In veterinary practice, clients often must make treatment choices for their animals, and the decisions they make can determine the outcome of treatment, in that owners can refuse to consent to a treatment option, choose not to follow treatment recommendations, or elect not to pursue any treatment at all.
Clients do not make these decisions alone. Veterinarians work at the interface between owners and their animals and have an important role in the decisions owners make about their animals.1 They inform their clients about examination and test results, provide diagnoses, recommend possible treatment options, and advise on likely prognoses. They have an expertise, trustworthiness, and authority that make clients value their opinions about important and emotional issues.2–4
Veterinarians' roles therefore afford them myriad opportunities to influence their clients' choices. But is exercising such influence legitimate? On the one hand, it could be argued that any influence that benefits patients is acceptable, if not mandatory. But, the doctrine of informed consent suggests that influence is generally unacceptable. The Royal College of Veterinary Surgeons, in its Guide to Professional Conduct, states that veterinarians should “respect [clients'] views” and “recognize that the client has freedom of choice.”5 Similarly, the AVMA, in its Principles of Veterinary Medical Ethics, states that veterinarians “should not engage in fraud, misrepresentation, or deceit.”6
On the other hand, influence could be argued as intrinsically wrong. However, some prominent American ethicists have suggested that persuasion might be acceptable in some cases,4,7 although without suggesting criteria for determining which cases those are. The Royal College of Veterinary Surgeons also adds that “veterinarians must … give due consideration to the client's concerns and wishes where these do not conflict with the patient's welfare.”5
How can a practitioner balance these extreme views? We believe that an approach based on reasonableness can provide a framework for practitioners to decide how much influence is legitimate. Drawing on US, Canadian, and United Kingdom legal precedent and ethical commentary, the present commentary examines possible forms of and reasons for influence and then discusses how conflicts among these reasons might be addressed and describes circumstances when veterinarians may or may not legitimately influence a client.
Influence
To understand influence better, consider a model of how owners make choices about treatment options (Figure 1). This model suggests ways in which veterinarians might influence various aspects of clients' decision making (Figure 2).
Steps in the client decision-making process.
Citation: Journal of the American Veterinary Medical Association 237, 3; 10.2460/javma.237.3.263
Forms of influence veterinarians can have over the client decision-making process.
Citation: Journal of the American Veterinary Medical Association 237, 3; 10.2460/javma.237.3.263
Weak methods of influence include the minimal influence that is inevitable, given that medical communication is unavoidably rhetorical, during any veterinarian-client communication.8,9 Veterinarians cannot avoid giving some information concerning topics such as pain, suffering, risk, and euthanasia. Indeed, such information is so central to the practice of veterinary medicine that not mentioning such topics would also influence clients. At the same time, veterinarians may influence clients accidentally through, for example, body language, the order in which they present options, phrasing, and unconscious repetition. This inevitability makes the question not whether influence is acceptable, but whether stronger methods of influence are acceptable.
Stronger methods of influence include persuading owners by giving personal opinions10 or engaging in joint11–13 or guided14,15 decision making. Other methods include providing prompts and reminders to encourage compliance16 or alter owners' evaluation.2 Even stronger methods include manipulating emotions (eg, by causing embarrassment or guilt) and manipulating information (eg, by withholding information or dishonesty).17,18 Extreme methods of coercion include threatening harm or force, such as cessation of treatment or prosecution.19 Withholding options is arguably the strongest form of coercion.
Several values come into play in clinical practice, and negotiating the interests of patient, owners, and the practice is a daily balance for veterinarians.4,20–22 The primary concern for veterinarians is the best interests of the animals, but one may also value the interests of clients or the veterinarian in terms of financial gains, ego, or companionship. One may also consider fulfilling clients' (and animals') choices valuable and, perhaps, consider that veterinarians should have some autonomy. Another value is concern for other animals and the public interest, particularly as this relates to disease prevention and control measures.23 These values can provide reasons for and against influencing clients.
Reasons against influencing clients—Veterinarians have at least a prima facie duty to respect their clients' choices.5,7 This principle is well established in Anglo-American medical ethics17,24 and in the common law of the United States, Canada, and the United Kingdom,25–28 and is based largely on the arguments of enlightenment philosophers such as Immanuel Kant29 and John Stuart Mill.30 In human medicine, respect for a patient's choices applies foremost to the patient's decision making about what happens to his or her own body. Patients have a right to allow breaches to their bodily integrity (eg, when consenting to an operation) that would otherwise constitute battery and to freely make informed decisions.31 In veterinary medicine, similar rights are not afforded to animals and veterinarians do not consider it an issue to influence animals, even through restraint or sedation. This difference is defended by appeal to the differences in decision-making abilities between humans and animals. Humans are considered competent in ways that animals are not.
