Clinical ethics consultation in a tertiary care veterinary teaching hospital

Christopher A. Adin Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Jeannine L. Moga Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Bruce W. Keene Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Callie A. Fogle Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Heather R. Hopkinson Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Charity A. Weyhrauch Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Steven L. Marks Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Rachel J. Ruderman North Carolina School of Science and Mathematics, Durham, NC 27705.

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Philip M. Rosoff Veterinary Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.
Departments of Pediatrics and Medicine, the Trent Center for Bioethics, Humanities and History of Medicine, and the Duke University Medical Center, School of Medicine, Duke University, Durham, NC 27710.

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Rapid advances in critical care techniques and life-sustaining measures in the late 20th century led many large human hospitals to encounter ethical dilemmas regarding end-of-life issues, decision-making capacity, clinical futility, and responsible use of resources. Human hospitals are now required to have an established protocol for addressing these ethical dilemmas, and the vast majority have created clinical ethics committees that are available to provide ethics consultations on request. Recent medical advances available at veterinary specialty hospitals have given rise to similar ethical dilemmas in the care of both small and large animal species, and such dilemmas are a major source of moral distress among veterinarians and staff members. In this report, we describe established methods for ethics consultation in human hospitals and outline the formation of a veterinary clinical ethics committee in a large tertiary referral hospital.

In response to increasingly complex medical technology, particularly the ability to maintain biological life in the face of otherwise fatal disease, and after several widely publicized court cases concerning end-of-life decision-making, ethics committees and ethics consultation services have become commonplace in human hospitals.1,2 Indeed, the Joint Commission, the accrediting body for health-care organizations in the United States, has required since the early 1990s that hospitals have mechanisms to resolve ethical dilemmas. These committees are now widespread and are generally accepted as a component of the services available to clinicians and human patients in this country.3–5

Rapid advances in the level of medical care available at veterinary referral centers have created a situation that is analogous to the developments in human health care in the 1970s. Veterinary clinicians are frequently faced with having to guide their clients and staff through decisions involving complex and expensive interventions for terminal patients, use of artificial ventilation, end-of-life care, and other issues of clinical futility.6 As the human-animal bond has intensified, many secondary and tertiary veterinary referral centers have recognized the importance of going beyond the physical care of their patients and have integrated social workers to attend to the psychosocial needs of their clients, who often have grief, guilt, and even clinical depression associated with stewardship of animals with major illnesses.7

It is important to distinguish clinical ethics from the animal welfare or professional ethics training that is now required in the veterinary professional curriculum.8 Clinical ethics has been defined as “a practical discipline that provides a structured approach to assist physicians in identifying, analyzing and resolving ethical issues in clinical medicine.”9 Aside from the potential legal implications of decisions related to end-of-life care and pet owners' rights, lack of specific experience and education in ethical decision-making among staff of veterinary practices is a major contributor to the high level of work-related stress.10 Of course, unique to veterinary practice is the unassailable fact that clients own their animals and hence exercise real property rights that, except for issues concerning humane treatment, are virtually unfettered.11–13

Thus, whereas veterinary medicine is replete with ethical problems that are unique to its praxis as well as those that it shares with its human counterpart, veterinarians are not taught a formal approach to the clinical ethics dilemmas that they face on a daily basis. Similarly, veterinarians and veterinary specialty hospitals are only now beginning to develop formal approaches to confronting and solving ethical challenges at an institutional level. The ultimate purpose of clinical ethics committees is to aid in guiding clinicians and clients through those instances when there is a conflict over the moral approach to a particular clinical scenario. In the present report, the established process of clinical ethics consultation in human hospitals is described and an initiative at the North Carolina State University Veterinary Hospital to create a clinical ethics committee and consultation service modeled on those in human medicine is outlined, with the intent to provide structure for a framework for clinical ethics discussions in large veterinary specialty hospital environments.

