James W. Yeates All veterinary patients die. Veterinarians may save lives, deliberately or unintentionally end them, or support practices that involve an animal’s premature death. Legally and culturally, the veterinary profession is the only one authorized to or that regularly kills its patients. This might be seen as contrary to, or as part of the veterinary professional’s role as a helper or healer. This chapter considers death in the context of veterinary ethics. It describes differing types of death and considers a range of ways in which death might be ethically significant for veterinarians or clients. The first sections are quite philosophical (more practically minded readers might choose to start later on and come back to them). Later sections consider the general types of ethical dilemmas veterinarians face in relation to death. Finally, some approaches to ethical decision-making are described and then applied to a specific example. We might differentiate death according to its method, context, and aim or purpose. For example, “humane slaughter” relates to (i) painless active killing of (ii) farmed animals for (iii) consumption. Similarly, veterinary professionals might define euthanasia as death that (i) minimizes suffering, (ii) is in the animal’s interests, and/or (iii) is caused intentionally for the animal’s benefit. The American Veterinary Medical Association (AVMA) defines euthanasia as “the humane termination of an animal’s life” and more precisely as “A method of killing that minimizes pain, distress, and anxiety experienced by the animal prior to loss of consciousness” (AVMA 2020). The second criterion (ii) is often considered in terms of avoiding later illness. For example, the Royal College of Veterinary Surgeons (RCVS) defines euthanasia as “painless killing to relieve suffering” (RCVS 2021). More widely, veterinary professionals might say euthanasia avoids life that would have overall negative value. The third criterion (iii) would mean that, for example, “humane slaughter” would not count as euthanasia even when it is humane and prevents an animal from continuing a miserable existence on a farm because the aim is not for the animal’s benefit. The term euthanasia is used in a wider range of cases than the above. It is applied to the killing of laboratory animals who are “surplus” or after use (which may be done humanely, but often is arguably not; Ambrose et al. 2000), of healthy animals per owner requests, and killing animals in shelters where intake exceeds expected rehoming opportunities. Whether these constitute euthanasia obviously depends on the criteria used and the case. The use of the term creates risks of misunderstanding and of killing being justified as euthanasia when it fulfills only one of the above criteria, such as use of humane methods. These etymological complexities have real-life implications. Using the term euthanasia might make us feel better about doing it, reducing moral stress. But it might also hide some moral concerns, insofar as “euthanasia” is a label that implies morally acceptable (or even laudable) killing. In cases that stretch or miss that definition, this might mislead people, and diminish the inclination to consider the moral aspects of the decision, making the thus-labeled killing more prevalent. We might also differentiate whether the method of killing is active killing/euthanasia (e.g. a percussive blow or barbiturate overdose) or passive (e.g. withholding treatment). Sometimes owners also make the distinction between killing as an intervention and “natural” death due to biological processes. In many cases, a passive, natural death may be expected to involve greater suffering than an active intervention. We might further categorize different active methods of killing (percussion, anoxia, toxic, chemical, etc.), which can have different welfare effects. Some common methods cause significant suffering (e.g. CO2 insufflation) but may be more convenient or less unpleasant for humans (AVMA 2020). We might also classify death in terms of the authority for the killing. While this authority might be based on the animal’s expected quality of life (e.g. veterinarians may be able to morally legitimize killing any animal to avoid severe suffering), the legal situation may differentiate killing based on whether it has the owner’s permission. We might think of death as ethically important in different ways and for different individuals. While veterinary professionals might believe that only their view is morally relevant, it is important to consider and understand other stakeholders’ views and to identify potential biases in our decision-making. Death as a Welfare Concern for the Patient As Indicator of Prior Suffering The process or cause of dying may be associated with unpleasant experiences or be caused by long-term conditions that involve suffering. Veterinary professionals might therefore see death as an indicator or symptom of (previous) welfare problems, and so avoid or reduce death in association with preventing its causes (e.g. reducing mortality rates by tackling flock diseases). Another approach is to consider death in terms of what life it excludes (Yeates 2010a). Where it prevents suffering, it can be considered to be beneficial. Where death prevents enjoyable life, it represents an opportunity cost or deprivation. This approach may be linked to a common intuition that killing a “healthy” animal seems worse than killing an “unhealthy” one (although the term “healthy” can be ambiguous, especially with regard to mental health). These ideas are often considered in terms of whether an animal’s