Meeting the Patient’s Interest in Veterinary Clinics. Ethical Dimensions of the 21st Century Animal Patient

The main objective of this paper is to introduce the concept of the “animal patient” to academic debates on animal ethics, veterinary ethics and medical ethics. This move reflects the prioritization of the animal patient in the veterinary profession’s own current ethical self-conception. Our paper contributes to the state of research by analysing the conceptual prerequisites for the constitution and understanding of animals as patients through the lens of two concepts fundamental to the medical field: health and disease. The first section describes, how these concepts are inextricably entangled with the animal’s becoming a patient. The understanding of health and disease, we determine, has a great impact on the actual treatment of animals as patients. We show that a naturalistic perspective on health and disease still prevails in the veterinary field. By contrast, we use a historical study to demonstrate how a socio-historical perspective on animal diseases enriches our understanding of veterinary practice and its ethical dimensions. This perspective will prove not only able to deal with the wide variety of veterinary patients, but also to release underlying normative processes to ethical reflection and research. We elaborate on that assertion by spelling out the constructive dimension between the veterinary gaze and the objects of its experience. The final section brings veterinary medicine’s ethical relationship to the animal patient into the picture. The discipline is guided by an ethical principle of advocacy, defined as the responsibility to recognise and defend the animal patient’s interest in health. Our principle conclusion is that ethical philosophical thinking on interactions between specific notions of health and disease and animal patients makes a substantial contribution to surmounting this moral challenge. As ‘health’ and ‘disease’ determine the options for the articulation of an animal patient’s interest, investigation into the ever-changing and particular conceptualisations of these notions fosters its recognition. We conclude with a prospect resulting from those theoretical insights: meeting the animal patient’s interest could furthermore mean seeking an articulation of the specific interactions between concrete, living animal patients and veterinary concepts.


Introduction Veterinary Ethics Turns to Clinical Practice
As experts on animals and their needs, veterinarians play a crucial role in nearly every context of human-animal interaction. Concern and care for animals as patients are fundamental to the veterinary profession's image. The first principle of veterinary medical ethics formulated by the American Veterinary Medical Association addresses animals solely in their role as patients: BA veterinarian shall be influenced only by the welfare of the patient, the needs of the client, the safety of the public, and the need to uphold the public trust vested in the veterinary profession; and shall avoid conflict of interest or the appearance thereof.^(AVMA 2016; italics ours) Aside from caring for their patients, engaging in animal welfare and animal protection is evidently a major responsibility of the veterinarian. This ideal also influences public perception of the profession and compels people to engage with veterinary medicine. A recent study has shown that most veterinary students in Germany derive their motivation to study veterinary medicine from personal respect for animals and an intent to help animals. 92% describe themselves as having an Baffinity for animals^, meaning that they view themselves as handling animals better than others, not fearing any animal, being especially fond of animals and ready to help them (Baumgärtel 2016). These points suggest that the ethical relationship between veterinarians and animals has become fundamentally oriented towards the animal as patient (as opposed to a sports-gear, economic asset etc.), whose health and welfare marks the highest good of veterinary practice and corresponding veterinary duties. In this paper we will bring this core idea of the veterinary profession under close scrutiny.
Both recent empirical evidence and historic evidence indicate that in the late twentieth century the focus of veterinary ethics has shifted away from topics like collegiality within the profession, standards of education, advertising policy, etc., towards the ethical dimensions of veterinary clinical practice and the interests of animals as patients in that context. Ethicists no longer automatically equate clinical care with ethical treatment (Woods 2013). Accordingly, problems and conflicts that arise within the veterinary clinic are being discussed more often in veterinary ethics. The majority of current debate and literature revolves around normative conflicts in veterinary clinics, especially the conflicts between the interest of the animal patient and the interest of its owner. For instance, Mullan and Main state: BA difficult decision may need to be reached in a case, say, where an owner requests euthanasia for a horse that is unable to work due to lameness^ (2001,394). Developing and delivering tools that help resolve normative conflicts and generate sound decisions has become a major task for ethicists (cf. Yeates 2010;Millar 2013;AVMA 2013). When is the right time to euthanise an animal? How should questions of over and undertreatment be dealt with? Should an owner's financial constraints justify limited clinical care? Such questions are significant in the current debate and reflect the present orientation of veterinary ethics (cf. Yeates 2009;Fentener van Vlissingen 2001;Sandøe and Christiansen 2008;Sandøe et al. 2016).
