Volume 197, Issue 3, September 2013, Pages 535–540
Open Access
Abstract
Veterinarians
have a key role in providing medical care for sports horses during and
between competitions, but the standard client:veterinarian relationship
that exists in companion and production animal medicine is distorted by
the involvement of third parties in sports medicine, resulting in
distinct ethical dilemmas which warrant focused academic attention. By
comparing the existing literature on human sports medicine, this article
reviews the ethical dilemmas which face veterinarians treating equine
athletes, and the role of regulators in contributing to or resolving
those dilemmas.
Major ethical dilemmas occur both
between and during competitions. These include conflicts of
responsibility, conflicts between the need for client confidentiality
and the need to share information in order to maximise animal welfare,
and the need for an evidence base for treatment. Although many of the
ethical problems faced in human and equine sports medicine are similar,
the duty conferred upon a veterinarian by the licensing authority to
ensure the welfare of animals committed to his or her care requires
different obligations to those of a human sports medicine doctor.
Suggested improvements to current practice which would help to address
ethical dilemmas in equine sports medicine include an enhanced system
for recording equine injuries, the use of professional Codes of Conduct
and Codes of Ethics to establish acceptable responses to common ethical
problems, and insistence that treatment of equine athletes is
evidence-based (so far as possible) rather than economics-driven.
Keywords
- Veterinary ethics;
- Equine sports medicine;
- Conflicts of interest;
- Evidence-based veterinary medicine;
- Equine welfare
Introduction
Although public concern about the use of horses in sport is not new (Higgins, 1996),
it has increased in recent years. Heightened public and academic
awareness of the welfare issues surrounding equestrian events including
(but not limited to) racing, eventing, endurance, dressage,
show-jumping, reining and polo (McLean and McGreevy, 2010)
was reflected in the media outcry about deaths and injuries of horses
in the 2011 and 2012 British Grand National steeplechase.1
Veterinarians
have a key role in providing medical care for horses at all times. Like
human sports medicine doctors, veterinarians treating elite equine
athletes face a potential conflict between their duty to safeguard the
welfare of the athlete under their care, and their responsibility to the
trainer/manager/owner of that athlete (and, in the human case, the
athlete himself) who are purchasing medical care and have an interest in
keeping the athlete competing. Increasing recognition amongst the
veterinary profession of the particular ethical issues associated with
equine sports medicine was reflected in the inclusion of a session
entitled ‘Ethics, Scope of Practice and Racing’ at the 2012 convention of the American Association of Equine Practitioners.2
This
article reviews the ethical dilemmas which face veterinarians treating
equine athletes, and the role of regulation in contributing to or
resolving those dilemmas. The focus is not on the moral question of
whether horses should be used for sport at all (see, for example, Campbell, 2013),
but rather on the ethical issues facing veterinarians when the use of
horses for sport is permitted by society and by law. Significant ethical
dilemmas face veterinarians between as well as during competitions. If
veterinarians are to safeguard not only the welfare of the animals under
their care but also the integrity of the veterinary profession, they
must play a proactive role in (1) identifying and addressing welfare
issues, (2) researching methods of reducing sports-related injuries, and
(3) ensuring that the treatment of equine athletes is evidence-based
rather than economics-driven.
Ethical issues surrounding the use of horses for sport, and the role of the veterinarian
Distortion of the standard veterinarian:client relationship
Although
a substantial body of work on welfare issues surrounding the use of
horses in sport exists, and examples are to be found in both the
interested lay press3,4 and the scientific literature (Jeffcott et al., 1982, Lam et al., 2007, Ely et al., 2009, Campbell, 2012 and Reed et al., 2012),5
relatively little academic or public attention has been paid to the
ethical dilemmas faced by veterinarians working in equestrian sport, or
to the role of veterinarians in addressing some of the issues.
All practising veterinarians carry responsibilities not only to animals but to owners, society and practice partners (Rollin, 1978, Main, 2006, Main, 2011 and Yeates, 2009).