Development and Standardization of Human Clinical Ethics Committees

Ethics consultation services first emerged in larger human hospitals in the 1970s, when technological advances fueled debate about end-of-life care and the definition of biological life in human intensive care units.14 As techniques for clinical ethics consultation became established in the United States, a national consensus statement was issued in an attempt to standardize the methods for ethics consultation in human hospitals.15 Simultaneously, it became clear that individuals engaged in ethics consultation required specific knowledge, skills, and attributes, which were first outlined as core competencies for health-care ethics consultation by a task force from the American Society for Bioethics and Humanities in 1998 and have been updated over time to fit with the modern medical and legal environments in human health care.16 The Veterans Healthcare Administration has taken a leadership role in assembling the current standards and guidelines for clinical ethics consultation in an online primer.14 In 2007, a random survey of US hospitals revealed that formal processes for clinical ethical consultations were available at 81% of 519 human hospitals and at 100% of hospitals with > 400 beds, with an estimated 36,000 ethics consultations performed in the United States each year.3

Composition of Ethics Committees

Ethics consultations can be performed by individuals, teams, or committees; however, the personnel involved must have the collective knowledge and skills to provide effective recommendations. Clinical ethics consultation requires a diverse set of knowledge and skills, which includes understanding of not only the ethical issues at hand but also the medical and mental health conditions of the patient, available treatments, organizational structure within the hospital, and methods for compassionate communication, consensus building, and leadership. Because it is difficult for a single individual to have strengths in all of these areas, teams or committees are typically composed of individuals from a variety of backgrounds that can jointly supply the required expertise as they work together to outline ethically acceptable alternatives. Committees in human hospitals are reportedly composed of physicians (34%), nurses (31%), social workers (11%), chaplains (10%), and administrators (9%), with the remaining 4% representing philosophers, theologians, attorneys, or laypersons.3 The leader of the team must be aware of the various competencies and strengths of the team members. Prior to engaging in ethics consultation, team members should receive specific training in medical ethics and in the processes involved in effective ethics consultation. Training of new committee members can be accomplished in-house by group review of previous ethical consultations as case studies to provide exposure to common ethical issues and facilitate review of available training resources.14 Hospital leadership have to recognize and support the time commitment that staff must dedicate to participation in an ethics consultation service and make the appropriate adjustments to cover gaps in clinical or administrative duties.

Methods for Clinical Ethics Consultation

Clinical ethics consultations should be performed in a structured manner to maintain consistent, high-quality service. The so-called CASES (an acronym derived from clarify the request, analyze the information, synthesize the recommendation, explain the synthesis, and support the consultation outcome) method14 outlined by the Veterans Healthcare Administration is widely used to guide teams through the process of ethics consultation (Appendix 1). A key step in initiating an ethics consult is to identify and clarify the ethical question that is to be addressed for a given case. A common yet often overlooked part of this process is rapid identification of questions or concerns that are not appropriate for consideration by the ethics committee, such as legal disputes, medical questions, requests for mental health interventions, or accusations of misconduct. Such considerations should instead be referred to the appropriate support team. A common misconception is that the clinical ethics team will supposedly “tell the requester what to do” or “clean up a mess”; instead, the ethics team must make it clear that its role is to provide unbiased options that are ethically acceptable, serving through consultation rather than through stepping in to take charge of a case.3,15 Once a clear ethical issue has been identified, construction of an ethics question typically would involve juxtaposition of the opposing views that led to the consultation request. For example, a question might arise regarding what are the ethically appropriate options for involved participants when the client believes X but the clinician believes Y.14 After establishing the central ethics question to be addressed, the consulting team is tasked with assembling the information necessary for the case, including a review of the medical record, relevant data regarding outcomes for the medical condition, and investigation of resources on medical ethics in the clinical field of interest. This process would typically involve meeting with interested parties such as clinicians, nurses, family members, friends, and the patients themselves in an attempt to gain insight into all perspectives on the current ethical question. The synthesis stage of the consultation is when ethical analysis and debate of moral issues is performed among the committee members, encouraging creativity and openness in discussions while reminding the participants that it is important to focus on evidence and data (eg, survival rate among patients with this condition) instead of opinions (eg, lack of belief that this patient will survive). Approaches to ethical analysis are varied, but 1 commonly used method involves principalism as described by Beauchamp and Childress17 (Appendix 2). Once a recommendation is constructed, it is time for a representative of the committee to explain that recommendation to the involved parties. Written recommendations can be included in the medical record as part of the legal documentation associated with the case, whereas notes or internal communications associated with the committee may be maintained as separate documents.

Formation of a Veterinary Ethics Committee

Social workers typically provide additional support to help inform veterinary hospital administrators and staff members in issues related to emotional welfare. In our hospital, one of the authors (JLM) recognized that veterinarians and staff were increasingly approaching her with issues that extended beyond a need for psychosocial support of clients and that centered on an ethical dilemma that was being faced by the health-care staff. In an effort to address this need for support of clinicians faced with ethical dilemmas in our institution, the chair of a well-established clinical ethics committee in a large human hospital (PMR) was contacted to provide guidance on the structure and function of clinical ethics committees in a health-care environment that is becoming increasingly similar to that faced by veterinary specialists and their staff.