Since the normative point of reference for contemporary veterinary ethics is the protection of the animal patient, i.e. the veterinarians' responsibility to recognize and foster the animal patient's interest, it is essential for veterinary ethicists to understand and analyse this concept of interest, to ask what this interest is, as well as to interrogate closely related notions like health and disease. The following article sketches out this line of research into the normativity of veterinary practice. This investigation will operate on a more fundamental level than decisionmaking tools, which presuppose that the question of interest has already been posed and answered. Common approaches to the problem borrow from human medicine and analogize the animal patient to a child or a comatose adult. Those analogies not only provide interesting parallels worthy of further investigation (Grimm and Huth 2017), but also need to be considered inherent to the ethical landscape in which veterinary medicine is practiced. In speaking of animal patients and medical responsibility towards them, comparisons to human medicine inevitably arise, especially in terms of ethical claims (Rollin 2006).
In practice, however, animal patients are not treated like human patients; even among animal patients, there is a high degree of inconsistency. The heterogeneity in the understanding of an adequate therapyfor example regarding requisite hygienic precautions in veterinary surgerycorrelates with the variety in the prevailing understanding of the respective animals. Veterinary instructions on surgery in hogs include no hygienic precautions, while the same treatment has proven to fail on dogs when hygienic precautions are disregarded (Gardiner 2009). In our understanding, meeting animal patients in ethical terms is to engage with this plurality and its correlative inconsistencies instead of lumping them together under the blanket term of Bpatient^equally applicable in the human and veterinary fields. Consequently, we consider the assumption that veterinary medicine becomes more humane by becoming more human-likeas in small animal practicea challenge for veterinary ethics, not its starting point.
To put the focus of ethical relevance on the animal and its interest as a patient means to centre veterinary ethical research on the animal. This paper will therefore aim at a conceptualization of the animal patient through ethical-philosophical reflexion on and investigation into the socio-historical conditions and normative presuppositions that constitute and shape the animal patient, its body and its interest. Doing so will present one promising way to fully achieve veterinary medicine's overarching ethical imperative of recognising the animal patient's interest and assist in clarifying the responsibility of veterinary medicine on a conceptual level.

Becoming an Animal Patient A Question of Health and Disease
How does an animal become an animal patient? The answer to this question seems obvious: An animal becomes a patient by becoming sick! This intuitively plausible answer, however, only shifts the problem to another question: What is a disease? (Rosenberg 2003) How does an animal become sick? The conditions of becoming sick and becoming a patient are doubtless closely intertwined and interdependent. For the purposes of this paper, however, we want to focus on the normative dimension characteristic of the processes of becoming a patient and becoming sick. In this chapter, we outline how animal patients and veterinary treatment are grounded in the normative differentiation between being healthy and being sick.
On a first level, clinical practice is guided by a normative dimension of the concept Banimal patient^as an ethical ideal: In determining whether a veterinarian acts ethically, the norm of aiming at the health-related interests of the animal patient is decisive. Acting according to this norm constitutes good veterinary clinical care. Actions that do not live up to this norm or stand against it are considered problematic. This idea of ethical consideration carries a number of important normative aspects. One relates to the idea of taking interests into account. Whenever we talk about interests, there is also a subject that has these interests. An interest-based concept of the animal patient goes along with the recognition of animals as self-determined beings. Respect is expressed by acknowledging the patient's interests, and that entails the recognition of some form of subjectivity. The B[…] unique place of veterinary expertise and advocacy in deciding animal-welfare cases^ (Carbone 2010) implies a corresponding responsibility towards the animal patient. In the advocacy model, the veterinarian's responsibility is to represent and to defend the animal patient's interest. The catchy slogan BVets speaking up for animals' welfare^recently unveiled by the British Veterinary Association underscores the crucial role Bspeaking for the animal^plays in the veterinary profession (BVA 2016;Baggot 2006). The emphasis on the patient's interest is also reflected in the debate on informed consent in veterinary medicine. Here, the question arises for whom the veterinarian does speak andif the advocatory model is usedwhat the contents of the patient's interests are (cf. Fettman and Rollin 2002). The aforementioned examples illustrate that the animal patient's interests have, generally speaking, become an important norm for determining what is ethically right and wrong in the clinic. However, those interests are not general interests of the animal in e.g. its welfare, the five freedoms or well-being. As an animal patient, its relevant interests are health-related. Investigating the normative determination of the animal patient's interest as governed by the concepts of health and disease allows for a more specific normative understanding of good clinical care than if that interest was conceptualised in light of established norms and principles like animal welfare or the utilitarian approach of balancing costs and benefits in a pathocentric frame as found in recent literature (Yeates 2013;Rollin 2006;Mullan and Main 2001).Those concepts of health and disease provide common foundational ground for the animal patient, its interest and the orientation of clinical care. It can be easily demonstrated that Bhealth^and Bdisease^are instrumental in structuring, interpreting and perceiving clinical care and imply strong normative dimensions. Disease is connoted as something bad that provokes suffering or harm and thus a need for help. In providing clinical care, veterinarians act according to the principle of beneficence with an intent to promote the animal's good: they help the animal get rid of disease as an unwanted evil. What can be done and what should be done are defined and decided by the two interrelated and entangled concepts of health and disease. The ethical orientation they provide lends those concepts their functional value.
