Legal and ethical veterinary practice: a scenario

Veterinary Nursing Journal

ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: http://www.tandfonline.com/loi/tvnj20

Legal and ethical veterinary practice: a scenario evaluation Sairéad Wild To cite this article: Sairéad Wild (2017) Legal and ethical veterinary practice: a scenario evaluation, Veterinary Nursing Journal, 32:2, 45-49, DOI: 10.1080/17415349.2016.1259833 To link to this article: http://dx.doi.org/10.1080/17415349.2016.1259833

Published online: 17 Jan 2017.

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Date: 30 May 2017, At: 06:57

CLINICAL

Legal and ethical veterinary practice: a scenario evaluation Sairéad Wild BSc (Hons), RVN The Old Golfhouse Veterinary Group, 4 Goddard’s Court, Watton, Norfolk IP25 6XT, UK

Sairéad Wild, BSc (Hons), RVN Sairéad graduated from Anglia Ruskin University, Cambridge in 2016, with a First Class BSc (Hons) in Veterinary Nursing with Applied Animal Behaviour. She currently works at the Old Golf House Veterinary Group in Watton, Norfolk, and has a special interest in infection control. Email: [email protected]

ABSTRACT: As newly enrolled student veterinary nurses (SVNs) enter into placement, there will be some who observe clinical practices which do not meet with the legal and ethical requirements of the profession. Reflecting on one scenario, a new graduate evaluates how four years of training has developed a deeper knowledge and more confident personal standpoint regarding the importance of their ability to step in as the patient’s advocate, and the desire to exercise agency in the promotion of ethical and legal delivery of practice.

Scenario overview Dentistry encompasses evaluation, diagnosis, prevention and treatment of diseases and disorders of the oral cavity and associated structures. In order to undertake this procedure observing best practice, a number of considerations must be made in identifying the best way to proceed while working within recognised legal, professional and ethical parameters. In this scenario, de-scaling, with extractions, was observed by a student veterinary nurse (SVN), and performed on a retired racing greyhound by a registered veterinary nurse (RVN), with total intravenous anaesthetic monitoring undertaken by an animal nursing assistant (ANA). The greyhound was neither intravenously catheterised nor intubated. The patient suffered a noteworthy amount of post-procedural gingival haemorrhage, which was regarded as normal, as greyhounds are prone to heavier post-surgical haemorrhaging than other breeds (Couto, Lara, Iazbik, & Brooks, 2006; Lara-García, Couto, Iazbik, & Brooks, 2008). Please note that the scenario is one of fiction and in no way reflects on the author's current or past affiliations.

The legal system (England and Wales) This comprises criminal and civil law. A summary of the differences between the

two systems are shown in Table 1, including when each is employed, the penalties imposed and the identity of those imposing them. One such act within criminal law is The Veterinary Surgeons Act (1966). Schedule three of the act stipulates who may and may not undertake veterinary treatments. In addition the RCVS guidance to the Code of Professional Conduct 2016 (CPC) explicitly states in Section 18.4 that RVNs are entitled to undertake routine dental hygiene work (“minor surgery”); however, they are not permitted to extract teeth. It goes on to state, in Section 18.9, that “monitoring a patient during anaesthesia ... is the responsibility of the VS, but may be carried out on his or her behalf by a suitably trained person”, citing an RVN or supervised SVN as the most suitable persons. The practice evidently regarded the ANA as a “suitably trained person”; however, not enrolled in any formal training, they held the same status as a lay-person: not entitled in law to carry out this Schedule 3 (Amendment) procedure and so were acting unlawfully. Despite the practice and the personnel in question considering themselves suitable for the roles, the patient’s owner may have had a different perspective, having signed a consent form presumably expecting the VS recommending the procedure to perform it, having not being advised otherwise. Abbitt (2010) describes four processes in the formation and execution

DOI: 10.1080/17415349.2016.1259833

© 2017 British Veterinary Nursing Association (BVNA)

Veterinary Nursing Journal • VOL 32 • February 2017 • Page 45

CLINICAL Table 1. Summary of the two classifications of the legal system (England and Wales) Classification

Overview

Criminal law

Criminal laws are intended to protect the public from harm and, where offences occur, these are punishable by the state. They are recognised by acts of parliament (Abbitt, 2010; Gray & Wilson, 2006). Individuals found to have broken such laws can find themselves subject to criminal proceedings involving prosecution, and be obliged to pay the penalty the judge deems fitting for the crime (Wager, 2011).

