Understanding and Coping with Moral Distress in Veterinary Medicine
Veterinary professionals often choose their careers because they are interested in promoting the wellbeing of animals. In previous MentorVet articles, we’ve discussed burnout in veterinary medicine and ways to recognize and address burnout in the workplace. In today’s article, we’ll discuss recognizing and addressing another contributor to burnout: moral distress in veterinary medicine.
What is moral distress?
The concept of moral distress was first introduced in 1984 by Andrew Jameton, Ph.D., in his book, Nursing Practice: The Ethical Issues.[i] He defined moral distress as “the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right.”(p617)
In other words, we experience moral distress when we find ourselves in a situation where we are asked or expected to make an ethically challenging choice that is in conflict with our values.
Since 1984, the concept of moral distress has been applied to other fields and healthcare professions, including veterinary medicine. Researchers in veterinary medicine in Australia, the U.S., U.K., and Europe have documented moral distress in both large and small animal practices.
What causes moral distress for veterinarians?
There are situations that may be morally distressing to veterinarians and their staff. Some of these examples include
Providing care given limited client finances
Animal abuse cases
Cosmetic procedures (tail docking and ear cropping)
Convenience procedures (declawing cats or devocalization of dogs)
Performing euthanasia when the veterinarian does not agree with the decision[ii], [iii], [iv], [v], [vi]
How Moral Distress Impacts the Veterinary Team
When veterinarians are asked to perform unnecessary procedures, including convenience euthanasia, or a client refuses to appropriately treat or euthanize a suffering animal, moral distress can arise. Moses and colleagues sought to document “the existence of unlabeled ethical conflict in North American veterinary clinical medicine” and its frequency.[vii](p2118)
They conducted an online survey evaluating moral distress among 889 North American veterinarians and its impact on their careers.
The results showed frequent exposure to ethical dilemmas with around 4 out of 5 veterinarians experiencing conflict with pet owners about how to proceed with a case. When asked about distress levels for a case in which they were not able to do the right thing for a patient, 72% of veterinarians reported their staff experienced moderate to severe stress and 77% of veterinarians reported moderate to severe stress for themselves. When asked about requests for inappropriate euthanasia and how much distress it caused, 63% of respondents reported moderate to severe stress.
When asked about their veterinary training and how many hours of training in self-care they received, more than 75% of the survey respondents reported no training in self-care.
Moses and colleagues found moral distress commonplace in the veterinary profession and suggested it may contribute to mental health problems, burnout, and compassion fatigue. In addition to recommending individual self-care changes to help mitigate moral distress, they also made the following recommendations for the veterinary clinic practice:
Changes in practice culture
Change in other external factors that increase compassion fatigue and burnout
Standardizing guidelines for care
Training and support in managing distress
Building Client Relationships to Prevent Moral Distress in Veterinary Medicine
Morgan and McDonald[viii] offer strategies to help veterinarians and their staff prevent or manage ethical tensions using a four-step process that includes: information gathering; education and counseling; relationship building; and activation and partnership.
Before initiating the four-step process, Morgan and McDonald recommend the veterinarian and their staff first take an inventory of their own views of animal care and the expected roles of clients.
While this framework may not always be feasible, it still provides an opportunity for client education as well as a foundation for understanding how to build a relationship with a pet owner to understand their expectations around pet care.
Step 1: Information Gathering
Morgan and McDonald recommend veterinarians engage with the clients directly through a series of open-ended questions:
How they obtained their animal?
Why they obtained their animal?
Who is the primary caregiver of the animal?
How do they care for their animal?
What are their expectations of their animal?
What are their care expectations of the veterinarian?[viii]
Step 2: Education and Counseling
Morgan and McDonald also recommend veterinarians have a discussion with the pet owner about the responsibilities and obligations of the veterinarian in providing care. As part of this discussion veterinarians begin to establish boundaries around appropriate care, including euthanasia as well as educating the client on the responsibilities that are associated with pet ownership.
Step 3: Relationship Building
After the initial two steps are completed, both the veterinarian and the pet owner will have a better understanding of how the other views pet ownership and veterinary care. The next phase, relationship building, is equally important as it will evolve over time and continue to clarify each other’s role in the animal’s life. While there will be differences of opinion in the care recommended at times, each person will understand they both have the best interests of the animal.
Step 4: Activation and Partnership
Morgan and McDonald’s fourth step, activation and partnership is used to resolve difficult choices such as healthy animal euthanasia. If the veterinarian has established a relationship with the owner, it makes it easier to explain their objection that includes the veterinarian’s values and beliefs about their responsibilities for animals. The partnership will also make a conversation about finding an alternative to euthanasia easier with a relationship that is based upon mutual respect.
The Moral Distress Map
Dudzinski proposes using a moral distress map to navigate “moral distress from emotional source to corrective actions.”[ix] (p1) While originally designed for human medicine practitioners, Dudzinski’s moral distress map can be utilized in veterinary medicine.
Dudzinski’s model acknowledges patient care is stressful even under normal circumstances and by utilizing a moral distress map, the practitioner can help differentiate emotions that are stressful from moral distress.
The moral distress map can be used in a group context or in a private meeting with either an active or inactive case that is causing conflict. Through a series of questions, the practitioner can identify the emotions, constraints, and conflicting responsibilities associated with the case.
As those questions are answered, potential corrective actions are posed until final action is taken to resolve the moral distress. According to Dudzinski (2016) consider the following questions:
1. What is the conflict?
Consider, what is the core problem here. What about this situation is bothering you or violating your personally held moral beliefs?
