Ethical and Practical Considerations Associated with Companion Animal Euthanasia

Round 1

Reviewer 1 Report

Congratulations on this thoroughly researched and well-written paper.

I enjoyed reading it and feel it will be of great benefit to veterinarians.

I have a couple of very minor comments for you -

1. Missing bracket on page 11, paragraph two, first sentence [52 instead of [52].

2. I thought the first sentence/elsewhere in the conclusion could mention the potential stress on owners/families too? The families can be highly stressed around euthanasia decisions and distressed when recollecting and describing prior experiences which may not have gone smoothly.  Great description of all the terms used in companion animal euthanasia eg 'dysthanasia'.

Well done on this paper, it definitely needs to be published!  All veterinarians will benefit from reading this.  

Author Response

Reviewer 1:

Congratulations on this thoroughly researched and well-written paper.

I enjoyed reading it and feel it will be of great benefit to veterinarians.

I have a couple of very minor comments for you -

1. Missing bracket on page 11, paragraph two, first sentence [52 instead of [52].

 Change made.

2. I thought the first sentence/elsewhere in the conclusion could mention the potential stress on owners/families too? The families can be highly stressed around euthanasia decisions and distressed when recollecting and describing prior experiences which may not have gone smoothly.  Great description of all the terms used in companion animal euthanasia eg 'dysthanasia'.

Excellent observation. This sentence now states, “Companion animal euthanasia is fraught with emotions and ethical challenges which can lead to moral and traumatic stress for veterinary professionals and animal owners.”

 

 

We really appreciate the positive feedback! Thank you.

Reviewer 2 Report

The link to the 5 freedoms is broken - this is reference 25. It comes up with a 404 error

This is an opinion piece and I feel there should be a disclaimer from the authors stating this.

I think that there should be a statement that one of the authors is the founder of CAETA.  Table 1 is a CAETA created tool. 

A paragraph on the status of animals as property and owner's having ultimate say in what happens to them would be helpful. 

There is discussion on why 'worrying what an owner might do' if euthanasia is rejected, and a statement that this is not a reason to comply with owner's wishes. However there is no discussion on veterinarians reporting an owner for animal cruelty (e.g., allowing suffering). This is an option - albeit a difficult one. The laws are different between countries and even between states in the US. There are good Samaritan laws in some but not others. This is a difficult topic but I feel it should be discussed. 

Author Response

Reviewer 2:

The link to the 5 freedoms is broken - this is reference 25. It comes up with a 404 error

This has now been resolved and the link works.

This is an opinion piece and I feel there should be a disclaimer from the authors stating this.

Just above the title of our paper denotes that this is a commentary. We feel this should be understood by readers.

I think that there should be a statement that one of the authors is the founder of CAETA.  Table 1 is a CAETA created tool. 

The author is denoted as connected to CAETA in the author’s affiliation, and CAETA is included in the Funding disclaimer. We will leave further requirements on this up to the publishers.

A paragraph on the status of animals as property and owner's having ultimate say in what happens to them would be helpful. 

We have added: “Complicating euthanasia decisions is the fact that companion animals are legal property, and barring violations of animal cruelty laws are subject to the owner’s disposition. Autonomy is considered a fundamental bioethical concern, but whose autonomy should be prioritized when considering euthanasia?  ” 

 There is discussion on why 'worrying what an owner might do' if euthanasia is rejected, and a statement that this is not a reason to comply with owner's wishes. However there is no discussion on veterinarians reporting an owner for animal cruelty (e.g., allowing suffering). This is an option - albeit a difficult one. The laws are different between countries and even between states in the US. There are good Samaritan laws in some but not others. This is a difficult topic but I feel it should be discussed. 

We have added a paragraph addressing this challenging circumstance in the section on When Euthanasia Should Be Performed.

Reviewer 3 Report

I think this paper has the potential to make an important contribution to the literature on companion animal euthanasia.. However, I feel that the paper as it stands has fallen short of doing what it promises to do in the title, as the title and the content of the paper do not always align.

I’d like to suggest that the authors reconsider the terminology used, and perhaps split the two types of euthanasia described into delayed and premature euthanasia. These would be better terms for the two extremes of timing, and the ethical implications of each could be usefully explored.

Use of ‘euthanasia’ for killing that is not in the animal’s interests seems to contradict Yeates’ opinion that we should reserve ‘euthanasia’ for the act when it is carried out in the best interests of the animal, and ‘killing’ for other situations, such as many that are described in the paper. Some more discussion of the use of the term would be welcome.

I think that the paper misses a discussion reagrding who can give informed consent for euthanasia,  and fails to mention the occurrence of malicious euthanasia (when someone other than the animal owner presents the animal for euthanasia to further some intended revenge scenario).

