Applied Animal Physiotherapy Ethics

Original Editor - Ansi van der Walt Top Contributors - Jess Bell, Kim Jackson and Tarina van der Stockt

Introduction[edit | edit source]

Jurisprudence is defined as "the study, knowledge, or science of law".[1] In relation to animal healthcare, jurisprudence refers to the various legislation, rules, regulations and guidelines that are relevant to veterinary practice.[2] Veterinary professionals are required to provide good care to the animals that they assess and treat.[3] They also have legal, moral and ethical obligations to their clients (i.e. an animal's owner) and veterinary colleagues.[2] A knowledge of the legal frameworks within which they work is, therefore, essential to ensure that they are able to practise in a safe, effective manner. However, in some instances, there may be conflict between the interests of the veterinary professional, client and the animal.[3] The veterinary professional must, therefore, also be able to address ethical challenges that arise in animal practice.

Norms[edit | edit source]

In any social interaction between people, certain norms apply. Norms are defined as "standards of behaviour which have been accepted by the community.”[4] Social structures are determined by behavioural norms, which have developed over many generations. Norms are not fixed across cultures, religions or countries - they are often varied,[4] but they are generally intended to enhance social cohesion.

Norms which determine behaviour include:[4]

  • Morals:[4]
    • "Morals are norms that have a 'right and wrong' attached to the behaviour"[4], such as envy, anger, pride, lust, dishonesty, vindictiveness, cruelty, and infidelity, etc
    • These thoughts, acts or feelings can result in harm to others
  • Social norms:
    • The “informal rules that govern behavior in groups and societies”[1]
    • Social norms have an impact on various behaviours, including courtesy and convention[4]
  • Aesthetic norms:
    • “Norms of appreciation of beauty and the morally good things in life”[4]
    • Examples of aesthetic norms include urban design, the design of a veterinary clinic[2][4]
  • Ethical norms:[4]
    • “Ethics are principles or beliefs, that govern a person’s view of right / wrong, good / bad, just / unjust etc. of a situation"[4]
    • Personal ethics - depend on the individual (religion, charity)
    • Professional / ethical norms - are used to manage behaviour across a profession

[5]

Laws[edit | edit source]

Laws are defined as “norms which the whole community accepts as binding and are obeyed by the whole society.”[4] Laws can be changed to fit the requirements of the community that they serve. Thus, laws should govern human behaviour and be obeyed by everyone. They formalise specific rights and are enforced by organisations of the state. When laws are disobeyed, the involved parties are typically prosecuted / punished.[4]

It is important that animal physiotherapists have an understanding of the practical implications of relevant laws and to consider how these laws apply to animal physiotherapists:[2]

  • As business managers and employers
  • In the context of their relationship with their clients
  • In the context of their relationship with other veterinary professionals
  • In terms of their responsibilities to the patient (the animal)

Ethics[edit | edit source]

Veterinary Ethics[edit | edit source]

Veterinary ethics refers to the “practical application of ethical theories, principles and moral standards to the conduct of individuals involved in veterinary service delivery systems that are meant to benefit animals, owners, and the public”.[6] The public generally believe that veterinary professionals have a “moral duty” to look after animals. This trust is based on the acceptance of or belief in the following:[6]

  • Sapiental authority
    • The public believes in the perceived wisdom and superior knowledge of veterinarians
  • Moral authority
    • Society expects veterinarians to always act in the best interest of their patients and clients
  • Charismatic authority
    • Relates to the historical, socially conditioned belief that healers have the power to make people well

[7]

Most statutory codes of veterinary practice make reference to the following:[2]

  • Veterinary ethics
  • Professional ethics
  • Standards of practice
  • Code of conduct
  • A commitment to uphold animal welfare and / or reduce suffering

Statutory bodies are government authorities established to regulate the veterinary profession and enforce codes of professional conduct.[6]

Ethical Reasoning[edit | edit source]

Because it is not possible to be fully prepared for every ethical challenge that you may face as a veterinary professional, the animal physiotherapist needs to have the skills to apply ethical reasoning to complex situations.[2][6]