2. What emotions are you experiencing from the conflict?
It is important to identify what emotions you are experiencing so that you can better understand your moral distress. Name your emotions. For example, are you feeling fear, anxiety, or frustration?
3. What precisely is the source of the moral distress?
Determining the source of moral distress will help in determining the next steps. For example, did the moral distress due because of differences in values or a pet owner not having enough money to pay for the recommended treatment?
4. Name the internal and external constraints to taking action.
Consider the barriers that prevent you from taking the action that you wish. An example of internal constraints is feeling powerless. An example of external constraints are institutional constraints, such as a client being unable to pay for the recommended care for their pet.
5. What obligations do you have that conflict with your responsibility?
Are there any other responsibilities you should consider in this situation?
6. What actions could you take?
This step involved considering what actions you will take to improve the outcomes for the patient in this case. Consider a wide range of options from most optimal to least optimal. Attempt to find the best case scenario given the context. In addition, consider how you will cope with your own moral distress. Consider reaching out to a trusted veterinary mentor for support or complete the veterinary wellbeing debrief.
7. What action will you take?
In the final step, you will consider how you will collaborate with the pet owner to find the appropriate course of action. The final decision may not be one that would be the most optimal or the decision that you would prefer, so also ensure that you are taking actions to care for yourself.
8. Practicing Acceptance
Lastly, self-care is essential to addressing moral distress. Previous MentorVet articles have highlighted several ways to address self-care and are highlighted below:
Exercise regularly, such as walking for 20 minutes a day a few times a week
Eat a well-balanced meal that eliminates or reduces processed foods
Limit or eliminate alcohol, tobacco, caffeine, and CBD products
Establish a sleep routine
Reduce your stress
Make choices that reflect your goals
Build or maintain healthy relationships with family and friends
Avoid toxic or negative people
Maintain a healthy weight
Attend to any chronic medical conditions
Additional Resources
Professional
Moral distress is found in other healthcare professions and while there is a process to address it, there are no easy answers: resolution requires a deliberate approach. The following are links to several organizations specific to veterinary medicine that may provide some help.
American Veterinary Medical Association: Animal Health and Welfare
Animal Ethics Dilemma- An interactive learning tool that is free with a simple registration.
The Animal Welfare Science, Ethics and Law Veterinary Association (AWSELVA).
The Australian Veterinarians for Animal Welfare and Ethics Group
Personal
Professional Quality of Life tool. This online assessment is designed for those people working in healthcare professions, including veterinary medicine. The ProQOL measures both the negative and positive effects of working with those who have experienced traumatic stress. The ProQOL has sub-scales for compassion satisfaction, burnout, and compassion fatigue. It has proven to be a valid measure of compassion satisfaction and fatigue. The ProQOL website also has several resources that may be helpful: https://proqol.org/proqol-1
Conclusion
Healthcare delivery, which encompasses many functions is essentially about the diagnosis, treatment, and management of disease. Whether human medicine or veterinary medicine, it is stressful. Moral distress is not the same as stress and its definition was first introduced by the nursing profession as a result of nurses reporting problems with providing appropriate care to terminally ill patients The definition of moral distress has since been expanded to encompass other fields as well as other healthcare professions, including veterinary medicine.
A recent study by Moses and colleagues found moral distress to be more commonplace in veterinary medicine and a potential contributor to mental health problems, burnout, and compassion fatigue. Changes in the culture and business model of veterinary practice have been recommended as one way to address moral distress.
Morgan and McDonald recommend a prevention model that begins with a four-step process that establishes a relationship between the veterinarian and the pet owner, that helps the other understand what their responsibilities and expectations are regarding the pet’s care. Dudzinski’s proposed implementing a moral distress map that can also be utilized to differentiate between emotions that are stressful during patient care from moral distress.
References
[i] Jameton A. What moral distress in nursing history could suggest about the future of health care. AMA Journal of Ethics, 2017;19(6),617-628. https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-04/mhst1-1706.pdf
[ii] Bachelor CE, McKeegan, DE. Survey of the frequency and perceived stressfulness of ethical dilemmas encountered in UK veterinary practice. Veterinary Record. 2012;170,(19). doi:10.1136/vr.100262
[iii] Kondrup SV, Anhøj KP, Rødsgaard-Rosenbeck C, Lund TB, Nissen MH, Sandø, P. The veterinarian’s dilemma: A study of how Danish small animal practitioners handle financially limited clients. Veterinary Record. 2016:179(596). doi: 10.1136/vr.103725
[iv] Quain A. The gift: Ethically indicated euthanasia in companion animal practice. Veterinary Science. 2021;8(141). doi.org.10.3390/vetsci8080141.
[v] Rollin BE. Euthanasia, moral stress, and chronic illness in veterinary medicine. Veterinary Clinics: Small Animal Practice. 2011;41: 651-659. doi:10.1016/j.cvsm.2011.03.005.
[vi] Springer S, Sandø P, Lund TB, Grimm H. “Patients’ interest first, but…” -Austrian veterinarians’ attitudes to moral challenges in modern small animal practice. Animals. 2019;9(241). doi:10.3390/ani9050241.
[vii] Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: survey of North American veterinarians. Journal of Veterinary Internal Medicine. 2018;32:115-2122. doi.org/10.1111/jvim.15315
[viii] Morgan CA, McDonald M. Ethical Dilemmas in Veterinary Medicine. Veterinary Clinics of North America: Small Animal Practice. 2007;37(1): 165–179. doi.org/10.1016/J.CVSM.2006.09.008
[ix] Dudzinski DM. Navigating moral distress using the moral distress map. Journal of Medical Ethics. 2016;42(5):321–324. doi.org/10.1136/MEDETHICS-2015-103156