Returning to the initial question, how animals become patients, the intuitive answer that animals become patients by getting sick now seems clearly insufficient. We also speak of animal patients during routine check-ups, the administration of prophylactic treatments or vaccinations, and so forth. In all those cases, the animal is not (necessarily) sick. Within clinical practice, diseases are conceptualised with reference to health. While diseases are understood as deviations from the idea of a healthy animal's life, health itself represents the privileged end of clinical care (Schramme 2012). The good has to be restored, maintained or enhanced. The notion of health therefore fulfils a teleological function, as Norbert Paul emphasises (2006). The examples above show that it is not the momentary sickness of an animal that turns it into a patient. As soon as animals are integrated in the axiology of health and disease, they become patients.
This approach takes into consideration that the distinction between Bhealthy^and Bunhealthy^is a blurry onenevertheless it is the decisive one for the legitimization of the animal patient's treatment. If a disease can be diagnosed, an effective impetus and justification for corresponding actions are supplied. On a concrete level of everyday clinical work, symptoms legitimise diagnostic measures such as examinations, the extraction of samples, diverse tests and consequent therapies. Veterinary treatment starts by determining how an animal is subject to the axiology of health and disease; in brief: it starts with a diagnosis. This is crucial, since, in a majority of cases, clinical interventions to promote and protect the health-related interests of the animal ultimately entail harm to the patient. Since one of medicine's most basic ethical criteria is the principle of nonmaleficence, any harm done requires strong justification. One decisive element in this legitimizing process is the category of disease. It can render certain medical interventions and therapies necessary, even if severe harm is done to the animal patient, and it can delegitimize others as futile. To illustrate this point in practical terms, take an English bulldog that is brought to surgery because of respiratory problems. The patient has to be harmed (surgery) in order for the medical treatment to result in benefit (relief from respiratory problems). The harm done to the English bulldog is justified by a reliable diagnosis (respiratory problems) and an expected benefit in terms of the dog's healthrelated interests. That brief example illustrates how the axiology of health and disease defines what is of relevance and what is not in veterinary practice, where therapy is indicated and where not, what counts as a sick or a healthy animal, and much more. It determines what is considered ethically right and wrong in veterinary clinics. Beyond its role in the constitution of animal patients, that axiology has normative implications for the animal's life outside the clinic, as well. Keeping a dog healthy through exercise, a nutritional regimen, free from parasites, etc. are examples in which the axiology we have described also functions as a norm outside the clinic, and medicalises areas of the animal's everyday life.
Because of their privileged role within the normative infrastructure of veterinary clinical care, health and disease factor decisively in ethical judgements. However, these notions have not been explicit issues of ethical consideration in veterinary ethics up to this point. Given their normative functions in clinical care, as well as in the understanding and treatment of animal patients, that lack of ethical reflection is surprising. Whereas in human medicine thorough reflections on the concepts of health and disease have been published (cf. ibid., Kingma 2017;Metzl and Kirkland 2010), no such debate exists in veterinary ethics. This is exactly the point upon which we would like to expand in the following.

