Veterinary Medical Ethics Déontologie vétérinaire Ethical question of the month — August 2016 A good friend and strong animal advocate who works at the local animal shelter contacts you for your professional opinion. A middle-aged cross-bred dog that has been at the shelter for several weeks has been treated symptomatically on two occasions by the shelter veterinarian for anorexia and dehydration. On both occasions the dog improved following treatment with analgesics, vitamins, and intravenous fluids. The dog is considered very “adoptable” but interested parties have been warned that the dog may need “extra care.” Recently an interested couple was told that the dog may need some extra veterinary attention but that if they did not adopt the dog, it likely would be euthanized. The couple agreed to the adoption but two days later the dog was found dead in the kennel. A postmortem examination revealed lymphoma. Your friend would like your professional opinion on the handling of this case. You appreciate all the good work that these shelters do and you know that the shelter veterinarian discounts her services to help support the shelter. How should you respond?
Question de déontologie du mois — Août 2016 Un bon ami et ardent défenseur des animaux qui travaille au refuge d’animaux local vous contacte pour obtenir votre opinion professionnelle. Un chien de race croisée et d’âge moyen qui est au refuge depuis plusieurs semaines a été traité à deux reprises par la vétérinaire du refuge pour cause d’anorexie et de déshydratation. Au cours des deux occasions, le chien s’est amélioré après le traitement analgésique, des vitamines et des solutions intraveineuses. Le chien est considéré comme très «adoptable», mais les parties intéressées ont été informées que le chien pourrait nécessiter des «soins supplémentaires». On a récemment dit à un couple intéressé que le chien pourrait avoir besoin de soins vétérinaires supplémentaires, mais que s’ils ne l’adoptaient pas, il serait probablement euthanasié. Le couple a accepté l’adoption, mais deux jours plus tard, le chien a été trouvé mort dans le chenil. Un lymphome a ensuite été découvert à l’autopsie. Votre ami aimerait connaître votre opinion professionnelle relativement à la gestion de ce cas. Vous appréciez l’excellent travail réalisé dans ces refuges et vous savez que la vétérinaire offre ses services à rabais pour appuyer le refuge. Comment devriezvous répondre?
Responses to the case presented are welcome. Please limit your reply to approximately 50 words and forward along with your name and address to: Ethical Choices, c/o Dr. Tim Blackwell, 6486 E. Garafraxa, Townline, Belwood, Ontario N0B 1J0; telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: [email protected] Suggested ethical questions of the month are also welcome! All ethical questions or scenarios in the ethics column are based on actual events, which are changed, including names, locations, species, etc., to protect the confidentiality of the parties involved.
Les réponses au cas présenté sont les bienvenues. Veuillez limiter votre réponse à environ 50 mots et nous la faire parvenir par la poste avec vos nom et adresse à l’adresse suivante : Choix déontologiques, a/s du D r Tim Blackwell, 6486, E. Garafraxa, Townline, Belwood (Ontario) N0B 1J0; téléphone : (519) 846-3413; télécopieur : (519) 846-8178; courriel : [email protected] Les propositions de questions déontologiques sont toujours bienvenues! Toutes les questions et situations présentées dans cette chronique s’inspirent d’événements réels dont nous modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.
Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs. CVJ / VOL 57 / AUGUST 2016
813
D É O N TO LO G I E V É T É R I N A I R E
Ethical question of the month — May 2016 A veterinarian treats a middle-aged dog with a mild cough symptomatically and fails to identify a heart murmur. Another veterinarian treats a vomiting dog symptomatically and fails to test for an intestinal blockage. A third veterinarian treats a calf that is not eating with antibiotics and fails to consider rabies in the differential diagnosis. In each of these cases a second opinion is sought after the initial treatment fails to resolve the clinical signs. In each case the second opinion veterinarian, with the benefit of knowing the failed treatment histories, performs further diagnostics and arrives at the correct diagnosis. In these and similar situations the initial veterinarians are at risk of being cited for a substandard level of care. Are veterinarians allowed to make mistakes? Does every case require that all possible diagnoses be explored at the time of the first examination?
