On Technology, Bullying and Compassion Fatigue

Technology has been described variously in theological terms (a “qualified blessing” from a God who gives of grace creatively) and ethical terms (generally neutral of itself, with potential for good or bad outcomes, depending on how it’s used). Most medical professionals (at least those who cling to some moral and ethical footing in their view of such things) hold certain technologies in high regard, like therapeutic tools that allow their patients to live longer, healthier lives. Yet they struggle with those things that push the envelope, which may sacrifice the judicious for the temporal.

It’s not these ethical dilemmas of which I speak. Technology has the ability to be a tremendous force for democratization of everyday life. People have access to information that is unfiltered, and can express themselves with a freedom that goes beyond even the seeming anonymity of road rage. The past few weeks have shown me the challenge that this technology creates for those in medicine, both human and in my own veterinary medical professions.

I am entering an unlikeable phase in life where I will start to lose friends and contemporaries to cancer and heart disease and strokes. I attended the funeral of a friend that left this life sooner than many of us felt ready. We know the right theology, we face reality, but it still stings. One of our other friends, who has lost a parent in recent years, commented that, near the end, there seems a need for blame to be assigned. She had maintained vigils at her own mother’s side as she slipped away, and still felt herself recoiling from the sight of hospital beds and fluid pumps. She remembers how she almost hated the nurses and doctors that couldn’t fix her mother, and who seemed almost as baffled at the deterioration of their patient as she did. All she could see was her mother worsen with no apparent plan by her caregivers to turn things around. That anger, fully known to be irrational in hindsight, is no less real in her memories.

As a veterinarian, I also know of another very sad case, this time of a colleague in New York. Her story can be found here, but it is heart-wrenching to hear its specifics. Briefly, this doctor had done what many veterinarians before her have done, which is to avoid the personal and professional pain of what is called “economic euthanasia,” where a pet is taken in by the doctor after the individual bringing it to the office expresses a financial inability (or unwillingness) to have treatment performed that would save its life. Dr. Shirley Sara Koshi successfully nursed a cat back to health, on her own time and at her own expense, after it had been turned over to her in such fashion by an individual who brought various cats to Dr. Koshi after they were removed from a New York City park. After its recovery, the individual attempted to reclaim the cat and was rebuffed unless and until the medical expenses were paid. Legally, the cat had been relinquished to Dr. Koshi and there were no ethical obligations (and, indeed, should have generated ethical objections) to return the cat to the individual who brought it to her in the first place.

Technology and emotion can supplant when legal options are scant. Enter social networking, specifically a pair of Facebook pages. The first, called “Regret-a-vet,” offers disgruntled consumers of veterinary services a forum to air their grievances, complete with lots of “Likes” and supportive comments. The second, and more venomous, is called “Veterinary Abuse Network,” and, in this case, ratcheted things up a bit. A full-tilt assault on Dr. Koshi ensued. The veterinarian did respond, regrettably pulling herself into the same mud as her opponents, but the social networking diatribe continued, unabated, for weeks and weeks.

When the body of Dr. Sochi was discovered after her suicide, a brief note on the “Veterinary Abuse Network” page found justice in the freedom that the cat had won, free of this imperialistic animal doctor. There was cheering at the death of this veterinarian. The Facebook destruction of a medical professional was complete.

Now to be sure, I don’t know all the specifics of this case, nor do I know all the factors that led to the suicide of a 55-year old veterinarian. But I do remember the brute honesty of my friend who admitted that her family needed a scapegoat when her mother died, and medical professionals served that role. The freedom to “rate” our physicians and veterinarians and others, via the anonymity of the Internet, is a technology that is fearsome to me and, I suspect, some of my friends in human medicine. The narcissism fueled by Facebook and other venues can destroy someone, and fast. I have never had to deal with it; someday I surely will.

Jean Bethke Elshtain once wrote that we must think of our political figures as being made of “flesh and bone,” not just as unfeeling figureheads in a political system. I think this relates to our medical professionals as well, a staggering percentage of whom are still (and often inexplicably) idealistic and face emotional and ethical issues head-on, and who must maintain a deep compassion for their patients and family members (and, yes, this means veterinarians as well as physicians; as one of the former, I can tell you how the short lifespan of my patients and their role in the family make my job and the job of my staff that much more exhausting). This compassion is exhausting, and we all seem to take it personally when a patient dies, no matter the reason. Jesus modeled well how to get away to a “lonely place” to regroup in communion with the Father when acts of compassion could be so, soulfully tiring. We have no room for that in medicine. The standard for an online review of a physician ought to differ from one made for an Italian restaurant or a carpet cleaning service, but the democratization of the Internet lumps them all together.