  • Ethical rules: specific statements that concern ethical behaviour
  • Ethical principles: broader models of behaviour that provide a basis for rules
  • Ethical theories: are used to justify ethical decisions that are made and help to resolve any conflict between rules

Normative Ethics[edit | edit source]

Normative ethics essentially provides a set of principles that can be used to solve ethical dilemmas.[6] A well-known example of a normative ethics principle is the idea that: “People should do to others what they would want others to do to them.”[6]

The three most well-known ethical theories are:[6]

  • Virtue ethical theories:
    • Emphasise the role of a person’s character in an interaction
  • Deontological theories (i.e. duty or obligation):
    • These relate to the duties of individuals towards other people and to the rights of individuals in an agreement
  • Teleological theories (i.e. consequences):
    • Consequences should be more favourable than unfavourable and they must not use individuals as a means to an end

Applied Ethics[edit | edit source]

An applied ethical issue will involve choosing between a number of conflicting normative principles, all of which might result in different outcomes. Applied ethical issues are commonly approached through the application of the following four principles: [6]

  • Beneficence - the duty to do good (i.e. maximise benefit)
  • Non-maleficence - the necessity to do no harm
  • Autonomy - the freedom to choose
  • Justice - the right to due process in interactions with other veterinary professionals, owners, the public and animals

[8]

A key ethical challenge in animal practice centres around whether the veterinary professional's primary responsibility is to the animal or the owner:[6]

  • The veterinary professional works in both the medical field and the agricultural field - this means they have a responsibility to the animal patient as a "sentient being". However, the patient is also considered the property of the client, so economic considerations have an impact on treatment
  • There is, therefore, a tripartite relationship in veterinary ethics between the veterinary professional, patient and owner. This can be a significant source of ethical dilemmas in instances where the animal therapist and owner have different ideas about what outcome is best for the patient[6]
  • Finally, public health considerations (e.g. rabies in South Africa[2]) can have a considerable impact on animal practice[6]

Veterinary Liability[edit | edit source]

Civil and Criminal Liability[edit | edit source]

Law of Delict[edit | edit source]

A delict is: “a conduct of a person that in a wrongful and culpable way causes harm to another."[4] The courts often use the "reasonable person test" to establish wrongful conduct. This test asks what a "reasonable person" would do in a certain situation.[4]

[9]

Individuals can only be held accountable for their actions if it is shown that they have the capacity to distinguish between what is right and what is wrong. Individuals can be found culpable or liable if it can be shown that their act was intentional or negligent.[4] “Harm” is said to occur when there is a negative impact on property, personality (i.e. identity, reputation, emotions etc) or anything that is considered worthy of protection.[4]

A veterinary professional would be criminally liable if she / he commits a criminal act. This might include crimen injuria, which is defined as “the unlawful and intentional publication [...] of matter concerning another which intends to injure his reputation” (i.e. defamation).[4]

The following issues are particularly relevant to veterinary professionals:[4]

  • Damage caused by animals
  • Vicarious liability (i.e. being held liable for the negligence / wrong-doing of your employees)
  • Negligence
  • Imperitia culpae adnumeratur - “want of skills is reckoned as a fault” except when acting is a necessity (e.g. an emergency where there are no alternatives, consent is given and reasonable care is shown)

NB: laws will vary between countries, so you will need to check specific legislation in your country and familiarise yourself with these points.