Question de déontologie du mois — Mai 2016 Un vétérinaire traite un chien d’âge mûr souffrant d’une légère toux symptomatique et il n’identifie pas un souffle cardiaque. Un autre vétérinaire traite les symptômes d’un chien qui vomit et n’effectue pas de tests pour détecter un blocage intestinal. Un troisième vétérinaire traite un veau qui ne mange pas à l’aide d’antibiotiques et n’envisage pas la rage dans le diagnostic différentiel. Dans chacun des cas, une deuxième opinion est sollicitée après que l’échec du traitement initial. Dans chacun des cas, le vétérinaire de la deuxième opinion, qui a l’avantage de connaître l’anamnèse des traitements infructueux, effectue d’autres tests diagnostiques et obtient le bon diagnostic. Dans ces situations et dans d’autres exemples semblables, les premiers vétérinaires s’exposent au risque d’être accusés d’avoir fourni des soins inférieurs aux normes. Doit-on, dans tous les cas, explorer tous les diagnostics possibles au moment du premier examen?
Pursuing all diagnostic possibilities – A comment Yes, I believe veterinarians can make mistakes like everyone else in society. As long as the veterinarian took a reasonable medical approach to a diagnosis, mistakes are always possible. These would include an appropriate VCPR, a detailed history of the case, a short list of the most likely diagnoses and the options for further diagnostic options plus the potential success of the current therapy chosen. A client
should be offered the choice of having all possible diagnoses explored, but they may chose not to follow that course of action. As for the risk of being cited for an insubstantial level of care, I might suggest the answer would be “it depends” and that would hold true for all of the cited examples. Clayton MacKay, DVM, Veterinary Consulting
An ethicist’s commentary on pursuing all diagnostic possibilities One of my human physician friends tells the story of being a medical student working in the emergency room of a large city hospital. It was standard practice for the hospital in those days to have a prominent specialist oversee the emergency room on weekends. On the weekend in question, a very well-known cardiologist was in the role of supervisor. A patient was brought in suffering from pain in the epigastric region and the cardiologist directed the diagnostic procedures. He ordered the full range of tests relevant to a heart attack, and was puzzled when all came back normal. He consulted with an emergency medicine specialist, who examined the patient and pointed out that he was showing all the classic signs of appendicitis! The point is that the cardiologist was programmed to look at everything primarily through a cardiological lens, and thereby missed a panoply of relevant data. I myself experienced a comparable incident when I was suffering great pain in my big toe and visited an orthopedic surgeon whom I had consulted before. Upon examination, he declared that I was suffering from “Morton’s toe,” a neurological problem that he proposed to treat by doing a neurectomy. Wanting to avoid surgery if possible, I consulted a general practitioner who recognized immediately the high likelihood of gout, which indeed turned out to be the case. 814
It is a cliché in both human and veterinary medicine that when one hears hoofbeats, one should think horses, not zebras. Specialists, on the contrary, are programmed to seek out zebras. Additionally, the general practitioner very often knows facts about the patient or client that are relevant to normal diagnosis and treatment, for example how likely the client is to adhere to a therapeutic regimen. When a human or animal patient is brought in suffering from chills, fever, vomiting, diarrhea, anorexia and similar common symptoms, the general practitioner is not obliged to think Ebola or Marburg virus, even though those diseases represent a theoretical possibility. The point is that in the situations cited in this case, the veterinarians diagnosed and treated based on probability and likelihood. Dogs vomit fairly regularly and at will. Dogs cough and calves go off feed for a multiplicity of reasons. Certainly, in the case of the calf, if rabies is common in the area, it would be reasonable to exclude it at the outset. But failing such an unusual condition, veterinarians do the reasonable thing based on common conditions resulting in the symptoms. Imagine a client’s response if a veterinarian would prescribe a full cardiac workup for a dog with a cough, or rabies testing for a calf who has just gone off feed! CVJ / VOL 57 / AUGUST 2016
CVJ / VOL 57 / AUGUST 2016
all,” he continued, “you need to pay for the diagnostic machinery.” That is an unacceptable way to practice medicine, and if followed, can place veterinary medicine in jeopardy with society. Only when your initial plausible diagnosis fails, is it reasonable to move forward with excluding less likely possibilities. Bernard E. Rollin, PhD
