Family - Pet Bond = Profit
Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate, American College of Healthcare Executives
HAB = human animal bond = the interaction of people and animals in our society = profit center of the future.
A majority of veterinarians make their living because of the human-animal bond, but most veterinarians do not capitalize upon the potentials available. The client calls the veterinarian because they have a concern about the well being of their animal and want an expert to assist them during their stressful decision time; they want peace of mind. The basic premise which needs to be taken when the phone rings is that "the phone shopper wants a good veterinarian at an affordable value." A phone emergency wants to be told they have done the right thing by calling and should come into the practice. No client who calls want to be told to stay home.
The contemporary pet programs such as active pet selection assistance (AVMA), pets by prescription (Delta Society), Prescribe Pets Not Pills (VPI Skeeter Foundation), and behavior management (AAHA) promote the human-animal bond while supporting the healthcare reverence for life and quality of care programs. VetOne has started publicizing the family-pet-veterinary bond. The new Iowa State University Press text, Promoting the Human-Animal Bond in Veterinary Practice, released in May 2001, has 26 appendices of practical application programs. HAB information abounds, but practice commitments vary.
Definition of BIOETHICS: applied ethics to real-life, day-to-day problems of ethical decision making in health care delivery.
In the past, veterinary ethics have been values we used to describe the profession, but bioethics are the values we use personally in practice. Sometimes the veterinarian is the person who makes the bioethical decision. But more often, the decision is laid at the feet of the medical lay people we come into contact with -- family, clients, public officials, judges, humane societies, and others. There is seldom any clear bioethical solution. Rather, there needs to be an awareness of its existence within the veterinary practice environment.
Choosing A Therapy When Doctors Disagree
This situation presents a wide array of ethical issues. Whether or not the client should be informed of the nature and prognosis of the illness is certainly pertinent, but is hardly the most significant question in the bioethics at hand. Attention should be focused upon a cluster of three basic ethical questions raised in this case:
Who should make the ultimate decision when choices between alternate modes of therapy must be made is an obvious issue that must be faced in a multi-veterinarian practice.
When we start to evaluate a patient, then continue to make the treatment decisions (often based on economics in lieu of best care), how should the client be involved in selecting the alternatives?
The third, and perhaps the most fundamental issue, is who makes the decision when each of the alternatives (often conservative medicine versus exploratory surgery) is substantially correct?
The option to be chosen in each of the above three questions is not a medical decision based on scientific training, but rather, a professional value judgement.
The American Medical Association states that active euthanasia is illegal, but they only deal with one species of an animal. Exactly what are the fundamental measures of animal value and worth which require the veterinary bioethics to be evaluated?
A pedigree animal with a genetic defect, or maybe just not meeting the specifications of the American Kennel Club.
Killing an animal because a family is relocating to a home that cannot allow animals, or maybe the travel requirements are too extensive to continue economic support of the family animal(s).
The medical ethics of letting an animal die due to a disease syndrome versus accelerating the process and minimizing the family cost or anguish.
A problematic issue in euthanasia is who should bring up the options first. Is it a client concern or a medical concern?
The alternatives in euthanasia are not based in veterinary science. They are based in personal value systems and practice philosophies.
Animal Abuse Or Neglect
This issue is sad but raises no difficult questions of principle at all. If there is a violation of the Animal Welfare Act - Code of Federal Regulations (CFR), Title 9, Chapter 1, Subchapter A, there is neglect; if it was intentional, it is abuse. Presumably in these cases, the individual or the family who has support responsibilities for the animal(s) is deemed inappropriate to the animal's welfare. But the veterinary practice which makes the decision to elevate the issue to the authorities must face bioethical issues.
Is neglect due to a lower than expected family knowledge of basic animal care, or is the situation caused by an overt disregard for the animal's welfare?
Does the practice have the right to decide between referral and in-house counseling? If referring the case would cause a greater trauma to the family unit than individual counseling by the practice staff, is there a decision to be made?
Will this counseling or referral (or lack of it) cause a loss in income or trust for the practice within the community?
If the community laws or rules tend to promote certain action, or an uncertain or undesirable disciplinary behavior, should that affect the bioethical issues of this situation?