Civil law

Civil laws address harm or loss suffered by individuals. This may include crimes such as dangerous driving resulting in injury, but more usually through a breach of “duty of care” (Gray & Wilson, 2006). They are concerned with disputes between private parties; for example, employer and employee, consumer and supplier. The injured party sues and the penalties are financial compensation (“damages”) or injunctions imposed by the judge.

Table 2. Consent: forming and execution of intent Element

Definition

Capacity

This describes the ability of the owner to understand what the procedure involves. This may be hindered by an emotional, educational or mental incapacity, rendering the client unable to digest the information

An intention to be legally bound

The offer of a statement of intent, from the offeror. This describes inviting the client to accept the position of being bound in law by the terms described, if they give consent

Offer and acceptance

If consent is given (the offer of legal-binding is accepted) the offer is formalised. This acceptance does not have to be in writing, but may also be implied (for example, by the owner bringing the patient into the surgery) or oral

Consideration

This refers to the exchanging of (usually) money from the client to the practice in acknowledgement of the procedure having been undertaken in accordance with the statement of intention

(Adapted from Abbitt, 2010)

of the intentions within consent, detailed in Table 2.

Informed consent Obtaining consent is a legal obligation for the practice, with non-obtainment considered to demonstrate negligence and, once obtained, consent is only recognised if it is deemed “informed” (Wager, 2011). A client is not expected to distinguish between a qualified and non-qualified member of staff (Earl, 2006) and therefore when giving consent, must trust that the person undertaking the procedure has sufficient training, competency and authority to carry out the task (Earl, 2006). In this case, the owner was not advised that an RVN would be undertaking extractions, nor an ANA monitoring the anaesthetic, therefore informed consent1 was not given, because they were not fully aware of what they were consenting to (Flemming, 2006). It could be argued that at the time of admission it was not clear that there would be extractions; however, this

point should then have been addressed. Informed consent is a vital component of valid consent (a concept based upon competence, age and maturity, and capacity of the client (Dye, 2006)) involving the provision of adequate information (Table 3), without which it cannot be considered valid (Kennedy & Grubb, 2000 cited in Dye, 2006, p. 82).

Duty of care The Animal Welfare Act (2006) includes Brambell’s Five Freedoms, which lists in its welfare duties the provision of “freedom from fear and distress”, inviting consideration of the distress caused to the dog from the blood-loss experienced during recovery. This was cleaned up with towels and the dog’s mouth bathed prior to discharge, the volume of blood lost was not disclosed to the owner, and the incident was not pursued. Another provision, “freedom from pain, injury and disease” also deserves consideration; the patient may well have experienced more pain

than necessary, as the procedure was carried out by the RVN and not a practised VS. Injury may have been caused and gone unidentified, perhaps manifesting in further periodontal complications. RVNs have a legal obligation to observe a “duty of care”; however, this pertains to clients and colleagues, and not patients, which are regarded as a “chattel” within law (Abbitt, 2010). Had the patient suffered such complications so as to die, the RVN and ANA might not be sued for the civil offence of breaching their duty of care, as the law does not recognise an owner’s level of distress regarding such loss; the greyhound was retired and therefore was not an “asset”. The RVN may be culpable for negligence under criminal law, as well as for acting outside the remit of an RVN (VS Act, 1966) and breaching the Animal Welfare Act (1966); additionally, they have a professional duty of care to the patient, laid out within their CPC, addressed again below. Had the level of the RVN’s participation been revealed to the client, and this pursued in court, magistrates may have