Although it may appear simple to establish a clinical ethics committee and ethics consultation service at a large academic tertiary-care veterinary hospital by replicating the procedures that are now commonplace throughout US human hospitals, there are unique aspects to veterinary medicine and the organization and operation of animal hospitals that present distinctive challenges. For any human or animal hospital, the foremost consideration relates to the administrative structure of the institution and the fact that any attempt to organize such a committee must fit within the mission statement and goals set forth by those charged with directing the overall functioning of the hospital. In the case of veterinary hospitals, such a venture is precedent setting and often requires considerable political and social finesse to convince a potentially skeptical group of leaders about the potential value of an ethics committee. It is vitally important to have at least 1 strong-minded proponent among institutional leaders who can guide the process. At our hospital, it was the Director of Medical Services and Associate Dean (SLM) who provided the required impetus for formation of the committee.

Through a series of preliminary meetings with the hospital director and with other key stakeholders, including the governing hospital board, we were given permission to create the committee with its initial purview being clinical consultation and education of staff and students. A selected solicitation for members was undertaken, with the goal of attaining broad representation of the clinical constituencies that would be served. Initially, members of the committee included 4 veterinary faculty members, a social worker, and 3 veterinary technicians from both large and small animal specialties. Currently, we are attempting to engage our community and envisage the addition of 1 or 2 community representatives who would provide input but would not be directly involved in consultative work. The committee members underwent an initial training period involving supervised reading and mock review of internal cases with oversight by an experienced expert in human ethics consultation (PMR). Finally, the committee's purpose and scope were announced internally to faculty and staff through brief presentations at faculty meetings, and a formal consultation process was created in late 2016. In the first 8 months that the committee was formally in operation, we performed 8 consultations regarding both large and small animal patients in a variety of complex situations and provided ethically acceptable alternatives within 8 hours after the initial request for all cases. To date, qualitative evaluation of the committee's function has been very positive; with time, it will be interesting to analyze reasons for consultation and feedback from requestors.

Ethical Challenges Unique to Veterinary Practice

As our Veterinary Clinical Ethics Committee venture has progressed, it has become apparent that there are a number of factors that are unique to veterinary practice and that will therefore require novel approaches to ethics consultations, compared with the well-developed processes associated with such consultations in human medicine. Issues prompting ethics consultation in a tertiary referral hospital involve many different species and clinical specialties yet have several common features. Selected examples of cases that have been referred for ethics consultation by our committee are summarized (Appendix 3) to illustrate some of the unique factors.

The business side of veterinary medicine

Physicians caring for human patients have been concerned about the increasing commercialization of medicine for some time. With the recent emphasis on patients as customers or consumers of health care and with the availability of fee-for-service selling of medical interventions, the human health-care industry has evolved into a huge business, accounting for approximately 20% of the United States' gross domestic product.18 Veterinarians, however, have been involved in the commercial side of animal health care since the very inception of the profession. Veterinarians well know that the owners of animals—be those pets or animals of commercial value—are clients and that their animals are patients, with the caveat that any one of those animals can be a patient only at the request of the client. In veterinary practice, there is an ever-present potential for what can be difficult-to-resolve tension between provision of services to clients (the customer owners of property) and the duties owed to sentient animals (the patients). Of course, the necessity to address often complementary, but sometimes competing, obligations is not a unique feature of veterinary practice. However, the recurring clash between the needs and desires of the client with those of the patient are perhaps highlighted most starkly in animal health-care settings and can result in wrenching ethical dilemmas for veterinary practitioners. Human patients are always the primary focus of the medical profession's directive to provide benefit and do no harm, even though this dictum is sometimes honored in the breach. Furthermore, human physicians are bound to advance the interests of their patients and serve as their advocates. Animals in the care of veterinarians exist in a variety of socioeconomic situations that can influence the manner in which they are viewed both by the veterinary profession and by society. These situations only sometimes consider an individual animal as a patient, although always view them as living, sentient creatures capable of suffering both physiologically and psychologically.

