Distinguish two types of advocate:
A veterinarian who supports and promotes, perhaps publicly, a particular moral cause (e.g. nonhuman animal welfare) or policy (e.g. outlawing puppy farms).
A veterinarian who acts for, and puts a case on behalf of, her patient and his/her interests.
Type 2 is our focus. Minimally, a patient advocate (PA) recognizes obligations regarding her patient and uses her position, medical knowledge, and clinical training to try to improve the patient’s health. In ethical terms, however, this description is vague. For example, it is compatible with acting only weakly for a patient’s sake and with sometimes seriously harming and subordinating the patient’s vital interests to the interests of others. In human medicine and biomedical writing, it is typically held or assumed that doctors will act (almost) always for their patients, subordinating their personal interests and the interests of others to those of the patient. This norm stretches back millennia to the Hippocratic Oath.Footnote 5
That veterinarians also have powerful moral duties towards their patients is increasingly recognized. Historically, companion animals received little protection. Now, in veterinary contexts, we more frequently hear words and phrases like these: the animal’s interests are central, primary or paramount; a veterinarian’s first duty, loyalty, obligation, and allegiance is to the patient; veterinary medicine is patient-centered and patient-focused. For example, veterinary ethicist Bernard Rollin (2002, p. 1147) claims that as ‘a clinician, the veterinarian’s primary obligation is to the best interests of the animal’, not to the client. In a similar vein, a writer in a veterinary ethics book (Legood 2000, p. 68) says that ‘Primarily, animals are…[the veterinarian’s] clients’.
Yet, the basic moral role of veterinarians, especially compared to the role of human health professionals, remains unclear and contested. Furthermore, there are often strong pressures (from clients, peers, employers, etc.) on veterinarians to refrain from pursuing their patients’ interests. Such pressures can be overt and obvious, or subtle and insidious. Indeed, veterinarians often wish to pursue their patients’ wellbeing, but in practice they may not always speak up for them (Hernandez et al. 2018). For all these reasons, it is important for veterinarians to be clear about their fundamental ethical role. What is this role? Discussing the veterinarian-client relation, Yeates and Main (2010) suggest that veterinarians may influence clients when client choices fail a test of ‘reasonableness’.Footnote 6 ‘Reasonableness’, they say, is not defined in terms of the veterinarian’s judgement about the best for the patient. Rather, it involves assessing the
reasonableness of a client’s choices relative to the decisions other owners have made in similar circumstances. If the owner has made an extreme decision, relative to choices made by others, that is deleterious to the animal’s welfare, then the veterinarian may legitimately exercise some influence (p. 266).
This test certainly legitimizes advocacy for the patient in many situations. However, we should observe that sometimes a veterinarian may judge or guess that a majority of clients would allow consequences to occur that are ‘deleterious to the animal’s welfare’. Thus, this proposal permits veterinarians, at least sometimes and in principle, to acquiesce in or even cause harm to their patients, even when they are in a position to attempt to prevent that harm. Christiansen et al. (2016) raise several contending answers to the question of when veterinarians may seek to influence clients. Should a veterinarian, they ask, who has a client with a chronically ill or aged animal companion
Share his or her preferred option in similar situations? Offer an opinion on the best decision for the animal and the client? Inform the client of the options but refuse to offer any guidance on decision-making? Or initiate a dialogue with the client about what to do? (p. 2)
A possible role for veterinarians, the authors suggest, is to respect client preferences and promote client autonomy through a process of shared decision-making with them. These two proposals, while arguably patient-centered in some senses of the term, fall short of describing the kind of strong patient advocacy this essay explores.
Bernard Rollin (2013, p. 20) claims that the ‘fundamental question of veterinary ethics’ is: ‘To whom does the veterinarian owe primary obligation—animal or owner?’ How should we answer this question, and what precisely do phrases like ‘primary obligation’ and ‘first allegiance’ mean? Rollin (2013, p. 20) asks: ‘Ought the model for the veterinarian be the pediatrician or the car mechanic?’Footnote 7 His answer is the pediatrician. The pediatrician advocates for her patient’s interests, including when those interests conflict with family/parent/guardian wishes and demands. For Rollin, such advocacy is also incumbent upon veterinarians. By developing Rollin’s simple comparison in this essay, we may see that there is in fact a range of possible caring behaviors and stances available to veterinarians.
Rollin contrasts veterinarians with car mechanics because many people have no serious qualms about destroying or not fixing their damaged automobiles. Of course, some owners do have strong feelings about their cars, not least, perhaps, about vintage or classic cars. Similarly, a vintage car mechanic might care quite strongly, in a certain sense, about the cars themselves. Such a mechanic not only repairs cars to please concerned owners, he also lovingly restores neglected cars and is upset when vintage models are ‘mistreated’ or discarded for convenience. He may try to persuade owners to have more ‘respect’ for them and to fix and salvage them where possible. Some sort of ‘sentimental’ or emotional value attaches to these car models. Maybe a few veterinarians still have attitudes to animals that are very roughly like this.
Very many contemporary veterinarians, in contrast, hold that animals have a significant moral value. Although these veterinarians believe their role is partly to benefit human clients, they also feel a moral duty to benefit their patients for the patients’ own sake. Animal patients have, for these health professionals, an intrinsic ethical value, not merely (like vintage cars) an instrumental ethical value. However, there are, ethically speaking, multitudes of ways in which an animal patient may be treated and regarded. First, there are many categories of moral behavior—we might list here action, principle, duty, thought, virtue, attitude, disposition, emotion, and care.Footnote 8
Second, there are stronger and weaker forms of such behavior directed at furthering the patient’s wellbeing. Here, the concepts of ‘strong’ and ‘weak’ do not have an entirely determinate denotation. These concepts encompass a range of possible actions, attitudes, and dispositions that may escape exhaustive enumeration. Pediatricians, we might in any case say, are strong, not weak, advocates for their child patients. Pediatricians do not see their role primarily as facilitators of guardian/parent preferences, or the interests of other parties, unless that is consistent with patient interests. Pediatricians believe their ‘primary obligation’ is to the children in their care, and they muster their resources and use their position to enhance those patients’ health and wellbeing. Where on the scale of ethical, protective, and caring behaviors, between the pediatrician and the vintage car mechanic, do veterinarians fit?
Adding further complexity to our question is the fact that the precise meaning of having ‘primary obligation’ to the patient is disputed even for pediatricians.Footnote 9 In sum, the increasingly used notions of ‘primary obligation’ and ‘advocacy’ are ambiguous. They need elaboration, clarification, and defense.