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Stepping up to the plate : animal welfare, veterinarians, and ethical conflicts Morgan, Carol Anne 2009

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STEPPING UP TO THE PLATE: ANIMAL WELFARE, VETERINARIANS, AND ETHICAL CONFLICTS by Carol Anne Morgan DVM, The University of Saskatchewan, 1988  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Interdisciplinary Studies)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2009 © Carol Anne Morgan, 2009  Abstract Veterinarians are often viewed as protectors of animals and veterinary organizations are quick to affirm that their member veterinarians value and promote animal welfare. Yet veterinarians sometimes appear to fail in their responsibility to promote the welfare of animals. Examples of this seemingly incongruous behaviour include conducting unnecessary medical procedures, failing to report animal abuse, or failing to mitigate pain and suffering during and/or after surgical procedures. To understand how veterinarians make decisions in situations where they are confronted with conflicting responsibilities to patients and clients, interviews with 41 veterinarians and observations of ten veterinarians practicing in Western Canada were conducted. Veterinarians in this study held diverse beliefs about what constitutes animal welfare, animal owners’ responsibilities concerning animals, and professional responsibilities within the veterinarian-client-patient relationship. They also used different methods to assess patients and clients against these belief structures. A significant finding of this research is that different veterinarians construct moral problems differently thereby creating diverse interpretations of ethically challenging situations. Participants also described providing preferential care to patients and clients who they assessed positively. Furthermore, participants voiced concerns about financial repercussions, lack of credibility in the community, and frustration with the animal protection authorities should they try to intervene on behalf of their patients. Understanding how veterinarians construct moral dilemmas, their decision-making in these situations, and the obstacles that hinder the promotion of animal welfare is important for the veterinary profession. This research underscores the importance of increased dialogue amongst members of the profession to clarify further their ethical responsibilities to clients and patients. It also highlights the need for animal protection systems that support veterinarians in their responsibilities to promote animal welfare and to mitigate animal pain and suffering.  ii  Table of Contents Abstract ...................................................................................................................... ii Table of Contents ...................................................................................................... iii List of Tables ............................................................................................................. vi List of Figures ........................................................................................................... vii Acknowledgements.................................................................................................. viii Dedication.................................................................................................................. ix Chapter 1:Thesis Introduction.................................................................................... 1 Thesis Goal ............................................................................................................ 1 Veterinarians as Protectors of Animals .................................................................. 2 Veterinary Responsibilities..................................................................................... 4 Competing Responsibilities.................................................................................... 6 Ethical Inquiry and Social Sciences Research ....................................................... 7 Chapter 2:Methods .................................................................................................. 11 Methodological Approach..................................................................................... 11 The Research Question ....................................................................................... 13 The Researcher as the Research Instrument ...................................................... 14 Study Design........................................................................................................ 16 Analysis of Data ................................................................................................... 24 Reporting Results................................................................................................. 26 Validity and Trustworthiness ................................................................................ 27 Limitations............................................................................................................ 27 Chapter 3:Veterinarians’ Conceptions of Welfare and Evaluations of Patients........ 29 Defining Animal Interests ..................................................................................... 30 Assessing Patient Welfare ................................................................................... 38 Evaluations of Individual Patient Attributes .......................................................... 49 Discussion............................................................................................................ 56 Conclusion ........................................................................................................... 64 Chapter 4:Veterinarians’ Assessments of Their Clients........................................... 65 Veterinarians’ Expectations of Client Responsibilities to Animals ........................ 65 Client Categorization............................................................................................ 71 Influences of Client Categorization on Decisions ................................................. 77  iii  Discussion............................................................................................................ 87 Conclusion ........................................................................................................... 93 Chapter 5:Veterinarians’ Views Regarding Their Professional Role ........................ 95 Views about the Veterinarians’ Role .................................................................... 97 Prioritizing the Interests of Patients and Clients ................................................... 99 The Importance of Client Autonomy................................................................... 102 The Importance of Information Disclosure ......................................................... 106 Discussion.......................................................................................................... 111 Conclusion ......................................................................................................... 122 Chapter 6:Veterinarians’ Constructions of Moral Problems and Moral Reasoning 124 Review of Veterinarians’ Views .......................................................................... 124 Construction of Moral Problems ......................................................................... 126 Reasoning Processes ........................................................................................ 134 Discussion.......................................................................................................... 141 Conclusion ......................................................................................................... 148 Chapter 7:Factors Hindering Veterinarians from Promoting Animal Welfare ......... 149 Concerns about Poor Animal Protection Laws and Enforcement....................... 149 Concerns about Credibility ................................................................................. 152 Conflicting Obligations to Employers and Colleagues........................................ 154 Concerns about Economic Health...................................................................... 155 Discussion.......................................................................................................... 157 Conclusion ......................................................................................................... 160 Chapter 8:Thesis Conclusions ............................................................................... 162 How do Veterinarians Make Decisions?............................................................. 162 Why do Veterinarians Appear to Fail to Promote the Welfare of Animals? ........ 164 Social Science Contribution to Normative Veterinary Ethics .............................. 166 Important Problems, Potential Solutions, and Possible Research Avenues....... 168 Conclusion ......................................................................................................... 177 References: ........................................................................................................... 179 Appendices............................................................................................................ 193 Appendix I – UBC Ethics.................................................................................... 193 Appendix II – Letter of Recruitment (First Phase) .............................................. 196 Appendix III – Letter of Recruitment (Second Phase) ........................................ 198  iv  Appendix IV – Consent Form (First Phase)........................................................ 200 Appendix V – Consent Form (Second Phase) ................................................... 202 Appendix VI – Information Pamphlet for Employees/Clients .............................. 205 Appendix VII – Interview Questions ................................................................... 206  v  List of Tables Table 1 Summary of participant demographics ..........................................................19 Table 2 Characteristics of the Information Provider Model ........................................114 Table 3 Characteristics of the Service Provider Model ..............................................115 Table 4 Characteristics of the Animal Advocate Model.............................................116 Table 5 Characteristics of the Client Advocate Model ..............................................116 Table 6 Comparison of Professional Models ............................................................118 Table 7 Different decision pathways veterinarians might use when asked to provide castration without anaesthesia. ..........................................................................130  vi  List of Figures Figure 1 Example of transcript coding ........................................................................25 Figure 2 Construction of moral problems in the veterinary-client-patient relationship.127 Figure 3 Interactions between beliefs and assessments. ..........................................131  vii  Acknowledgements This project was a long time in the making. I would like to thank my doctoral committee for their support, thoughtful review, and most of all their patience. Many thanks to my primary supervisor Michael McDonald who willingly volunteered to oversee this rather unique project and who provided ongoing insight, wisdom, and guidance with an even and gentle manner. I would also like to thank David Fraser for his dedication to clarity of thought by identifying the underlying problems in my sometimes muddled thinking and for his valiant attempts to teach me grammar and punctuation; Susan Cox for her commitment to trying to keep my methodological plumb line plumb, and for trying to rewire (I think successfully) my reductionist positivist brain into one of a qualitative researcher; and finally, I would like to thank Peter SandØe for his apparent ability to read my mind when my writing lacked clarity and refinement. I am very thankful to have had such a talented and supportive group assisting me. Both the W. Maurice Young Centre for Applied Ethics and the UBC Animal Welfare Program are incredible places to learn, grow, and interact with faculty, visiting scholars, and students. I would also like to thank all of my study participants for without their contribution this research would not be possible. They willingly gave me time out of their busy practices lives. They made me think. I know that I appreciate their assistance and I believe that other members of the veterinary profession will also benefit from their words. Lastly, I would like to acknowledge the support of my family and friends, in particular Wilf Krutzmann and Kathleen McInnis, and my graduate student colleagues who all listened when I complained. My experience at the University of British Columbia would not have been nearly so positive without the humour and efficient assistance of Janice Matautia, the Interdisciplinary Studies Graduate Program administrative assistant.  viii  Dedication  For Chris and all the others, for reminding me of what really matters.  ix  Chapter 1: Thesis Introduction The public often regards veterinarians and the veterinary profession as animal healers, protectors, and defenders of animal welfare. This viewpoint is integrated into policies and procedures involving the use of animals. For example, the Canadian Council on Animal Care requires that a veterinarian sit on all institutional animal ethics committees and help institutions in fulfilling their responsibilities to mitigate pain and suffering in experimental animals.1 When the welfare of individual animals is brought into question, Canadian provincial animal protection legislation commonly directs responsible agencies to seek the opinion of a veterinarian to assess the animal(s). Animal sporting organizations frequently require event organizers to hire a veterinarian to examine animal athletes in order to ensure that they are healthy enough to compete in the event. Veterinarians are seen as a brake, tempering the use of animals and ensuring their appropriate care. Veterinary associations give support to this position by declaring their professional responsibility to promote the welfare of animals.2,3 Yet veterinarians perform procedures that are harmful to animals or perform them in a manner that reduces patient welfare. Veterinarians perform cosmetic procedures, such as ear cropping, that provide little or no benefit to the patient. Many veterinarians also fail to provide post-operative analgesics for routine surgical procedures.4-7 Veterinarians refrain from reporting instances of animal abuse even when they believe that they are morally obligated to do so and sometimes resist attempts to entrench this felt obligation into legislation.8 At times, the notion of the beneficent veterinarian promoting the welfare of animals appears to differ from the way veterinarians actually act. Thesis Goal In order to understand why veterinarians sometimes appear to fail in their responsibility to promote animal welfare, this dissertation explores how veterinarians make decisions about the care of their patients. In particular, I investigate instances where there is tension between the interests of a veterinary client (as perceived by the veterinarian) and the interests of the veterinary patient.  1  Veterinarians fulfill many roles in society including working for governmental agencies in regulating food safety, research facilities, academic institutions, and in private practice. These differing roles present distinct ethical challenges which require veterinarians to balance their professional responsibilities. However, this research focuses only on situations involving veterinarians in private practice, who make their living by providing services to individual animal owners. Even within this subset, veterinarians may experience conflicting responsibilities to parties outside the veterinarian-client-patient relationship. For example, veterinarians have a responsibility to the public to uphold food safety regulations and the responsibility to maintain client confidentiality. These responsibilities might compete when a veterinarian diagnoses an animal with a disease that may affect human health. Many types of conflicting responsibilities may occur in veterinary medicine. However, this dissertation focuses on animal welfare and veterinarians’ (sometimes) conflicting responsibilities within the veterinarian-client-patient relationship. In addition to exploring how veterinarians make decisions at the hub of these conflicting responsibilities, this dissertation also describes how the actual practices of veterinarians can sometimes deviate from the conception of veterinarians as animal healers. In part, my awareness of this discrepancy between actions and ideals is based on personal practice experience (described in Chapter 2). Furthermore, the veterinary ethics literature, although limited, also demonstrates that there is no shortage of ethical challenges in veterinary medicine.9-15 Through the thoughts and experiences of veterinary practitioners, this dissertation documents instances in which veterinarians appear to deviate from their role as promoters of animal welfare. Veterinarians as Protectors of Animals Veterinary organizations declare that member veterinarians should value and promote animal welfare. Both the Alberta and British Columbia Veterinary Medical Associations include in their mission statements avowals of promoting animal well being. The Saskatchewan Veterinary Medical Association states, “it is the responsibility of each member to provide his [sic] patient with the best possible veterinary care”.16 In 2004, the Canadian Veterinary Medical Association (CVMA) adopted a version of the veterinary  2  oath that includes a promise to promote animal welfare, an addition that sets it apart from the American Veterinary Medical Association’s version.17 Veterinary associations also develop positions and codes that guide veterinarians on how to promote animal welfare. The CVMA develops animal welfare position statements in part to guide veterinarians18 and to “suggest the opinion that a right-thinking member of the profession would hold”.19 For example, some of its position statements stipulate that cosmetic surgery is unacceptable, that anaesthesia and analgesia should be routine for surgical procedures performed on farm animals over 1 week of age, and that animal abuse should be reported to an appropriate authority.20 In a recent symposium on veterinary ethics convened by the American Association for the Advancement of Science, speakers suggested that veterinarians have a “duty of being an advocate for pets” and that food animal practitioners have “a responsibility to the animal, to be its advocate when advising the owner on the best care for its health and welfare”.21 Rollin14 estimates that over 90% of veterinarians embrace what he calls the “new social ethic for animals” which allows the use of animals but affords them certain protections or rights based on their innate needs. Interpretations of this consensus ethic include certain proscriptions and prescriptions such as that veterinarians should not perform cosmetic surgery, that they should report instances of animal abuse, and that they should use appropriate anaesthesia and analgesia for painful procedures.14 Nevertheless, 69% of British Columbian veterinarians surveyed admitted to performing tail docking on puppies, mostly without the use of anaesthesia or analgesia.  22  In one  survey 88% of respondent veterinarians reported that they had treated an animal that they suspected was the victim of animal cruelty but only 27% of respondents had ever reported a case of suspected abuse to legal authorities.23 Only 10% of veterinarians strongly agreed that veterinarians should have a legal obligation to report deliberate animal abuse, and only 5.5% strongly believed that veterinarians should be legally required to report animal neglect.8 In a study of veterinary students planning to practice in food animal medicine, 29%, 26% and 23% agreed that hot iron branding was humane for cattle, small ruminants, and pigs, respectively.24 Why do members of the profession continue to perform cosmetic procedures, resist attempts to mandate animal abuse  3  reporting, or believe that hot iron branding is humane when the veterinary profession professes to promote the welfare of animals and to mitigate pain and suffering? Veterinary Responsibilities Members of a profession are considered different from other members of society in that they have ‘professed’ or pledged to uphold the societal ‘good’.25 Koehn25 says that professionals “act morally and consequently have authority if and when they abide by the terms of their publicly made pledges” and that these pledges “commit professionals to furthering an end which is genuinely good”.25 Koehn’s Aristotelian approach focuses on role-defined ‘ends’ for professionals. Veterinarians’ public pledges, such as the veterinary oath, create expectations in the eyes of the public and individual clients with respect to veterinarians’ ‘ends’ and the ‘good’ that the veterinary profession provides. These expectations are based on assumptions of how veterinarians should act. Coupled with formal veterinary ethical tenets declared by the profession, these societal expectations create veterinary responsibilities. Bayles26 argues that professionals have responsibilities to three main groups: 1) clients and employers, 2) colleagues and the profession, and 3) third parties including members of the public at large.26 One difficulty in applying this framework of obligations to veterinary medicine is that the treatment and moral standing of veterinary patients is the source of profound debate.27 Some philosophers suggest that it is nonsense to speak of moral claims for animals at all since animals lack moral standing.28,29 Furthermore, social scientists have noted that perceptions of the moral importance of animals appears to fluctuate30,31 depending on the context of the human-animal relationship, and that human-animal interactions are plagued with ambiguity and ambivalence.13,32,33 Disagreement over the moral importance of animals, and inconsistency in the treatment of animals, make interpretations of veterinarians’ responsibilities difficult. Thus, veterinarians are pulled in different directions in their dayto-day interactions with clients and patients. Nevertheless, Rollin14,34-37 claims that society shows increasing concern for the treatment of animals and that this necessitates veterinarians’ serious consideration of the interests of animals. More importantly to this research, through the professional tenets described above, the veterinary profession  4  agrees that veterinarians at least have responsibilities concerning animalsi if not responsibilities directly to animals.38,39 The same organizations that promulgate the notion that veterinarians are beneficent promoters of animal welfare also require veterinarians to consider the interests of clients. Professional codes provide veterinarians with significant detail regarding their obligations to clients. Veterinarians should be honest, fair, and candid with their clients.38 Once entering into a veterinarian-client-patient relationship, veterinarians owe clients duties to 1) obtain informed consent, 2) charge fair fees, 3) provide follow-up care, 4) create proper medical records, 5) safeguard medical records, 6) disclose medical records appropriately, 7) provide an appropriate standard of care, 8) avoid conflicts of interest, 9) maintain adequate facilities, and 10) appropriately supervise employees.40 These responsibilities are owed to both patients and clients although clearly some of these are pertinent only to veterinary clients. In particular, the obligation to obtain informed consent must be owed to the client rather than the patient. According to the BCVMA Code of Ethics s. 36 “Every member’s duties to the client include at all times the duty to obtain informed consent as the services to be provided to a patient, by providing the client with the information including advice, reasonably required to enable the client to make informed choices concerning the health care of their animals”.38 Members must also “inform the client in clear terms of the nature of and reasons for the services recommended and provide as appropriate, an estimate of the fee for the same” (BCVMA Code s. 38).38 Veterinarians must also be “forthright, objective and impartial in serving their clients” (BCVMA Code s. 35).38 Taken together, these duties place a significant emphasis on client interests. To use the language of biomedical ethics, these tenets require veterinarians to respect their client’s autonomy relative to decisions regarding animals. i  Although some veterinary organizations clearly state that veterinarians have responsibilities to animals or to patients, a more appropriate term may be ‘responsibilities concerning animals’. As most animals are unable to make claims on their own behalf, it is difficult to argue that veterinarians have direct responsibilities to animals. In a similar situation, a pediatrician may not have duties to an infant but duties concerning an infant, because an infant is not the sort of entity that can make a claim. A pediatrician may have a duty to the infant’s parents or to society to protect the interests of the infant. As such, veterinarians have responsibilities to veterinary clients and the public at large concerning the beneficent treatment of animals. However, I will, at times, refer to ‘responsibilities to patients’ for simplicity sake.  5  Bayles 26 maintains that professionals must remain autonomous themselves and in doing so they must balance their obligations to clients, colleagues, and the public; in other words, professionals should not blindly follow the instructions of their clients. In order to maintain their professional position, veterinarians must consider all of their obligations, including responsibilities concerning patients, and then act appropriately. How should veterinarians manage situations of competing responsibilities? Competing Responsibilities Conflicts can occur when the interests of the client (either explicitly stated or assumed) and those of the patient differ and the veterinarian feels divided loyalties.41 Veterinarians routinely face situations where they are “called upon to serve as an advocate of both parties’ (owner’s and animal’s) interests, even when these interests conflict” 11 because there are occasions when clients may wish to manage or treat their animals in ways that do not conform to the veterinarian’s conception of patient welfare. Rollin describes the tension veterinarians feel in serving both patient and client as the “fundamental question in veterinary medical ethics”.14,37 Competing responsibilities to patients (to promote animal welfare) and to clients (to respect client autonomy) can give rise to moral concern for clients, professionals, and those members of the public concerned about animal well being. Competing responsibilities create what many refer to as veterinary dilemmas.10,13,42,43 ‘Dilemmas’, as reported in veterinary ethics literature, may include requests by clients to perform unnecessary procedures (cosmetic surgeries); requests to perform procedures that are harmful, painful, or stressful to the animal (e.g. dehorning and castration of cattle); requests for euthanasia of healthy animals; breaking client confidentiality to protect animals; and refusal by or inability of clients to provide the necessary resources (e.g. financial, time commitment) for care of patients, to name a few. ‘Dilemmas’, as defined in the biomedical ethics literature, are conflicts between responsibilities or obligations of equal moral weight.44 In a broader sense, ‘dilemma’ relates to a difficult choice due to contextual factors such as reprisals from clients or loss of income. For example, a veterinarian may know that a client engages in dog fighting  6  but chooses not to report the client to authorities because she worries that the client may retaliate or she may lose contact with the client, thus preventing further medical care to the dogs. Ethically, the obvious course of action is to report the client to the authorities. This obvious ethical solution is reflected in the fact that dog fighting contravenes the Animal Cruelty section of the Criminal Code of Canada.45 Beyond legal proscriptions, veterinarians are ethically responsible to reduce animal suffering.17,46,47 Condoning dog fighting diametrically opposes this responsibility. Although an ethically correct solution is at hand, practical, sometimes self-interested, concerns confound right action. Nevertheless, pragmatically, veterinarians worry about the actual consequences of calling humane authorities especially given that these cases are difficult to document and prosecution is often unsuccessful. Although a clearly correct course of action exists, veterinarians may find themselves seeking other alternatives. This dissertation explores how veterinarians make decisions in situations where there may be a more clearly correct course of action but that action is difficult to take (practical dilemmas); it also explores situations that are normatively less clear (moral dilemmas). Ethical Inquiry and Social Sciences Research With the use of social science methodology, this dissertation explores veterinarians’ views about competing responsibilities to promote animal welfare and to respect client autonomy. Descriptive ethics is research aimed at eliciting an “accurate depiction and articulation of opinions and practices of a moral nature, as these are exemplified in the customs, mores, practices, traditions and ideologies of groups and individuals,”48 whereas normative ethics “involves the making of moral judgements – judgements about right and wrong action”48 based on theoretical ethics. However, debate continues regarding the relationship between descriptive and normative ethics in applied situations such as medical ethics.49 Hoffmaster 50 proposes that moral decision-making should come from a ‘ground up’ approach, that is one that focuses on local knowledge acquired through social science research – a more descriptive ethics approach. Contextual features of a situation are more important than the application of theoretical principles.  7  However, Zussman 49 argues that Hoffmaster’s views on the importance of social science research, in particular ethnography, blurs the lines between descriptive and normative ethics. Zussman suggests that social scientists frequently hold unacknowledged normative assumptions, and that applied ethicists suffer from a lack of facts that are normally gathered by empirical research. Instead of favouring one approach over another he argues that applied medical ethics has “the ability to import into medicine a set of ethical standards that are not native to the occupational and organisational cultures of medicine”.49 Thus, combining the two disciplines allows descriptions of the views, attitudes, beliefs, and processes of individuals or populations to inform ethical analysis. In turn, Solomon  51  suggests that there are 10 ways that social science research  informs ethical analysis. In other words, the descriptive ‘is’, obtained through empirical research of moral beliefs and views, can inform the normative ‘ought’. She categorizes social science contributions into three groups. Firstly, she suggests that social sciences contribute to bioethics by “facilitating the move from ethical analysis to ethically justifiable behaviour”.51 She further delineates this first category as research that informs ethical analysis by 1) “documenting gaps between espoused ideals and actual practice,” 2) “revealing the nature of individual moral reflection and level of personal skill at ethical analysis,” 3) “describing the institutional and environmental context that mediates moral action” and/or, 4) “providing data to stimulate individual and institutional moral accountability.” She suggests that these contributions of social science research “can make bioethics more effective.” Secondly, she argues that social science research can enhance ethical analysis and justification by highlighting the relevance of moral principles in a given context and by testing the accuracy of consequentialist claims made in normative ethical arguments. Thirdly, social science research can generate new normative concerns or provide clarification to already acknowledged moral problems. Zussman and Solomon offer compelling reasons to explore the beliefs, views, and practices of medical practitioners, through social science research, as contributions to bioethics. It is my belief that social science research can offer similar benefits to  8  veterinary ethics. Through empirical exploration of veterinarians’ decision-making processes, this dissertation highlights normative aspects of veterinary practice that should be useful to practitioners and the veterinary profession. This dissertation adds to the currently small collection of social science studies that touch on veterinary ethics (see 13,30,52-61) and moral reasoning research (see 62-67) focusing on the veterinary profession. I am not aware of any literature detailing how veterinarians actually describe their own decision-making in situations where they have conflicting responsibilities to clients and concerning patients. In the chapters that follow, I present social science research aimed at informing normative veterinary ethics. This research provides descriptive data on how veterinarians negotiate these conflicting responsibilities and offers a framework for how veterinarians frame moral problems. By embarking on this exploratory research, I plan to touch on Solomon’s first and third category of contributions. This research contributes to the move between ethical theory and ethically justified behaviour and it also highlights new normative concerns. Chapter 2 provides a description of the research methods employed. In Chapter 3, veterinarians’ views about animal welfare and the importance of life and death are presented, including their thoughts about methods to assess welfare. These views form a significant part of how veterinarians recognize a situation as being morally important. This chapter also describes how veterinarians sometimes assess the merits of individual animals and how these assessments influence how they handle decisions. Chapter 4 describes how veterinarians assess their clients and make decisions based on these assessments. Chapter 5 explores veterinarians’ beliefs about their professional roles and presents four models to explain how veterinarians characterize the importance of their responsibilities to clients and patients. Data presented in these three chapters (Chapters 3 – 5) form the basis for Chapter 6. In this chapter, I will present a theoretical framework explaining the processes that veterinarians use when constructing and resolving moral problems. Beliefs about what constitutes the welfare of patients (Chapter 3), beliefs about the responsibilities of clients (Chapter 4) and beliefs about professional role and responsibilities (Chapter 5) all influence how veterinarians frame moral problems.  9  Finally, Chapter 7 explores practical factors inhibiting veterinarians from acting on their moral beliefs – what Solomon describes as institutional or environmental context mediating moral behaviour. Each of these results chapters combines descriptive material as well as highlighting normative elements. The concluding chapters describes the professional, social and ethical implications of this research and offers some potential direction to resolve problems raised throughout the dissertation as well as suggestions for future research.  10  Chapter 2: Methods Throughout my practice life, I have found that veterinarians respond in very different ways to situations involving competing responsibilities to clients and patients. I became curious to understand why individuals with similar educational backgrounds responded so differently to a similar practice situation. Why would one veterinarian accede to a client’s request and release a dog suffering from a fractured femur without any treatment, when another veterinarian would not tolerate such an approach? Instead, she might threaten to call the humane authorities if the client did not either agree to euthanize the patient or pursue surgical repair? Was this simply a difference in clinical judgment or were other factors involved? This chapter outlines the methodology I employed to understand veterinarians’ decisions. Methodological Approach To understand how veterinarians make decisions in ethically challenging situations, research methods should enable the researcher to uncover knowledge that is grounded in the practitioner’s experience. This type of information is difficult to obtain in survey format particularly when the range of decision pathways and permutations are currently unknown. Practitioners may come to a similar decision but reach the decision through very different paths of justification. Although two practitioners may refuse to cropii dogs’ ears, one practitioner’s refusal is vested in moral beliefs about animal integrity, whereas the other practitioner’s primary concern is for her reputation should the procedure fail. Two very different motivations for refusal to perform the procedure end in the same result. For this reason, the outcomes of decisions (data often obtain by survey studies) are an inadequate proxy to understand how veterinarians actually make such decisions. By contrast, qualitative methods offer a more nuanced approach. The use of qualitative methods “enables us to make sense of reality, to describe and explain the social world, and to develop explanatory models and theories”.68 Qualitative methods are particularly useful “when little is known about a phenomenon, when the investigator suspects that the present knowledge or theories ii  Ear cropping is a surgical procedure performed for cosmetic reasons involving cutting away a portion of the ear flap or pinna in order to make the ear stand erect.  11  may be biased, or when the research question pertains to understanding or describing a particular phenomenon or event about which little is known”.68 Although there are a number of interesting studies on veterinary decision-making, there is very little research regarding veterinary moral decision-making and even less about moral decision-making relating to resolving situations of conflicting professional responsibilities. Several descriptive studies have been conducted. A Dutch study used questionnaires to elicit veterinarians’ opinions and decision factors regarding moral problems.52 This study used structured surveys with predetermined categories to study veterinarians’ views about factors involved in ethical decisions in veterinary practice. Respondents rated categories such as pain, health, well being, and integrity as factors in their decisions. In addition, the authors also explored the perceived importance of common ethical issues in veterinary medicine such as convenience euthanasia and nontherapeutic surgeries. While this study provides interesting results and forms the beginnings of descriptive ethics literature in veterinary medicine, the structured survey format did not allow veterinarians to offer their own views and perceptions about their decision-making. Another study from the Netherlands used Q-methodology to describe four discourses food animal veterinarians use.69 In describing these ‘discourses’, the researcher identified stances that show some veterinarians identify with statements that show dedication to animal welfare, others with statements that support ‘good’ producers, and still other veterinarians concern themselves with their position as a professional. This study did not examine decision-making itself but the author suggests that understanding veterinary discourses will help in the understanding of veterinary decisions. A third study explored ethical concerns and attitudes of veterinary students but not decision-making.54 A series of studies used standardized moral judgment tests to assess veterinarians’ and veterinary students’ moral decision-making based on moral psychology theories. These studies were not sensitive to the unique moral problems that veterinarians face in practice but measured veterinarians’ responses to predetermined moral dilemmas.62-64,66,67,70-72  12  Finally, one researcher used ethnography to study the interactions of veterinarians with their patients and clients in companion animal practice 53,59 and in particular associated with euthanasia encounters.30 The latter study elaborated on the fluidity of the moral standing of animals as did another study of declawing in veterinary practice.61 To my knowledge, there are no studies using qualitative methods to understand how veterinarians make decisions relating to competing responsibilities to patients and clients. Since there is minimal research focusing on veterinary moral decision-making, the open and exploratory nature of qualitative methods is particularly well suited to investigation of this topic. The Research Question Appropriate framing of the research question is very important when using qualitative methods.68,73 The research question and all other facets of the research design including sampling, data collection, and analysis should fall into alignment 73 as this cohesion lends to the believability of the study results.74 Understanding how individuals make decisions is challenging at the best of times. Decision-making in morally charged situations may be even more challenging because these decisions may be more intuitive rather than rationally justified choices.75 Regardless, understanding and describing the process by which veterinarians believe they make decisions should assist in furthering dialogue in applied veterinary ethics. The primary question of this research may be stated as follows:iii How do veterinarians believe they make decisions when their responsibilities to clients and patients compete? The study has an additional sub-question: What factors influence veterinarians and how do veterinarians believe that they incorporate these factors into their decisions? To some degree the research question dictates the methodological approach.74 In order to understand how veterinarians make decisions, I chose to use a grounded iii  It is important to distinguish between 1) the way that veterinarians believe that they make decisions, 2) how veterinarians talk about the their beliefs about their decision-making, and 3) how they actually make decisions. This research utilizes interview and observational methods that provide 2 different types of data. Interviews (both formal and informal during the observation periods) provide data on how veterinarians talk about the way that they think they make decisions or their construction of the decision-making process. How they describe this process may be different than their beliefs about the process. The observations provide slightly different data in that there are environmental and social clues that an observer may notice that appear to influence decisions and the subject may not talk about or believe to be part of the decision process.  13  theory approach for three reasons. Firstly, grounded theory is a particularly useful approach in the discovery phase of research when little is known about the research topic.76 Secondly, grounded theory aims to “generate explanatory theories of human behaviour” 68 and develop relationships between conceptual qualitative data.77 The purpose of grounded theory is to develop a theory of the social interactions or processes of the individuals or topic studied.78 Thus, grounded theory is well suited to researching veterinarians’ understandings of their decision processes or how they make decisions. Although much of the research results presented in Chapters 3, 4, and 5 are descriptive in nature, Chapter 6 combines these descriptive elements into a theory of decisionmaking. Finally, different qualitative methodologies have inherent philosophical underpinnings. Grounded theory, although sometimes maligned for being too prescriptive in describing defined steps in data collection and analysis, has an inherently methodical ‘formalistic’ approach.79 By using grounded theory the research seeks to develop a theoretical understanding of the research question that may be generalized more readily than other methodologies permit.76 I believe that the results of this research and the theory that emerges from it can be generalized to other populations of veterinarians. The Researcher as the Research Instrument An interesting feature of any qualitative approach is that the researcher becomes the research instrument. Importantly, the reader should be aware that the researcher has underlying biases that cannot and should not be ignored. Rather than denying biases, researchers are encouraged to declare their biases and try to ‘bracket’ them when collecting and analyzing data. As a practicing veterinarian I have made many decisions in situations where my responsibility to promote animal welfare conflicted with my responsibilities to clients. In 1988, when I first graduated from the Western College of Veterinary Medicine in Saskatoon, Saskatchewan, I practiced in a mixed animal predominantly dairy practice in southern Ontario. I then moved to small animal practice in the Toronto area, then to emergency small animal practice in Victoria, British Columbia, and finally into locum  14  practiceiv in dozens of practices throughout British Columbia. During my career I have cropped dogs’ ears; docked puppy tails; declawed cats; euthanized healthy animals; castrated cattle, pigs, and sheep without anesthesia/analgesia; dehorned cattle without sufficient anesthesia; withheld post-operative analgesia in cases where the animal was presumably painful; failed to report animal abuse; kept animals alive for the benefit of their owners; watched as non-ambulatory dairy cows were dragged from the barn by their necks into a truck heading to the slaughter plant; and the list goes on. Thus, I am not a neophyte when it comes to animal care or veterinary medicine. I am also not particularly proud of all of my decisions throughout my career. In fact, as a result of my moral distress, I began to explore moral philosophy both informally and formally though undergraduate studies in the Department of Philosophy at the University of Victoria, before embarking of this doctoral research. Evidence of this educational experience is apparent throughout the analysis and reporting of my research results. My history in practice and educational background are important for two reasons. Firstly, having a significant practice background likely improved my rapport with participants. Being an insider has benefits by facilitating access to ‘the field’ and improving the validity of the research findings.80 Secondly, as noted in the introduction, views about the moral standing and value of animals are diverse in our society. My views on what I consider appropriate treatment of animals or the responsibilities of veterinarians will have an influence on how I collect, interpret, and analyze research data. Although I hold my own views about veterinarians’ responsibilities concerning animals and what constitutes animal welfare, throughout this research I have endeavored to seek understanding of my participants’ beliefs, conceptualizations, and actions, while limiting the influence of my own values. The data collection and analysis are a synthesis of both my own and my participants’ views and experiences. In other words, the data are my understanding of participants’ experiences and in this way coconstructed, following a constructivist approach to grounded theory.78  iv  ‘Locums’ are veterinarians hired as replacements for practitioners on holidays, ill or otherwise away from the practice. Locum veterinarians are contracted to work specified days and are considered self-employed.  15  Study Design Originally, this study was designed as a Master’s research project and thus was smaller in magnitude. As I am interested in how veterinarians’ make decisions about their responsibilities concerning patients and clients, I chose to use personal interviews with veterinarians. I began interviewing British Columbian veterinarians in July 2002 and continued until May 2003. In June 2003 I was hired by the British Columbia Veterinary Medical Association (BCVMA) as the Deputy Registrar. One of my duties was handling complaint cases against veterinarians with respect to professional misconduct. At the same time, I transferred from a Masters program into a doctoral program. Data collected from 20 interviews during the year as a Masters student served as a basis for my doctoral research. I substantially expanded the size and scope of the project for this dissertation. Given my duties as an employee of the BCVMA, I decided not to collect data from veterinarians in BC in the event that I might encounter a situation where my duties as a BCVMA employee conflicted with my responsibilities as a researcher. Thus, I implemented data collection in two parts. Initially, I conducted interviews with practitioners in BC (July 2002 – May 2003). In the second segment, I interviewed veterinarians from the three other Western Canadian provinces and also conducted observations of veterinarians in their daily interactions with patients and clients (June 2004 – January 2005). This hiatus between data collection segments afforded me ample opportunity to review my data collection strategies and analyze data. Ethical Considerations To ensure that participants of this research were treated fairly and in adherence to Tri-Council policies on research involving human subjects, I developed a recruitment letter, informed consent form, and informational leaflet for potential participants (see Appendices II - V). These informational materials and the design of the study were approved at the UBC Behavioural Research Ethics Board (see Ethics Approval Certificates Appendix I). Potential participants were given these materials before the interviews and given the opportunity to ask questions, before being asked to sign the consent form. As the veterinary community is somewhat small, I have taken measures  16  to assure that participants’ responses are anonymous and to assure confidentiality, such as anonymizing audiotapes, using pseudonyms and modifying quotes to remove references that might distinguish the participant. In addition to protecting study participants and assuring that they were appropriately informed about their rights as research participants, I needed to address concerns about non-study participants who might be observed during participant observation sessions. I developed an information leaflet (Appendix V) that explained the study and assured veterinary clients and co-workers that their personal information would not be revealed. I made these leaflets available to participants, clinic staff, and clients. In order to minimize discomfort for veterinary clients, I decided not to observe participants while they talked about or performed euthanasia of companion animals with the client present. Having a researcher observe these potentially intensively emotional discussions or procedures may have been quite distressing to clients. In addition, these types of observations were not central to the research topic; that is, the potential harms did not outweigh the benefits and thus I simply excused myself from these situations. Recruitment In order to obtain diversity in the participant group, I recruited individuals from different practice styles (food animal, companion animal, or mixed animal practitionersv), geographic areas (rural vs. urban), genders, practice experience (time since graduation), and with different financial interests in their practice (owner vs. associate or locum). Potential interview candidates in the first phase of data collection were sent a letter of recruitment via mail or facsimile (Appendix II). Recruitment of participants was also limited by travel constraints as I sent letters to practices in a prescribed travel region to reduce travel time and costs. Letters were addressed to individual practitioners in sole practices or as a generic letter to the veterinarians in the practice in the case of multiplepractitioner practices. A few participants in the first phase heard about the study and expressed an interest in participating. As well, some participants recommended other potential research candidates. v  For the purposes of this dissertation, unless otherwise noted, horses are considered companion animals along with dogs and cats. Veterinarians in this study classified at food animal practices worked with cattle, pigs, poultry, sheep or goats. Mixed animal veterinarians work with at least one category of food animals and companion animals.  17  In the second phase of data collection, individual veterinarians or practices were sent a letter of recruitment via mail, email, or facsimile (Appendix III). This letter was slightly different from the original recruitment letter as potential subjects were also asked if they would be willing to allow me to observe them. Individuals or practices were selected for recruitment based on the same categories noted above. In the fall of 2004, I planned to drive across the four Western Canadian provinces conducting interviews. Potential participants were contacted based on this geographical route, which included a large loop from Vancouver to Winnipeg. In keeping with grounded theory, I selected participants to observe and solicited more interview participants based on emerging themes in order to solidify my emerging theory. In order to further explore emerging themes and test theory development, a third phase of recruitment letters were sent in the late fall of 2004 with the intent of sampling additional veterinarians with specific kinds of experiences. Selection and Participant Demographics As noted in my submission to the university Behavioural Research Ethics Board, all licensed veterinarians who wished to participate were accepted into the study. However, recruitment was restricted to the categories noted above and thus, sampling was essentially purposive. Also as noted above, in the third phase of recruitment, I targeted individuals that I thought would assist me in furthering my understanding of the emerging theory. This form of sampling is called theoretical sampling,78,81 as is common with a grounded theory approach.79 Throughout the three phases of recruitment, a total of 47 practices containing approximately 136 veterinarians were contacted to participate in the study. Forty-two participants agreed to participate and forty-one were selected.vi Table 1 shows participant demographics. Participant practice experience ranged from less than one year to over 40 forty years. Nineteen women and 22 men participated with practice focus including five specializing in food animal practice, 15 in mixed animal practice (ten with significant food animal practice experience) and 21 companion animal practitioners vi  One veterinarian agreed to participate but we had trouble finding a mutually agreeable time and the practice was in a remote area making travel difficult.  