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“We wouldn’t let a dog suffer like this”: What can doctors learn from veterinarians’ experience of euthanasia?

Juliet Duncan (left) is a lecturer in veterinary anaesthesia. She recently completed a part-time PhD investigating undergraduate student attitudes to pain in non-verbal patients.

David Jeffrey (right) is an honorary lecturer in palliative medicine at Edinburgh University. He has recently competed a PhD at Edinburgh exploring empathy in medical students. For correspondence re this article he can be contacted at dijeffrey@btinternet.com

Among supporters for the legalisation of euthanasia some have articulated their feelings as, “We would not let a dog suffer like this”, implying that since euthanasia is an uncomplicated and humane way of disposing of an animal it should therefore be available as a treatment option for human patients who are suffering. However, little thought has been given to the complex feelings and potential burden that performing euthanasia places on individual veterinarians, nor on the conflicting feelings of owner.

Little thought has been given to the complex feelings and potential burden that performing euthanasia places on veterinarians.

Although euthanasia and physician-assisted suicide in humans raise separate moral concerns, there has been little consideration in the literature of the effects on doctors of participation. It is appropriate to consider, from an interdisciplinary perspective, the effects on doctors’ well-being of participating in euthanasia or assisted suicide. The terminology of the debate is often emotive, but for this article, euthanasia is the deliberate administration of medication with the explicit intention of ending a patient’s life (with or without an explicit request). Physician-assisted suicide (PAS) is prescribing or supplying drugs with the explicit intention of enabling a patient to end their life.

Veterinarians’ experience of euthanasia in companion animals

The commonest ethical dilemmas cited by veterinarians in small animal practice include; limiting treatment due to financial constraints, euthanasia of healthy animals, and owners insisting on continued active treatments of terminally ill animals.

Veterinary work is perceived as stressful by over 80% of UK vets.1 The Proportional Mortality Ratio (PMR) for suicide in veterinarians is four times that of the general population and around twice that of other healthcare professionals.2 There are a number of complex interacting factors in this susceptibility to suicide, including; personality, work-related stressors, ready access to means, stigma of mental illness, isolation and drug misuse.

Veterinarians have to balance their ethical duties towards the animal and its owner, which may conflict. Attitudes to death and euthanasia are formed within their work experience of routine euthanasia of companion and production animals. The exposure to the suicide of peers raises the possibility of “suicide contagion”.3 Veterinarians may experience a tension between their desire to preserve life and an owner’s desire to have a healthy pet killed, termed ‘convenience euthanasia’. Bartram suggests they may respond to this pressure by modifying their attitudes to preserving life and come to perceive euthanasia as a positive outcome.3 This altered attitude to death may even lower their inhibition towards perceiving suicide as a solution to their own problems. The veterinary profession, in providing animal euthanasia, may normalise suicide, with death perceived as a rational solution to intractable problems. As Bartram points out, no rigorous studies have interrogated this hypothesis yet.3

The veterinary profession, in providing animal euthanasia, may normalise suicide.

Some veterinarians suffer moral distress as a result of a compromise of one’s professional integrity and obligations and this can engender feelings of professional isolation, low job satisfaction, burnout and a resulting high staff turnover.4 In a recent study of veterinary practitioners, over 70% of respondents described experiencing moderate to severe moral distress as a result of not being able to “do the right thing”.4 When asked about conflict with pet owners over how to proceed, 32% of vets said this occurred “often” and 52% “sometimes”.4 With specific respect to euthanasia, almost 30% of respondents said that they “often” or “sometimes” receive inappropriate requests for the procedure. About 20% of the veterinarians acceded to these requests, 45% admitting moderate distress and 18% severe distress.4

Veterinarians have a legal option of refusing euthanasia in companion animals, although refusal is uncommon.5 In a survey of 58 vets 40 reported wanting to refuse euthanasia but not doing so.5 Reasons for refusal included; healthy dogs, absence of suffering and for the convenience of clients. Some reported being pressured into euthanasia by clients and by other veterinary surgeons. Some respondents never refused a request for euthanising a dog. There were no reports of respondents being pressurised into refusing. It appears there is a one-way pressure toward euthanasia.5 Some respondents commented that their refusal might only mean that the dog will be destroyed by a different veterinary surgeon. These concerns have relevance for doctors who have been reassured that there will be no compulsion to participate in PAS.