Historicising Health and Disease in Animals
Health-Related Interests of Animals as Socio-Historical Developments As Volker Hess points out, the perception of biological norms as natural and irrefutable is widespread among physicians and other professionals in the life sciences (Hess 1997). But this idea appears to remain particularly untouched in the case of veterinary medicine, where health and disease are conceptualised in a naturalistic frame through exclusive reference to an animal's biological or physiological nature. In practical terms, illness is understood as a deviation from the normal, natural state of the animal, and health-related interests as directed toward regaining health. Restoring an animal's health is equated with bringing the animal back into its natural state (Gunnarson 2006). Scientific knowledge is therefore all that is required to identify health-related interests. As Larry Carbone puts it: "[...] policy writers (and clinicians) often hope that robust-enough scientific and medical facts can generate policy prescriptions for action without any messy involvement of values and ethics^(2010).
One possible explanation for the persistence of a strictly naturalistic perspective in veterinary medicine is that the anthropocentric tradition in the social sciences translated to a general marginalisation of animals. In disciplines like the philosophy and sociology of medicine, medical anthropology and medical history, there has been scant research on veterinary knowledge and practices. In this chapter we demonstrate how the disregard for animals in the social sciences is linked to a naturalizing perspective on health and disease in animal patients. Using a historical case study which adopts a socio-historical perspective on animals and their diseases, thus proving that the exclusion of animals from debates on medical policies is unjustified, we pave the way for further investigation into the ethical dimensions of becoming an animal patient.
In line with the anthropocentric tradition in the social sciences, veterinary medicine's own historiography does not grant animal patients historicity. Historical developments in veterinary medicine are usually described with respect to an evolving understanding of animal diseases. All that changes is the amount of knowledge physicians and scientists have acquired on pathologies. The animal patients themselves, as healthy or unhealthy beings, are perceived as constant, ahistorical facts (cf. Driesch and Peters 2003;Swabe 1999). Patients are merely the site in nature where disease occurs. The key approaches to veterinary history consequently exclude animal patients from their scope (Haarmann and Weich 2016). In recent decades, however, some animal patient-oriented research has been published, thus breaking with that tradition (explicitly referenced in this paper : Gardiner 2009;Jones 1997;Woods 2007; for an overview see Mishra 2014). These studies have initiated reflection on contemporary veterinary practice "by tracing the heterogeneous pathways that led to the apparent solidity of the present, in historicizing those aspects […] that appear to be outside history, in showing the role of thought in making up our presentB (Rose 2007, 5). By critically examining how clinical veterinary care has developed within a complex network of society, culture and science, animals, veterinarians, consumers and owners, they not only provide an empirically informed historical account and an alternative approach to understanding present realities in veterinary medicine, but also tools to reshape the discipline (Jones et al. 2014). Susan Jones' arguments in her study on a feline disease serve to illustrate this shift in perspective pars pro toto. The core motive behind Jones' historical analysis of the disease known as Feline Urological Syndrome (FUS) is to challenge the assumption that animal diseases are purely biological events. Being a historian, Jones takes Charles Rosenberg's prominent theory on diseases in a historical perspective as her point of departure. Rosenberg argues that disease is determined Bnot only by its biological aspects, but also by factors such as the professional and ideological values of each generation of healers, and a larger set of sociocultural values^ (Jones 1997, 203). Rosenberg's complex model for framing diseases serves as a tool to analyse historical changes and developments in medicine, patients and the axiology of health and disease.