Table 3. Information to include in demonstrating best practice in achieving informed consent Points to include

Remarks

1

The treatment options or diagnostics available and a detailed description of each, in a language the owner can understand

To include euthanasia if appropriate

2

Who is to perform the treatment/surgery

Particularly if this is an RVN under Schedule 3 of the VS Act, or a student under supervision

3

Explanation of the significance, side effects and risks, however small, of the treatment

4

Any likely future treatment and care involved

For each option in point 1

5

An estimate of the costs involved

For each option in point 1. This should be done before the owner decides which course of treatment to pursue, so as not to influence their decision-making

(Adapted from Abbitt, 2010; Gray & Clarke, 2012, Chap. 9.)

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CLINICAL concluded that the dog had been exposed to unnecessary suffering and the RVN deemed to have behaved criminally and obliged to bear the consequences (Wood, 2011).

Codes of Professional Conduct Sitting alongside the VS Act are the CPCs; these offer guidance to VSs and RVNs regarding expectations of professional conduct, but they are not laws. If they are breached and a complaint is raised, it is ultimately taken up by the RCVS Disciplinary Committee and formally heard, having passed through four previous investigative stages. Since the introduction of the Royal Charter in 2014, all RVNs joining the RCVS register become regulated professionals, accountable for their actions. Within the CPC there are five principles of practice (Table 4) by which to conduct their professional responsibilities. It is possible that all five of these principles were dishonoured during the scenario in question. Identifying one’s level of competence is a key consideration within the CPC, and objective reflection by the RVN may have highlighted that they ought not consider themselves competent with procedures they were not specifically

trained in, demonstrating dishonesty and lack of integrity to the client, as well as a breach of trust. Professional accountability did not appear to have been addressed but, had the episode been exposed to the client, it would certainly have placed the RVN in an uncomfortable position professionally. These guiding principles were not complied with and adherence to many of the six areas of professional responsibility may also have gone unheeded (Table 5).

Introducing ethics This scenario presents some conflicting perspectives, with overlap between frameworks discussed, when one considers the outcome of the case on its apparent worth. From the owner’s perspective, the care her dog experienced and the adherence to the legal obligations for the delivery of the procedure were not obviously undermined, and therefore the practice may have continued to use the RVN, as they had in the past, for dentals and associated extractions. Further to these legal and ethical obligations, an additional set of ethical frameworks can be applied to the scenario, facilitating a supplementary perspective on the scenario. Ethics can be defined contextually as “moral and legal cornerstones of contemporary health care” (Farsides, 2013); there are four main schools of ethical thought:

three principle schools are Deontology, Virtue and Utilitarian (expanded upon in Table 6) and the fourth, Medical, discussed below. The more “modern” Medical Ethics model, first drafted by Thomas Percival in 1803 (Waddington, 1975), is a hybrid of utilitarian and deontological schools, honed to address the unique dilemmas faced by the veterinary profession. It comprises four principles (Table 7), by which healthcare-givers might adhere. If these were to be applied to the scenario, similar conclusions may be drawn to those found when superimposing the previous schools of thought onto practice. The scenario points to the idea that the welfare of the patient was not, apparently, the most important consideration in this case, and neither was the observation of law and regulation. In order to consider how the scenario could be prevented from recurring in the future, reflection upon the circumstances is necessary.

Professional reflection Reflective practice is a professional obligation for RVNs and VSs, allowing scrutiny, gaining of self-awareness and a clearer picture of their behaviour within the parameters of the profession (Somerville & Keeling, 2003). It assists individuals

Table 4. The five principles of practice 1

Professional competence

2

Honesty and integrity

3

Independence and impartiality

4

Client confidentiality and trust

5

Professional accountability

(RCVS, Code of Professional Conduct for Veterinary Nurses, 2016).

