Applied Animal Physiotherapy Ethics

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

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (6/05/2021)

Introduction

Jurisprudence is defined as "the study, knowledge, or science of law" and it refers to all legislation, rules, regulations and guidelines that are relevant to veterinary practice. Veterinary professions are required to provide good care for the animals that they assess and treat and they have legal, moral and ethical obligations to their clients, patients and veterinary colleagues. A knowledge of the legal frameworks within which they work is, therefore, essential to ensure 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 (or owner) and the animal. The veterinary professional must, therefore, also be equipped with knowledge of the ethical challenges that surround animal practice.

Norms

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

Norms which determine behaviour include:

• Morals
  • Norms that have right or wrong associated with a behaviour, such as envy, anger, pride, lust, dishonesty, vindictiveness, cruelty, and infidelity, etc. These thoughts / acts can result in harm.
• Social norms
  • The “informal rules that govern behavior in groups and societies.” Social norms have an impact on various behaviours, including fashion, courtesy and convention

• Aesthetic norms
  • “Norms of appreciation of beauty and the morally good things in life.” Examples of aesthetic norms include urban design, tidy veterinary clinics, well-kept gardens

• Ethical norms
  • “Ethics are principles or beliefs, that govern a person’s view of right/wrong, good/bad, just/unjust etc. of a situation":
    • Personal ethics - depend on the individual (religion, charity)
    • Professional / ethical norms - are used to manage behaviour across a profession

Laws

Laws are defined as “norms which the whole community accepts as binding and are obeyed by the whole society.” 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.

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 as business managers and employers
• Apply to animal physiotherapists in the context of their relationship with their clients
• Apply to animal physiotherapists in the context of their relationship with other veterinary professionals
• Apply to animal physiotherapists in terms of their responsibilities to the patient (the animal)

Ethics

Veterinary Ethics

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”. 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:

• Sapiental Authority - i.e. the public believes in the perceived wisdom and superior knowledge of veterinarians
• Moral Authority - i.e society expects veterinarians to always act in the best interest of their patients and clients
• Charismatic Authority - i.e. relates to the historical socially conditioned belief that healers have the powers to dispel disease

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

• 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.

Ethical Reasoning

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.

• 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

Normative ethics essentially provide a set of principles that can be used to solve ethical dilemmas. Bernard Rollin said of regulating professions (including the veterinary profession):

“you regulate yourselves the way we [society] would regulate you if we understood what you do, which we don't. But we will know if you don't self-regulate properly and then we will regulate you, despite our lack of understanding.”

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.”

The three most well-known ethical theories are:

• 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

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:

• Beneficence - the duty to do good (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, public and animals

Fundamental challenges in veterinary ethics include:

• Is the veterinary professional's primary responsibility to the animal or the owner?
• The responsibility of the professional to the animal patient as a sentient being - related to the notion that veterinary professionals work in the medical field
• Economic consideration to the client in that the patient is property - related to the notion that veterinary professionals work in the agricultural field
• The tripartite relationship in veterinary ethics between the veterinary professional–patient–owner. This is a significant source of ethical dilemmas when perceptions of the best outcome for the patient differ.
• Additional challenge of public health considerations (e.g. rabies in South Africa)

Veterinary Liability

Civil and Criminal Liability

Law of Delict

A delict is: “a conduct of a person that in a wrongful and culpable way causes harm to another." The courts typically use an objective test to establish wrongful conduct, usually the reasonable person test. In this test a "reasonable person" is used as a legal personification (i.e. this person is expected to have a minimum level of knowledge and mental capacity).

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 / liable if it can be shown that their act was intentional or negligent. “Harm” is said to occur when there is a negative impact on property, personality (i.e. identity, reputation, emotions etc) or any thing that is considered worthy of protection.

The following issues are particularly relevant to veterinary professionals:

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

The South African Health Professions Act 56 of 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".

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

• 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

Criminal Liability

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

Contract Law

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

• Consequences

• The agreement is legally binding
• The offer and its acceptance

Specific verbal contracts in veterinary practice may include:

• Fee quotations or estimates for treatment
• Agreement 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:

• 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

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.

Risk is often assumed by the veterinarian without the owner understanding that there is a risk — for example an owner may consent to surgery to remove a tumour without realising that there is a risk the tumor may have already spread, requiring either further surgery or euthanasia. Veterinarians must warn clients of any “material risk” associated with a treatment.

A risk is considered material if:

• A reasonable person is likely to consider it significant OR

• The veterinarian is reasonably aware that a client would consider it significant

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

• History of non-payment
• Unacceptable client behaviour (e.g. rudeness)
• Treatment outside of the practitioner’s experience / ability
• The client interferes with the treatment in an unacceptable way
• The animal is uncontrollable and it endangers the veterinary professional
• The intervention requested is illegal
• Euthanasia of a healthy animal is requested

Other Aspects of Veterinary Ethics

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. The following are important considerations for the veterinary professional who is being asked to testify:

• 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

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 / sue doctors with whom they have a positive relationship.

Other factors associated with malpractice complaints include:

• Waiting times (see below)
• Unexpected costs
• Unexpected outcomes/complications
• Not adequately prepared for what to expect during/after the procedure
• Devaluing the observations of the client
• Maloccurence suggested by another practitioner

Waiting Times

One study of human patients looked specifically at the patient complaints of doctors who were sued more often and found that the complaint most reliably correlated with lawsuits was related to wait time - patients who had to wait more than 15 minutes to see the doctor were more likely to sue him / her.

In an animal therapy context, clients may be feeling 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.