Jones points out that Rosenberg explicitly excludes animals and their diseases from his account of the socio-historical development of disease: BIn one of its primary aspects, disease must be construed as a biological event little modified by the particular context in which it occurs. As such it exists in animals, who presumably do not socially construct their ailments and negotiate attitudinal responses to sufferers, but who do experience pain and impairment of function^ (Rosenberg 1992;cited in Jones 1997, 203). While Rosenberg locates the origin of complexity and variability in the human patient, he reduces the experience of sickness in animal patients to a biological event. Interestingly, his strategy of exclusion via naturalisation is not based on the concepts of health and disease as natural norms. Instead, he employs the conceptualisation of animals as natural beings to convert medical normativity into natural and irrefutable facts in the case of animal patients. Jones' historical studywhich we will summarize in briefis targeted at Rosenberg's differentiation between human diseases as historical concepts and animal diseases as ahistorical and biological facts. For the purpose and within the scope of this paper, Jones' detailed genealogy of FUS during the 1960s in the USA has to be narrowed down to the crucial steps of her argument: First, the source of FUS is not located in a pathological process. Quite the contrary, FUS originates in the social realm: Housecats urinating in flats. This socialas opposed to biologicalproblem is transformed into a medical problem by defining a new standard of health for housecats. BHousecats not conforming to this behaviour [not urinating in flats; KW/HG] standard (or otherwise appearing to be ill) became patients^ (Jones 1997, 231). Framing a social problem as a medical problem appears as a strategy for controlling the deviant and unappreciated behaviour of cats. In doing this, not only the Bill cat^but also the Bhealthy cat^, i.e. the socially conforming cat is constituted. As Jones demonstrates, as soon as FUS provides the option to understand and interpret certain unwanted aspects of the cohabitation between cats and humans as caused by a disease, normative consequences follow. The cat turns into a patient, and new responsibilities ensue: treatment not punishment is the appropriate reaction to a cat urinating in the flat. As a patient, the cat defines Bher relationship to the anxious owner and her frustrated doctor.^(ibid. 203) The disease emerges as a new normative register, incorporating Ba constellation of signs and symptoms into what became known as FUS^(ibid. 206). As a new framework for interpretation and decision-making, FUS effects changes on a series of different levels: The interpersonal relationships shift such that the client is now dealing with a sick patient and not a misbehaved cat. Now in possession of a catchy diagnosis to explain the problem, the veterinarian becomes the Bgo-to expert^in the matter. Further, on a professional/ scientific level of knowledge production, a new field of research in veterinary medicine opens up. And, finally, the change to the normative foundations both produces new possibilities for acting right or acting wrong and generates new legitimizing narratives for medical treatment.
As Jones' study on 'Feline Urinary Syndrome' illustrates, Bbecoming sick^in animals does not derive from a manifestation of a biological process. The understanding of Bmedicine^or Btherapy^that posits disease as a natural fact crumbles. Instead, veterinary medicine has a much more profound impact on animals: by turning them into patients, it subordinates their lives and bodies to a standardization that responds to their societal existence as much as it influences and shapes that existence. Studies of animal diseases have illuminated how, in this process of standardization, the normativity of health and disease is first developed: it rather emerges than gets discovered. As a consequence, for veterinary ethics, the scope of ethical reflection on veterinary clinical care expands to the investigation into the concepts of Bhealth^and Bdisease^. Framing diseases means framing veterinary decision making: sociocultural studies of animal diseases have the potential to enrich our understanding of veterinary practice and its ethical dimensions.

A Practical Application
Viewing Variety in Health-Related Interests So far, two perspectives on the concepts of health and disease in animals have been introduced. In the first, they are conceptualised as natural norms that seemingly provide firm moral ground. In the second, health and disease are conceptualised as dependent on changeable socio-historical norms. But how do these different perspectives on health, disease and animal patients connect to the current debate in veterinary ethics? Our response to that question focuses on a commonly encountered ethical problem in veterinary medicine: the wide variety of animal patients and their differing treatment (cf. Whiting 2013). As Gardiner states, becoming a patient in veterinary medicine is marked by Bdramatic variations, with some animals effectively treated as 'infectious agents' themselves, to be wiped out entirely, and others receiving a high degree of individual care and attention^ (2009,358). Both the interpretation of this variety and the ethical consequences drawn from it change depending on how health and disease are conceptualised.
