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Moral distress and euthanasia: what, if anything, can doctors learn from vets?

Felicitas Selter is a postdoc at the Institute for Ethics, History and Philosophy of Medicine at Hannover Medical School.

Kirsten Persson is a postdoc at the Institute for Animal Hygiene, Animal Welfare and Farm Animal Behaviour at the University of Veterinary Medicine Hannover.

Gerald Neitzke is a member of the Institute for Ethics, History and Philosophy of Medicine and the Clinical Ethics Committee at Hannover Medical School.*

Do three more years with a high quality of life justify this therapy, which will be associated with six months of serious discomfort for the patient? …Is it better to choose chemotherapy or to allow ‘natural’ death?”

These and related questions are no longer exclusively associated with human medicine. Many animals, accordingly classified as companion animals, nowadays have the status of family members, and palliative veterinary medicine has caught up enormously in recent years. On these matters, it is worthwhile for veterinarians to take a look at human medicine and clinical ethics. But likewise there are issues where general practitioners and human medicine can benefit from the experience of veterinarians.

The standard good death ideal of small animal practice involves an animal’s euthanasia at the end of its life.1 Small animal practitioners are familiar with euthanasia and grieving family members but also with their own feelings accompanying the act of ending a patient’s life. In the UK and elsewhere, the legalisation of euthanasia or physician assisted suicide (PAS) is currently debated. Examining the effects of killing on the involved physicians with a view to small animal practice, with its decades-long experience in this field, seems therefore sensible.2 We propose elsewhere to approach questions surrounding end-of-life decisions with an eye on both medical and veterinary ethics.1,3 But it is also essential to first consider which experiences from small animal practitioners may be transferrable to general practitioners to begin with.

Considerable moral distress (even suicidal tendencies) regarding animal euthanasia are well documented…

Many vets experience moral distress as a result of not being able to do the right thing, for instance when there is a conflict between themselves and the animal’s owner.4 With regard to end-of-life decisions, the majority of these conflicts fall into one of two categories: either the vet perceives euthanasia as the right thing to do for this pet in this situation but the owner refuses to have their animal killed, or the vet perceives euthanasia as wrong (at least right now) but the owner wants to have their pet immediately killed. Duncan and Jeffrey, in focusing exclusively on the latter kind of conflict, regard this as a “one-way pressure to euthanasia” in the veterinary profession and argue that this is relevant for physicians “who have been reassured that there will be no compulsion to participate in PAS“.2

Moral distress in veterinary medicine

Considerable moral distress (even suicidal tendencies) regarding animal euthanasia are well documented but there is no consensus in the literature on underlying reasons.5,6 Many veterinarians perceive the option to euthanise as a gift they value very highly and in fact as advantageous in comparison to human medicine.7 Findings suggest that whether euthanasia is perceived as a gift, a burden or even a pressure on the part of animal owners depends not least on whether veterinarians feel they are doing the right thing or whether they feel pressured to perform euthanasia against their better judgment.8 This ambiguity – euthanasia has famously been described as “a double-edged sword in veterinary medicine”7 – is only marginally addressed by Duncan and Jeffrey.2 They make it appear as if vets unanimously perceive euthanasia very negatively and as if euthanasia was one major reason for considerate moral distress and higher suicide rates in the veterinary profession. This is an inadequate depiction of current research.

Significant dissimilarities between human and animal euthanasia

Given that there could be cases of medically indicated euthanasia which veterinarians might still perceive as stressful, the controversial hypothesis that the act of killing as such can contribute to moral distress and increased suicide rates in veterinarians might be accepted here, for the sake of the argument. This still does not necessarily correspond to the “gap between agreeing with the theoretical concept of euthanasia or PAS and being actively involved in the process” in human medicine.2 One reason is that, for all their similarities, there also exist considerable dissimilarities between human and companion animal patients.

In veterinary medicine, there is usually no direct access to the patients‘ preferences or consent regarding end-of-life decisions.