18  (three working with horses and small animals and one equine only). Of the participants 17 were practice associates or locums, and 22 practice owners or partners.vii I originally classified participants as rural or urban based on the population of the town or city in which they practiced. However, I found it difficult to categorize some participants because their practice history and practice style was quite varied. For example, some practitioners lived in well populated towns but conducted their practice in primarily rural areas. For this reason I have not included this demographic information. Table 1 Summary of participant demographics  Practice Styleviii  Years in Practiceix  Financial  <5 Years 27%  5-10 Years 17%  10-20 Years 32%  > 20 Years 24%  Owner 56%  4  5  2  6  8  15  6  11  7  1  6  5  7  2  7  11  44%(n=39)  Food 12%  8  Non-owner  Mixed 37%  10  (n=39)  Companion 54%  Investment  Male 54% Female 46%  vii  Two participants were practicing in non-traditional ways and did not fit into either an owner or associate/locum category.  viii  Practice style categories were separated into companion animal (pets and horses), food (livestock excluding horses), and mixed (both food and companion animal practitioners).  ix  Years since graduation is used as an estimate of the participant’s experience level. Participants were categorized at the time of the interview into one of the following categories - < 5 years, 5-10 years, 10-20 years, and > 20 years since graduation.  19  Interviews and Interview Procedures Over the thirty-month period, I conducted 41 interviews with private practitioners with interviews ranging from 40 to 150 minutes. Interviews took place at a variety of locations including the participant’s practice, office, home, and in coffee shops/restaurants. Before the interview, I gave participants a consent form (Appendix IV and Appendix V) outlining the purpose of the study, describing their rights, and assuring confidentiality. Just prior to the interview, I reviewed the consent form with participants and asked them to sign it. I reminded participants that they could terminate the interview at any time. A few participants asked me to stop the tape during the interview because they became emotional (crying) or because they wanted to tell a story but did not want it recorded. Most of the interviews were conducted in private settings although approximately one third of the interviews were in open areas, easily audible by other people including the general public, family members, colleagues, and employees. Participants decided on the location of the interview. One interviewx included two participants but all others included only one participant. However, in one interview a colleague made comments during the interview process, which were not included in the analysis as the colleague was not included in the informed consent process. Interviews were loosely structured, in-depth, and conducted in person with the exception of two interviews that were conducted via telephone. I developed a series of questions (Appendix VII) although participants were encouraged to raise topics or stories of their own, an approach that enhances validity.82 As is common with a grounded theory approach, I modified research questions throughout the data collection process. Initially, I assumed that veterinarians would have no difficulty in recognizing situations of competing responsibilities and for the most part, they did not. However, early in the study I discovered that some veterinarians rarely felt tension between their professional responsibilities to either patient or client. For participants who had difficulty readily identifying these situations, I asked about common ethical dilemmas defined in the literature (e.g. the lack of use of anaesthesia in cattle castration or dehorning, cosmetic x  This interview included the owner of the practice and an associate veterinarian, who agreed to participate together.  20  surgery in companion animals) and invited participants to comment on whether or not they thought these procedures were acceptable and why or why not. In keeping with a grounded theory approach, I modified the line of questioning during the interviews and included questions about situations that earlier participants claimed to be morally problematic. Thus, not all participants received or responded to the same questions. Additionally, depending on the nature of the discussion during the interview, I used different prompts to elicit information. After each interview, I recorded field notes about the interview including details about the setting, participant, and my impressions during and after the interview. All interviews were audio taped and transcribed verbatim by myself or by a transcriptionist. Audiotapes and transcripts were identified by a pseudonym. All information contained in the tapes that might reveal the identity of the participant was altered including names and places. I compared each transcript to the audiotape for accuracy and made corrections as needed. Unfortunately, one tape was damaged and the contents of the interview were lost. Two other tapes revealed poor audio quality. However, I recorded detailed field notes following these interviews to capture the essence of the interview as well as other pertinent information. Fieldwork Data Collection and Procedures To supplement interview data, I observed veterinarians interacting with patients and clients because “observation adds breadth to research and provides answers to contextual questions that cannot be answered by interview alone”.68 Veterinarians recruited in the second recruitment phase were asked if they were willing to allow me to observe them as they practiced veterinary medicine. Of those who participated in an interview, most (13/17) agreed to allow me to observe them, however due to financial constraints I chose to observe only ten different veterinarians from seven practices (one mixed animal, three companion animal, and three food animal). I spent two or three days at each practice. Participants were asked to advise their clients, colleagues, and employees that I would be observing the practice. Generally, I conducted observations after the personal interview, although in the case of one practice, interviews with the veterinary staff (three  21  participants) were interspersed between periods of observation. In these cases, I was able to refer directly to observations when conducting the interview. In the situations where the participant was interviewed before the observation session, I frequently had the opportunity to discuss specific cases between appointments, at the end of the day, or in the vehicle between farm calls. Thus, in all cases of observations, I was able to talk to participants about their actual actions, although some were in a more formal interview setting. Hammersley and Atkinson 80 describe four different types of participant observation – complete participation, participant as observer, observer as participant and complete observer. In most cases I acted as an observer as participant, watching and listening to the veterinarian as he or she interacted with client, staff members, and their patients. In some cases, lengthy car rides between farm calls provided ample time for informal conversation. This informal talk was extremely valuable to me. Between farm calls and between appointments I was able to query participants on how they decided to respond to clients and patients in the ways that they did. Participants frequently queried me as well. Occasionally participants appealed to me as a veterinarian soliciting my opinion on a case. At times it was difficult for me to maintain my status as an observer. In one case a stray critically injured dog was admitted to the clinic after being hit by a car. The policy of the clinic (unfortunately accustomed to this sort of occurrence) was to provide minimal care while attempting to determine if the dog was owned. I offered (twice) to pay for the cost of initiating medical care for the dog. My offer was declined (twice). In this way I served as an insider and an outsider during observations moving into and out of the categories as observer-as-participant and participant-as-observer. I also used other sources of data. One large practice organized a meeting with all of the veterinarians in the practice. The meeting turned into a fascinating focus group session with participants willingly discussing animal welfare issues relevant to their area of food animal practice. In other practices, during interviews, participants interrupted the interview to attend to patients and I was able to observe their interactions during this time. For all observation sessions I recorded field notes. Written or audio taped field notes from observations were transcribed and included in data analysis.  22  Finally, throughout the data collection period and data analysis, I continued to practice veterinary medicine. I had and continue to have the opportunity to interact with veterinarians in a busy emergency practice and to observe veterinarians as they work with clients and patients. Although I cannot include these observations in my data, it is impossible to un-see or un-hear things. Some of these informal conversations and observations provide another layer on top of the more formal methods of data collection. In some particularly interesting instances, I recorded interactions in my journal. In an example of a journal excerpt below, I wrote about an encounter that I had while working as a veterinarian. “[The technician] was holding the puppy, who was obviously in pain, on the table in the treatment room. He had a fractured skull, apparently caused by the other dog in the house – a dispute over food. I asked if they were going to euthanize or try to treat the puppy? [The technician] didn’t know and that [the attending veterinarian] was discussing options with the puppy’s owner in the exam room. [The attending vet] came in to the prep room and advised the technician that the owners had opted to euthanize the puppy. I offered to try to find some charitable funding to treat the puppy. [The attending vet] said, “no, that wouldn’t be fair to the puppy.” She felt his injuries were so severe that euthanasia was the best course of action. Although I didn’t necessarily agree or disagree on this point, I thought it was odd that I was denied the opportunity to fund treatment but that opportunity had been given to the owner. In other words, if the best thing for the puppy was to euthanize it, why did she give the owners the option of treating? So, although the veterinarian believed that treatment was inappropriate, she gave that option to the client. The client’s viewpoint on the appropriateness of treatment versus euthanasia held privileged status over the veterinarian’s opinion of the animal’s best interests. This experience was not used as data but no doubt it influenced me when I considered how veterinarians respond to their responsibility as promoters of animal welfare. These types of experiences affected my interpretations of data and analysis. The research also affected the way I practiced. In one instance I offered a reduced fee to the owner of a cat with a very treatable problem, who had requested euthanasia. The staff members present (some of which I had worked with for over ten years) were surprised by the fact that I offered help to a client they categorized as ‘a jerk’. My analysis of client assessments presented in Chapter 4 has influenced how I practice and  23  assess my clients. Thus, my values and experiences throughout my practice life influence my research analysis, and my research analysis has influenced my practice. Analysis of Data In keeping with grounded theory, analysis of interview and field note data continued throughout the data collection period to assist in refining questions posed to participants.76,77,79,81,83 This is an iterative process. Grounded theory generally involves ‘fracturing’ the data or breaking into pieces rather than looking at transcripts as a whole, although fractured data is taken in the context of the whole interview. Initially I spent time listening to the audiotapes to become quite familiar with the participants’ stories and the way that they talked about things. Transcripts and field notes were also read and reread to gain an overall impression of the data present before initiating coding. Coding methods are very important in grounded theory. I initially coded transcripts on paper, line-by-line, highlighting concepts, beliefs, and processes. This type of coding (‘open coding’ 79 or ‘initial coding’ 78) was inductive and based on the ideas present in the data rather than predetermined codes. This initial coding on paper of individual transcripts allowed me to develop broad ideas about initial categories. I then loaded the transcripts into qualitative data software QSR N6 and coded transcripts and field notes line-by-line with the aid of the software. The next stage of coding is ‘focused coding’, which is more abstract than initial coding and should “synthesize and explain larger segments of data”.78 Recurrent ideas or initial codes were coded into themes. Themes are more abstract than initial codes and describe an underlying meaning.68 Analysis of themes generates categories. For example, one category entitled “My Job” contained pieces of data relating to themes about veterinarians’ perceptions about their role, such as the importance of informed consent. Although participants rarely used the words “informed consent”, they repeatedly talked about ensuring client understanding. I used this process for all recurrent concepts until categories were saturated. ‘Saturation’ means that further data collection no longer reveals new category properties or insights.78 Categorization and sub-categorization of themes produces ‘trees’ of concepts or different types of processes. As this research focuses on decision-making by 24  veterinarians I looked for instances in both field note and interview data where the participant modified (or appeared to modify) decisions based on specific information or beliefs. These pivotal pieces of information are important in understanding what turns veterinarians from one course of action to another. Throughout the coding process, I used memos, matrices, and diagrams to facilitate analysis. These documents also become data as the process continues and theory is developed. Below is an example of more focused coding. This example shows how the categories of ‘My Job’, ‘Animal Welfare Concern’, ‘Animal Welfare Indicator’ and Decision Process’ are applied to the transcript. Figure 1. An example of transcript coding.  My Job – AW is an  OK, I would say – safely – animal welfare concerns override all  important vet  others in the way we deal with animals here. Animal welfare  responsibility.  concerns start to occur when animals no longer fit into the system.  AW concern – some animals can’t handle system, don’t ‘fit’. AW indicator – not eating.  So cattle come into the feedlot. They live in their home pens. They’re fed, everything is great. They get sick, they get treated, they go back. All that’s fine. What happens are those animals that fall out of the system, that don’t eat either because they’re sick or they can’t figure out how to eat out of the bunk. Or they have other, lameness problems and all those kind of things. So those cattle end  AW concern –  up on their own someplace else, and they become an animal  Lameness (pain??)  welfare concern in and of themselves that are independent of the  Decision process – cost  production system. And so in my view, the production system  benefit approach.  doesn’t impose any animal welfare issues directly on the animal as  Decision Process – animal that doesn’t fit is a humane concern AW concern – suffering  long as they fit in. When they don’t fit in you have to deal with that. So, the cost based approach there becomes less relevant because these animals, they’re already discounted. They already don’t fit, so to deal with them on a cost basis becomes less and less relevant. And it just becomes – is this animal suffering or is it not? And if it is, what are we going to do about it?  25  This except shows how the participant thought about his responsibilities as a veterinarian to promote animal welfare, animal welfare concerns (not fitting into the system), welfare indicators (not eating) and an example of a decision process (cost/benefit). A central task of grounded theory is to develop theory of the social processes involved and go beyond descriptive data. ‘Theory’ may be interpreted in different ways and may include positivist or interpretative orientations.78 Positivist definitions of theory seek to explain and predict social processes. Hypotheses might be tested and results predicted. Charmaz78 suggests that positivist theory “favors deterministic explanations and emphasizes generality and universality.” Interpretative definitions of theory give “priority to showing patterns and connections rather than linear reasoning”.78 An interpretative theory “assumes emergent, multiple realities; indeterminacy; facts and values as inextricably linked; truth as provisional; and social life as processual.”78 This research favours the latter definition of theory although there are elements of both orientations. Reporting Results Representative quotations presented in this dissertation are edited to enhance ease of reading and understanding. Editing quotations is a common practice when reporting qualitative research. Pauses in conversation and interjections such as ‘um’, ‘uh’, and ‘like’ are generally removed. Overlapping speech is not represented in the quotations but separated as if the participant and interviewer were taking turns speaking. In some cases, sections of text are removed to link together the pieces of a story or related concepts. In these instances, a series of three periods (…) indicate that I have removed text. I have endeavoured to represent the participant’s words in a manner consistent with their thoughts on a topic. I have not reorganized text; I only removed sections of text. In some instances, words are added to quotations to clarify the meaning of the quote or to remove identifying features such as names or places. In these cases, the inserted words are placed in square brackets [ ]. Some non-verbal communication such as laughter is identified by round brackets (). In order to assure anonymity of participants, each participant was assigned a pseudonym. In the following chapters, terms such as ‘a few’, ‘many’, and ‘most’ are used to describe relative trends in  26  participant responses. These are rough measures and merely represent the strength of trends in the data. Validity and Trustworthiness Evaluating validity and reliability of qualitative studies is sometimes difficult, which is compounded by the use of different criteria and the nomenclature by different authors. Charmaz 78 suggests the grounded theory evaluative criteria will vary depending on the evaluator and their purposes of the evaluation. She argues that grounded theory studies should have credibility, originality, resonance, and be useful. However, grounded theory has a long tradition with well-established techniques. Studies following these established techniques and conform to this tradition may be judged more trustworthy than studies that deviate from these practices. The following techniques were used to achieve trustworthiness and validity of this research: 1) the research methods were coherent with research question; 74 2) sampling and recruitment followed the grounded theory tenets of data saturation and theoretical sampling;79 3) data collection and analysis occurred concurrently;78,79 4) pacing of data collection offered ample opportunity for analysis and theorizing;74 5) negative examples were accounted for and described;79 6) interview and observation data offered a method of triangulation, and 7) a research audit was maintained including methodological and theoretical memos.79 Limitations As noted above, there is very little research regarding veterinary decision-making. This study offers of a framework of how veterinarians and the veterinary profession might attempt to analyze ethically challenging topics and advance discussion in the area of veterinary ethics. The main limitation of this study is the broad exploratory nature of the research question. This study cannot offer significant detail on any specific type of veterinary decision, such as end-of-life decisions in companion animals. Instead, this study offers a general theory of how veterinarians make decisions in situations of competing professional responsibilities. Thus, this study is constrained by its generality, and while I believe that the results of this research are useful to the veterinary profession, it merely contributes to the first steps of empirical ethics inquiry in the veterinary profession. The remaining chapters offer a sketch of veterinary moral  27  decision-making, in situations of competing responsibilities, and should be taken as the beginning of (ideally) a long line of empirical ethics research.  28  Chapter 3: Veterinarians’ Conceptions of Welfare and Evaluations of Patients As set out in Chapter 1, veterinarians have a recognized professional responsibility to promote animal welfare. Veterinary practitioners are immersed in assessing the health and welfare of animals through their daily activities of preventing and treating disease. But what do they understand by ‘animal welfare’? This understanding is central to how they negotiate competing responsibilities to patients and clients. Furthermore, veterinarians’ perceptions of the relative importance of competing responsibilities to patients and clients are important to how they manage these responsibilities. This chapter will explore participants’ ideas about animal welfare and their views on evaluating and promoting patient welfare. Fraser et al 84 suggest that concern about animal welfare appears in three forms: concern about biological functioning, concern about animal feelings (positive and/or negative), and concern about ‘natural living’. Some authors focus on biological functioning, which is often linked to survival and evolutionary fitness.85,86 Others focus on affective states or feelings.87,88 Positive affective states might include happiness and contentment, whereas negative affective states might include pain, suffering, boredom, and frustration. Finally ‘natural living’ emphasizes the ability to fulfil species-specific activities or goals.14,89,90 Defining and assessing the welfare of animals is a source of debate amongst animal welfare scientists and philosophers, and many definitions of welfare exist.91-93 Each conception of animal welfare seems to suffer from a lack of completeness and Fraser et al 94 argue that comprehensive approaches to animal welfare should attempt to address all three elements. Since defining the welfare interests is controversial and veterinarians are likely to disagree about the definition of welfare, this leaves veterinarians in a somewhat tenuous position with respect to their responsibilities. In order to fulfill their responsibility to promote animal welfare, exactly what should veterinary practitioners promote? Aside from more general views about what constitutes welfare, veterinarians working with individual animals must consider the needs of a particular animal rather than the needs of animals in general, or a particular species. Animal welfare researchers  29  may study the welfare interests of a group of animals (e.g. pain in the castration of calves or boredom in caged hens) to make general recommendations on the use of anaesthesia or housing modifications respectively. When promoting animal welfare practicing veterinarians must take into account not only the species-specific needs of animals, but also the specific needs of the individual animals that they are treating. Veterinarians often assess the needs of individuals and make decisions based, at least in part, on those needs. This chapter describes research findings that relate to participants’ views about their patients’ welfare. I will first explore how participants conceptualize the interests of animals. These include not only health and welfare but also continued life or hastened death. Secondly, I will present veterinarians’ views about methods for assessing animal welfare. Thirdly, I will describe participants’ judgements of patient attributes and how these judgements appear to influence their decisions with respect to the importance of animal interests. Finally, in the discussion, I will review these empirical findings in light of veterinarians’ professional responsibility to promote animal welfare and I will draw attention to the practical importance of these findings for practitioners, the profession, and the field of veterinary ethics. Defining Animal Interests Sentient animals have interests that are based, in part, on their level of awareness.11,12,27,89 Few would argue that the patients of the vast majority of veterinarians have at least a basic level of consciousness that makes invasive procedures, injuries, or illnesses morally significant. Veterinary patientsxi are harmed if they feel pain for example. Thus, veterinary patients have an interest in being free of pain. Different types of interests have a bearing on veterinarians’ responsibility to promote animal welfare. The perceptions of interviewed veterinarians’ regarding the interests of animals can be divided into two broad categories – welfare interests and interests in continued life or a quick death.  xi  With the exception of one participant, whose practice focused on birds, the patients of the participants in this study were higher mammals including dogs, cats, cattle, horses, pigs, sheep and goats.  30  Defining Animal Welfare Interests Participants mentioned aspects of animal welfare that can be sorted into Fraser’s categories of functioning, feeling (or affective states), and natural living. During interviews participants uniformly cited the importance of providing basic necessities for biological functioning such as the provision of food and water, when defining the interests of animals. “[Animal welfare is] basically providing the essentials for animal life or husbandry. Whether it be water, feed, shelter, all those types of things… what’s required for each animal under the {provincial legislation} and that sort of thing. So that’s a little bit of a crude definition of it.” Paul, food animal practitioner Regardless of practice style, all veterinarians mentioned this aspect of welfare during interviews. Another aspect of functioning cited by most participants was health. The maintenance of health through disease prevention, and return to health through treatment of illness and injury, were key to maintaining animal welfare in the eyes of participants (although participants assessed health, illness and injury differently). However the impact of disease on the affective states of animals was also important for some veterinarians, particularly in the context of poor health causing pain and suffering. In the following quote, Tessa, a companion animal practitioner, mentioned food and water as a part of welfare and also pain and suffering and normal functioning. Although health is important, it matters when it negatively affects function or affective states. “Well I think animal welfare is basically, first of all is the animal in pain? Is it suffering? And that’s very judgmental. But any obvious pain or obstruction to normal…activity. If they have an ulcerating tumour on their foot for instance, and they can’t walk – that’s obviously an animal welfare issue. If they’ve got a large mass on their side that’s not ulcerated and it doesn’t seem to bother them and that doesn’t interfere with their function, I guess that would be a different matter. So, the minimum standard of existence is animal welfare. Is the animal getting enough food and water? Does it have a reasonable quality of life? I guess that’s what I would consider animal welfare.” Tessa, companion animal practitioner  31  This quote is important because it demonstrates that health does not always coincide with animal welfare. If an animal has a disease or condition (a mass) but the condition does not negatively influence the animal’s affective state, then it may not be an animal welfare problem. In other words, health is not necessarily vital to positive animal welfare. In addition to differentiating between health and welfare, Tessa also mentions another important theme for all participants when considering animal interests – pain. Negative affective states such as pain and suffering were prominent animal welfare concerns for all participants. “Keep them free of pain [and] suffering - [those] would be the big ones.” Max, mixed animal practitioner Veterinarians treat sick and injured animals – conditions that frequently concomitantly cause pain. Veterinarians also perform surgical procedures on healthy animals procedures that can also cause pain. Therefore it is not surprising, that pain, and suffering associated with pain, were central to participants’ concerns about animal welfare. Other than pain, some participants, particularly those working with companion animals, mentioned other negative experiences such as anxiety, fear, and distress when describing a patient’s welfare. Below, a companion animal practitioner described how a dog did not manage well after becoming blind; he suggests that the condition negatively impacted his patient’s quality of life as the illness caused anxiety. “He was blind by the time he was 8 years old, and just freaked out...It was a chronic onset of blindness. He just turned into a wing nut. [He] just couldn’t handle the blindness. He got very aggressive, very socially intimidated, defecating all over the house. We had to put him to sleep. He just couldn’t compensate. His quality of life with his disease was very bad. But you and I both have lots of blind dogs in the practice that have great lives. Same disease, totally different outcome. Their quality of life is different based upon their circumstances. So you base your decisions on whether these guys have good quality of life based on how well they are tolerating their pain. Are they managing their pain? Are they managing their blindness? Are they managing their incontinence? It’s different for everybody. You have to have the judgment to know the difference between what’s working and what isn’t.” Jerry, companion animal practitioner  32  The dog was anxious and distressed by his blindness, leading both the veterinarian and client to the conclusion that the dog suffered from poor quality of life. Although some participants mentioned negative affective states other than pain and suffering, such as fear and anxiety, these were mentioned much less frequently than was pain. Food animal participants cited mental experiences (with the exception of pain and suffering) very infrequently. One participant indicated that animals raised for food generally did not “suffer from much mental or psychological stress” (Harry, mixed animal practitioner) with the exception of isolated instances, such as castration or dehorning. None of the veterinarians in this study expressly mentioned negative experiences such as boredom or frustration. Aside from concerns about negative affective states, several participants included positive mental states such as happiness and comfort, in defining animal welfare. “I do feel a responsibility that they should live a comfortable life, as comfortable as we can make it, and as happy as we can make it.” Angela, companion animal practitioner Participants citing ‘comfort’ and ‘happiness’ as welfare considerations were primarily those working with companion animals. However, some veterinarians defined ‘happiness’ as the absence of negative welfare elements, such as pain. Terms like ‘happiness’ could be used in situations where animals presumably felt positive feelings or in situations where they merely lacked negative ones like pain. Thus, participants used similar terms but used them to mean different things. Besides functioning and feelings (positive or negative), a few participants talked about natural behaviour. In particular, specialist food animal practitioners (those focusing on herd health in one species) were more familiar with all aspects of the ‘Five Freedoms’, a framework frequently used to describe animal interests developed by the UK Farm Animal Welfare Council.95 The Five Freedoms include 1) freedom from thirst, hunger, and malnutrition, 2) freedom from discomfort, 3) freedom from pain, injury, and disease, 4) freedom to express normal behaviour, and 5) freedom from fear and distress. Most mixed and companion animal practitioners were not familiar with the Five Freedoms and  33  did not refer to the ‘freedoms’ or more specifically the freedom to express natural behaviours. Interestingly, food animal participants focusing on one species (e.g. swine) or a production segment (e.g. feedlots) believed that animals raised in more intensive production systems had ‘good’ welfare, including satisfaction of natural behaviours. In the following quote, Peter, a swine specialist, talked about correcting hygiene problems within some pens in an intensive swine system. In these intensive systems animals are housed in barren often restrictive environments, frequently without bedding. “Welfare wise, you still come back to the Five Freedoms. All these criteria are met. I don’t like the fact that they don’t dung in the right spots; they’re dunging everywhere in the pen and the pigs live in poop. That’s not acceptable. But pigs, behaviourally, they are doing what they need to do, to either cool off or figure out their little environments. They’ve got food and water; they are under a roof, the extremes of weather are not in their face. They can do what they desire to do in that environment” Peter, food animal practitioner Peter identified food, water and shelter as elements of welfare as well the ability to behaviourally adapt to the environment. In other parts of the interview, he suggested that it might be better if swine had more freedom to move and that piglets seemed ‘happier’ with bedding. Nonetheless, he believed that intensive production systems provide all of the animal welfare criteria laid out in the Five Freedoms. In his view, the pigs are able to modify their behaviour within their environment, satisfying the freedom to express natural behaviour. Thus, Peter’s interpretation of the freedom to express natural behaviour illustrates that some veterinarians may use terminology differently than what might be a more usual interpretation of intensive production systems – that the animal do not have the opportunity to engage in natural behaviours. In a similar vein, while acknowledging the five freedoms as a common formula for animal welfare, John, a large animal practitioner, questioned what natural behaviour means. Carol: Probably the most controversial one, in terms of the Five Freedoms, is the freedom to express normal behaviours. So how do you see that fitting into the feedlot situation?  34  John: That’s a good question. It’s probably something that needs to be addressed. I guess I haven’t thought about it very deeply. I guess before I went too far I would like someone to define what normal behaviour is in cattle. I think sometimes we confuse normal behaviour with what we perceive to be normal environment, which may not be equal. Some people may talk about normal behaviour being out on grass. That may or may not be true, so I guess I can’t answer that. Although John defined welfare as the ‘five freedoms’ previously in the interview, he had difficulty defining natural behaviour in cattle and whether this aspect of welfare is satisfied in feedlot cattle. In summary, virtually all participants included elements such as normal functioning and the significance of pain and suffering when defining animal welfare. Companion animal practitioners appeared to be more inclined to include some positive mental states such as comfort and happiness when defining animal welfare; those working with food animals did so less frequently. Conversely, food animal practitioners cited the ability to express natural behaviours when defining animal welfare, although defining ‘naturalness’ was difficult. Companion and mixed animal practitioners seemed less likely to mention natural behaviour as a feature of welfare. Animal Life and Death Although veterinarians are responsible for promoting the welfare of their patients, i.e. welfare interests, animals may have other interests such as a long life.96 Although life itself is not usually considered an animal welfare issue, some participants identified the moral importance of animal death, or the value of animal life, as a factor influencing their decisions. Veterinarians held different beliefs about the significance of animal life and death. Few participants thought that death was trivial but its importance differed amongst participants. Those working with food animals understood death as part of humans’ use of animals. “In the end, the interests of the animals are zero because they’re going to be slaughtered anyway and that’s the ultimate, isn’t it? It’s a short-term care-giving circumstance because the term is ended with the slaughter of the animal.” Harry, mixed animal practitioner 35  The acceptability of the use and death of these animals is a tacit assumption in food animal practice. The length of a patient’s length of life is relevant only in achieving the human goal of production of food or other animal products. This situation is very different from those participants working with companion animals. Most companion animal practitioners interviewed opposed killing healthy animals. Many participants said that they would refuse to euthanize healthy animals claiming that the animals ‘deserved to live’ or ‘deserved to have a chance’. Nevertheless, many also believed that euthanasia is acceptable if the patient has a poor prognosis or poor quality of life. These participants thought that death, while not an ideal consequence, is often not the worst possible consequence. “I truly feel there are worse things that can happen to an animal, and probably people too, than death. I don’t think it’s the worst thing in the world, so for the old dog that’s in arthritis pain. Pain is pain. I would rather relieve or alleviate the pain wherever possible and if the only way of doing that is euthanasia, then I can do that… If I feel that I am helping this animal out, this one doesn’t break my heart. Putting down the young healthy dog, that kind of thing, that bothers me…Like I said, death is not the worst thing that could happen to them. I think a bad life is worse than a good death.” Max, mixed animal practitioner For most participants, death, particularly of a healthy animal, has significance and ending life requires justification. Killing animals should somehow benefit the patient and not merely satisfy a human goal, such as relieving a client of an inconvenient animal. This position is flanked on one end of the spectrum by those who consider premature death of an animal as unfortunate but not a significant moral loss, a similar position to that of food animal practitioners. Sandy, a rural companion animal practitioner, talked about euthanizing animals; she admitted that she does euthanize healthy animals or those with minor medical problems at the client’s request. She linked this decision to her belief about the cognitive abilities of animals. “They don’t have a sense of future. So [euthanasia is] essentially like having an anaesthetic and they’re just not waking up from it…Now if somebody was to tell  36  me that dogs were conscious of what was going on and that they could foresee the future and what not, I might feel differently.” Sandy, companion animal practitioner At the other end of the spectrum were veterinarians who hold a very strong sanctity-of-life view. Some participants did not “really believe in euthanasia” for companion animals, particularly for patients with treatable illnesses or injuries. One participant criticized other veterinarians and the veterinary profession in general, for having a laissez-faire approach to animal euthanasia and for offering it to clients as a “treatment option”. She claimed that many veterinarians are “quick to euthanize” and do not really appreciate the importance of individual animals’ lives. In addition to diverse beliefs about the importance of the quantity of life of their patients, participants also differed in their views regarding their responsibility to end life. Many participants suggested that patients with poor quality of life ought to be euthanized; in other words, some patients have an interest in a good death. “[I will tell the client], “I think you should euthanize this animal, because I think it’s suffering and although we might be able to keep it going for a month or whatever, I still think that it would be the dignified thing to do”. And I have no qualms about doing that. And I will not stop doing that in those cases where I feel the animal’s well-being is at stake.” Aaron, companion animal practitioner Other participants were more ambivalent about a quick death for patients suffering from a poor quality of life. They believed that dying a natural death is acceptable even if animals experience pain or suffer in the process of dying. “If people want to let things go the natural way, generally it’s a situation where the cat simply isn’t eating any more and it’s just gradually fading away. People go that way too. It’s not nice but it is the way of the world.” Scott, companion animal practitioner Holding the view that a natural death is acceptable and that a quick death is less morally important was not necessarily linked to conceptions of the sanctity-of-life. For Scott, and a few other companion animal practitioners, allowing animals to die a natural death – and  37  not insisting on a quick death as Aaron advocated – was not linked to personal beliefs about the sanctity-of-animal life but to prioritizing the wishes of clients. In summary, participants held different beliefs about the importance of continued life. Food animal practitioners did not mention sanctity-of-life as a factor affecting their decisions; the quantity of life was only important for human goals. Many (but not all) companion animal practitioners felt the quantity of a patient’s life was important; however, when an animal has a poor quality of life, many (but not all) participants believed that a good death was preferable to a bad life. These beliefs influence veterinarians when they assess the interests of animals – for example, animals may have an interest in continued life or an interest in a quick and dignified death. Assessing Patient Welfare In addition to having different beliefs about animal interests, participants cited using different tools to assess animal welfare. Since most participants defined animal welfare as normal functioning and freedom from pain and suffering, the tools they used to evaluate patient welfare focused on assessments of these aspects of welfare. Participants used patient behaviour, physiological changes, and clinical measures, to assess welfare. Details of how veterinarians use these tools to determine whether an animal is in good health or free from pain and suffering is beyond the scope of this research. Of greater importance to this research are participants’ judgements of whether an animal has good welfare or not, that is, whether veterinarians have met their responsibilities to alleviate pain and suffering and to promote health and welfare. In these sections, I will present different strategies participants mentioned when assessing the welfare of their patients. Since participants uniformly believed that pain and suffering were prominent concerns, the majority of the data relates to these animal welfare concepts. In addition, those veterinarians working extensively with food animals concentrated on animal performance (or productivity) as a measure of welfare. Some participants used information and assessments generated by animal owners in order to assess patient welfare.  38  Assessing Welfare through Pain Evaluation Pain was a clear indication that a patient’s welfare is compromised according to most participants. Unlike most humans, who can deliver a verbal report of pain, assessing pain in animals is more difficult. Veterinarians use physiological markers of pain (e.g. elevated heart rate) and behavioural markers (e.g. vocalization). In addition to recognizing pain in animals, participants categorized pain in different ways relating to duration of pain (e.g. short-term or long-term) and severity (e.g. severe pain or minor pain). This quantification of pain assisted participants in evaluating the importance or acceptability of pain when assessing welfare. In the following quote, Harry, a mixed animal practitioner, defined animal welfare as the Five Freedoms and talked about one tenet – freedom from pain. “There’s freedom from pain: is it freedom from chronic pain or is it freedom from acute pain? Castrating calves – they’re not going to be freed from that pain at all, and I guess I am a little harder than some veterinarians in that I view a well done castration is probably ten or fifteen seconds of exquisite pain and it’s done…I think the pain is minimal when done by a skilful veterinarian and I consider myself a skilful veterinarian. I would go out and do two hundred bulls…The castration was twenty seconds and it was with a very sharp blade and they walked out of there. I think there was more distress with the vaccinations that usually accompanied. They walked out of there and they would go over and eat and drink immediately which is not a complete measure, but I think it is a measure of happiness. And they would be moving relatively normal and that was a measure for me that I’d done a good job.” Harry, mixed animal practitioner While acknowledging that the calves must feel pain when castrated, Harry used behavioural observations – feeding and normal ambulation – immediately following the procedure to assess the impact of the pain on his patients’ welfare. From these assessment methods, he categorized the pain as short-term but ‘exquisite’; and he suggests that post-operative behaviour can be used as a measure of happiness. He also questions whether the Five Freedom tenet of freedom from pain refers to short-term or long-term pain. In this scenario, he questioned whether veterinarians have a responsibility to mitigate all pain or just significant (long-term) pain.  39  In another quote about cattle castration, Max, a mixed animal practitioner, mentioned that pain research suggests that younger animals feel pain, but clinical observations do not necessarily support conclusions that younger animals suffer castration pain in the same way as older ones. He referred to a feedlot receiving calves of very different sizes: “They may bring in some calves to be castrated and these calves range all the way from 300 pounds to 1100 pounds…The 300 pound one – we’re more than likely not going to use any anaesthesia on him. Get an assistant to do an effective tail jack and the job is done. On the 1100 pound, he’s probably doing to get an epidural and possibly get some Rompun…And then the logical question is: why does the 1100 pound one deserve anaesthesia and the 300 pound one doesn’t? It becomes a little harder to answer that. Baby calves are routinely castrated without anything. And how you measure their pain? And I’ve read the studies and…even though they are smaller and they don’t kick as hard, their cortisol levels still went up and their heart rates were still elevated and so you can argue they still feel pain. Experience would suggest that looking at them and recovery time and the amount of inflammation present and everything else, that it perhaps is shorter in those younger ones than it is in the older ones.” Max, mixed animal practitioner Max mentioned studies using physiological data (heart rate and cortisol levels) and behavioural parameters (kicking) to assess pain. He acknowledged that pain is likely to exist in an animal of any size but he used clinical parameters (recovery and inflammation) to justify castrating smaller calves without anaesthesia. Although small calves may heal faster and thus have less pain over time than larger animals, he suggested that longer healing times justify the use of anaesthesia in larger animals. In this way, shorter-term pain is deemed more acceptable than long-term pain, making the use of anaesthesia more important in larger animals. Categorization of pain allows veterinarians to make judgements about the acceptability of the pain. Although the use of behavioural measures was commonly cited as a method to recognize and categorize pain, participants differ on their interpretation of behaviours. In the following pair of quotes, the participants talk about the degree of pain that would cause beef cattle to be three-legged lamexii.  xii  Three-legged lame refers to a lameness in which the animal holds one limb up and ambulates on the remaining three legs, presumably as a response to pain on weight bearing.  40  “How do you decide at what point do you administer pain medication?…We could maybe agree that three-legged lame is pretty painful but there’s all sorts of degrees in between. And when do you implement that? And when do you override that?…An animal with typical foot rot – I don’t know off the top of my head, if they need pain medication or not. I guess all of us live with a certain amount of pain” John, food animal practitioner “[Producers] shouldn’t really be transporting anything with a fracture without stabilizing it…but I figure if [the animal] can run a quarter section away from you while I’m trying to examine their leg,xiii they can probably go on a trailer. Because if they can do that, they’re not suffering.” Maureen, mixed animal practitioner Both practitioners talked about the degree of pain in three-legged lame animals. John believes that this is an indication of severe lameness but Maureen does not necessarily agree depending on how well the animal can ambulate. She mentioned that there may be pain but that the pain is not of sufficient severity or duration to count as suffering. Both quotes illustrate the view that some pain is acceptable, as John noted pain is an inevitable part of life, needing to be balanced against other considerations. Interpreting behavioural cues was difficult for some and interpretations of similar behaviours differed. The practice at which John works considers femoral fractures in feedlot cattle an emergency, requiring immediate euthanasia. However, another participant did not necessarily agree with this interpretation and believed that pain evaluation is subjective and debatable. In this quote, Jenny, a food animal practitioner, discussed whether a feedlot steer with a broken leg should be euthanized if immediate slaughter of the animal was not possible. “Depending on where [the fracture] is you can get enough tissue swelling. And if the animal is a small pen, easy access to water and stuff, you could argue…[that] it’s no different than human being having a broken arm and then you cast it…How much pain that might be, could be debated I think. If there is a lot of muscle in the area and a lot of swelling and it in fact acts like a cast, you could argue – how much pain has that animal suffered if it stood an extra day around? I don’t know. That’s a subjective thing.” Jenny, food animal practitioner xiii  The participant was describing a non-weight bearing injury to the leg, in other words, the animal was three-legged lame.  41  In addition to concerns about subjectivity in pain assessment, categorization of pain as modest short-term pain (for an extra day) makes waiting to slaughter the animal an acceptable option. Many food animal practitioners mentioned their concern with the reliability of assessing pain in animals and voiced concerns that pain evaluation was too subjective. Susie, a mixed animal practitioner, does not use post-operative analgesics in cattle after caesarean sections because she does not believe that there is any evidence justifying their use. “So you asked me about routine pain management [for caesareans]. No I haven’t considered it. I don’t think that that’s necessary…There’s not really any studies that assess the cow’s pain the next day after a C-section, but I don’t know – I guess I just see them doing real well. They go right to the calf right away and don’t go off their feed, and those are all pretty good assessments of how good they feel” Susie, mixed animal practitioner This appeal to scientific data (or lack of data) was common as some participants indicated that pain evaluation was too subjective. Nevertheless, a few participants working with food animals felt that assessing pain in animals was not problematic or debatable. “Nonsteroidal anti-inflammatory medication in food producing animals? We use a lot of it. Because I don’t believe in doing any procedure without giving something for pain or postoperative pain, and you know I have never, have never had a client refuse an injection of a nonsteroidal anti-inflammatory in an animal or an epidural or a local anaesthetic. I have never ever had a client refuse that. Ever! Because it’s not optional. If I do a C-section on a cow it’s not optional. She is getting a shot of nonsteroidal anti inflammatory.” Murray, mixed animal practitioner This quote illustrates a different mindset regarding pain in food animals. While some participants rarely used pain medication, a few others used medication routinely. In summary, participants assessed pain through behavioural and physiological observations, although they appeared to interpret similar evidence differently.  