Google Maps and Moral Authority

At a recent conference held for the leadership of state veterinary medical associations, I had the opportunity to listen to the sobering economic statistics that veterinary medicine faces. These are not, by the way, altogether new or shocking (I’ve listened to them and read them well before the average new graduate entered the profession with the 2.7:1 debt to income ratio of the Class of 2014), and my profession always seems to endure. When care for the equine-based transportation infrastructure was supplanted by Fords and Chryslers a century ago, veterinarians began a focus on pets that now dominates the profession. So we contend today in practice with few patients named “Trigger” and more named “Toonces,” a paradigm shift of the first order, and, increasingly, with our medical expertise supplanted by the opinions of “Dr. Google.” It is a reminder that, whatever the intensity of the human-animal bond, much of our profession is supported exclusively by the discretionary income of others. We’re not unique among professions who consider the practice of their craft a fragile thing indeed. The palpable angst of the many physicians who blog in this site, those who face challenges in the human medical profession far more revolutionary than evolutionary, sometimes seem to blunt the big professional worries faced in my field.

But common to all of us is a sensed need to practice defensively. No one wants to offer low-hanging fruit to the trial lawyers, or to spend depressing amounts of time dealing with liability cases. We all document things assiduously. When the dust settles in a case, I may ultimately look like an idiot, but it sure better not be because of a failure to accurately chronicle what I was saying or thinking.

But now, according to a bright veterinarian who is a marketing guru and speaker (and, curiously, about whom I say all those things without sarcasm and with notable reverence), we have new fears. In a competitive marketplace for services, we need to stand out; we need to offer something that others do not. Any medical professional knows that already seems to be stamped on our DNA—we got to medical or dental or veterinary or whatever school because we were driven to be the best, to stand out, and we have the emotional scars and empty Prilosec bottles to prove it. It’s what makes us all, not just DVMs, think, as American Veterinary Medical Association (AVMA) Executive Vice President Ron Dehaven recently stated, that “ninety-nine percent of veterinarians think they communicate better than their peers.” We crave excellence in what we do, and how we communicate it, and have reasonable expectations that the work we do and the hours we sacrifice will make us just a bit different than our peers. We will offer that optimal “experience” that the gurus say we must.

So often the way we stand out has nothing to do with our medical or surgical competence, but has everything to do with how we are perceived in the public. Dr. Google, and his cousin, Professor Yelp, and what seem like a host of other sites can give us star ratings that appear whenever someone in the public just seeks our phone number online and is automatically shown a “Google Map” of our location, complete with our reviews. These can build up our professional egos, or crush our spirits. Chillingly, statistics say that 69 percent of the population would place as much stock in an online review of a medical professional as they would from the personal recommendation of a friend. We have become, as Tristam Englehardt, Jr., has commented, a society of “moral strangers.” The online opinions of a disgruntled former employee or the supportive golfing buddy of a doctor, neither of whom has to particularly identify as such, are granted the same authority for help in making significant and important and often difficult medical choices as a trusted friend. How awful.

I’ve written of the consequences of online bullying of a veterinary colleague before, bullying that seemed to have contributed to her suicide. Medical professionals have long had to worry about what happens if the outcome of a case is not optimal. Now they (we) must monitor the Internet as sentinels waiting for the poor rating from a client or patient we may have inadvertently offended, from any number of rating sites. I say this as someone whose practice has great online reviews; hooray for me. But popularity, and especially online popularity, is ephemeral. Does this change how we practice? Does it change how we share the truth or protect our staff or other patients from toxic people? Does it mean that standard medical ethics are replaced by the business model of “the customer is always right”? How do we even try to change the cultural authority of anonymous (or nearly so) online reviews? I don’t like how it may impact the way I now practice, but I must accept its presence and deal with its ramifications. For those who face remarkable burdens to practice ethically and honestly within their professions, it offers one more sobering burden to doing just that.

Why Dr. Kevorkian Was No Hero…and I Often Am

Admittedly that title is provocative. In a sense, both the late Dr. Jack Kevorkian and I could be considered to be in the business of euthanasia (though I hope I will someday be remembered for far more), but the species of our patients differs. And that, as they say, makes all the difference in the world.

A few weeks ago, I reflected upon how euthanasia of my animal patients offers a glimpse into the debate over human euthanasia, and what trends may be portended by this ethically-accepted practice for animals if starts to become more widely-accepted when applied to humans. But why the distinction? Why do we look at this difficult but necessary part of a veterinarian’s work as a genuinely humane way to end animal pain and suffering but have such qualms about applying it to people? Perhaps it could be found in Leon Kass’s “moral wisdom of repugnance” or good old natural law? A few of my thoughts.