In veterinary medicine, there is usually no direct access to the patients‘ preferences or consent regarding end-of-life decisions. Human medicine, on the other hand, cares for patients with different capabilities and capacities to consent. Arguably, how stressful the active termination of a life is perceived depends, among other things, on whether or not the patient is able to make autonomous choices and to consent, i.e. that it is morally relevant for the physician whether their patient is competent, formerly competent with a living will/presumed will or never was competent. If this is accepted, a comparison between euthanasia of humans and animals is only or at least especially meaningful with regard to a very specific group of human patients, namely those who were never able to consent (e.g. small infants or severely cognitively disabled persons from birth). Approaching end-of-life ethics with an eye to these human patients and companion animals would be worthwhile for both doctors and vets, but generalisations should be made very cautiously.

In summary, it can be assumed that in both human and veterinary medicine there exists a discrepancy between a doctor’s belief that euthanasia would be the right thing to do and an emotional discomfort with the actual act. This being said, the discrepancies may very well have different origins or lend themselves to comparison only in very specific cases and patients. It would be too hasty to equate euthanasia with serious moral distress and higher suicidality as a lesson learned from veterinary medicine.

Conclusion

General practitioners and palliative care providers are well-advised to exchange experiences with their colleagues from small animal practices. However, due to the extremely wide range of reasons that can precede animal euthanasia (terminal illness, financial constraints, danger to the public and even mere convenience), it is likely that the emotions associated with euthanasia can be extremely varied. Physicians, unlike veterinarians, are usually dealing with patients who have expressed their wish for euthanasia. Killing humans as such could be valued differently from killing pets. Cases that allow a comparison are therefore limited to the euthanasia of patients who can behaviourally express (dis)approval, but who were never capable of consenting, such as small infants and severely cognitively disabled patients. However, at least in human medicine, this moves the debate very much to the margins and significantly narrows the group of patients suitable for fruitful comparison.

This does not preclude that the act of ending a life itself, regardless of the reasons preceding or accompanying it, may cause significant distress to both physicians and veterinarians or may completely be rejected. It is possible to support euthanasia and PAS (in general or in specific cases) on a purely theoretical level and still feel considerate emotional and psychological distress in the face of actually performing the deed. To our knowledge, however, this has not yet been investigated inter-disciplinarily. For future research, it would be interesting to see whether veterinarians and physicians who have performed euthanasia report similar experiences with regard to the decision-making process and the act of killing, or whether differences can be found and if these (dis)similarities can be mainly attributed to a. different professions or species affiliation, b. context (e.g., dependent on the reasons for or circumstances of the euthanasia), c. the doctor’s character traits or d. other aspects. More in-depth research on these and related matters is doubtlessly needed.

*The authors are working together in a DFG-funded project concerned with end-of-life decisions of human and animal patients.

References

  1. Selter F, Persson K, Risse J, Kunzmann P, Neitzke G. Dying like a dog: the convergence of concepts of a good death in human and veterinary medicine. Med Health Care Philos [Internet]. 2021 Sep 15 [cited 2021 Sep 15]; Available from: https://doi.org/10.1007/s11019-021-10050-3
  2. Duncan J, Jeffrey D. ‘We wouldn’t let a dog suffer like this.’ Br J Gen Pract. 2021 Nov 1;71(712):514–5.
  3. Persson K, Selter F, Neitzke G, Kunzmann P. Philosophy of a “Good Death” in Small Animals and Consequences for Euthanasia in Animal Law and Veterinary Practice. Animals. 2020 Jan;10(1):124.
  4. Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med. 2018 Nov;32(6):2115–22.
  5. Batchelor CEM, McKeegan DEF. Survey of the frequency and perceived stressfulness of ethical dilemmas encountered in UK veterinary practice. Vet Rec. 2012 Jan 7;170(1):19.
  6. Fawcett A. Euthanasia and morally justifiable killing in a veterinary clinical context. In: Johnston J, Probyn-Rapsey F, editors. Animal Death [Internet]. Sydney University Press; 2013 [cited 2019 Oct 8]. p. 205–20. Available from: https://www.jstor.org/stable/j.ctt1gxxpvf.18
  7. Rollin BE. Euthanasia, Moral Stress, and Chronic Illness in Veterinary Medicine. Vet Clin North Am Small Anim Pract. 2011 May 1;41(3):651–9.
  8. Hartnack S, Springer S, Pittavino M, Grimm H. Attitudes of Austrian veterinarians towards euthanasia in small animal practice: impacts of age and gender on views on euthanasia. BMC Vet Res [Internet]. 2016 Dec [cited 2019 Jan 28];12(1). Available from: http://bmcvetres.biomedcentral.com/articles/10.1186/s12917-016-0649-0

Featured image by Patrick Hendry on Unsplash

Ethics of the Ordinary is a regular column on BJGP Life that explores ethical and moral concerns relevant to general practice and primary care.