Table 5. Sections of the CPC (VN), breached across the scenario SECTION 1 VNs and animals 1.1

VNs must make animal health and welfare their first consideration when attending to animals

1.2

VNs must keep within their own area of competence and must refer cases responsibly

SECTION 2 VNs and clients 2.1

VNs must be open and honest with clients

SECTION 3 VNs and the profession 3.5

VNs must not hold out themselves [...] as having expertise they cannot substantiate

SECTION 4 VNs and the veterinary team 4.2

VNs must ensure that tasks are delegated only to those who have the appropriate competence and registration

SECTION 5 VNs and the RCVS 5.1

VNs must be appropriately registered with the RCVS

SECTION 6 VNs and the public 6.4

VNs must comply with legislation relevant to the provision of veterinary services

6.5

VNs must not engage in any activity or behaviour that would [...] bring the profession into disrepute or undermine public confidence in the profession



CLINICAL Table 6. Ethical schools of thought and their application to veterinary practice Ethical school

Principles

Application to the scenario

Deontology

Focuses on the rightness or wrongness of actions, rather than consequences; in other words, “following the rules”. Its followers subscribe strictly to a set of principles enshrined in laws, ecumenical commandments or professional codes of conduct

The dental could have been rebooked when the VS was available; it was not an emergency procedure. The practice staff were aware that the RVN was undertaking the dental, and therefore were complicit in deceiving the owner. Elements of the CPC (VN and VS), and VS Act were violated, and it was not through the necessity to prevent (immediate) suffering of the patient. The consequences were that the animal did experience suffering (excessive bleeding, pain and anxiety). There was no apparent adherence to this school of ethical thought, as many rules were broken. The appropriate pathway would have been to report the practice to the RCVS

Virtue Ethics

Making decisions based on not causing more harm oneself, irrespective of whether, in doing so, others are further harmed. Individuals of good virtue will apply them to any situation and so live a good life and do morally good things (Bolsin, Faunce, & Oakley, 2005)

Had virtue ethics been utilised in this scenario, the VS would have been clear with the owner that the dental would not be carried out by themselves, but by an unqualified (in the context of extractions) RVN and monitored by an unqualified ANA. The RVN would not have undertaken the procedure, because they knew it was not right to do so without relevant authority or qualification; virtue ethics was not considered in the judgement. The RCVS expects RVNs to be caring and accountable for their actions. One could argue that the procedure was carried out with a desire to care, but this would need to be carefully weighed against the possibility of having to account for the breaches of the CPC (VN) and VS Act

Utilitarianism

The moral worth of an action is solely determined by its contribution towards maximising satisfaction or reward among all individuals. “The greatest happiness of the greatest number” (Bentham, 1780)

This school seems to fit most closely with the decisions made regarding this case. The owner was not told about the staff undertaking the procedure, the animal had the procedure at the designated time, and appeared to be discharged with no harm done; any rotten teeth which may have caused future complications had been removed. From the point of view of the practice the client was happy (the work was done and the dog was returned with no unexpected presentations) and the practice had fitted in another client and received payment for this. The practice was happy and the owner was happy; perhaps the individual who benefitted least was the dog, which suffered excessive bleeding and may also have experienced complications at a later date due to the RVN not having formal training in the procedure. This rather overshadows the VN declaration on joining the RCVS register of the “constant endeavour ... to ensure the health and welfare of animals in my care”.

Table 7. Four principles of Medical Ethics and their equivalent principles in the ethical matrix Principle

Definition

Equivalent principle

Non-maleficence

Not putting animals in a worse position than they are already in, either by intervention or non-intervention

Well-being

Beneficence

Proactively putting animals in a better position than they are already in; making them better off

Autonomy

Respecting the decisions of owners – not necessarily agreeing, but being supportive to them in the decision they choose to make

Autonomy

Justice

Fairness and respect for the rights of individuals

Fairness

(Adapted from Yeates, 2011, p. 7).

