Introduction

Consideration of any ethical dilemma in veterinary practice will necessitate regard for professionalism. While clients may be interested in the ethical viewpoint of the veterinarian caring for their animals, they are more likely to witness the overt application of this viewpoint through the veterinarian’s professional behavior. Clients have been shown to desire a balance between technical competence, professionalism, and humanity in their veterinarian (Hughes et al. 2018). It is important that the veterinary profession conducts ongoing oversight of colleagues’ behaviors in order to uphold standards and ensure every individual balances the competing demands of clients, animals, and the organization in which they practice. A veterinarian may lose their license to practice veterinary medicine if they are found to be demonstrating professional misconduct or falling below the standards expected of them, even if their ethical beliefs have guided this behavior. There is therefore a relationship between ethics and professionalism, which at times causes conflict for the individual and requires discussion.

Ethics and Professionalism

A veterinarian’s ability to practice appropriately and professionally is dependent on not only clinical skills and knowledge but also a willingness to engage in ethical reasoning and challenge themselves and others regarding approaches to the treatment or welfare of their animal patients (Hernandez et al. 2018). The concepts of ethics and professionalism are therefore intricately linked, and there is much debate within the literature about their meanings. Dunn (2016) is concerned that they have become conflated, particularly within an educational context where medical ethics may be “recast” as medical professionalism in order to increase relevance to students, without any real change to the curriculum. He is concerned that by teaching a professional behavior approach to medical ethics, the flexibility ethical reasoning provides is lost and that students emerge only knowing how to follow a rule book, which inevitably cannot cover all scenarios and possibilities.

In contrast, Mackenzie (2017) views medical professionalism, or professional ethics as he also calls it, as one of the “major sectors” of medical ethics. His description of medical professionalism relates to the belief systems and values of doctors, defining what patients can expect regarding standards of care. Indeed, ethics and professionalism are often placed together within healthcare curricula and Doukas et al. (2012) argue that the teaching of ethics and humanities form the building blocks of professionalism in medical students, promoting patient-centered and critical thinking skills. Professionalism is commonly described within medical curricula as encompassing the attitudes, values, and behaviors expected of physicians (Swick et al. 1999). Buyx et al. (2008) argue that medical ethics teaching should include the teaching of moral reasoning skills, relevant ethical knowledge, and the development of “certain character traits.”

It is helpful when contemplating ethics and professionalism to consider whether an individual can be ethical while being unprofessional and vice versa. A practical example helps illustrate this situation. A veterinarian encounters a dilemma around poor welfare standards on a pig farm that happens to be a very good client of the practice in which she is employed. Her ethical principles will not let her stand back and allow the mistreatment of animals to continue. She could decide to report the farm to a local news outlet – here she is acting ethically but unprofessionally. Her strong principles are maintained but she is not behaving as expected for a professional by breaking client confidentiality. Alternatively, she could be professional with her work despite violating her ethical principles to improve the animals’ care, by, for example, continuing to supply antibiotics to stop infections due to tail biting, which could be prevented by providing better environmental enrichment for the pigs. Here she is acting professionally by continuing to maintain her presence on the farm and keep this important client, but unethically, as she is not acting to improve the welfare of these pigs by addressing the root cause of these issues. Of course, a compromise could also be negotiated whereby an enrichment plan for the animals’ environment could be developed alongside a short-term course of antibiotics, demonstrating that ethics and professionalism are not always mutually exclusive. This scenario illustrates the relationship between ethics and professionalism.

Even though veterinarians frequently find themselves in complex ethical situations, their moral reasoning skills are not always sufficient to navigate these dilemmas, potentially contributing to high levels of moral stress and burnout (Batchelor et al. 2015; Kipperman et al. 2018; Moses et al. 2018) (see Chapter 22 for a discussion of moral stress). Veterinarians’ behaviors in navigating these dilemmas is an active demonstration of their professionalism, which is therefore likely to suffer if they are unable to do so. If this is occurring frequently, it is likely to pose additional stress and increase the likelihood of a professional negligence case being brought by either a client or colleague. Hence it is clear how closely linked ethics and professionalism are. It is of concern that many veterinary curricula are not addressing this gap in development, with only 18 out of 30 accredited US veterinary schools providing ethics instruction in one survey (Shivley et al. 2016). This situation is improving as accrediting bodies include ethics teaching within required subject areas, but potentially not to the extent that is required (De Briyne et al. 2020).

It has been argued that the term veterinary ethics has caused confusion due to the tendency to apply it in an animal welfare context, worsened by the lack of professional ethics content within curricula (May 2013). May argues strongly that veterinary professional ethics is “more than etiquette” because veterinarians must understand their roles and responsibilities fully, navigate their relationships with both patients and clients, and engage in ethical reasoning in order to receive the respect and credibility that comes with membership in a profession.