For humans, the right of self-determination often extends to the individual's property. In business, this may include rights to information,32 against misinformation,33 and against being coerced into uses of property34 (with some exceptions such as taxation). These rights are usually taken to extend to one's animals.35,36 Thus, influencing owners' choices regarding treatment of their animals can be considered an infringement of the right of self-determination.
Another reason against exercising influence over client decision making is the effect this might have on the animals' welfare in the future. If clients do not trust veterinarians, they may be disinclined to seek veterinary advice. This argument is not completely convincing, in that such mistrust might not occur and influence that is done in secret would not adversely affect the trust relationship.
Reasons for influencing clients—The main temptations to exercise influence over clients' decision making come from concerns for the interests of the stakeholders: the veterinarian, the client, and the patient. Concerns for the interests of the veterinarian and the client are not legitimate grounds for exercising influence. Tannenbaum7 has highlighted the illegitimacy of influencing clients for personal profit. But concerns related to cost should not preclude offering the best options.37 Veterinarians should also resist influencing a client into making decisions out of concern for the client's own good. Although veterinarians may be able to claim authority about what is good for the animals in their care, they cannot claim to know better than a competent and informed client which decision is in the client's best interests.38
Legitimate reasons for influencing clients must come from veterinarians' duties to others. First and foremost are concerns for the patients' welfare. In those instances when the veterinarian believes that a client's choices are deleterious to the animal's best interests, achieving an acceptable outcome may require exercising influence over the clients.4 In the human mental health field, some authors argue that exercising influence over certain patients will lead to improved treatment and a better quality of life.39,40 The same might be true in certain aspects of veterinary practice, particularly when the clients' concerns might not be in the patients' best interests.
Solutions
Practitioners therefore face conflicts between reasons for (eg, to ensure patient welfare) and against (eg, to respect client choice) exercising influence over client decision making. One proposed solution to these conflicts is to treat neither set of reasons as absolute and to, instead, find some balance between them.17,41 Unfortunately, this suggestion is not especially helpful.21,42 It works in easy cases, such as when minor influence would prevent severe welfare harms or when major influence would provide minimal welfare benefits, but is too vague to be helpful in deciding a best course for most everyday decisions.43
On the other hand, making decisions based only on concerns for the client's wishes or only on concerns for the animal's welfare is equally unsatisfactory. The option of always respecting clients' wishes would accord with civil law and business ethics but would potentially lead practitioners to allow or cause major welfare harms. For example, it would preclude the option of reporting owners guilty of malicious cruelty. Given that veterinarians have a duty to promote their patients' welfare, this seems an unattractive option.
The option of always prioritizing patient welfare is more appealing44 and, indeed, the apparent position for veterinarians in the United Kingdom. Each must swear an oath that their “constant endeavor will be to ensure the welfare of animals committed to [their] care.”5 Even without this promise, one could argue that one's duties to patients should trump any respect for clients' wishes.
Such a principle would somewhat parallel the legal situation regarding parental choices for their children. Parents generally make decisions about the care given to their children, and these decisions are usually respected by pediatricians. However, doctors may override a parent's choices if doing so is in the best interests of the child.45–47 If, as has been argued, animals are increasingly being treated more like family members than property,48 then the same reasoning could be extended to animals. However, differences exist between the veterinarian's position and the pediatrician's. The possibility of state intervention supports the latter; that is, pediatricians may defer influence to the courts, which can order or forbid certain treatments. In contrast, the possibility of court intervention is available to veterinarians only in those few cases when owners have committed a criminal offense (eg, animal cruelty). This could change if the legal status of the human-animal relationships were to change from one of ownership to guardianship.7,49–51
On the other hand, even if veterinarians could always act in their patients' interests, doing so might not be desirable. This principle would logically entail extreme forms of coercion to secure even minor welfare benefits, such as threatening elderly owners with court cases for failing to brush their animals' teeth.
Fortunately, in some cases, veterinarians can both respect their clients' wishes and ensure animal welfare. This happens, for instance, in situations when respecting the clients' uninfluenced choices better serves animal welfare. Competent owners may make better choices than their veterinarians, especially in terms of quality-of-life assessments, because they know their animals better.52,53 In these cases, minimizing or avoiding influence on the client's choices may actually enhance patient care. Excessive influence can lead to less engagement54 and may lead to quality-of-life issues being missed and patient needs going unfulfilled.55–57 Influenced clients may also reassert themselves later on, potentially reducing compliance.
There are also situations when exerting influence may actually provide greater respect for a client's right to free choice. That is, some influence may enhance both client wishes and animal welfare by empowering clients in their decision making. An obvious example is in giving owners the information they need to make an informed choice. This may be considered as enhancing their ability to make decisions through combating the cognitive shortcoming of ignorance.