life is (or was or is going to be) “worth living” or “worth avoiding” for the animal (Yeates 2011; Mellor 2016). Defining when an animal’s life is worth living or worth avoiding is difficult, involving complex predictions and subjective judgments. In practice, there may be some considerable gray zone between lives veterinary professionals can confidently say are worth living or avoiding for the animal. Nevertheless, many of us feel those judgments can be made at least in some cases. We might also differentiate cases where the animal cannot conceivably have a good future quality of life (e.g. some incurable, painful condition) versus those in which the patient could have had a good quality of life, but the circumstances mean this is effectively not an available option for the veterinarian (not without undue sacrifices by the vet, for example by providing extensive free treatment). Another way in which veterinary professionals might consider death is in terms of whether it fulfills or prevents the satisfaction of the animal’s preference. There is limited evidence that veterinary patients have life/death preferences or the cognitive abilities needed for a life/death preference such as a concept of one’s self, but veterinary professionals might consider animals as having preferences for which life is necessary (Simmons 2009), and death prevents the fulfillment of those desires. Another paradigm is to consider that life has intrinsic value, and its shortening therefore destroys that value (Taylor 1983; Butterworth and Yeates 2018). It is hard to say here for whom the life has value. If it is for the animal, then the deprivation-based approach noted above seems more germane. If not for the animals, then this approach might conflict with concerns for the animal (e.g. that veterinary professionals should keep animals alive even when they would be “better off dead”). Veterinarians tend not to talk about an inherent value of life for animals (Rathwell-Deault et al. 2017a, 2017b). A related model is to consider that animals have a right to life, either a positive right to be kept alive or a negative right not to be killed. This right might be limited to those animals who can conceivably claim this right, which would exclude veterinary patients (and, arguably, neonatal humans). Alternatively, this right might be afforded only to animals who are the “subject-of-a-life” (Regan 2017 [1983], 1997). Another paradigm is to generalize from concepts applied to humans based on animals’ reasoning (Pluhar 1995). While death relates primarily to the animals who die, it also affects other stakeholders. Owners might have a preference as to whether their animal lives or dies. Veterinary professionals might think owners have a moral right to decide, since the animal is their property, because they are best placed to make decisions in their animal’s best interests, or because veterinary professionals have a contractual relationship with them. Often these factors get combined or conflated, but differentiating them may help us make decisions in difficult cases such as when owners are absent or seem irresponsible. Death might cause human caregivers grief and loss of companionship. Ongoing life might necessitate their expenditure of money or time, affecting their own quality of life (Christiansen et al. 2013), or give them enjoyment or profit. Veterinary professionals might think such concerns should factor into their decisions alongside the animal’s interests, or that veterinary professionals should prioritize the patient’s interests (e.g. not keep a suffering animal alive for the owner’s profit). Studies have documented a high prevalence of occupational stress and euthanasia-related strain among people working in animal shelters, veterinary clinics, and biomedical research facilities (Scotney et al. 2015; LaFollette et al. 2020). We might similarly be concerned with the impact of euthanasia on veterinary professionals (Rathwell-Deault et al. 2017a, 2017b). Veterinary professionals might find saving animals to be rewarding or beneficial to their self-image, morale, reputation, research, or career, although it can be argued that veterinary professionals should morally not take such factors into account in most cases (e.g. not keep animals alive to boost practice profit). Veterinary professionals may experience negative emotional effects related to various aspects of death due to: Even if veterinary professionals do not factor these into patient decisions, the profession should aim to minimize their negative effects. We might also see death as an indicator of the veterinarian’s, or owner’s, values. Some owners seem to think that providing more treatment or declining euthanasia somehow shows they love their animal more. Vets might view euthanasia as evidence of failure and treatment as more heroic. Some owners seem reluctant to euthanize their animal for problems that they have caused or failed to prevent, as if that would mean their failure is less severe (or at least recognize it as such). One might also see euthanasia as taking responsibility (rather than ducking it). Another idea is that killing animals somehow desensitizes the killer to killing. This might be linked to explicit acceptance or rationalization of killing in general and/or to cognitive biases that defend previous acts of killing to avoid cognitive dissonance. There are some data suggesting that vets become more at ease with killing animals with time (Ogden et al. 2012). This may provide a useful coping mechanism for the stresses of practice that helps veterinary professionals’ mental health and resilience. Conversely, it