Euthanasia's moral stress: a high psychological price
Dr. Karen Reamsnyder remembers the day well.
Her client was an angry middle-aged man requesting euthanasia for his dog, a healthy looking small mixed breed.
"I remember telling him, 'This dog is healthy, and I don't feel comfortable putting this animal to sleep. Have you tried to place it?' "
"I don't have time for that," he replied. "I'll be honest with you. If you refuse to do it now, I'm driving down the street and going to open up the door and kick the dog out on the road."
"I was absolutely shocked," says Reamsnyder, who at the time, was just starting her career. "This guy was angry, and I just kept thinking about the possible abuse situation to this animal."
She performed the euthanasia with the client, who demanded to be present.
A practitioner now for 26 years and owner of the Raynham Veterinary Hospital in Raynham, Mass., Reamsnyder says she still regrets doing it.
The incident, however, helped shape her attitude on euthanasia. Today, she refuses to perform convenience euthanasia. Instead, her hospital attempts to find other alternatives rather than put them down. In fact, when a client calls to request euthanasia, her receptionist gathers information on the age of the animal, condition and informs the client that the doctor will do a physical examination first and may or may not perform the euthanasia.
"I never forgot that incident," she adds, but experiences like it were important for her to create the policy she now puts into practice.
Euthanasia inherently causes veterinarians moral stress.
Bernard E. Rollin, Ph.D., veterinary ethicist at Colorado State University, says that this moral stress is the single largest source of job dissatisfaction.
It's no wonder, Rollin says. Veterinarians are trained to heal, but they are routinely confronted with ending life rather than saving it. In many cases, veterinarians are asked to kill healthy animals out of convenience to the owner or because they can't afford treatment, he says.
The ethics of euthanasia is an extremely complicated issue because it cuts right to a person's core beliefs which often conflict with a client's beliefs.
"You can't devote your life to one purpose and flagrantly violate that on demand without paying a high psychological price," he says. "Can you imagine, four years earlier a dog was hit by a car? It was brought into the clinic, you did surgery and actually saved the animal. Now, the same client brings it in lame and ask to have it euthanized because it can no longer jog with the owner."
Scenarios like that cause moral stress.
According to Dr. Marsha L. Heinke, a DVM Newsmagazine contributor and president of Marsha L. Heinke, CPA Inc., euthanasia is an emotional, psychological and economic issue that every veterinarian must come to grips with. "I was recently reminded that veterinary medicine is one of the toughest professions because it is the only one that deals with elective killing. And it's a wake up call on why depression, anxiety, turnover, substance abuse and sometimes, in really extreme cases, suicide, is present in the veterinary profession."
How do you create a situation to obviate moral stress? Provide options to clients and do everything you can, within reason, to help extend an animal's life, Rollin says. He adds that practitioners choose either the role of garage mechanic or one of a pediatrician for each case. The garage mechanic does exactly what a client demands, while a pediatrician only does what is in the best interest of the child. "In any given case, you have to ask yourself what model are you working from."
Of all the ethical dilemmas practitioners regularly face, the decision to euthanize an animal can be one of the hardest. That decision becomes even more complicated when the animal requires an expensive procedure that its owner cannot afford or because of a behavior problem.
Dr. Douglas K. Wyler, DVM, of the Animal Medical Hospital and Bird Clinic in Hempstead, N.Y., agrees. "We try to let them know what they're in for in a best-case scenario and a worst-case scenario," he says. "Because even in a best-case scenario, the animal may require a lifetime of care. We present them the facts and give them their options."
Those options can include euthanasia, which brings a core ethical issue into focus: life vs. livelihood.
In some cases, pet owners want to put the animal down rather than spend money on proper pet care and "they're not willing to make the change in their lifestyle to accommodate their pet's behaviors," says John Snyder of the Humane Society of the United States.
In cases like these - where the animal is relatively healthy and the behaviors can be corrected - many practitioners offer to place the animal elsewhere and sometimes provide basic medical treatment.
"If someone comes in with a perfectly healthy animal," Wyler says, "and they want to euthanize for economic reasons, we'll do our best to help them find a home."
The situation becomes more difficult when dealing with a severely sick animal. Due to recent advances in medicine and nutrition, more pets reach the geriatric age, says Dr. Thomas Lane, DVM, professor emeritus at the University of Florida's College of Veterinary Medicine. That means more cases of cancer, kidney failure and other diseases associated with older animals.