The standard relationship between veterinarian and client often does
not apply with competition horses, when the veterinarian may be obliged
to relate not only to the owner, but also to a trainer, a rider, a team
manager, and selectors. This exacerbates the potential conflicts of
interest faced by all veterinarians, and justifies focused academic
consideration, as research into as the ethics of sports medicine does
within human medical ethics (Murthy et al., 2012).
Ethical dilemmas facing veterinarians during competitions
The
ethical issues confronting veterinarians include problems of
confidentiality, owner/trainer’s unrealistic expectations of treatment,
the use and abuse of medication, and conflicts of duty to the horse and
its human connections. These are broadly analogous to those faced by
doctors working in human sports medicine (Anderson and Gerrard, 2005).
However, unlike human sports medicine, there has been little analysis
in the veterinary literature of how these issues might be effectively
addressed. This applies particularly to the dilemmas encountered by and
the behaviour of veterinarians before, after or between (rather than
during) competitions.
During
a competition, at least at elite level, the duties and obligations of
veterinarians are well-defined by regulatory bodies. Thus, for example,
the Fédération Equestre Internationale (FEI) publishes Veterinary
Regulations which are updated annually.6
These rules define the categories of veterinarians at FEI events, and
detail their responsibilities. Similarly, the British Horseracing
Authority’s (BHA) Equine Science and Welfare Department sets the
requirements for experience and competence of racecourse veterinarians,
and BHA veterinary officers are present on race days to advise Stewards,
monitor equipment and work with treating veterinarians who are
providing clinical care.
Regulations in racing and other equine sports extend to the administration of therapeutic drugs and to drug-testing (Toutain, 2010),
so that the responsibilities of veterinarians are clearly defined, and
decisions about what constitutes ethical behaviour are consequently
relatively simple to make. However, these responsibilities may be less
well defined at low-level competitions. Mechanisms by which
recommendations for ethical good practice for event veterinarians can be
transferred from elite to grass-roots level warrant further research.
Ethical dilemmas facing veterinarians between competitions
Unlike
the intra-competition period, regulations and advice from sports
governing and professional bodies about how veterinarians ought to deal
with ethical dilemmas which occur outside of competition is limited. The
exception to this generalisation is advice about medication between
competitions, which does exist. The FEI maintains a searchable on-line
database of prohibited substances,7
and both the FEI and BHA publish lists of drug detection times.
Interestingly, there is a divergence of ethical approach towards
medication adopted by the BHA and the FEI. The BHA stance is that it is
never in the best interest of a horse to be raced whilst under the
effect of medication,8
whereas the FEI believes that there is some welfare benefit in allowing
horses to compete on specified, ‘permitted’ medications, e.g.
anti-ulcer drugs including omeprazole, most antibiotics, topical wound
ointments (not including corticosteroids) and ‘preventative or restorative joint therapies’ administered by some routes.
Veterinarians
are bound by law and by guides to professional conduct to act within
relevant legislation and local rules. The potential for disciplinary and
legal proceedings to result from failure to act within rules was
illustrated by the disciplinary case of the UK’s Royal College of
Veterinary Surgeons (RCVS) vs. Main (2011),
in which one of the charges against the defendant was that he had
injected a horse with a substance on the day of a race when he either
knew or ought to have known that to do so contravened BHA rules.9
Other
than medication regulations, however, there is little advice available
to veterinarians on ethical decision making surrounding
between-competition treatment of equine athletes. The goal of treating
athletes (short term performance) differs from the usual goals of
treating companion animals (quality of life across years, longevity and
freedom from disease and/or pain). It also differs from the usual aims
of maximising productivity and minimise welfare insults for production
animals. There is an overriding, economically-driven requirement in both
equine and human sports medicine to return the athlete to competition
as soon as possible. Combined with the complexity of responsibilities to
the animal–owner–trainer–team axis, this causes ethical pressures on
veterinarians that are unique to sports medicine and encompass issues of
autonomy, confidentiality, and rationale for treatment.
Conflicts of responsibility
In
human medicine, the concept of autonomy refers to a person’s right
(providing that he is adequately informed, capable of understanding, and
rational) to make decisions about what happens to him, and to have
those decisions respected by others (Beauchamp and Childress, 2009). Autonomy is a problem in human sports medicine (Dunn et al., 2007)
when the patient’s right to make informed decisions about his own
treatment free of the influence of others may be compromised by the
interests of team owners and managers who wish the player to keep
competing.