Functions of animals

Interactions with human patients occur in a variety of settings (eg, hospitals, outpatient clinics, and nursing homes), and the patients themselves have variable cognitive abilities, ranging from developing intellectual capabilities in normal infants and children to dementia in elderly persons. But irrespective of the capacities or potential capacities of individuals, their moral status is relatively static. Whether they communicate for themselves or are unable to do so and must have others speak and decide for them, they remain distinctly special in the sense that their moral standing is entrenched and inherent upon them as members of the species Homo sapiens. The moral status of animals is dependent on the degree to which we consider them more or less different from ourselves, which is broadly based on our perception of their cognitive abilities. In general, the status of animals is believed to be less than that of humans, especially in law. However, there are those who argue that this limited-view speciesism is incoherent and thus animals should be accorded moral respect on the basis of a more generalizable standard.19 That being said, nonhuman animals remain a form of property—albeit living property—that can be bought, sold, traded, and even killed at will. This singular status creates ethical problems in veterinary medicine that are unique and distinct from those in human medicine.

Unlike human physicians whose patients are people, veterinarians have patients that are animals of numerous species with their distinct and often sui generis clinical requirements and other needs; moreover, they are encountered in a much greater number of distinctive clinical and physical situations, which can have profound implications for the types and broad range of care they require and receive. Not surprisingly, the wide array of settings can also affect the ethical challenges faced by veterinarians and their colleagues. For example, animals in zoos that are maintained for perhaps both exhibition and species conservation engender singular ethical questions that are poles apart from those for companion animals. Similarly, animals that are used for research or food or that are commercially valuable (eg, Thoroughbred racehorses or pedigreed dogs) can generate potentially unique ethical challenges determined in large part by their relationship to the humans that own and make use of them. A veterinary specialty hospital will inevitably have to confront the difficulties associated with each of these situations. Therefore, a clinical ethics committee must be prepared to cope with and manage the potential disputes and disagreements regarding case management that can arise among concerned parties.

Animals as property

Arguably, the most complex ethical problems with which veterinary health-care workers must contend find their origin in the legal status of animals as chattel property. Derived from the old French word chattel, referring to cattle or livestock, it can also be specified as “a movable possession; any possession or piece of property other than real estate or a freehold.”20 Thus, the word applies to living creatures (nonhuman animals and, in some parts of the world, people) as well as to inanimate objects. Depending on the laws in effect in the jurisdiction where the chattel property resides (with its owner), the manner with which the owner can treat and dispose of his or her property can be more or less restricted. For example, assuming that an owner of a nonliving object—a piece of furniture or automobile, perhaps—has complete title of possession, then the owner can transfer that title to another or even destroy the object insofar as he or she obeys any laws or rules that regulate the transaction. Similarly, owners of nonhuman animals enjoy analogous powers of possession that are additionally subject only to laws governing humane treatment, including the appropriate and acceptable manner of killing the animal at the owner's discretion. This kind of almost-absolute authority over the life and death of sentient beings can lead to disagreements between veterinarians or veterinary technicians and owners who want to pursue a course of action that is counter to the expert recommendations of health-care workers.21 Although some have argued that nonwild animals, especially those kept as pets, should enjoy a higher-ranking status than mere chattel (albeit, living) possessions, and despite various jurisdictions that have legislatively begun to refer to animal owners as guardians, the fact remains that animals continue to legally exist as property.22,23

The influence of money

Intimately associated with the status of animal patients as property is the overwhelming and often dispositive influence of money on veterinary medical decision-making.24,25 This is not to say that the practice of human medicine is not also dependent on, or impacted by, financial considerations of one sort or another, simply that those considerations tend to be of a different nature. Despite the relatively high percentage of people without health insurance in the United States, most patients have some form of health insurance that shields them from the immediate financial impact of medical decision-making. In our experience at a university human medical hospital, even uninsured persons rarely forgo critical treatments and other interventions, despite the economic consequences they may face. Moreover, physicians (and hospitals as entities) have a professional duty to treat all patients, irrespective of their ability to pay, even if this ethical obligation may be less obviously obeyed except in emergency situations when federal law commands that they do so.26 In all of these aspects, the influence of money in human medicine is very different from that in veterinary medicine.