In the naturalizing interpretation, health and disease refer to a notion of an ideal animal patient, whose treatment depends solely on clinical data extracted from its physical body. The only normative criterion for the ethical treatment of animal patients remains the correct diagnosis of the biological, natural processes that express themselves as disease and health. What is ethically right or wrong remains subordinate to a preexisting nature of things which can be represented in a better or worse manner. Within this interpretation, the great variety and discrepancies in the actual treatment of animals (e.g. companion animals vs. farmed animals) can only be explained as corruptions of the ideal. That view is indeed pervasive in the veterinary profession: Economic constraints and socio-cultural meanings are held to impede, corrupt and distort the clinical care that, on its own, would rely solely on an objective notion of health (Whiting 2013). A demarcation line is drawn between an invariable realm of nature and a realm of everchanging and thus unreliable societal relations and interpretations. Animal patients as healthy or unhealthy organisms are located in the first realm. Differing and changing demands on and understandings of animalsas production units or sports equipmentbelong to the societal realm. In this perspective, the core moral obligation of the veterinarian becomes the defence of the natural animal and its natural health against the distortions these are subjected to in society. Within this framework, medical treatment in livestock farming that aims at restoring the animal's productivity, e.g. the treatment of mastitis in dairy cows, is to be criticised with an ethical impetus since productivity is understood in opposition to the natural health of the animal. It seems that, in this case, treatment would not be legitimised by the animal's (natural) interest in health, but by alien interests, like the owner's or the industry's in e.g. milk yield. The Bnatural^animal and its health are set apart from its Bsocietal existence^as a unit in livestock production, resource, piece of sports equipment etc.
In a historical perspective on health and disease, such a division is understood as one strategy among the changing ways animal diseases are framed. The normativity of health and disease neither derives from a given natural state of an animal, nor does this animal appear in its natural reality when represented in the axiomatic of health and disease. Instead, those concepts are understood as constitutive parts of the diverse societal existences animals lead. Seen in that light, veterinarians and their patients appear immersed in the constitution of the diverse and contradictory landscape of modern human-animal relations. The existence of a dairy cow as a milk-producing unit is reflected and transformed within the particular understanding of that cow as an animal patient, just as the meaning of a companion animal as a beloved individual gets translated into applicable health-related standards. In becoming patients, animals do not express one natural norm of health, but become embedded in a pluralistic axiomatic structure of health and disease that is the result of an ongoing deliberation between society, science and medicine (Paul 2006).
While the sole focus on productivity in livestock farming does provoke firm ethical critique for good reasons, those reasons must be accurately pinpointed (Metzl and Kirkland 2010). With regard to veterinary ethics, the opposition of societal realities to an ideal that can be described as an ahistorical notion of health fails. The basis of critique shifts from a transcendent, absolute idea of health as a natural fact, to the immanent critique of health as a normative concept that structures the Bmaking the patient^as a process. In fact, the variety of meanings of health in animalsin contrast to the much more unified idea of health in human medicineallows for an excellent and serviceable access to the multiple functions that medicine fulfils in our society by articulating its particular normativities. While an understanding of health as context-independent norm has little explanatory power with regard to complex, changing and even contradictory empirical realities in contemporary veterinary medicine, different veterinary patient categories can be explained from a socio-historical perspective by taking into account the contingency and plasticity of medical normativity. In the following section we explore consequences for the ethical understanding of the Banimal patient^.

Understanding Animal Patients
How the Veterinary Gaze Shapes the Object of Its Expertise Earlier in this paper, we situated the animal patient in a reciprocal relationship between veterinary practice and animal, mediated by the shared normativity of health and disease. Health is the principle object of the veterinary institution's research, knowledge and practice, and it is also the interest of the animal. That common interest in health not onlyas shown in chapters 3 and 4constitutes the self-understanding of veterinary medicine, it is also the root of the discipline's fundamental normative and ethical dimension: the descriptive knowledge and therapeutic methods of veterinary medicine target a patient capable of interests. A veterinary practice is therefore responsible to the creature it treats.
Given the fundamental significanceboth scientific and ethicalof the concepts of health and disease, their understanding and meaning cannot be reduced to mere linguistic convention, but instead have to be examined with care and detail. As shown in chapter 3, viewing health and disease from a purely naturalistic perspective precludes such analysis by reducing them to self-evident descriptive facts. The historical perspective corrected this somewhat limited view by presenting the 'given' as a product of complex socio-historical processes, thereby opening it up to further research and discussion, in addition to yielding finer and more differentiated tools to analyse the current state of veterinary medicinee.g. the existence and evolution of variety in animal patients and a corresponding pluralism in concepts of health.
This historically informed view also creates an increased receptivity to the ethical challenge of scientifically representing an animal's interest in healthwhich, as we will see in the next section, is a key aspect of veterinary medicine's ethical self-understanding. By viewing the concept of health as pluralistic, rather than unitary, and socio-historically conditioned, rather than simply given, the scientific view of the animal becomes more differentiated and nuanced, conscious of its own defining power over its patient's (own) interest.