Ethics and professionalism are clearly distinct concepts, but particularly when teaching veterinary students, it may be helpful to use the vehicle of professionalism – how veterinarians behave – to illustrate ethical theory. There is a strong argument that professionalism teaching should be integrated throughout a clinical curriculum including ethical theory instruction, and a delivery combination of ethicists and clinicians provides expertise and relevance (Cruess and Cruess 2008). Extending this approach to the clinical context could help with issues of moral stress in veterinarians, for example by utilizing veterinary ethical expertise to guide and inform policy and practice, working closely with clinicians.

Professions and Professionalism

Before examining the concept of professionalism in more depth, it is helpful to consider the meaning of the word profession. While the Oxford English Dictionary (2018) defines a profession as “An occupation in which a professed knowledge of some subject, field or science is applied; a vocation or career, especially one that involves prolonged training and a formal qualification”: a second definition is also included, “More widely: any occupation by which a person regularly earns a living.”

The use of the term “professional” has therefore become somewhat broad, with it frequently being used synonymously with occupation and therefore losing its original meaning (Swick 2000). However, this does not detract from the importance of professionalism to those professions who identify with the first definition. When evidence of abuse of power or protectionism for this status emerges, and the changing nature of access to knowledge is considered, the concept of professionalism is perhaps even more crucial to consider.

To further understand what is meant by the term “professionalism” it is helpful to examine the work of social scientists who have been considering the role of professions in society for many years. In many cases this work is centered on the medical profession, which is identified as a foundation profession because of the pivotal role of healthcare in society. This literature tends to focus on society’s relationship with professions – often called the social contract – rather than a professional’s direct relationship with individuals such as the patient–doctor relationship (Cruess and Cruess 2009). The exchange within this contract is the profession’s expertise and knowledge for the benefit of society, often protected by law, in return for an enhanced social standing.

While the practice of medicine has clear differences to that of veterinary medicine, the delivery of healthcare to both humans and animals has changed immeasurably in recent times. Similar challenges to both professions in the distribution of resources and dilemmas in clinical decision-making mean much of this literature can be drawn upon when considering veterinary professionalism. The somewhat nostalgic view of doctors or veterinarians as being entirely altruistic and paternalistic in their approach is perhaps unrealistic in the era of high-cost treatments and specialization (Shirley and Padgett 2006), and this situation has accelerated the discourse around professionalism.

Human Medical Professionalism

In the past 20 years, there has been an increasing emphasis within the medical profession on defining, teaching, and assessing medical professionalism. This seems appropriate because as part of their contract with society, the public should be reassured that those entering the profession reach the standards of behavior expected of them (Buyx et al. 2008). This has always been an expectation of medical training, but previously these elements of a curriculum were delivered via the “hidden curriculum,” rather than being formally included as elements of instruction (Hafferty and Franks 1994). Students were exposed to role models, rituals, and routines that they learned from often without realizing they were changing their behaviors to align with the expectations of the profession and society. The formalization of this enculturation has advanced in medical and healthcare education (Birden et al. 2013), with an increasing emphasis on reflective practice.

There are numerous definitions of medical professionalism, which are often lists of values, attributes, and behaviors that make an acceptable view of what being a doctor is or should be. While professionalism as a teachable concept is helped by a definition (Birden et al. 2013), Wynia et al. (2014) argue that this reductionist context leads to a “check list” approach to behaviors, without truly considering the broader, less individual perspective of professional standards and the “belief system” needed to underpin public trust in the actions and advice of doctors.

The discourse around medical professionalism has extended so widely that individual organizations have their own definitions and guidance. For example, the Royal College of Physicians (RCP) in the UK defines professionalism as “a set of values, behaviors and relationships that underpin the trust the public has in doctors” (RCP 2005). They set out seven roles of the doctor that help individuals to understand and interpret medical professionalism: healer, patient partner, team worker, manager and leader, advocate, learner, and teacher and innovator (Tweedie et al. 2018). Empirical work utilizing the perspective of multiple stakeholders to define medical professionalism has also generated lists of attributes. For example, Jha et al. (2006) identified seven themes: compliance to values, patient access, doctor–patient relationships, demeanor, management, personal awareness, and motivation.

There are also important cultural elements to consider around definitions of professionalism (Al-Rumayyan et al. 2017). This would perhaps be even more overt in the veterinary context, with different cultures having very diverse approaches to the status of animals in society. Indeed, the social status of veterinarians is hugely varied throughout the world, a reflection of this situation.

Evolution of the Veterinary Profession

The veterinary profession has gone through extensive changes as it adapts to societal needs and the evolving roles animals play in our lives. The close existence of humans and animals means veterinarians contribute significantly to public health, something not always recognized by society. While animal healthcare has always been important, it took a cattle rinderpest outbreak in Europe in the eighteenth century to evolve the veterinary profession into an organized one (Dunlop and Williams 1996). This early scientific understanding of infectious disease led to the opening of the first formal veterinary school in France in 1762. The first school in the UK also had its roots in agriculture and opened in 1790. However, the profession itself was only recognized in 1844 when the Royal College of Veterinary Surgeons (RCVS) was established. In the United States, veterinary schools began establishing in the mid to late nineteenth century (Dunlop and Williams 1996). The profession began organizing formally through the American Veterinary Medical Association (AVMA) in 1863.