Professional or Ethical Liability[edit | edit source]

The South African Health Professions Act 56 (1974) defines unprofessional conduct as: “improper or disgraceful or dishonourable or unworthy conduct or conduct which, when regard is had to the profession of a person who is registered in terms of this Act, is improper or disgraceful or dishonourable or unworthy".[4]

In the veterinary field, unprofessional conduct can, therefore, be separated into four key areas:[4]

  • Veterinary malpractice
  • Improper and disgraceful conduct towards patients or owners
  • Improper and disgraceful conduct towards colleagues
  • Any other improper / disgraceful conduct that is considered unbecoming in a veterinary professional

Contract Law[edit | edit source]

A contract is an agreement which creates specific obligations.[4] Contracts are only considered legal if all parties come to an agreement (i.e. consensus). The following must be agreed upon:[4]

  • Consequences
  • That the agreement is legally binding
  • The offer and its acceptance

You may come across verbal contracts in veterinary practice, such as:[4]

  • Fee quotations or estimates for treatment
  • Agreements about treatment options
  • Consent to management
  • Permission for euthanasia or necropsy

Verbal contracts are binding, but there are certain disadvantages to this type of agreement:[4]

  • Both parties must be present
  • There can be disagreement about the contract
  • There may be misunderstanding about language used and treatments or procedures discussed

Consent[edit | edit source]

The veterinarian is not allowed to treat an animal without the owner’s consent unless it is an emergency or there is a statutory duty.[4]

When treating patients, veterinarians may be aware that there is an inherent risk in a treatment. The owner may not, however, be aware of this risk. For example, an owner may consent to surgery to remove a tumour without realising that there is a risk the tumour may have spread, requiring either further surgery or euthanasia.[2] Veterinarians must, therefore, warn clients of any “material risk” associated with a treatment.[4]

A risk is considered material if:[4]

  • A reasonable person is likely to consider it significant OR
  • The veterinarian is reasonably aware that a client would consider it significant

[10]

It is acceptable for a veterinary practitioner to refuse to treat clients for a number of reasons, including:[4]

  • History of non-payment
  • Client behaves in an unacceptable manner
  • The required treatment falls outside of the practitioner’s experience / ability
  • The client interferes with the treatment
  • The animal cannot be controlled, which puts the veterinary professional in danger
  • The owner requests an illegal intervention
  • The owner requests euthanasia of a healthy animal

Other Aspects of Veterinary Ethics[edit | edit source]

Sometimes veterinary professionals may be called on to be expert witnesses in court. Witnesses must be able to prove that they are experts in their field through their qualifications and experience.[4] The following are important considerations for the veterinary professional who is being asked to testify:[4]

  • Your opinion must be relevant to the case
  • You should not take sides during the case
  • The court can discredit your opinion
  • You should be prepared to admit if the questions asked are outside your area of expertise

Relationships and Malpractice[edit | edit source]

Quality of care alone has been shown to be a poor predictor of medical malpractice claims in human patients. Instead, it has been found that communication has a significant impact on malpractice suits - patients are less likely to complain about or sue doctors with whom they have a positive relationship.[11]

Other factors associated with malpractice complaints include:[12][13]

  • Waiting times (see below)
  • Unexpected costs
  • Unexpected outcomes or complications
  • Not feeling adequately prepared for what to expect during or after a procedure
  • Feeling devalued
  • Another practitioner suggests that maloccurence (i.e. wrong treatment) has occurred

[14]

Waiting Times[edit | edit source]

One study of human patients looked specifically at the patient complaints of doctors who were sued more often. This study found that the complaint most reliably associated with lawsuits was related to long waiting times - patients who had to wait more than 15 minutes to see the doctor were more likely to sue him / her.[13]

In an animal therapy context, it is important to remember that clients may feel anxious, stressed or vulnerable and they may have a poor understanding of what to expect. They may be worried about their pet and / or experiencing financial stress due to their pet’s condition. Being kept waiting can enhance these feelings of powerlessness, and many clients may respond with anger.[2]

Disappointing Outcomes in Veterinary Care[edit | edit source]

The following areas have been identified as potentially causing owners to feel disappointed with the care their animals receive:

  • Fragmentation of care and communication lapses:[15]
    • There are often increasing numbers of healthcare providers involved in an animal’s care - clients may not establish the same bond that they would with a single professional. Thus, they may be less likely to give the veterinary professional the “benefit of the doubt”, which can lead to malpractice claims
    • Malpractice claims are more likely if other providers suggest that one professional involved failed to provide adequate care[15] (i.e. maloccurrence)[12]
  • The Veterinary Facility as a business:[2][15]
    • Any veterinary facility, including a veterinary physiotherapy facility, is a business that needs to generate revenue to thrive
    • The veterinary professional must take care that any "up-selling" is done sensitively, and never undermines the trust that the client has in the veterinary professional as an advocate
    • During times of stress and anxiety, owners may agree to treatment plans that are resource depleting (e.g. they cost money, time and energy) and which may not ensure the animal survives / has an acceptable quality of life
    • The veterinary professional must be mindful, open and honest when advising clients, as receiving a large bill for a disappointing outcome can often trigger a complaint
  • Diagnostic process and hypothesis testing:[15]
    • Hypothesis testing is considered the best way to reach an accurate diagnosis in animals, especially when clients have financial constraints
    • This involves observing how a patient responds to treatment for a presumed diagnosis made on available information
    • If the client does not clearly understand the nature of this process, they may believe the veterinarian has made diagnostic and treatment errors
  • Standard of Care:[15]
    • Errors are common in both human and animal care
    • Standard of care is largely determined by establishing whether or not professionals with similar training would, in a similar case, have noticed the error, provided a different treatment and avoided harm
    • Comparing a practitioner’s actions against an accepted standard of care is a common method of determining malpractice

Transactional Analysis in Client Interactions[edit | edit source]

Every interaction between a veterinary professional and a client is an inter-personal transaction. The emotional state of each party in the transaction has implications for the success of the interaction.[2]

Clients often feel vulnerable, anxious and uncertain in interactions with veterinary or medical professionals, and feel that they have little control over the situation.[2] Thus, this doctor-patient relationship has been described as paternalistic - i.e. the doctor / health professional directs the care while the patient plays a passive role.[16]

Even when medical doctors attempt to understand their patient’s agendas, it has been found that doctors interrupt their patients after an average of 11 seconds. When doctors fail to listen to and understand their patients’ goals, they are less likely to create a patient-centred plan.[17]

In a veterinarian-client relationship, the pet owner may “go along” with advice, without understanding the intervention, in the belief that the "health professional knows best". However, if there is a negative outcome, this approach can lead to frustration[2] and it can adversely affect pet owners' perceptions of the veterinary practitioner's motivations.[18]

Thus, veterinary professionals must ensure that their clients feel:[2]

  • Heard
  • Informed
  • Empowered
  • Validated

Building Positive Client Relationships[edit | edit source]

  • Informed Consent: [11][15]
    • Not simply the signing of a document - it should be seen as a tool to develop a stronger practitioner-client alliance
    • It helps to reduce anxiety in clients, bridges the gap between the patient and clinician’s knowledge, and reduces uncertainty for clients
  • Effective communication skills are essential:[11][15]
    • Active listening
    • Establishing rapport
  • Communication behaviours associated with fewer claims in a medical setting include:[11]
    • More orientation statements that are used to educate clients about potential outcomes and what to expect
    • More laughter and humour in interactions
    • More attempts to gain the client’s opinions, check if they understand, and to ask them to share their perspectives

There is also a growing realisation that, following adverse medical events in human patients, open communication and attempts at reconciliation can actually promote patient safety. Moreover, when this approach is adopted, there is no associated increase in liability claims.[19]

[20]

Client Expectations[edit | edit source]

Clients may respond with anger in situations where their needs or expectations are not met.[11] Clear two-way communication is important to ensure that you know what expectations your client has. It also allows you to have conversations with your client about:[11]

  • A realistic prognosis for the patient
  • Likely expectations for the animal owner in terms of time and involvement in the recovery / rehabilitation process

Summary[edit | edit source]

  • When working with animals, you must always consider the three-way relationship between the veterinary practitioner, owner and patient
  • Each country has its own laws, norms and ethical frameworks to guide the animal physiotherapist
  • You will need to familiarise yourself with the specific competencies of veterinary practitioners in your location
  • Positive communication between the veterinary practitioner and the client will enhance outcomes and client satisfaction