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General practitioners are responsible for diagnosing probabilities rather than excluding all possibilities, however remote. In all the cases cited in our example, the general practitioner should not be blamed for not finding the correct diagnosis on the first go around. In response to the specific question the case poses, veterinarians being human, and not omniscient, are allowed to make mistakes. I once heard a dean of a veterinary school tell a student not to be afraid to prescribe a wide variety of diagnostic tests. “After
Question de déontologie du mois — Août 2016 Un bon ami et ardent défenseur des animaux qui travaille au refuge d’animaux local vous contacte pour obtenir votre opinion professionnelle. Un chien de race croisée et d’âge moyen qui est au refuge depuis plusieurs semaines a été traité à deux reprises par la vétérinaire du refuge pour cause d’anorexie et de déshydratation. Au cours des deux occasions, le chien s’est amélioré après le traitement analgésique, des vitamines et des solutions intraveineuses. Le chien est considéré comme très «adoptable», mais les parties intéressées ont été informées que le chien pourrait nécessiter des «soins supplémentaires». On a récemment dit à un couple intéressé que le chien pourrait avoir besoin de soins vétérinaires supplémentaires, mais que s’ils ne l’adoptaient pas, il serait probablement euthanasié. Le couple a accepté l’adoption, mais deux jours plus tard, le chien a été trouvé mort dans le chenil. Un lymphome a ensuite été découvert à l’autopsie. Votre ami aimerait connaître votre opinion professionnelle relativement à la gestion de ce cas. Vous appréciez l’excellent travail réalisé dans ces refuges et vous savez que la vétérinaire offre ses services à rabais pour appuyer le refuge. Comment devriezvous répondre?
Responses to the case presented are welcome. Please limit your reply to approximately 50 words and forward along with your name and address to: Ethical Choices, c/o Dr. Tim Blackwell, 6486 E. Garafraxa, Townline, Belwood, Ontario N0B 1J0; telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: [email protected] Suggested ethical questions of the month are also welcome! All ethical questions or scenarios in the ethics column are based on actual events, which are changed, including names, locations, species, etc., to protect the confidentiality of the parties involved.
Les réponses au cas présenté sont les bienvenues. Veuillez limiter votre réponse à environ 50 mots et nous la faire parvenir par la poste avec vos nom et adresse à l’adresse suivante : Choix déontologiques, a/s du D r Tim Blackwell, 6486, E. Garafraxa, Townline, Belwood (Ontario) N0B 1J0; téléphone : (519) 846-3413; télécopieur : (519) 846-8178; courriel : [email protected] Les propositions de questions déontologiques sont toujours bienvenues! Toutes les questions et situations présentées dans cette chronique s’inspirent d’événements réels dont nous modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.
Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs. CVJ / VOL 57 / AUGUST 2016
813
D É O N TO LO G I E V É T É R I N A I R E
Ethical question of the month — May 2016 A veterinarian treats a middle-aged dog with a mild cough symptomatically and fails to identify a heart murmur. Another veterinarian treats a vomiting dog symptomatically and fails to test for an intestinal blockage. A third veterinarian treats a calf that is not eating with antibiotics and fails to consider rabies in the differential diagnosis. In each of these cases a second opinion is sought after the initial treatment fails to resolve the clinical signs. In each case the second opinion veterinarian, with the benefit of knowing the failed treatment histories, performs further diagnostics and arrives at the correct diagnosis. In these and similar situations the initial veterinarians are at risk of being cited for a substandard level of care. Are veterinarians allowed to make mistakes? Does every case require that all possible diagnoses be explored at the time of the first examination?
Question de déontologie du mois — Mai 2016 Un vétérinaire traite un chien d’âge mûr souffrant d’une légère toux symptomatique et il n’identifie pas un souffle cardiaque. Un autre vétérinaire traite les symptômes d’un chien qui vomit et n’effectue pas de tests pour détecter un blocage intestinal. Un troisième vétérinaire traite un veau qui ne mange pas à l’aide d’antibiotiques et n’envisage pas la rage dans le diagnostic différentiel. Dans chacun des cas, une deuxième opinion est sollicitée après que l’échec du traitement initial. Dans chacun des cas, le vétérinaire de la deuxième opinion, qui a l’avantage de connaître l’anamnèse des traitements infructueux, effectue d’autres tests diagnostiques et obtient le bon diagnostic. Dans ces situations et dans d’autres exemples semblables, les premiers vétérinaires s’exposent au risque d’être accusés d’avoir fourni des soins inférieurs aux normes. Doit-on, dans tous les cas, explorer tous les diagnostics possibles au moment du premier examen?