42  Participants categorized pain in terms of duration and severity and on this basis made decisions about the care or treatment of patients. How veterinarians categorize pain influences decisions on whether to use analgesics, whether to transport injured animals for slaughter, and whether to euthanize animals. However, pain assessment was viewed by many mixed and food animal practitioners as highly subjective. Assessing Suffering As noted above in the section on Defining Animal Welfare Interests, participants used the term ‘suffering’ in conjunction with the term pain; animals suffered from severe and/or chronic pain. Whether an animal experienced pain is different from whether they suffered. Categorization of pain and the judgment of pain as unacceptable were linked to determining suffering. Participants also used the term ‘suffering’ in other contexts, particularly in relation to physical manifestations of disease such as vomiting or difficulty breathing. Many small animal practitioners indicated that vomiting was a clinical sign that they used to judge whether an animal had a poor quality of life, although they might not be experiencing pain. However, some participants did not include these types of clinical signs as evidence of suffering. Sonja, a companion animal practitioner, suggested that a patient with repeated vomiting episodes due to an intestinal foreign body was not suffering. “I guess I wouldn’t call that suffering at that point. I mean it’s not comfortable that’s for sure. He’s obviously not in good shape…I wouldn’t call that suffering” Sonja, companion animal practitioner Other non-painful manifestations of disease also lead veterinarians to judge animals as suffering. However, participants were not consistent in these determinations of suffering. Although many participants considered dyspnea (difficulty breathing) as a sign of suffering, one participant did not, but focused instead on pain when evaluating suffering. Below, Sally, a companion animal practitioner, recalled when a client brought in his kitten for emergency treatment. The kitten was having significant difficulty breathing and was placed on oxygen. The client refused to pay for the required emergency care for the kitten and also refused euthanasia. The veterinarian chose to send the kitten home with the client and the kitten died very shortly afterwards. 43  Carol: In that situation would you have ever thought of calling the SPCA in terms of cruelty though? That he was willing to take the cat home rather than [euthanize the kitten]. Sally: If it was just that one situation, no. I don’t know that that cat was in pain, and if the cat wasn’t in pain then I don’t have a problem with the cat dying naturally. Carol: And the respiratory distress? You focus mainly on pain then? Sally: Yeah. Safety, food, shelter, and happiness, which is one of the hardest things to measure or evaluate. Recalling that many veterinarians focused on the provision of necessities and the alleviation of pain and suffering when defining animal welfare. These examples show that some participants use a definition of suffering that is closely linked to pain and does not account for non-pain negative affective states. For Sally, dying from respiratory disease was not painful and therefore, did not involve suffering. Thus dying at home without medical attention was not necessarily a moral concern. Veterinarians may agree that they are responsible for promoting animal welfare. They may also agree that important elements of the promotion of animal welfare (for veterinarians at least) are the reduction or elimination of pain and suffering. Nevertheless, veterinarians do not agree that specific clinical signs, such as vomiting or dyspnea, constitute suffering. The volume of data about assessing and making determinations about animal suffering is limited in this study and deserves further research. Performance In addition to using physiological and behavioural evidence to assess welfare, some participants also used performance as a measure of welfare. In food animal production, the concept of ‘performance’ relates closely to animal productivity and ultimately economics. Animals that perform or produce ‘well’ are those animals that gain weight efficiently (e.g. animals used for food such as swine or beef cattle), produce products efficiently (e.g. milk production), or are prolific (e.g. breeding animals). Thus, ‘performance’ criterion will depend on an individual animal’s use. For beef or pork  44  production, animals must gain weight at an appropriate rate. Animals failing to gain sufficient weight cannot be slaughtered through the regular processes, and therefore do not ‘perform’ well. Although those specializing in food production veterinary practice were generally aware of the Five Freedoms, these participants most frequently mentioned assessing animal welfare through performance indicators, i.e. good performance, such as appropriate weight gain, is an indication that welfare is also good. As an example, John, a feedlot specialist, indicated that his initial treatment recommendation for lame cattle consisted of the administration of antibiotics. He does not recommend analgesics in these animals because he believed that the need for pain relievers is not well established based on performance measures. “My thought is that that will be figured out – whether or not using [analgesics- will improve animal performance – well that sounds rather crass, but in the end of the day if we assume that’s a proxy for animal suffering. How else would you measure it? John, food animal practitioner John used ‘performance’ (in this case weight gain) as a proxy for suffering. His argument is as follows; 1. If an animal performs well (gains weight), then it is not suffering. 2. Lame animals may perform well without the use of analgesics. 3. Therefore, lame cattle that gain weight are not suffering. Thus, even though John uses the term ‘suffering’, he draws conclusions about suffering by a performance indicator such as weight gain. The idea that performance indicators significantly influence those specializing in food animal practice is also illustrated in the following two quotes. Two different swine practitioners discussed the treatment of rectal prolapsesxiv and both cite research on the subject – research focusing on animal performance.  xiv  A rectal prolapse is a condition commonly affecting growing pigs in which rectal tissue protrudes through the anus. This tissue is at risk of damage from desiccation, blunt trauma (e.g. rubbing on the side of pen), or cannibalization by other pigs.  45  Peter: [A researcher did] a study to show the options for rectal prolapses. At the end of the day there was no difference if you left the pig to have other pigs to chew it off, or you separated the pigs and let it rot off, or whether you surgically intervened with the prolapse tube or you resected and sewed it up. At the end there was really no statistical difference in the end result. Carol: In terms of what? Peter: The pig making it to slaughter, development of rectal strictures, death, or otherwise. He mentioned ‘making it to slaughter’, health (rectal strictures) and death as criteria for evaluating a treatment plan, however, health and death link to performance criteria. Pigs with rectal strictures will not gain weight or will become ill. Animals dying from being cannibalized by other animals will not make it to slaughter and thus do not perform well. According to Peter, the research did not account for non-functioning aspects of welfare such as the degree to which affected animals experienced pain, distress, or anxiety. When questioned about the importance of assessing pain in various treatment options, Peter agreed that treatment of prolapses (e.g. surgical repair) or allowing other pigs to ‘chew it off’ cause pain to the animal. He added that these animals should probably be euthanized for welfare reasons. On the other hand, Paul disagreed that pigs with rectal prolapses should be euthanized. He cited the same research and believed that allowing other animals ‘to chew them off’ is a viable course of action. “How do you treat a rectal prolapse?…The most common thing to do now is just leave them. Let the pigs take care of it themselves and it’s usually gone within a day….The other pigs in the pen will chew it off within hours often…I’ve personally found that the animal suffers less, it heals quicker and they’re back to normal normal growth and normal behaviour - faster…I think the animal suffers with it hanging out there waiting for it to die off and fall off versus the pigs taking it off themselves… Do you do the quick and simple one or do you do the long and less agonizing one? {Carol: Why not just kill them?} Most of the time they happen when they’re anywhere from fifty to one hundred and fifty pounds, so they’re not going to be slaughter age yet and they won’t get virtually anything for those pigs.” Paul, food animal practitioner  46  Although cannibalization might be painful, Paul believed that this may be the best option. The evidence to suggest this method is preferable is that pigs return to normal growth rates and normal behaviour more quickly than other methods. Contrary to Peter’s opinion that these animals should be euthanized, Paul suggested that euthanasia is a less than ideal option because the pigs cannot be slaughtered, i.e. the performance of the farm would suffer if all pigs with this condition were euthanized. While animal ‘suffering’ is a factor, veterinarians considered the level of suffering and the degree to which suffering affected performance. This is yet another way that veterinarians assessed suffering. Another example of the use of performance measures to assess welfare comes from a field note following a visit to a hog barn with Peter. “I knew there was a major cultural difference in the way that Peter and I interpreted an animal’s condition when we were walking through the finishing barn. One of the pigs was three-legged lame, carrying one hind leg, big swollen joint. He asked me, in front of the producer, what I thought should be done with the pig. I said that I thought it should be euthanized if treatment wasn’t an option. He countered my interpretation of the animal’s behaviour as painful and suffering by saying, “How can I recommend euthanizing him when he’s the same size as all the other ones in the pen? He’s getting to the feed, he’s gaining weight”.” Even though the animal was showing signs of pain through its behaviour, Peter focused on the animal’s size and appropriate weight gain as evidence of adequate welfare. Client Assessments Another method veterinarians use to evaluate welfare is patient history as provided by the client. History taking constitutes part of the examination of a patient. Veterinarians depend on clients for factual information about the animal such as eating, exercise, and voiding patterns. They also rely on client interpretations to decide how well a patient might respond to a treatment. In the following quote, the veterinarian discussed how communicating with the client regarding the animals’ preferences aids in quality of life assessments and predictions. “We often discuss what’s important to their pet. What they think their pet likes to do, what it still can do. How would coming in for chemotherapy treatments interfere with that? How frightened is it of being at the doctor’s? How does it handle having procedures? So that they can kind of feel that they’re making the 47  decision they’re most comfortable with. [A decision] dependent on not only the medical side of things but also the side of things that came from their pet…Things like euthanasia, that comes up quite a bit. What does your pet really like to do?…It’s not interacting the same or it doesn’t get up and move. It just sleeps the whole time. Is that real ‘quality of life’? And I think that’s probably just as important as physiologic changes.” Anna, companion animal practitioner Discussions with clients about patients’ likes and dislikes and how various medical treatments may affect these preferences were common for those working with companion animals. Animal owners have greater access to animals to observe their behaviour and how disease behaviour may manifest in their animals, and veterinarians use this information to assess the level of welfare. Because the client has much more access to the patient’s behaviours and preferences, some participants believed that clients were better judges of patient welfare than were veterinarians. “I think owners can judge an animal’s quality of life better than anyone can - better than a vet, better than anyone. They know when an animal is happy and when it’s not so happy.” Sally, companion animal practitioner These participants relied not only on information gathered by animal caregivers but took the position that caregivers would be able to make judgments about patient welfare based on their knowledge and history of their animal. However some participants believed that caregivers are sometimes poor judges. Some clients evaluated their animals’ welfare as very poor, poor enough to justify euthanasia. Angie, a companion animal practitioner, relayed a story of a client requesting euthanasia because they felt their dog had a poor quality of life. “They paid the bill already and [I’m] faced with this dog sitting here, munching on all the treats, running around wagging it’s tail. I’ve had [this happen] a number of times. And I find that really hard because you’re getting one story from the people. Maybe it’s true, maybe they are having problems at home, but it’s hard to tell here. And sometimes I don’t always believe the story I’m getting either” Angie, companion animal practitioner  48  The veterinarian was concerned about the disparity between her perception of a dog and that of the client. Her first impression of the dog was so drastically different from the client’s report that she has trouble trusting the client’s interpretation. Another example shows that clients may sometimes believe that an animal’s welfare is better than does the veterinarian, and pursue treatment that a veterinarian considers futile. “A nine-year-old Great Dane that’s been in congestive heart failure for literally two years. This animal is horribly cachectic and literally its getting it’s chest drained every week for the last two years…I find that absolutely horrendous, absolutely horrendous…An animal that is wobbling and walking around barely. There is no quality of life there.” Aaron, companion animal practitioner The practitioner later expressed his frustration that his colleague allowed repeated procedures on a dog with a very poor quality of life. Presumably, the owner of the dog felt that that the dog’s quality of life was acceptable enough to warrant continued treatment. This disparity in perception led him to question the client’s opinion and whether the client was acting responsibly. In summary, in addition to beliefs regarding what should count as animal welfare being or how welfare should be conceptualized, participants used different methods to measure welfare. Participants used health parameters, performance criterion, preference satisfaction, and behavioural observations to assess animal well being. Participants involved in production oriented veterinary medicine, in general, appeared more likely to use performance criteria when assessing animal welfare (e.g., weight gain). Companion animal practitioners used quite diverse methods of assessing welfare, sometimes relying on client interpretations of patient welfare. Evaluations of Individual Patient Attributes The overarching goal of this dissertation is to explore why veterinarians sometimes appear to fail to promote the well being of their patients. So far, I have shown that participants had different beliefs about the interests of animals as well as different means of evaluating welfare. In addition, participants also evaluated attributes of individual patients when managing their competing responsibilities to patients and clients. Participants cited characteristics such as usefulness, tractability, age or 49  anticipated life span, and attractiveness as factors that affected decisions about a particular patient. Usefulness Much of the time, a veterinary client will define the use of the animal. The usefulness of an animal is not truly a characteristic of the animal. Instead, it is an assessment of how well an animal is suited to a given purpose. For example, an infertile cow or sow is not useful in furthering a producer’s goal of making more animals to sell for meat. Thus, usefulness attributes, such as fertility in female animals, are contingent on the proposed use of the animal. A feedlot practitioner explains that the goal of owning or treating beef cattle is to make beef. “If they’re not going to be large enough to make beef out of, then [producers] just euthanize them” John, food animal practitioner Useful animals in food animal practice are those that have high utility for food and/or reproduction. Veterinarians involved in food animal medicine evaluate an animal’s usefulness based on cost of treatment and prognosis against the animal’s monetary value. Animals requiring medical intervention exceeding their monetary worth are frequently euthanized or slaughtered. A veterinarian would generally not recommend a treatment for an animal unlikely to reach market weight. In contrast, ‘usefulness’ in companion animal practice is linked to qualities that make animals good companions. With the exception of purebred breeding animals, companion animals generally have little or no monetary value. However, some companion animal practitioners considered the usefulness of patients when making decisions surrounding euthanasia. When presented with a healthy animal for euthanasia, some participants would refuse to perform euthanasia because the animal could be useful to others. “[I tell them, “You] should give someone else a chance to enjoy having time with him. Just because you don’t think he’ll be happy, you don’t know for sure.” A lot  50  of times people get it in their head that there is no other home that their animal would be suitable [for] but their home. It’s just not true” Angie, companion animal practitioner Although Angie may have concerns about the needlessly ending the life of an animal she framed her concerns as the loss of a potentially useful animal. In another example of evaluating patient usefulness, Aaron refused to euthanize healthy animals with the exception of aggressive animals. “We don’t euthanize healthy animals…A caveat to that previous statement: we have euthanized healthy animals from owners where there has been aggression, whether it’s a dog or cat. That is one circumstance where we will. And we feel strongly about that. Where there is a history of biting people or children, we will have no qualms about euthanizing a dog. Because by and large, [our] experience is that they are very difficult to retrain and you still can’t trust them. So if people come to us, usually we wait for a history either of a severe bite or more than one bite. Okay we’ve got a repeat offender on the part of the pet and yes we will euthanize such animals.” Aaron, companion animal practitioner This quote illustrates that some veterinarians refuse to euthanize healthy animals as they consider this a harm. Nevertheless, if the animal is an unfit companion, i.e. dangerous animals, veterinarians are more likely to agree to do so. Not only are dangerous animals not useful but they are detrimental as companions. A few participants holding a very strong sanctity-of-life belief urge clients to manage aggressive animals (e.g. pharmacologically or with behavioural therapy) and may refuse to euthanize animals unless the client made an effort to resolve the situation. Age or Anticipated Lifespan Companion animal practitioners included patient age or anticipated lifespan in some of their decisions, particularly associated with client requests for euthanasia of relatively healthy animals. Most participants would refuse client requests to perform euthanasia in young animals, particularly healthy young animals. Some participants said that they were less likely to refuse to perform euthanasia on older animals, even though the animal’s quality of life did not necessarily warrant euthanasia in the veterinarian’s opinion. 51  “You get the pre-Christmas flourish of people putting down the dogs that, sure they have [medical] problems, but they aren’t imminently life threatening. They bring [the pets] in and they want them to be put down right then and there. They’re not adoptable candidates really because they are in their twilight years. I find that [situation] one of the toughest because, short of chastising the client for being selfish, what other options do you have?…I’d say for the most part I haven’t tried to talk them out of [euthanasia] because unfortunately, for these pets, it’s a matter of time. Some of them have months to a year at the most.” Abby, companion animal practitioner As Abby noted, older animals are frequently viewed as poor candidates for adoption into another home. Veterinarians confronted with the prospect of fulfilling a client’s request for unnecessary euthanasia of an animal may comply, they may refuse to perform the procedure, they may try to ‘talk them out of it’, or, sometimes, they will take possession of the animal in order to find a new home. Patient age influences some veterinarians’ strategy in these situations. Expected lifespan also influenced decisions about expending resources on ill or injured animals. Veterinarians will sometimes donate their services when a client is unwilling or unable to pay for services. This is a very common scenario in veterinary practice. Veterinarians will also offer to take possession of the animal in order to treat it and then find another home for the animal. Veterinarians have no formal obligation to perform these charitable acts; nevertheless, they are commonplace in companion animal practice. Decisions to offer charitable services were influenced by the patient age. Some participants would chose not to rescue or offer to treat an older animal at reduced costs, as Sally described. “I wouldn’t do it if it was an old dog, it didn’t have a very long life expectancy or if it was a nasty dog that didn’t get along with people – basically an animal that is a problem to adopt out.” Sally, companion animal practitioner Additionally, some participants said that they felt uncomfortable encouraging clients to consent to therapies or diagnostic tests in older animals, even when the client might be willing and able to pay for the services. In part, these animals may be less able to tolerate medical and surgical interventions, but some participants also felt concerned about expending resources on older animals.  52  “Sometimes I do also feel awkward about it – a little bit. There are times when we are getting into huge amount of work on an 18, 19-year-old cat. Gee, you know…is this right? All the energy and emotion and expense that you’re pouring into this case when there are younger animals elsewhere or people that need to have that kind of attention. It’s hard.” Scott, companion animal practitioner Thus, patient age or anticipated lifespan (prognosis) influenced some veterinarians when deciding whether to recommend tests or therapies, when deciding whether or not to perform euthanasia, and when deciding whether to offer charitable services. Tractability Patients’ tractability influenced participants’ decisions about the use of anaesthesia or sedation. Tractability refers to the ease of handling a patient. Veterinary patients can be quite dangerous to the veterinarian and anyone assisting the veterinarian in performing procedures. Thus, it is not surprising that that ease of handling will influence the level of anaesthesia or sedation required. Vaccinating a lion is not the same, from a safety standpoint, as vaccinating a house cat. In food animal practice, animals that were difficult to restrain or agitated were sedated or anaesthetized in order to perform procedures. More tractable patients could be restrained by physical means. Veterinarians frequently cited tractability as influencing how they performed procedures such as castration and dehorning. Difficult and dangerous patients receive anaesthesia or sedation. The following excerpts show how patient tractability influences participants when deciding to use anaesthesia for cattle castration. “I’ve only done one castration on a little calf without using local or without using an epidural. I almost never do, partly because I’ve been kicked in the face by a bull.” Maureen, mixed animal practitioner “I think depending on the bull, I always have [sedation] there if I find I need it. I’ve never had to. I’ve found with the tail jack and [local anaesthesia in] the testicles – it’s fine.” Susie, mixed animal practitioner  53  In the first quote a calf is easily restrained for castration without anaesthesia and in the second quote, Susie suggests she will use sedation in castration of bulls only if needed. Difficult-to-manage patients received sedation and/or anaesthesia, often for reasons other than the animals’ own distress or pain. Removal of ‘cancer eye’ in beef cattle is another example. This procedure involves surgical removal of the entire globe. Michael, a mixed animal practitioner, explained that he always sedated cows for this procedure in addition to using local anaesthesia because sedation made the procedure less stressful to both patient and veterinarian. However, he indicated that his partner only used sedation if the animal was ‘difficult’. As noted above, short-term pain seemed acceptable to some practitioners, and using anaesthesia or sedation made more sense for personal safety reasons or to improve efficiency. For some practitioners, being able to ‘get the job done’ was important. ‘Efficiency’ related to speed and accuracy of a procedure. In the quote below, Paul, a food animal practitioner, talked about bovine castration. This excerpt follows an explanation of the rationale for using anaesthesia and/or sedation when dehorning. In dehorning, he used local anaesthesia based on patient tractability and whether the procedure could be accomplished quickly with physical restraint alone. Carol: And castrations, same sort of thing, time? Paul: Time… the only animals I sedated were the ones that were too wild to do, it was far too slow otherwise. Carol: Or using a local? Paul: Never. Carol: Didn’t work? Paul: Not for castrating, I never did it - it was too slow. Carol: Too slow. Did you talk to {the producer} about it? Did you ever say ‘do you want me to do this’? Paul: Dehornings, yes. Castrating, not really. It was all about time because most of the time… we were doing anywhere from 50 to 100 or 150 to 200 [animals] and they want to do them in a day.”  54  As Paul indicated, he would only use anaesthesia in animals that were too intractable to castrate without it. The reason he gave for deciding not to use anaesthesia was that the time required to administer it. Thus, the attributes of certain animals, their ‘wildness’, influence some veterinarians’ decision to use anaesthesia or sedation. Smaller animals or calmer animals were less likely to receive sedation or anesthesia than their larger or more difficult conspecifics. Patient Attractiveness Veterinarians will sometimes evaluate the attractiveness (either appearance or personality) of animals when considering whether to offer reduced fee or free services to clients with financial difficulty. Unappealing animals were less likely to benefit from veterinarians’ donations of services or attempts to locate new homes. A ‘nice’, ‘good’, or ‘cute’ animal may receive care when clients cannot afford therapy. “Well this animal is too nice, too good an animal [and the] people can’t afford it, so we go ahead and do it and you take the burden of the expense on yourself.” Larry, mixed animal practitioner In the following quote, Michael, a mixed animal practitioner, mentioned that the cuteness of animal and the niceness of the client influence his decision to perform a salvage procedure (limb amputation) on a pet with a fractured leg. “We’ll amputate that leg for one hundred bucks. That’s really cheap… and it’s funny because it depends on how cute the animal is and how nice the person is.” Michael, mixed animal practitioner Negative patient attributes also influenced these types of decisions. The speaker in the next quote refused to reduce a client’s bill because her dog is ‘rotten’ and bites. He felt justified in assisting some clients and patients and not others. Martin: [The little dog] just bites everybody that comes in, as soon as it doesn’t like somebody…rotten little dog… I will not do it for free for that person. I did it cheaply to begin with…She brought the dog in yesterday because it had something stuck in the back of its throat. It felt like the jaw was dislocated or something like that. We took a couple of x-rays, sorted it out…and then she said, “That’s a lot of money. Could you please reduce it.”. No, I am not. I’ve got certain animals, certain situations that I am more than happy to do for free. There are certain situations that I’m not. And that’s my decision.  55  Carol: So why didn’t you want to do it for less? Martin: Because it’s a rotten little dog. It should be euthanized. Frequently, participants used a combination of patient attributes. When deciding whether he should assist a client with the surgical repair of a fractured femur in a dog, Jerry considered the dog’s age, prognosis, and attractiveness. He contrasted the favourable attributes of this patient with unfavourable attributes of another patient, as justification for intervening on behalf of the dog. “He’s a beautiful young healthy dog with a perfect future, I’d take him home before I’d euthanize him, and I’d be willing to do that. Now if there was a vicious landshark [of a] cat in here – just a real arse hole, who had blocked 6 times [a urinary tract obstruction],…I know that we’re not going to be able to adopt that cat because he’s an 8-year-old asshole” Jerry, companion animal practitioner Although the cat may have a treatable condition, because it is older and is difficult, Jerry is less inclined to expend charitable resources on it. In summary, attractive animals may receive preferential treatment by some veterinarians, benefiting from free or reduced veterinary care, or a new home. Furthermore, difficult animals may be more at risk of death from euthanasia, and may be less likely to benefit from veterinary services. Patient age or anticipated lifespan (linked to prognosis) also influenced veterinary decisions in similar ways. These patient attributes may ultimately tie into the usefulness of a companion animal, in other words nice, attractive and young animals are good pets. However, companion animal practitioners did not specifically frame these attributes as a function of the animals’ usefulness to people. By contrast, food animal practitioners did frame patient attributes as a function of their usefulness to people rather than their emotional appeal. Discussion Participants in this study were unified in believing that part of ‘animal welfare’ included the satisfaction of certain basic needs such as food and water. Likewise, participants routinely mentioned pain and suffering as a detriment to welfare. However, as noted in the section on pain assessment methods, some participants did not  56  acknowledge short-term pain as an animal welfare problem. Many participants mentioned suffering when defining animal welfare; however, suffering frequently related only to severe and/or enduring pain, whereas others included non-painful physical manifestations (e.g. vomiting, dyspnea) of disease having negative affective consequences as evidence of poor welfare. Diversity in Defining Animal Welfare Interests Although participants appear to agree about what constitutes animal welfare, they used different criteria when defining welfare interests and different ways of assessing welfare. Disagreement over animal welfare terminology has been previously recognized 11,97,98  and makes it more difficult to have a plain discussion within the profession  regarding a veterinarian’s responsibilities concerning their patients. Although health and absence of pain and suffering were common elements cited by participants, many participants working with food animals did not include positive mental states when defining welfare. These practitioners may not take seriously the concept of ‘happiness’ or contentment in food animals. Negative mental experiences not associated with pain were not commonly discussed. It is not surprising that veterinarians focus on the negative mental experiences of pain. But, by neglecting to include the harms to animals of non-pain negative mental experiences (such as boredom or frustration) and by neglecting positive aspects of affect (happiness, joy, contentment), veterinarians may not be accounting for all aspects of welfare. This diversity in defining and interpreting welfare highlights that when veterinarians talk about furthering animal welfare and fulfilling their responsibilities to mitigate pain and suffering, they may mean very different things. When veterinarians use the same term welfare for different conceptions of welfare it is 1) difficult to establish an accurate assessment of the profession’s ethic regarding animal welfare, and 2) it makes dialogue concerning the welfare of animals amongst colleagues difficult. In order to ‘first consider the needs of the patient’ 46 and to promote animal welfare, veterinarians and the veterinary profession should consider codifying what animal welfare means to the profession. Only then can the public and individual practitioners gauge whether they are fulfilling their responsibility to promote animal wellfare.  57  In addition, using terms such as ‘pain’ or ‘suffering’ in ways that differ from common usage may confuse client communications. For example, companion animal practitioners with a narrow conception of suffering may fail to inform their clients that a pet with severe dyspnea may be suffering. When clients ask, “Is he is pain?” or ”Is she suffering?” veterinarians defining these terms narrowly or in ways that deviate from normal interpretations may fail to give clients the information that they request. Thus, beliefs regarding animal welfare and different uses of terminology might complicate appropriate communications with clients. Ethical tenets urging veterinarians to first consider the needs of their patients and to advocate for the interests of animals provide veterinarians a normative push. However, due to diversities in defining welfare, the profession may have difficulty communicating effectively amongst themselves, to the public, and to clients. Neglecting to consider all aspects of animal welfare may result in less than ideal care for animals. While the interests of animals need to be balanced against the interests of clients (and others), without first being clear on understanding those interests, veterinarians are bound to have difficulty adequately negotiating their responsibilities. Underlying Beliefs Regarding Responsibilities Concerning Animals Throughout interviews participants made normative claims as well as factual claims about animals. For example, some participants did not include short-term pain in welfare assessment as though it was not morally relevant. Some participants felt that eliminating pain in patients was too great an expectation to place on clients and veterinarians. These beliefs are separate from questions about whether animals experience pain or how to estimate pain severity. In fact, some veterinarians regarded some pain as morally acceptable. Although these veterinarians may recognize that a patient will experience pain during a procedure, beliefs about responsibilities concerning animals (in particular the responsibility to alleviate all pain) affects how a veterinarian frames a situation as being morally important or not. Food animal practitioners who do not acknowledge short-term pain as an animal welfare concern may feel that they are promoting animal welfare and minimizing pain and suffering even when they castrate animals without any form of anaesthesia.  58  Inherent in animal welfare definitions are moral valuations. Ethical concern for the well being of animals is inextricably bound to conceptions of animal welfare.93,99,100 It is important for veterinarians to be aware of their personal beliefs about animals and the ethical treatment of animals. These beliefs underpin interactions with clients, patients, and colleagues. Not only will a veterinarian’s beliefs about responsibilities concerning animals influence the way he or she practices, it will likely influence development of policies within that practice that may affect their staff and associate veterinarians. In addition, veterinarians involved in policy development at the local, national, and international level will bring their beliefs regarding animals with them in influencing policy regarding animal use and care. The public is increasingly concerned about animal pain and this concern deserve consideration.101 As veterinarians have responsibilities to the public, by failing to account for animal pain veterinarians may be neglecting what the public views as their responsibilities. Furthermore, veterinarians’ beliefs about the moral importance of animal pain have ramifications for the profession. There is no question that veterinarians must be able to work within the current-day constraints of animal use. However, lack of concern for any type of pain (short-term or long-term) sends the profession and its individuals down a dangerous path. While ignoring animal pain may not be cruelty, it may well be regarded as callous. Unlike cruelty, callousness involves a lack of concern for animal harm.102 Virtue ethics literature in veterinary medicine is sparse and focuses on virtues important to interactions with clients and colleagues such as respect, integrity, courtesy, and candour. Veterinary oaths 17,47 include a pledge of compassion. In deviating from this pledge, veterinarians may fail to cultivate the character traits important to the profession and to developing trust in the profession by the public. Underlying Beliefs about the Importance of Animal Life The importance of animal death and life was another aspect on which veterinarians disagreed. Food animal veterinarians did not mention the value of life as a factor influencing their decisions. There is a tacit assumption that animals will be used for food or products and for the gain of the producer. However, companion animal veterinarians were much more diverse in their beliefs regarding the importance of life and  59  death. Sanders 30 suggests that concept of animal ‘personhood’ fluctuates amongst individual practitioners. In his findings, animals new to the practice or unfamiliar to the veterinarian are afforded a level of moral status more consistent with an object, and euthanasia of these animals is dispensed without much emotional investment. In contrast, patients having a presence in the practice, or those with a long history of illness and treatment, are much more difficult for the veterinarian to euthanize. Sanders argues that companion animals hold a moral status somewhere between objects and persons. Although not related to veterinary medicine, similar research regarding the ambiguity of the standing of food animals supports a similar conclusion.31 Conceptions of the standing of animals differ between people, but also include the status of the animals and the stage of its ‘career’. Thus, the standing of animals is fluid depending on the animal’s life or career stage. Some animals are elevated to personhood while others are objectified.13,33 Although participants working with companion animals may be influenced by clients’ perceptions of their animals or the veterinarian-patient relationship as Sanders suggests, some participants felt very strongly that animal life was morally significant regardless of any human-animal relationship. Veterinarians with a strong sanctity-of-life view may interpret some situations, such as euthanasia, as a clear violation of their responsibilities to animals. Veterinarians believing that continued life is better than death in most circumstances may be more willing to accept a patient quality of life that other veterinarians would find inappropriate. In contrast, participants believing that animals deserved respect, dignity, and/or freedom from pain may be more inclined to encourage euthanasia. Like attitudes toward pain, attitudes toward animal life affect the treatment options that veterinarians present to clients. Important to ensuring continued trust in the profession is to ensure that professionals are honest and candid.26 It may be particularly important for veterinarians holding strong views regarding the importance of animal life to candidly state these beliefs to animal owners. Additionally greater discussion within the profession regarding how personal values regarding animals influence perceptions and beliefs may lead to greater reflection within the profession. As society grapples with finding a moral place for animals,13,33,103-  60  108  veterinarians will continue to be confronted with people holding very divergent values  relating to animals. Subjectivity in Welfare Assessment Methods Participants used different methods to assist in evaluating the welfare of their patients including physical (health, weight gain), clinical (healing), behavioural, and client-based history. A difference amongst participants was the level of scientific uncertainty that they would tolerate. When making welfare assessments, some participants were more inclined to rely on highly objective information such as weight gain or reproductive parameters (e.g. number of live piglets per year). These participants were less likely to give credence to seemingly less objective evaluations such as observing behaviour in animals. By focusing exclusively on performance parameters and coarse forms of behavioural evaluation, some practitioners may underestimate the harms to animals.100 Some participants expressed concern about the lack of scientific data to support making treatment decisions in some species. For example, as there were no studies on the use of analgesia in post-caesarean section cows, one participant felt that analgesia was not necessary in view of cows’ mothering behaviour following surgery. Alternatively, some participants were more likely to make arguments by analogy – if surgery is likely to hurt a person or has proved painful in another species then it is likely to cause pain to another species of animal. While both of these approaches have pitfalls, the profession and its members should reflect on the necessity of concrete scientific studies before embarking on a course of treatment or omitting a course of treatment aimed at benefiting their patients. Although well constructed and executed scientific research may be the gold standard for the knowledge base within the profession, should the profession rely solely on scientific research when trying to further the interests of animals? In other words, when clear scientific knowledge is lacking, should the profession take a precautionary approach with respect to animal welfare and assume that animals are more likely to experience similar states to humans undergoing similar medical procedures rather than that they are less likely to experience similar states. More research into key areas of concern, such as post-operative analgesia in various types of  61  surgeries in various species, will assist practitioners in making treatment recommendations. Appropriateness of Veterinarians or Clients as Proxies Practitioners use information gathered from their clients about patient history and behaviour. This information is invaluable for deciding on treatment or diagnostic recommendations and even in prognosticating. Some participants indicated that animal owners’ animals are the best judges of how a patient is managing in his or her life. This position goes beyond garnering information from the owner to accepting their assessment or interpretation of the patient’s welfare. Other participants were uncomfortable trusting clients’ subjective evaluations of patients. To what extent should veterinarians rely on client interpretations of patient welfare? Although clients can frequently offer physiological or behavioural information to assist veterinarians, they may not be able to judge the ‘best interests’ of animals as they may lack the expertise required to make these evaluations.109 In human medicine, decision-making for incompetent patients focuses on what the patient might have decided had she been competent, or alternatively on the best interests of the patient assessed by what a reasonable person would choose.110 However, given that there is a significant barrier between animal and human caregiver, the reasonable-person standard used in human medicine may not be as simple when applied to veterinary medicine. Some participants clearly believed that some of their clients were poor decision-makers for their patients. Trust in the quality of clients’ decisions is linked in part to assessments of clients themselves (see next chapter). Rather than assuming or refuting the client’s interpretation of a patient’s welfare, a productive approach might be to use their interpretation as a starting point for communicating about patient welfare and the client’s perceptions. Inequitable Treatment of Patients Participants cited many instances in which they provided different types of treatment to patients based on patient attributes. More tractable animals received less pain mitigation. Some veterinarians pressed clients harder to treat young animals than old. In some cases “nice” animals were rescued and found new homes while ugly, old, 62  or aggressive animals were euthanized. Similarly “cute” animals received free or discounted medical care while less attractive ones did not. All of these statements are oversimplifications of the complex context of veterinary practice but they illustrate how judgements of patient attributes result in quite different care to patients. Evaluations based on adoptability (useful and attractive companions) are likely pragmatic choices; the likelihood that a new home will be found influences whether to intervene to preserve the animal’s life. However, attractiveness evaluations in the case of donation of services are more difficult to explain. Likewise, reducing the risk of harm by sedating or anaesthetizing less tractable animals seems reasonable from a personal safety standpoint. However, tractable animals are likely to feel similar levels of pain. These valuations of animals are not unique to veterinarians. Kellert’s 111 research on valuations of animals concludes that there are 9 categories of how people value animals.xv Serpell 112 claims that people value animals depending on utility and affection evaluations. Useful and socially attractive animals are highly prized (e.g. guide dogs), whereas detrimental and unattractive animals (e.g. wild rats) are not. Serpell explicitly states that this system does not account for ethical considerations relating to animals. Nevertheless, these evaluations of animals have ethical consequences. While placing values on animals based on utility and affection evaluations is common, as animal care professionals to what extent, if any, should veterinarians allow these evaluations to influence their treatment of animals? Sanders 59 notes that unruly, dangerous, and nasty veterinary patients are sometimes labelled as problematic by veterinarians. He suggests that veterinarians sometimes relegate difficult patients “to a kind of moral category in that their troublesome behaviour is seen by veterinarians as the result of individual choice or character flaws.”59 Indeed veterinarians may be making morally questionable decisions when they choose to favour useful and attractive animals over unattractive animals. While unequal treatment of equals is quite apparent in society’s use of animals, veterinarians should reflect upon whether this is appropriate for animal health professionals.  xv  Kellert’s value categories include utilitarian, naturalistic, ecologistic-scientific, aesthetic, symbolic, dominionistic, humanistic, moralistic, and negativistic.  63  Conclusion Animal welfare, a central concept to the veterinary profession, was framed in surprisingly diverse ways by participants of this study. Participants used different criteria when defining and assessing the interests of animals. Although the veterinarians used similar language, the terms used meant different things to different participants. Also the comfort level of participants with respect to scientific certainty about animal welfare influenced how they managed their patients. The way that veterinarians think about animal welfare affects how they interpret their responsibilities concerning patients. If a veterinarian does not include ‘happiness’ in their definition of welfare, or does not believe that happiness can be assessed in animals, then they may be less likely to identify a situation as problematic from a welfare standpoint than a veterinarian who includes happiness in their definition. In order for veterinarians to fulfill their responsibilities to promote animal welfare and alleviate pain and suffering, veterinarians and the veterinary profession should attempt to clarify definitions and assessment methods of animal welfare. Participants sometimes conflated the well being of patients with underlying beliefs about the level of care that was reasonable to provide and seemingly did not recognize when they were making both scientific and normative claims. Personal reflection about these beliefs and communication amongst veterinarians and between veterinarians and clients is vital to understanding, formulating and questioning our responsibilities concerning animals. Likewise, personal biases about the ‘goodness’ of one patient over another requires reflection about the appropriateness of this practice both from a sense of fairness to clients and also to the development of the kind of character that veterinarians as animal health professionals should engender.  64  Chapter 4: Veterinarians’ Assessments of Their Clients Clients set the stage for the care of the patient by choosing when to seek the advice or services of a veterinarian,113 by authorizing diagnostic or treatments plans (or not), and by continuing treatments and recommendations initiated by the veterinarian. The manner and degree that clients influence veterinarians’ decision-making has received very little investigation. One study suggests that companion animal veterinarians evaluate the bond between a client and pet and these evaluations influence the way that the veterinarian treats the animal.114 An ethnographic study showed that classifying clients as ‘good’ or ‘problematic’ helps veterinarians by “justifying the difficult decisions one is forced to make in all medical settings.”53 A similar study indicates that veterinarians judge the legitimacy of clients’ rationale relating to euthanasia.30 However, these latter studies did not explore how assessments influenced veterinary decisions with respect to patient care. This chapter explores veterinarians’ beliefs about clients’ responsibilities to their animals and how veterinarians assess their clients as moral players in veterinary decisions. I will also describe how these assessments connect to the way that veterinarians frame and respond to moral problems. Finally, in the discussion I will raise some normative questions based on the empirical data presented in the chapter. Veterinarians’ Expectations of Client Responsibilities to Animals As noted in the previous chapter, veterinarians sometimes conflate animal welfare assessments with their beliefs about the reasonable use of animals. For some, shortterm animal pain was a reasonable cost to further the interests of the client. Beliefs about the responsible use and care of animals allow veterinarians to assess whether clients have reasonable interests, when negotiating situations where there is tension between the interests of veterinary clients and patients. However, as I will show in the following sections, participants had differing expectations of how clients should manage their animals. Participants also had expectations about the level of resources clients should expend to further the treatment and care of patients.  65  Beliefs about Legitimate Animal Usexvi Veterinarians hold beliefs about the appropriateness of client use and treatment of animals. Expectations about the care and treatment of animals differed depending on their primary use. For example, slaughter of food animals is not an animal welfare concernxvii for many veterinarians, whereas, killing companion animals is often cited as an ethical issue. Concerns about castration usually center on pain mitigation rather than the acceptability of surgically altering animals. In other words, castration to make an animal more useful (either as a companion or a food animal) is accepted but the method is sometimes questioned. The CVMA endorses the castration of animals.115,116 Nevertheless, altering animals for other non-therapeutic reasons such as tail docking or ear cropping is not acceptable to the CVMA.117 The reason for accepting one physical alteration and opposing another, in part stem from views about acceptable practices in the use of animals for food or companionship. While no participant in this study questioned the acceptability of spaying and neutering companion animals (a procedure that makes animals more appropriate pets), participants’ views about the acceptability of cosmetic procedures differed. For example, some veterinarians thought that client requests for tail docking or ear cropping in puppies were unreasonable. Below is an excerpt of an interview with two companion animal practitioners. Scott: As far as the tail docking issue…we explain to them that we are now a non docking clinic. I thought originally that we were going to have some real mad people on our hands but people actually respect that. They actually look and they say ‘huh, interesting, I hadn’t actually thought of that, that that was a questionable thing.’ And I had a Jack Russell breeder in …and she asked us about it. But I said, ‘I’m sorry but we don’t do this anymore.’ [She said], ‘Oh. Okay, I’ll go back and call the association and see if this is something that they can do without; and see if they can still be registered without their tails done.’ And they were quite happy that they didn’t have to do it. And some of the Rottie breeders they kind of thought, ‘ uh you don’t do tail docks?’ Now I don’t know if they go to another clinic xvi  Although ‘use’ often refers to the category of animal use for food or companionship, for example, certain procedures or treatments are linked to the category of use. For example, companion animals undergo cosmetic surgery to conform to a breed standard. Cattle are castrated to improve efficiency of beef production. Thus, for the purposes of this dissertation ‘use’ includes management or treatments intended to make animals more appropriate to their assigned function.  xvii  Slaughter is acceptable in principle, although the method of slaughter may certainly raise welfare concerns.  