First, even the most strident of animal rights advocates could find that the technological and logical capabilities of human beings compel them to exert some superiority over non-human animals, if only to relieve pain when we see it. If animals have rights, others (specifically humans, who have the wherewithal to act upon them) have responsibilities to those animals. Even those like me, who find little practical use in using the language of rights for animals, can recognize the awesome powers human beings have for good and evil over the natural world, and thereby derive a responsibility to tend to the pain of those animals that cannot provide for themselves. Intellectually we have a hard time believing that we can legally take the lives of healthy animals for food or clothing (even if vegetarians dislike its practice) and yet have no authority to euthanize the gravely ill and dying. While the acceptable criteria for animal euthanasia may well differ (some veterinarians will not euthanize pets that have behavioral problems but are otherwise healthy, for example, whereas others will do so if a pet owner is just “tired of” their pet—that’s a subject for another time), it is well-respected as part of the veterinarian’s principal duty to “relieve animal suffering” as our oath states, and appears well within the ethical bounds of being a good and moral person. I read a piece by another veterinarian today that felt like our oath should well be extended to state “relief of animal AND HUMAN suffering,” as the process of slow pet death can be so poisonous to the human family enduring it. There is a certain restoration of wholeness that comes from the removal of that pain and perceived suffering in a creature that cannot understand it nor benefit from it (see my comments below). When people are given the freedom to address their pet’s AND their family’s quality of life issues, the relief is palpable. Though not ultimately my decision, I can ethically apply the “best interests” standard to both my patients and the human family and recommend euthanasia based on all applicable factors. For a physician to apply those same standards would be alarming.

Second, and obviously, I am not a “people doctor.” The medicine certainly overlaps substantially, but I have heard no one who realistically wishes to merge the professions. I’ve mentioned before that the Hippocratic Oath is primarily focused on healing disease, not relieving suffering, and euthanasia directly violates that. It is a primary reason (though not the only one) that the Oath is under such assault now. Whether we look at the Judeo-Christian view of anthropology as humanity made in the image of God or the secular idea that our species is distinguished by higher capacities than other species, there is an inarguable “otherness” to human beings. We have courts to help ensure justice, but certainly do not expect even brainy animals like dolphins and chimpanzees to do the same. Our fearsome capabilities to exert justice on one another limit, in civilized society at least, the role for taking the lives of other human beings to the domain of the state. As a veterinarian, I don’t need the courts to help me decide if the patient’s “time” has come, because I am acting entirely within ethical bounds and my own professional oath. For a physician, charged with doing all she can to heal disease in a patient, to usurp the role that legitimately belongs to the government and work to end a life is a horror, regardless of whether or not it is carried out in the name of compassion.

Third, the “otherness” of humans carries into the dying process itself. While facing the approach of death can, perhaps counter-intuitively, be a time of growth and transformation for human beings, a time to heal relationships and face eternity, there is nothing to suggest that such things happen in animals. I can find no redemptive purpose in prolongation of life in a moribund pet for the animal itself, but have observed that very thing in the death of a relative of mine, albeit a rather distant relative and as viewed via Facebook, as he very slowly died from cancer. His bad days were bad indeed, but his good days offered him and his family great joy as they treasured the sunsets and the breezes, enjoying the few days left on this Earth and gathering in what it meant for life after death. The privilege of dying with his family surrounding him, to themselves be able to impute his brave submission to a death that they might someday face, would have disappeared had a physician helped to sacrifice his life on an altar of compassion. That’s part of why our oaths are different, and why I can be a hero and why Dr. Kevorkian was decidedly not, even as we ostensibly carry out the same task.