may make us less likely to reconsider our ethics and perhaps more likely to engage in killing that we believe is morally wrong. We might also worry that killing animals might promote or reinforce societal attitudes that animals are unimportant or disposable. Veterinary professionals might also worry that a lack of regard for animal life could also encourage a lack of concern for, say, animal suffering or responsible ownership. Conversely, refusing to kill an animal might make a difference in terms of how owners see animals, e.g. in promoting responsibility. Killing animals may detract from veterinary professionals’ image as healers or make us seem uncaring. Conversely, attempting to save animals through expensive treatment may be perceived as profiteering and clients may see vets as incompetent or exploitative if the animal still dies. Vets might also be criticized for seeming to “coerce” owners into or against euthanasia unduly. Ignoring clients’ wishes might conceivably make owners less willing to present animals for treatment. Veterinary professionals might think that the best reputation for the profession is to be known to always do what is right, regardless of the reputational element – but veterinary professionals know what is right is not always perceived as such by others. Veterinarians in practice have a variety of roles and face various ethical dilemmas related to end-of-life decisions. These can often involve (combinations of) the following: Veterinarians often face dilemmas regarding whether to kill an animal actively. In other cases, vets have to make the difficult decision on whether to provide a treatment that may reduce an animal’s longevity (e.g. providing analgesics that may quicken renal deterioration or surgery that has a risk of perioperative death). Some cases may seem easy (e.g. euthanasia with owner permission to avoid extreme suffering in a terminal case): others may involve more complicated trade-offs (e.g. the choice is between a short, happier life and a longer, less happy one), prompting the question of whether the “total happiness” is better overall. A secondary dilemma may relate to the method of death. It can be hard to evaluate what method is always best, although some clearly cause considerable pain or suffering (e.g. hypercapnia and asphyxiation). In practice, this dilemma may simply be a predictive factual question of which method would cause the least suffering. Veterinary professionals might also reframe some dilemmas about whether to kill or allow an animal to die “naturally” in terms of the method and the suffering involved. A “natural” death may involve considerably more suffering, so a dilemma over whether to kill might reflect, on one side, a motivation not to actively kill an animal and, on the other, a desire to prevent a longer dying process involving considerably more suffering. Other dilemmas concern whether to save an animal from dying. Considering the animal, the outcome of death is the same. However, veterinarians might feel that there is a difference insofar as killing involves a deliberate act, whereas failing to save is an omission. Vets might intuitively feel they have less responsibility to extend lives than to avoid shortening them (and so veterinary professionals feel less guilty when patients die than if they killed them), especially knowing it is impossible for us to save every patient, whereas it is possible to kill none of them. Human medicine differentiates euthanasia based on whether it is voluntary (patient consent), involuntary (contrary to the patient’s wishes), or nonvoluntary (patient has no expressed wishes). The questions around animals’ concepts of death mean these definitions are unhelpful when applied to the patient (Persson et al. 2020), but veterinary professionals might apply them to the owner: for example, if veterinary professionals think owners should be able to insist on and/or refuse euthanasia (but not necessarily both), or to consider cases where an owner is not available and in which it might seem illogical not to euthanize a suffering animal in the absence of consent. Veterinarians have a duty to guide pet owners facing the loss of their animal (Fernandez-Mehler et al. 2013). While this chapter is not about owners’ decisions per se, it is worth noting that veterinarians may have very different views from other people (Duerr et al. 2011); owners may choose euthanasia because they feel morally “overwhelmed” (Rohrer Bley 2018), or because death is irreversible and therefore “final,” and veterinary professionals can help owners to avoid biases such as that euthanasia indicates less love than life-saving treatment (Yeates 2013). At the same time, owners can apply considerable moral pressure on veterinarians. They may request euthanasia for an animal that the veterinary professional considers could have a life worth living. They may try to make us feel guilty for not offering free or subsidized treatment. They may threaten public criticism, litigation, or official complaints. They may simply make discussions unnecessarily challenging or unpleasant. In all cases, veterinary professionals might feel they should simply do what is right. Sometimes, veterinary professionals might legitimately take such risks into account (although doing so can seem unfair insofar as such clients then benefit from such behavior whereas “nicer” clients do not). Other times, veterinary professionals should stand steadfast with integrity. Another veterinary role is to moderate the emotional impacts of death on owners, particularly in their feelings of loss and bereavement. Veterinary