Discussions about whether patient autonomy can exist when the patient is an animal (see, for example, Chan and Harris, 2011)
are outside the scope of this paper. Nevertheless, autonomy may be a
problem in veterinary sports medicine when the owner’s, trainer’s and
indeed the veterinarian’s rights to make an autonomous decision
conflict. The trainer has an interest in keeping the horse in training
and returning it to competition as soon as possible. The owner may or
may not share that interest. Veterinarians in UK admitted to the RCVS
promise that: ‘above all (their) constant endeavour will be to ensure the health and welfare of animals committed to (their) care’.10
The veterinarian therefore ought to treat the horse to ensure maximise
welfare, which might involve a period of rest that is unacceptable to a
trainer.
In a survey of human sports medicine doctors (Anderson and Gerrard, 2005)
the conflict between doctors’ autonomous right to treat the athlete
with the aim of maximising recovery (welfare) and the autonomous right
of managers/trainers to decide on the most appropriate treatment for
players in their employment was identified by half of the respondents as
a major ethical dilemma. A similar dilemma exists for veterinarians
whose right to make an autonomous decision about best treatment aimed at
maximising long-term welfare conflicts with the owner or trainer’s
right to make autonomous decisions about their animals. The veterinarian
may have different priorities from the owner or trainer, and an
assistant and partner veterinarian might have different priorities from
each other according to considerations of practice viability and
financial responsibility to other members of the practice, particularly
if it is dependent upon work as a team or a trainer’s regular
veterinarian (Anderson and Gerrard, 2005).
Dunn et al. (2007)
argued that in human sports medicine a physician’s reputation may be
built on ability to effect short-term repair or to improve performance,
rather than on long-term preservation of the athlete’s health, and that
this might influence a clinician’s decision making process to the
detriment of the patient’s long-term welfare. Media exposure may also
exert pressure, and the kudos surrounding treating a high-profile
patient might persuade clinicians to treat beyond their expertise (Murthy et al., 2012).
Similar pressures are likely to exist in equine medicine, where
owners/trainers may expect the veterinarian to treat the horse to
optimise performance. Rumours and anecdote abound regarding the
administration to horses by veterinarians of intra-articular medications
or other treatments such as intravenous infusions, which are not
currently detectable on routine dope tests. Unsurprisingly, most such
rumours are unsubstantiated.11
There may anyway be difficulty in differentiating between excessive
treatment and legitimate, routine maintenance of elite athletes. This
distinction may be wilfully blurred when efforts are being made to turn
mediocre animals into more successful performers. Variation in
medication rules between international racing jurisdictions further
confuse the situation (Higgins, 1996) and provide the façade of an (unacceptable) excuse for such behaviour.12
The relationship between such pressures and clinical decision-making
processes, including whether to refer and the influence of insurance13 on treatment decisions, requires further investigation.
The
conflict between the veterinarian’s responsibility to the horse and to
the trainer/team who employ the veterinarian is analogous to a doctor’s
conflicting loyalties to the athlete and to the team with whom the
doctor has a contract (Anderson and Gerrard, 2005).
Even in human medicine, in extreme examples, such conflict can result
in medical harm being caused to the patient, as in the case of a doctor
who (at the player’s request) deliberately injured a player in order
that a substitution might be made by his team.14
However,
there is a significant difference between human and equine sports
medicine because horses, unlike human athletes, are unable to express
their views. Consequently, given his duty to prioritise the welfare of
the animal under his care, where the veterinarian’s assessment of what
is best for the health of the athlete differs from the preferred
solution of the owner/trainer the veterinarian ought to act as the animal’s advocate.
Interestingly, in one survey (Anderson and Gerrard, 2005), 28% of medics listed themselves
as one of those to whom they were responsible when treating athletes.