in identifying strengths and weaknesses within themselves and their practice, which can then be analysed and evaluated (Bulman, 2008). A range of models are available to support reflection; Gibbs’ (1988) reflective cycle (Figure 1) allows the SVN “witness” to consider the scenario from a newer position of increased experience, knowledge and confidence, accumulated since witnessing the situation several years previously. In describing the scenario, it was clear that all senior staff were aware of this unlawful practice, and it was not an isolated incident. As a new SVN at that time, there was mindfulness of holding the position of a guest in the practice. Even as a new student, it was clear that what was occurring was inappropriate, and Page 48 • VOL 32 • February 2017 • Veterinary Nursing Journal

when an explicit request to have “not seen that” was issued, the SVN was conscious of becoming complicit by complying. There was knowledge of having witnessed wrong-doing, and a measurable feeling of guilt at being aware of the potential that the animal suffered more than one might expect, but knowing that any action being taken was unlikely. Additionally, there was a feeling of disappointment that staff who should be in a position of demonstrating best practice should undertake such unconcealed malpractice; perhaps there was also a naivety regarding expected standards of practice. At that time, to whistle-blow was alarming and complex, holding personal risk (losing a training position, future references, accruement of hours, reputation and possibly a qualification), and there was a naivety regarding

expected standards of practice. Having since developed a clearer personal ethical stance and increased professional knowledge and experience, this ongoing practice demonstrates such a high level of misconduct, legally, professionally and ethically, that it is evident that advice should have been sought at the time; although it would have been impossible to raise concerns internally, due to the personal relationships and dynamics of the management hierarchy. If one considers that the patient suffered bleeding levels in keeping with that particular breed, there was possibly no long-term physical harm inflicted. The client was not unhappy with the perceived treatment and so did not feel harmed by the experience. However, this could easily have not been the © 2017 British Veterinary Nursing Association (BVNA)

CLINICAL Note 1. Given by a client who has had the opportunity to consider a range of reasonable treatment options, with associated fee estimates, and had the significance and main risks explained to them (RCVS, 2016). References Abbitt, G. (2010). Legal, ethical and professional issues for veterinary nurses. The Veterinary Nurse, 1, 186–188. Animal Welfare Act, 2006. (2006). London: HMSO. Bentham, J. (1907). An introduction to the principles of morals and legislation. Retrieved November 20, 2016, from http://www.econlib.org/library/Bentham/bnthPML1.html. Bolsin, S., Faunce, T., & Oakley, J. (2005). Practical virtue ethics: Healthcare whistleblowing and portable digital technology. Journal of Medical Ethics, 31, 612–618. Bulman, C. (2008). An introduction to reflection. In C. Bulman & S. Schutz (Eds.), Reflective practice in nursing (4th ed.). Retrieved from https://books.google.co.uk/ books?id=2qV0ZIjJ3eAC&dq=Reflective+Practice +in+Nursing+4th+ed&q=contents#v=snippet&q= contents&f=false Couto, C. G., Lara, A., Iazbik, M. C., & Brooks, M. B. (2006). Evaluation of platelet aggregation using a point-of-care instrument in retired racing greyhounds. Journal of Veterinary Internal Medicine, 20, 365–370. Dye, K. (2006). Consent to treatment of veterinary practice. In S. Pullen & C. Gray (Eds.), Ethics, law and the veterinary nurse ( pp. 77–90). London: Butterworth Heinmann Elsevier.

Figure 1. Gibbs (1988) reflective cycle case had complications arisen, particularly if no VS was to hand. The procedure was undertaken by an RVN to free up the VS for other duties; a cost-saving for the practice. It might be in the practice’s interest to have considered whether income lost by observing the legal implications of the clinical contract was worth the personal financial cost of defending a court case or being struck off the RCVS registers, if complications occurred. With this in mind, careful reflection by the practice managers might identify the need for a new protocol, using the RVN for routine scale and polish procedures but ensuring that, should extractions be necessary, a VS was always on site to step in.

