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Ethics, Morals and Vets: Why Does Conflict Affect Us?

Lisa Moses, VMD, DACVIM, CVMA
painmedicine@angell.org
angell.org/painmedicine
617-541-5140

If you’ve attended a veterinary conference or read a veterinary journal in the last few years you’ve seen the alarming statistics and warnings about a crisis in veterinarians’ well-being and emotional health.  One trigger for this attention came in 2014, when the U.S. Center for Disease Control and Prevention published a survey of over 10,000 veterinarians.1,2 The CDC reported that among the veterinarians surveyed, 1 in 6 had contemplated suicide and 1 in 10 experienced serious psychological distress in the course of their work. Of course, most of us didn’t need published findings to notice that discussions of burn out, compassion fatigue, professional attrition and difficult client interactions commonly filled the space of our conversations with colleagues. In the course of my clinical veterinary practice, I saw a change happening in how my peers (and I) handled difficulties encountered on a daily basis and changes in what those daily dilemmas were.

Around 2005, my concerns about the impact of those everyday dilemmas in veterinary practice prompted investigation of the phenomena of compassion fatigue. “Compassion fatigue” is an unfortunate misnomer; loss or fatigue of the capacity to have compassion in work isn’t really the problem. In fact, most veterinarians with compassion fatigue have trouble limiting how much or how hard they work. It’s better defined as exhaustion of emotional resources needed to cope with the realities of the sad, frustrating, and difficult situations encountered during caregiving to people, animals or both. Professionals with compassion fatigue rarely lose compassion for those they are helping. Instead, personal relationships and compassion for one’s self is usually what is fatigued or lost.

Compassion fatigue was first identified and labeled as such in professionals providing care to Vietnam War veterans.3 Prior to this, mental health researchers recognized that professionals providing care to Holocaust survivors and victims of natural disasters exhibited some of the same signs of trauma as those they were helping. Because of this, compassion fatigue is also called “vicarious trauma” or secondary PTSD.4 Interestingly, Dr. Charles Figley, the psychologist who coined the name almost immediately recognized that compassion fatigue affects animal care professionals and included them in published work documenting and defining the problem early in the history of the field.5,6 For those of you reading this and thinking something like “I don’t work in situations anything like the horrors of a natural disaster,” psychologists figured out a long time ago that the cumulative effects of frequent smaller scale events that cause either conscious or subconscious emotional impact also cause compassion fatigue. These events, also called “critical incidents” in psychology parlance, can involve death, difficult discussions, working with grieving clients, etc. Veterinarians experience critical incidents about five times more often than physicians, according to one widely quoted study.6

The end results of my research about compassion fatigue (and the workshops with hundreds of veterinary professionals who felt like this concept resonated for them) explained a lot of what I saw happening in our profession. But, over time, I recognized that in all the discussions about how compassion fatigue impacts us, we weren’t really looking for root causes of why it happens in the first place. What about these critical incidents makes them so hard? I also realized that lots of veterinarians don’t have compassion fatigue, but still really struggle with difficult situations in everyday practice. In my own practice experience both in the Emergency and Critical Care Service and in my current Pain and Palliative Care practice, I recognized that we had a lot of discussions about cases where it didn’t seem like there was a good or right option in how to proceed, or we disagreed with choices that clients made about veterinary care. Gradually, it dawned on me that what was (mostly) missing from all the research, discussions and well-meant suggestions for making professional life better was a potential source of all this angst: moral distress.

Moral distress may be unfamiliar to you in name, but you probably know it when you feel it. The concept was defined in 1984 by Andrew Jameton about the psychological distress and emotional impact that nurses feel when they know the right thing to do, but institutional constraints or other external factors make it nearly impossible to do so.7 Since the 1980s a vast field of scholarship and literature has blossomed around moral distress in all kinds of professions. There is intense debate in the scholarly worlds of bioethics about what the definition of moral distress should include. For example: is it moral distress when you are uncertain of what the right thing to do is or only when you know what’s right but are prevented from doing it? In veterinary medicine, as I discovered upon investigating further, we hadn’t even documented that moral distress exists, so questions of limiting the scope are in our future.