professionals might also consider factors such as owners having “a chance to say goodbye” and practical considerations (e.g. before a weekend). Most owners now stay with their pet during euthanasia (Dickinson et al. 2014), so veterinary professionals can reduce owners’ distress by performing euthanasia well (Brackenridge and Shoemaker 1996; Endenburg et al. 1999). Owners value support from veterinarians after their animal’s death (Adams et al. 2000). Practices may also direct clients to grief support services (Dickinson et al. 2014). Veterinarians and veterinary nurses can play particularly important roles in supporting owners to feel that their decision was the correct one, and validating their feelings of loss. It is quite logical to presume that frequent exposure to death and end-of-life decisions would cause anxiety and moral stress for veterinary professionals (Rollin 2011; Morris 2012a), and many veterinarians have some discomfort with killing in some scenarios (Hartnack et al. 2016; Persson et al. 2020). Some veterinarians report feeling coerced by their employer or practice manager to proceed with euthanasia decisions they do not feel serve the patient’s best interest (Kipperman 2017). The veterinary or shelter team can be an important source of mutual support (Anderson et al. 2013; Hartnack et al. 2016) (see Chapter 22 for a discussion of emotional self-care). Many societies ascribe value to how cadavers are treated. Owners may wish to have bodies or ashes back or be opposed to postmortems or educational uses for spiritual or psychological reasons. More broadly, veterinary professionals might feel there is something wrong with “disrespectful” handling of cadavers, not in terms of its impact on the animal (who cannot experience such handling and probably had no predeath preferences on their postmortem disposal), but in terms of indirectly indicating or encouraging negative attitudes or lack of respect for owner wishes. While euthanasia may allow a fee, veterinarians arguably often undercharge for euthanasia services, given the time veterinary professionals can spend on doing it well and sympathetically. However, charging for euthanasia may discourage presentation (e.g. by members of the public finding casualty wildlife) or lead owners to choose less humane options. Available quality-of-life assessment tools include scoring systems (Morton 2007), checklists (Yeates 2013), and frameworks (Morgan 2005; van Herten 2015). Information on communication skills related to end-of-life decisions can be found in Shaw et al. (2007) and Nogueira Borden et al. (2010). Perhaps the most valuable method is discussion with other colleagues. Historically, euthanasia ethics was insufficiently discussed (Fogle and Abrahamson 1990) but now that its importance is recognized, peer discussions are more obviously legitimate and beneficial. End-of-life decisions for veterinarians may be helped by training in ethical thinking and communication, end-of-life protocols, consent form templates and resources for pet owners, psychological support of veterinarians, quality-of-life assessment and decision-making guides and tools, and updates in relevant legislation (Yeates 2010b; Rollin 2011; Knesl et al. 2018; Persson et al. 2020). Figure 21.1 is an algorithm to provide guidance regarding euthanasia decisions. Figure 21.1 Decision tree to provide guidance to veterinarians faced with euthanasia decisions (Source: British Veterinary Association [BVA] 2016). With this philosophical analysis to draw upon, we can consider some specific scenarios to imagine how veterinary professionals would personally address such cases. In many cases, veterinarians face decisions about killing animals who have conditions that are expected to involve ongoing or future suffering, which can therefore be described as (genuine) euthanasia cases. Veterinarians may find some of these decisions morally relatively simple in terms of whether to euthanize an animal, even if it can be hard to know exactly when to euthanize an animal. These decisions may depend primarily on patient condition and prognostic factors (Mallery 1999), or on owner preferences. We might feel that euthanasia would be best for a patient, but the owner might prefer continued life (Case Study 21.1). Sometimes this preference might be based on misunderstanding or the false hope that the veterinarian can “correct” the problem. Sometimes it may be that this disagreement is a “cover” from another concern (e.g. if the owner feels guilty for not having prevented the cause of the suffering that indicates euthanasia, then they may be disinclined toward euthanasia as it subconsciously confirms their self-perceived failure). Other times it may be a simple ethical disagreement about what is valuable (e.g. if they think life is sacred).
21
Death
Introduction
Types of Death
Ethical Significance of Death
As the Avoidance of Continued Life
As Frustration of Preferences for Life
Death as a Nonwelfare, Animal-Based Ethical Concern
Value of Life
Right to Life
Ethical Concerns in Relation to Other Stakeholders
Owner and Client Preferences
Impacts on Owners and Others Who Work with Animals
Impacts on Veterinarians’ Interests
Death as Indicator of Owner/Vet Attitudes
Death as a Cause of Owner/Veterinarian Attitudes
Societal Impacts
Reputation of the Veterinary Profession
Veterinary Roles and Dilemmas
Shortening Animals’ Lives
Saving Lives
Interacting with Owners
Managing Our Emotions
Handling of Cadavers
Euthanasia Fees
Improving Decision-making
Specific Scenarios
Ill Animals
Lack of Consent for Euthanasia
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