66  but we thought that it may be good to be the first clinic to say no to that, and be a little bit of an example. Because first of all we don’t think we are losing a lot of good clients by not doing the tail docking. Angie: A lot of them were just coming in for that and that was about it. These backyard breeders, they weren’t even purebreds, not that it matters. But, [they think] ‘well [the puppy’s] got some Rottweiler in it, so chop the tail off’! Carol: But there is even less justification [if it’s not a purebred]? As you say not that it matters to the dog. Angie: But [the dog is] not going to be a show animal. They’re not going to be registered or anything. I think that it’s all silly. These veterinarians believed that tail docking is an unacceptable procedure in general but particularly unacceptable in non-purebred dogs because these dogs were not used as show animals. Tied to this perspective was an assessment of the type of client. The type of client who would request this type of procedure was not a good client. These veterinarians chose to make a clinic policy against tail docking. However, other veterinarians felt that tail docking was reasonable, particularly for some dogs to fulfill a breed standard or to reduce harms to people or their property. “The tail docking of puppies – I don’t have as much of a problem with. …Quite a few of the owners request to have [their dog’s tail] off because [the dog is] clearing the coffee tables. That sort of thing…[I saw a dog with a tail that] could knock over a small kid. I still sit on the fence. But I can at least wrap my mind around those puppies because it feels way better to do it as a puppy than as an adult. As an adult, I really am reluctant to do it. I’ve seen a lot of bad recoveries.” Abby, mixed animal practitioner Abby was more reluctant to dock the tails of older dogs because she believed that harm to the dog is more serious, and she weighed the client’s interest in having the dog’s or puppy’s tail docked against these harms. Veterinarians assessed whether clients’ use of animals was reasonable against the expected harms to the animal. In the case of dog tail docking, modification of an animal in the pursuit of human interests was reasonable for some veterinarians given that harms to the animal were mitigated. But for other veterinarians, the modification of dogs was not justifiable and they developed a rule against performing the procedure in their practice. 67  Judging the acceptability of animal use comes from established societal norms (e.g. slaughter of cattle for food is acceptable) and from personal beliefs about particular practices (e.g. cosmetic surgery). A few veterinarians held the view that they should not judge clients’ use of animals unless it was outrageous. “But to say to the client, “Well you live in New York City and so you have a cat in a high rise apartment who never gets to see the light of day. I think that’s wrong.” Or to say to that hog producer, “You have sows in farrowing crates and I really think that that’s wrong.” Unless I can give him a better solution and he has confidence in me to be able to say from an economical point of view, from an animal welfare point of view, from a disease point of view, from an energy efficiency and housing point of view, here is a better way – and why it’s a better way? If I just come in there and judge him, without giving him a solution or offering a solution, he’ll just look at me as being another member of PETA…I have a lot of Pit Bull breeders…North America’s number one fighting dog lives [here]…And you know the man who owns that dog treats that dog better than you or I treat our kids. The fact that the dog had to go to work, which going to work meant fighting another dog…We are going to judge that?…We want to get our heads on right and make sure that our thinking is consistent. So humane treatment, welfare, for me welfare is making sure animals aren’t abused and suffering unnecessarily.” Murray, mixed animal practitioner This is a complicated quote. Murray believed that it is not the place of veterinarians to judge the way clients use animals unless they can 1) offer an alternative to the current practice, 2) prove that an alternative is acceptable from an economic, health, and animal welfare viewpoint, and 3) determine whether the clients are causing unnecessary suffering or abusing animals. Since there are no good alternatives to housing sows in crates, he believed that veterinarians should not judge how clients house sows. He, like all of the other participants, did not believe that animal abuse is acceptable as it causes unnecessary suffering but he offered a startling example. Murray suggested that a client who uses his dog as a fighting animal is good owner because he cares for the dog. The dog’s occupation is, for Murray, none of his business and the suffering presumably caused by fighting is an occupational hazard. Other veterinarians, upon finding clear evidence of dog fighting, would report the client to the authorities but Murray believed that it is not appropriate to judge this client’s use of his animal.  68  Level of Expenditure in Responsible Animal Care As noted above, veterinarians believe that clients should use their animals reasonably (whatever that might mean) but often times medical treatment resources (e.g. money or time) are limited. Veterinarians hold different beliefs about the type and level of responsibility clients have to their animals. Financial constraints frequently limit the level of care an animal will receive. Although clients may prefer that their animals be afforded the best medical care possible, they may have competing interests such as to pay their suppliers, pay for rent, buy food, or go on a luxury holiday, rather than pay for medical care of their animals. Veterinarians recognize financial constraints as part of practicing veterinary medicine. “The owner either has money constraints or emotional constraints that affect their decision and I have to live within those parameters.” Larry, mixed animal practitioner “I hate to think of pets as disposable and they can go get another cat, but in a certain sense…if a cat comes up diabetic, something that’s going to be long term on-going expense, I’m not going to insist or make someone feel guilty for considering euthanasia. And if I know that they are really lacking in the funds, I will give euthanasia as an option to them.” Abby, mixed animal practitioner Some participants believe that clients are not responsible for paying for extensive veterinary care; however other participants believed that clients should place the interests of their animal ahead of some of their own interests (e.g. a holiday or car). Participants had diverse views about the level of care for which animal owners were responsible. Some participants held the view that animal owners were responsibly for providing food, water, and shelter, and should be able to pay for euthanasia in the case of illness or injury. The level for resource expenditure according to these participants was relatively low. Others expected that responsible animal owners should invest in medical care. For example, Marion believed that clients should pay to repair their animal’s fractured limbs.  “We will tell our clients, ‘you’ve got to fund some of this, you have to pay 69  some of this. You have to take some responsibility. What do you have in your budget?’ What do you do? And you have to make the client responsible.” Marion, companion animal practitioner The extent to which clients are responsible for animals appears to be linked in part to veterinarians’ views regarding the value of animal life. For example, companion animal veterinarians often expect clients to expend more resources on dogs and cats than on rodents. In addition to beliefs about the importance a specific patient’s life, beliefs about the level of expenditure (financial or otherwise) differed depending on the circumstances of the client. Below Sean explained that although he now placed greater value on a patient’s life and generally refuses to euthanize animals with readily treatable conditions, he would assess (judge) the client and his/her circumstances before agreeing to euthanize a cat with a treatable condition. “I’ve mellowed a lot in the last ten years and I do put value in the pet’s life – much more than I used to – and I would sort of try to be a bit of a judge of people who came in. But I would take the person’s side if.. the lady had cancer, [for example] and she was at her wits end.” Sean, companion animal practitioner Not only did the client’s life circumstances influence expectations of resource expenditure, clients’ actions also affected it. For example, some veterinarians expected clients who delayed seeking care or who were responsible for patient injuries to expend more resources to treat the patient. Aaron described a client who he felt was responsible for their dog’s injury. “I’m frustrated and I literally want to smack these people across the head, because they’ve had a dog that’s been repeatedly captured by the CRDxviii for running away from home. They don’t tie it up. This time it got hit by a car, it had a horribly broken leg that would have cost them about $ 1500-2000 to repair. They did not have the money. They had seriously contemplated euthanasia, I said no. I don’t think this is a reasonable option, I can at least amputate the leg for a lot less and they did go for that option. But at the same time I wanted to tell them, ‘folks, you’re responsible for this you’ve known for a long time that it’s just a question of time before this dog was going to get in trouble. Yet you’re not taking the proper responsibility, you should be mortgaging your house as far as I am concerned’.” Aaron, companion animal practitioner xviii  CRD means Capital Regional District or the responsible authority for handling stray animals.  70  Some veterinarians assessed the actions and behaviour of their clients in light of their beliefs regarding responsible animal care. In similar cases to the one above, had a dog fractured his leg because a child had left the backyard gate open, it is possible that a veterinarian may have responded differently to the situation and may not have refused euthanasia. Thus, the context around clients’ actions appears to influence some veterinarians when deciding whether a client is acting acceptably when limiting the provision of resources for veterinary care. In summary, veterinarians in this study had different views about what constitutes the reasonable use of animals. They also had different expectations about the level of care that clients should provide to their animal when they need veterinary treatment. These expectations varied depending on the value that the veterinarian placed on the animal, the life circumstances of the client, and the behaviour of the client. Some veterinarians expected a lot of clients and some expected very little. These beliefs combined to create a measuring stick against which veterinarians adjudicated whether clients were acting reasonably in a given situation. Client Categorization As noted above, client behaviours and circumstances influenced veterinarians’ views about the level of resource allocation clients ought to provide for veterinary care as well as how clients chose to use or manage their animals. When talking about morally problematic encounters, participants frequently identified client attitudes and behaviour as influencing the decisions they make. Categorizing clients helped veterinarians to make decisions about intervening in order to assist patients. ‘Good’ Clients Participants talked about ‘good’ clients or ‘A’ client as those willing to pay for veterinary services and who listened to and heeded veterinarians’ advice. ‘Good’ veterinary clients were conscientious, attentive, compliant, caring with respect to their animal, and were forthright about their resources. “[Clients that] take care of their animals, not necessarily people who throw money at you…but they’re aware. If there’s a problem they come. They ask questions.  71  They bring them in for annual exams. They’re on top of things. They provide the appropriate exercise and companionship and those kind of things.” Leslie, companion animal practitioner The concept of ‘caring’ had different meanings depending on the beliefs of the veterinarian. For example, some participants understood ‘caring’ clients as those willing to end suffering by euthanasia if necessary. In contrast, other veterinarians might characterize caring clients as those willing to purse treatment to prolong life even if the animal might suffer. In food animal practice, some veterinarians favoured clients who were progressive in terms of technology and cared for the welfare of the herd as a unit rather than individual animals. They viewed treatment of individual animals (beyond euthanasia) as unwise economically and likely to prolong suffering. ‘Good’ producers had the appropriate protocols in place to manage their animals efficiently and humanely. In this way, ‘caring’ for animals linked to beliefs about appropriate animal use and care. However, other food animal practitioners looked favourably on clients who cared about the lives of individuals. “And that was one of the things that concerned me about the whole feedlot industry. These animals are, pure and simple, only for profit. A cow-calf operator, yes he wants to make the money but he wants his cows comfortable. He knows his cows. He knows his calves. I see very [few] cases of abuse or cruelty in the cow-calf operators. I do see them but rarely. [In a feedlot] it’s not unusual to go see a calf with a broken leg lying in a pen for a couple of days because it wasn’t convenient for somebody to shoot him.” Michael, mixed animal practitioner Michael preferred the type of care provided by cow/calf client and labeled feedlot clients as generally uncaring and negligent. Although participants held different interpretations of the ‘good’ client, they frequently cited the ‘goodness’ of clients when making decisions. ‘Problematic’ Clients On the other hand, veterinarians also categorize some clients as problematic and describe them as ‘not a good’ clients or ‘C’ clients. Veterinarians identify clients who are known or who are suspected to fail in their responsibilities to their animal or to the  72  veterinarian as problematic. Problematic clients may fail to comply with treatment recommendations. Martin suggested that some clients are more diligent with respect to compliance than others are. “To send that same animal home, the same problem, going home with two different owners. One who is going to give really good care and [the other is] not going to give good care. You got the same problem but two different potential outcomes, two different situations. A fractured leg is an example. Somebody says “Look, we don’t have the money to repair this fractured leg”…So you can splint it up and you can say, “Well look, we can splint it but it’s entirely up to you. Whether or not that animal is going to get better by whether or not you keep that animal confined and how dry you keep this. You have to take good care of that splint…but if you do it, the chances are the dog is going to be fine.” If I give that [same dog] to another person…I know they are just going to turn the dog out in the backyard …[and] he is going to snap that splint. It’s going to be in a lot of pain. Same dog, same situation…different people.” Martin, mixed animal practitioner Martin showed that his assessments of clients as inattentive or non-compliant influenced his decisions about the kind of veterinary treatments he offers. Problematic client characteristics include non-compliance, excessive concern about fees, mistrust of veterinary expertise, and poor decision-making about the animal (e.g. not seeking advice at the appropriate time, misinterpreting an animal’s illness, not providing adequate care). They may also be personally disagreeable or present a financial risk to the veterinarian. As noted above, factors important to veterinarians in categorizing good clients were caring and compassion. Some veterinarians assessed clients who seemed indifferent to their animals as selfish or uncaring. “I have a hard time with the pre-Christmas flourish of people putting down the dogs that have problems, but they aren’t imminently life threatening. They bring them in and they want them to be put down right then and there…Short of chastising the client for being selfish, what other options do you have?” Abby, mixed animal practitioner  73  In food animal practice, clients or stockmen who do not recognize problems in a timely fashion or who are inattentive were categorized as problematic clients. Peter talked about his concerns with some employees of feedlots. “It still comes down to people - the quality of the people. If you’ve got drunks and alcoholics looking after your animals because they’re the cheapest labour force there is, what do you expect? Unfortunately, we’ve dealt with feedlots that have that…If you have a drunk running the show, don’t expect performance and don’t expect profitability here.” Peter, food animal practitioner In summary, some clients were clearly categorized as good or bad, although many clients likely do not fall neatly into these categories. Veterinarians frequently mentioned terms such as ‘good client’ or ‘A’ clients when describing clients with whom they enjoyed working. These clients were caring, compliant, conscientious, and willing to pay for veterinary services. However, participants’ interpretations of these attributes differed – a good swine producer might have different attributes than a good dog owner. Veterinarians also identified some clients as ‘problematic’. These clients were uncaring, financially risky, lack conscientiousness, were incompliant, and possibly personally disagreeable. The importance of different client characteristics to different veterinarians’ decisions deserves further inquiry, as the data in this study were limited. Client Assessment Methods Veterinarians use different methods to categorize their clients. Veterinarians having a long relationship were able to ‘get a feel’ for clients and how well they managed their animals. A joint history allows veterinarians to gauge clients as good or problematic. However, veterinarians frequently work with clients without a well established veterinarian-client relationship. New clients, infrequent clients, emergency situations, or working as a locum all create uncertainty for veterinarians in assessing clients. In these situations, veterinarians used different cues to assist them in their evaluations of clients. These cues included non-verbal interactions with clients, client behaviour to patients during the visit, demographic cues (type of animals owned, age, perceived socio-economic status), and client history with other veterinarians.  74  During interactions with clients, participants claimed to evaluate clients’ non-verbal reactions to recommendations. If clients appeared annoyed, uninterested, suspicious, or upset by the veterinarian’s recommendations, this influenced some veterinarians to modify their recommendations. Many times, participants claimed to use clues from body language or the lack of a verbal response to assume that clients would not proceed with the recommended treatment or diagnostic plan. In the quotation below, Sally talked about a case involving a dog with a fractured leg. “We took an x-ray. Sure enough, she fractured her femur. So I told him that. I then went through the treatment options. For full 90 %, 95% return to function, would be to plate or use some sort of fixator on that leg. I gave him a price quote for that and his eyes bulged when I said that. And then I could see that price might be a problem. And I said, “If you can’t afford that, then we could amputate because a dog can function just fine on three legs”. And I gave him the price cost of that and he started crying. And I realized he started crying because there was no way he could afford this and he was realizing that he was going to have to put his dog down. A one-year-old dog.” xix Sally, companion animal practitioner Through non-verbal cues, Sally believed that the client both cared about his dog and was unable to pay for veterinary services. Although the client appeared to care for the dog, he represented a problem to the veterinarian - a financial risk - because he appeared to be unable to finance the best treatment option. Based on her clients’ emotional reactions, the veterinarian modified her treatment recommendations. In addition to interactions with clients, some participants mentioned that they use other cues to assess clients. For example, financial ability was assessed by a variety of factors. Young adults were assumed less able to pay for veterinary services. Those with seemingly lucrative occupations were assumed able to pay for care. Those clients driving expensive cars, or wearing expensive clothing or jewelry who refused to follow treatment or diagnostic recommendations were considered uncaring. Clients who appeared to be able to pay for care but would not, even if they professed to care for their animal were considered cheap, hence problematic. xix  The outcome of this case was tragic. The client opted to take his dog home and did not seek further veterinary care. Instead he applied a splint to the limb himself. After several weeks, he returned home to find that the dog had chewed off the splint and a portion of the dead limb. The dog was euthanized.  75  Clients who took the time to form relationships with the veterinarian or who frequented a veterinarian (even if not the veterinarian involved) received more positive evaluations. Maureen, a practitioner in a small town, advised that she would not do after-hours emergency calls if she were unfamiliar with the client, even if the animal needed medical attention. You always feel sorry for the animal but I can’t help but think that those people could have established a relationship earlier. We’ve had people come in to say, I’m new to town, I just want to see the clinic, I just want to know what vets work here.” Maureen, mixed animal practitioner Maureen worried that clients who fail to have an ongoing relationship with a veterinarian represent a financial risk. Clients who were infrequent users of veterinary services, those that ‘haven’t seen a vet in years’, may be categorized as uncaring, irresponsible, or unwilling to provide adequate care. Jerry talked about a rule of thumb to evaluate clients who are infrequent users of veterinary services. “I think if you had to make a top-of-the-head guess about it...if they’ve never been to a veterinary clinic, the odds are those people just didn’t want to spend any money on their dog. But there are surprises.” Jerry, companion animal practitioner Finally, some veterinarians test clients to see how diligent they are in seeking solutions to their animals’ problems. Clients willing to try alternative solutions to a problem are viewed more positively. For example, clients sometimes request euthanasia of cats that are urinating inappropriately. Veterinarians will frequently refuse to perform euthanasia if the client has not attempted to try alternatives to modify the animal’s behaviour, even if the client is not interested in pursuing alternatives. Once the client tries behavioural modification, having passed this test, veterinarians reassess the client as having acted responsibly. “You can have a feel of what they’ve gone through then. Like, if you see them the month before and they were going through hell with their pet because you know it was urinating all over the house, and they tried all kinds of things and you know that, then you can certainly be more compassionate with them.” Melissa, companion animal practitioner  76  In another example of testing clients, Samantha considers clients to be uncaring if they request euthanasia without seeking medical advice first. In order to differentiate those clients who care from those who do not, she establishes a policy of charging for an examination before discussing euthanasia in order to test the client’s willingness to treat their animal. “Well, it’s always a problem with new clients that are wanting a euthanasia. So for instance with this cat, it was an eighteen-year-old cat that is ready to be euthanized according to the owner. We have a real problem with that because there’s a lot of treatable things. Invariably these pets are geriatric. They’re often cats. They often haven’t been seen by a vet for years and years and years. And so that’s my problem - people being unaware that there’s something you can do. Unwilling to help geriatric patients… So then we try to do an exam for everything and we do charge for it. So often that stops them at the door, and frankly that’s okay because if they don’t want to do an exam before the euthanasia and spend the money on it, I don’t want to euthanize their pet for them essentially.” Samantha, companion animal practitioner In this quote, Samantha identified clients who have not developed a relationship with a veterinarian and who are requesting euthanasia as problematic. In order to weed out clients who are unwilling to consider alternatives to euthanasia, she instituted a policy that presents a financial test for these clients. In summary, participants used different methods to assess the ‘goodness’ of their clients. Client behaviours, client demographics, and a client’s veterinary history all contributed to veterinarians’ assessments as did client demographics. Influences of Client Categorization on Decisions Participants talked about assessments of their clients as influencing decisions that they made about animals. Assessments of individual clients influenced decisions about 1) the level of information disclosure about diagnostic or treatment options, 2) donation of services, 3) refusal of services, and 4) tolerating substandard care.  77  Information Disclosure Participants used assessments of clients when deciding how much information to give clients. Veterinarians who had a long history with a client were able to base their decisions regarding animal care on their knowledge of their client. In these cases client categorization simplified client communications. “Well for me [the veterinarian-client-patient relationship] helps me to make a decision as to how to approach any problems they might have with their animals, also as far as medications go, whether I feel comfortable giving them certain medications or not. And it kind of helps to categorize people somewhat. If you have a client that just wants bare bones stuff and you know them that way [and] you can kind of work at that level with them. Whereas if you know that someone wants top notch work – the whole kit and caboodle – you can go to that level as well.” Melissa, companion animal practitioner Veterinarians having an ongoing relationship with the client were able to judge, based on past experience, the sort of care the client expected for their animal. Knowing how their clients value their animals allowed practitioners to tailor treatment and diagnostic plans according to beliefs about their client’s views. ‘Bare bones’ clients might be given less than ideal options, with detailed financial estimates, that afford an animal minimal care. Conversely, ‘top notch’ clients may be given information only about premium care options with less emphasis on financial estimates. In situations where a veterinarian does not have a history with a client, some participants used cues mentioned above to categorize clients and potentially limit disclosure of information. “I’ve been around long enough to know when a client comes in, he’s 23 years old, he’s got $125 in his pocket and he walks in with a dog with an obvious femoral fracture…that really isn’t time well spent if I try to convince them that they have to come up with $3000 to fix this leg. If you get that out right off the bat – that they can’t really afford the exam fee – well you better start thinking of some alternatives. And that’s the time when you start directing them in a different direction.” Jerry, companion animal practitioner  78  Jerry’s evaluation of the client’s ability to pay affected how he communicated with the client and the type of care recommendations that he would make. In the same way, categorizing food animal producers according to the kind of operation they run, veterinarians are able to assess what sort of recommendation to give regarding treatment of an animal. Stan suggested that commercial cattle producers are more likely to have severe financial constraints than are cattle breeders. In deciding whether to use post-operative analgesics for caesarean sections in beef cattle, he indicated that economics prevail but perhaps more so for the commercial producer. “From the producer’s side it’s the overall cost of it…Commercial cow-calf as opposed to purebred cow-calf are different as far as economics go. You have to have a pretty sharp pencil with the commercial cow/calf.” Stan, mixed animal practitioner Stan and numerous other participants indicated that they did not offer or suggest analgesia for food animals due to financial constraints, although many admitted not having discussed it with their client. By categorizing clients as wanting or needing a certain level of service, veterinarians limit disclosure of information to clients. These client assessments limit clients from furthering the care of animals. Thus, these assumptions by veterinarians might hinder them from promoting the welfare of patients. Alternatively, rather than limiting information disclosure to clients believed to want (or need) an inexpensive option, some veterinarians were more explicit and detailed when disclosing information if they believed that a client represented a risk. “This sounds awfully judgmental, but sometimes you can get a feel for people, and you’re [thinking] ‘this person’s kind of not right’…I mean there’s complainers in the world and probably people who are more willing to sue in the world. And I think sometimes they’re fairly close and so in those cases I just try to make sure I document everything very thoroughly and be quite clear.” Tessa, companion animal practitioner Tessa intuitively felt a ‘problem’ with some clients and evaluated them as potentially litigious. Veterinarians concerned about personal risk may present clients that they identify as problematic with the gold standard of care only. This strategy was aimed at reducing their risk in the event of litigation or complaints to the regulatory body. 79  Donation of Services Evaluations of the worth or ‘goodness’ of their client influenced some participants’ decisions to help clients financially. Veterinarians frequently provide free or reduced-cost services to clients in financial need. When deciding to assist clients, veterinarians assess their clients’ merits. Some participants indicated that they were more likely to seek financial alternatives, such as reduced fees or financing, if they considered the client a good client, even if they were unable to pay for services. “If someone truly cares about their pet?...They’re concerned? They really want to treat but they have no money?…I try to work with them.” Samantha, companion animal practitioner Some participants extended credit to or financially assisted clients who appeared truly concerned with their animals. Sometimes, good clients also received significant altruistic donations of veterinary services, often without the client even being aware of the veterinarians’ efforts. In the following quote, Abby talked about her employer’s policy regarding ‘cut rate’ work or providing treatment at a reduced rate. “He would pick and choose clients quite a bit: ones that he felt really cared for the animal; provided a good home; honest people that appreciated it. And not all of them did. You get people who walk out the door and they don’t realize how lucky they were…But if he felt that the situation was due to neglect, not neglect per se, but not necessarily the best environment for that animal…he wouldn’t offer to do as much.” Abby, mixed animal practitioner This quote also shows that the veterinarian assessed the clients’ ability (or willingness) to care for the patient as well as whether they cared about the animal, before providing charitable services. Caring clients are more likely to provide a good environment for an animal and are given the benefit of free or reduced rate services. Seemingly uncaring owners are not given the benefit of charity. Some participants talked about penalizing clients who they identified as difficult. “It’s funny because it depends on how cute the animal is and how nice the person is. We take after-hours calls and when they call you at two in the morning and the  80  first thing they say is, “I’m very sorry to bug you this late at night but”, their bill just went down fifty bucks. (laughter) When the person calls and [says] “My dog just got into quills and I need to see you right now!!” Well their bill just went up fifty bucks.” Michael, mixed animal practitioner Michael’s statement was made in jest but it illustrates veterinarians’ feelings about helping some clients or penalizing others. Many participants in this study were predisposed to provide free or reduced costs services but their willingness to do so depended on the veterinarian’s evaluation of the client as good or problematic. Refusal of Services Although it is not surprising that veterinarians would like to reward good clients with free or reduced cost services, participants sometimes refused to render care to animals owned by problematic clients. Many participants stated that they would perform euthanasia at no cost if the animal were suffering from a serious injury/illness. However, sometimes veterinarians so angered by clients’ behaviour would refuse to be bullied or blackmailed. In the following excerpt, Sally, a companion animal practitioner, talked about a belligerent client. The dialogue shows that Sally would have made a different decision about the care of the kitten if the client had been less belligerent. Sally: Two hours later, 2:30 am, he shows up at our doors with a cat in respiratory distress…The man still had no money and he wanted me to treat his animal...It was a kitten in critical condition, she was in respiratory distress, prognosis poor. He said, “Is there any chance my cat can make it?” I said, “There is a chance. I don’t think it’s very good, but there is a chance.” He said, “I want to take it.”…I said “OK, this is how much it’s going to cost” and he said “Well I don’t have any money”. And I said “Well then I can’t help you.” And what ended up happening, I told him I would not help him if he didn’t have any money – and he knew that before hand. Call the SPCA and they would fix it, and he refused that and I refused to help him and so he took his cat back home and called …the next day [and said] that his cat died 10 minutes after leaving the hospital…So I put a cost on helping that kitten in some ways. I don’t know, is that right or wrong?…He was nuts. He was nuts and he was really ignorant to begin with. He cursed me out on the phone when he called at 12:30. When I said there was an emergency fee, and when he found out I wouldn’t see the cat without him paying, he cursed me out on the phone. Then he showed up and he was very rude and ignorant. Carol: Would it have made any difference if he were nice? Sally: yes (chuckle). 81  Carol: Oh it would have? What would you have done if he were nice? Sally: He was trying to, what’s the word, push me into treating his animal by being belligerent…Bully me! He was trying to bully me into taking care of his cat. And me as an individual, I won’t allow it. I said, ‘No I’m not going to help’. And he tried to make me feel guilty. He tried to curse me out. He tried to tell me I was completely unethical. I won’t deal with people like that. But was it at the expense of this kitten, maybe. In this story, the client’s behaviour heavily influenced Sally and she acknowledged that if the client had been agreeable, the outcome for the kitten might have been different. In these types of situations, veterinarians have few alternatives to manage problematic clients. Refusal of services is one of the few ways veterinarians can exercise control, although sometimes patients pay the price. Some veterinarians talked about clients who emotionally blackmailed them. “We’re very easy to blackmail, you know. Because usually we’re in the profession because we like animals – most of us – and so people always blackmail us. [They say], “If you don’t do it I’ll drive over him with a truck” or something like that. Even if the welfare of the animal is your primary objective, you should not become the garbage dump for everybody to drop off their animals if they don’t want [them]…I mean, let them drive over the poor thing. Maybe he won’t do it because he’s too chicken or maybe it’ll give him something to think about when he squishes the poor cat. I kind of refuse to play along with this kind of blackmail.” Leslie, companion animal practitioner This veterinarian is an avid promoter of animal welfare within the community. In maintaining that veterinarians should be able to stand on principle of helping animals and treating them as valued family members, veterinarians sometimes feel forced to refuse care. Non-compliant, difficult clients – problematic clients – are more likely to be refused service or assistance. Unfortunately, the animals in these scenarios were denied veterinary care or a peaceful death based on their owners’ perceived faults. Tolerating Substandard Care Assessments of clients influenced veterinarians when deciding whether to contact the humane authorities. Veterinarians often encounter situations of substandard or even  82  inhumane animal care. In these situations, veterinarians decide whether they will continue to work with clients, terminate the relationship completely, or contact the humane authorities. Although veterinarians might recognize that animal care is inadequate and inappropriate, they intervened in different ways, sometimes based on their assessments of the client. In some cases, veterinarians tolerated poor animal care. Some participants suggested that incremental progress in borderline neglect cases was acceptable but only if the client seemed to be motivated to improve. Some of these problematic clients were malleable enough that the veterinarian continued to provide care if they could see some progress. In the following excerpt, Harry talked about a dog breeder who provides marginal care. “She cares for them, she wants to care for them, but she doesn’t care for them well, as well as she should because of the numbers…It’s not errors of commission. It’s errors of omission. I’ve been dealing with her for a long time. It’s one of these people where you make incremental progress and then you go back, and then you make incremental progress. She’s probably one of my top ten or fifteen clients for money but I had two veterinarians who said, “Oh I’m not going to see her because she’s just being irresponsible. She’s a puppy mill”… She is trying very hard and she takes probably more than three of your suggestions to heart and really tries hard. So, that’s as much success as we’re going to have. It sometimes takes a little stretching in my mind to keep on being her veterinarian but I see incremental progress all the time.” Harry, mixed animal practitioner In this situation, Harry suggested that the client is trying hard and cares about her animals but does not provide appropriate care. Rather than dismissing her as a client, he believed that he can improve the circumstances for the animals incrementally. Most participants related some experience in cases where the care provided to the patients by clients was substandard. In some cases, the neglect was quite severe. Following are Maureen’s comments about a client who had approximately 20 % of his cattle die from starvation over a period of several months. Although Maureen acknowledged that the animals died from neglect, she indicated that the client is normally someone who cared about his animals.  83  “So that’s tricky because we know him as a client here with his other animals and his other pets. And I mean they get a bug bite practically and they’re on the phone, with his horses and their other animals, so they’re very conscientious people. And so to see this happen was really weird for me because I know what they’re normally like. And he was feeding them, he just didn’t know all the right requirements.” Maureen, mixed animal practitioner These cattle died over a long period of time and the client did not seek the assistance of the veterinarian when they began dying. Maureen only became involved in the situation when the local humane authorities became involved. Due to her experience with the client and her belief that he was conscientious, she treated the episode as an unfortunate case of ignorance about cattle nutrition. Ultimately she defended the client to the humane authorities to avoid legal intervention. In another example of substandard care, Aaron described a client as someone who ‘horribly neglects’ her animals. “They brought me this dog that so-called had it’s paw stuck underneath the door, and you know it essentially had an open fracture that was about 5 to 7 days old – just a horrible fracture. And the clients were saying “Oh I wasn’t too sure I thought it might heal on it’s own.” So, it’s part neglect, there’s part ignorance, and there is certainly a part gross misconduct as far as I am concerned... She felt bad about it. Some people’s lives… are so horribly dysfunctional that often it’s not because of lack of awareness. It’s that their life is completely spiraling out of control. I think they are still capable of guilt and shame and other areas of feeling, obviously because she brought the animal to me ultimately. So I have to give them credit for that…Ultimately we decided not to [call the SPCA] because she knew what she had done and this may sound silly, but she sounded contrite and sincerely apologetic.” Aaron, companion animal practitioner Even though Aaron knew the client as someone who did not provide adequate care to her animals, he chose not to contact the humane authorities because the client was contrite. Clients who veterinarians judged favourably (usually conscientious in the cattle starvation case or contrite in the fractured paw case) were not reported to the humane authorities.  84  Clients judged unfavourably did not receive such protection from some veterinarians. Marion described two cases, both SPCA checksxx, with dramatically different outcomes for the patients. In the first case, she evaluated the owners of two severely sick and neglected horses. “Those people shouldn’t have horses. I will tell you, I don’t even think they should have children…it’s disgusting. I look at them and I think, “You are rearing children? And you are dumb as a post.” They are not intelligent people and they don’t have the self-preservation to go and get more education….They live in a pigsty…Some people are just lazy, dumb people”. Marion, companion animal practitioner Marion insisted on euthanizing both horses and admits that she was nasty to the horse owners. However, in a second example, she described another SPCA call to a severely neglected horse that she believed was in worse physical shape than another horse she advised to euthanize for humane reasons. Although the horse was in poor shape and neglected, Marion had sympathy for the clients. She described the elderly owner as follows: “She’s going to be ninety…I bet you she weighs 70 pounds soaking wet..I go into their house and meet the lady’s son. The lady has a boy who speaks through a tracheostomy site. I think at first, “Oh you probably smoked yourself into that.” I find out that the boy got hit four years ago in a crosswalk and he speaks through that and he is all buggered up on his right hand side…They have nothing. They live with nothing. They have no money. They have a whole bunch of rotten chicken eggs out on their back porch. The stench is amazing… That situation was very difficult for me because I thought, “Man, the best thing for this horse…would be to put the horse down.” I talked to the boy about that too, and his eyes filled with tears…[I told the SPCA to] go back and pay the lady a visit because her son is more buggered up than the horse.” Marion, companion animal practitioner In both stories, Marion described very ill horses, but in the first case, she evaluated the owners as ‘white trash’ in her own words. She had sympathy for the owners in the second example, and did not insist on euthanizing the horse, even when she believed xx  The Society for the Prevention of Cruelty to Animals will contact a veterinarian or instruct an animal owner to contact a veterinarian as a result of an allegation of animal abuse or neglect. The veterinarian will examine the animal and make recommendations to both the client (who pays for the exam) and also the SPCA, who is acting as an animal cruelty and neglect enforcement authority.  85  euthanasia was in the horse’s interests. Rather than euthanizing the horse, Marion helped the clients care for it by donating services and dropping off food. Having a long, well established relationship hampered veterinarians in some situations because they sympathized with their clients. During one interview, the veterinarian was adamant that he would always intervene when he thought animals were suffering. This participant, a food animal practitioner, recounted a story in which he encountered pigs housed in inhumane conditions and he euthanized the animals immediately. However, when we visited one barn having very sick animals, he did not intervene in such a dramatic way because he had sympathy for the producer. My field notes from this period read: “There were a number of animals that were seriously sick. One pig was lying on the slated flooring at the back of the pen. I could barely see her because she was barely moving, lying out flat and covered with (feces). She was trembling. Another gestating sow was in a crate at the end of a line of gestation crates. She too was barely visible, covered with (feces), immobile in the dim barn. A third little weanling pig, half the size of its pen mates had swollen joints almost the size of its head, one that was badly ulcerated. I was appalled by the state of the barn. It was unlike the other barns we had visited. I pointed out the pig at the back of the pen and [the veterinarian] said, ‘yeah, he hasn’t had a chance to take care of [meaning euthanize] some of these animals.” Afterwards, in the car, I asked why he hadn’t done something else about these animals – euthanized them himself or read the producer the riot act. Had he considered calling the SPCA? He said that he wasn’t happy about the situation. He didn’t want to say too much to the producer because I was there – it might embarrass him. But he said that he also felt badly for the producer who was having a hard time at home and also taking care of so many animals and he was unable to hire help. Employees were difficult to get and keep.” This situation was a clear example of substandard care and although the veterinarian was adamant that poor care should not be tolerated, his vision of the client as a good client, who had fallen on hard times, influenced his decision on how to handle the situation and he decided not to intervene by contacting the humane authorities. In summary, assessments of clients and clients’ circumstances influence veterinarians’ decisions about the care of patients. Some participants altered the level of information they disclosed to clients based on these assessments. Clients identified as nice or caring might receive free or reduced cost veterinary services. Yet, problematic 86  clients were not assisted and neither were their animals. Clients who did not provide an adequate level of care might be afforded protection from humane authorities based on their positive attributes. Discussion In order to make decisions about animal care, participants in this study included evaluations of clients as part of their decision process. Veterinarians held beliefs about the appropriate use (and use-associated management) of animals and the degree that clients should invest resources into the care and treatment of an animal. These beliefs created expectations, on the part of the veterinarian, about the way a client should be acting with respect to their animal. As a result of these expectations, participants evaluated the ‘goodness’ of clients. This study corroborates previous research 53 that showed that veterinarians categorize some of their clients as good and some as problematic. Ongoing relationships with clients allow veterinarians to assess them as good or problematic, as do other cues. Non-verbal cues including emotional responses and physical appearance (youth or appearance of wealth) triggered assumptions about clients’ ability to finance veterinary services. Clients appearing not to care about their animals, particularly if they were assessed as able to pay for veterinary care were judged more harshly. Having a proven history of providing care to the animal through regular examination and treatment compliance aided veterinarians in assessing a client as responsible. Some veterinarians tested clients by evaluating their willingness to participate in treatment plans or diagnostic tests. Evaluating clients allows veterinarians to make decisions about disclosing information to clients, providing free or reduced cost services, refusing service, and in managing cases of substandard care. Before considering some normative questions that this research raises, it is important to make explicit some linkages between the data presented in this chapter with data from the previous chapter. As noted in the previous chapter, participants’ valued animal life at different levels. They also valuated animals based on attributes such as usefulness, anticipated lifespan, and attractiveness. A young, cute, or nice companion animal with a readily treatable illness or injury will be evaluated differently than a nasty or  87  old patient. These valuations of patients appear to influence their beliefs about the appropriate care and use of animals. Recall a quote in Chapter 3 from Martin, who refused to donate services to the client of an aggressive dog.  “I’ve got certain animals, certain situations, that I am more than happy to do for free. There are certain situations that I’m not. And that’s my decision….it’s a rotten little dog. It should be euthanized.” Martin, companion animal practitioner Martin placed little value on his patient and believed that it was not a good companion (belief about animal use) and that it should be euthanized. These beliefs about this particular dog created expectations about how the client should behave. When his client asked for a reduced free due to financial constraints, he refused, believing that the client was acting unreasonably simply by having the pet. Thus, veterinarians judging animals as valuable or non-valuable (according to their own criteria) may develop expectations about the appropriate care and use for that animal. Beliefs about appropriate care and use of animals in turn influence assessments of welfare. In Chapter 3, I showed that veterinarians categorize pain; some believed that the pain caused by castration without anaesthesia was short-term. Because it was shortterm, it is acceptable to perform castration without anaesthesia in animals intended for food. Castration without anaesthesia in animals used as companions is not acceptable, and companion animals would suffer if they experienced castration without anaesthesia. Thus, the category of use of the animal influences the beliefs about appropriate animal care, which in turn influences assessments of welfare. When assessing welfare, participants sometimes used information from clients. Veterinarians rely on clients for information about patient behaviours and clinical signs (e.g. patient anorexia or lameness). Some participants relied on client judgements of animal welfare when making some decisions. For example, a client may feel that their animal is not in pain and does not require analgesics. Alternatively, a client may believe that their animal is in so much pain that they demand euthanasia. Veterinarians judging these clients as reliable sources of information about the animal’s welfare may simply  88  accept the client’s interpretation. However, veterinarians, as noted in Chapter 3, do not always trust client assessments of welfare. Veterinarians may disregard information regarding the welfare of patients from clients deemed unreliable. Assessments of clients, positively or negatively, influence the trustworthiness of the information they provide, which in turn, might influence how veterinarians assess welfare. 109xxi Beliefs about the value of animals, in general, and the value of specific animals, are interconnected with beliefs about how animals should be used and the level of care that is appropriate to provide. The welfare of animals is inextricably intertwined with ethics 99,100. In veterinary medicine, assessments of client ‘goodness’ are intertwined with beliefs about animal welfare, beliefs about the ethics of animal care and use, and beliefs about the value of animals. Meshing of these various beliefs along with assessments of patients and clients may result in diverse opinions or reactions to morally significant scenarios. Veterinarians, and those working with veterinarians, may find this exploration of the complex interconnections in the veterinary-client-patient relationship useful in furthering moral reflection about veterinarians’ responsibilities to clients and patients. Information presented in this chapter raises a number of normative questions. Appropriate Uses and Levels of Care Veterinarians’ beliefs about the appropriate animal use (and procedures related to use) and the level of care that veterinary clients should provide will influence many veterinary decisions. These decisions include whether to use analgesics; whether to conduct certain procedures (e.g. non-therapeutic surgery); whether to perform euthanasia; and whether to contact the humane authorities in abuse or neglect situations, among others. For example, veterinarians believing that clients have expended too many resources may encourage euthanasia of the pet. Alternatively, veterinarians may refuse euthanasia when they believe that clients have not expended enough resources to diagnose or treat a problem. Rollin 14 suggests that the treatment of animals can no longer be left to the discretion of the animal owner as there are societal norms governing their care. Hewson 118,119 argues that animal welfare is a public good and that the veterinary profession should lead in promoting the welfare of xxi  For further discussion on this topic, please see Morgan 2007.  