Scenarios for Bio-ethical Discussions

The following are hypothetical scenarios that are based on reality. These are issues that we see in practices across the country, and the answers are as many as there are practices.

The Case of the Generous Technician

Jill McClarry, a technician responsible for inventory management at a large veterinary clinic, was told during her training as a buyer that the practice was very sensitive to any type of inducements given to staff by manufacturers' representatives beyond "modest tokens of friendship". The practice felt that as long as staff were entertained or received tokens of appreciation of little or no value that their position as a purchasing agent would not be compromised.

Question: Why would a practice feel the need for such a policy? What would constitute "a modest token of friendship"? What would exceed that?

The first year of Jill's job involved nothing that could even be remotely linked to the "bribery policy." One salesperson for a large vaccine manufacturer had become good friends with Jill and offered to take her to dinner, so that they could quietly discuss some of the emerging practice trends that would affect the next year's business. Jill was happy to go to dinner, because it was a good social opportunity to enjoy quiet conversation with her friend Barbara, the sales representative. The dinner went very well and was very productive for both Jill and the practice.

Question: Does anyone feel uncomfortable accepting a dinner under this policy?

Later that year, Barbara invited Jill to attend an ice show with her, completely as a recreational activity. Jill remembered the dinner, felt that it would be very pleasant to attend anything with Barbara, and quickly accepted. On the date of the planned entertainment, Jill received a note from Barbara with four tickets saying that she was terribly sorry that she could not come to town, but wanted Jill to invite other friends and enjoy the ice show.

Question: What should Jill do? Why? What harm has been done?

The following spring, Barbara contacted Jill and asked her to speak to a drug manufacturer's trade association on the buyer's view of sales and service in veterinary practices. Jill was very happy to receive the invitation to speak and was happier later to hear that there was an honorarium of $500 associated with the speaking engagement. She worked very hard on her speech, and it was very well received. She felt she earned every penny of the $500 in extra work.

Question: Did she do anything wrong by accepting? Was Barbara's involvement a problem? What danger might exist in this situation?

In late summer, Barbara spent almost two days with Jill, acquainting her with some of the changes that would be made in the product lines and to bring her up to date on some new product lines that were to be watched in the industry. Two weeks later, Jill received a $1,000 check from Barbara's company, with a notation that this was for her time and with great appreciation for advising Barbara on the needs of drug representatives such as herself.

Question: How has Jill compromised her relationship as a practice purchasing agent? As long as she intends not to be influenced by the money, can she take it?

Jill realized she was in clear violation of the "bribery policy", but was not sure where she crossed the line.

Question: Did Jill do anything illegal? Did she cause any animal harm? Did she steal from her employer? Did Jill cross the line of "trustworthy" in her practice role? If Jill made an error in judgment, when did it first occur? Could she have continued working with Barbara after saying "no" to a gift or other act of friendship?

Choosing a Therapy When Doctors Disagree

Attention should be focused on a cluster of three basic ethical questions raised in this next case:

1.  The inpatient nurse technician (IPNT) has been caring for Dr. Smith's patient, based on her written records and personal counsel.

2.  On Dr. Smith's day off, Dr. Jones assumes the case, and asks the IPNT why certain tests did not appear in the medical record.

3.  The IPNT stated they were never ordered, so she never conducted them. She added that he would need to talk directly to Dr. Smith about why she was doing what she was doing.

Question: What are the danger signs at this point? Do they relate to standards of care or practice protocols?

During rounds later that day, Dr. Jones asked Dr. Heavybreather if he would run specific tests to rule out some of the potential causes. Dr. Heavybreather looked at the record and the inpatient records, which had been well maintained by the IPNT.

Later that day, Dr. Jones ordered the tests that he and Dr. Heavybreather had discussed, to assist Dr. Smith when she returned the following day.

The IPNT did as she directed, drew the samples, and sent them to the appropriate reference lab that afternoon, documenting the dictated orders of Dr. Jones on the inpatient record.

Question: What are the new danger signs at this point? Do they relate to standards of care or practice protocols? What are alternative actions that could be considered?

The following morning, Dr. Smith came in and saw the ordered tests in the medical record, and started screaming at the IPNT. She said she had trusted the IPNT with her patient, and felt betrayed that the IPNT would so carelessly follow the directions of the most junior doctor in the practice, Dr. Jones.

Question: What are the choices of the IPNT at this point? How would you assess the attending doctor's actions? Do they relate to practice protocols? Have the standards of care been improved, changed, or ignored? What are alternative actions that could be considered?

Dr. Heavybreather came in, when he heard the screaming, and tried to restore order. Dr. Jones then came through the back door, since he was on "late start" that morning. Dr. Heavybreather got Dr. Jones and Dr. Smith to join him in the surgery, closed the door, and asked for the two stories causing the conflict and screaming.

Question: What are Dr. Heavybreather's choices at this point? How should the IPNT respond to the employer's actions? Are they zone-specific issues? Do they relate to practice protocols? Have the standards of care been violated, and if so, what should be done? What are alternative actions that should have been considered by the employer?

Dr. Jones knew nothing of the earlier screaming, so he was stuttering, while trying to determine the issues. Dr. Smith was pointing and yelling at Dr. Jones, while the staff watched through the surgery windows. The employer, Dr. Heavybreather, is looking as if he is about to explode.

Question: How should the staff respond to the surgery suite displays? Are they in any jeopardy if they pretend to ignore the doctor melt-down? What are alternative actions that could be considered by the staff at this point?

Shift focus and keep thinking:

Scenario: Now bring these issues "home" to your own practice, and assess what protocols and procedures are in place to prevent the above scenario from occurring in part, the same way, or worse in your realm of influence.

 Who should make the ultimate decision, when choices between alternate modes of therapy must be made, is an obvious issue that must be faced in a multi-veterinarian practice?

 When we start to evaluate a patient, then continue to make the treatment decisions, often based on economics in lieu of best care, how should the client be involved in selecting the alternatives?

 The third, and perhaps the most fundamental issue, is who makes the decision, when each of the alternatives, often conservative medicine versus exploratory surgery, is substantially correct?

The option to be chosen in each of the above three questions is not a medical decision based on scientific training, but rather, a professional value judgment.

Active Euthanasia

Let's now look at euthanasia as a practice bio-ethical issue.

Question: If a doctor admits a euthanasia, who should be involved in the administration of the lethal dose?

Question: Should the same people be doing all the euthanasias all the time?

Question: Should all animals have the same cost levied for euthanasia?

Question: Should a "Golden Client" be assessed a fee for euthanasia, and a long chemotherapy regimen that extended the quality of life a full year, when it was a suffering decision made between the client and the doctor?

Question: Which client type should be charged more for euthanasia services?

Question: Can the practice implement a high-fee euthanasia and require the client to sign away ownership, so the animal can be adopted, once the animal's health and protection is current?

Animal Abuse and Neglect

Question: What is the difference between animal abuse and neglect?

Question: Who should be doing all evaluations for Animal Control?

Question: Could all animals have the same standards applied, even lion dogs?

Question: How should a "known client" be assessed for a complaint, compared to a pet owner, who has never seen a veterinarian, and keeps the dog on a chain by the back door for home security?

Question: Which client type should be considered reportable to community authorities if animal abuse is suspected?

Question: Can the practice implement a proactive community support program for animal welfare? What could you do in the media?
Hint: There is a ninety-five percent correlation between animal abuse and child abuse in the same household.