Proceedings of VetFest 2020 Fawcett, A – Moral distress in veterinarians: why ethical challenges impact wellbeing.

Moral distress in veterinarians: why ethical challenges impact wellbeing

Anne Fawcett Sydney School of Veterinary Science

University of Sydney, NSW, 2006 anne.fawcett@sydney.edu.au

Supervisors: McGreevy, PD; Mullan, SM. What is an ethically challenging situation (ECS)? An ethically challenging situation (ECS) can be understood as a situation where we are required to manage competing choices, where there may be conflict between the interests of different stakeholders, and no easy way of prioritising one way forward over another. Other terms used to describe an ECS include dilemma, ethical dilemma, moral dilemma or moral conflict. How common are ethically challenging situations? Ethically challenging situations are encountered in veterinary practice settings frequently(Batchelor and McKeegan, 2012, Crane et al., 2015, Kipperman et al., 2018, Moses et al., 2018, Lehnus et al., 2019), with the majority of veterinarians experiencing an ethically challenging situation at least once per week(Batchelor and McKeegan, 2012, Kipperman et al., 2018, Lehnus et al., 2019). What is moral distress? Stress or distress arising from an ECS is known as moral stress or moral distress(Fawcett and Mullan, 2018). The terms moral stress and moral distress are often used interchangeably in veterinary ethics literature. It has been described as the “psychological disequilibrium experienced from being constrained from following the perceived correct moral path”(Arbe Montoya et al., 2019). The term moral stress was first used in the human nursing literature to describe a situation “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”(Jameton, 1984). It was later used to describe the type of stress experienced by animal health professionals who pursued their work because of their love for animals, but found themselves in participating in the humane killing of vast numbers of healthy animals in shelters(Rollin, 1986, Rollin, 2011). Moral distress has been defined as “the experience of psychological distress that results from engaging in, or failing to prevent, decisions or behaviours that transgress, or come to transgress, personally held moral or ethical beliefs”(Crane et al., 2015). Moral stress may lead to moral injury, which may be confused with burnout(Dean et al., 2019), and may lead to absenteeism and career attrition among animal care professionals. According to the founders of Moral Injury in Healthcare, moral injury occurs “when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first”(Dean et al., 2019). In addition, moral injury is the result of conflicting obligations to patient wellbeing and the health care system. Moral stress/distress/ and moral injury are stressors which can increase our vulnerability to compassion fatigue (Debbie Stoewen, personal comments, 2020) and can contribute to psychological morbidity/mortality.

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What are the types of ethically challenging situation encountered by veterinarians? According to surveys of ECS, types encountered by veterinarians included:

• Financial limitations restricting treatment options (Batchelor and McKeegan, 2012)(Kipperman et al., 2018)(Moses et al., 2018)(Lehnus et al., 2019)

• Client wishing to continue treatment despite poor animal quality of life/futile treatment (Batchelor and McKeegan, 2012)(Moses et al., 2018)(Lehnus et al., 2019) or acting against best interests of animal(Kipperman et al., 2018)

• Convenience/economic “euthanasia” or euthanasia for reasons vet did not agree with (Batchelor and McKeegan, 2012)(Kipperman et al., 2018)

• Balancing welfare/interests of animal against welfare of client (Crane et al., 2015)(Moses et al., 2018)

• Assisting other veterinarians who they believed were providing incompetent care(Crane et al., 2015)

• Euthanasia in general (Crane et al., 2015) • Suspected animal abuse (Crane et al., 2015) • Disagreement with clients or colleagues about appropriate treatment/management

of a case (Moses et al., 2018)(Lehnus et al., 2019) • Being asked to do something in their clinical practice that feels like the wrong thing

to do (Moses et al., 2018)(Lehnus et al., 2019) • Being asked to do things that are outside of your skill set for financial or other

reasons (Moses et al., 2018). • The decision to assist in treatment and breeding of animals with extreme traits

associated with health problems (Ryan et al., 2019). • Whether to use animals for blood transfusions or as sources of organs for

transplants, which animals to source these from and how to treat source animals (Ryan et al., 2019).