Given the fact that health insurance for animals remains relatively uncommon in the United States (exceptions include those animals of great commercial value), owners are personally liable for the costs of health care for their property, and this can have profound effects on the type and scope of diagnostic and therapeutic interventions they are willing (or able) to financially bear.26 Although humans can also be at risk of forgoing potentially lifesaving or curative treatment because of a lack of funds,27 animal owners' pecuniary interest in the health and welfare of their animals can range from the calculated and personally prudential viewpoint (as might be the case for farm animals raised for food) to possible sacrifice of individual fiscal well-being to initiate or continue treatment (as might be the case for companion animals) to a cold calculus (as might be involved in requests for so-called convenience euthanasia). These facts place veterinary health-care workers in ethically challenging situations in which their duties to their patients may (and often are) easily overridden by the fact that owner disposition of their property (albeit living and sentient) is virtually unfettered, except for restrictions on maltreatment and the imposition of unnecessary suffering. Indeed, numerous legal cases regarding animals have arisen from conflicts over monetary interests and from lack of consensus as to who should be the decision-makers when there are disagreements about treatment.28 The nature and frequency of these financial conflicts are likely related to the veterinary practice type; primary care providers are frequently faced with performing euthanasia when clients are unable to afford the cost of advanced care for their animals, whereas specialists at tertiary referral institutions may often feel coerced to perform futile procedures on animals when motivated pet owners have unlimited financial resources (Appendix 3). However, all veterinarians in clinical practice will likely encounter ethically challenging situations in which end-of-life decisions are influenced by financial resources, even when animals have treatable conditions. This leads to the question of whether euthanasia of a plausibly salvageable animal patient is morally reasonable when the only obstacle is money.

Because most veterinary care in the United States is provided under a fee-for-service form of reimbursement, there are also potential personal financial conflicts of interest that may arise when veterinarians make recommendations for various interventions. Although similar challenges exist and have engendered analogous concerns and abuses in the human medical field given the third-party health insurance system, most patients are directly shielded from the monetary costs (however, not the physiologic costs) of such conflicts of interest.29–31

Responsibilities of owners of animals

The responsibilities of owners of animals is another important issue that constantly confronts veterinarians. The question is whether owners who have undertaken the responsibility of caring for a living, sentient creature have thereby accepted a binding duty to provide a minimum of appropriate health care for their charges (property) beyond that required by laws and regulations regarding minimal animal welfare and protection from cruel and abusive treatment. Some have argued that this is indeed the case, and that such a duty is inherently demanded by the owner-animal relationship that forms the basis of ownership (or guardianship, as some would have it),32 although at least 1 state court has ruled otherwise.33 Several states have laws that seem to require that owners obtain at least some form of veterinary care for their animals that is sufficient to prevent or minimize suffering.34 Of course, there are many kinds of animal-human relationships, and it would seem excessive to demand an owner of a farm animal that is being raised for food (a relationship judged by some to be almost purely financial) to assume the same duties and provide the same type and scope of veterinary care as those expected of an owner of a companion animal. Indeed, a similar analysis can be made for human relationships where people are expected to display both more caring and care for those individuals directly close to them, such as relatives and good friends, than that displayed for strangers. It would seem odd, if not absurd, to argue that individuals have a moral duty to personally ensure provision of health care to people unknown to them (aside from efforts resulting from collective action, such as a national health insurance scheme funded by taxes levied on the general public) and with whom the only association might be a shared species membership. This is not to say that fellow humans should not expect to receive care and medical treatment, simply that we as individuals are not necessarily directly accountable for such provisions. In an analogous manner, an individual's duties toward care for his or her own animals would be greater than they would be for someone else's animals. However, it is not unreasonable to suggest that empathy for the suffering of animals imposes some modest moral requirements on veterinary health-care providers regardless of their relation to the animals' owners (ie, themselves, relatives, acquaintances, or strangers). This aspect of moral responsibility can be manifested in various clinical situations, ranging from evaluating the quality of life of a horse with advanced laminitis to assessing treatment of a terminal cancer patient that is perceived to be suffering.35–37

Moral value of animals

Compared with humans, animals are generally placed on a lower moral plane. Even within the animal kingdom, there is a tendency to create ordinal rankings of the moral worth of creatures, both between and within species, depending upon animal-human relationships. In addition, different human cultures view animals differently and this directly influences the manner in which they are treated or are permitted to be treated. In North America and Western Europe (and undoubtedly other places), nonferal dogs and cats are typically regarded as companions and, in many instances, are considered members of families. In other parts of the world, they may be considered nuisances, pests, or even sources of sustenance. Similarly, horses may be pets, working animals, highly valued sports animals, or even livestock depending on the circumstances in which they live, their relationship to the humans who own them, and the social practices of the society in which they reside.