This conflates the proposal that conflicts between autonomy of owners,
trainers and veterinarians can be stressful, much as ethical dilemmas
cause stress for veterinarians in general practice ( Batchelor and McKeegan, 2012). Dunn et al. (2007)
asked how a doctor can recognise that the team has a legitimate
interest in outcome and yet remain loyal to the patient? For a
veterinarian, the equivalent question is how he can recognise that the
owner/trainer/team has a legitimate interest in the outcome of
treatment, and yet fulfil his obligation to safeguard the welfare of
animals under his care.
Codes
of Professional Conduct such as those of the RCVS and the American
Veterinary Medical Association (AVMA) fulfil a useful role here in
establishing systems of addressing common ethical dilemmas which can
both ‘protect practitioners from unacceptable demands and external pressures’ ( Anderson, 2009) and be used as a yardstick against which actions can be measured, for example during a disciplinary hearing.
Patient confidentiality and information sharing
Issues about autonomy and conflicts of loyalty in sports medicine carry associated questions of patient confidentiality (Murthy et al., 2012).
When there are many layers to the client–veterinarian relationship
decision-making may be delayed, and the veterinarian may be unsure about
who is and is not entitled to share in patient information which ought
normally to remain confidential.15
This ethical dilemma was recognised in the development of the AAEP’s
protocol to improve transparency and communication in the
owner–trainer–veterinarian relationship.16
Where
many people are acting as owners or owner’s agents, and where multiple
veterinarians become involved in an animal’s care, problems develop not
only of client confidentiality, but also, conversely, through
compromising animal welfare by failing to share medical information This
can occur during routine treatment if one trainer employs multiple
veterinarians, particularly if those veterinarians are competing with
one another for the work. Although the RCVS (and other) Codes of
Professional Conduct encourage transfer of clinical information between
veterinarians, client confidentiality must also be protected, and it is
in any case difficult for veterinarians to exchange information if the
trainer/owner does not make them aware that there are several
veterinarians caring for one animal.
Under
current rules governing elite equestrian sport, veterinarians have a
duty to ensure that the owner/trainer/rider of the horse is fully
informed about the implications for the rules of competition concerning
any therapeutic drugs, and to record that information accurately, but
they are not expected to inform regulators directly if such treatment
has been given. Under BHA rules, the trainer remains strictly liable if a
horse fails a drugs test. However, the 2010 ‘Clean Sport’ regulations
of the FEI for the first time designated veterinarians as potential
‘additional responsible persons’ (the rider being the main ‘Person
responsible’ and as such strictly liable), thus raising the possibility
that veterinarians could have their FEI accreditation removed and be
penalised under certain circumstances if found to have contributed to a
horse testing positive.
The
maintenance of a Medication Logbook required by FEI medication control
regulations (2010) goes some way to creating a system which records in
one place details of those medications that have been given to a horse,
and provides access by interested parties. However, the use is limited
by the fact that, although prohibited substance administration should be recorded, the recording of non-prohibited medications is voluntary.
The
potential responsibility of veterinarians to share information about
injuries (rather than drugs) is ambiguous. Although the RCVS requires
that veterinarians keep clinical records, there is no requirement by
sports governing bodies to record injuries which occur outside of
competition or any (non-medicinal) treatment. Although the BHA collects
and analyses information about injuries and fatalities during racing,
and the FEI is developing a programme of surveillance of injuries which
occur during competition, systems enabling veterinarians to record
injuries which occur between competitions appear to be lacking.17
The transmission of information about injuries between private and team
veterinarians may be hampered if a rider, rather like a human athlete (Anderson and Gerrard, 2005) is aware of an injury but chooses not to divulge that to the team veterinarian for fear of jeopardising a team place.
In
human medicine in the USA, a doctor has a duty to reveal confidential
information (e.g. a cardiac condition in a race driver) when failure to
do so may expose others to harm (Murthy, 2012). Risks of harm might be
associated with some non-medicinal equine treatments, for example if the
insensitivity caused by a neurectomy performed to mask lameness causes a
horse to stumble and throw the rider, or injure spectators. Competing
with an injured horse could also of course compromise the welfare of
that horse. In the absence of a regulatory mechanism dictating that
private veterinarians must record injuries and non-medicinal treatments
in a manner accessible to regulators or team veterinarians, the need to
protect client confidentiality probably overrides any sense of
responsibility to those individuals. This does not excuse, however, the
veterinarian’s responsibility for the welfare of the horse, for example
in UK under the RCVS Professional Codes of Conduct and the Animal
Welfare Act (2006).18
Thus the veterinarian who knows that an animal is injured or not fully
recovered and that the owner/rider nonetheless intends to compete it has
a potential conflict of interest between his duty to the animal’s
welfare and to client confidentiality.