Animal Rights, Part I

I find it rather curious that in my line of work, as a veterinarian in small-animal clinical practice, I have very few conversations that tackle the issue of the rights of my animal patients. Maybe it’s because much of the legal landscape dictates the relationship we have with pets: I am still my dog’s “owner.” Harm that comes to a pet can lead to damages based entirely on the “replacement value” of the pet, not due to pain and suffering, or other subjective factors. Property rights, not moral rights, are where the law speaks.
As I have tried to draw my own conclusions on what rights, if any, animals may have, I largely read books with which I disagree, much to my dismay. Chief among these, of course, are the writings of Peter Singer. His notion of “speciesism,” a pejorative term that equates differentiation of value between humans and non-human animals (heretofore I’ll just call them “animals”) to be a great moral evil akin to racism and sexism, would seem to many to be a crackpot theory from an irrelevant, ivory tower philosophy professor. But the utilitarian idea espoused in Singer’s landmark Animal Liberation that equates the level of moral consideration of an individual, human or animal to be commensurate with the level of pain the creature may feel is probably more accepted in Western society than many of us realize. An entire branch of sociological study is dedicated to the “human-animal bond.” That bond is significant, and often a very positive force for human mental health and animal welfare. But we may have a greater emotional connection with a beloved pet than a dying relative, and unwittingly afford them moral status based on this emotional bond. More troubling, Singer’s radicalism is (surprisingly) fast becoming mainstream as the inherent dignity of human beings is undermined by ethical relativism and limitless personal autonomy.
But, as with many things, the reflexive response is unsatisfying as well. Christians who recoil at the subjugation of human dignity at the altar of animal liberation fail to understand our relationship to the animals God has created (and, indeed, all of creation) by misunderstanding Scripture. Much abuse can be heaped upon the Genesis 1:28 “dominion” mandate. In their view, the moral status of animals is utilitarian, but not Peter Singer’s utilitarianism. Animals were placed here for us, and we should enjoy what they provide for us without much concern for them beyond that.
But that, too, fails to understand the message of “dominion.” We are given power over animals, but that is fraught with responsibility as stewards of creatures that God takes very seriously. Some authors, prominent among them Robert Wennberg, go to lengths to find rights for animals in the Bible, particularly the right not to be eaten as human food. Ultimately, they struggle to find strong scriptural support, rely on extrabiblical sources, and don’t address in a practical way what “dominion” means .
I’ve become convinced that an effective view toward animal rights (one that really holds water) is based on a stewardship ethic that can only be found in Christian thought as put forth in Scripture. This will take some unpacking, and I will attempt to do that over a few blogs.

On Oaths…

There is a joke told among veterinarians that physicians are essentially veterinarians that have limited their practice to a single species. It is true that great similarities exist between humans and animals physiologically, and much medicine overlaps. But there’s a big difference between the ethical practice of veterinary and human medicine. The Veterinarian’s Oath diverges from the Hippocratic Oath in its focus. Physicians are charged within their oath to a primary emphasis on healing and curing disease, the relief of suffering assumed secondary. Veterinarians, instead, are foundationally called to “protect animal health” and relieve suffering through their oath. These are important distinctions.
Nigel Cameron has chronicled the migration that human medicine, with its growing emphasis on the relief of suffering, has made toward the veterinary model. In The New Medicine: Life and Death after Hippocrates, he laments this change, finding the drift to be a source of double-minded tension which pits healing and relief of suffering against each other. Veterinarians must deal with some of this tension, where the cure for a disease process cannot create undue pain and cause substantial detriment to the quality of an animal’s life. For example, some of the stronger chemotherapy drugs, from which human patients may be willing to endure the more difficult side-effects (at a great loss of quality of life, at least temporarily) are not reasonable options for dogs or cats. The default position in veterinary medicine is avoidance of suffering. Additionally, the protection of animal health can entail taking one life for the betterment of another, an accepted fact within a profession that has multiple obligations and must make decisions from among animals and between the “non-equals” of animals and humans. Euthanasia in the face of pain or suffering is entirely consistent with the stated aims of the Veterinarian’s Oath. It is entirely inconsistent with the Hippocrtatic Oath and centuries of tradition in human medicine.
Some eschew the Hippocratic tradition in medicine as they favor an ethic that skews toward radical patient autonomy and perverse avoidance of anything that would be considered a burden or could negatively impact the perception of dignity, all in the name of compassion. Ironically, as some of human medicine migrates toward a veterinary model, veterinarians may be heading the other way. As advancements in drugs and technology intersect a stronger human-animal bond, treatments that would be burdensome to humans are increasingly used in companion animals. Some veterinarians can fall headlong into a vitalism that seeks to prolong animal life at any cost. We may find that physicians are becoming more like veterinarians just as veterinarians seem to become more like physicians, with both groups violating the underlying premises of their respective oaths.
But humans are different from animals. We must understand personhood ontologically, and the distinctions in moral status between humans and animals, to recognize the variation between the two oaths. With these blurred (or maybe even reversed in some cases) the risks to the integrity of human dignity, and the Hippocratic tradition, become great indeed.