Ethical dilemma: What a veterinary client wants
Dr. Lee Saltz is not that different from you. He's a beloved small animal practitioner. He has built his practice on quality medicine and committed relationships to his clients and their pets. It's not unusual for clients to have his private phone number. A phone call from a client after hours is the norm, not an exception. So consider his sticky situation and see if you'd handle it the same way.
Setting the stage for conflict
Ms. Weiss has been a client of Dr. Saltz's since her 9-year-old Labrador, Jack, was a puppy. Dr. Saltz and his staff treat Jack like he's one of Ms. Weiss's children. Over time, this kind of treatment has made her a frequent and diligent client, but on the other hand, she often becomes emotionally volatile when faced with even the most minor of her dog's medical issues.Recently, Jack was presented with a swelling on his lower left rear leg. Ms. Weiss had noticed the swelling for the past two weeks. Jack had started limping and seemed to be experiencing discomfort, so she brought him to see Dr. Saltz. The exam revealed a hard swelling on the proximal tibia about the size of a small lime, and radiographs showed it to be a bony mass. It was clearly painful and the limping was pronounced. Dr. Saltz told Ms. Weiss that he was concerned and added that a growth like this in an older, large-breed dog was often bone cancer. There were other possibilities, he said, but osteosarcoma was at the top of his list. He advised her of the guarded prognosis—amputation was the treatment of choice after a biopsy confirmed the nature of the growth.
Ms. Weiss was crushed. She did not want her dog in pain any longer, and she did not want the tumor to spread. Dr. Saltz told her that it would only take seven days to get the biopsy result, but Ms. Weiss did not want to wait that long to help her dog. The doctor was confident of his diagnosis but not absolutely sure, and he advised Ms. Weiss to wait for the biopsy results. The client listened, but through her tears she decided she wanted him to do the amputation immediately because she felt time was an issue. Dr. Saltz, knowing how volatile his client was (and after informing her of the risks)proceeded with the surgery.
Jack did well during the surgery, but it was for naught. Unfortunately, eight days after the amputation, the biopsy result indicated that this was not an osteosarcoma but rather a severe inflammatory bone lesion.
Ms. Weiss was furious. She blamed Dr. Saltz for not standing his ground and allowing her to make a poor decision at a vulnerable time. She said removing the limb unnecessarily created permanent disfigurement and discomfort for her dog. She filed a complaint with the state regulatory agency and claimed Dr. Saltz was guilty of malpractice. Dr. Saltz insisted that Ms. Weiss made an informed decision after hearing all the options and that he was simply honoring the decision she had chosen to make.
Dr. Rosenberg's response: Dr. Saltz was wrong
The veterinarian and the pet owner should work as a team. Dr. Saltz valued his client's wishes as well as her allegiance to his practice. The question here is: where does professional judgment stop and client intimidation begin? His initial recommendation was to biopsy the mass and proceed based on the lab results. This is the standard approach to such a case.
Technically, Dr. Saltz acted with informed consent. But ethically, he was bound to act in the best interests of the pet and the owner. Rolling the dice on a potential diagnosis when the result was the loss of a limb was not an acceptable course of action. His efforts should have been directed toward educating the pet owner that a seven-day delay to obtain the biopsy results would not drastically influence the potential cancer to spread.
Even when a client is aware of all potential consequences, the veterinarian must abide by medical judgments that he or she believes are ethical and sound. This may require that a veterinarian not give in to the wishes of an emotional pet owner. In this case, Dr. Saltz made the wrong decision.
Do you agree with Dr. Saltz's decision or Dr. Rosenberg's conclusion? What would you have done? Tell us how you would handle such a dilemma.
Dr. Rosenberg is director of the Voorhees Veterinary Center in Voorhees, N.J. He is a member of the New Jersey Board of Veterinary Medical Examiners.