A study of veterinarians in the United Kingdom found that 57% of respondents experienced ethical dilemmas once or twice a week, while one-third of respondents faced ethical dilemmas three to five times per week.1
Despite the fact that ethical dilemmas could likely be found in many of our interactions with clients and patients, ethics rarely rise to the surface of our awareness unless there is an extreme situation. Recognizing how often ethics are involved in our day-to-day experiences is important, because each of those moments is an opportunity to define ourselves and to shape how we interact with—and are seen by—the world. Further, ethics has been called one of the top three reasons that veterinarians leave equine practice,2 making addressing the issue of ethics crucial to long-term success in equine practice.
Ethics can be loosely defined as a sense of right and wrong, fair and unfair— principles or standards to which one should adhere. The Oxford dictionary defines ethics as “moral principles that govern a person’s behavior or the conducting of an activity.”3
From the standpoint of the American Association of Equine Practitioners (AAEP), ethical behavior is described as follows: “Professional ethics embodies the behaviors of honesty, integrity and kindness while obeying rules and regulations set forth with mutual respect for opinion and preservation of dignity in interpersonal relationships. The conduct should be in a manner that will enhance the worthiness of the profession. The ethical practice of medicine includes those remedies and treatments that have, as their short or long-term goal, the health and welfare of the horse.”⁴ The definition set forth by the AAEP is considerably more prescriptive than the dictionary definition.
Recognizing the potential differences between personal and professional ethics is important. The way we choose to make decisions in our personal lives and the consequences of those decisions are necessarily different from those we use in a professional setting.
In our profession, we have bodies of evidence, “best practices” and other tools that we can lean on to make recommendations and that dictate how we treat our patients. Our governing bodies ensure that the care we provide meets a certain standard.
This is not so in our personal lives, where our decisions are based more on our values and our goals in a particular situation, as well as any potential consequences. The values we use to guide decisions in our personal lives are not necessarily those that we use to make recommendations to clients and provide care to patients.
There will be times when one’s personal and professional ethics line up well—and other times when they are farther apart.
Generally speaking, we have less choice in how we conduct ourselves ethically in our profession because of the governing bodies that dictate certain aspects of our behavior. The professional ethical standards determined by licensing bodies or our veterinary associations, such as AAEP, provide a foundation from which we can decide as individual practitioners what ethical practice looks like.
Despite this, one of the most challenging and frustrating aspects of ethics is that virtually everyone has a different perspective. This is because ethics are determined by our own internal compasses, our own core values, and our own experiences and perspectives.
Recognizing that everyone brings his or her own view of ethics to the practice of veterinary medicine and to the individual decision-making process is essential. Determining whether a particular situation is a question of ethics can be up for interpretation.
You must recognize how personal ethics can be essential to successful navigation of ethical situations, because simply doing what another practitioner would or has done might not be a path that feels true for you.
Moral Distress
There are tolls to dealing with ethical dilemmas in practice. One of the most significant is moral distress—that inthe- moment stress that is felt when the ethically appropriate action one desires to undertake is not possible due to organizational, internal or situational constraints.5
Moral distress has defined outcomes, including frustration, anger, guilt, anxiety and isolation.5 Further, moral distress contributes to psychological distress, which in turn contributes to risk of suicide.
Moral distress has also been suggested to be the top cause of compassion fatigue.⁶
The presence of constraints is a foundational aspect of moral distress. While little can be done about organizational constraints, there are situational or internal constraints that can be changed. Internal constraints include a perception of powerlessness, an absence of assertiveness, self-doubt and a culture of obedience.
The impact of moral distress in the long term is moral residue, which is the hangover or resulting damage from the situation in which moral distress occurred. Moral distress and moral residue have not received the same attention as compassion fatigue, burnout, depression or anxiety, but both have serious consequences on practitioners and influence their mental health and their ability to practice. This adds to the need to attend to the role that ethics plays in our daily lives and in our practices.
Addressing Conflict
At the heart of ethical dilemmas is conflict—the clash between right and wrong, should and shouldn’t, just and unjust. Often the conflict occurs internally (within ourselves) and externally (with others, be they clients, colleagues or family members). Recognizing this has value because we can use conflict management theories to help us become more aware of how we are working through the process of handling an ethical issue.
There are five conflict styles: avoiding, competing, compromising, collaborating and accommodating. Avoiding is when we avoid the conflict, perhaps by having our receptionist schedule the call with another veterinarian. Competing is when we want things to be done our way without concessions. Compromising is when both parties move toward the middle and make concessions. Collaborating is when both parties work toward a solution that is mutually acceptable. Lastly, accommodating is conceding to the other person’s wishes.