Veterinarians have a legal option of refusing euthanasia in companion animals, although refusal is uncommon.

Doctors participating in euthanasia and physician-assisted suicide (PAS).

There is a lack of data about the effects on doctors of participating in euthanasia or PAS. A recent review of the literature identified only nine studies on this topic which met the selection criteria. Most were from the Netherlands or Oregon.6 30-50% of doctors described emotional burden or discomfort about participating in euthanasia or PAS, and a significant persisting impact was reported in 15-20%.6 Participating in euthanasia or PAS conflicted with their perceptions of their professional role, responsibilities and personal expectations.6

A literature review of the emotional and psychological effects of PAS and euthanasia on participating physicians concluded that many doctors described being profoundly adversely affected by their experience.7 There was also evidence of pressure on doctors by some patients to assist in suicide. A Canadian study of participating doctors found that although 66% of doctors had initially expressed willingness to participate in PAS, 60% refused to participate when surveyed 18 months after legalisation, largely due to the emotional and clinical burdens.8 Conversely, some doctors in the Netherlands, participating in euthanasia, feel that they have contributed positively to the quality of the dying process.

An unconscious bias can influence a doctor’s assessment and choice of treatment options offered to patients.

Moral distress in doctors

Clinicians’ perspectives are central to the debate, since proponents of euthanasia and PAS have assumed that doctors should be involved, presenting these interventions as medical treatment options. However, we suggest that as the choice for euthanasia or PAS is often a social issue, doctors might not need to be involved. Research suggests a link between a clinician’s attributes and the wish to hasten death among terminally ill cancer patients.9 An unconscious bias can influence a doctor’s assessment and choice of treatment options offered to patients, sometimes leading to collusion and a failure to explore the patient’s real concerns, or to question their perspectives on the futility of living.

The psychological consequences of adverse patient outcomes on doctors are well documented, reactions which are exacerbated when the clinician has a personal responsibility for a patient’s death or when a patient commits suicide. Some doctors reported feeling lonely, others guilt, reflecting on the responsibility inherent in taking of a life. There appears to be a gap between agreeing with the theoretical concept of euthanasia or PAS and being actively involved in the process.

The experience of veterinarians in carrying out euthanasia in companion animals should give the medical profession pause for thought.

Conclusions

The experience of veterinarians in carrying out euthanasia in companion animals should give the medical profession pause for thought. Veterinarians experience high levels of moral distress which may be implicated in their higher-than-normal risk of suicide. Further qualitative research is needed to elucidate the specific psychological impact on veterinarians of participating in euthanasia in animals. The literature on psychological impact on healthcare professionals involved in euthanasia or physician assisted suicide is scanty. There is a need to address the impact on doctors of carrying out euthanasia and PAS, to review the support available to them and consider the possible consequences for recruitment and training.

References

1. Robinson D, Hooker H. The UK Veterinary Profession in 2006: the Findings of a Survey of the Profession.: Royal College of Veterinary Surgeons; 2006.

2. Mellanby RJ. Incidence of suicide in the veterinary profession in England and Wales. Veterinary Record. 2005;157:415-7.

3. Bartram DJ, Baldwin DS. Veterinary surgeons and suicide: a structured review of possible influences and increased risk. Veterinary Record. 2010;166:388-97.

4. Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: a survey of North American veterinarians. J Vet Intern Med. 2018;32:2115-22.

5. Yeates J, Main DCJ. Veterinary options on refusing euthanasia: Justification and philosophical frameworks. Veterinary Record. 2011;168:263-8.

6. Kelly B, Handley T, Kissane D, et al. “An indelible mark” the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings. Palliative and Supportive Care. 2020;18:82-8.

7. Stevens KR. Emotional and Psychological Effects of Physician Assisted Suicide and Euthanasia on Participating Physicians. Issues in Law and Medicine. 2006;21:187-92.

8. Bouthillier M-E, Opotrny L. A qualitative study of physicians’ conscientious objections to medical aid in dying. Palliative Medicine. 2019;33.

9. Kelly BJ, Burnett PC, Pelusi D, et al. Association between clinician factors and a patient’s wish to hasten death:terminally ill cancer patients and their doctors. Psychosomatics. 2004;45:311-8.

 

Featured image by Jesse Schoff at Unsplash      

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