goal of this is to prevent the escalation of problems and, consequently, the need for euthanasia. Protocols should be in place for when such cases present in practice, with team meetings and communication being of paramount importance. There should be clear policies and procedures to follow before a healthy, aggressive dog is euthanased.
Conclusions
Euthanasia of aggressive but otherwise healthy dogs is an emotional event for both owners and veterinary professionals. RVNs must be aware of the legalities of their role in such a procedure, and ensure that they are working within their Code of Professional Conduct and The Veterinary Surgeons Act 1966. RVNs declare to make the health and welfare of their patients their priority, and this statement must always be at the forefront of their minds when considering an ethical dilemma in practice.
No two situations are ever the same, and the line between what is ethical and what is not is often blurred and subjective. Ethical theories and frameworks should be used to guide decision-making, and to establish what is best for the patient, owner and the general public. The RVN's role in owner and public education is hugely important in early identification of behavioural problems, and implementation of preventive strategies to reduce the incidence of these highly emotive situations in veterinary practice.
KEY POINTS
- RVNs should have knowledge of the laws that affect the decision-making process of the euthanasia of aggressive dogs.
- Ethical theories and frameworks may guide decision-making, but there is no dedicated veterinary ethical framework available.
- RVNs should ensure they have an up-to-date knowledge base on canine training and behavioural management strategies, as erroneous information can be highly detrimental.
- RVNs play a significant role in owner education, and this should apply to all dog owners, not just those with stereotypically aggressive dog breeds.