What a shame. What a tragic story. What a reminder that technology can be our friend, and can be used to bully us all. And that bullying can hit us in our weakest place—the place that says we just don’t care. Be ready.

Can Vets Help Physicians Consider Euthanasia?

I had no plans to write on the issues of human versus animal euthanasia, since it seems like I’ve spent more than enough words on the topic previously. Then I began to tackle the mail, journals and newsletters in my mailbox and came across a submission that made me want to re-open the whole issue. In the July issue of “Veterinary Practice News,” Dr. Alice Villalobos, a well-respected palliative-care veterinary oncologist and previous president of the Society for Veterinary Medical Ethics, submitted a “ViewPoint” piece that asked, “Can vets help physicians consider euthanasia?”

First of all, I have great respect for Dr. Villalobos as a veterinarian who has made a great contribution to the welfare of animals by the development of a “quality of life” scale that helps assess, in a more tangible way than to attempt a determination of “suffering,” when an animal patient should continue to receive treatment, including palliative or hospice care, or when euthanasia should be considered the most humane option. The article that includes this information, by the way, is found at the ”Pawspice” (rhymes with “hospice”) website. You may find it a fascinating read.

Her piece starts solidly, with the reflection that the veterinary standard for hospice care, including euthanasia, is spilling into human hospice, in some states at least: “…there is no way to deny that there is a societal trend for crossover to the way veterinarians assist animals at the end of life.” Indeed. Ask the legislatures in Vermont, Oregon, Washington, and Montana. And she further reflects that it goes the other way as well: some veterinarians adopt a vitalist model that would place enough guilt to convince someone into spending resources, financial and emotional, on an end-stage renal failure patient to try “’…one more day to keep her going,’” ultimately ending in a pet that dies in the hospital and away from human family members. Some veterinarians increasingly imitate some of their human medical colleagues that wish to extend life at all costs.

I find it appropriate to condemn this kind of practice—it is paternalistic and unkind to human and animal alike. The patient, of course, has no voice, and a veterinarian can effectively bully a client into doing extensive and futile procedures or face the shame of “killing” their pet. Where Dr. Villalobos goes off the rails is in the next section of her piece. Here she makes her argument for human euthanasia:

“Many seriously sick, old and frail people receive brilliant medicine and supportive care as hospital patients. Then they get transferred into a facility where they become humiliated persons whose bodies are being warehoused until they die.

“Baby boomers fear that they will get futile medicine or live too long in chronic pain, past their desired time, languishing year after year in tomorrow’s thriving extended care industry.”

Okay, perhaps this is just genuine emotion, and not an ad hominem attack on the human medical field. There is plenty to criticize in the way we treat human beings at the end of life. But she goes on:

“What about the horrendous emotional suffering of people whose bodies and/ or minds have withered into vegetative tissue barely resembling their original self? The distraught families of warehoused persons feel guilty and hopeless because they are barely recognized or not acknowledged at all during visits.”

Several critiques here: how does one who is in a vegetative state (curiously defined as “bodies and/ or minds”—I am curious what a “vegetative body” resembles) have the wherewithal to suffer so horrendously? I thought their minds had already withered to an unrecognizable degree. Must we resemble our “original self” to maintain human dignity? A visit to a fifty-year high school reunion will challenge that view. And how did we shift the focus to the guilt and hopelessness of family members, not the patient? Ought these, then, be the predominant foci of our ethical decisions?

But my greatest criticism is the ethical leap Dr. Villalobos makes here: A decision to forego burdensome medical treatment that would extend life necessitates euthanasia. She infers (at a minimum) that a decision to forego treatment is the same as the decision to have a physician actively end life, perhaps even absent the patient’s will. They are certainly not, and effective palliative medicine in human medicine has shown this. Allowing a patient to die as a result of the underlying disease is not euthanasia. While this is not generally practical or advisable in veterinary medicine, humans can “die with dignity,” to use that wretchedly-abused term, without being euthanized. Yes, it is different.

Euthanasia is a big part of how I, and other veterinarians, can fulfill our mission to relieve animal pain when they become moribund or face intractable pain. It has always been ethically sound for us to do so. We recognize that an extension of the process of dying offers little of value to our patients. The same cannot be said of human beings, where interpersonal relationships are more complicated—and the risks of hastening the end of life are far more complex. To make this jump is ethically unsound and, frankly, rather sloppy.