I have to confess that it seemed pretty silly to me to question whether veterinarians experienced moral distress. As my mentor, Dr. Mildred Solomon, said on the first day of my formal bioethics training “…most clinicians turn to bioethics when they feel morally troubled by aspects of their work…” I recognized that impulse in myself and assumed that I was unlikely to be alone in this. During my training, Dr. Solomon taught me about the ground breaking research she undertook in the late 1980s and early 1990s. In the wake of expanding social and legal debate about life-sustaining technology and patients’ rights, she was the first researcher to ask ICU physicians and nurses whether they ever felt like the medical care they delivered to patients was “the wrong thing to do” and if so, why did they do it.8 That very question was one that I rarely heard uttered in veterinary hospitals, but I knew that my colleagues and I thought a lot about. I was urged to start my research by documenting the “existence” of moral distress in veterinary medicine and then turn my attention to what prompted my training in the first place: the question of futile or non-beneficial care in veterinary medicine.

Years down the road, I published “Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians” along with colleagues from the world of public health research, psychiatry, and bioethics.9 We specifically published our findings in an open access format so they would reach more veterinarians (visit tinyurl.com/EthicalConflict for a direct link). We surveyed almost 900 veterinarians in North America and found that a majority of respondents reported feeling conflict over what care is appropriate to provide. Over 70% of respondents felt that the obstacles that prevented them from providing appropriate care caused them or their staff moderate to severe distress. Seventy‐nine percent of participants report being asked to provide care that they consider futile. More than 70% of participants reported no training in conflict resolution or self‐care.

We concluded that veterinarians reported widespread ethical conflict and moral distress across many practice types and demographics. Most veterinarians have little to no training on how to decrease the impact of these problems. The findings weren’t surprising to us, but we actually expected even higher levels of moral distress. We suspect the reason for this is that although it was clear that ethical conflict and resulting moral distress is common and important, they aren’t widely recognized as such or self-labeled by veterinarians. We proposed a series of potential solutions to mitigate moral distress in our community at all levels: profession-wide, institutional, and individual. Since well‐researched and effective tools are used to decrease moral distress in human healthcare, some of these could be/are being adapted to ameliorate this problem in our profession as well.

My hope in undertaking this research, and the subsequent work I’m doing, is that it will help our profession understand how significant moral distress is, even if it seems scary to acknowledge how common the ethical conflicts that produces it are. I know that to many of us, discussing ethical dilemmas seems like it would open a Pandora’s Box of emotions and add to an already difficult work day. My answer to that is that we know moral distress has an insidious cumulative effect even if you don’t feel it at the time or you push it aside. That’s why I’m convinced it plays a big role in all the statistics about veterinarians’ mental health.

This is not ivory-tower stuff; we can utilize existing and create new practical solutions that don’t place all the burden on individuals to fix this problem themselves. One thing that was clear in the research: veterinarians rely heavily on each other to navigate ethical dilemmas and counteract moral distress. Our relationships with each other are a great source of strength we can build upon.

Thanks to all of you who have already participated in my research; I’m really grateful to your help and support.

References:

  1. Anon. Veterinarians and Mental Health: CDC Results and Resources. AVMAWork Blog 2015. Available at: http://atwork.avma.org/2015/02/12/veterinarians-and-mental-health-cdc-results-and-resources/. Accessed December 26, 2017.
  2. Anon. Notes from the Field: Prevalence of Risk Factors for Suicide Among Veterinarians — United States, 2014. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6405a6.htm?s_cid=mm6405a6_w. Accessed December 26, 2017.
  3. Cohen SP. Compassion Fatigue and the Veterinary Health Team. Vet Clin North Am Small Anim Pract 2007;37:123–134.
  4. Figley C. Compassion fatigue as secondary traumatic stress disorder: An overview. Compassion Fatigue 1995;1.
  5. Figley CR, Roop RG. Compassion fatigue in the animal-care community. Washington, D.C: Humane Society Press; 2006.
  6. Mitchener KL, Ogilvie GK. Understanding Compassion Fatigue: Keys for the Caring Veterinary Healthcare Team. J Am Anim Hosp Assoc 2002;38:307–310.
  7. Jameton A. What Moral Distress in Nursing History Could Suggest about the Future of Health Care. AMA J Ethics 2017;19:617.
  8. Solomon MZ, O’Donnell L, Jennings B, et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health 1993;83:14–23.
  9. Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med 0. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/jvim.15315. Accessed October 23, 2018.
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