89  animals. Since veterinarians have diverse views about the appropriate use and level of care, implementation of social policy relating to animal care may be difficult. Provincial legislation provides some direction, requiring animal owners to provide food, water, and shelter. Some provinces require animal owners to provide their animals’ veterinary care, but the degree of care is not delineated. Food animal quality assurance programs might require veterinary care but do not stipulate the level of care. Like human medical care, the costs to diagnose and/or treat medical problems seem limitless. To what level of veterinary care are animal owners responsible? Beliefs about the appropriate level of care that clients should provide to their animals become increasingly important in situations of neglect. At what point does poor animal care become neglect? Several provinces now require veterinarians to report instances of animal abuse. Humane authorities rely, in part, on individual veterinarians to identify lapses in the standard of humane care. Yet, many veterinarians practice in relative isolation and create their own ideas about appropriate care. In order to promote the welfare of animals, the topic of what constitutes adequate veterinary care deserves more discussion within the profession. Oftentimes standards of care presented through formal educational venues (such as continuing education seminars and conferences) present a best-practices level of care rather than a minimum level of care. Since the level of animal care that is appropriate is value-based and not solely scientific (although science might influence decisions), veterinarians need to explore this question with those groups who have an interest in the care and treatment of animals. One solution to this might be increased dialogue between veterinary associations, their members, and humane authorities including court decisions regarding adequate and inadequate levels of care. Veterinary Partiality Some participants in this study indicated that, based on their assessments, they treated clients differently. Although provincial regulatory bodies state that veterinarians have a responsibility to treat clients impartially, fairly, and objectively,38,120 some practitioners did not treat clients impartially. Good clients were more likely to receive financial assistance than were problematic clients. Veterinarians were more likely to refuse or terminate services to problematic clients.  90  Although veterinarians may not be able to assist all needy clients with the provision of charitable services, the manner in which veterinarians chose to distribute charitable services is morally important. Rather than basing these decisions of the affability of clients, veterinarians should consider whether assessing the ‘goodness’ of a client is an appropriate method to dispense charitable acts. Besides questions about equitable treatment of clients, veterinarians’ assessments of clients as irresponsible or uncaring affected whether patients received veterinary services. The animal of a good client might receive free veterinary care when the animal of a problematic client would not. Veterinarians may wish to consider why the animal of an apparently uncaring or disagreeable client ought to be treated differently in their practice. Practitioners may wish to consider whether patient need rather than client characteristics should determine the distribution of their charitable resources. In other words, veterinarians might consider taking a more patient-centred approach rather than a client-centred one. Furthermore, the profession appears to consider provision of free or reduced cost service as supererogatory acts;12 acts that are praiseworthy but not morally obligatory.44 Some countries require veterinarians to provide animals relief in emergency situations,39,46 however, neither provincial legislation nor veterinary regulation obliges veterinarians in Canada to assist animals in many situation including emergencies. Should veterinarians be morally responsible for providing free services? If so, under what circumstances should veterinarians provide service and to what degree? If resources are limited, veterinarians and the veterinary profession might consider developing equitable procedures or further augmenting systems that provide animals care in, at least, some situations. Some participants refused service to or terminated relationships with difficult clients. Problematic clients not only impede the routine of the practice  53  they present  risks to the veterinarian. Risks may include personal safety, financial risk, litigation, or complaints to the veterinary regulatory body. Uncaring clients are considered disagreeable and may create emotional turmoil for veterinarians who worry about the consequences to the patient. According to provincial regulatory bodies, veterinarians are entitled to terminate a client relationship under certain circumstances.40 ‘Firing’ clients is a method that veterinarians can employ to limit their exposure to disagreeable or risky 91  clients – problematic clients. Some of the veterinarians in this study recognized that animals may suffer because they refused service to the client. Nevertheless, they felt justified in doing so. Although veterinarians should be able to control how they engage with clients in their own practices, how should veterinarians respond to problematic clients, particularly when their patient may be at risk? Is terminating or refusing service acceptable? The circumstances under which veterinarians should refuse services to clients or terminate veterinary client relationships deserve more investigation and discussion. Another interesting result of this study showed that veterinarians were less likely to report cases of substandard care to the humane authorities if they assessed clients as a caring or contrite, or sympathized with them. Some participants felt that seeking the assistance of the humane authorities was confrontational and that caring clients did not deserve this type of treatment, regardless of the poor care they provided to their animals. Some veterinarians would refrain from contacting the humane authorities as long as they could appreciate incremental improvement in animal care. Moreover, clients classified more negatively yet providing similar levels of care to their animals were treated differently. Veterinarians penalized these problematic clients by calling the humane authorities. In this strange paradox, the animals of marginally good clients may not receive what veterinarians consider good treatment, but the animals of problematic clients may receive attention and assistance from the humane authorities. Veterinarians’ Ability in Assessing Client Interests A final concern that this research raises is the ability and appropriateness of veterinarians’ assessments of clients’ interests. Some participants revised diagnostic or treatment recommendations based on a client’s non-verbal cues, hurriedly revising treatment recommendations based on clients’ emotional responses. Clients, when first encountering troubling news, might not be in an appropriate frame of mind to make important decisions. Veterinarians may misinterpret clients’ responses as unwillingness or inability to provide care for their animal.  Alternatively, presumed wealthy clients, who  balk at treatment for an animal because they are planning a holiday, may be assessed by a practitioner as selfish or uncaring. However, these clients may simply be voicing  92  their concerns about the turmoil they are experiencing. More research into client decision-making and communication patterns in these situations may help veterinarians to better understand the reliability of assessing clients. Veterinary education provides little or no formal training in assessing the mental states of people. Nor are veterinarians formally equipped to deal with situations in which people are having difficulty functioning in their day-to-day lives. Thus, veterinarians may not be the best judges or they may not be able to make good predictions of how well some people will manage to cope with the challenges of providing care to their animals. The veterinary profession suffers from a lack of allied support that the human medical system enjoys. In order to promote the welfare of animals and assist veterinarians in fulfilling their responsibilities to both clients and patients, the veterinary profession should consider methods to resolve this problem. Regardless of veterinarians’ ability to evaluate clients, the acceptability of the criteria used, and the level of influence this evaluation has on treatment decisions, it is unclear what level of influence these sorts of evaluations should have when making decisions affecting the well being of patients and clients. Evaluations of clients’ and assumptions made about clients’ interests, raise questions about professionalism, autonomy, and informed consent, which will be discussed in greater detail in the following chapter. Conclusion Veterinarians held different beliefs about the acceptable use and the level of care clients should provide to animals. Categorization of clients according to their fulfilment of these responsibilities, caused veterinarians to modify their decisions about patient care and the type of information they provide clients. These assessments influence veterinarians when deciding to refuse services, when deciding to provide free or reduced cost services, when disclosing information, and when tolerating substandard patient care. Problematic veterinary clients reduce the level of enjoyment of veterinary practice121 and impede the normal routine of the practice.53 They also present moral problems for participants when trying to negotiate their responsibilities to patients. For the practitioner, this information presented may allow them to consider whether and if so,  93  how, they should be evaluating their clients. Veterinarians should also consider whether their assessments of clients have unintended negative consequences for their patients. For the veterinary profession, the fact that veterinarians do assess the merits of their client highlights the need for increased discussion within the profession and within the general public about animal owners’ responsibilities to animals and veterinarians’ responsibilities to patients.  94  Chapter 5: Veterinarians’ Views Regarding Their Professional Role So far, I have shown that veterinarians hold beliefs about what constitutes animal welfare and also about the appropriate care and use of animals by owners. Participants evaluated their patients and clients based, in part, on these beliefs. Veterinarians also described their professional role in managing ethically difficult situations. Members of a profession have ‘role defined’ obligations, meaning that by accepting the role of a professional, the individual promises to behave in certain ways and to fulfil (or at least attempt to fulfil) professional responsibilities.122 As previously noted, veterinary organizations explicitly define roles and responsibilities for their members. In general terms, national organizations define the societal role of veterinarians such as promoters of animal welfare and protectors of animal and human health.17,47 Provincial regulatory bodies provide further direction about the responsibilities of individual veterinarians, particularly in the veterinary-client-patient relationship. How do veterinarians interpret these role-defined responsibilities in their daily interactions with patients and clients? Historically, the veterinary profession was built on the treatment of military horses, the preservation of food resources and the management of zoonotic disease, but with time the profession expanded to include the treatment of animals previously considered of limited usefulness such as pets.13,33 There has been a shift in the way that both the public and veterinarians understand veterinary responsibilities107 with an increasing focus on care of companion animals. Nonetheless, this shift is somewhat controversial amongst some members of the profession who suggest that the profession should readjust its focus back to the prevention of food borne and zoonotic disease.123 Thus, members of the profession may not have a unified concept of their professional role or their associated responsibilities. This chapter explores how different veterinarians conceptualize their professional role. Rollin 14,37 claims that the fundamental question in veterinary ethics can be distilled down to a question of the prioritization of responsibility to patient or client. “Does the veterinarian have primary allegiance to the client or animal? Are animals moral objects in themselves, or are they of moral concern as someone’s  95  animals? Is the model for the veterinarian the garage mechanic or the pediatrician?”14 In this short passage, Rollin raises a number of interesting questions. The first question presents a dichotomous scenario in which a practitioner must choose between one of two parties: the client or the (animal) patient. This choice is predicated on the answer to the second question: whether animals are moral objects in themselves. The final question provides a tool to help conceptualize the problem, whereby the animal is seen either as an object or as a person. As a rhetorical device, this dichotomous thinking beautifully illustrates the tension in veterinary medicine regarding the standing of the involved entities. However, research suggests that human-animal interactions not dichotomous issues, rather they are clouded by ambivalence and ambiguity.13,32,33 Perceptions about the importance of animals vary111 but even within established an human-animal relationship, for example relationships with pets, human perceptions of the moral standing of the animal can be fluid.30,31 For example, Sanders30 found that veterinarians view some patients as more likened to objects that are “executed” with “little show of regret” rather than euthanized with great concern. However, patients with whom veterinarians had an identifiable relationship are afforded a greater moral standing. In a similar vein, Wilke31 noted that the moral standing of livestock changes with an animal’s ‘career’ with breeding animals and those needing nursing care garnering a status more akin to pets, unlike those animals about to be sent for slaughter. In other words, the moral standing of animals is influenced by their relationships with people. Thus, Rollin’s dichotomy may be oversimplified. This chapter presents participants’ views about 1) their professional role in society, 2) the priority to be given to the interests of patients or clients, 3) the importance of client autonomy, and 4) the importance of disclosing accurate information about the treatment and care of the patient to their clients. Based on these findings, I develop four professional models of the veterinarian-client-patient relationship. A discussion concerning the profession’s responsibilities follows, and highlights some ethically interesting problems with the way participants sometimes perceive their role.  96  Views about the Veterinarians’ Role As professionals, participants universally recognized that they play a role in both human and animal health and welfare. Maintaining the health and welfare of animals benefits both people and animals. Some participants emphasized the importance of the profession in improving human lives. This included providing safe food. “Our responsibility to society, at the end of the day, is [that] we’re part of the food chain… Our responsibility, ultimately, is food production and to produce stuff that’s safe for your children to consume.” Peter, food animal practitioner As well as ensuring the production of safe food, the veterinary profession benefits human health through the reduction of zoonotic disease transmission and the enhancement of mental and/or emotional human health by fostering and preserving the human-animal bond. “It’s human health, it’s human mental health in a lot of [the cases] and human physical health sometimes, depending on what’s going on. So we play a big role for people as well as with our animals and probably a bigger role with people than even with the animals themselves.” Angela, companion animal practitioner Other veterinarians emphasized animal welfare as the major role of veterinarians in society – regardless of any immediate human benefit. The belief in the importance of animal welfare to society, and consequently the veterinary profession, seemed to stem, in part, from the concepts of stewardship. Several participants indicated that veterinarians should be the stewards of animals and are responsible for animals in general and not exclusively for their own patients. “I think that veterinarians have to be responsible for the stewardship of animals…We’re the ones that are trained and can make the judgments, and so we have that obligation to direct the owners and [direct them] in the right direction” Earl, companion animal practitioner “[Veterinarians have] accepted the responsibility to be the people that are looking out for the welfare of our patients. That’s our number one job – to consider the welfare of our patients. And not just our patients but all animals, whether they’re patients or not.” Mercy, mixed animal practitioner  97  Beyond this sense of stewardship, some participants believed the welfare of animals is a ‘good’ in itself because animals are worthy creatures deserving respect. Rather than benefiting people through animals, these participants felt that societal support of animal welfare was evidence of a healthy well-balanced society. Treating animals well is a measure of how well society is doing – in a moral sense, and that respectful treatment of animals was virtuous. In the following quote, the companion animal practitioner, who prefaced this quote with a story of how he grew up in a community surrounded by wildlife, explained that his drive to become a veterinarian came from the respect he held for wild animals. “It just always seemed to me that as a society there had to be professionals who stood up for those who didn’t stand up for themselves…There are still animals that we see on a daily basis in our society that nobody speaks for, and again it comes down to advocacy….My role as a veterinarian is to make sure that as an advocate I do what I can for the patient. I think the trickle-down is then I can make society a better place because then we have better relationships with the animals around us…If we treat animals around us humanely and if we treat them respectfully, whether we still kill them and eat them or not, we can still do it respectfully and we can still do it appropriately. If we have a society that fails those two things, then we don’t have a very developed society.” Jerry, companion animal practitioner A few veterinarians practicing exclusively with food animals believed that a significant role for a veterinarian was to improve productivity and the economic health of their clients. “I think it more goes to the heart of how I rationalize my existence as a veterinarian… I value my services because I think that they help the producer and so I have an easier time justifying all that I do. ” John, food animal practitioner In summary, virtually all participants believed that veterinarians benefited society by improving the lives of both people and animals. However, they differed in their emphasis on benefiting humans through animal use and benefiting animals themselves. Some participants believed that veterinarians serve society by making animals more useful or safe for humans, whereas others believed that veterinarians further the betterment of society by protecting and teaching respect for animals as living beings. A few participants believed that veterinarians played an economic role by improving  98  productivity. These different stances towards the profession’s role in society likely influence how veterinarians manage their responsibilities within the veterinarian-clientpatient relationship. Prioritizing the Interests of Patients and Clients Although many times the interests of patients and clients are concordant, many participants indicated that they encounter situations in which the interests of patients conflict with those of their clients. Veterinarians grappled with balancing their responsibilities and negotiating these conflicts. “It can be a really wicked triangle between what you want to do and what the client wants to do and what’s best for the animal.” Melissa, mixed animal practitioner “That’s a big ethical area: Where do you put the importance of the (veterinarianclient-patient) relationship, because it’s the client who pays the bill but it’s the animal who is receiving the care. And where do you draw the line in terms of adjusting your care to meet the needs of the client?” Sandy, companion animal practitioner In daily activities, veterinarians must decide how to juggle their responsibilities to patients and clients and sometimes veterinarians choose sides. Approximately one third of participants identified their patients as their primary concern. “My focus is always on the animal. I secondarily, or closely afterwards, will look at the needs of the client. But no, my business is first and foremost with the wellbeing of the animal, and secondarily to their integration in a home of human beings.” Aaron, companion animal practitioner “My first responsibility is to the patient and the second is to the client. I don’t see it the other way round…it has to be that way. If it isn’t that way then immediately my hands become very tied and I can’t have another opinion other than the opinion of that client. I can’t do anything other than what the client wants me to do.” Mercy, mixed animal practitioner Regardless of some veterinarians’ conviction that the animal should be their priority, they also noted that clients play a significant role in decisions. Clients control the veterinary  99  access to the patient and can limit veterinarians’ latitude in treatment and care options. Interestingly, some participants identified clients as ‘gatekeepers’. “My responsibility first and foremost is the humane treatment and care of the animal, because I’m its advocate. Because the client sees things differently than I do and the animal sees things differently than I can understand - because I don’t understand the animals that well. So I kind of have taken on the mission that I am the advocate for its humane care and treatment. However, I also understand that there is a big doorway that I have to get through – to do what I am able to do. And that doorway has a gatekeeper and there is a key to open that door and that’s the client. So that in all cases I am respectful of that. I have to satisfy or I have to be trusted by the gatekeeper to allow him the confidence in me to open the door, turn the key to let me through to help his animals.” Murray, mixed animal practitioner By recognizing that clients enhance or limit veterinary access to the patient, as a strategy some participants tried to satisfy the needs of their client in the short term in order to gain client trust. Fostering trust allowed them to effect change for the betterment of animals in the long term. Several participants believed that short term harms to patients could result in long term benefits to the patient, if the client learned from the interaction. For these participants, a veterinarian may feel obliged to further the interests of the patient but in order to gain access to the patient the client’s needs must also be satisfied. “Well, first and foremost I’m responsible for the care of the patient. But I know that if I am not being responsible with a client, that the patient may get poor care and so I can’t give the patient good care at the expense of not getting along with the client.” Sally, companion animal practitioner Although some participants talked about this strategy to further the interests of patients, other participants thought it important and morally correct to consider the interests of both patient and client, rather than advocate for the animal. Many participants tried to achieve a balance of satisfying the needs of the clients, while minimizing harms and risks to patients. “I think there are definitely lots of [veterinarians] out here that work on the client’s behalf and not the animal’s, and I try and work on both of their parts…There are vets out there that just work on the client’s behalf and just do whatever it is they want doing.” Amanda, mixed animal practitioner  100  In addition to illustrating that some veterinarians try to balance the needs of both patients and clients, Amanda also indicated that she believes that ‘lots’ of veterinarians give priority to client interests. Some participants of this study confirmed that they tended to align themselves with the concerns of the client, and although the treatment of the animal was an important consideration, ultimately the client was central. “I have a responsibility to the animals but I don’t believe - I have a problem thinking - that my primary responsibility is the animal…So when it comes to “My prime responsibility is the animal”, if I were to put it that way, it would be really difficult for me to practice.” Michael, mixed animal practitioner In contrast to participants who placed the interests of animals in the forefront, these veterinarians focused on the needs of their clients and seemed to favour a more instrumental view of animals. “My purpose is to help their pet feel better and in doing that help the person feel better. I always tell my clients that “People come first…the idea of a pet is to be a support to you. So if this animal starts costing you more than you can afford, or if this animal is peeing on your breakfast and really giving you trouble, it is not your responsibility to care for that pet to your own detriment.” So they always have an out with me. If it’s not a suitable pet, then it’s not fulfilling its role as their pet, then it’s okay to get it another home or put it to sleep. So, people first, pets second. But then the pet has to be feeling well so the person can enjoy it.” Sylvia, companion animal practitioner Some participants noted that their clients held differing values relating to the type and quality of care that patients should receive and that these values should be respected. The responsibility of a practitioner involved fulfilling the needs of the client. The following excerpt shows that this food animal practitioner believes that veterinarians should seek to identify (and satisfy) the clients’ goals. “The clients that I have, have different profit centers, and you have to first understand and respect where they make their living because everyone should make a fair living throughout the system…So what you do is, is understand as much as you can the components that allow that person to make a living and then work from there. In the case here, [the] commercial producer makes a living on a price per pound, made to the market, so as a vet you work on that. And then you try to use innovations and ideas and management…So by understanding your customers’ motivation, you use your skills or whatever to help them.” Lex, food animal practitioner 101  According to this view, clients (customers) choose to manage their animals in certain ways and their choice should be respected and given priority. In some cases, participants accepted requests for services that the veterinarian believed were definitely not in the animal’s interests; placing the importance of client interests clearly over those of the animal. In the quotation below, Sean, a companion animal practitioner described the evolution of his attitude regarding client choice over the course of his practice life. “So I changed my attitude towards the animal. The animal is now not a total commodity - just a way to practice my profession [or] a way to make money and to make Mrs. Jones happy – whatever she wanted she would get. If someone came into me 20 years ago and said, “I want my cat’s tail sewn up its ass”, I’d quote. It was that calculated and cold. And a lot of my friends of my age were the same. [They would] do anything, as long as they’d be left alone. Don’t get sued; just do it.” Sean, companion animal practitioner  In this quote, the participant created a fictitious scenario – one that was clearly detrimental to the patient – in order to illustrate how he was accustomed to practicing. A client, such as Mrs. Jones, would make a decision regarding the treatment of the patient and the veterinarian would follow the client’s wishes without questioning the appropriateness of the decision. In other words, the wishes of the client were given clear priority over the interests of the patient. In summary, participants held differing beliefs about how veterinarians should order their responsibilities to patients and clients when interests conflict. Some felt that veterinarians should place the interests of animals first: others believed that both the client’s and patient’s interests must be accounted for, and still others believed that the interests of clients should be at the forefront. These beliefs regarding prioritization of responsibilities appear to fall on a continuum and not into clear discrete categories. The Importance of Client Autonomy Although participants claimed to prioritize the interests of patients or clients within the veterinarian-client-patient relationship, they were also influenced by their beliefs  102  regarding professional behaviour. Many participants discussed their attitudes towards client autonomy, although they did not use the term ‘autonomy’. Patient autonomy is an important concept in medical ethics. In veterinary medicine the concept of client autonomy is found in the informed consent doctrine.124 According to provincial veterinary regulatory bodies, veterinarians must first obtain informed consent before treating a patient. This process aids in ensuring the autonomy of animal owners. Participants varied in the way they viewed client autonomy with some placing significant importance on it and others giving it less emphasis. Some participants held that veterinarians should provide clients with information only and allow clients to make decisions for themselves. For these participants, client autonomy in decision making was very important. “Well it’s always the choice of the owner. Always, always, always, to make decisions on their pet. It is my duty to inform them as much as I can about what is going on with their animal and to give them options as a way of informing them, because people don’t know how you treat a femoral fracture. People don’t know how you treat lymphoma in a cat. The general public does not know that. So it’s my duty to inform them of what they can do with their animal. That’s my job. My job is not to make the decision of what to do. So, as long as I am informing the owner of their options, then they make the decisions. And it makes it very easy for me because the decision is the hard part. Giving them their options isn’t the hard part.” Sally, companion animal practitioner For Sally, the veterinarian’s responsibility is to act as a resource to provide information and the client must act as the final decision maker. Although some of the participants holding this view may believe that their patients were their first responsibility, their sense of professionalism and responsibility to allow clients to choose superseded responsibilities to patients. Another participant reiterated that veterinarians should not impose their own views on decisions, particularly on difficult decisions such as euthanasia. “I find some people want you to make the choice and that is one thing that was really stressed in school. You cannot choose when to put the animal down and even if they tell you “Tell me what to do”, you have to give them the options and say, “I can’t choose for you”.” Angie, companion animal practitioner  103  Although the decision to euthanize a pet is understandably difficult for many people, this participant felt that her professional responsibility prohibited her from influencing client decisions. ‘It’s their choice’, ‘The owner has the right to decide’, ‘It’s not my choice’ were common phrases of those who both respect the client’s autonomy and view their clients as the final decision maker for the patient. As a third example of how some participants place great value on clients’ autonomous decisions, below is a field note excerpt that illustrates how one veterinarian communicated with a client about various treatment options. In this case, a dog was admitted to the hospital for radiographs of a lump on its jaw. The veterinarian strongly suspected bone cancer, which generally carries a poor prognosis for the patient. “[The veterinarian] talked to the client on the phone. I only heard one side of the conversation. He told her that the X-rays were strongly suspicious of cancer. He mentioned that the treatment of choice was to remove a large portion of the jaw and possibly do radiation therapy. The client must have asked what she should do because [the veterinarian] said that the choice was completely up to her. If she wanted to put the dog to sleep, that was fine. If she wanted to do surgery, that was fine. If she wanted to wait until her dog was having trouble managing his life, then that was fine too. He said, “Whatever you decide to do, is the right decision. Whatever you decide, is fine, no matter what you decide”.” The veterinarian in this scenario placed great importance on the client’s choice to make a treatment decision, to the degree that he offered the client little direction in choosing one option. Participants placing great importance on client autonomy thought that veterinarians should provide factual material in the form of all reasonable options for treatment but should not influence clients in making decisions. In contrast to those citing the importance of respecting client autonomy, some veterinarians admitted to influencing clients and believed that, at least in some cases, it was acceptable to make decisions for clients. Those placing less importance on client autonomy seemed to divide into two camps depending on the context – those that influenced decisions for the betterment of clients and those for the betterment of their patients.  104  Overriding or heavily influencing client decisions may be classified as medical paternalism  44  by making decisions for the benefit of the client.xxii Some participants  believed that at times a veterinarian should act paternalistically to further the interests of the client regardless of the client’s own views or stated preferences. According to the veterinarian, clients may be acting unreasonably and may be denying their own valid interests. For example, one participant determined that a problem was too great for the client to manage and suggested euthanasia even when the patient’s condition was potentially manageable. “Sometimes I have recommended euthanasia for the sake of the owner because the owner was completely and emotionally destroyed by the situation and wasn’t able to handle it any more, financially or emotionally, and the person was mentally not…capable of handling it or understanding it, or the expenses were just mounting up so high that it was just becoming impractical for this person to deal with it…I put a lot of emphasis on compassion for the animal but sometimes you have to look at the owner and say this person’s just cannot handle this anymore.” Scott, companion animal practitioner By recommending a course of action, Scott made an evaluation of the client’s ability to manage the problem with their animal and felt a responsibility to ‘help’ the client relieve themselves of the burdens of caring for the pet. A veterinary recommendation to euthanize a pet would likely carry significant weight for a client and by doing so, may limit the client’s autonomy. Alternatively, veterinarians may override or influence clients in order to direct clients towards a path they believe is more beneficial for the patient. As professionals and experts relating to animal care, some participants believed that the veterinarian should encourage clients to follow a path depending on the veterinarian’s views of the most appropriate course of action. In the following quote, Marion described her experience with a client and his dog suffering from a serious illness. In her story, she outlined how the client was unwilling to euthanize his dog although he visited the clinic because the dog was not doing well. Given that the dog had a serious disease with a  xxii  Medical paternalism describes the situation in which physicians are “inclined to act beneficently by protecting patients against the potentially harmful consequences of their choices.”14  105  poor prognosis, she believed that euthanasia was the best course of action for the patient. “He couldn’t kill the dog. He just couldn’t take his dog’s life. And he sat in the exam room all day. I stayed with him because that dog needed to go to heaven…It took a while to convince him that the dog would be better off in heaven than here - suffering. And sometimes I think that’s our job. That’s a really hard thing… to make them make the right decision...Some people are very selfish. They’ll hold on forever.” Marion, companion animal practitioner Although the client did not wish to euthanize his dog, the veterinarian believed that it was the best course of action under the circumstances – there was only one correct decision in her view. The quote also shows how she believed that it was her job to convince the client and ‘make them make the right decision’. To some participants, directing clients or overriding their decisions was not only acceptable but it was a responsibility. Participants talked about ‘redirecting’, ‘encouraging’, ‘convincing’, ‘manipulating’, and ‘coercing’ clients into making decisions that the veterinarian believed was appropriate. This belief and its associated behaviours is not paternalismxxiii in that it is not aimed at benefiting the client but rather replaces client values and beliefs regarding the care of the patient with those of the veterinarian. In summary, some participants placed great importance on client autonomy and felt that clients should always be the final decision makers with respect to the care and treatment of the patient. Some held this view even when clients indicated that they did not wish to make decisions. Alternatively, some veterinarians placed less weight on the importance of client autonomy. In some cases, participants mentioned influencing client decisions for the betterment of the client in a paternalistic fashion. Other veterinarians mentioned influencing client decisions for the betterment of the patient. The Importance of Information Disclosure Another recurrent theme cited by participants was the importance of the responsibility to disclose accurate information to clients. This responsibility is frequently xxiii  ‘Paternalism’ is sometimes interpreted as oppressive manipulation, for the purposes of this dissertation, ‘paternalism’ is defined in the ethical sense of protecting the individual from the consequences of their choice as noted in previous footnote xxiii.  106  contained in professional rules governing veterinarians. Nevertheless, participants held differing beliefs regarding their role in disclosing information. Disclosure of information is closely linked to the concept of client autonomy. As mentioned in the above section, some participants believed that it was a veterinarian’s responsibility to inform their client by providing clients with a variety of treatment options to ensure that clients could make their own decisions. “You know some [veterinarians] say you should just say “This is the choice to make” and [clients] respond to that better. For me, that’s not what I do. I always give people options, even people who have said, “I have no money”. I give them the ultimate A level, most expensive option, all the way down.” Angela, companion animal practitioner This quote shows that Angela believed that it was important to disclose all treatment options even when she knew that some of these options were not viable options for some of her clients. Participants highlighting the importance of giving clients options for the treatment of their animals also mentioned the importance of education as a professional responsibility. Although the veterinarian may hold substantially different values relating to the patient or opinions on treatment options, their responsibility lies in providing the client information. Some participants evaluated clients as poor decision-makers or caregivers, yet they still felt obliged to fully inform these clients of treatment options. “Ethically I have to give a client all options available… for any animal – regardless of its situation. All too often, I come into a situation where I feel an animal has been either neglected or downright abused and I would like to scream at the top of my voice, “You’re a turkey! I want to take this animal away from you!” I can’t do that.” Aaron, companion animal practitioner In addition to capturing the frustration that some veterinarians feel, this quote illustrates that Aaron felt obliged to give clients all the options even if he did not agree with how clients managed their animals. He believes the professional obligation to provide clients with complete treatment information and respect the clients’ choices often overrides his views regarding the treatment of the animal.  107  In contrast, other participants preferred to limit the amount of information that they disclosed. For example, participants would neglect to provide all available options and instead give only a preferred option. “If I really feel strongly that surgery is the best option for the pet, then I don’t give another option to start with – until they express that surgery is not feasible financially. Because what I’ve found in the past is, if you say “Well surgery is the best option but this is the other option”, even the people that can afford the surgery will read you as saying, “There is another option” and they’ll always take the cheaper option. Whereas, if you start off saying “This is what we need to do”, and then if that’s not feasible, you say, “Well if that is not feasible, then this is what we can do”. Everybody has their own approach…That’s what I find works for me.” Abby, companion animal practitioner By limiting the disclosure of information to clients, some participants could achieve what they thought was a better decision. Limiting information in the form of treatment options also occurred in non-financial situations. Some participants indicated that they would direct clients down one path or another in order to serve what they thought was best for either the client or the patient even if the client might find alternate options acceptable. Those believing that paternalism or alternatively directivenessxxiv was acceptable or desirable also held that information should be limited at times. In addition to limiting information, some veterinarians used different strategies to deliver information in such a way as to influence their client. In describing the management of a critically ill animal, the participant in the following quote identified himself as an advocate for the patient. He believed that this role required him to direct the client towards the best option for the patient, in this case euthanasia. “I believe that my role as a veterinarian professionally isn’t to extend that cat’s life to the last day. My role as a veterinarian is as his advocate and to say [to the client] “I’ve been down this road a thousand times and he’s going to die real soon and it isn’t going to be pretty. So I’m going to redirect you off that route and direct you on this route, because I am his advocate.” Jerry, companion animal practitioner  xxiv  This word is chosen to indicate that veterinarians directed clients in order to further the interests of the animal. It is different from paternalism in that the veterinarian is not making decisions or recommendations based on the client’s interests but instead makes them for the patient’s interests. Perhaps ‘maternalism’ is more appropriate for the latter situation.  108  The felt responsibility to ‘direct’ clients to make better decisions influenced how veterinarians delivered information as well as whether they offered all the relevant treatment options. Veterinarians reported using different forms of communication to ‘manipulate’ or ‘convince’ their clients to follow a specific treatment option. Another companion animal practitioner, Steve, alleged that some veterinarians do manipulate clients and he is critical that veterinarians urge clients to euthanize animals even when the client is not ready to do so. “I know veterinarians that will brow-beat their clients, intimidate them, will make them feel like heartless, self-centered asses basically. They manipulate them.” Steve, companion animal practitioner In addition to delivering information to convince or manipulate clients, in some situations veterinarians felt compelled to significantly alter information in order to protect an animal. In the following dialogue, Harry, a mixed animal practitioner, described a situation involving a racehorse that was injured and required rest and analgesics. He did not believe that the client would give the horse the necessary rest and biased the information he provided. Carol: So if the horse was in pain and you’re saying [to yourself] ‘Well he should have pain killers but I don’t trust these folks to rest him’, you wouldn’t give him painkillers? Harry: And that’s a real conundrum. What the horse needed was painkillers, wrapping, and standing still and not walking too far for three weeks. And the problem is that [the trainer] would get the pain-killers and [the horse] would look better so [the trainer] would think, ‘Oh, he’s fine. We’ll run him. We’ll breeze him,’ and he wasn’t….The next question I know you should ask here is: well, to what end would you [go]? What would you do to get that owner, that trainer, not to race the horse? Would you lie to him? Yeah I would. I would say “The horse is sore but I’m seeing a real problem over here. If you run this horse I think that this horse would have a fracture” – when I don’t really think he would have a fracture…And I would give him the pain killers and I would really hope somehow that the little lie would induce him to [rest the horse]…I wouldn’t say it’s lying, I wouldn’t make up a condition but I would accentuate things a bit. In another example of altering information to achieve a desired outcome, Angela, a companion animal practitioner, described a problem she encountered with an elderly  109  woman and a cat with lower urinary tract disorder. Only in this case, the veterinarian altered the information to protect the client. “He was owned by a ninety-some old lady who lived an hour and a half out of town. She is blind, no family, no friends to look after her, no nursing out there…[The cat] was peeing all over the place…so she was living in filth essentially. So her neighbour helped her out a fair bit…She brought the cat in for the third or fourth time…but the cat had a lot of problems….The neighbour appealed to me and said, ‘Is there any way we can convince her to get rid of the cat?’ And [the owner] said she won’t get rid of him - she might give him to the SPCA, but the SPCA wouldn’t take the cat…She would not leave [her home] because the [nursing] home they wanted her to go to wouldn’t allow animals. So my biggest dilemma was how much I coloured the severity of the condition and how probable it was to treat. Now I said it was treatable but I coloured it quite dark, in order to get her to euthanize the cat and coloured it …that the cat was suffering….I could have done some [treatments], although the cat would come back again and again and again. Money was a big concern and she had very little…I would have taken every penny of what she had, because she would do anything for her cat. But at the end she cried but she thanked me for taking her cat out of its pain and I did feel uncomfortable about that but at the same time I felt good because she could go to the home.” Angela, companion animal practitioner At the urging of her client’s friend, Angela encouraged euthanasia although the client did not wish to euthanize her cat. In order to further what the veterinarian perceived was in the best interests of the client, she ‘coloured’ the level of suffering the cat was experiencing. In addition to trying to protect clients by altering information given to them, some veterinarians simply limited disclosing information on the assumption that the clients were not interested in pursuing options that are more expensive. For example, many food animal practitioners did not discuss various options that would minimize harms to animals because they did not believe that the client would be willing to pay for the treatment. The use of anesthetics and analgesics in routine procedures such as castration and dehorning were common examples. Some practitioners used postoperative analgesics after common surgeries such as caesarean sections in beef cattle, but others (as reflected in the following dialogue) presupposed that clients would be unwilling to pay for post-operative analgesia.  110  Carol: Some people have told me that they do give Anafen to cows, post Csection.. Michael: Yeah, but it is expensive…it would be a thirty-five dollar shot to give to a cow. Carol: Have you tried to approach some [clients] or some of your better [clients]? Michael: No. I wonder if I would be surprised. And you see as veterinarians a lot of times we tend to under-estimate what our clients will pay for and what they would want and I think we would be surprised. In summary, some participants believed that, at times, limiting treatment options, delivering information in a biased way, or actually altering information was acceptable in order to achieve a better solution for either the client or patient. Some veterinarians reported limiting the amount or quality of the information given in order to protect the client rather than the animal. Some participants admitted to bending the truth in order to further what the veterinarian perceived was in the interests of the client or patient. Additionally some participants simply neglected to inform clients based on assumptions of clients’ desires. In contrast, some participants believed that disclosing information fully was an important professional responsibility, regardless of the consequences to patient or client. As with the continuums noted regarding prioritizing interests and the importance of client autonomy, participants held diverse views regarding the importance of fully informing clients regarding the care of patients. Discussion This research presents intriguing examples of veterinarians’ views about their role and responsibilities within the veterinarian-patient-relationship. Although participants were unified in their sense of obligation to prevent harms to the public through control of zoonotic or food borne diseases, participants differed in how they valued animals and consequently how they saw the profession contributing to society. Some participants focused primarily on instrumental uses of animals and assumed that the profession should support the appropriate use of animals. Ideas about professional societal role will likely influence individual practitioners’ beliefs about their role within the veterinarianclient-patient relationship. For example, although a veterinarian may believe that she  111  has responsibilities concerning animals and that the interests of her patients are important, she might believe that her professional role is to serve people. Thus, the interests of her client are her primary responsibility. In contrast, some participants believed that the primary role of the profession is animal protection and that as individual practitioners their responsibilities centre on furthering the welfare of their patients. Rollin 14 suggests that, “over 90 per cent of veterinarians are inclined toward the paediatrician model”, which places the interests of animals at the forefront. This research does not support this claim. Some veterinarians claimed primary allegiance to the animal; whereas, others said their primary allegiance was to the client. Still other participants did not believe that it was their role to claim allegiance to either side; professionally, veterinarians should try to remain more neutral. Thus, veterinarians’ perceptions about their professional roles are far more varied than Rollin suggests. Tannenbaum  12  argues that veterinarians “accept the fact that the animal is the  client’s property” and that “both doctor and client usually understand (even if they do not state this understanding explicitly) that the doctor is working for the client, who retains the right to decide what services will be provided.” While veterinarians are aware that animals are considered legal property, this research indicates that some veterinarians do agree with Tannenbaum’s position and others do not. The value placed on animals and patients varied amongst participants. These valuations influence veterinarians’ perceived roles and the way that they view their responsibilities. Some veterinarians felt justified in failing to disclose information or altering information in order to protect either the patient or the client, and did not believe that clients were always entitled to make decisions. This diversity of thought may be problematic for the profession. What types of responsibilities do different kinds of veterinarians have to animals? Articles on professional role that appear in the veterinary literature, make prescriptive claims that veterinarians should be controlling disease in human populations,125 that veterinarians should focus on food safety and emerging disease,123 and that veterinarians should be leaders in furthering animal welfare.119,126-130 Practitioners, the veterinary profession, and veterinary educators are increasingly called to serve as leaders in animal  112  welfare.118,119,126-132 In many instances, these roles and their underlying values compete with one another. Understanding the diversity of thought about professional responsibilities highlights possible sources of confusion and contention within the profession, between veterinarians and their clients, and between the profession and public. In addition to veterinary clients, veterinarians also have responsibilities to a society, which may well conceptualize veterinary responsibilities in ways quite different from those that appear in the veterinary literature or amongst veterinarians such as the participants in this research. My research should encourage the profession to expand the dialogue regarding professional roles and responsibilities. Additionally further research exploring public perceptions of veterinarians’ responsibilities might be very useful and illuminating for the profession. Professional Models Professional ethics literature is rich with descriptive metaphors illuminating the nature of the professional-client or professional-patient relationship. Bayles 26 depicts these relationships as principal/agents, contractors, friendships, paternalistic, and fiduciary. Veatch 133 characterizes physician-patient relationships using models entitled ‘engineering’, ‘contractual’, ‘collegial’, and ‘priestly’. Alternatively, Emanuel and Emanuel 134  use ‘paternalistic’, ‘informative’, ‘interpretative’, and ‘deliberative’ models for the same  relationship. Winslow 135 in describing models for nursing employs a ‘military’, ‘legal’, or ‘advocacy’ metaphor. In relation to veterinary medicine Tannenbaum 12 employs the ‘consultant’, ‘business’, ‘friend’ and ‘healer’ models. Rollin 14 makes use of the ‘car mechanic’ and ‘pediatrician’ model. However, these models do not seem to account for the diversity of views participants cited in this study when considering their professional role. By combining the three recurrent concepts – prioritizing interests, the importance of client autonomy, and the importance of information disclosure – in different ways, four different professional models emerge from the data. These typologies are useful in understanding veterinarians’ perceptions about their role in the veterinarian-client-patient relationship.  