The
animal’s welfare should always be paramount, but this is complicated
when the veterinarian’s income is dependent upon retaining clients.
Although the FEI Clean Sport regulations (2010) suggest that
veterinarians should contribute to decisions about whether a horse is
unfit to compete, in the absence of any notification mechanism it
remains possible for owners/trainers/riders to obscure and indeed to
ignore such veterinary advice. Improved regulation covering the
recording of injuries and/or non-medicinal treatments and the obligatory
transmission of that information to regulatory authorities would
improve the welfare of competing horses, and protect veterinarians from
potential conflicts of interest and concerns about client
confidentiality.
Ethics and evidence-based medicine
Questions
about how veterinarians should act ethically between competitions
relate closely to the issue of evidence-based veterinary medicine (Anon, 2012).
In the UK, the Animal Welfare Act (2006) prohibits causing unnecessary
suffering. Combined with the veterinarian’s duty to safeguard the
welfare of any animal under his care, this ought to ensure that no
procedure is undertaken which causes (even temporary) harm, unless the
harm is necessary in the sense that a benefit is reasonably expected to
result from it.
The
need to avoid causing unnecessary harm (non-maleficence) is an accepted
tenet of human medicine which ought to apply to veterinary medicine, and
which is frequently underwritten by an implicit cost:benefit analysis
of proposed treatments. For example, each time a veterinarian vaccinates
a horse he is causing harm, since the injection is painful and handling
may be stressful, but that is outweighed by the perceived benefit of
protection against disease. However, the debate about (for example)
thermocautery or ‘firing’ of equine tendons as a treatment for tendon
injury provides a current example of refusal by some veterinarians to
adopt such a cost:benefit approach in clinical practice. In 1983, a
study of the ‘pathology of tendon injury and repair, especially after
firing’ was published (Silver et al., 1983). The authors concluded that ‘On
the basis of the pathological and biochemical evidence…. line ‘firing’
cannot be considered a desirable or effective treatment of acute or
chronic equine tendon injury’. This study has recently been cited as constituting ‘the final verdict of non-effectiveness (and detriment to welfare)… on the medieval technique of tendon firing’ ( van Weeren, 2012).19
Nonetheless,
despite the lack of evidence of efficacy for a ‘treatment’ which is
painful and deforming, and the RCVS having recently adopted a robust
stance against firing,20 some members of the veterinary profession remain prepared to undertake and defend the procedure21 (Harris, 2012 and Jepson, 2012).
A
lack of evidence base for treatments is not uncommon in sports
medicine, even in the human field where technology advances rapidly and
evidence-based medicine lags behind (Dunn et al., 2007).
Where the overriding objective is to return the athlete (human or
equine) to athletic function as soon as possible, there are inevitable
economic pressures to use unproven treatments in the hope of a ‘quick
fix’. Additional pressure to use a particular unproven treatment may be
brought to bear on the veterinarian by owners/trainers who believe that
it confers a competitive advantage.
Dunn et al. (2007)
proposed that the ethical duty of a medical doctor when a treatment is
unproven extends only to ensuring that the athlete is fully informed,
and then leaving the athlete to exercise his autonomous choice. Because
they are unable to express autonomous choices, this is insufficient in
the case of equine athletes, especially since the trainer/owner may make
decisions which are not in the horse’s best welfare interests. Thus the
veterinarian, unlike the doctor, has a responsibility when faced with a
lack of evidence to act as an advocate for the animal. This does not
necessarily preclude recommending a treatment the efficacy of which is
unproven due to its novelty and small patient numbers. However, it does
surely preclude offering or agreeing to a request from a trainer to
undertake a treatment such as firing which is painful, causes a visible
harm, and which has not been proven to offer any therapeutic benefit
exceeding that of alternative, less painful treatments. In such a
situation it cannot be reasonably assumed that the harm/pain will be
outweighed by the benefit, and thus any suffering caused would be
unnecessary, and, in the UK for example, would contravene the Animal
Welfare Act (2006).