Changes in human–animal relationships and the perception of animals in society have led to extensive evolution to the veterinary role as the gatekeepers to animal health. Veterinarians no longer work in small, regional practices treating all species and working all hours in a “James Herriot¹” model. The modernization of agriculture has led to increases in herd and flock size with associated reductions in the overall numbers of animal keepers. Families no longer keep a cow in the backyard for milk production – instead multinational corporations own thousands of high-producing dairy cows selling milk in bulk to supermarkets for purchase (Jones 2003). The number of veterinarians treating farm animal species has therefore reduced dramatically, but in parallel a significant increase in pet ownership has seen a rise in veterinarians treating only small animals (Leighton 2004).

Animals have moved from “barnyard to bedroom” and expectations from society are high when treating these four-legged family members. This work has become increasingly specialized and the technology and medications available are on a par with human healthcare, potentially limiting access due to the expense of these advances. This is not considered a positive by all members of the profession, as the public health aspect of the veterinarian’s role has become increasingly minimized (Jones 2003; Leighton 2004). This argument is often countered by one around the importance of pets in supporting human mental health and well-being (McNicholas et al. 2005).

There is an interesting further historical perspective when considering the veterinarian as a professional. As the medical profession evolved in the eighteenth century, there were two distinct types of doctors: the university educated “professional” physician, and the hands-on surgeon “practitioner” (Mackenzie 2017). Eventually the roles merged, and all treatment of patients involved educated professionals, whether surgical or medical. Cruess and Cruess (2009) also take a historical view on the evolution of “the healer” and “the professional,” with the advent of scientific knowledge empowering the development of the medical profession, with codes of ethics continuing to guide behavior throughout this evolution. The veterinary profession evolved in a similar way, with farriers extending their skills to cover basic surgery until veterinary education began formally and took over the treatment of animals surgically. These scenarios add evidence to the status of veterinary medicine as a profession: members have specific and detailed knowledge, unique to their activities, and generally self-regulate each other to a defined set of standards.

As with many professions, the social contract of the veterinary profession with society has changed as access to knowledge has increased (Cruess and Cruess 2000), and clients are increasingly demanding expert care for their animals. A relationship-centered, dialogue-based approach to the treatment of animals is increasingly sought (Pyatt et al. 2020), with the veterinarian–client–patient relationship central to all decision-making along with increasing involvement of other animal healthcare professionals. The business of veterinary practice has also changed significantly, becoming a viable economic venture with associated external financial investment and speculation (Tannenbaum 1995). These changes led the US veterinary profession to examine its purpose and function in the 1990s through a series of reports calling for professionalization of the business side of practices (Brown et al. 1999; Cron et al. 2000).

These changes to the veterinary profession are somewhat at odds with traditional views of professionalism. William Osler observed, “The practice of medicine is not a business and can never be one … our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations” (Osler 1932). While he was referring to human medicine, the same could be argued in the context of animal patients, as it is the business side of practice that causes many of the ethical dilemmas that arise daily for veterinarians (Kipperman et al. 2018).

The profession has also altered demographically, from being a white male-dominated group to a more diverse, predominantly female profession in many countries (Lloyd 2006; RCVS 2018). New graduates rightly expect a more appropriate work–life balance even though the vocational roots of the profession are still very much in existence. All these changes together increasingly cause ethical conflict and challenges to veterinary professionalism.

Veterinary Professionalism

Veterinarians study to obtain a specific set of knowledge and skills and have the privilege of applying this knowledge to diagnose and treat animals. In return for this, they obtain a status and title – usually Doctor – and some form of self-regulation within a defined code of conduct. This is another privilege afforded to professions by society – that the best placed person to define how a veterinarian should behave is another veterinarian. The concept of veterinary professionalism is therefore important to both veterinarians and society. If the profession itself does not understand professionalism, then this social contract will be at risk, and likely the welfare of animals more generally. Professionalism should therefore be an ongoing discussion for the veterinary profession, and a key topic within veterinary education for both students and veterinarians (Mossop 2012a).

Tannenbaum (1995) describes veterinary professionalism as “five pillars,” extracted from the AVMA Veterinarian’s Oath (AVMA n.d.c). These are further explained as the foundations of professionalism in which veterinarians can take pride: scientific knowledge, attention to ethics, benefit to society, protection of animal health, and engagement in self-improvement. Mossop (2012b) describes a definition with a central component of balancing responsibilities – to animals, clients, employers, and society –which has many similarities with the core tenet of veterinary ethical dilemmas (Table 6.1). How veterinarians navigate these dilemmas is dependent on their ability to appropriately balance these responsibilities, with the resulting outcomes demonstrating their professionalism (see Case Study 6.1).