Re-evaluating the options Having developed confidence on a personal level, and accrued knowledge regarding ethical thought and the professional requirements of the VN, the SVN might again reflect back regretfully for not highlighting this example of gross misconduct; however, there was a sense of not being fully aware of what was and was not permissible by experienced RVNs. It would have been possible to report the incident to an external body such as the SVN's college/university, BVNA helpline or the RCVS; however, the SVN felt too embarrassed to raise the issue in case they had misunderstood the context and felt humiliated. Now better-versed in legislation, professional conduct and accountability, the SVN would certainly air their concerns with the personnel in question.


A suggestion of a meeting to rethink this practise would address the problem informally, but with the welfare of the patient as the priority, it rests with anyone witnessing a deliberate breach of rules to become the patient’s advocate. If the informal suggestions are met with resistance, then alerting the RCVS's Professional Conduct Department would seem a natural progression.

Conclusion This scenario highlights breaches of both the legal system of England and Wales, the The Veterinary Surgeons Act (1966), including the Schedule 3 (Amendment) order (2002) and the CPC for both the VS and VN, and the SVN would, with the knowledge gained from professional education and self-development, now seek to whistle-blow on this practice’s behaviour if no resolution was reached informally. The practice’s utilitarian viewpoint can only remain watertight until the first formal complaint, and it is surely better to identify and develop a new, lawful protocol to prevent such an event, than to lose money, reputation, trust, employment and possibly patients’ lives by being swayed by financial gain. With a professional requirement to “ensure the health and welfare of the animals committed to my care” (CPC (VN), 2016) if observing gross misconduct in the future, SVNs should not be afraid to overcome personal reservations and address the situation with those involved.

Earl, E. (2006). Negligence and whistle-blowing. In S. Pullen & C. Gray (Eds.), Ethics, law and the veterinary nurse (Chap. 4). London: Butterworth Heinmann Elsevier. Farsides, B. (2013). An ethical perspective: Consent and patient autonomy. In J. Tingle & A. Cribb (Eds.), Nursing, law and ethics (4th ed., p. 122). Oxford: Wiley Blackwell. Flemming, D. (2006). Informed consent: What you must tell your clients. Retrieved March 18, 2016, from http://www.ivis. org/proceedings/navc/2006/LA/171.asp?LA=1 Gibbs, G. (1988). Learning by Doing: A guide to teaching and learning methods. Oxford: Oxford Polytechnic Further Education Unit. Gray, C., & Wilson, K. (2006). Introduction to the legal system. In S. Pullen & C. Gray (Eds.), Ethics, law and the veterinary nurse ( pp. 23–28). London: Butterworth Heinemann Elsevier. Gray, C., & Clarke, C. (2012). Client communication and practice organization. In B. Cooper, E. Mullineaux, & L. Turner (Eds.), BSAVA textbook of veterinary nursing (5th ed., pp. 207–227). BSAVA: Gloucester. Lara-García, A., Couto, C. G., Iazbik, M. C., & Brooks, M. B. (2008). Postoperative bleeding in retired racing greyhounds. Journal of Veterinary Internal Medicine, 22, 525–533. RCVS. (2016). Code of professional conduct for veterinary nurses. Retrieved March 18, 2016, from http://www.rcvs.org. uk/advice-and-guidance/code-of-professional-conduct-forveterinary-nurses/ Somerville, D., & Keeling, J. (2003). A practical approach to promote reflective practice within nursing. Nursing Times, 100, 42–45. Veterinary Surgeons Act 1966 (Schedule 3 Amendment) Order 2002. (2002). 2002 SI 2002/1479. London: HMSO. The Veterinary Surgeons Act 1966. (1966). c.36. London: HMSO. Waddington, I. (1975). The development of medical ethics A sociological analysis. Medical History, 19, 36–51. Wager, C. (2011). Informed consent: What do veterinary nurses need to know? The Veterinary Nurse, 2, 344–349. Wood, S. (2011). The professional, legal and ethical issues in VN: A scenario. The Veterinary Nurse, 2, 164–168. Yeates, J. (2011). Ethics and animal welfare. In V. Aspinal (Ed.), The complete textbook of veterinary nursing (pp. 1–10). London: Saunders Elsevier.
