BUSINESS OF PRACTICE: STRENGTHENING THE FOUNDATION OF YOUR PRACTICE


care for working equids in third-world countries are another example where the principle of justice is applied in veterinary medicine.


Case Examples


The Black-and-White At the 2019 AAEP ethics session, a case was dis- cussed where a trainer in a large barn requested that a Dr. X, a young veterinarian newly employed by a large practice, dispense antibiotics to a new horse with a nasal discharge that had never been seen by the veterinarian or the practice. The trainer, a long-term client and large source of in- come to the practice, claimed that Dr. Y, the practice owner, “does this all the time,” and was resistant to Dr. X’s request to perform an examination on the patient. Dr. X felt torn between pleasing the trainer and meeting the expectations of her new boss, and insisting on performing the examination before dispensing the requested medication. The appropriate course of action in this case is


clearly supported simply by adhering to the AVMA’s Principles of Veterinary Medical Ethics, which clearly states, “A veterinarian shall provide compe- tent veterinary medical clinical care under the terms of a veterinarian-client-patient relationship (VCPR).”3 Particularly in light of current concerns regarding antibiotic stewardship, Dr. X would be making the most ethical decision by refusing to dis- pense the medications. One would hope that Dr. Y would support this decision.


The Gray


Case #1. A mid-level junior hunter presents with an acute right front lameness 2 weeks prior to an important competition. The horse flexes off with distal flexion of the limb, and the trainer requests that Dr. X perform a coffin-joint injection in an effort to restore the horse to soundness prior to the com- petition. The trainer at this large competition barn typically makes all of the medical decisions on be- half of the horse owners. Dr. X agrees that a coffin- joint injection will most likely help relieve symptoms, but has concerns that there could be a soft-tissue injury in the foot underlying the lame- ness. Dr. X recommends radiographs and possibly magnetic resonance imaging (MRI) to rule-out a soft-tissue injury prior to providing treatment. The trainer refuses further diagnostics. As outlined previously, under the principle of au- tonomy, the first question in this case should be who is the appropriate surrogate, and are the decisions being made in the best interest of the horse? If the owner of the horse were made aware of the potential risks of treating the horse and proceeding to the competition, would they choose to take the diagnos- tic steps recommended by the veterinarian? The veterinarian could address this question by speak- ing directly to the owner of the horse regarding


exam findings and recommendations rather than relying on communication with the trainer. When balancing the principles of beneficence and nonmaleficence, does the benefit of treating the joint, relieving pain, and allowing the horse to go to the show outweigh the risk that a career-ending injury could result if an underlying soft-tissue injury is present but unidentified? If the veterinarian de- termines that the risk of a more serious injury is significant, this would help justify a decision to re- fuse treatment without the benefit of further diagnostics. Finally, under the principle of justice, if this horse


were a young Grand Prix jumper with potential for international success instead of an older junior hunter, would the decision change? The veterinar- ian should take care to offer the same level of care for every horse.


Case #2. An older amateur dressage horse has had 3 colic episodes during the past month. All have been uncomplicated and resolved with a single dose of flunixin meglumine administered by the trainer, who communicated with the veterinarian over the phone. After the third episode, the trainer requests that the veterinarian prescribe an omeprazole/rani- tidine powder from a compounding pharmacy that the trainer believes he has had good luck with in “ulcery horses.” The veterinarian suggests that gastroscopy would be the best next step in order to make a definitive diagnosis, and that treatment rec- ommendations would depend on the results. Fur- thermore, the veterinarian informs the trainer that compounded omeprazole/ranitidine products are not reliably effective for treating ulcers. The trainer refuses the gastroscopy and persists in demanding the prescription. Once again, the first question in this case is whether the trainer is the appropriate surrogate decision maker for this horse. If informed about the value of gastroscopy for making a diagnosis and distinguishing between squamous and glandular ul- cers for the purposes of determining the best course of treatment, the owner of the horse might make a different decision. In addition, the owner, who will be financially responsible for the medications, should have the option of choosing whether to treat the horse with an effective medication that may be more expensive in place of the unreliable product requested by the trainer. The veterinarian should communicate directly with the owner rather than relying on the decisions of the trainer. What happens if the owner is involved in the decision-making process and aligns with the train- er’s request for compounded omeprazole/ranitidine without gastroscopy? Adherence to the principle of nonmaleficence would guide the veterinarian to re- fuse this prescription request, as treating with an ineffective medication could cause harm to the horse. This should outweigh the benefit of making the trainer and owner happy.


AAEP PROCEEDINGS  Vol. 66  2020 183


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