The scope of that power is intuitively understood by every veterinarian, as it is the essence of his/her everyday routine. But the theoretical view of an animal has even more material consequences, as this view will legitimise and inform the practical manipulation and transformation of that animal's body -and, in more recent developments, its cognitive and emotional 'state of mind' as well. A few examples illustrate that argument. The previously cited study on urinating cats demonstrated how a new normality for a housecat could be established by defining a new standard of cat health. The English Bulldog with respiratory problems briefly mentioned above illustrates how what once counted as an inherent quality of the English Bulldog, advertised as a laid-back and slow character who loves to share life on the sofa, could be turned into a pathology. Such behaviour no longer expresses the character of the English bulldog, but a severe obstruction of the respiratory tract. Accordingly, pharyngolaryngeal surgery has become routine in early brachycephalic dog life (Dupré and Heidenreich 2016). And finally, dairy cows have shown how the societal and political demand for more milk could be translated into a question of fertility and udder health. Fulfilling that demand thus became a veterinary issue and embedded and transferred to the idea of a healthy dairy cow (Woods 2007). That is not only changing the idea of health in cows, but also the cows themselvestheir biological and physiological representation, as well as their bodily presence. Practices like rectal examination and the extraction of egg cells link the changed understanding of dairy cows to an altered cow: Certain aspects of its vitality have been exposed to manipulation, others are isolated in order to generate knowledge or new therapies. Shifting borderlines between what counts as Bdisease, symptom of diseases, or inescapable conditions of life^ (Rose 2007, 83) interact with both the presumed essence of the animal (species) in question and the changing societal demands on animals. The clamour for more milk, translated to the standard of health for dairy cows, is paralleled by the medical enhancement of social skills in companion animals. Separation anxiety in dogs has become a common medical indication for the rising use of psychopharmaceuticals. That kind of medicalisation indicates a growing acceptance of psychological sensitivity and a self-regulatory ability in dogs: psychological sensitivity is being established as a normal canine quality. By contrast, the need for closeness in cats is less pronounced than in dogs: the use of feline pheromones (e.g. felifriend) to deter aggression and enhance feline social skills in cat-to-cat interaction, as well as in cat-human interaction, elevates the cat to a higher standard of Bbeing a housecat^.
Becoming an animal patient thus refers to a process through which the animal patient itself is constituted. The necessary theoretical basis for a profound analysis of how animal patients exemplify the effects of Bthe societal demands made on each single body to be a very particular body with specific capacities and supposed or neglected rights^ (Eitler 2014, 273) can be found for instance in body theory and body history (cf. Featherstone et al. 1991;Jones and Porter 1994;Farquhar and Lock 2007). The profound alterations to animals' bodies via historically changing, medical representations and their respective clinical treatments further weaken the naturalistic idea of a primordial, proper body that exists outside of cultural encoding. They prove that veterinary medicine's gaze actively (although not exclusively) shapes the object of its knowledge, simply by being an imminently practical form of theory. Medical knowledge and practices change the meaning of life continuouslythe relativity and historicity that exist between Blife^and (medical) Bpolitics^has been expressed by biopolitics (Lemke 2011). Animal patients are a paradigmatic example of the entanglement of bodily and symbolic meaning. No animal patient's existence is possible outside of its specific coconstruction by medical discourse (and other social realms, cf. Schrepfer and Scranton 2004). It is therefore of vital ethical importance to veterinary medicine to be aware of and reflect on its own entanglement in the productive normativity that determines its own scope of actions and decisions, as well as its patient's interest.

Meeting Animal Patients: Conclusions From Representation to Articulation
The previous section presented the structural ethical problem that arises from the normative power of the concepts of health and disease when these are used as guiding norms for treatment, thereby altering and transforming animal patients' existences. This concluding part explores how the advocacy model's imperative to respond to and protect the animal patient's interest in health adds to the problem. What is this interest of the animal patient? And where does it derive from? Exploring the ethical implications of this notion of the animal patient will ultimately result in concrete proposals for fostering and developing the advocacy model and a rethinking of veterinary medicine's relation to its patients.