We must ultimately decide if ethical principles must apply to humans and animals identically or if human beings are a different sort of being, based on our innate “human-ness.” And we must realize that, as our technology develops further and can extend life longer, popular sentiment and cultural ethics will equate the decision to cease or withhold treatment with euthanasia. Maybe we have our work cut out for us, even if it means revisiting the issue a few more times than we think we have to do.

Euthanasia Week

Last week was “one of those weeks” in the world of small animal veterinary medicine. Somehow all my cases that had been “circling the drain,” as we so elegantly put it, finally were pulled into its vortex, and we had a wave of euthanasia sweep through my practice. Three animals in renal failure in one day, a congestive heart failure, several cancer patients: the usual supects. It is a challenge to keep your spirits up in veterinary medicine as you hasten the passing of the sick and dying, even as you maintain clinical distance. Each case was different, but there was a certain consistency to what I did, maintaining faithfulness to my oath to relieve animal pain and suffering, through euthanasia if that was the only way to do so successfully. By Friday evening, as I placed my umpteenth (it seemed) fatal overdose of pentobarbital into a cephalic vein catheter while tearful family members held the pet they had raised from a puppy or kitten, or rescued from a shelter, or a dozen other stories, I began to think about this process in the context of human beings. For most people, this very difficult, but expected and necessary, part of my profession is well within the ethical boundaries in relation to animals. What if it becomes ethically permissible in the human medical profession someday? What patterns from my experience may be expected to carry over?

The comparison is imperfect, of course (and, indeed, I hope it would remain so no matter what!). Relationships with animals do not carry the baggage, for good or ill, of our human relationships. But people with their dying pets faced the decision seriously, with a desire to know the “right time,” when a cure was impossible, quality of life issues were substantially diminished, and their pets appeared to be suffering. (As a brief excursus, I don’t know how or if animals suffer; that seems to suggest a level of sophistication that few, if any, nonhumans have, including levels of physical, mental and spiritual dysfunction. That said, a pet euthanasia consultation is rarely a teachable moment for such philosophical sublimities and I just let them know that their pet may be suffering, or at risk of suffering, if they are just in awful condition.)

Most people look to me to give a green light to their choice, perhaps to nudge them past the guilt of a decision. “What would you do if she was your dog,” is asked of me daily, last week by a young married couple clutching an old beagle with inoperable bladder cancer and in end-stage kidney failure. That answer was easy. But they wanted my response to give ethical license for their choice. Legally, animals are “property,” the possessions of their human owners; we even call our clients the “owner” of their pets. Yet people look to us for moral guidance on when to end the life of their property. If human euthanasia is normalized, much more is at stake, and physicians will assume my role. I take comfort that I can provide peace and closure by reassuring my clients that their pet will be better off if we don’t force her to go to the bitter end. I am chilled to think of the comfort that a physician could similarly take in easing the decisions of those left behind to avoid the bitter end for their own family members. My euthanized patients don’t send me heartwarming, career-affirming “Thank You” cards; their families sure do.

I also noted a real, but subtle, dynamic in my staff, one that I think translates to human caregivers as well. My technicians and ward attendants could see full well that these patients would not get better. They heard me pronounce grave prognoses. They knew the patients in their care were dying, and they would find themselves frustrated with the pet owners that tarried on their decision to euthanize. The staff of veterinary hospitals is overflowing with idealists that advocate strongly for their animal patients. Without knowing it, my staff’s body language showed frustration and resignation, and those making the decision could sense the subtle pressure.

Certainly we see nurses and others in the ICU or in nursing homes that advocate for halting treatment they genuinely feel is burdensome to the patient and futile to recovery. Watching a patient slowly die is emotionally and intellectually exhausting. As sad as my staff is to lose a pet in our care, we all know the sense of relief that we feel when the call for euthanasia is made. We’ve usually stopped feeling guilty when we know we’ve done everything we can and that we can hasten the end. It is peaceful and quick, gentle and painless, which natural death so often is not. If human euthanasia is acceptable, expect this same subtle pressure and eventual sense of relief among hospital staff members, too.

This week is better (the positive aspect of losing so many of the moribund in one week is that the circle of life usually swings back the next). But I can’t help but think about the possibilities that the future holds, where human euthanasia is acceptable and even embraced. No, animals are not people ontologically-not yet, at least. But maybe I have seen the future for human medicine from my own vantage point as a veterinarian, and it should concern us all.