Other examples when exerting influence may enhance client decision making by combating cognitive shortcomings are instances when owners have irrational background beliefs (eg, when a client believes that all cancers are fatal, a veterinarian may enhance decision making by not describing a neoplasia as cancer) or irrational background values (eg, when a client has an irrational fear of needles, a veterinarian may omit descriptions of how blood samples are collected). Such cases may necessitate withholding information. Interpreting or highlighting facts may be necessary when owners are unable to interpret information (eg, because of a lack of familiarity with the species). Influencing the decision-making process may be necessary when owners are not competent to make decisions on their own, owing for example to an inability to use information in rational reasoning,58,59 a lack of basic cognitive capacities,27 or their being emotionally overwhelmed by the situation.60 It could be argued that these clients should be influenced to improve their decision making in the same way as informing them enhances their autonomy.
Exerting influence is also defensible when clients explicitly want to be influenced. This is not uncommon; most owners want their veterinarians to share their knowledge and opinions, and many clients want assistance in the interpretation, evaluation, and choice-making steps of decision making. Archetypically, the client asks the veterinarian, “So, what would you do?” Some owners may want to engage in joint decision making, and others may explicitly ask the veterinarian to lead them through the decision-making process. Other owners may want the veterinarian to exert some measure of influence because they wish to avoid the responsibility of making decisions. This may be especially common with complex cases or emotionally involved decisions, such as euthanasia. Owners may also want to be influenced in instances when they want what is best for their animals but need some measure of influence from their veterinarian to make a decision. In extreme cases, owners might want to be influenced as a means to avoid prosecution. Of course, clients should not be influenced into wanting influence.
One could extend these arguments to suggest that influence is legitimate when it helps owners choose what they “really” want. One could consider this in terms of what the owner will want after the event (as in Israeli law concerning medical treatment61). For example, some owners are grateful for having been influenced into making an earlier euthanasia decision. Even though at the time they wanted to keep the animal alive, they are pleased once the decision has been made. In the extreme, one could try to influence clients to choose what they would want if they were better at making choices.18,62,63 However, this is analogous to influencing mental health patients in human medicine64 and is a dangerous strategy that risks potentially harmful abuses of power.65
Finally, there are situations when exerting influence may respect an owner's wishes because doing so prevents a greater influence from another source. This occurs, for example, when another person is unduly influencing an owner, and counteracting this influence may increase the client's autonomy. This would include instances when another layperson, veterinarian, or paraprofessional has influenced an owner. It might also extend to instances when veterinarians suggest that owners obtain a second opinion because they fear they themselves have been excessively influential.
Other situations—This leaves a few situations when the conflict between respect for the owner's wishes and concern for the animal's welfare cannot be reconciled. In these cases, a client's absolute right to free choice can operate insofar as the client is able to make acceptable decisions. When a client chooses an acceptable option, then influence to change the client's mind is inappropriate. When a client chooses an unacceptable option, influence may be justified to help the client make an acceptable decision but not beyond this point.
The problem is in drawing the line between what is acceptable versus unacceptable. One useful suggestion is that acceptable should be considered in terms of reasonableness. Reasonableness should not be defined in terms of whether the veterinarian agrees. It could, perhaps, be defined in terms of consistency of reasoning (eg, the decision is consistent with the owner's own fundamental beliefs and wishes). In practice, however, veterinarians may be unable to elucidate all of a client's reasoning steps. Therefore, it may be more useful to assess reasonableness of a client's choices relative to the decisions other owners have made in similar circumstances. If an owner has made an extreme decision, relative to choices made by others, that is deleterious to the animal's welfare, then the veterinarian may legitimately exercise some influence. This approach would fit with US, Canadian, and United Kingdom legislation, which characterizes owners' welfare duties in terms of what is reasonable.36,49
As a final thought, it could be argued that veterinarians who wish to influence clients should be prepared to provide the treatment free of charge. First, this provides a safeguard against allowing the practice's financial concerns to subconsciously motivate the veterinarian. Second, veterinarians cannot claim authority over how owners spend their money because clients know their own interests better. This argument might, however, be limited to treatments that go beyond reasonable expectations of clients, in that an essential component of animal ownership might be considered to include an obligation to fund reasonably necessary treatment.
Conclusions
In this commentary, we have suggested instances when exerting influence over owner decision making might be legitimate. Exerting influence over client decision making is legitimate only when it is done to respect the client's wishes and ensure animal welfare. It cannot legitimately be done to further the client's or the veterinarian's interests. Importantly, these suggestions only provide general guidance, and specific cases will differ. Thus, practitioners still must engage in reflection, self-examination, and discussion with colleagues.
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