The Need for Veterinary Ethics Committees and Ethics Consultations

The myriad medical and social challenges in veterinary medicine, some of which have been outlined in the present report, raise important ethical concerns that are centered around the fundamental questions of what is the right thing to do and what should veterinary professionals do, all within the confines of applicable laws and the professional duties of veterinarians and allied health workers. Navigating these kinds of quandaries while understanding the impact a decision can have on the patient, the patient's owner, and the personnel caring for them both can be extraordinarily onerous. Indeed, in both the veterinary and human medical fields, these situations are a major cause of moral distress and burnout for individuals who are constantly attempting to cope with pressure of doing the “right thing” or feeling powerless to do so.10,38–40 There is good evidence from the human medical literature that effective ethics consultation can relieve or diminish many of these stressors and promote better patient (and family) care.41–46

Initial Impressions of the Veterinary Ethics Committee

Although the initial success in establishing a veterinary ethics committee and initiating a consultation service (albeit a slow-growing one) at the North Carolina State University Veterinary Hospital was evident, we continue to be cognizant of the challenges that remain. These include the difficulties attendant on initiation of any novel endeavor introduced into a culture that may be inherently suspicious of unfamiliar processes and wary of individuals who may be perceived as a form of so-called ethics police.47 Demonstration of the anticipated value of ethics consultation in a veterinary hospital setting will undoubtedly be an uphill struggle. The individuals performing the ethics consultations were selected on the basis of their backgrounds and expertise, and a corollary challenge is to promote acceptance of the authenticity and authority of their advice. This is especially demanding because the members of the committee have other better-known and recognized roles in the organization; hence, assuming the additional mantle of an ethics consultant can engender confusion and suspicion. In regard to the more established human ethics consultations, there has been a long-standing movement to credential consultants, thereby validating their knowledge and skills; such a strategy would also be ideal in veterinary medical settings in the future.48,49 In the meantime, members of the committee have embarked on formalized clinical ethics education activities that include guided readings of the relevant literature and role-play exercises to gain experience in facilitating consultation and to acquire the core competencies of ethics consultants, as described by the American Society for Bioethics and Humanities.16,50 Finally, the committee continues to explore ways in which it can be of service to the various members of the hospital community, mostly through educational outreach and possible extension of the committee's role to include policy initiation and review for the hospital administration.

Creation of an ethics committee in a veterinary specialty hospital was a novel venture, but one that we believed to be long overdue. With the increasing complexity and escalating costs of veterinary medical and surgical care, both the breadth and depth of what can be done for (and to) animals are conflicting more and more frequently with questions about what should be done. Undoubtedly, differences of opinion about these important issues will result in disputes regarding the best course of action or, as seems often to be the case in human medicine, the least undesirable approach. However, letting clinical controversies conclude on their own (as almost all do with sufficient time) can be deeply dissatisfying to all involved. Whether the expected outcome is achieved or not, the availability of an operating mechanism for ethics consultation has been very positive in relieving stress for staff and house officers who previously felt alone in their moral distress when dealing with challenging situations. Handling of such cases in a manner that is ethically acceptable, morally sound, and agreeable to all interested parties may require a facilitated approach, which has been shown to be successful in the human medical arena.

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  • 27. Laurentine KA, Bramstedt KA. Too poor for transplant: finance and insurance issues in transplant ethics. Prog Transplant 2010;20:178185.

  • 28. North American Specialty Insurance Company v. John Paul Pucek, David Fogg, Brett Setzer, and Robert L. Edwards. F 3rd: United States Court of Appeals, 6th Circuit, 2013;1179.

    • Search Google Scholar
    • Export Citation
  • 29. Emanuel EJ, Ubel PA, Kessler JB, et al. Using behavioral economics to design physician incentives that deliver high-value care. Ann Intern Med 2016;164:114119.

  • 30. Schroeder SA, Frist W. Phasing out fee-for-service payment. N Engl J Med 2013;368:20292032.

  • 31. Shih T, Chen LM, Nallamothu BK. Will bundled payments change health care? Circulation 2015;131:21512158.

  • 32. Coleman P. Man['s best friend] does not live by bread alone: imposing a duty to provide veterinary care. Anim Law 2005;12:731.

  • 33. People v. Arroyo. NYS2d: Criminal Court, City of New York, Kings County, 2004;836.

  • 34. Crimes Relating to Animals; Abuse or Neglect of Animal, Subtitle 6, Section 10–604. Maryland Criminal Code. US, 2010.

  • 35. Rollin BE. An ethicist's commentary on the case of a client who won't euthanize a suffering foal. Can Vet J 2000;41:830831.

