Vet Ethics: How Much Is Enough?

Not long ago I was invited by the AVA Western Branch to be involved in a presentation on the topic of whether we are “going overboard with our pets”.

In the ensuing discussion, one of the examples raised was whether using intravenous fluids for routine de-sexing was over-servicing. There are certainly clients who believe that some or even much of what vets do is over-servicing. Some resent being bombarded with various tests and products. The use of comprehensive parasite control, the increase in wellness check-ups and blood profiles, and the regular use of dental procedures have all come in for criticism from various quarters.

The concept of over-servicing is also familiar to the medical profession. Here, there is a political and social justice question of the distribution of resources and the regulation of the amount of taxpayer money spent on medical services. This question is largely missing from the vet profession.

So what is over-servicing? The Saunders Comprehensive Veterinary Dictionary 2007 defines it as “carrying out more clinical or preventative work on an animal or herd than is needed or was requested by the owner, with the express intention of raising a higher fee”.

The motive of increasing profit certainly seems to be important to the concept of over-servicing. A vet may, of course, provide unnecessary medical services because she misapprehends their worth, does so out of habit, relies upon out-dated evidence, or wants to appease a client. Such actions may be critiqued on grounds of competence or unprofessionalism. It appears to be characteristic of over-servicing, however, that the aim of making more money is present.

Returning to human medicine for a moment, we can note that there has been some criticism of the idea of “vertically integrated” medical super-clinics because of their propensity to encourage over-servicing. In this situation, it may be in the financial interest of doctors or their employers to refer to in-house radiology or pharmaceutical services, even when they privately know it could be unnecessary or excessive. The presence of this incentive, of course, is intrinsic to veterinary practice as we know it.

What is wrong with over-servicing in the vet profession? A test or procedure which clearly carried more risk than probable benefit to the patient would be wrong. Unnecessary general anaesthetics or vaccinations are examples.

The client’s needs should also be considered. The client has a right to expect that her money will be spent on things which are medically warranted. To recommend treatments not clinically indicated or probably useless is therefore a kind of fraud or cheating. It may involve lying to or misinforming the client.

The notion of medical warrant or benefit is important here. But it may be unclear just what the benefit is in some cases. For example, are IV fluids of benefit in very short surgical procedures in young animals? The answer to such questions may require evidence and expert advice. Grey areas may remain. In other cases possible benefits may be present yet utterly marginal. We could recommend blood tests for all patients every three months, but are the resulting gains in diagnosis anything more than minuscule?

Some may say that if the client is given various options and is willing to pay for them then they are not being over-serviced. But if the vet believes that there is no medical warrant for an intervention, presumably he must be willing to tell the client that that is so, unless he is to be suspected of mercenary behaviour. We also must recognise that the vet, while he is entitled to make a profit and to run a business, is the patient’s advocate. He must inform the client when he thinks the potential harms outweigh the benefits to the patient.

What if the client insists, despite the vet taking reasonable steps to ensure the client is not badly misinformed or unduly influenced, on a non-harmful procedure which is medically unwarranted? Now the vet may be acting on a quite different motive to the pecuniary one. She may rather be offering comfort or solace to the client at no risk to the patient. But perhaps she will do well, as a general rule, not to encourage or facilitate the take-up of such tests or procedures, and in some cases to gently counsel the client as to the reasons that testing or procedures are unnecessary at this time.

Finally, it may be worth noting that what was once perhaps considered over-servicing (in-house blood tests, radical surgeries, chemotherapy, behaviour modification) is now routinely practiced. We do more tests, procedures, and check-ups than we used to do. Many of us would seek to avoid the accusation of over-servicing by pointing to the (scientifically defensible) medical benefits for the patient and the informed consent of the client.

SIMON COGHLAN

Replies: luke.martin@vetmag.com.au or sarcy3@hotmail.com