Many individuals have a preferred style, but we all have the ability to use any style depending on the situation. We tend to use different styles depending on how much we care about the issue and how much we care about the other people or stakeholders that are involved. There is benefit to each of these approaches, and there is no right or wrong. In ethical dilemmas, it can be important to choose a style that will result in an outcome you find acceptable. For instance, if you are unwilling to perform a neurectomy on a horse that will be used for jumping, the accommodating style would not be appropriate.
Stakeholders
There are many different ways to think through ethical dilemmas in practice. One of them is to consider the different stakeholders that are involved. There are several obvious stakeholders—the client, the horse, the veterinarian. In equine practice, we need to be mindful of who the client is. Often, when we say “client,” we are considering any combination of owner(s), trainer, rider and/or barn manager. Further, there are stakeholders who are more removed, such as colleagues, family and friends, and society.
When using a stakeholder approach, you think about how each stakeholder would be affected by your actions and what they are likely to expect of you in a given situation.
One challenge that arises from using only this approach is that often it gives rise to conflicting expectations. Society might expect one thing (for instance, medication-free competition), while the trainer or rider expects the horse to receive the medication it needs to compete in an upcoming competition.
That means that the veterinarian is trying to act in the best interest of the horse in the long term. Identifying all of the stakeholders and understanding their expectations can help us define the complexity of the issue.
Take-Home Message
Knowing how to handle an ethical situation in the moment can be difficult, and doing so is contingent upon recognizing the situation as an ethical dilemma. A frequent component of ethical dilemmas is an incomplete picture of the situation; we often don’t know the full story. We are privy to a small part of someone else’s existence, and we make judgements and decisions based on what we know.
On occasion, what initially seems like an ethical conflict is one in which you need more information about the request that is being made of you. To this end, ensuring that we gather as much information as possible and ask questions to clarify information about which we are unsure is an important first step.
Further, seeking to understand the other person’s perspective is of tremendous value. Strive to use empathy and reflective listening to ensure that you’ve appreciated the complexities of the other person’s situation.
Lastly, embrace compassion for yourself and the others involved. No one makes the “right” decision all the time, for any number of reasons. When you wish that you’d acted another way, be kind to yourself and speak to yourself as you would to a friend. Beating yourself up only adds to the distress the situation has caused.
In some situations, we can make a decision and behave in ways that agree with our personal and professional ethics. In those cases, making the decision isn’t the difficult part, but accepting the consequences of that decision might be challenging.
We might not agree to a client’s medical request because it is not in the best interest of the horse, but then we might have to deal with the consequences of losing that client.
Ethical dilemmas can be intensely personal. I have shied away from discussions with colleagues regarding ethical situations in which I’ve been involved for fear of judgement, and because, upon reflection, I felt embarrassed by the actions I had chosen.
As a profession, as we recognize the extent to which psychological distress, depression, anxiety, burnout or compassion fatigue affect us, it’s crucial to be compassionate and kind with ourselves and others.
Remember that at the end of the day, another’s actions are that person’s.
Two simple ideas have helped me recognize where my compass was pointing. The first is that I alone am the one who is responsible for protecting my license.
The second is that I am the one who needs to be able to sleep at night knowing that the decisions I have made were personally and professionally correct for me.
Resources
1. Batchelor,C.E.M.; McKeegan, D.E.F. Survey of the frequency and perceived stressfulness of ethical dilemmas encountered in UK veterinary practice. Vet Rec. 2012; 170(19).
2. Kraft, K. Commentary: Three reasons millennials are leaving equine practice. DVM360 Magazine. Dec 2015. http://veterinarynews.dvm360.com/commentary-3-reasons-millennials-are-leaving-equine-practice
3. “Ethics”—Oxford English Dictionary. Accessed June 15, 2017. https://en.oxforddictionaries. com/definition/ethics
4. AAEP Ethical and Professional Guidelines. Accessed June 15, 2017. https://aaep.org/guidelines/aaep-ethical-and-professional-guidelines
5. Epstein, E.G.; Hamric, A.B. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009; 20(4):330-342.
6. Kahler, S.C. Moral stress the top trigger in veterinarians’ compassion fatigue. JAVMA News, Dec 2014. https://www.avma.org/News/JAVMANews/Pages/150101e.aspx.