The section on compassion fatigue etc. really belongs in the introduction, setting up the case for an ethical discussion of euthanasia.

The practical tips are useful but jar with the title. If keeping them in, the title needs to be changed. The 14 point guide to good euthanasia does  not seem to be evidence-based - this should be made clearer in the paper.

Specific points:

1.      The title refers to ethical concerns/issues when the article considers practical aspects of euthanasia. Either the title needs to reflect this inclusion or the section on practicalities needs to be removed (or rewritten to better link ethical aspects with practical aspects).

2.      The opening statement invites a much greater comparison between medicine and veterinary medicine. I think you need to revisit this statement and consider the topic of requests for euthanasia in human and animal patients (and the ethical aspects of who is requesting euthanasia and who is giving consent?)

3.      Reference to the animal’s ‘best interests’ on p2 requires some more exploration of what these are and how they can be evaluated, perhaps linking with quality of life assessment?

4.      Reference to quality of life scales merits more discussion – in particular the accusations of subjectivity. Whose opinions should we value at the end of life?

5.      ‘Not every manifestation of suffering warrants euthanasia’ – it would be good to unpack this statement a little more. The examples provided are limited. What are the parameters for suffering that does not warrant euthanasia? The reference to animal hospice or palliative care again needs to be expanded upon – if hospice is used to delay a euthanasia decision, which criteria should be used to make that decision later?

6.      The sentence ‘An intention-based definition of euthanasia that centers on benefiting the recipient may better ensure that such decisions would be based primarily from the perspective of the animal and may serve to reduce the prevalence of decisions to end a companion animal’s life as a means of resolving dilemmas between serving the owner’s, patient’s, and the veterinarian’s interests’ brings the focus back to a best interests-based approach to euthanasia decision-making but I feel that this area needs more discussion to support this suggestion.

7.      The section ‘How to Perform Euthanasia’ jars with the paper’s title. Perhaps it would be useful to explore the ethical problems with dysthanasia here instead?

8.      Please explain the term ‘pet crematories’ as it is not a term that is recognised in many countries.

9.      The ethics of using deceased animals for teaching and training needs more debate. This topic would also bring in such aspects as transparency and informed consent, which would need more discussion.

1.   As stated previously, the section titled ‘Consequences of companion animal euthanasia’ would sit better in the introduction as a rationale for the paper’s main premise that all euthanasia decisions should be made ethically.

 

Author Response

Reviewer 3:
I think this paper has the potential to make an important contribution to the literature on companion animal euthanasia. However, I feel that the paper as it stands has fallen short of doing what it promises to do in the title, as the title and the content of the paper do not always align.

I’d like to suggest that the authors reconsider the terminology used, and perhaps split the two types of euthanasia described into delayed and premature euthanasia. These would be better terms for the two extremes of timing, and the ethical implications of each could be usefully explored.

The reviewer raises an interesting and novel approach to classifying the timing of euthanasia decisions. We prefer our classification, as we believe that the ethical implications of each category would be clearer and mitigation of these forms of euthanasia can then be more specifically addressed. For example, the profession can work to educate pet owners about preparation associated with the costs of veterinary care and the availability of pet health insurance to mitigate economic euthanasia. The title has been adjusted to better reflect practical considerations.

Use of ‘euthanasia’ for killing that is not in the animal’s interests seems to contradict Yeates’ opinion that we should reserve ‘euthanasia’ for the act when it is carried out in the best interests of the animal, and ‘killing’ for other situations, such as many that are described in the paper. Some more discussion of the use of the term would be welcome.

While we considered the semantic inconsistency of the terms convenience or economic euthanasia as not strictly meeting Yeates’ definition of euthanasia, we don’t believe that encouraging use of the term ‘killing’ when vets perform unethical euthanasia is likely to be accepted, and we are concerned that use of this term and its emotional connotations may exacerbate the moral stress and poor mental health already prevalent in the profession.

I think that the paper misses a discussion regarding who can give informed consent for euthanasia and fails to mention the occurrence of malicious euthanasia (when someone other than the animal owner presents the animal for euthanasia to further some intended revenge scenario).

We have added a sentence acknowledging the legal status of animals as property and owner autonomy. While malicious euthanasia requests occur and are certainly ethical concerns, we don’t feel such uncommon settings warrant attention in this essay.

The section on compassion fatigue etc. really belongs in the introduction, setting up the case for an ethical discussion of euthanasia.

We feel that the section on Consequences of Euthanasia is best suited for the end of the essay. This section leads in to the first sentence of the Conclusion acknowledging that euthanasia is stressful for numerous stakeholders.