113  Information Provider Model Some participants focused on the importance on their professional responsibility to provide information that would allow clients to make autonomous decisions regarding their animals. These veterinarians held that the clients should be the decision-makers and barring cruelty “clients always have the final say”. In communicating with clients, participants sought to impart information and to educate. Although a veterinarian may hold strong personal beliefs about how animals should be treated and how client and patient interests should be prioritized, these beliefs did not influence their perception of their professional role. Instead of choosing allegiances to either patients or clients, some veterinarians felt that their professional role was to remain neutral. From this stance, veterinarians ought to be detached experts. Professional rules and possibly legal structures appear to influence these veterinarians to maintain what is formally considered an appropriate veterinarian-client-patient relationship, which includes providing their clients with adequate and appropriate information and placing emphasis on client autonomy. Table 2 Characteristics of the Information Provider Model  Prioritization of interests  Not relevant  Importance of client autonomy  Higher importance  Importance of disclosing information  Higher importance  Service Provider Model Another professional model that seemed to emerge from the data was that of a service provider or perhaps a business model. Clients request a service and the veterinarian provides it. Although some participants holding this view of the veterinarianpatient-client relationship might believe that animals have morally relevant interests, their professional role did not involve arbitrating the conflicting interests of clients and patients. Their role was to provide services to patients and clients, as requested by the client. “Judging” the appropriateness of the clients’ wishes was either inappropriate and/or outside their professional responsibilities. Unlike the Information Provider Model,  114  informing clients of all the options or providing detailed information was less important. A client requesting a service was provided the service without being given alternatives or having the consequences (likely to the patient) of their decisions explained. Routine procedures such as castration in food animals without anaesthesia/analgesia or cosmetic surgeries in companion animals are examples of contexts where this model may predominate. Table 3 Characteristics of the Service Provider Model  Prioritization of interests  Clients first  Importance of client autonomy  Higher importance  Importance of disclosing information  Lower importance  Animal Advocate Model In this model, veterinarians prioritized the interests of patients. Perceiving themselves to be experts in animal health and welfare, participants felt justified or even obligated to direct clients toward treatments that the veterinarian considered appropriate for the animal. Full disclosure of information was less important for these participants. In some instances, participants would fail to disclose options or complications, or exaggerate or minimize complications and risks, in order to pursue the course of action they felt most appropriate for the animal. In communicating with clients, these veterinarians appeared to be more willing to direct clients and may “push”, “convince”, “coerce”, or “manipulate” a client to further the interests of the animal. Since the interests of animal are favoured and the autonomy of clients is less important, this model of the veterinarian-client-patient relationship may be more apparent in situations where substandard care or abuse exists.  115  Table 4: Characteristics of the Animal Advocate Model  Prioritization of interests  Animals first  Importance of client autonomy  Lower importance  Importance of disclosing information  Lower importance  Client Advocate Model Finally, in contrast to the above model, the Client Advocate model places the interests of the animal secondary to those of the client. These veterinarians may view their patients more instrumentally and may be uncomfortable with spending resources (financial, emotional, temporal, etc.) on the patient to the detriment of the client. Unlike the Service Provider model, they paternalistically pursue what they believe to be the best course of action for the client, regardless of the clients’ stated wishes. Like the Animal Advocate model, client advocates may present limited or altered disclosure relating to treatment options and risks. These veterinarians may “release” clients from the responsibility of animal ownership or give them “permission” to abandon treatment or euthanize animals. Table 5. Characteristics of the Client Advocate Model  Prioritization of interests  Clients first  Importance of client autonomy  Lower importance  Importance of disclosing information  Lower importance  Usefulness of Professional Models These models do not have firm boundaries and it is unlikely that any individual veterinarian fits neatly into one model or another. Participants of this study were not catalogued as belonging to one model or another. Instead, it seems more likely that individuals may hold general beliefs regarding their role, which shift depending on context. These models serve as a heuristic for the profession and veterinarians to use when contemplating the veterinarian’s role in various situations. It is important to remember that these models emerged from situations in which they felt compelled to 116  resolve a conflict in their responsibilities. It is possible to draw some parallels between the models presented here and those found in the veterinary literature. For example, Rollin’s paediatrician model likely has some similarities to the Animal Advocate Model and the car mechanic model similar to the Service Provider Model. This research forms a different type of framework, whereby veterinarians account for the interests of patients and clients, as well as their professional responsibilities. Structuring the recurrent concepts emerging from the data into professional/client models as described above may provide a useful tool for practitioners to recognize their own views and actions, and thus facilitate self-reflection. These models may help the profession question the appropriateness of acting within one model or another in specific circumstances. For example, acting paternalistically or withholding information may be appropriate in some circumstances but not in others. Each of these models presents moral questions for individual veterinarians and for the profession (summarized in Table 6). The remainder of the discussion focuses on potential problems associated with each model.  117  Table 6. Comparison of Professional Models  Model Attributes  Information Provider  Service Provider  Client Advocate  Animal Advocate  Irrelevant  Secondary  Secondary  Primary  Important  Important  Less Important  Less Important  Important  Less Important  Less Important  Less Important  Reinforces client autonomy  Appear to reinforce client autonomy Potentially limits client autonomy  Protects clients  Protects patients  Area of Emphasis Priority of Animal Interests Client Autonomy Information Disclosure Advantages/Disadvantages Advantages  Disadvantages  Abandons clients in decisionmaking  Fails to protect Fails to animals protect animals  Limits client autonomy  Limits client autonomy  May reduce public trust in the profession  May reduce public trust in the profession  The strength of the Information Provider model is in ensuring that clients are informed, maximizing client autonomy. Veterinarians are generally unable to provide all information; rather it is a matter of the degree of information provided. Those favouring the Information Provider model strive to provide all reasonable options and the information that clients need to make decisions. However, even well informed clients may have difficulties making decisions. Two important problems with this model include: 1) clients may have difficulties making decisions without the assistance of the experienced veterinarian, and 2) sometimes clients will knowingly make choices that are harmful to the patient. By merely providing information to clients without elaborating on the morally relevant consequences of various decisions, veterinarians may not be satisfying responsibilities to clients, patients, and/or third parties.  118  With respect to the first problem, clients rely on veterinarians not only for the knowledge but also for their experience with various procedures. For example, a veterinarian may be able to cite the statistics relating to prognosis or cure rate, but factual information may be insufficient to assist clients in making ‘good’ decisions about a patient. Emanuel and Emanuel 134 argue that patients in human medicine may be unaware of their own values or that these values change over time. In helping patients to explore their values, a physician may be better able to provide better recommendations for treatment. Further, these authors suggest that ‘value articulation’ may include encouraging patients to consider what sort of values they ought to have, rather than the values they do have. Fulford 136 suggests that medicine should be value-based as well as evidence-based. Not only should the facts and scientific data count in the decision process, the values relating to patient preferences should influence treatment plans. If value articulation and value-based medicine are important in the human field in order to ensure that human patients receive adequate support and information from their health care providers, how does this need translate into veterinary medicine? Clients unsure of how to proceed may feel abandoned by the veterinarian who adopts the pure information provider role in the decision process. Although veterinarians likely formulate treatment options based in part on their own value perceptions, some veterinarians offered options that they believed were inferior. Clients frequently perceive veterinarians to be the experts in animal well being and seek out their advice for this reason. Veterinarians providing information and options, which are sometimes complicated and voluminous, may fail in assisting their clients in these value-based decisions. Additionally, clients lack the experience to know how well most animals do with a specific treatment and rely on veterinarians for this type of advice. A second problem with the Information Provider Model is that in allowing clients to make unaided decisions regarding the care of animals, patients may suffer as a result. Veterinarians have a responsibility to promote animal welfare and to reduce suffering to their patients. By simply providing information to clients and allowing clients to make poor decisions, especially decisions that would result in suffering, veterinarians may be failing in their responsibilities to animals and the public who expect veterinarians to mitigate animal suffering. For example, some veterinarians offer post-operative 119  analgesia as an option and inform their clients of the benefits of its use. However, if the client declines post-operative analgesia and the veterinarian honours this decision, the consequences to the patient could be significant. Offering post-operative analgesics as an optional ‘add-on service’ may fail to protect the well being of patients. The Service Provider model is susceptible to similar concerns. By honouring client autonomy, veterinarians may ignore responsibilities concerning animals. However, by simply agreeing with a client’s decision without providing the necessary information to make an informed decision, veterinarians may actually be limiting client autonomy. For example, some veterinarians will provide little or no information to clients regarding the risks or alternatives to declawing in cats and simply agree to perform the procedure as though the client already understands all the risks, harms, and alternatives. Some clients assume that the procedure is simple and risk-free because it is routine. In a similar vein, participants mentioned that they would not use anaesthesia when dehorning cattle or postoperative analgesics in food animals if their clients did not approve them. However, some participants did not inform the client of the benefits of anaesthesia and analgesia. While simply providing requested services, some participants failed to fully inform clients of options and alternatives. As veterinary medicine becomes more technologically advanced and as research regarding animal welfare becomes more complex, assuming that clients have adequate knowledge is an error. In addition to supporting potentially ‘false’ client autonomy, placing all decisions of care and treatment into the hands of clients may fail to protect the welfare of patients. Both the Client Advocate and Animal Advocate models suffer from similar concerns about failing to adequately inform clients. Beyond failing to provide complete and accurate details, veterinarians advocating a specific course of action, substitute their own values and beliefs in place of their clients’. These values go beyond merely considering animals as instrumentally or intrinsically valuable. Attitudes regarding quality of life, sanctity of life, and health, influence what is considered a ‘good’ or ‘best’ treatment option. Some veterinarians consider death a ‘good’ option in some cases while others believe that euthanasia is a last resort. Some veterinarians believe that short-term pain is acceptable but others do not. Veterinarians hold diverse views about what counts as animal welfare. They also hold different views about the level of veterinary services that 120  clients should provide their animals (Chapter 4). While it is understandable that veterinarians may believe that they have a good grasp of what is ‘good’ for an animal or the level of care that is adequate to provide an animal, veterinarians themselves are not uniform in these beliefs. It is likely that veterinarians acting as advocates for either patients or clients may hold very different views from those of the clients. Determinations about what is good or best for the patient or the client are not the sole territoryxxv of veterinarians, and practitioners need to exercise caution when influencing, undermining, or forcing decisions on clients. Unlike the Service Provider Model, Animal and Client advocates may intentionally withhold or bias information in order to achieve a better result, thus limiting client autonomy. Debate continues regarding the acceptability or the level of acceptability of paternalism within human medicine and how to order principles such as autonomy and beneficence.44,137 Differing from human medicine, in which the intent to act beneficently limits the autonomy of the same individual, veterinarians wishing to act beneficently to their patients may harm their clients and/or limit their autonomy. Animals are property and barring cruelty, animal owners (veterinary clients) have a legal right to make these determinations and be apprised of all of the options.124 This right is reinforced through provincial veterinary bylaws requiring veterinarians to provide detailed information in order to obtain informed consent.138 Ethically, it is less clear how much leeway clients should have in making decisions regarding the animals. The question remains why average veterinary practitioners would risk rehoming an animal that they have agreed to euthanize, or why they would risk disciplinary action by deceiving clients in order to improve a patient’s chance of recovery. When otherwise upstanding professionals feel compelled to break professional rules or wilfully limit a client’s autonomy in order to act beneficently towards their patient, the current regulatory and legal structures affecting veterinarians should be re-evaluated. These formal codes differ from the way some veterinarians actually think about and act in these situations.  xxv  For example, in a situation involving a mentally distressed animal owner failing to provide adequate care, veterinarians may not have the skills to decide what is best for patient or client. Veterinarians and animal owners may need to seek assistance and advice from human health care workers, animal welfare scientists, and ethicists to help to decipher what is the best course of action under specific circumstances.  121  Finally, in deciding to convince a client that a patient ‘needs to be euthanized’, the veterinarian may be endangering the trust that clients place in veterinarians or veterinary medicine. When clients discover that their veterinarian suggested euthanasia when other treatments were available or that their veterinarian presented only one option for treatment when others exist, clients could lose trust in the veterinary profession. Coe 139 found that veterinary clients disapproved of veterinarians who presented limited treatment options or provided only the ‘best option’. Coe’s participants preferred a variety of options. Due to the power differentials between clients and veterinarians, as in any professional client relationship, it is important that clients are able to trust both veterinarians and the veterinary profession. Failing to gain and deserve the trust of clients could have long-term ramifications for the profession. Conclusion This chapter shows that veterinarians have different views about their professional role and their responsibilities to patients and clients. Veterinarians hold various beliefs about the appropriate balance of responsibilities to patients and clients, the importance of client autonomy and the importance of information disclosure. These beliefs have been synthesized in four profession-client models. These models represent veterinarians’ perceptions of their professional responsibilities describing how they react to client requests for procedures or the types of alternatives that veterinarians present to clients. By exploring professional-client/patient models in veterinary medicine, veterinarians may be better able to understand their own views and values. Understanding how one interacts with clients and how and why these interactions shift according to context will help individual practitioners reflect on their personal strategies and help the profession develop consensus on key issues. For example, some veterinarians believed that they should rank their responsibilities to patients over those to clients. In order to do this, they limited or altered information given to clients. Under what circumstances is this behaviour appropriate? Other veterinarians provided information to clients but did not assist them in making decisions. Should veterinarians have responsibilities to animals that require them to do more than merely provide  122  information to clients? Is the client always the appropriate decision-maker? These questions should be actively discussed and debated within professional forums. Furthermore, understanding and recognizing the various models helps to identify potentially problematic areas within the veterinarian-client-patient relationship. Some participants limited or distorted information given to clients in order to protect patients. These findings suggest professional regulatory bodies may inadequately articulate veterinary responsibilities to patients. The veterinary profession publicly declares responsibilities to animals through the Veterinary Oath, 140 yet many provincial regulations do not include any reference to responsibilities concerning animals. This finding also suggests that veterinarians and the veterinary profession should consider what it means to promote animal welfare and to what degree individual veterinarians should intervene in order to do so.  123  Chapter 6: Veterinarians’ Constructions of Moral Problems and Moral Reasoning The main goal of this research is to understand how veterinarians believe that they make decisions when experiencing conflicting responsibilities to clients and patients. By understanding how veterinarians make decisions, we may be able to understand why veterinarians sometimes appear to fail to protect animals or promote animal welfare. This chapter combines the data presented in the previous three chapters and explores these central questions. First, I will briefly review this data in the context of questions veterinarians pose to themselves. Secondly, I will present a theoretical framework of how veterinarians appear to construct moral problems in the practice setting, based on the answers to these questions. Thirdly, I will explore methods of moral reasoning that participants used in ethically challenging situations. A discussion about moral decision making follows. Review of Veterinarians’ Views The data presented in the previous three chapters show that participants mentioned similar types of factors when making decisions, although they appear to hold differing views within each category. Chapter 3 illustrates veterinarians’ views about patient interests and how they assessed their patients. Participants had beliefs about what constituted animal welfare. Some focused on functioning aspects of well being including health and productivity. Most mentioned pain and suffering as important detriments to welfare, although participants differed in their views about how pain is categorized and consequently the moral importance of different kinds of pain. These elements of animal welfare can be termed welfare interests. Some participants also felt that continued life, particularly if the patient experienced good welfare, was in the animals’ interests. Thus, the interests of patients could include both the quality and the quantity of life. Veterinarians deal with sick and injured animals on a daily basis. They also conduct routine procedures such as non-therapeutic surgeries (castration, spaying, cosmetic surgeries, dehorning, declawing), vaccination, pregnancy determination, and routine physical examinations, all of which can negatively affect a patient’s well being in the short term. When considering a course of treatment for a sick or injured animal or  124  whether to conduct a routine or elective procedure, participants appeared to answer the question “Is this (procedure or treatment) bad for the patient?” Additionally, it is not simply a matter of whether a procedure or treatment is conducted but also how it is conducted. A procedure may be good or at least neutral for the animal’s welfare but if is conducted poorly (e.g. without anaesthesia and/or post-operative analgesia) then a veterinarian may judge the procedure or treatment as bad for the animal. Another group of ideas that participants mentioned surrounded the behaviour of their clients. They held beliefs about how clients ought to use their animals as well as how they ought to treat them. Using these beliefs as a measuring stick, participants categorized clients. By doing so, veterinarians assessed whether clients were making good decisions with respect to their animals. For example, veterinarians holding more instrumental views about animals (that is, how they should be used) may believe that clients who pursue intensive diagnostics and treatments are wasting their resources. They viewed this behaviour as unreasonable. The question that participants posed to themselves can be framed as, “Is my client acting reasonably in the given circumstances?” In making these assessments, context played a significant role. For example, some participants viewed clients who provided substandard care more favourably if they were trying (yet failing) to meet the needs of the animals. In Chapter 4, I presented two situations in which one participant assessed the owners of neglected horses differently, although she felt the horses suffered from similar bad health and welfare. In the first case, the veterinarian assessed the client positively because the client had numerous personal challenges including a physically challenged son, who held a strong emotional attachment to the horse. In the other situation, she identified a client as ‘white trash’ and insisted on euthanizing the involved horses. In the first case, the veterinarian likely felt that the client was behaving reasonably given the circumstances, yet in the second situation she did not believe the client acted reasonably. A third recurrent theme centred on professional role. In Chapter 5, I developed four models of the veterinarian-client-patient relationship. When participants described personal examples of morally difficult situations or responded to my queries about commonly identified moral ‘dilemmas’ in veterinary medicine, one key theme focused on whether the situation involved professional responsibility. In other words, participants 125  appeared to ask “Do I have a professional responsibility to protect the interests of my patient in this situation?”, or in short “Is it my job to intervene?” Participants seemed to consider the elements of societal professional role, the prioritization of client/patient interests, and the importance of client autonomy when answering this question. Although individual veterinarians might gravitate to one professional model or another based on their beliefs about professional responsibility, circumstances appeared to influence how they felt about their professional role. Construction of Moral Problems As I noted in Chapter 2, most participants had no trouble giving examples of situations in which they had conflicting responsibilities to clients and patients; however, some participants had difficulty offering examples or did not identify some situations morally problematic although others did. The reasons for the diversity between veterinarians, in part, rest in their beliefs and assessments about animal interests, responsibilities of clients as animal owners, and their role as veterinary practitioners. During interactions with study participants, it became apparent that some situations were morally clear to most veterinarians. For example, virtually all veterinarians believed that provision of food and water to animals was central to their welfare and that clients had a responsibility to provide these items. Most veterinarians believed those situations where animals were denied adequate food and water generally caused significant harm to animals and that animal owners were not acting reasonably by failing to provide food and water. In general, participants felt that they had some responsibility for the protection of these animals. Thus, almost all participants recognized this type of neglect as a moral problem for which they should intervene in some way, although they might differ in the nature of the intervention. However, many situations did not create such a clear consensus amongst participants. Some individuals were clearly frustrated by the plethora of moral dilemmas whereas others had difficulty identifying situations that represented moral problems. Why do veterinarians judge situations differently? As veterinarians appear to hold diverse beliefs about animal interests, client reasonability, and professional role, combinations of different ideas result in one veterinarian identifying a situation as morally  126  difficult while another does not. One element in moral decision-making is the recognition that a situation is morally problematic; that is also known as moral sensitivity.141,142 However, since the moral standing of animals is unclear, using the term ‘recognition’ or ‘sensitivity’ may presuppose that a moral dilemma is clearly apparent. Perhaps a better way to think about veterinarians’ identification of moral problems is that they construct them based on their beliefs. People construct problems in order to “make sense of complex and troubling situations.”143 Thus the construction of moral problems is the awareness of situations that they find morally troubling. Figure 2 offers a framework of how veterinarians appear to construct moral problems that they believe they have some responsibility to resolve. In essence veterinarians consider three elements or attempt to answer three questions: identification of a violation of animal interests (Is this situation bad for the animal?), an assessment of the client’s actions or intentions (Is the client acting reasonably?), and their professional responsibilities (Is it my job to intervene?). The first step involves identifying an animal welfare problem or a situation that is “bad” for the animal(s). For example, some veterinarians did not believe that animals had an interest in continued life. Thus, some veterinarians would not consider a request to euthanize an otherwise healthy animal as bad for the animal and hence would conclude that this situation does not present a moral problem. Others would view euthanasia of a healthy animal as ‘bad’ for the animal. Figure 2. Construction of moral problems.  Is this situation bad for the animal? Yes  No  Is the client acting reasonably? No  Is it my job to intervene? Yes  Moral problem. Intervention needed  No moral problem  Yes  No moral problem for veterinarian No  No moral problem for veterinarian  127  After veterinarians identify a situation as bad for the animal, they move to the next question: is the client acting reasonably in caring for the animal or making a request of the veterinarian for services? Veterinarians may consider whether clients are providing adequate levels of care or whether client requests to perform certain procedures are acceptable under the circumstances. For example, a veterinarian might believe that dehorning of mature cattle is an animal welfare problem but they may also believe that a client’s request for these services is acceptable based on the client’s situation or rationale, such as a legal requirement to dehorn before an animal can be pastured on a community pasture. Although there may still be questions about the appropriateness of dehorning mature cattle in general, under particular circumstances some veterinarians might accept that the situation does not present them with a moral problem for which they need to intervene. However, if the veterinarian does not believe the client is acting reasonably in the given circumstances, the third and final step in constructing a moral problem involves deciding whether s/he has a professional responsibility to intervene. At this stage, veterinarians’ perceptions about their role in the veterinarian-client-patient relationship influence the construction of moral problems. In some situations, some veterinarians do not believe that they have a responsibility to actively protect patients, even when they believe that a situation is harmful to an animal, and the client is not acting reasonably (in the veterinarian’s view). Some veterinarians may accept the directions of clients without question (such as withholding anaesthesia or analgesia during or after surgery). Other veterinarians may believe that they have a responsibility to provide information but must refrain from influencing the client’s decision. Although a moral problem may exist for the client or a third party such as the SPCA or law enforcement officials, the situation does not present a problem for which the veterinarian should intervene (beyond giving options to the client) to protect the interests of the patient. Still others may believe that they have a professional responsibility to intervene on behalf of the patient. If veterinarians believe that the situation is within the realm of their professional responsibility, then they will identify the situation as a moral problem that requires a serious attempt to resolve competing responsibilities to patients and clients. What I have termed a ‘veterinary moral problem’. Veterinarians often have limited 128  options for intervention. As animals are legally considered property, veterinary clients have significant control over the care and treatment of their animals. If this care falls below the threshold provided by the law, veterinarians have the opportunity to seek the assistance of humane authorities. If the care of animals does not meet this threshold, at least in the veterinarians’ estimation, then veterinarians may use other methods of exerting influence. This intervention may include altered methods of communication including persuasion (covert or overt, as described in Chapter 5), proceeding with treatment or euthanasia without client permission, deception, refusal of service, termination of the veterinarian-client-patient relationship, offers of charity (free or reduced fee service) and offering to take custody of the animal. This framework provides a way of understanding how different veterinarians may arrive at different conclusions or interpretations of a situation and also why some veterinarians appear to fail to promote the welfare of animals. For example, some veterinarians agree to castrate cattle without anaesthesia, a procedure that causes at least some degree of pain. How do some veterinarians come to this conclusion when others would never consider it acceptable? Permutations of answers to the three questions will result in different interpretations of situations, as illustrated in Table 7. Veterinarian A may consider the pain or distress sufficiently minimal or short-term that it does not represent an animal welfare problem. Questions about client reasonability or professional role are irrelevant. Veterinarian B might believe that castration without anaesthesia harms the patient’s welfare but may believe that the client is acting reasonably by refusing anaesthesia. On the other hand, Veterinarian C might think that the patient should have anaesthesia and that clients are responsible to pay for it, however, this veterinarian might believe that the veterinary role is limited to providing information or following client instructions. Although these three veterinarians might hold different beliefs and/or use different reasoning processes, the consequence to the animal is the same – castration without anaesthesia. In the last column of Table 7, Veterinarian D believes that castration without anaesthesia is harmful to the patient, that the client is not acting reasonably by refusing anaesthesia, and that the veterinarian is responsible to intervene to protect the patient’s interests. In this case, Veterinarian D may proceed with the procedure but use anaesthesia without the client’s consent or he might refuse to  129  provide the service. Thus, Veterinarian D has constructed a moral problem for which veterinarians are responsible to intervene in some way. Table 7. Different decision pathways veterinarians might use when asked to provide castration without anaesthesia.  Is this situation bad for the animal? Is the client acting reasonably? Is it my job to intervene? Is this a moral problem? Is this a veterinary moral problem? Consequence to patient  Veterinarian A No  Veterinarian B Yes  Veterinarian C Yes  Veterinarian D Yes  NA  Yes  No  No  NA  NA  No  Yes  No  Maybe  Yes/Maybe  Yes  NA  NA  No  Yes  Castration without anesthesia  Castration without anesthesia  Castration without anesthesia  ?? Intervention Needed  The theoretical framework presented in Figure 2 and the example process in Table 7, suggest that the process is linear but it quite likely is not. Central to answering these questions are veterinarians’ beliefs and methods of assessing animal interests, client responsibility, and their beliefs about their professional role. Figure 3 illustrates how beliefs influence assessments. Beliefs about what constitutes animal welfare influences how veterinarians assess welfare and beliefs about responsible animal use and care influences how veterinarians assess their clients’ behaviour. Beliefs and assessments within one category influence beliefs and assessments in another. Beliefs about client responsibility likely influence assessments of animal welfare and concerns about welfare are influenced by assessments of client reliability. For example, veterinarians may adjust their assessments of a patient’s welfare based on reports from a trusted client that the veterinarian knows is generally responsible. Conversely, judgements of clients as poor decision-makers might influence veterinarians’ assessments of patient welfare. These interactions could ultimately influence veterinarians’ perception of their role within a certain situation. For example, significant  130  animal welfare concerns might shift a veterinarian from the Information Provider Model to the Animal Advocate Model. Figure 3. Interactions between beliefs and assessments.  Beliefs about patient interests  Assessment methods Is this situation bad for the animal?  Beliefs about client responsibility  Client assessments  Is the client acting reasonably?  Is it my job to intervene?  This framework is a conceptual tool for analyzing the elements involved in constructing moral problems. The quotation below offers an example of the construction of a moral problem. Tessa described her interaction with the owners of a dog near the end of life. “A standard poodle, it’s owned by these two young French guys…The first time I saw the dog, they had brought it in and they’d put it on the scale and when I walked into the room and I thought the dog was dying...He had a very large tumour in his mouth and he was literally moribund… So I talked to them for over half an hour about euthanasia …They seemed to be really understanding…They said ‘We want to go home and think about it’ but they seemed like they were going to do it [euthanize]…And they came back and saw my colleague…a month later…He said, “Oh they’ll be back for euthanasia.” And they weren’t!…It’s one of those ones where I’m [thinking], “Well they were nice people. They really loved their dog,” but the dog, (pause) it was just awful. And I said [to my boss], “I’m going to call the SPCA.” And my boss is like, “Well just wait, just wait.” So they did book a euthanasia and they came in and …one brother said to me, “Would it be wrong to just take him home for one more night?” and I said, “Yes, it would. It would be wrong. You need to let him go.” Tessa, companion animal practitioner  131  Through this narrative, elements of construction of a moral problem are evident. She evaluates the patient’s welfare as unacceptable based on her beliefs about animal welfare. The dog has a serious health problem causing it to be moribund. Tessa then evaluated the clients but with difficulty. They seemed nice and caring, and appeared to understand the distress their dog was experiencing. Although the dog’s owners appeared to care for the dog, they did not appear to be meeting the dog’s needs. In her first encounter with the clients, Tessa understood that they may need time to consider their options or spend time with their dog before euthanizing. This may be a valid client interest, and since they cared and seemed to understand, she believed that they were acting reasonably. Although she was not comfortable with the situation because the clients did not immediately euthanize the animal, she believed that the client was acting reasonably. She provided clients information and did not feel the need to intervene any further. However, as time proceeded, Tessa reassessed the clients and believed that are no longer acting reasonably. She then proceeded to the final step and identified the situation as a veterinary moral problem, one that required her intervention. She decided that it was her professional responsibility to intervene on behalf of the dog by calling the humane authorities. However, her employer cautioned against this and she ultimately resolved the problem by advising the owners that “it would be wrong” to fail to euthanize the dog. In another example, Alex explained that attempts by his clients to resolve their cat’s inappropriate urination problem influenced how he identified the situation as morally problematic. “Animals can be a great source of stress to owners. They can create tremendous anxiety for people. You get families that are in conflict over a thirteen-year-old cat that’s urinating around the house or spraying. The husband and wife are at odds, the kids are at odds. It’s creating work. It’s creating a negative environment at home. It’s not fair at that point to put that animal into a different environment. Should that animal be euthanized? Is it healthy still? Yes, it’s still healthy. If they have done a lot of the things you have recommended to try and alleviate the problem [and] it’s not working, is it fair to say to them “NO, I refuse to do that, you are going to have to deal with this problem”. And send them home back into that horrible negative situation. Or do you give in and you see the relief on people’s faces sometimes when you say, “You know you have tried very hard, the problem 132  is not getting any better. I can see the stress it’s causing you. Really for everyone’s sake, including the animal that’s in the middle of all this stress and feeling the stress that you‘re feeling, it might be the kindest thing for everybody to put that animal down.” And you see the relief wash over people when you give them permission to do that. So euthanasia is a very complex, emotional, and philosophical decision to make and again you can’t be too black and white on it. I want to be involved, I want to know why. But I do euthanize healthy animals in the scenario like I just gave you. Perhaps I’ll be accused of euthanizing a healthy animal. But it is best for the animal.” Alex, companion animal practitioner Throughout the interview, Alex expressed that euthanasia of healthy animals was a serious moral problem for veterinarians; animals have an interest in continued life. But because the clients in this scenario had tried to resolve the problem by various therapies (making them reasonable pet owners), Alex believed that the situation was no longer a moral problem. Although he recognized that he might ”be accused of euthanizing a healthy animal”, he believed that the clients are acting reasonably and in turn he determined that it was in the cat’s interests to be euthanized. Thus, the normally problematic situation of euthanasia of healthy animals is neutralized. By performing euthanasia, Alex is acting in the interests of both his patient and client fulfilling his responsibilities to both. Rather than acknowledging the best interests as an absolute standard, best interests are redefined. However, some veterinarians would not agree with the reconstruction of this situation, and they would refuse to euthanize the cat. Instead, they might recommend finding the cat a new home, making the cat an outdoor cat, or segregating the cat to one area of the house, believing that they are obligated to protect the continued life interests of the patient. In summary, participants in this study appeared to ask and answer three questions when considering whether situations were morally problematic for them as professionals. Although I have presented the three questions as a linear thought process – Is this situation bad for the animal? Is the client acting reasonably? And is this my job to intervene? – the process is quite likely much more interconnected based on new information and new evaluations. Different permutations of answers to these questions result in similar or different consequences for the patient. This framework of  133  moral problem construction helps us to understand the process that participants appear to use and also why some veterinarians appear to fail to protect animals. Reasoning Processes Throughout the process of constructing moral problems, veterinarians used different reasoning processes. Reasoning processes are the methods that veterinarians use to combine the factors important to them when constructing moral problems and contemplating if or how they should intervene when they encounter what they consider a veterinary moral problem. In some instances, participants were more rule-oriented, developing guidelines based on their beliefs, accepted standards or on their experiences in similar situations (a more deontic approach). Other methods of arbitrating decisions included weighing the harms, risks, and benefits of various outcomes (an outcome or consequentialist approach) and whether a practice or procedure was generally accepted (a conventionalist approach). Finally a few participants mentioned the importance of becoming the right kind of animal owner or veterinarian when making decisions regarding animal care (a virtue approach). Rule Development Some situations arise so often that veterinarians develop rules or personal guidelines to manage or even avoid the situation in the future. In the following quote, Aaron explains why he refuses to declaw cats. Frequently veterinarians will agree to declaw cats, even when they oppose the procedure, if the client threatens to seek euthanasia as an alternative. Aaron does not accept this as a justification. “If [a client] honestly seriously contemplates euthanizing a healthy animal because it’s destroying her furniture or his furniture or whatever the cat’s doing, sorry that’s not acceptable. Pets are entities that have their behaviours that come with their own wonderful personalities and that should be taken into account when you adopt an animal.” Aaron, companion animal practitioner Regardless of the harms that the cat may cause the client (personal physical harms or property damage), Aaron believes that it is never appropriate to declaw cats. Aaron’s reasoning does not involve weighing harms and benefits but rather he believes that cats  134  have certain protections based on the belief that they are ‘entities’. This status should prohibit veterinarians and clients from engaging in the declaw procedure. Thus, he develops a rule or a principle that in his view should be universally accepted amongst veterinarians. Some participants developed rules based on expected outcomes. Alex recognized that tail docking is problematic and tries to avoid it, but he believes ear cropping is clearly wrong and refuses to perform the procedure. “Docking tails…that’s always a bit of a dilemma, we’re trying to move away from docking tails - a lot of people are trying to move away from docking tails and removal of dew claws unnecessarily. Cropping of ears is not in the same discussion. It’s a no-brainer, you just don’t do it…Well that’s purely aesthetic, and to me it’s just cruel. There is no reason on earth to crop a dog’s ears. Is there a reason to dock tails? Probably not but the consequences of docking a tail are much less from an animal welfare point of view. You see animals that have had their ears cropped that have a lot of complications that certainly have a lot of pain, develop head shyness or aggressive around the head. Tail docking you tend not to run into any problem.” Alex, companion animal practitioner Alex explained that both procedures, ear cropping and tail docking, provide no benefit to the animal and are, to varying degrees, bad for the animal. Both of these procedures are unnecessary and a reasonable client would not request them. Nevertheless, ear cropping is clearly unacceptable because the consequences are severe. This harm/benefit analysis, that is harm to the animal weighed against benefit to the client, makes one cosmetic procedure (tail docking) somewhat acceptable and another cosmetic procedure (ear cropping) unacceptable. This determination results in a policy against performing ear cropping. Although this reasoning approach is not the same as affording animals with certain inherent protections (as Aaron does), some participants develop rules around procedures that clearly are a net loss, seemingly a version of rule utilitarianism. In another example, Sally described how she has developed a rule for herself that prohibits euthanasia of healthy animals based on her previous experiences. The quote below follows a story in which Sally described how she begrudgingly agreed to euthanize a house-soiling cat at the client’s request. She regretted the decision. 135  “It does come down to euthanasia, which is why I don’t like it. Because I don’t like to euthanize…So am I looking out for the best interest of the cat [by refusing to euthanize a house-soiling cat]? Many people would argue that I am not. Many people would say that if I did not euthanize that cat, the owner would take it home and abuse it – kick it when it peed on the carpet. Or not feed it. Or let it go, where it was beat up by other cats or something like that. And I can see that argument…[It might be] the best thing for this cat is to be euthanized…But because I don’t know that, I have to make some sort of rule for myself on where I draw the line with euthanasia” Sally, companion animal practitioner Sally considers the argument that the negative consequences of failing to euthanize the cat (being abused at home) as plausible but rejects it because she is unable to ascertain the likely consequences. Due to her belief that euthanasia is appropriate only when the patient suffers from a poor welfare, she decided that she needed to develop a rule to assist her in avoiding this situation in the future. When facing conflicting interests between patients and clients, some veterinarians establish ‘lines’ that should not be crossed. In doing so, they attempt to establish boundaries of acceptable behaviour at least for themselves and possibly, for all veterinarians, thus creating rules of conduct. Outcome Orientation Weighing potential outcomes was by far the most common reasoning method amongst participants. Many participants appeared to use a form of cost (or harm)/benefit analysis when deciding how to proceed. However, participants differed (not surprisingly) in the parameters they included in the analysis. Calculated harms to the patient depended on the beliefs veterinarians held about animal interests. For example, in the following quote, Jerry contemplated what he would do if the owner of a dog with a fractured femur were to request euthanasia. “I’m not going to kill a perfectly healthy golden retriever…How did I come to that decision? He’s a beautiful young healthy dog with a perfect future, I’d take him home before I’d euthanize him, and I’d be willing to do that. Now if there was a vicious land shark cat in here, just a real arse hole, who had blocked six times, and they didn’t want to do a [surgery to prevent urinary blockages], and I know that they’re not going to be able to adopt that cat, cause he’s an eight-year-old asshole.” Jerry, companion animal practitioner  136  This quote shows that Jerry considered his options of euthanizing a dog with a fractured leg or finding a new home for the dog. Although euthanasia would end suffering, he considered death as a harm to this animal. As this dog has a good prognosis, has good potential for a long life, and is a beautiful dog, the benefits to saving the dog far outweigh the harms of treatment. Thus, finding the dog a new home would result in a higher net benefit, than would euthanizing the dog. However, an older, nasty cat with an uncertain prognosis is a different situation. Trying to find a new home for this type of patient would not be feasible; therefore euthanasia is acceptable. As noted above, some veterinarians would develop a policy against certain procedures citing that harm generally outweighs the benefits, for example cosmetic surgery. Other veterinarians might agree with this harm/benefit analysis but nevertheless they would agree to perform procedures on a case-by-case basis because they feared that clients might cause greater harm to the animal. For example, clients will sometimes perform procedures such as tail docking themselves. Some veterinarians agreed to perform the surgery because they would perform the procedure more humanely (by using local anesthesia), and/or perform the surgery better than would the client. Thus, veterinarians weighed the harms and benefits to the patient when a veterinarian performed an unnecessary and harmful procedure against the harms of a client performing the same procedure. In this way, some veterinarians concluded that the best intervention to a morally problematic situation was to conduct procedure, which they opposed, themselves. Veterinarians also took into account potential negative consequences for themselves when considering embarking on procedures that were not necessarily in the interests of the animal. During the interview, Steve, a companion animal practitioner, mentioned that he would perform some unnecessary surgeries (tail docking) because the harms to the animals are minimal and he is able to satisfy clients by performing the procedures. He added that this is partially a business decision. However, Steve refuses to perform some unnecessary procedures, such as removal of benign lumps, on some animals. In this long excerpt, Steve described the elements that he considers when making decisions.  