References[edit | edit source]

  1. 1.0 1.1 Legal Information Institute. Jurisprudence [Internet]. Cornell Law School [cited 5 May 2021]. Available from: https://www.law.cornell.edu/wex/jurisprudence
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Van der Walt A. Applied Animal Physiotherapy Ethics Course. Physioplus, 2021.
  3. 3.0 3.1 Hernandez E, Fawcett A, Brouwer E, Rau J, Turner PV. Speaking Up: Veterinary Ethical Responsibilities and Animal Welfare Issues in Everyday Practice. Animals (Basel). 2018;8(1):15.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 Van Vollenhoven E. The veterinarian / veterinary para-professional and the South African law [Internet]. South African Veterinary Council. 2016 [cited 5 May 2021]. Available from: https://www.savc.org.za/pdf_docs/FINAL_LawEthicsBookletCPD2015_4Nov2016.pdf
  5. The Ethics Centre. What is the difference between Ethics, Morality and the Law?. Available from: https://www.youtube.com/watch?v=Xki2fRA0bY8 [last accessed 7/7/2021]
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Kimera SI, Mlangwa JED. Veterinary ethics. In: ten Have H editor. Encyclopedia of Global Bioethics. Springer. 2016.
  7. RCVSKnowledge. Ethics and evidence-based veterinary medicine. Available from: https://www.youtube.com/watch?v=THX1GpD0jEo [last accessed 7/7/2021]
  8. USMLE pass. Examples of Autonomy, Beneficence, Nonmaleficence, and Justice - Ethical Principles. Available from: https://www.youtube.com/watch?v=h5ow1-ezNyc [last accessed 7/7/2021]
  9. Michael Pirovano. The Reasonable Person Standard. Available from: https://www.youtube.com/watch?v=J8-E_jIJgX0 [last accessed 7/7/2021]
  10. WTH is Bioethics? Informed Consent. Available from: https://www.youtube.com/watch?v=xTIdmv2VzNs [last accessed 7/7/2021]
  11. 11.0 11.1 11.2 11.3 11.4 11.5 Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims. Proc (Bayl Univ Med Cent). 2003;16(2):157-61.
  12. 12.0 12.1 Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-70.
  13. 13.0 13.1 Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual.;14(4):153-9.
  14. Healthcare Triage. How Can Doctors Avoid Malpractice Suits? Be Nice. Available from: https://www.youtube.com/watch?v=pm6kmaGuQe0 [last accessed 7/7/2021]
  15. 15.0 15.1 15.2 15.3 15.4 15.5 15.6 O'Connell D, Bonvicini KA. Addressing disappointment in veterinary practice. Vet Clin North Am Small Anim Pract. 2007;37(1):135-49.
  16. Lazcano-Ponce E, Angeles-Llerenas A, Rodríguez-Valentín R, Salvador-Carulla L, Domínguez-Esponda R, Astudillo-García CI et al. Communication patterns in the doctor-patient relationship: evaluating determinants associated with low paternalism in Mexico. BMC Med Ethics. 2020;21(1):125.
  17. Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, Castaneda-Guarderas A, Gionfriddo MR, Branda ME et al. Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters. J Gen Intern Med. 2019;34(1):36-40.
  18. Janke N, Coe JB, Bernardo TM, Dewey CE, Stone EA. Pet owners' and veterinarians' perceptions of information exchange and clinical decision-making in companion animal practice. PLoS One. 2021;16(2):e0245632.
  19. Kachalia A, Sands K, Niel MV, Dodson S, Roche S, Novack V et al. Effects of a communication-and-resolution program on hospitals' malpractice claims and costs. Health Aff (Millwood). 2018;37(11):1836-44.
  20. Burnsie's RVT Vids. Communication In the Veterinary Field (VETERINARY ASSISTANT EDUCATION). Available from: https://www.youtube.com/watch?v=acbZCHJAgwo [last accessed 7/7/2021]