The practical tips are useful but jar with the title. If keeping them in, the title needs to be changed. The 14 point guide to good euthanasia does not seem to be evidence-based - this should be made clearer in the paper.

Thank you for this suggestion. A clarifying statement has been added to the 14-point guide.

Specific points:

1. The title refers to ethical concerns/issues when the article considers practical aspects of euthanasia. Either the title needs to reflect this inclusion or the section on practicalities needs to be removed (or rewritten to better link ethical aspects with practical aspects).

We have modified the title and abstract to include practical aspects associated with euthanasia.

2. The opening statement invites a much greater comparison between medicine and veterinary medicine. I think you need to revisit this statement and consider the topic of requests for euthanasia in human and animal patients (and the ethical aspects of who is requesting euthanasia and who is giving consent?)

We have added a sentence addressing this concern. While the reviewer raises interesting points, we feel such considerations are more suited to a philosophical essay. We have intentionally limited many philosophical debates relevant to euthanasia to make the essay more suitable to practitioners and to limit the length of the essay.

3.Reference to the animal’s ‘best interests’ on p2 requires some more exploration of what these are and how they can be evaluated, perhaps linking with quality of life assessment?

We feel such considerations are more suited to a philosophical essay. We have intentionally limited many philosophical debates to make the essay more suitable to practitioners and to limit the length of the essay. In addition, there are few clear guidelines to answer the questions posed by the reviewer as we noted in the essay: “there are few objective tools to determine exactly when euthanasia is needed.” We observe that while QOL scales are available, they suffer from subjectivity and variability between observers.

4.Reference to quality of life scales merits more discussion – in particular the accusations of subjectivity. Whose opinions should we value at the end of life?

We feel further exploration is beyond the scope of the title. We agree that more discussion on quality of life would be valuable, however having noted it in this essay will hopefully lead to further publications on the subject.

5. ‘Not every manifestation of suffering warrants euthanasia’ – it would be good to unpack this statement a little more. The examples provided are limited. What are the parameters for suffering that does not warrant euthanasia? The reference to animal hospice or palliative care again needs to be expanded upon – if hospice is used to delay a euthanasia decision, which criteria should be used to make that decision later?

We feel the clarifying statements and examples within the paragraph are enough for the scope of the paper.  That said, your comment and other reader’s similar questions are good reason for another paper or book inclusion that more fully explores the topic. 

6. The sentence ‘An intention-based definition of euthanasia that centers on benefiting the recipient may better ensure that such decisions would be based primarily from the perspective of the animal and may serve to reduce the prevalence of decisions to end a companion animal’s life as a means of resolving dilemmas between serving the owner’s, patient’s, and the veterinarian’s interests’ brings the focus back to a best interests-based approach to euthanasia decision-making but I feel that this area needs more discussion to support this suggestion.

We feel that the philosophical concept of an animal’s best interest has been adequately explored for an essay suitable for the typical veterinary practitioner.

7. The section ‘How to Perform Euthanasia’ jars with the paper’s title. Perhaps it would be useful to explore the ethical problems with dysthanasia here instead?

We have modified the title and abstract to include practical aspects associated with euthanasia

8. Please explain the term ‘pet crematories’ as it is not a term that is recognized in many countries.

We have added a definition of cremation tied to the term crematory.

9. The ethics of using deceased animals for teaching and training needs more debate. This topic would also bring in such aspects as transparency and informed consent, which would need more discussion.

We have expanded this section with an additional paragraph and have expressly noted the need for transparency.

10. As stated previously, the section titled ‘Consequences of companion animal euthanasia’ would sit better in the introduction as a rationale for the paper’s main premise that all euthanasia decisions should be made ethically.

We feel that the section on Consequences of Euthanasia is best suited for the end of the essay. This section leads in to the first sentence of the Conclusion acknowledging that euthanasia is stressful for numerous stakeholders.

Reviewer 4 Report

As the article is written as an essay, I found it interesting. Some countries have laws that specify the circumstances under which an animal may be killed (euthanized). Isn't there similar legislation in the United States? If yes, please include those rules in your essay.

Author Response

Reviewer 4:

As the article is written as an essay, I found it interesting. Some countries have laws that specify the circumstances under which an animal may be killed (euthanized). Isn't there similar legislation in the United States? If yes, please include those rules in your essay.

To our knowledge, there are no rules or laws in the US specifying under what conditions owned companion animals can or should be euthanized. Only the AVMA Guidelines which we cite in the essay. There are laws allowing for euthanasia of unowned suffering animals by veterinarians.

 

Round 2

Reviewer 3 Report

Thank you for the responses to my comments and suggestions.