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Ethics of the Ordinary

Andrew Papanikitas* is deputy editor of the BJGP. He is on twitter @gentlemedic
Peter Toon is a retired GP writer and virtue ethicist
Paquita De Zulueta, is Hon. senior lecturer in medical ethics and law at Imperial College and recently retired GP. She is on twitter @PdeZ_doc
David Misselbrook is senior ethics advisor for the BJGP
John Spicer* is a South London GP, ethicist and medical educator. He is on twitter @johnspicer3
This week’s BJGP Life articles (see bottom of article for what is coming up) will have an ethical or philosophical flavour, as BJGP Life launches a new column: Ethics of the ordinary (EotO) is a regular column that explores ‘ethical and moral concerns relevant to general practice and primary care.’

…so much general practice… involves moral complexity.

There are many reasons why primary care generates ethical and philosophical issues. Patients are likely to be meaningfully autonomous -fully clothed and fully conscious, more empowered to contest medical ideas of best interests and risk.1 Primary care teams look after entire families, and generally do not discharge patients who choose not to comply with their recommendations. They can be left to look after patients deemed ‘untreatable’ by secondary care services.2 They often have a holistic understanding of patients’ backgrounds, life stories and values acquired from longer term relationships built on trust and familiarity. And there is just so much general practice happening out there that involves moral complexity. A patient attends during a full surgery, distraught over a marital breakdown – how much time should you give them? Can this teenager be in a consensual relationship with their few-years-older partner? Should we be motivated by compassion or duty? Should we delay the initial COVID-19 vaccination programme because of possible risks? The issues are as endless and everyday as general practice itself. And it is a poorly kept secret that ethics teaching in undergraduate and postgraduate medical education is often delivered by general practitioners.3
Some cases involve much discussed ‘ethical dilemmas,” such as those concerning abortion or end of life care, or arise from societal or technological changes such as assisted fertility or advances in genomic medicine. But many raise everyday and ordinary issues which are ‘unsexy‘4 from a popular or academic perspective because they are not associated with a new technology, a change in the law or a moral panic. Dramatic and technology-driven ethical issues also clearly affect community and primary care settings. Issues and conflict may also arise in the interface between teams, whether they are located in hospitals or community settings.5
The ethics of the ordinary is a reference to the of issues and decisions found in everyday practice.6,7,8 It may be that the public interest, or academic funding, or political gaze, have moved on. It may be that that undramatic instances still raise moral questions worth answering. EotO relates to all healthcare settings (not just general practice and not just those which are patient-facing).

We called for a body of knowledge and community of scholars to support primary healthcare…

EOTO has also been embodied as a mundane revolution in UK primary care, by groups of British GPs and allied academics in a variety of disciplines. Admiring the relative success of clinical ethics committees in hospitals and national groups9 like the Genethics Forum and the UK Clinical Ethics Network, some set up discussion groups,10 others contacted their local hospital ethics committee with their dilemmas.11 We called for a body of knowledge and community of scholars to support primary healthcare12,13 and ran a series of conferences at the Royal Society of Medicine over a decade, with support from the Institute of Medical Ethics, The University of Oxford and the RCGP.14,15 A large group of us wrote an award-winning handbook of primary care ethics,16 cited in the RCGP curriculum. The BJGP ran an A-Z of medical philosophy – explicitly inviting readers to use the ideas in reflecting on their own professional lives.17 During this period the RCGP committee on medical ethics has been a presence at the RCGP annual conference, running sessions on (inter alia): shared decision-making, part-time working, sponsorship, guidelines and conflicts of interests as well as tackling artificial intelligence and genomic medicine in primary care.18
The references below represent the range and evolution of issues raised, and a collegial community which is far from homogenous in world view and intellectual tradition. You will see familiar authors from past and present, and we invite the wider BJGP and BJGP life community to join us in this discourse. We will include both solicited and reasonably argued unsolicited work in the EotO column. EotO will not shy away from controversial or divisive topics, and collegial discussion in the comments is encouraged. Please ensure that debate is respectful, and founded on reasonable arguments and facts.
What to expect the week commencing 14th February 2022 on BJGP Life:

