I was so happy you saved his life I did the crazy happy dance.
The ethics of veterinary practice, particularly oncology, is an interesting topic for numerous reasons and one that should be discussed more frequently and fervently. These ethical dilemmas are perhaps more frequent and challenging for surgical, medical, and radiation oncologists because of the nature of what we do on a daily basis but the relative lack of evidence to support what we do. I am relatively frequently presenting owners with surgical options which have either not been performed before or have been reported in non-peer reviewed list servs and forums; and medical and radiation oncologists will often recommend treatment protocols for diseases for which there are no published studies or there are published studies which show no survival benefit for these treatments. Moreover, we often neglect to consider the potential deleterious effects of these treatments and the impact that these can have on quality of life.
Owners are advocates for their pets and informed consent is necessary prior to starting any treatment. Informed consent is the process of obtaining permission from the patient or, for veterinarians, their owner(s) so that they have an opportunity to decide about their health care. In the medical profession, this definition originates from the legal and ethical rights of the patient and from the ethical duty of the physician to involve the patient in health care decisions.1 Informed consent, at least in theory, has transitioned from a paternalistic approach (whereby the doctor was the only one to make treatment decisions) to a more collaborative approach (whereby the doctor and patient discuss the pros and cons of the various treatment options and the patient decides the treatment option they prefer, with or without guidance from the doctor).1 Unlike our human counterparts, veterinarians are not obligated by legal precedence and our only obligation to our patients and their owners for informed consent is moral rather than legal.2
In “Owner Consent in Veterinary Medicine”, the American Veterinary Medical Association (AVMA) states that the “information received by them (the owner) has been understood, and that they are consenting to the recommended treatments or procedures”.2 This definition reflects the often used paternalistic approach used by many veterinarians whereby owners, despite being informed of the recommended treatment and its associated risks and costs, are not involved in the decision-making process other than to say “yes” or “no” to the recommended treatment. In contrast, the Royal College of Veterinary Surgeons (RCVS) in the United Kingdom (UK) states informed consent “can only be given by a client who has had the opportunity to consider a range of reasonable treatment options, with associated fees, and had the significance and main risks explained to them.”3 Similarly, the Code of Good Veterinary Practice of the Federation of Veterinarians of Europe states that the veterinarian must provide information of the “risks, the costs and benefits of the different and alternative diagnostic and therapeutic routes.”1 The essential difference between the definitions of informed consent between the AVMA and RCVS/Europe is that owners in the UK and Europe are collaborating with their veterinarian in making an informed decision (based on a discussion of the benefits, risks, and costs of a number of procedures and/or treatments) regarding their pet rather than the paternalistic approach favored by the AVMA.
How many of us collaborate with our clients and how many of us adopt the paternalistic approach? How many of us truly involve owners in the decision-making process for their pets by discussing a number of different treatment options, if available, and explaining the risks and benefits of each option and the evidence to support these options? More importantly, how many of us do this impartially and without inserting our own personal biases (unless requested)? Surgical oncologists are perhaps more fortunate than medical and radiation oncologists as we often have more published literature to be able to inform owners on the benefits, risks, and outcomes of surgical procedures. However, we are also bound, at least morally, to inform owners when we do not have studies to support the efficacy of proposed treatment options (for example, surgical re-excisions for narrowly excised tumors, chemotherapy for high-grade soft tissue sarcomas and non-metastatic apocrine gland anal sac adenocarcinomas, and radiation therapy for incompletely excised soft tissue sarcomas) and to discuss the reasons why these treatments may not have provided a beneficial effect on outcome (e.g., retrospective study, low case numbers, heterogenous groups, etc).
As an avid proponent of evidence-based medicine and collaborative informed consent, my two challenges to us all are:
1. If you are not already, do not use the paternalistic informed consent as defined by the AVMA but rather the collaborative informed consent as defined by the RCVS and the Federation of Veterinarians of Europe.
2. When we do not have published evidence for procedures/treatments and when we ignore published evidence in favor of our own opinions because of criticisms of the design and/or interpretation of these studies or disbelief of the results, then this should inspire us to search for this evidence for the benefit of our animals, owners, and profession.
As oncologists, we are a collaborative group of like-minded specialists and clinicians and, as the Veterinary Society of Surgical Oncology has shown since its inception, it is possible to work together to develop large, multi-institutional studies to fill these gaps in our knowledge base and practice evidence-based rather than opinion-based medicine.
Passantino A, Quartarone V, Russo M. Informed consent in veterinary medicine: legal and medical perspectives in Italy. Open Journal of Animal Sciences 1:128-134, 201