Pursuing all diagnostic possibilities – A comment Yes, I believe veterinarians can make mistakes like everyone else in society. As long as the veterinarian took a reasonable medical approach to a diagnosis, mistakes are always possible. These would include an appropriate VCPR, a detailed history of the case, a short list of the most likely diagnoses and the options for further diagnostic options plus the potential success of the current therapy chosen. A client
should be offered the choice of having all possible diagnoses explored, but they may chose not to follow that course of action. As for the risk of being cited for an insubstantial level of care, I might suggest the answer would be “it depends” and that would hold true for all of the cited examples. Clayton MacKay, DVM, Veterinary Consulting
An ethicist’s commentary on pursuing all diagnostic possibilities One of my human physician friends tells the story of being a medical student working in the emergency room of a large city hospital. It was standard practice for the hospital in those days to have a prominent specialist oversee the emergency room on weekends. On the weekend in question, a very well-known cardiologist was in the role of supervisor. A patient was brought in suffering from pain in the epigastric region and the cardiologist directed the diagnostic procedures. He ordered the full range of tests relevant to a heart attack, and was puzzled when all came back normal. He consulted with an emergency medicine specialist, who examined the patient and pointed out that he was showing all the classic signs of appendicitis! The point is that the cardiologist was programmed to look at everything primarily through a cardiological lens, and thereby missed a panoply of relevant data. I myself experienced a comparable incident when I was suffering great pain in my big toe and visited an orthopedic surgeon whom I had consulted before. Upon examination, he declared that I was suffering from “Morton’s toe,” a neurological problem that he proposed to treat by doing a neurectomy. Wanting to avoid surgery if possible, I consulted a general practitioner who recognized immediately the high likelihood of gout, which indeed turned out to be the case. 814
It is a cliché in both human and veterinary medicine that when one hears hoofbeats, one should think horses, not zebras. Specialists, on the contrary, are programmed to seek out zebras. Additionally, the general practitioner very often knows facts about the patient or client that are relevant to normal diagnosis and treatment, for example how likely the client is to adhere to a therapeutic regimen. When a human or animal patient is brought in suffering from chills, fever, vomiting, diarrhea, anorexia and similar common symptoms, the general practitioner is not obliged to think Ebola or Marburg virus, even though those diseases represent a theoretical possibility. The point is that in the situations cited in this case, the veterinarians diagnosed and treated based on probability and likelihood. Dogs vomit fairly regularly and at will. Dogs cough and calves go off feed for a multiplicity of reasons. Certainly, in the case of the calf, if rabies is common in the area, it would be reasonable to exclude it at the outset. But failing such an unusual condition, veterinarians do the reasonable thing based on common conditions resulting in the symptoms. Imagine a client’s response if a veterinarian would prescribe a full cardiac workup for a dog with a cough, or rabies testing for a calf who has just gone off feed! CVJ / VOL 57 / AUGUST 2016
CVJ / VOL 57 / AUGUST 2016
all,” he continued, “you need to pay for the diagnostic machinery.” That is an unacceptable way to practice medicine, and if followed, can place veterinary medicine in jeopardy with society. Only when your initial plausible diagnosis fails, is it reasonable to move forward with excluding less likely possibilities. Bernard E. Rollin, PhD
815
V E T E R I N A RY M E D I CA L E T H I C S
General practitioners are responsible for diagnosing probabilities rather than excluding all possibilities, however remote. In all the cases cited in our example, the general practitioner should not be blamed for not finding the correct diagnosis on the first go around. In response to the specific question the case poses, veterinarians being human, and not omniscient, are allowed to make mistakes. I once heard a dean of a veterinary school tell a student not to be afraid to prescribe a wide variety of diagnostic tests. “After