The Key Questions
It is often said that issues of bioethics fall into two categories: some concern procedures for decisions, others the substance for decisions. The distinction, while intuitive, is not easy to sustain. How do we know which values should be followed unless we know what values should to be sought?
In biomedical ethics, there are usually five basic decision-making agents that require consideration by the veterinary practice:
1. The hospital has arrived at a series of policy judgements over the life at the practice, often based on facilities, equipment, and staff limitations or capabilities.
2. The technicians and staff often prefer certain types of cases or admissions, and certain treatment modalities that allow them a comfort zone of operation.
3. The client may wish to be involved in, and not merely informed of, the decisions being made in the case. The values of the client may or may not match the values of the practice.
4. The patient has certain needs and the animal's welfare must be considered when extending any morbid state (the arguments concerning an animal's "rights" are certainly bioethical issues).
5. The veterinarian not only makes the policies of the hospital, but is also bound to interpret them on a case-by-case basis in light of state-of-the-art veterinary medical knowledge, as well as fiscal management concerns of the practice and client.
There is a traditional adage in medicine, that is, "First, do no harm." In the previous bioethical issues, some would feel that the solutions were clear and definitive, that ethical issues do not exist. The areas discussed are illustrative of veterinary medical situations where there is room for reasonable people to disagree. The reason for this article was to make the concept of ethics in biomedical decisions become a reality, to show that bioethics do apply to veterinary practices, and to offer the opinion that bioethics should be an element of the decision making process in quality health care delivery in the veterinary practice.
The Psychological Bond
The American Veterinary Medical Association developed and has available all the documents and aides needed for active pet selection assistance by veterinary practices, including some very well done color brochures. The Delta Society has developed the protocols for pets by prescription within the community and school environment. Either of these programs can develop new pet owners, clients who are already bonded to the practice since they selected their pet with the expert assistance of the veterinary professionals of that facility.
One of the hottest topics on the continuing education seminar circuit in recent years has been behavior management. The problem is proactive behavior management services are a staff function as much as a professional service, and the staff members seldom get to attend the seminars. Resources are available at almost no cost to the veterinary healthcare facility. There are multiple human/companion animal bond (H/CAB) programs available from non-profit organizations. The international clearing house for interdisciplinary HAB groups and programs is the Delta Society (800-869-6898). The American Veterinary Medical Association (708/925-8070) has the pet placement handouts and information as well as hosting the American Association of Human Animal Bond Veterinarians (AAHABV).
The best companion animal practices realize they "sell" only one thing: peace of mind for the client. They concurrently are a patient advocate and tell the client what is needed for the best of the pet, either of wellness or professional diagnostic concerns. The client is allowed to select from the list, They are allowed to "buy" what they think they can afford. Lesser cost alternatives are not offered UNTIL the client asks for lesser cost alternatives, but the "options" must be kept in perspective of lesser diagnostics, lesser response rates, or lesser probability of desired healthcare effects. Clients prefer to "buy" and hate being "sold" in most every occurrence, and a smart practice leader trains and rehearses the practice team to "sell" ONLY peace of mind, freedom from fears, or psychological comfort while allowing the client to "buy" products and services to their heart's content.
Behavior management is one form of HAB practice service. Obedience training is not behavior management, it is most often handler and location specific. HAB behavior management is teaching and rewarding the pet an appropriate family behavior by positive reinforcement. Allowing the client to "buy" these services is a client privilege most practices do not yet offer. Behavior management programs are easily initiated for dogs using the Gentle Leader head collar. The 65-page head collar booklet provides the techniques needed for behavior management, but the "caring" practice offers their technician staff as trainers to help the client if they get stuck ($20 per appointment). This veterinary practice behavior management effort often leads to Puppy Clubs, Senior Clubs, and other client "social" programs, which add to the practice bonding (and concurrently increases the client annual return rates -- and practice liquidity). In some cases, the practice supports a Pet Partner Program (Delta Society), and gains from the community good will and human interest media stories.
Behavior management is a potential practice area for staff to excel. Most are client education programs best done by trained staff members (e.g., house training, feeding, etc.). In America, most animals lose their home and often their lives because of behavior problems. It is similar in other countries. The veterinary practice team which helps prevent this "disposable pet" syndrome not only keeps clients, but gains positive recognition in the community. Recognition for helping animals is a marketing benefit to the practice without having to advertise or market routine services or products.
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