First of all, the advocacy model refers to the idea of representation. As a representational relation, the veterinary situation implies a dualistic structure in which the animal patient, as the passively conceptualised object of representation, is subjected to the human activities of representing, evaluating and judging. The potentially hierarchical character of the veterinarian's representational relationship to his or her animal patient constantly runs the risk of colliding with a second central motif of the advocacy model: the represented counterpart as a being that harbours interests which need to be minded. That assigns the animal patient some form of subjecthood, effectively rendering the animal patient a source of moral obligation and the veterinarian a physician, instead of a mechanic. It is precisely the ethical potential of autonomy, which is suggested by the notion of the animal patient as holder of an interest, which is precluded in the naturalistic perspective. Its concept of a genuinely objective animal equates the descriptive assessment of the animal with the immediate presentation of its interest as a patient. This very drastic take on the representational act completely excludes the animal in its subjective quality, capable of forming own interests, from the veterinary context. The solely theoretical identification of an object of knowledge leaves no room for apprehending the animal patient's responses to its representations. The situation is improved once the ahistorical and self-evident characterisation of the animal is substituted for its characterisation as a societal being formed by socio-historical realities, a move that opens the previously off-limits animal up to research and better understanding via an examination of the specific conditions that produce the current diversity of animal patients.
However, not much is won in regard to the ethical ideal of respecting some kind of moral subject if the reduction of the animal patient's interest to a 'natural interest in health' is simply exchanged for societal determinism. Calling the normativity of health and disease into question is merely one step on the way to that ideal. It is another step to address animal patients not only as objects, determined by nature (or society), but as active agents that Bshape the medicine they receive^ (Gardiner 2009, 356). We therefore put forward that, in order to fully convert the ethical principle of advocacy into actuality and most thoroughly recognise the animal patient's interest, one has to complement the critical scrutiny of the normative social structure in which that interest unfolds with an interrogation of animals' activities within that structure, the specific ways in which they fulfil or resist the societal demands to which they are subjected, and which are mirrored in their role as patients. Since the animal patient defies the concept of equating the patient's autonomy with speech, it is of central ethical relevance to establish awareness for the animal's particular capacity to Bspeak^, understood as the capacity Bto make a difference that calls for response^ (Bennett 2010, 32). Thus it becomes necessary to stay even more alert to subtle reactions within veterinary medicine's processes of representation, of applying medical knowledge to a patient subject. A heightened sensitivity to the act of representation that is informed by an awareness of both its silencing dangers and its ultimate goal of promoting the articulation of the represented, is therefore a first consequence of our argument. This requires a readiness to be surprised, corrected or even outfoxed by permanently changing, active animal patients.
Veterinary medicine's self-imposed ethical ideal of advocating and defending its patients' interests in health magnifies the significance of the animal patient's moral or ethical status as some kind of subject. While the fundamental normative ideal in veterinary medicine (to grant moral or ethical subjecthood to its animal patients) is as clear as the importance that fulfilling this imperative (to define that subjectivity, its interest, its health) has for clinical practice, there has been interestingly little research into what that interest or subject actually is. BIn veterinary professional terms, animal subject status is usually contained within fairly vague guidelines which say that veterinarians must act to promote the welfare of animals under their care ( Gardiner 2009, 359). We have approached the practical uncertainty regarding the animal patient and the kind of subjecthood it implies by proposing an analysis of it as a relational socio-historical figure along the central medical axiology of health and disease. From that perspective, the animal patient ceases to be an ahistorically and unchangeably defined essence and starts being recognized as an agent in different and differing social contexts, demands and conditions. This view suggests and explains the existence of a variety of ways of becoming a subject, of being a patient and of having interests.
Taking the advocacy model's imperative seriously means extensive and detailed research into both the social conditions involved in constituting the many forms of health and disease, as well as the respective animals' behaviour within and against these processes, in order to see more clearly what exactly the resulting animal patient is and what actually constitutes its specific interest. Two lines of research promise to shed further light on this question: ongoing socio-historical research on subjectivity as a result of therapeutisation and disciplination in the wake of Michel Foucault, which is only beginning to include animals (Taylor 2013;Wadiwel 2015;Wolfe 2013), as well as current animal studies analyses of animal's specific form of subjecthood in terms of agency (cf. Wirth et al. 2016;McFarland and Hediger 2009). Although they have yet to begin to acknowledge and embrace the animal as a patient at all, both could help strengthen veterinary medicine's ethos that the animal patient is not something we need to define, but to which we need to respond to.