Gary Patronek, VMD, Ph.D. and director of the Center for Animals and Public Policy at Tufts University, adds that veterinary medicine has become so sophisticated, life-saving procedures can extend an animal's life. Since technology will only improve, veterinarians will be confronted with the ethical question of when enough medical intervention is enough. "We have tools now that can extend life pretty heroically," he says.
The whole issue of evaluating the quality of life for an animal is "on the agenda for the 21st century," Patronek adds. "What is an appropriate quality of life for a companion animal, whether it is in the home or whether it is in an institutional setting? How do you begin to gauge these things?" he asks.
Mary Garrett, a pet owner living in Phoenix, faced this dilemma last September, when her 18-year-old cat's liver and kidneys began to shut down. She says her veterinarian presented her with the option of trying blood transfusions or choosing euthanasia, and Garrett selected the latter. "My first thought was for the cat and her quality of life, the second part was a financial issue," Garrett says. "If it didn't improve her life, it would have been a huge financial burden to undertake."
Nearly every practitioner has faced situations like Garrett's, in which they must advise clients of their options. The animal's chances for survival and its quality of life often can ease the decision to euthanize.
Lane cites the example of a horse that fractured its leg to the elbow after being hit by a car.
"It's entirely feasible that if this animal was put in a sling, over the course of the year the animal could begin to heal," he says. "But it could never be ridden again and any pressure on the leg would create a great deal of pain."
Practitioners must often weigh these odds, trying to intersect what can be done for an animal with whether a client is willing to follow through.
"My approach is very consistent with survivability," says Dr. Don J. Harris, DVM, of the Avian and Exotic Animal Medical Center in Miami. "If it's better than 50-50, it's worth trying. If there's a reasonable chance the animal is going to survive, I don't want a lack of funds to prevent that.
"I try to establish whether they really want to do everything possible and whether they are sincere about paying for the care," Harris says. "In very rare cases, I will allow them to make payments."
Strength of the bond
When determining a client's sincerity, practitioners must judge the strength of the human-animal bond and the sentimental value the client attaches to the pet. "I've seen people come in with Parakeets who they bought for $9.99 at a Wards store who will think nothing of spending hundreds of dollars on them," Wyler says.
"I'm shocked and surprised when some people who will come in and look like they don't have their next meal paid for, but they'll reach into their pocket and pull out a wad of $100 bills for their animal."
Laurel Lagoni, director of the Argus Institute for Families and Veterinary Medicine at Colorado State University, attributes this phenomenon to a change in the way pets are perceived. As people move more frequently, pets often fill the void created by leaving family and friends. "There's a higher divorce rate now than before," Lagoni says. "People are waiting longer to have children, so they might have animals instead of children."
Because clients feel such attachment to their pets, practitioners should explain all the options thoroughly, but let them make the final decision. Wyler says he helps his clients find resources to pay for care, "asking them to go through their mind as far as who can offer them financial aid" and suggesting family and friends as potential loan sources.
While Harris and Wyler have allowed trusted longtime clients to make payments, they keep such cases to a minimum. Most practitioners require payment upfront, with rare exception. "We support and understand that they have to charge for their services," says Snyder of the Humane Society, citing the potential snowball of too much pro-bono work. "Because if they did, every good Samaritan would be bringing in animals and the vet wouldn't be able to stay in business."
Many practitioners try heading off economic euthanasia by suggesting pet insurance as soon as they see a new animal. "We recommend that right from day one," Wyler says. "Every client that I have ever had has a tremendous sense of security from having that insurance." Policies usually require the client to pay the practitioner initially and later reimburse payment based on the coverage. Another option is CareCredit, which lets pet owners apply for credit in participating practitioners' offices.
In situations where euthanasia becomes inevitable, Lagoni says veterinarians must relate to clients on a human level when discussing the decision. She recommends "comfort rooms" where owners can say goodbye to their pet before the anesthesia is administered.
"I think veterinarians recognize very readily that when there is no cure, euthanasia is going to be the end result," Lane says. "So there's a real opportunity in veterinary medicine to counsel, to serve in a compassionate form and help the owners deal with the situation."
And euthanasia is humane, experts say. Rollin adds, "The time that euthanasia is good is when you have a lingering debilitating illness that is going to cause much suffering. It turns out that in human medicine, people want euthanasia not because they worry about death, but they worry about much suffering."
Rollin adds, "I think the bottom line is that a responsible veterinarian will not stand around and let the animal experience perennial moments of agony. Frank McMillan wrote, 'euthanasia is not a treatment, it is a substitute until we have a treatment.' "