137  Steve: Whether it’s a cost benefit analysis, whether it’s a cost risk analysis. I’ve told people lots of times now, “Look your dog’s 12; your dog’s 14. You’re asking me to do something that really won’t have any impact on your dog, like taking a lump off, but if we give your dog an anaesthetic, I can’t guarantee it will be the same dog afterwards...” Carol: It’s risk to the pet vs. benefit to the owner? Steve: Well you can look at it in all different ways. What are the risks? The owner has a cost, the owner has the risk of losing the pet, the veterinarian has the risk of losing a patient and losing a client, who blames them for taking this down a path it shouldn’t have gone down. So it’s all part and parcel of the risk. Carol: The line isn’t the animal? Steve: The line includes the animal. Carol: Does it? Steve: Well yeah, you have got a beautiful happy 12-year-old dog. People come in here with a 14-year-old giant breed dog and I’m going “Oh my God, don’t bring it in here. This dog is in a precarious fine balance. Don’t touch this dog; it’s doing great. Thanks for dropping by” So the pet plays a role but so do all the other things. . Even though the requested procedure will not benefit the animal, he used a form of ‘calculation’ to decide whether to proceed with a treatment or procedure. The calculation takes into account the costs and benefits of three parties – the patient, client, and veterinarian. When the risk to the patient is significant (e.g. death), he would not agree to perform the requested service. He included in the calculation potential risks for himself including the financial risk of losing a client. He alluded to risk of clients blaming him for negative outcomes. He does not have a rule against performing unnecessary procedures; rather he weighs the risks of harm to the animal, client, and himself against the benefits to himself and the client. Outcome analysis in food animal practice generally appears less complex. As the production of food is a business endeavour, harms, benefits, and risks are primarily measured on a monetary scale. Food animal practitioners were quite uniform in  138  weighing harms to animals in the form of suffering, against the monetary benefits to clients. Veterinarians specializing in production medicine often develop decision trees for their clients to achieve optimal productivity. These flow charts assist producers in treatment or euthanasia decisions relating to problems associated with poor animal productivity. These decision trees are based on cost/benefit analyses relating to the probability of success of a treatment and anticipated growth or reproductive measures. “I’ve developed basically flow charts for these guys if you encounter risk problems. Let’s say it’s a swollen joint, a lame pig. Based on what I know about the diseases going through the system, this [treatment] is the first thing that you do with this pig as far as treating it and try for two or three days. [If] it doesn’t work, then you do [another treatment] and then if that doesn’t work then you stop and then they’re euthanized or you make a decision what you want to do with this thing…[This is the process] for virtually ninety percent of the scenarios they’re going to run into.” Paul, food animal practitioner This process of quantifying pain and suffering caused by joint pain against projected benefits through production of animal-based products is a common decision process of those working with food animals. Although not explicitly accounting for humane factors, some practitioners suggest that these decision processes mitigate suffering. John, when discussing the use of pain relievers in cattle lameness, suggests that suffering is mitigated by cost/benefit analysis. “If you apply the cost benefit deal, it’s pretty easy to quickly find out which cattle are going to respond…if they’re not going to make slaughter weight, then their fate is decided for them. So that pain and suffering is mitigated by that process. They’re just not allowed to suffer for very long, the suffering is not going to continue. It’s not going to be a valuable animal…you can’t keep them around without any kind of incremental value.” John, food animal practitioner Thus, some veterinarians believe that the cost/benefit process mitigates suffering. Although the suffering of animals is not directly factored into the equation, animals failing to gain weight appropriately (due to suffering or otherwise) are euthanized.  139  Conventionalist Approaches A few participants mentioned that societal expectations about animal use influenced their reasoning. Sally believed that declawing cats is acceptable based on the procedure being widely accepted in society. “Well right now I think that declawing is OK, because cats are bred to be pets. Is it nice to the cat? Definitely not, but if that’s what makes a cat a pet, and I think it does to hundreds of thousands of owners, then it’s OK. I do think there are alternatives; I do think owners should know that they can buy a scratching post and that their cats can be just fine with claws. But right now that is just such a part of our society that it’s OK to declaw.” Sally, companion animal practitioner This conventionalist approach to moral reasoning influenced her beliefs about the acceptable treatment of animals. By this reasoning, the client is acting reasonably because declawing is accepted by current conventions (one approach to moral reasoning), even though the welfare of the patient is negatively affected. Concerns about Virtue Although most participants described using outcome based approaches, a few participants mentioned that they were concerned about virtue. In the following field note excerpt from observations at a food animal practice, one veterinarian described the practice of restricting feed to feedlot cattle in order to moderate their growth and maximize profit. “I talked with one of the vets today about the practice of restricting feed in the cattle in order to hit a market. He explained that normally, feedlot cattle will gain approximately 3 pounds per day. Producers may predict that there will be a good market in the fall, for example, but the cattle would be at market weight earlier. So in order to hit the market, they will sometimes restrict their feed so that they only gain 1 pound per day. He mentioned that they can lose up to 2 % of the animals during this process but that those losses are offset by the increased beef prices. He said that he had posted [conducted autopsies on] animals that have nothing but stones and paint chips and wood in their rumens because they are desperate to eat. They will eat anything. What bothered him was that when he would drive down the alleyway in the feedlot, the cattle would come running when they saw his truck. He said that the cattle knew that his truck was not a feed truck, they were just so hungry and hoping to be fed. He considered this a serious animal welfare problem. He mentioned that some colleagues would assist feedlot owners in setting up these restricted feeding schedules. I asked him why he went along  140  with it and he shrugged ‘I don’t know’. What bothered him the most was what he considered the arrogance of making an animal gain only 1 pound per day when they were designed to gain 3 pounds per day. Losses were expected and acceptable but the arrogant human manipulation was not.” This story is particularly interesting because it describes veterinarians who are willing to impose chronic hunger on their patients and accept death in 2% of the animals, for the economic benefit of their clients. Perhaps more interesting is that the veterinarian telling the story considered this practice of feed restriction ‘arrogant’. This deviation from the common cost/benefit method of decision-making in intensively raised animals stands out. The primary criticism is not that the harms to the animals outweighed the benefits but that the virtue of the participants involved was questionable. In summary, some veterinarians developed rules for themselves or for their clinic particularly for routine procedures or frequently encountered scenarios. The vast majority of participants appeared to use some form of harm/benefit analysis on a caseby-case basis when reasoning, although they included different elements in the analysis and weighed harms differently. A few participants also mentioned the importance of following social convention and the importance of virtue in decision-making. Discussion This research indicates that veterinarians frame situations based on conceptions of animal interests, client reasonability, and veterinary role in the veterinarian-clientpatient relationship. Veterinarians differed in their analysis and ultimately their decisions with respect to what was good or bad for animals as well as the nature of client and veterinary responsibilities concerning animals. Different permutations of answers to the questions 1) “Is this situation bad for the animal(s)?” 2) “Is the client acting reasonably?”, and 3) “Is it my job to intervene?” result in differences between veterinarians’ construction of moral problems. Some veterinarians might identify a situation as morally problematic while others would not. Moral problems appeared in two forms, ones that were within the realm of veterinary responsibility and ones that were not. For example, the castration of cattle without anaesthesia might be a moral problem but because it is  141  accepted practice, it does not represent a problem for which the veterinarian must respond; the individual practitioner is not obliged to intervene in the problem. Conceptualizations of moral problems by veterinarians were also influenced by the moral reasoning methods they employed. Practitioners developed ‘lines’ of appropriate animal use and professional role based on different reasoning processes. For some veterinarians, animals had absolute protections in some situations such as declawing of cats or ear cropping of dogs. Veterinarians holding a deontic approach were able to create certain boundaries that influenced how they assessed the interests of animals, whether a client was behaving reasonably and their professional role. These rules or boundaries assisted them in making decisions about intervention, such as to refuse service. This Kantian approach to resolving moral questions allows some veterinarians to work from universalizable principles144 that obligate veterinarians to treat animals in certain ways or afford them certain protections. Whether veterinarians believed that these principles apply to all veterinarians deserves more attention. Nevertheless, the primary method of reasoning resembled utilitarianism  145,146  in  that veterinarians weighed costs and benefits to the animal and/or the cost to the animal against the benefit to clients. However, participants weighed costs and benefits differently and accounted for different types of costs to animals. Veterinarians working with companion animals viewed harms to individual animals that might include pain, distress, anxiety, suffering, and death. Those working with food animals particularly those specializing in production medicine were more likely to include only significant pain and suffering; pain and suffering that led to economic consequences in their harm/benefit analysis. Additionally, production medicine practitioners were more likely to view farms as a unit and weighed costs to individual animals in light of the health (in both medical and economic terms) of the entire system. Accounting for the interests of individual animals was of less concern for these practitioners, whereas companion and mixed animal practitioners frequently focused on harms to individual animals. Frequently, participants cited multiple reasoning approaches even within a given circumstance rather than maintaining a purely deontic or utilitarian approach. The use of multiple moral reasoning approaches is not uncommon.147  142  Some veterinary ethics authors encourage more methodical moral decisionmaking by veterinarians and recommend that veterinarians should develop alternative solutions and then work through utilitarian and/or deontonlogical decision pathways to reach a decision.148,149 However, Rest 141 suggests that moral reasoning is only one facet of morality and that moral psychology consists of four components – moral sensitivity, moral judgment (or reasoning), moral motivation and moral character. Moral sensitivity involves the ability to recognize situations or facets of a problem that are morally important.141,142 This sensitivity is necessary to the moral decision-making process. Is moral sensitivity a useful concept in veterinary medicine? Moral Sensitivity in Veterinary Medicine Research on moral sensitivity in other professionals uses standardized tests to assess whether research participants are able to recognize the morally relevant features in a given scenario.150,151 These studies examined how well individuals identified predetermined morally relevant features of a carefully crafted scenario. Similarly designed studies may be useful in veterinary medicine or veterinary education to assess the level of veterinarians' sensitivity to moral problems in veterinary medicine. Nevertheless, the veterinary profession suffers from a significant handicap. Because the appropriate treatment of veterinary patients is not clearly delineated  13,32  and their moral  standing appears ambiguous,30,59 there may well be debate as to whether a situation is morally problematic or not, similar to abortion debates in human medicine. In order to make decisions about balancing their responsibilities to both patients and clients, veterinarians must first recognize that these responsibilities may be at odds with one another. In other words, the way veterinarians construct moral problems is related to their sensitivity to morally relevant factors. Increased dialogue within the profession could help some veterinarians understand why others find some situations “complex and troubling.” This dialogue may help to solidify consensus within the profession about what constitutes a morally problematic situation. Ultimately, members of the profession may become more uniformly aware of morally relevant issues (such as the moral importance of even short-term pain) thus increasing moral sensitivity.  143  Moral Reasoning and Moral Development Another aspect of moral problem construction involved the reasoning processes that veterinarians use. Initial work on moral reasoning stemmed from research into moral development. Kohlberg 152,153 theorized that moral development consisted of a stepwise process of acquiring and using increasingly complex concepts relating to interactions with others. For Kohlberg, moral development progressed from concerns about self, to concerns about following conventions and rules, and finally to moral principles. Following Kohlberg’s work, researchers developed standardized tests to study moral judgment, and some researchers evaluated moral reasoning in veterinarians and veterinary students. Self et al63 compared large-animal veterinary practitioners to smallanimal practitioners to test the hypothesis that those working with small animals had higher levels of moral reasoning. The authors found no difference in scores between the two groups. Following Gilligan’s concerns about gender bias in the more traditional formulations of moral reasoning, one study suggests that female veterinary students have a greater ‘care’ orientation and male veterinary students have a greater ‘justice’ orientation.62 In a later study of medical and veterinary medical students, it was found that both male and female students had similar moral reasoning patterns.72 Numerous studies document the effects of professional education on moral reasoning and show that students’ moral reasoning skills did not increase 67 throughout professional education as expected. Also students became more uniform in their reasoning, which suggests that professional education has a strong socializing effect. Still other studies attempt to measure the success of ethics education through increases in moral reasoning scores of veterinary students.67 Tannenbaum  12  is critical of these studies because of concerns about poor  research design and poorly justified conclusions. It is important to recognize that the above mentioned studies were not designed on veterinary moral problems but were based on standardized moral tests. Although the standing of almost all human beings is well established, the standing of animals is not. Because of this uncertainty, veterinarians may reason differently when it comes to standardized tests involving  144  human focused scenarios, making the result of these tests less reliable. Researchers wishing to study moral reasoning within the veterinary profession or the effect of moral education on veterinarians and students should consider developing tests that are more sensitive to veterinary problems as has been done in the field of dentistry.151 Nevertheless, many of the veterinarians in this study used some form of cost/benefit analysis when considering the appropriate use of animals and treatment of veterinary patients. This raises important questions for veterinarians and the profession. By what moral reasoning process should veterinarians accommodate competing responsibilities to patients and clients? Are cost/benefit analyses always the best way to resolve competing interests? Do veterinary patients have certain protections that prohibit certain practices and thus rule out the use of a cost/benefit analysis? For example, should all animals be afforded the protection of anaesthesia during surgery regardless of the benefits to humans of withholding it? As loath as the veterinary profession is to acknowledge or claim that animal’s have some rights or strong protections, this may be an area of ethical inquiry that the profession ought to pursue as a way to solidify or delineate our responsibilities concerning animals. Moral Problems and Veterinary Moral Problems In the framework presented in this chapter, moral problems are differentiated from veterinary moral problems. Veterinarians identified situations that, while potentially morally problematic, are not within the realm of their professional responsibilities. In this way, some veterinarians believed that while intervening in a situation to assist an animal might be morally praiseworthy, these interventions should not be considered a professional responsibility. For example, one veterinarian may believe that veterinarians are obliged to provide emergency care to animals, at least initially and minimally, regardless of whether the client is available to give consent or pay for the services. Some foreign veterinary associations have codified this responsibility.39 46 Other veterinarians suggest that provision of emergency care is a supererogatory act (a praiseworthy but not morally obligatory action 44). The nature of veterinarians’ responsibilities concerning animals comes into question. Which problems are simply moral problems and which are within the realm of professional responsibility, for which  145  individual veterinarians are responsible to intervene? Examples of situations may include some provision of services to animals owned by the indigent, reporting animal neglect, provision of anesthesia in all surgical procedures, and the restriction of nontherapeutic surgeries. In other words, are all moral problems as determined in the presented framework actually moral problems for veterinarians and the veterinary profession? Questions about veterinary responsibility concerning animals need further consideration by the profession within Canada. Moral Problem Construction and Professional Credibility As animal health professionals, veterinarians are frequently asked to provide opinions on the acceptability and appropriate use and treatment of animals. Veterinary clients, governmental and non-governmental organizations, research institutions, and the courts rely on veterinarians’ recommendations regarding the use and care of animals. The opinions of veterinarians are important at the practice level in formulating treatment plans for patients and clients and developing clinic or hospital policy. It is also important at the level of public policy. Therefore, it is important that both veterinarians and the institutions relying on veterinary opinions recognize that veterinarians construct moral problems based on their beliefs and assessment methods and that these beliefs and assessment methods are not uniform. As animal welfare and animal use questions are inextricably intertwined with ethics,99,100 unreflective veterinarians or those lacking moral sensitivity might be unaware of their underlying value assumptions. Fraser93 argues that properly conceived animal welfare science is a combination of scientific and ethical elements. Sandøe et al 154 suggest that animal welfare scientists providing advice on animal welfare issues “have a responsibility to reflect on, and be open about, the limitations of the contribution that they can make as scientists”. These limitations to scientific certitude include, amongst other things, uncertainty about priorities. Likewise, veterinarians may well heed this advice and reflect upon and acknowledge underlying values that influence their decisions and beliefs. Hewson 118,119,128,129 urges veterinarians, veterinary associations, and veterinary educators to improve veterinarians’ and veterinary students knowledge of animal welfare  146  science. This is an important claim and should be taken seriously as veterinarians may neglect non-health facets of animal welfare or may not take seriously the short and long term implications of short term pain.155 Although scientific information would likely influence beliefs about client and professional responsibilities, these are ethical questions, not scientific ones, and require ethical analysis and reflection. Knowledge of scientific elements alone will not help veterinarians assess whether a client is acting reasonably or whether they have professional responsibilities in a given situation, and if so, how to balance those responsibilities. The view that science is value neutral persists in academic institutions and those educating veterinarians and veterinary students about animal welfare must have a firm understanding of and sensitivity to the interactions between the science and the ethics.93 A potential criticism of my researchxxvi is that people do not actually invoke moral reasoning before making decisions. Haidt 75 takes an essentially emotivist position and suggests that moral reasoning is a post hoc mechanism for justifying moral decisions made by intuition. For example, the judgment that abortion is morally wrong is not based on the belief that life begins at conception, but rather positing that life begins at conception justifies the intuitive belief that abortion is wrong. In Haidt’s view, for most people there is no active moral reasoning. But, the role of justification serves a function in influencing the thoughts and intuitions of others and therefore is important in moral discussions. Whether people reason through rational decision processes as purportedly measured by moral reasoning tests, or simply by intuition providing post hoc justification for their intuition as Haidt suggests, is an interesting question. Regardless, the way veterinarians conceptualize or appear to conceptualize moral problems, and how they describe their reasoning processes (or justify their intuitions) has important implications for the veterinary profession as well for those using or concerned with the use of animals. Veterinarians and the profession have a responsibility to actively reflect upon and provide reasonable justification for their decisions.  xxvi  Haidt criticism could apply to any moral decision-making research that presupposes that people actively reflect on their moral decisions.  147  Conclusion The purpose of this chapter was to explore how veterinarians conceptualize morally problematic situations and how they reason in these situations. Veterinarians consider the interests of their patient, client reasonability, and their own professional responsibilities when negotiating situations in which the interests of patients may conflict with those of clients. By combining different conceptions of these three elements, (that might change over time) veterinarians may develop a myriad of conceptions about moral problems, some of which may be within their professional realm of responsibility. This research suggests that veterinarians are not uniform in the way they conceptualize moral problems or in the way that they reason. This diversity presents a number of problems for the profession or at least highlights potentially problematic areas. These findings assist in understanding why sometimes veterinarians do not appear to fulfill their responsibilities concerning patients – they conceptualize their responsibilities differently. Even those veterinarians that agree that a situation presents a veterinary moral problem will disagree on the best approach to resolve it. Further research focusing on the construction of moral problems in veterinary medicine will be useful for the veterinary profession. Increasing awareness and stimulating dialogue about moral problems within veterinary medicine will assist in furthering discussions about human and veterinary responsibilities to animals.  148  Chapter 7: Factors Hindering Veterinarians from Promoting Animal Welfare As noted in the previous chapter, veterinarians construct moral problems in different ways. Once identifying a veterinary moral problem, veterinarians felt that they had a responsibility to intervene in some way to protect the interests of the animals. For example, most veterinarians who discover evidence of animal abusexxvii believe that they are morally obligated to intervene in some way such as reporting to the appropriate authorities.8 However, of veterinarians who believe that they have examined abused animals, only a small percentage report this abuse to the proper authorities.23 Although veterinarians recognize abuse as a veterinary moral problem and feel obliged to intervene, carrying out the actions necessary to stop the abuse is sometimes pragmatically difficult 8. These situations represent practical dilemmas; that is, although the right action appears clear, other factors may influence veterinarians into following a path that they believe is less morally acceptable but more pragmatic. This chapter describes obstacles that participants cited that hinder them from promoting the welfare of patients. These obstacles include concerns about poor animal protection regulation and enforcement, their credibility within their community, conflicting interests with employers, and personal economic health. Concerns about Poor Animal Protection Laws and Enforcement In cases of abuse or substandard care, veterinarians expressed concerns about contacting humane organizations for a number of reasons. In the following quote, Aaron talked about the inadequacy of the provincial humane authority. “I think [the SPCA is] horribly ineffectual, and I think it’s not so much a measure of what their mandate is, it’s a measure of the lousy laws and legislation that we have in place to protect animals. I’m happy to hear in Californiaxxviii they’re exercising a lot more power in trying to maintain some semblance of respect for 4legged creatures but it just hasn’t reached us yet. They’re still a commodity.” Aaron, companion animal practitioner  xxvii  Also as previously noted, defining animal abuse, or substandard care, depends on beliefs about animal welfare and client responsibility. xxviii  In recent years, much animal protection legislation has been proposed or adopted in various jurisdictions in California. California is considered the testing ground for legislation modification by animal welfare/rights groups.  149  Poor legislation and inadequate enforcement of the current legislation were reasons cited by several veterinarians for failing to contact humane authorities in potentially abusive or neglectful situations. In addition, some veterinarians would not report to humane authorities because they believed it was too difficult and ultimately futile. Animal abuse cases are difficult to prosecute and it takes time and resources for veterinarians to assist in prosecuting these cases. In the excerpt below, Melissa, a mixed animal practitioner, detailed some reasons for failing to report negligent animal care. Melissa: Those lines are so blurry. What constitutes neglect? That they hadn’t seen a vet for 3 years? Is that negligence even if they’ve been healthy?…The dog whose mouth is so rotten, you can’t even get close to him. But [the owners] won’t get the teeth looked at or have anything done with the teeth. They just want antibiotics. We just refuse to have them in our clinic. We don’t need that. And at that level, just because we don’t have the problem doesn’t mean the problem’s not there anymore and I guess we could be more responsible about taking a role with that sort of thing. Carol: What stops you from being more responsible as you say? Melissa: Just not wanting to rock the boat I think…I am thinking of a specific case. The person argued with me for an hour, and still wouldn’t do anything about [their dog’s teeth]. Yes, I probably should have called the SPCA because it is a negligent and an inhumane thing, but I didn’t. Why??…Because it’s easier to turn a blind eye to it. It’s the easier thing to do. You don’t want to get involved with it. The people aren’t nice to deal with anyway, so if they walk out the door and go somewhere else that’s fine. If you call somebody in (the SPCA), you are going to have to deal with the paperwork and the legalities. And then you’re going to have to deal with the bad PR because they’re going to tell 10 people about it. Yeah it’s easier. Carol: How much of an issue is the PR issue for you? Melissa: It’s a pretty big issue, you know. Somehow the vet is always the bad person in those cases. Unless there’s been some heroic saving going on. But in a seizure? The person who’s initiating the seizure is the bad guy…I think more the commitment you’d have to make seeing it through is even bigger than the retribution…You lodge the complaint, then there’s the chance you’re going to have to be called into court, and that’s a pain in the butt. And then these things get thrown out and ... it can be a huge waste of time. This is an important quote. In the first segment Melissa constructs a veterinary moral problem – insufficient provision of veterinary care by the client. She attempted to resolve 150  the problem by refusing service or firing the client. However, she acknowledged that this action does not really solve the problem and suggested that she could be “more responsible” to protect the interests of the patient by calling the humane authorities. She then identified several reasons for failing to report a case that she described as animal neglect. The reasons cited generally flow from potential harms to the veterinarian or the veterinary practice. Detrimental aspects of reporting animal neglect include the use of the veterinarian’s resources to report and follow through with the case (a detriment to personal economic health, see section below) and negative repercussions within the community or bad public relations, which could also affect personal economic health or standing within the community (see Concerns about credibility below). In addition, Melissa believed that the potential for improving the situation for the animal is slim because it is difficult to obtain a conviction in animal abuse cases (“these things get thrown out”). In her estimation, the harms to the veterinarian outweigh the unlikely benefits to the patient. In other words, pursuing legal remedies is often futile. As well as concerns about animal protection legislation, the difficulties of working with humane authorities, and frustration with the courts, some veterinarians although worried about neglectful care, had sympathy for clients. As mentioned in Chapter 4, some veterinarians identified cases of inadequate care but were reticent to call the humane authorities because they felt that the clients were trying to resolve the problem. The clients seemed to care about the patient, especially those who showed evidence of contrition. Many times veterinarians attempted to assist clients identified as problematic (from a resource standpoint) but also good (from a compassion standpoint). Veterinarians unable to assist clients in improving the standard of care felt that there were few alternative avenues of assistance. Michael: I have a pair of clients. They are originally from [Africa]. They don’t have a tradition of farming but they’re giving it a try. It’s a very nice couple. Their animals are extremely skinny. Sometimes I go and look at these huge abscesses. We try to educate them but it just doesn’t go through their heads. One of my associates said, “Let’s call the SPCA on them and I’m like, “They’re not doing it intentionally”….I have sat with them and [said to them], “You see that straw? Your animals cannot eat straw. You need hay, you need good hay. They’re too skinny.” [They respond], ‘Oh yes doctor, oh yes doctor, oh yes doctor’, and then a month later you go and it’s the same thing. But they’re terribly nice and then at what point do you say, “You know what? I’m calling the SPCA”? 151  Carol: Are you saying it’s the right thing to do but ...you feel bad because they’re trying? Is that right? Michael: Yes! They’re doing it out of ignorance, although I’m trying to educate them as much as I can. It just doesn’t go through their heads. And I don’t know, maybe they shouldn’t have cattle?…But it would hurt them. That’s their living. Usually SPCA cases become public. I’m an immigrant myself and I know how difficult it is. It’s going to be harsh for them. Then every time I get called I get really angry and I don’t know what to do. I just, I just keep on going and I keep on trying and I keep on telling them and hopefully one day they will listen. Michael, a mixed animal practitioner, was concerned about his clients and he did not want to report them to the humane authorities because he felt that doing so would harm them. Although he recognized that the animal care was substandard, he felt he had few alternatives to improve the care that would not seriously harm his ‘nice’ clients. His concerns focus on how animal protection laws are enforced rather than their futility. In his mind, there are no intermediate steps between trying to handle the problem himself and seriously harming his clients by invoking the confrontational step of contacting the humane authorities. This type of situation shows that in the minds of some veterinarians, there are no alternatives to assist patients except for seemingly futile education attempts directed at the client or by throwing their clients to the wolves. In other words, there is no official method of soliciting outside help from animal protection authorities that will assist the patients and the clients. Concerns about Credibility Some participants mentioned that promoting the interests of patients too vigorously might damage their credibility in the community. Bad public relations might affect a veterinarian economically or psychologically/emotionally. In addition to concerns about bad press in cases of animal abuse, some food animal practitioners mentioned that to maintain credibility they must work within the current production systems even if they believe that some of the ‘accepted’ husbandry practices harm animal welfare. “Well these people own the animals - we don’t, okay. So, if you want to alienate yourself – I mean you’re going to have no credibility within the industry. You need to work with these people.” Jenny, food animal practitioner 152  “Working with these people” meant finding solutions that would benefit the client in some way and not just the patients. In the quote below, Martin suggested that producers will replace veterinarians who are not sensitive to the producers’ financial goals. “Information is going to fall on deaf ears if what you do to producers is say, ‘Look, what you’ve got to do is lose some money and these animals will be in better shape’. If that’s what you’re telling them, they’ll get somebody else. I mean, that’s laughable.” Martin, mixed animal practitioner Credibility for food animal practitioners correlated to their ability to make positive economic advances for their clients. Without a positive economic incentive, clients would be unlikely to accept or implement recommendations about animal welfare. Indeed, they might be considered ‘laughable’. When they believe that they lack credibility, veterinarians worry about losing their clients and also about losing respect within their local community. In the following quote, Michael suggests that being publicly critical of certain feedlot production practices could be detrimental to him but also to others including some of his staff members. “The whole industry is standardized...this is the way they’re making their money so then I would just sound like a PETA member or whatever. And it would hurt my reputation. See I’m still living in a small town. I have a lot of large animal clients. They sell their cattle to (the feedlot). I have staff members who work with feedlots, you know? [I don’t want] to be known out there as the ‘vet that hates feedlots.’” Michael, mixed animal practitioner Michael, by no means an animal use abolitionist, is afraid of being identified as a PETA member if he suggests changes to the standard feedlot practices. This loss of credibility concerns Michael, and since he is in a small town, he also worries about the ramifications to his staff members associated with the industry. Because veterinarians interact directly with producers, they are well positioned to promote animal welfare advances. However, some participants expressed concerns about pushing the envelope too far and being identified as radical or impractical. Even practitioners who want to actively promote animal interests sometimes felt that they have to maintain a more conservative stance in order to maintain their credibility.  153  Conflicting Obligations to Employers and Colleagues Veterinarians working locumsxxix or veterinarian employees complained of conflicting responsibilities to their employers and to their patients. Sometimes employed and locum veterinarians felt uncomfortable about privileging their own beliefs about ethically appropriate animal care ahead of their employers’ views. “Because I’m a locum, [with] tail docking I do find myself caught between a rock and a hard place sometimes. I’ll come in for a day of work and there’s a litter of puppies that have been booked in for me for tail docking and dew claws. And it doesn’t happen very often. I’ve probably only done two or three in my three years of doing locums, but I’m torn…because I’m working for someone else. These aren’t my clients. It’s not my decision. As long as I feel I’m doing it as safely as I can and as painlessly as I can. But if it was my own practice I wouldn’t be doing it”. Mercy, mixed animal practitioner Cosmetic procedures, declawing, and convenience euthanasia were procedures that some veterinarians personally opposed and would normally refuse to conduct but felt some obligation to perform when employed by another veterinarian. Additionally, although some veterinarians felt that all patients should receive post-operative analgesia for routine surgical procedure, they followed hospital protocols that made post-operative analgesia optional at the client’s request. Some participants may have concerns about loss of income or employment if they refused to conform to the practice policies. However, the more prevalent concern appeared to be reticence to place professional and/or public judgments on the opinions or polices of the practice owner. Although the CVMA produces position statements on these issues, there is really no clear professional consensus on the acceptability of cosmetic surgery, behavioural surgery, convenience euthanasia, and analgesic management. Some participants felt they could not impose their views on another practitioner’s clients or practice. In other words, they felt that they had limited professional autonomy when employed by a practitioner with differing views.  xxix  Locum veterinarians are relief veterinarians. They fill the place of the regular practitioner and charge the practice owner a fee.  154  Concerns about Economic Health As noted in all of the above sections, non-financial concerns influence how participants acted. Some of these concerns can potentially have a financial component as well. In particular, veterinarians could experience financial penalties if they contacted humane authorities, publicly opposed ‘traditional’ farming practices, or contravened existing practice policy could all have negative monetary ramifications for veterinarians. The monetary concerns come from expending resources (in the case of assisting in animal protection) or failing to attract new clients through reduced community or professional credibility. Veterinarians also had concerns about financial losses from angry or disappointed clients. Although promoting the welfare of patients is usually economically favourable for veterinarians, frequently it is the client placing financial constraints on the veterinarian. Concern about the cost of care is an ever-present factor in veterinary medicine. It has been said that veterinarians practice with a calculator in one hand. This is not to say that veterinarians are obsessed with money or profits but that the cost of veterinary care is a significant concern for animal owners. Although veterinarians hold their own beliefs about the level of care that animals should be afforded, many participants noted that veterinarians must satisfy their clients to both maintain access to their patients and to maintain a viable business. Participants noted that this is a very real conflict of interest. “I don’t think that other professions have to put sheer financial survival ahead of their professional ethics as much as veterinarians do.” Harry, mixed animal practitioner The cost of running a veterinary practice is substantial and considered to be the highest amongst the professions 156. Although clients sometimes request services or procedures that are not in the best interests of patients, some veterinarians felt that their own survival may be at risk if they fail to follow the wishes of the client, particularly if a client generates substantial income for the practice. For example, the sale of veterinary pharmaceuticals to large food animal producers by veterinarians can often generate significant income. Food animal practitioners now have fewer clients with much greater numbers of animals per client. The loss of a lucrative client could substantially affect  155  economic viability. The following field note excerpt my interpretation of one participant’s fear about inflaming a client who had a large outstanding account. “I was somewhat astounded at the amount of money that goes into drugs for feedlots. Michael said that some feedlots will buy over $10,000 worth of drugs from a practice and have that on their client account. Then when the vet gets ‘summoned’ to conduct some procedure that they don’t really agree with, they sort of feel obligated to do it – they worried about annoying the client and losing their business, but perhaps more so, they worried that the client might walk away from their debt at the clinic and the vet would be left holding the $10K bill.” Some regulatory structures may exacerbate this common tension within the veterinarian-client-patient relationship. At the time of data collection, regulations controlling the transport of non-ambulatory livestock required veterinarians to examine an animal and authorize or deny the transport of the animal for slaughter.xxx Several participants in food animal practice mentioned that rather than protecting animals or the beef-consuming public, the regulations merely created conflicts of interest for the veterinarian. In the view of some participants, the regulations left too much to the discretion of the veterinarian and veterinary clients recognized this. Abby talked about her frustrations with needing to make ad hoc decisions about the appropriateness of humane transport in light of her professional relationship with the client. “And we have to break it down. Unfortunately, [we have] to set [it out] on paper. This is reasonable and this is not. And then enforce it. But it’s hard when you’re mixing your economic viability of having a client and not wanting to piss them off and going for the best thing for the animal.” Abby, mixed animal practitioner Veterinarians talked about clients ‘glowering down on them’ when they considered not approving an animal for transport. While clearly wanting to favour the interests of the patient, some veterinarians still felt compelled to approve the transport. Fortunately, in 2005 the regulations surrounding transport of non-ambulatory animals have changed and non-ambulatory animals cannot be transported for slaughter.157 However, this example  xxx  During the collection of data for this research, the management of non-ambulatory cattle underwent significant changes. The governmental impetus behind requiring veterinarians to authorize transport of non-ambulatory cattle was concern for human health. Bovine spongiform encephalitis (BSE or mad cow disease) had not yet been reported in Canada but reports in the UK and other parts of the world created the need for veterinary oversight of nonambulatory animals.  156  illustrates how poorly constructed public policy can create obstacles for veterinarians in furthering the welfare of animals. Discussion When trying to promote the interests of patients, veterinarians sometimes face personal or professional obstacles such as the loss of revenue, loss of resources, loss of credibility with their clients or other veterinarians, client resentment, and lack of support in the community. An important point to remember is that some of the concerns outlined by participants may not be valid. For example, some participants worried that reporting animal abuse would result in bad community relations. However, anecdotal evidence suggests otherwise.158 Others worried that if they spoke out against certain standard husbandry practices, that they might be identified as radical or impractical even when there is sound scientific evidence to support their concerns. These are empirical questions that could be explored through social science research that could either confirm or alleviate these concerns. Nevertheless, participants’ views about potential repercussions to themselves are important to understanding why veterinarians sometimes appear to fail to promote animal welfare. It is important for veterinarians to remember that they are not simply business owners who exchange a service for payment. As professionals, veterinarians have responsibilities outside of the veterinarian-client-patient relationship. The public has an interest in making sure that animals are treated humanely. In addition, other veterinarians have an interest in making sure that their colleagues behave in manner that “promotes the honour and dignity”38 of the profession. Rest  141,142  suggests that part of  moral decision-making includes moral motivation and moral character; in other words having the right intentions and the moral fortitude to follow through. Moral education of veterinary students and veterinarians may assist in highlighting the importance of moral reflection about professional responsibilities over self-interested concerns. When veterinarians encounter situations in which they perceive that assisting animals may somehow harm the veterinarian socially, professionally, or fiscally, they should attempt to mitigate these conflicts of interest. Mitigating conflicts of interest can be accomplished through avoiding the situation (such as refusing to sell large volumes of  157  pharmaceuticals or allowing clients to run up their accounts) or by making the conflict explicit. The veterinary profession should give significant thought to how the ethics of veterinary business influences individual practitioners and whether veterinarians should have restrictions on the ways that they generate income. For example, physicians do not prescribe and sell pharmaceuticals, a practice, which is universally accepted in veterinary medicine. However, given the current practice environment, the most obvious method that veterinarians can use to mitigate conflicts of interest is by making the conflict explicit, in other words by explaining the problem to their client. Researchers in veterinary communications suggest that improving practitioners’ communication skills will improve client compliance and ultimately patient care 159,160. Using communication in ethically challenging situations is an important skill for veterinarians and may help to resolve some of the perceived obstructions to promoting good patient care.161 Veterinarians need to be able to recognize how their clients value their patients and how they interpret good care, but veterinarians also need to communicate their concerns, their position, and their professional responsibilities in order to create moral boundaries within the veterinarian-client-patient relationship161. Nevertheless, veterinarians are not solely responsible for ensuring the appropriate care and use of animals. Some authors urge veterinarians to be leaders in promoting the interests of animals.14,36,37,118,119,129,130,162 These appeals are well founded and previous chapters reinforce that veterinarians should take seriously their responsibilities concerning animals. However, practical obstacles actually hinder veterinarians from acting on their felt obligations. Veterinarians represent a very thin line of protection for these animals when their owners are unwilling or unable to provide them necessary resources. If protecting animals is important to society and to veterinarians, obstacles hindering veterinarians from furthering the interests of animals should be addressed. Werhane163 argues that systems are flawed if they do not encourage people within the system to act ethically. Legislative, regulatory and business systems that do not support veterinarians in fulfilling their responsibilities concerning animals should be scrutinised. This research supports previous research emphasizing barriers to veterinarians in reporting animal abuse.8,23 Veterinarians are concerned about repercussions from  158  clients and the community. They are also concerned about expending personal resources to pursue abuse cases. They complained that the legislation and enforcement of animal abuse legislation was poor and thus did not offset the negative consequences of reporting. Currently in most jurisdictions in Canada, veterinarians are not required to report cases of animal abuse to the humane authorities; nor are they protected from civil litigation or regulatory complaints initiated by the subject of these complaints.164 At the same time, in most provinces, charitable organizations enforce animal abuse legislation. These organizations receive much of their funding from private donations 165 making the successful pursuit of animal abuse convictions difficult due to lack of financial resources. The lack of legal mandate to report animal abuse and practical deterrents to reporting animal abuse do not support veterinarians in fulfilling their responsibilities concerning animals. The veterinary profession, animal welfare advocacy organizations, and humane authorities need to work cooperatively to create systems that will encourage veterinarians to act in a way that is consistent with their responsibilities to minimize suffering and to promote animal well being. In instances of substandard care or neglect, veterinarians prefer to try to educate clients rather than reporting their clients to humane authorities 8,23. However, veterinarians may lack the resources to educate certain clients. Although veterinarians are accustomed to educating clients about their animals’ medical conditions, veterinarians receive little or no formal training in education techniques. Additionally, veterinarians are not social workers nor are veterinary practices social agencies. Veterinarians may have insufficient education and skills to assess and manage cases in which clients lack motivation, skill, or ability to improve the care of their animals. Currently, the resources that are available to veterinarians are usually provided through humane organizations that are mandated to enforce cruelty legislation. When animal care does not meet the threshold of a legal definition of abuse or when veterinarians have sympathy for clients’ personal circumstances, some humane organizations may be unable to provide services to assist animal owners to improve animal care. Many of these organizations have insufficient resources to fulfil their legislated mandate, let alone to adequately instruct poor animal caregivers to improve animal care. In other words, there is no social net for animals. To address these situations that fall into the gap  159  between acceptable and unacceptable animal care, the profession should consider avenues to develop a network to assist these clients and their animals. In addition to humane protection resources, regulatory systems that place veterinarians at odds with their clients also create obstacles for veterinarians. Some of the interviews for this research were conducted around the time of Canada’s first case of bovine spongiform encephalitis (BSE or mad cow disease). The regulatory structure that required veterinarians to authorize transport of non-ambulatory livestock is no longer in place because it is now considered unacceptable to transport non-ambulatory animals for slaughter 157. However, this regulatory structure and ones similar to it may place veterinarians in difficult situations. For example, food commodity groups in Canada have developed animal welfare standards for member producers. Currently, the producers’ veterinarian might inspect the producer’s premises and animal care practices for the purpose of a third-party audit for food safety and animal welfare standards. It may be difficult for veterinarians to conduct these inspections without having conflicting personal interests. Ideally, veterinarians would not place themselves, or would not be placed, in circumstances where there are potential or real conflicts of interest. Regulatory structures originating from governmental policy or legislation that do not account for conflicting obligations of the professionals used to enforce them, place veterinarians in situations that are pragmatically challenging. Conclusion Rollin 14 asserts that the fundamental question in veterinary medicine is whether veterinarians owe primary allegiance to their patients or to their clients. However, even when veterinarians are able to answer the question affirmatively in favour of their patients, other factors inhibit them from pursuing the interests of animals. Veterinarians engaged in private practice by the nature of their position in the community are influenced by very real and practical factors that obstruct them from pursuing the interests of animals. Poor legislation, inadequate resources to ensure the enforcement of current legislation, and frustration with the lack of convictions, leave some veterinarians very jaded with respect to reporting their concerns about the care of patients to humane authorities. Additional concerns about loss of income, resources,  160  and community standing aggravate the situation. Poorly crafted regulatory structures and the lack of support resources in dealing with these conflicts may cause veterinarians to “turn a blind eye.” Moral education and ethical reflection might help veterinarians to evaluate or re-evaluate their moral motivations and reaffirm the importance of moral character in these situations. Good communications skills might assist in improving patient care and client understanding of their responsibilities concerning their animals. Additionally, improved communications amongst colleagues about practical ethical challenges that practitioners face may assist them practically (e.g. what should I do?) and provide social support. Veterinarians may be encouraged by ethicists and animal welfare advocates to further the interests of animals by reporting abuse, pressuring food producers to improve animal care, and by refusing to engage in morally questionable veterinary procedures such as cosmetic surgeries. Nevertheless, without addressing practical factors that obstruct practitioners, these appeals may do little to improve the care of animals. If the public wishes veterinarians to protect animals, the existing public systems need to address the concerns of veterinarians.  