  • 36. Rollin BE. Oncology and ethics. Reprod Domest Anim 2003;38:5053.

  • 37. What is acceptable? Vet Rec 2015;176:87.

  • 38. Henrich NJ, Dodek PM, Alden L, et al. Causes of moral distress in the intensive care unit: a qualitative study. J Crit Care 2016;35:5762.

  • 39. Whitehead PB, Herbertson RK, Hamric AB, et al. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh 2015;47:117125.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40. Tran L, Crane MF, Phillips JK. The distinct role of performing euthanasia on depression and suicide in veterinarians. J Occup Health Psychol 2014;19:123132.

  • 41. Wocial L, Ackerman V, Leland B, et al. Pediatric ethics and communication excellence (PEACE) rounds: decreasing moral distress and patient length of stay in the PICU. HEC Forum 2017;29:7591.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42. Akabayashi A, Slingsby BT, Nagao N, et al. An eight-year follow-up national study of medical school and general hospital ethics committees in Japan. BMC Med Ethics 2007;8:8.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43. Bruce CR, Peña A, Kusin BB, et al. An embedded model for ethics consultation: characteristics, outcomes, and challenges. AJOB Empir Bioeth 2014;5:818.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 44. Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998;26:252259.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45. Schneiderman LJ. Effect of ethics consultations in the intensive care unit. Crit Care Med 2006;34:S359S363.

  • 46. Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med 2000;28:39203924.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47. Smith ML, Weise KL. The goals of ethics consultation: rejecting the role of “ethics police”. Am J Bioeth 2007;7:4244.

  • 48. Fins JJ, Kodish E, Cohn F, et al. A pilot evaluation of portfolios for quality attestation of clinical ethics consultants. Am J Bioeth 2016;16:1524.

  • 49. Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants: a two-step model from the American Society for Bioethics and Humanities. Hastings Cent Rep 2013;43:2636.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50. American Society for Bioethics and Humanities. Core competencies for healthcare ethics consultation. 2nd ed. Glenview, Ill: American Society for Bioethics and Humanities, 2011.

    • Search Google Scholar
    • Export Citation

Appendix 1

The CASES approach to clinical ethics consultation in human medicine.

ActionDescription
Clarify AssembleObtain initial information and identify the ethics question. Collect and summarize information related to the patient's medical condition, the patient's wishes, the clinician's and staff's opinions, and ethical resources related to the question.
SynthesizePerform ethical analysis and debate potential ethically appropriate options within the committee.
ExplainShare the ethical analysis and options with the requestors, producing a written record of the consultation and the committee's recommendations.
SupportObtain feedback on the consultation process and use this to improve future ethics consultation service.

Modified from the National Center for Ethics in Health Care. Ethics consultation: responding to ethics questions in health care. 2nd ed. Washington, DC: US Department of Veterans Affairs, 2015;1–56.14

Appendix 2

The 4 principles of bioethics.

PrincipleExplanation
AutonomyAssuming consciousness and intellectual capacity, the patient (or animal owner) has a right to decide his or her own (or owned animal's) fate.
BeneficenceWe must act in the best interest of the patient.
Nonmaleficence“First, do no harm”; we must avoid causing harm to the patient.
JusticeWe have a duty to treat all persons equally and to provide others with their fair share; as a caveat, we must avoid overburdening any individual.

Modified from Beauchamp TL, Childress JF. Biomedical ethics. 7th ed. New York: Oxford University Press, 2012;57–272.18

Appendix 3

Selected examples of veterinary ethics consultations undertaken by the clinical ethics committee and consultation service initiated in 2016 at the North Carolina State University Veterinary Hospital.

Case informationEthical issuesCommittee's recommendations and outcome
A juvenile ruminant with malnutrition and osteopenia was rescued from a hoarding situation. One fractured pelvic limb had recently been amputated. The animal was reexamined because of fracture of the contralateral pelvic limb. The client requested amputation of the affected limb and fitting of the animal for a cart. Ample funds were available through the rescue organization, but the clinician was unwilling to perform the procedure on the grounds of ethical objections.Quality of life, futility, and treatment boundariesAffirmation that bilateral pelvic limb amputation is an atypical procedure in a ruminant and quality of life woud be a concern.

Confirmation that established hospital policy allowed refusal of service when an atypical procedure is requested.

Provision of guidance regarding presentation of options to client, with strong recommendation for euthanasia after summarizing the ethical concerns.