Evidence
based veterinary medicine – particularly equine medicine, where numbers
are small – may not always be possible. Although one might speculate
that the pressures to treat rapidly in equine sports medicine result in
quicker translation of research into practice than in other branches of
veterinary medicine, this is unproven. The translation of research into
practice is problematic in human medicine (Zerhouni, 2009) and likely to be further limited in veterinary medicine (Toews, 2011). Notwithstanding such limitations, it is unethical to undertake harmful procedures in defiance of what evidence is
available, or solely because the owner/trainer requests it. It is
nonetheless interesting to note that divisions within the veterinary
profession in the UK over the issue of firing reflect the description by
Anderson (2009)
of inconsistent attitudes between human sports doctors about when it is
and is not ethical to undertake client-requested treatments or actions.
There is a role here for professional Codes, which can provide
authority to a veterinarian who is refusing to undertake a treatment
despite the owner/trainer’s insistence that he do so, and also for
voluntary ‘Codes of Ethics’ (Anderson, 2009) to be agreed by those working in particular circumstances, for example as racecourse veterinarians.
Anecdotally,
the public example of one member of the profession having been
disciplined for breaking professional Codes of Conduct (for example the
much-publicised removal of a veterinary surgeon from the RCVS register
for having back-dated equine vaccination certificates22)
can make it subsequently easier for other members of the same
profession to resist pressure from owners/trainers to act in the same
way.
Evidence-based
science depends upon research, and investigative work by veterinarians
into methods of preventing, reducing and treating sporting injuries in
equine athletes (see, for example, Weller et al., 2006, Nagy et al., 2010, Clegg, 2012, Kalisiak, 2012, Nagy et al., 2012 and Reed and Leahy, 2013)
is an important aspect of the profession’s moral responsibility to
animals under their care, and of demonstrating concern for animal
welfare (Peter, 2010).
Mechanisms by which research, particularly if carried out under proper
regulated legislation, are translated into ‘accepted practice’, and the
ethics of practice-based clinical research are areas both requiring
further study.
Conclusions
The
position of veterinarians treating sports animals differs from that of
veterinarians in companion or production animal practice, and deserves
particular ethical consideration. Codes of Professional Conduct and
Codes of Ethics have a useful role in establishing acceptable responses
to common ethical dilemmas, and by so doing protecting veterinarians
against pressure from those who may not be acting in the horse’s best
interests, and against accusations of unethical conduct. The continued
development of such Codes by bodies to which veterinarians working in
sports medicine are affiliated would be beneficial.
Systems
for recording and sharing information about drug administration are
better developed than for injuries. To fulfil their stated aim of
protecting the welfare of competition horses, governing bodies should
develop compulsory systems for recording injuries (both during and
between competitions) designed to enable veterinarians to provide
relevant information without compromising client confidentiality. It is
incumbent upon governing bodies of all equine disciplines to
transparently collect, collate and analyse such data, and to make it
publicly available. Such information is crucial in establishing an
evidence base about the incidence, types and causes of injuries in
competition horses both during and between competitions. The role of
veterinarians in using such data to undertake research which prevents,
reduces and treats equine sporting injuries is an ethically important
one, and further study is required into the most effective ways of
translating such research into practice.
Conflict of interest statement
The
author of this paper does not have a financial or personal relationship
with other people or organisations that could inappropriately influence
or bias the content of the paper.
Acknowledgments
The
author would like to thank Karen Coumbe and Dr. Andrew Higgins for
discussions and comments on draft versions of this article. She would
also like to acknowledge the Department of Production and Population
Health of the Royal Veterinary College and its research office for
assessing the manuscript according to the Royal Veterinary College’s
Code of Good Research Practice (Authorisation Number PPH_00524). The
author is funded by The Wellcome Trust as a Biomedical Ethics Research
Fellow.
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