• Management of inappropriate or inadequate feeding of animals (Ryan et al., 2019).

This list is not comprehensive. The majority of respondents to these surveys were companion animal veterinarians working in the US, Australia or the UK. Covid-19 has presented some unique ethical challenges for veterinary team members. As part of my PhD I am running a survey on ethically challenging situations encountered by veterinarians, animal health technicians and veterinary nurses around the world. The survey is totally anonymous and takes 15-20 minutes to complete. To respond, please copy and paste the following link into your browser: https://redcap.sydney.edu.au/surveys/?s=KDFEFHCKX3 Why do we not always resolve ECS to our satisfaction? Reasons for people failing to resolve ethically challenging situations to their satisfaction, or in a way that aligns with their values, include but are not limited to:

• Failing to recognise we are not acting in accordance with our values (for example, not offering analgesia because of a perception that the client is unwilling or unable to pay)(Morgan, 2009);

• Lack of autonomy(Wallace and Buchanan, 2019); • Concerns about job security, fear of reprimand or ostracism, bullying in the

workplace(Parker and Evans, 2007, Gardner and Rasmussen, 2018); • Fear of alienating clients(Fawcett et al., 2018a); • A need to fit in; • Cognitive fatigue/cognitive overload(Timmons and Byrne, 2019);

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• Time constraints(Fawcett, 2019).

Another concern is, until recently, a lack of explicit discussion of ethics in veterinary curricula. Thus, in just eight years ago, 78% of veterinarians (UK) reported they did not have adequate training in veterinary ethics (Batchelor and McKeegan, 2012), while in the US in 2018, while 51% of veterinarians received ethics training, 23% disagreed that it prepared them to address ECS (38% were neutral and 39% felt training helped)(Kipperman et al., 2018). The same year, 71% of veterinarians reported no training with regard to “resolving differences of opinion about what is the best care for patients”(Moses et al., 2018). Interestingly, the ethical reasoning abilities of practicing veterinarians were found to be no better than those of the general public, and moral reasoning of veterinarians did not improve with years of experience(Batchelor et al., 2015).

The above factors, in combination with limited ethical reasoning ability, can lead to poor quality decisions, decision regret and rumination for those of us involved in or party to decision making; as well as poor animal welfare outcomes resulting from poor decisions(Batchelor et al., 2015).

How do we reduce moral distress and prevent moral injury?

While “self-care” has been recommended for veterinarians, it is important to recognise that self-care will not eliminate moral distress because it fails to address the initiating source of moral distress, and is unlikely to address job demands that can exacerbate moral distress(Mathieu and McLean, 2014, Mathieu, 2015).

According to Longstaff, moral injury can be reduced by:

• Developing a purpose/mission that transcends mere survival decisions are assessed in relation to that purpose

• Improving decision making to reduce decision regret/moral distress(Longstaff, 2020)

Therefore we need to:

1. Find out why team members are here and what keeps them here – this information can be used to develop a vision/mission. It is important to look for common ground.

2. Give ourselves and team members space to make complex decisions.

The more complex an issue, the more time is required to make a decision(Fawcett, 2019). While veterinary team members are often required to multi-task, ethically challenging situations usually demand our full attention and focus (the Holy-Grail in practice: monotasking).

We need time to identify all potential stakeholders, gather evidence (including but not limited to peer-reviewed literature, policies, legislation and specialist advice), and canvas a range of opinions and perspectives.

Ethical frameworks or approaches aid decision making by ensuring that ethically challenging situations are evaluated from a range of perspectives. Ethical frameworks utilised to aid in veterinary ethical decision making have been described elsewhere but include utilitarianism, deontology, the ethical matrix, principalism, virtue ethics(Mullan and Fawcett, 2017, Rollin, 2006) and David Fraser’s “practical” ethic for animals(Fraser, 2012, Fawcett et al., 2018b). In this session it is suggested that a combination of these tools is

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used, with more frameworks likely required to approach more complex or “higher stakes” ethical challenges.

