I was terrified when I started my consulting career. As I walked out to call in my first client, I was full of doubt, just as everyone is. Could I do it? I wasn’t very good in most social situations – was this the right career for me?
In the end, consulting actually came naturally to me, but I always found the consulting room a lonely place – I often wondered if anyone else did things the same way as me. I often felt as if I was winging it, and I had no idea how other people behaved in their own consulting rooms. I decided to investigate if anyone else had talked about it online.
Much to my surprise, I discovered a whole field of ethical studies devoted to it. It blew my mind that what felt like a very personal and subjective experience could have studies and papers devoted to it. It was here I learned about the physician agency and paternalism.
Laying down the law
Physicians, because of their years of training (and, for non-new graduates, experience), have a significant informational advantage over their patients. This advantage, and the market power it generates, is referred to in medical ethical literature as “physician agency”, and it uses different models to describe how the vet uses this information gap in their behaviour towards clients.
The earliest developed view of this physician-patient relationship is the “paternalistic” view. Here, the physician is a “perfect agent” – they always behave in the best interests of the patient, and in exactly the way the patient would for themselves if they had the physician’s level of training and experience.
The patient is passive, the physician makes all the decisions, and there is no benefit to the client gaining any information about their condition – they just do what they’re told.
It doesn’t take an advanced level of knowledge of human behaviour to see flaws with this approach. How many physicians can honestly say they are “perfect agents”?
A little knowledge is a dangerous thing
Consequently, the “standard” view of physician agency was developed – this model understands the gap in knowledge between physician and patient is large, and can be exploited by less-than-scrupulous physicians to their own ends. With this model, there is always a benefit to the patient learning more about their medical condition – the smaller the information gap, the better for the patient.
This model, however, assumes the client will always make a rational decision based on the information, and ignores the effects anxiety or fear of a medical diagnosis or procedure can have on a patient’s decision making.
If we understand we can’t always be trusted to be perfect agents as clinicians, we should probably accept that patients can’t always be perfect agents for themselves – I know I can’t.
What you don’t know can’t hurt you
In the “emotional” view, the emotions of the patients are taken into account. Here, the physician is entirely altruistic, but is able to withhold information from the patient, or even outright lie to them if he/she feels this information may lead to an incorrect decision.
This leads a difficult ethical question – when you’re dealing with an anxious client, is the role of a benevolent physician to inform them completely or to pass on only the information relevant to make them comply with therapy? This is, effectively, a clash between the old paternalistic and standard models of physician agency.
However, these models were all developed for human medicine. In veterinary medicine, of course, there is the elephant in the room (occasionally, literally) – the animal.
A moral dilemma
Is it the veterinary physician’s role to always be an advocate for the animals, even to the detriment of the client’s wishes and views (an approach similar to that of human paediatricians), or should the client’s wishes always come first?
This is a tricky ethical area for me, and I suspect many vets, to deal with.
When I qualified, I swore an oath to do my utmost to protect the welfare of the animals under my care, but – in the real world of general practice – it is not uncommon for the decisions that would improve pet welfare to clash with two other factors – the need for the practice as a whole to make money and, more commonly, the wishes of the client (especially when their financial situation is taken into account).
Getting emotional
My own approach to clients and their pets turns out to be most similar to the emotional model – I personally dislike the paternalistic approach, where the client is effectively just told what to do (the approach largely taken, in my experience, by vets of an older generation), but I have realised over the years some clients prefer this, and will return to see vets who offer this approach in preference to ones who like to have them involved in the decision making.
Similarly, a lot of clients ask me ”what would you do if he was your dog?” – a subtle way (okay, not that subtle) of asking me to make the decision for them. We live in an age where a lot of information is freely available on the internet, and I take the view that if I don’t inform clients, they will educate themselves online (as best they can as a layman) and, in doing so, often find wrong information or misinterpret correct information.
Additionally, our patients are unable to understand their diagnoses – however the client feels, a pet will never become depressed on discovering they have an incurable terminal condition. This means less of an excuse to withhold information from clients, as I think they are more likely to make a rational decision than when they are thinking about their own personal health… well, for the most part.
Taking control
When dealing with a hysterical (or very emotional) owner I always try and advise them to discuss options with other family members or friends – even here I am reluctant to make decisions for them, but I’d prefer they had a cooling off period while they consider the situation.
There are conditions where there just isn’t time for that, of course. When a dog is presented to me with gastric dilatation, I become much more paternalistic, and give the owner two very stark options – immediate intervention or euthanasia to end the dog’s suffering, and I lean strongly towards the intervention approach unless there are other problems.
My experience and training is required to immediately help the dog, and the owner is unlikely to be able to contribute significantly to my decision making.
Money matters
As with everything in life, there are complications. The first situation is the need for the practice to make money.
I have been present in emergency meetings to discuss the fact practice takings were significantly reduced from the year before. A few days later, in a consultation for a dog with otitis externa, I found myself reaching for an ear medication I knew was expensive, even though I was pretty certain a cheaper ear ointment would clear up the condition just as well.
This was probably the first time in my career I felt I was making a decision for the client based on purely financial gain for the practice. Technically, there was nothing wrong with my selection, and it worked for the dog very well, but I knew deep down my reasons for making that decision were financially, not medically motivated. It is a decision I hope I won’t make again.
Honouring the client’s wishes
A bigger issue arises when the decision of the client is not, in my opinion, in the best interests of the pet’s welfare. For instance, as happens to me relatively frequently, I am asked to euthanise an elderly cat with treatable hyperthyroidism because the client doesn’t want the animal “messed about”.
In this situation, I will strongly advise and discuss all options with the client, but if their decision is still the same (even if I think it is the wrong one) I will carry out their wishes – because, if I refuse, what kind of a victory have I won? The client has an animal they no longer want, and the animal is still suffering from the condition.
No single solution
While I was surprised and a little excited to discover how much research and ethical debate has gone into something I thought nobody would have thought about for a second (I do love a good ethical debate); ultimately, I’m not convinced you can hammer all those moments in the consulting room into a neat model.
Client and veterinary interactions are a complex mish-mash of information, emotional and financial concerns, which vary from vet to vet, case to case and client to client.
Sometimes I’m “paternalistic”, sometimes I’m “standard”, and sometimes I’m “emotional”. Sometimes, I’m just tired, and want to get home after a long day.
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