161  Chapter 8: Thesis Conclusions The goal of this dissertation was to explore the discrepancy between espoused ideals of promoting animal welfare and the actual practices of veterinarians. In addition to the responsibility to promote animal welfare, veterinarians have professional responsibilities to clients. In some cases these responsibilities compete. In order to understand how veterinarians manage these (at times) conflicting responsibilities, I examined how veterinarians believe that they make decisions and the factors that they incorporate into their decision-making. This chapter summarizes veterinarians’ decisionmaking and then highlights three main reasons why veterinarians appear to fail in promoting animal welfare. I then explore how this social science research contributes to the field of veterinary ethics, highlight some particularly important findings and offer some suggestions for solutions or new research avenues. How do Veterinarians Make Decisions? Participants in this research appeared to incorporate a number of factors when making decisions. Some of the most salient factors included the degree of harm or benefit an anticipated procedure or treatment would likely have on the patient. Participants included various elements based on their beliefs about what constituted good animal welfare and whether death or continued life constitutes an animal interest. All participants included pain and suffering as an important element in their decisions. Yet participants evaluated pain and suffering differently. Some participants focused more on functioning aspects of welfare such as growth and productivity, whereas others used animal behaviour and client evaluations in their assessments of how well a patient was doing. Connected to beliefs about welfare were ideas about the level of care that an animal ought to receive. Food animals, in general, were viewed differently than companion animals in this respect. The level of care that a farmer ought to provide his cattle, for example, is different from the level of care that a dog owner ought to provide his dog. However, differences in the level of care were not uniformly split along species lines. Practitioners from within practice categories (i.e. food, mixed, companion) had different beliefs about what is appropriate. Regardless, beliefs about the appropriate  162  level of care that an animal owner ought to provide influenced whether veterinarians would conduct a procedure, perform a treatment, or solicit the assistance of outside agencies such as the SPCA. Beliefs about animal interests and owner responsibility form the foundation of how veterinarians assess harms and benefits to patients and whether harms and benefits are reasonable in light of clients’ circumstances. As a general rule, participants seemed to use consequentialist methods to determine whether the harms to a patient outweighed the benefits to a client. In some cases participants included patient attributes such as usefulness and attractiveness in these equations, as well as evaluations of client ‘goodness’. Nevertheless, some participants used deontic reasoning stating that animals had some protections that could not be calculated away. Participants’ decisions were also influenced by beliefs about their responsibilities within the veterinarian-client-patient relationship. Some believed that they should behave as impartial technical experts (Information Provider Model); some believed that they should follow the wishes of the client without much input (Service Provider Model); and others believed that their professional responsibilities included advocating for either patient or client. Shifts between these professional models are influenced by beliefs about animal interests and the level of care that owners ought to provide. For example, a veterinarian may move from an information-provider role into an advocacy model when they assess that a patient is not doing well and that the owner has an obligation to end suffering. Again, it appeared that some participants used consequentialist methods of assessing harms when deciding how to interact with clients whom they believed were providing insufficient or inappropriate care. Other participants were more influenced by their perceived role-defined responsibilities to clients rather than the actual consequences. Finally some participants expressed concerns about harms to themselves – financial, professional, or psychological – and these influenced how they would handle a situation. For example, some participants agreed to treat an animal in a less than ideal way because they worried about annoying their clients and consequently losing revenue. One participant refused to conduct ear cropping because he worried about client  163  complaints rather than about the appropriateness of the procedure. Negative or positive personal consequences shape how some participants made decisions in some cases. The factors, beliefs, evaluations, and reasoning processes all affect veterinary decisionmaking. Why do Veterinarians Appear to Fail to Promote the Welfare of Animals? Understanding veterinary decision-making can aid in understanding why veterinarians sometimes appear to fail to promote animal welfare. In the introduction to this dissertation I cited studies that show that veterinarians sometimes fail to report animal abuse even when they felt that they were morally obliged to do so;8 that veterinarians sometimes conduct cosmetic procedures22 even when their national professional association condemns these procedures;117 and how approximately one quarter of veterinary students felt that hot iron branding of livestock was acceptable.24 The factors and processes that veterinarians use in making decisions sheds light on why these seemingly incongruous beliefs reside in the minds of professionals who swear to prevent pain and suffering and to promote animal welfare. I have categorized possible explanations into three types. First, some veterinarians did not believe that they were failing in their responsibilities to further animal welfare. These veterinarians interpreted their responsibilities concerning patients in light of their beliefs about animal interests, client reasonability, and professional role. In other words, participants recognized or constructed moral problems differently. For example, even though professional organizations or animal welfare scientists may consider a particular practice detrimental to animal welfare, some veterinarians did not agree. Others might agree that certain practices represent an animal welfare problem, for example hot iron branding, but were influenced by their beliefs about client or professional responsibility. These veterinarians balanced animal welfare against clients’ interests and this balancing influenced whether they perceived situations as morally problematic for them as professionals. In a way, this finding represents a methodological problem. I embarked on this research assuming that veterinarians would have similar concerns as I have, about the moral importance of various situations such as conducting castration without  164  anaesthesia.xxxi However, this proved not to be the case. Veterinarians in this study appear to have quite varied beliefs about what counts as animal interests, what clients ought to provide, and veterinarians’ professional role within the veterinarian-client-patient relationship. In other words they “fail” to identify moral problems; problems that are identified in the literature and/or by professional organizations. Secondly, veterinarians were influenced by their judgements of patients and clients as individuals. “Good clients” and “good patients” received special care such as reduced fees or even free care. However, practitioners having sympathy for certain clients, or having a long and trusting relationship with a client, might ignore or justify poor animal care. Conversely, veterinarians might refuse services to difficult clients to the detriment of the patient, although they would otherwise assist animals of more likeable clients in similar situations (for example in emergencies). These judgements about clients affected veterinarians’ treatment of patients, more as a car mechanic would behave to a poor customer than as a paediatrician would to a poor parent, to use Rollin’s metaphor.14 Troublesome, old, or unattractive patients received fewer benefits such as free veterinary care and/or adoption instead of euthanasia. Veterinarians may decide not to give sedation, analgesics, or anaesthesia to tractable animals (tractable due to size, fear, or behavioural attributesxxxii) because physical restraint alone allows the practitioner to perform painful procedures. Withholding sedation, analgesics, and anaesthesia is easier or faster with easily managed patients. Thus veterinarians’ judgments of individual patients and clients affected whether and how vigorously veterinarians promoted the interests of patients. Thirdly, economic, social and legal obstacles inhibited veterinarians from pursuing responsibilities concerning patients and sometimes caused practitioners to ‘turn a blind eye’ to patients in need of assistance. Some veterinarians felt that seeking the assistance of humane authorities was futile; legislation protecting animals is poorly worded, poorly enforced, and rarely successfully prosecuted. Some participants also xxxi  This finding also supports the use of qualitative methods for this type of research, because this finding may have been overlooked if I had used quantitative methods instead.  xxxii  Prey animals (e.g. cattle) may not react to painful stimuli in the same way as predators.  165  raised concerns about harms to themselves in the form of resource expenditures needed in order to assist with animal abuse cases or negative repercussions within the community. Bad public relations or reduced credibility also concerned some participants who wished they could be more vocal against current industry traditions that they felt were harmful to animals. Additionally, veterinarians employed by other veterinarians felt that they had limited autonomy with respect to making decisions impacting their patients. They were also concerned about personal ramifications from members of the community or the veterinary practice if they promoted an animal welfare agenda. Some were nervous about annoying clients and losing income. These concerns originate from fears about risks to the practitioner themselves, their practice, or their personal relationships. These concerns may at times weigh more heavily than veterinarians’ felt responsibilities to promote the welfare of patients. Social Science Contribution to Normative Veterinary Ethics As mentioned in Chapter 1, Solomon51 describes different ways that social science research can contribute to normative ethical inquiry; that is, how the ‘is’ can inform the ‘ought.’51 Throughout this dissertation I have provided examples of veterinarians’ decisions that do not appear to conform to official statements of their professional responsibilities to promote animal welfare and to respect client autonomy. Veterinarians admitted to coercing and manipulating clients, contrary to the professional code requirements which state that veterinarians should serve clients with integrity, honesty, and candor.38,120 They also gave examples of failing to promote animal welfare and to mitigate pain and suffering as required by the Canadian Veterinary Oath.47 The quotations that fill this dissertation document gaps between espoused ideals and actual practice. This is one way in which social science research can contribute to ethical inquiry.51 Qualitative data in the voices of practitioners facilitates an appreciation of the complex and multilayered process of decision-making grounded in the context of veterinary practice. Gaps between espoused ideals and actual practices indicate that there is either a need to re-evaluate the norms or a need to modify current practices to enable practitioners to conform to the official norms, or both. Perhaps more importantly, the contextualized data presented here might help to stimulate reflection amongst  166  individuals and dialogue within the profession about these norms, their appropriateness, and the impact official norms have on ethical practice. Beyond such documentation, this dissertation contributes to veterinary ethics and normative inquiry in several ways. This research emphasizes the diversity amongst veterinarians in their views about what constitutes a moral problem and also how veterinarians frame problems involving the well being of patients. The way that veterinarians construct moral problems illustrates how these gaps between espoused ideals and actual practices might occur. In other words, this research reveals “the nature of individual moral reflection and level of personal skill at ethical analysis.”51 This research also describes the environmental and legislative contexts in which veterinarians practice, a third way that social sciences can contribute to ethical inquiry.51 Veterinarians in private practice are business owners as well as health professionals and must balance their responsibilities to patients and clients with their responsibilities to themselves. Animals are legally considered property and animal owners have significant power over whether and the way that animals receive veterinary care.113 Veterinarians must take these constraints into account when making choices. The nature of individual practitioners’ moral reflection and decision making also raises new normative questions for both practitioners and the veterinary profession. For example, veterinarians wishing to assist their patients sometimes heavily influenced their clients in order to protect their patients. Is this ‘directiveness’ or veterinary ‘maternalism’ acceptable? Who is best situated to make decisions about animal welfare? Veterinarians’ assessments of patients and clients as good or problematic influenced them to adjust their responsibilities to patients and clients. Is it acceptable for veterinarians to use these types of judgments in their decision making? Are veterinarians entitled to deny care in emergency situations or are they obligated to provide that would in normal circumstances be viewed as supererogatory? Calling attention to a wider range of normative concerns is another way that this social science based research informs applied ethics analysis. In summary, the findings presented here contribute to the field of applied veterinary ethics in several ways. This research documents what actually happens in  167  veterinary practices and shows how veterinarians reflect on and reason through moral problems. It also explores the context in which veterinarians practice and the diverse constraints on their decision-making. Finally, the data highlight normative questions that are not routinely discussed in the literature. Important Problems, Potential Solutions, and Possible Research Avenues In the following sections I will highlight some important findings that represent challenges or problems for veterinarians and the veterinary community. I will also suggest potential solutions to these problems and identify new avenues of research. Diversity of Views About Animal Welfare and Assessing Welfare There is a significant discussion about what constitutes animal welfare and how to assess welfare; experts immersed in animal welfare do not agree on a definition.91,93 Chapter 3 shows that veterinarians used different definitions of animal welfare and assessed welfare differently. Although they used similar words to talk about animal welfare, such as pain and suffering, the meanings they attached to these words were quite different. For example, for some veterinarians ‘suffering’ may involve severe or prolonged pain only, whereas other veterinarians included a variety of negative affective states (not simply pain) when defining suffering. Additionally, some veterinarians use only production parameters to evaluate welfare and did not always account for behavioural features that might indicate that an animal is experiencing poor welfare. Thus, veterinarians may claim to be committed to promoting the welfare of animals, yet mean very different things by it with these meanings having very different outcomes for animals. This research shows that some veterinarians used very narrow definitions of welfare. Veterinarians’ narrow view of welfare has not gone unnoticed.118,119,129,130,166 Failing to account for non-pain aspects of welfare can have serious consequences to patients. For example, veterinarians might ignore negative aspects of frustration or boredom in confined agricultural animals because the health and productivity of the animals are good. Narrow conceptions of animal welfare may also have an impact of animal owners as well as those concerned with the treatment of animals (e.g. SPCAs) because veterinarians may fail to provide comprehensive advice on the care and use of 168  animals. With increasing emphasis placed on the well being of animals by society at large, the veterinary profession might lose credibility if its members define and assess welfare too narrowly or incompletely. Veterinary educators recognize that veterinarians and students require more information on the science of animal welfare.130,167 In addition to more opportunities for veterinarians and students to learn about more comprehensive definitions of welfare, there should be an effective method for transferring this information to busy practitioners. Recently the World Animal Health Organisation (OIE) adopted a definition of animal welfare that focuses on the animal’s experience and uses a comprehensive interpretation. The OIE defines animal welfare as “how an animal is coping with the conditions in which it lives. An animal is in a good state of welfare if (as indicated by scientific evidence) it is healthy, comfortable, well nourished, safe, able to express innate behaviour, and if it is not suffering from unpleasant states such as pain, fear, and distress. Good animal welfare requires disease prevention and veterinary treatment, appropriate shelter, management, nutrition, humane handling and humane slaughter/killing. Animal welfare refers to the state of the animal; the treatment that an animal receives is covered by other terms such as animal care, animal husbandry, and humane treatment.”168 Both the Canadian and American Veterinary Medical Associations recently adopted this definition as well.xxxiii Adoption of this more comprehensive definition of animal welfare may have an impact on how practitioners interpret an animal’s situation and how they answer the question “Is this ‘bad’ for the animal?” The impact of the OIE and North American move to adopt an expanded definition of welfare, and the recent veterinary educators’ emphasis on animal welfare, will likely influence veterinarians’ beliefs about animal welfare and how they assess it. The influence that these changes have on veterinary decisions would make an interesting longitudinal research project in the decades to come with this research serving as a baseline. Nevertheless, more important than the adoption of a formal definition of welfare are the actual consequences of veterinarians’ interpretations and assessments of welfare. The research presented here helps to inform the discussion about animal xxxiii  Personal communication with Dr. Warren Skippon, CVMA Animal Welfare Committee Liaison. March 9, 2009.  169  welfare by providing the context in which veterinarians assess welfare. For example, companion animal veterinarians rely on information from clients to assess welfare. Tools developed to assess aspects of welfare in veterinary practice also rely on client assessments,169-171 yet veterinarians do not always and perhaps should not always accept client assessments as reliable. Thus, this research highlights potential problems with this approach. Although this research provides some information on the welfare assessment methods that practitioners use, further research exploring the details of veterinary assessments would be advantageous. Need for Clarification of Responsibilities Concerning Animals Members of the profession must remember that animal welfare is an inherently ethical concept and not a value-free scientific notion. 98-100 Until very recently, animal welfare was framed by veterinary organizations as a human responsibility,172,173 making the concept more human-centred rather than animal-centred. The promise to promote animal welfare in the Canadian Veterinary Oath47 implies that veterinarians should advocate for a certain level of animal care – that is, certain types of human behaviour that allow animals to have a positive life. The Oath should offer more than ethereal promises to promote animal welfare. Arguably, the spirit of this tenet of the Oath is to promote appropriate care of animals amongst members of the profession, society, and animal owners, and not only animals under the immediate care of a veterinarian. Yet the definition of appropriate levels of veterinary care within this context of wider responsibilities for animal welfare is open to interpretation. Provincial animal protection legislation frequently defines animal owners’ responsibilities in terms of preventing animal distress. Owners are obliged to provide food, water, shelter, and to make sure that illness and injury are addressed. Some provincial legislation requires animal owners to provide appropriate veterinary care,174-176 yet legislation does not provide detail on the level of veterinary care. In addition to provincial animal protection legislation, there are some resources that outline animal owner responsibilities. In the companion animal sector, the CVMA has developed Codes of Practice for Kennels177 and Catteries.178 The National Farm Animal Care Council179 develops codes of practice for the care of various livestock species. These documents  170  offer recommendations for care, that is, they outline owner’s responsibilities. However, these documents do not cover all animals (for example pet dogs and cats) and they are currently not enforceable as they are only guidelines. More important to this discussion, these documents do not provide significant detail with respect to the accepted level of veterinary care, only that veterinary care programs should be in place. These provisions leave the onus on the veterinarian and client to decide what is and is not the acceptable level of veterinary care. For example, an animal may still lie in a feedlot pen or a doghouse with an unstabilized fractured leg because a veterinarian felt that the standard of care was acceptable under the circumstance. Although standards of care exist in veterinary medicine, the boundaries of acceptable care and substandard care do not appear to be clear. Veterinary practitioners often find themselves in open negotiations with clients about the level of care the client is willing to pursue. To assist both practitioners and animals, veterinary associations need to work towards the development of more detailed articulations of animal owners’ responsibilities to animals and to codify ‘appropriate veterinary care’ used in legislation and other resource documents. Aside from the importance of more concrete articulations of animal owners’ responsibilities to provide veterinary care, the veterinary profession should also consider further articulation of veterinary responsibilities concerning patients. The Veterinary Oath offers general responsibilities and the CVMA animal welfare position statements provide more concrete proscriptions and prescriptions for veterinary conduct. Yet these articulations do not appear to significantly influence veterinary behaviour. Some veterinarians still conduct cosmetic surgery and perform surgery without anaesthesia and/or analgesia on older animals, contrary to CVMA guidelines. It is possible that the CVMA is out of touch with societal views about veterinarians’ responsibilities concerning animals and that public views are more in line with the views and practices of some veterinarians. However, research regarding public views about veterinary responsibilities would help to clarify this question and may assist the veterinary profession in further clarifying their role and codification of veterinary behaviour. Nevertheless, some public views about the treatment of animals are clear, such as the mitigation of pain. Not all veterinarians in this study believed that the mitigation of pain was a professional responsibility in all cases. In order to assist veterinarians to fulfill 171  their responsibility to promote animal well being, the veterinary profession should consider different ways to further clarify the nature of these professional responsibilities. The UK Royal College of Veterinary Surgeons (RCVS) has a Code of Conduct that provides detail into veterinary responsibilities concerning patients. For example, the RCVS requires veterinarians to provide, at least, minimal emergency care to all animals39, regardless of the ability of the client to pay for services. Additionally, veterinarians “must not cause any patient to suffer i.  by carrying out any unnecessary mutilation,  ii.  by excessive restraint or discipline,  iii.  by failing to maintain adequate pain control and relief of suffering,  iv.  by neglect.”39  These are only examples of the types of responsibilities veterinarians that the profession in Canada may wish to codify. Unlike the RCVS and the American Veterinary Medical Association (in its Principles of Veterinary Ethics),46 the Canadian Veterinary Medical Association has not developed a code of ethics or conduct. This may be due to the fact that the CVMA has no jurisdiction over the practice of individual practitioners. Nevertheless, as a national veterinary association, the CVMA is well positioned to institute this dialogue with provincial veterinary regulatory bodies. The Canadian Medical Association maintains a code of ethics for physicians which the provincial medical associations adopt.180 Professional associations and provincial regulatory bodies should take this task seriously in order to assist veterinarians, protect patients, as well as to protect the integrity of, and trust in, the profession. Need for Ethical Reflection and Moral Education Participants in this study differed in the way that they constructed moral problems, or recognized that a situation was morally problematic. Differing beliefs and evaluations of professional role, client responsibility, and animal well being, resulted in substantially different outcomes for animals. For example some beef practitioners may argue that restricting feed and growth rates is an acceptable practice because the animals are only  172  slightly harmed and the client benefits significantly, whereas others might find it unacceptable. Companion animal practitioners may insist that a dog with a femoral fracture should be euthanized if the client is unwilling or unable to finance a repair; whereas others view sending the animal home to heal as an acceptable option as long as the client was fully informed of their options. Differences in moral problem construction of these magnitudes highlight the lack of clarity in responsibilities concerning animals, as noted above, but they also suggest that veterinarians may lack the necessary tools to recognize and work through moral problems. Individual practitioners might well benefit merely from learning that different veterinarians formulate problems differently. The framework presented in Chapter 6 can serve as a heuristic for reflection on this diversity. In order to begin fruitful dialogue within the profession regarding ethical problems, veterinarians should be aware that colleagues might approach situations from very different stances. Being able to methodically dissect arguments and pinpoint the area in which disagreement occurs is essential to advancing dialogue about ethical issues. For example, veterinarians working together to develop policy might be better able to understand each other’s views,xxxiv if they understand how different people construct problems differently. The variability in moral problem construction also suggests that moral education of veterinarians and veterinary students may need improvement. Some professions require continuing education in ethics and the veterinary profession should consider adding ethics as a continuing education requirement. While ethics education in veterinary medicine is in its infancy, some veterinary schools offer significant formal ethics instruction  14,181,182  . Veterinary educators should be cautioned that ethics is a  formal discipline requiring significant education and ideally those with advanced education in ethics should deliver this type of curriculum. It should not simply be a reiteration of existing norms, professional rules, and regulations. Veterinary ethics is the application of moral philosophy and social sciences and ethics education needs a firm grounding in both disciplines. xxxiv  In fact, following a presentation on this research, a veterinarian working for the Canadian Food Inspection Agency informed me that the framework helped him to understand some of the problems they encountered with policy development and implementation.  173  Although empirical research on veterinary moral reasoning and sensitivity does exist,62-67,70-72 these studies are not based in veterinary contexts.. Further research into how veterinarians recognize moral problems and the way that they reason should be grounded in the veterinarians’ experience. In a similar way, research aimed at measuring the effectiveness of veterinary ethics education must account for the unique context of veterinarians as their patients’ moral standing is uncertain. Veterinary Evaluations of Clients and Patients, and its Impact As shown in Chapter 3, some veterinarians admitted to favouring some patients over others when providing medical care. Nice or cute animals may receive better care than irritable or ugly ones. In cases involving veterinarians taking on the responsibility of adopting unwanted animals, these judgments may be pragmatically prudent. However, in cases where the animal will remain with the original owner, this form of favouritism seems more difficult to defend. Chapter 4 describes how veterinarians assess their clients and treat them differently based on these assessments. Apart from significant concerns that clients should be treated fairly 11 these assessments can have negative consequences for animals. Veterinarians may misinterpret non-verbal cues from clients causing the veterinarian to alter treatment or diagnostic recommendations. They may also have preconceived notions of how much a client can afford or is willing to pay and limit information based on this judgment. Veterinarians may identify clients as difficult or uncaring and these assessments might cause the veterinarian to refuse services to the client (and patient). Clients providing substandard care to their animals may be treated to free services or a call to the humane authorities depending on whether the veterinarian likes them or not. The information provided in his dissertation may be useful to practitioners to help them become more aware of their evaluations of clients and patients. It might also help veterinarians to reflect upon the consequences of their assessments and whether it is acceptable to favour some patients and clients over others, and if so, what circumstances justify this preferential treatment.  174  This research offers only a brief sketch of how veterinarians categorized their clients and patients. The topic deserves further research. In part, I did not delve into significant detail about client assessments with participants because it seemed almost second nature. In other words, as an insider I did not pay adequate attention to this finding until well into the research process. This is one of the pitfalls of being an ‘insider’.80 Further research into the types of factors veterinarians used in evaluations, for example demographics, behaviour, client history, etc., as well as their importance to veterinarians might be informative. Furthermore, the degree of impact that these evaluations have on communications with clients, and treatment of patients may be very instructive for the profession. Need for Well-Structured Animal Protection Systems In Chapter 7, some veterinarians expressed frustration with legal and regulatory structures in place to protect animals. They also indicated their concern about experiencing negative consequences originating from their colleagues or community should they try to pursue the well being of their patients. Although veterinarians may be encouraged to fulfill responsibilities concerning animals (whatever they might be), practical concerns inhibited them and caused some frustration for practitioners. As already noted, discussions to further elucidate the nature of veterinary responsibilities concerning patients will help veterinarians in defining and defending their responsibilities to colleagues, the public, their community and their own clients. Clear guidance from legislation (e.g. mandatory abuse reporting) and regulatory bodies (e.g. prohibition of cosmetic surgery) will help to relieve some of these problems. Improving veterinarians’ communications about their responsibilities will also help to alleviate some of these concerns161. Nonetheless, veterinarians signaled that organizational structures hindered them. Organizational systems should encourage members to act ethically.163 In order to encourage individual practitioners to fulfill responsibilities to animals, the veterinary profession should consider additional ways to mitigate these organizational factors. Animal protection systems vary from province to province. In most provinces charitable organizations investigate and prosecute alleged cases of animal abuse. Some  175  veterinarians expressed frustration about dealing with humane organizations because they felt seeking their assistance was futile. These organizations depend on public charity and therefore may be unable to afford extensive investigations. However, the province of Manitoba has vested the responsibility of cruelty investigation with the provincial government and provides public funds to investigate and prosecute abuse cases. If veterinary organizations are truly concerned with promoting the welfare of animals, their members, and the profession, they should encourage governments to resolve this funding problem. Still, some veterinarians indicated that they would not seek the assistance of humane authorities because they had sympathy for clients and did not wish to subject them to the stigma of abuse investigation. Alternatively, care provided by a client might be substandard but insufficient to meet the threshold of the definition of abuse. At times, veterinarians mistrusted the intentions of clients and would alter or misrepresent information in order to protect animals. Currently veterinarians are aware of few support structures to assist them in managing these problem situations. Who should veterinarians contact when they have trouble correcting substandard animal care? Although some humane authorities may be able to assist, veterinarians show reticence about contacting them. How should a veterinarian deal with the problem of an incompetent client (for example, someone suffering from Alzheimer’s disease) who is not providing adequate care to a pet, or how should a veterinarian inform a competent but mistrusted client? The profession needs to work with humane organizations to find solutions to these problems in ways the veterinarians are comfortable and to fill the gap between legally definable negligent care and poor care. For example, the profession may engage the assistance of those trained to manage stressful situations such as social workers and psychologists, or those trained to weigh competing responsibilities such as ethicists. These alternative strategies may take the form of help-lines or decision tribunals provided by veterinary regulatory bodies or professional associations in concert with humane organizations. Financing veterinary medical care is an ongoing problem. In Chapter 4, I showed how participants decided to offer reduced rates or free services to patients and clients, based in part on how much they liked them. To offer free or reduced rate service to 176  some without a good fiscal plan is financially risky for small business owners such as veterinarians156. Veterinarians should not be expected to unendingly sacrifice their professional, financial and emotional health for the benefit of animals, clients, or the profession. From a pragmatic point, doing so would not be sustainable. As with the debate about the nature of animal owner and veterinary responsibilities concerning animals, to fulfill the profession’s responsibility to promote animal welfare, the veterinary profession should engage in the debate about society’s responsibilities concerning animals. Many animal protection authorities suffer from lack of government support and funding, and this harms veterinarians and animals. The veterinary profession suffers from a lack of support from other professions (e.g. social workers) that the medical profession enjoys. The profession should actively try to resolve these problems by engaging the assistance of other professions, possibly in conjunction with humane authorities. Individual veterinarians finance animal care to some degree but more sustainable methods of providing veterinary care to the indigent should be explored. Although the veterinary profession and its members should concern themselves with the well being of animals, they are not solely responsible for it. The profession should work with governmental and non-governmental organizations to construct ethically sustainable solutions for the problems that veterinarians encounter when trying to assist animals. Conclusion Veterinary practitioners fill a difficult role in society that can be very stressful at times. Why do veterinarians sometimes fail to step up to the plate and promote animal welfare? By understanding how veterinarians claim to make decisions when their responsibilities to patients and clients compete, we can begin to understand why veterinarians sometimes conduct themselves in ways that appear counterintuitive. Differences in beliefs and assessments about patient welfare, lack of clarity in client and veterinary responsibilities, and economic and organizational obstacles all influence veterinarians’ decision making and thus their behaviour. The purpose of this research was not to denigrate veterinarians but to highlight problems that individuals and the profession face in fulfilling their responsibilities. It is my  177  hope that the information presented in this dissertation will, in part, be useful as a tool of self-reflection. 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Available at http://web2.gov.mb.va/laws/statutes/1996/c0699e.php. Accessed March 10, 2009. 175. Province of British Columbia. Prevention of Cruelty to Animal Act. Available at http://www.bclaws.ca. Accessed March 10, 2009. 176. Province of Alberta. Animal Protection Act. Available at http://www.qp.gov.ab.ca/catalogue/catalog_results.cfm. Accessed March 10, 2009.  191  177. Canadian Veterinary Medical Association. A code of practice for Canadian kennel operations, second edition May 2007. Available at http://canadianveterinarians.net. Accessed March 10, 2009. 178. Canadian Veterinary Medical Association. A code of practice for Canadian catteries. Document in progress. 2009. 179. National Farm Animal Care Council. Codes of Practice. Available at http://nfacc.ca/code.aspx. Accessed March 10, 2009. 180. Canadian Medical Association. CMA Code of Ethics. Available at http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed April 15, 2009. 181. Rutgers LJE. The Use of the Reflective Equilibrium Method in Normative Veterinary Ethics In: W. van der Burg and T. van Willigenburg, eds. Reflective Equilibrium. Dordrecht: Kluwer Academic Publishers, 1998. 182. Dich T, Hansen T, Christiansen SB, et al. Teaching ethics to agricultural and veterinary students - experiences from Denmark In: M. Marie, ed. Animal Bioethics, Principles and Teaching Methods. Wageningen, NL: Academic Publishers, 2005.  192  Appendices Appendix I – UBC Ethics  193  194  195  Appendix II – Letter of Recruitment (First Phase)  THE UNIVERSITY OF BRITISH COLUMBIA Individual Interdisciplinary Studies Graduate Program (Leonard S. Klinck Building) University of British Columbia Vancouver, B.C. Canada V6T 1Z2  Carol Morgan DVM PhD Candidate #227-6356 Agricultural Road University of British Columbia Vancouver, B.C V6T 1Z2 Date Name/Address Dear Colleagues I am a veterinarian (WCVM 1988) currently practicing on Vancouver Island. After years of private practice, I have taken an interest in the study of ethics, with a specific focus on ethics in veterinary medicine. I am conducting research for my doctoral degree in the Individual Interdisciplinary Studies Graduate Program at the University of British Columbia. My thesis – Stepping Up to the Plate: Animal Welfare, Veterinarians, and Ethical Conflicts - focuses on decision-making techniques and resources that veterinarians utilize when resolving ethical conflicts involving the welfare of animals. I would like to invite you to participate in the research, which I believe could be very important to veterinarians. The format of the research involves personal interviews conducted by me, at either your practice or an alternate location of your choice. The interviews should take approximately 1 – 2 hours. The interview will be unstructured exploring your experiences in situations where ethical conflicts may arise or concerns that you may have with ethics in veterinary practice. Any information collected through these interviews will be held in strict confidence and your anonymity is assured. If you are interested in participating in this research, please contact me: Carol Morgan DVM  196  Address Should you have any questions regarding the interview or the project you can contact me at the above address or my supervisor Dr. Michael McDonald at The Centre for Applied Ethics, University of British Columbia, phone number 604-822-8625. Please be assured that your participation in this project is strictly voluntary and you are under no obligation to participate. Thank you for you anticipated assistance.  Carol Morgan DVM  197  Appendix III – Letter of Recruitment (Second Phase)  THE UNIVERSITY OF BRITISH COLUMBIA Individual Interdisciplinary Studies Graduate Program (Leonard S. Klinck Building) University of British Columbia Vancouver, B.C. Canada V6T 1Z2  Carol Morgan DVM PhD Candidate #227-6356 Agricultural Road University of British Columbia Vancouver, B.C V6T 1Z2 Date Name Address Dear Colleagues I am a veterinarian (WCVM 1988) currently practicing on Vancouver Island. After years of private practice, I have taken an interest in the study of ethics, with a specific focus on ethics in veterinary medicine. I am conducting research for my doctoral degree in the Individual Interdisciplinary Studies Graduate Program at the University of British Columbia. My thesis – Stepping Up to the Plate: Animal Welfare, Veterinarians, and Ethical Conflicts - focuses on decision-making techniques and resources that veterinarians utilize when resolving ethical conflicts involving the welfare of animals. I would like to invite you to participate in the research, which I believe could be very important to veterinarians. The format of the research involves personal interviews conducted by me, at either your practice or an alternate location of your choice. The interviews should take approximately 1 – 2 hours. The interview will be unstructured exploring your experiences in situations where ethical conflicts may arise or concerns that you may have with ethics in veterinary practice. In addition, I would like to observe veterinarians in their day-to-day work related activities in order to gain insight into how decisions are made. Please consider whether you would be interested in allowing me to join you in your practice for 2 or more days. Due to time constraints, I am only able to observe a relatively small number of individuals. Should you choose to participate in a personal interview, you are under no obligation to allow me to observe at your practice.  198  Any information collected through these interviews and observations that could identify you will be held in strict confidence. If you are interested in participating in this research, please contact me: Carol Morgan DVM Address Should you have any questions regarding the interview or the project you can contact me at the above address or my supervisor Dr. Michael McDonald at The Centre for Applied Ethics, University of British Columbia, phone number 604-822-8625. Please be assured that your participation in this project is strictly voluntary and you are under no obligation to participate. Thank you for you anticipated assistance.  Carol Morgan DVM  199  Appendix IV – Consent Form (First Phase)  THE UNIVERSITY OF BRITISH COLUMBIA Individual Interdisciplinary Studies Graduate Program (Leonard S. Klinck Building) University of British Columbia Vancouver, B.C. Canada V6T 1Z2  CONSENT FORM Version: May 2002 Stepping Up to the Plate: Animal Welfare, Veterinarians, and Ethical Conflicts Principal Investigator/Supervisor: Dr. Michael McDonald The W.Maurice Young Centre for Applied Ethics University of British Columbia # 227-6356 Agricultural Road Vancouver, B.C. Ph: 604-822-8625 Co-Investigator: Carol Morgan DVM Individual Interdisciplinary Studies Graduate Program University of British Columbia PhD Candidate Ph: 250Purpose: The purpose of the research is to explore ethical quandaries encountered in private veterinary practice with specific reference to the well being of animals and how veterinarians make decisions in resolving these quandaries. Complicating factors affecting the way in which ethical quandaries are resolved will also be explored. Study Procedure: The study involves semi-structured open-ended interviews. This interview should take approximately one to two hours. A summary of this interview will be provided to me for my perusal. I understand that I may modify this summary if it is not an accurate representation of my views. Confidentiality: Any information resulting from this research study will be kept strictly confidential. All documents and audiotapes will be identified only by code number and kept in a locked filing cabinet. Hard copies of interview transcripts will be stored under  200  lock and key, and computer document versions will be stored on a password and firewall protected computer. Participants will not be identified by name in any report of the completed study or in any future use of the data. Transcripts will be modified to remove identifying statements (places, names) to ensure confidentiality. Contact: If I have any question or desire further information with respect to this study, I may contact Carol Morgan at 250-. If I have any concerns about my treatment or rights as a research subject, I may contact the Director of Research Services at the University of British Columbia at 604-822-8598. Consent: I understand that my participation in this study is entirely voluntary and that I may refuse to participate or withdraw from the study at any time. I understand that data from this study may be used for future academic publications. I have been assured that any of the data collected and used in future publications will not contain any information that may be used to identify me, and that my confidentiality has been ensured. I have received a copy of this consent form for my own records. I consent to participate in the study.  ________________________________________________________________ Subject Signature Date  Signature of a Witness  Date  201  Appendix V – Consent Form (Second Phase)  THE UNIVERSITY OF BRITISH COLUMBIA Individual Interdisciplinary Studies Graduate Program (Leonard S. Klinck Building) University of British Columbia Vancouver, B.C. Canada V6T 1Z2  CONSENT FORM Version: June 2004 Stepping Up to the Plate: Animal Welfare, Veterinarians, and Ethical Conflicts Principal Investigator/Supervisor: Dr. Michael McDonald The W. Maurice Young Centre for Applied Ethics University of British Columbia # 227-6356 Agricultural Road Vancouver, B.C. Ph: 604-822-8625 Co-Investigator:  Carol Morgan DVM Individual Interdisciplinary Studies Graduate Program University of British Columbia Ph.D. Candidate - Thesis Research Ph: 250-  Purpose: The purpose of the research is to explore ethical conflicts encountered in private veterinary practice with specific reference to the well being of animals and how veterinarians make decisions in resolving these conflicts. Complicating factors affecting the way in which ethical conflicts are resolved will also be explored. Study Procedure: The study involves semi-structured open-ended interviews. This interview should take approximately one to two hours. A summary of this interview will be provided to me for my perusal. I understand that I may modify this summary if it is not an accurate representation of my views. This study also involves observations of veterinarians in the work setting. The student investigator will observe veterinarian interactions with clients and staff. The student investigator will endeavor to avoid disrupting the veterinarian, staff and others as much 202  as possible. Observations will last for a 2 – 5 day period as agreed upon by the participant and co-investigator. Please check one box: I am willing to allow the student investigator (Carol Morgan) to observe my practice related activities for a mutually agreed upon period of time. I will take responsibility for ensuring that my veterinary staff and veterinary clients are informed regarding the presence of the student investigator and nature of the research. I am not interested in participating in the observation segment of the study. Confidentiality: Any information resulting from this research study will be kept strictly confidential. All documents and audiotapes will be identified only by code number and kept in a locked filing cabinet. Hard copies of interview transcripts and notes will be stored under lock and key, and computer document versions will be stored on a password and firewall protected computer. Participants will not be identified by name in any report of the completed study or in any future use of the data. Transcripts will be modified to remove identifying statements (places, names) to ensure confidentiality. Contact: If I have any question or desire further information with respect to this study, I may contact Carol Morgan at 250-478-9543. If I have any concerns about my treatment or rights as a research subject, I may contact the Director of Research Services at the University of British Columbia at 604-822-8598. Consent: I understand that my participation in this study is entirely voluntary and that I may refuse to participate or withdraw from the study at any time. I understand that data from this study may be used for future academic publications. I have been assured that any of the data collected and used in future publications will not contain any information that may be used to identify me, and that my confidentiality has been ensured. I have received a copy of this consent form for my own records. I consent to participate in the study.  203  ________________________________________________________________ Subject Signature Date Signature of a Witness  Date  204  Appendix VI – Information Pamphlet for Employees/Clients THE UNIVERSITY OF BRITISH COLUMBIA Individual Interdisciplinary Studies Graduate Program (Leonard S. Klinck Building) University of British Columbia Vancouver, B.C. Canada V6T 1Z2  Research Study Stepping Up to the Plate: Animal Welfare, Veterinarians, and Ethical Conflicts 1. What is the research about? This research project is focused on how veterinarians make decisions with respect to the well being of animals. This research forms part of the requirements for a doctoral program at the University of British Columbia and is being conducted by Carol Morgan, a practicing veterinarian. . 2. Who is participating in the research? Selected veterinarians from Western Canada have been chosen to participate in this study. The researcher will be observing participating veterinarians in their day-to-day activities in their veterinary practices. 3. How might this study affect me? As part of the observation process involves veterinarians and their interactions with their clients, you may be asked if you are willing to be observed during your visit. You will be provided with the opportunity to give your verbal consent to allow the researcher to observe your interaction with the veterinarian. If you do not wish to be observed during your interactions with the veterinarian, please do not hesitate to voice your concerns to the researcher, your veterinarian or any of the veterinary staff. You may refuse to be observed, and you are free to change your mind about being observed at any time. The research will be conducted during the regular activities of the veterinarian participants, and so no additional time will be required. How will my confidentiality be protected? 4. Your confidentiality is assured. No data identifying you, your family, or your animal(s) will be recorded or released to anyone. Any observations recorded will be identified by code names or pseudonyms in order to protect the identity of all individuals involved. If you any questions or desire further information with respect to this study, you may contact: Carol Morgan camorgan@interchange.ubc.ca Individual Interdisciplinary Studies Graduate Program The University of British Columbia Room 230, 6356 Agricultural Road Vancouver, B.C. V6T 1Z2 OR  The Director of Research Services at the University of British Columbia at 604-822-8598.  205  Appendix VII – Interview Questions Sample Interview Questions 1) Tell me a little about your practice, perhaps you could run through an average day in your practice? 2) How would you describe your role in the vet/client/patient relationship? 3) How would you define animal welfare or animal well being? 4) Veterinary medicine can be highly stressful and emotional, have you encountered or do you know of any situations that you would consider to be an ethical conflict especially where the well being of your patients is concerned? Can you describe the situation? How did you go about deciding what to do? How was the situation resolved? What may have complicated the situation for you? For example, were you afraid of losing a client or possibly something else?  206  

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