On Wednesday, Felicitas Selter, Kirsten Persson, and Gerald Neitzke discuss the similarities and differences in animal and human euthanasia as a source of moral distress for the practitioner.
On Thursday, Helen Burn explains that because legalised physician-assisted dying would likely involve GPs, GPs should think about their views on the issue.
On Friday, Matthew Davis and Ana Worthington argue that the arguments in favour of the recent Assisted Dying Bill at its second reading in the UK House of Lords are based on flawed evidence.
On Saturday, Koki Kato introduces us to phenomenology as an approach to understanding patient-centred care, using his own illness-experience as a worked example.
On Sunday Samar Razaq reflects on truth, medical opinion and the scholarship in the age of Twitter.

All this week’s BJGP Life articles have been recently independently submitted (none were commissioned). We hope that they generate discussion and collegial debate.
References
1. Brody H. The essence of primary care, p. 56-61 in The Healer’s Power. New Haven: Yale University Press. 1992
2. Pellegrino E. The healing relationship: the architronics of clinical medicine, in Shelp EA, ed. The clinical encounters: the moral fabric of the patient-physician relationship. Reidel, Dordrecht 1983
3. Misselbrook D (2012) The BJGP is open for ethics. Br J Gen Pract, DOI: https://doi.org/10.3399/bjgp12X629964
4. Butcher F (2011), The appeal of ‘unsexy’ ethics, https://wellcome755.rssing.com/chan-8434298/latest-article2.php (accessed 12/2/22)
5. Wiles K et al, Ethics in the interface between multidisciplinary teams: a narrative in stages for inter-professional education, London J Prim Care (Abingdon). 2016; 8(6): 100–104. doi: 10.1080/17571472.2016.1244892
6. Papanikitas A and Toon P, Last but not least: the ethics of the ordinary, Br J Gen Pract, 2010; 60 (580): 863-864. https://bjgp.org/content/60/580/863.full
7. Cyril et al, Ethics of the ordinary: a class response, Br J Gen Pract, 2012; 62 (595): e143-e146. DOI: https://doi.org/10.3399/bjgp12X625283
8. Gardner J et al, Emerging themes in the everyday ethics of primary care, Clinical Ethics 2011; 6 (4):211-214 doi: https://doi.org/10.1258/ce.2011.011034
9. Peile E. Supporting primary care with ethics advice and education, BMJ, 2001; 323(7303): 3–4. doi: 10.1136/bmj.323.7303.3
10. Evans Patel G, King A, and Spicer J, Healthcare ethics: learning in the workplace, Work Based Learning in Primary Care 2006; 4: 57–64 https://www.researchgate.net/publication/321318915_Healthcare_ethics_Learning_in_the_workplace accessed 12/2/22
11. Sokol D (2009), Who wants to be the flu GP? http://news.bbc.co.uk/1/hi/health/8135658.stm (accessed 12/2/22)
12. Papanikitas A, Toon P. Primary care ethics: a body of literature and a community of scholars? Journal of the Royal Society of Medicine. 2011;104(3):94-96. doi: https://doi.org/10.1258/jrsm.2010.100353
13. De Zulueta P. (2008) Welcome to the ethics section of the London Journal of Primary Care London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2008.11493183
14. Papanikitas A, et al. (2011) Ethics of the ordinary: a meeting run by the Royal Society of Medicine with the Royal College of General Practitioners. London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2011.11493331
15. Papanikitas A et al, 4th annual primary care ethics conference: ethics education and lifelong learning London J Prim Care (Abingdon). 2014; 6(6): 164–168. doi: https://doi.org/10.1080/17571472.2014.11494369
16. Jewell D, Brave new ethics, Br J Gen Pract 2019; 69 (681): 200. doi: https://doi.org/10.3399/bjgp19X702053
17. Misselbrook D (2013) An A-Z of medical philosophy. Br J Gen Pract, doi: https://doi.org/10.3399/bjgp13X660841
18. Papanikitas A. (2016) Education and debate: a manifesto for ethics and values at annual healthcare conferences. London Journal of Primary Care 8:6, pages 96-99. https://doi.org/10.1080/17571472.2016.1244152
Featured image: From the classroom to the clinic, by Andrew Papanikitas

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