Outcome: the client requested euthanasia after discussion with clinical team.
A diagnosis of cancer had recently been made for a giant-breed dog. The dog was expected to survive for 3 to 5 months. On examination, the dog was nonambulatory and had signs of severe pain secondary to diskospondylitis. Bacteria collected from aspirate of the affected intervertebral disk space were resistant to all safe-to-use orally administered antimicrobials, and signs of pain did not improve after IV treatment with analgesics and antimicrobials for 4 days. The clinician and staff were concerned about the dog's level of pain and extremely poor long-term prognosis.Quality of life, futility, and treatment boundariesAffirmation of poor long-term prognosis and inability to relieve animal's pain with medical treatment.

Development with clinician of 2 ethically acceptable treatment options (surgical stabilization of the verbral column to relieve pain or euthanasia) and establishment of a 48-hour time limit for decision.

Outcome: after 48 hours, the dog's signs of pain and neurologic status were unimproved. The client declined treatment but wanted to continue medical care. At 72 hours, the dog's condition remained unimproved and the client agreed to euthanasia.
A geriatric cat with asthma of several years' duration and more recent lung lobe consolidation developed life-threatening dyspnea that was not responsive to supplemental oxygen administration. The cat was referred for ventilator treatment. Sepsis and multiple organ dysfunction were being managed, but the cat remained dependent on the ventilator following 2 attempts to discontinue its use over a 72-hour period. Intensive care unit staff were concerned that cat was suffering.Allocation of resources, futility, and treatment boundariesAcknowledgment of the potential for suffering when an animal is weaned from ventilator support, although the cat was kept unconscious while receiving artificial ventilation.

Recommendation to set treatment boundaries and a time limit with agreement to undertake 1 additional attempt to wean the cat from the ventilator after 24 hours. If unsuccessful, offer conversion to hospice care with discontinuation of ventilator support and administration of antihypotensive agents, but continuation of propofol treatment to prevent patient suffering.

Outcome: the client agreed to the plan. The cat failed to respond to weaning from ventilator support and later died in owner's lap while receiving the propofol infusion. Use of the term “allow natural death” was important to resolution because the client was opposed to euthanasia or CPR.

Contributor Notes

Address correspondence to Dr. Adin (adinc@uf.edu).

Dr. Adin's present address is Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610.

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    • Search Google Scholar
    • Export Citation
  • 29. Emanuel EJ, Ubel PA, Kessler JB, et al. Using behavioral economics to design physician incentives that deliver high-value care. Ann Intern Med 2016;164:114119.

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  • 36. Rollin BE. Oncology and ethics. Reprod Domest Anim 2003;38:5053.

  • 37. What is acceptable? Vet Rec 2015;176:87.

  • 38. Henrich NJ, Dodek PM, Alden L, et al. Causes of moral distress in the intensive care unit: a qualitative study. J Crit Care 2016;35:5762.

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    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40. Tran L, Crane MF, Phillips JK. The distinct role of performing euthanasia on depression and suicide in veterinarians. J Occup Health Psychol 2014;19:123132.

  • 41. Wocial L, Ackerman V, Leland B, et al. Pediatric ethics and communication excellence (PEACE) rounds: decreasing moral distress and patient length of stay in the PICU. HEC Forum 2017;29:7591.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42. Akabayashi A, Slingsby BT, Nagao N, et al. An eight-year follow-up national study of medical school and general hospital ethics committees in Japan. BMC Med Ethics 2007;8:8.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43. Bruce CR, Peña A, Kusin BB, et al. An embedded model for ethics consultation: characteristics, outcomes, and challenges. AJOB Empir Bioeth 2014;5:818.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 44. Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998;26:252259.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45. Schneiderman LJ. Effect of ethics consultations in the intensive care unit. Crit Care Med 2006;34:S359S363.

  • 46. Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med 2000;28:39203924.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47. Smith ML, Weise KL. The goals of ethics consultation: rejecting the role of “ethics police”. Am J Bioeth 2007;7:4244.

  • 48. Fins JJ, Kodish E, Cohn F, et al. A pilot evaluation of portfolios for quality attestation of clinical ethics consultants. Am J Bioeth 2016;16:1524.

  • 49. Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants: a two-step model from the American Society for Bioethics and Humanities. Hastings Cent Rep 2013;43:2636.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50. American Society for Bioethics and Humanities. Core competencies for healthcare ethics consultation. 2nd ed. Glenview, Ill: American Society for Bioethics and Humanities, 2011.

    • Search Google Scholar
    • Export Citation

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