Ethical frameworks aid decision making but cannot make decisions – the application of these varies with context and the values of decision makers. Such frameworks can be applied prospectively, in ethical rounds, or in ethical discussion within case rounds, and retrospectively, in “ethical morbidity and mortality rounds”.

3. Involve as many team members as possible.

Decisions made “without a necessary ethical deliberation and without the right involvement of all the team this could have a negative impact among the professionals”(Teixeira et al., 2014, Wensley et al., 2020). Both lack of autonomy, or too much personal responsibility may be detrimental(Wallace and Buchanan, 2019).

Autonomy “refers to decision latitude or skill discretion that reflects control over one’s own work and is an important resource in coping with job stress”(Wallace, 2017). It is a particularly scarce resource among female veterinarians and non-veterinary term members, who report less autonomy and are also less likely to be in a position of authority in the workplace compared to male veterinarians(Wallace and Buchanan, 2019). Respect for the autonomy of patients is considered a virtue of healthcare providers(Beauchamp and Childress, 2013).

While autonomy, responsibility and discretion may be linked to job satisfaction(Wallace and Buchanan, 2019), a lack of autonomy has been linked to burnout(Moir and Van den Brink, 2020). Autonomy can be promoted by fostering shared decision making in the face of ethical challenges.

Where to from here?

Ethical challenging situations are a common and potentially very serious workplace stressor for veterinary team members. They may also disclose animal welfare issues and it is therefore important that we a) recognise these and b) address them.

We need to determine what ethical challenges are experienced by veterinary team members – not just veterinarians.

We also need to move away from the concept of the veterinarian as the moral hero – a key decision maker who has the capacity to make the perfect decision. This does not reflect the reality of veterinarians, in the same way that the discussion about veterinary wellbeing needs to move away from situating sole responsibility of addressing wellbeing within the individual, towards considering systematic factors and how workplaces can impact and promote wellbeing.

We also need to develop ethics curricula based on the most common and stressful ethically challenging situations.

Ethical rounds and ethical M&Ms may help create a psychologically safe space for discussing contentious issues, and may improve ethical sensitivity and ethical reasoning within veterinary teams.

Resources – ethics • Everyday Ethics, In Practice • Veterinary Medical Ethics, Canadian Veterinary Journal • Animal Ethics Dilemma http://www.aedilemma.net/

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• Building a psychologically safe workplace: Amy Edmonson https://www.youtube.com/watch?v=LhoLuui9gX8

• ANZCVS Animal Welfare chapter https://www.anzcvs.org.au/chapters/animal+welfare+chapter

• Animal Welfare Science, Ethics and Law veterinary association https://www.awselva.org.uk/

• Society for Veterinary Medical Ethics https://www.svme.org/ • AVA Animal Welfare and Ethics Group https://www.ava.com.au/about-us/ava-

groups/animal-welfare-ethics/ Resources – personal [NB as moral distress is associated with burnout and compassion fatigue, these are some resources that may help]

• Self-assess your professional quality of life using the Professional Quality of Life Measure: https://www.proqol.org/

• Françoise Mathieu, TED talk: The Edge of Compassion https://www.youtube.com/watch?v=IcaUA6A37q8

• Action for Happiness calendars: https://www.actionforhappiness.org/calendars • Coping with Stress and Burnout as a Veterinarian by Dr Nadine Hamilton

https://www.australianacademicpress.com.au/books/details/319/Coping_with_Stress_and_Burnout_as_a_Veterinarian

• Mindfulness for wellbeing and peak performance (free MOOC via Monash University) https://www.futurelearn.com/courses/mindfulness-wellbeing-performance

• Centre for Mindful Self-Compassion https://centerformsc.org/learn-msc/# References ARBE MONTOYA, A. I., HAZEL, S., MATTHEW, S. M. & MCARTHUR, M. L. 2019. Moral distress in

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