Caution: Eight moral hazards to beware of in vet life

Getty: ablokhin When you become a veterinarian, no one ever stops to enumerate all the ways in which your professional behavior can prove corrosive to your personal values. While you may have taken a medical ethics course in college or veterinary school, 10 to one its contents tended toward the theoretical and addressed only the specific ethical standards we should abide by in our roles as medical or veterinary professionals. The traditional classroom cannot offer much practical insight into how we are likely to react when a client, colleague, case, or coworker presents us with a moral or ethical quandary in real time. Even a case-based classroom’s hypotheticals cannot possibly prepare us for real-life scenarios in which we are challenged—ethically or morally—much less how to handle conflicts between our personal morals and the ethical standards of our profession. Some things we have to just learn by doing. After all, how we practice when no one is looking serves as both ultimate medical ethics exam and test of our moral fiber. None of us really knows the strength of our moral backbone until it is stress-tested. Morals vs. ethics Before I launch into some common veterinary scenarios, indulge me as I refresh our collective memory: Morals refer to our conception of the global “right” and “wrong” of things—our personal values, if you will. Ethics comes down to these principles as generally accepted by a specific community—in our case, a moral “standard of care” veterinarians have collectively agreed to adhere to. So why does this distinction matter? Pardon the digression as I explain: In practical terms, it is possible to be ethical and not moral. For example, if you refuse to declaw a cat because you believe it is inhumane to do so, you would be abiding by your own personal moral code. Nevertheless, it is considered ethical to declaw a cat given veterinary medicine’s reigning code explicitly allows veterinarians to perform this procedure. But if your boss requires you to perform the procedure and you comply despite your moral misgivings, you would be abiding by veterinary ethical standards but violating your own moral code. Now, let’s say your boss requires you to extract the same cat’s canines for the owner’s “comfort.” In this case, it would be both immoral and unethical to do so. That is because our profession’s guiding principles do not support this procedure; and since you vowed to abide by the profession’s rules when you joined it, performing it would be immoral as well, regardless of where you stand on de-fanging cats. To summarize: It is possible to be ethical and not moral, but the opposite is not possible in the context of a profession you have joined of your own free will and to which you have explicitly pledged ethical compliance. Hence, to violate our ethical code would be immoral. Interestingly, not all veterinary professionals agree, arguing anything the law allows is fair game, ethically speaking. Not so! Ethics can be more restrictive and vice versa, which is why I choose to belabor the point. (Confusingly, perhaps.) Sure, it has been tedious and more than a little pedantic to run through this but, trust me, we can all use a little refresher—myself included, of course. Moral hazards defined “Moral hazard” is a term coined more than 350 years ago by the insurance industry to describe how an individual or entity might elect to assume a greater risk on behalf of an insurance company simply because they know they won’t be on the hook should the insurance company be forced to make a big payout. For example, it is what happens when we tell our clients we won’t make a note of their puppy’s wiggly patellas, sharky overbite, or undescended testicle on our medical records but—wink-wink—urge them to get pet health insurance ASAP. More broadly, however, I tend to think of moral hazards as they apply to veterinary medicine as those uniquely veterinary pitfalls we all tend to stumble into at one point or another in the course of our careers. Regardless of your role in the profession, unexpected moral and ethical risks abound. No receptionist, kennel worker, vet tech, associate, medical director, practice manager, or owner is immune. While the ways in which we can morally and ethically stray can look vastly different depending on our role, it is undoubtedly true those with the most responsibility experience the greatest exposure to veterinary moral hazards, some of which I’ve outlined below: 1) Insurance decisions It is not just the standard moral hazard veterinarians confront when it comes to insurance. In addition to pushing policies for the congenitally challenged and the otherwise impaired (which we are all tempted to do at our own moral peril). There is also the looking the other way that happens with rescue pets, co-worker’s pets, and—gasp!—even our own. This is why many policies now prohibit veterinarians from treating their own pets. 2) Insurance-based bill-padding This is a common pitfall. Knowing patients have an active policy in their name has a way of enticing us to sway our recommendations. Instead of approaching a problem deliberately and stepwise, we are more likely to throw diagnostics at the wall to see what sticks. We are also more likely to be more aggressive with our pricier treatment options. 3) The luxury tax If at any point we find ourselves changing how we practice because we know a client is inherently less price-sensitive, that is a red flag for sure. After all, bill-padding also becomes an issue when dealing with the client who just pulled up in a Maybach or the one you know lives in a $10-million home. However, that is not quite as common as a 90 percent reimbursement policy with a $10,000 annual cap, is it? 4) Production-based bill-padding Thankfully, I’ve only seen this happen with one person in all the years I’ve paid employees on a production basis (this includes techs, managers, and associates). But it was a depressing day I realized we had a bona fide bill-padder in the house. It can be hard to spot but once you do you cannot unsee it. For many of us who are paid this way, it can become a tricky daily exercise to remain aware of our motivations in this regard. Few of us want to fall into the trap of changing how we practice—either over- or under-charging—because we fear leaning too far or not far enough into the production pay of it all. 5) Case-stealing Luckily, it is easier to spot production-based bill padding since this behavior is often accompanied by case-stealing and other inability-to-play-well-with-others behaviors. I view case-stealing (which can present in various ways), as another version of bill-padding, but one that inevitably takes a distinctly ugly turn when it comes to team morale and office politics in general. 6) Altering medical records This is one we are hard pressed to avoid given we often forget to include crucial case information after the fact. In most instances, we know we are benefiting the patient when we include greater detail. Nevertheless, changing medical records when we stand to benefit legally and financially is a common moral curveball for most of us. 7) WWTVD? “What would the veterinarian do?” This is a weird one. We are often asked by clients what we would do if we were in their shoes. Responding honestly and transparently without equivocation is a choice, but it is not always the best one. Most clients do not really want to know what you would do nor would it be fair to tell them flat out. On the other hand, I ask myself this question every day when faced with complex cases. What would I want if this were my own pet? After all, if how I practice is based in anything, it is along the lines of the Golden Rule: Offer your client what you would recommend for yourself. But this, too, presents its own moral questions, doesn’t it? 8) Euthanasia I know veterinarians who will not even raise this issue with clients. They feel it is up to the client to bring it up themselves. This seems strange to me, personally (and potentially self-serving, as well), but we are given a whole lot of leeway when it comes to euthanasia in our ethical code. Nevertheless, it presents a serious moral quagmire and it is a clear breach of ethics should it ever become obvious there is a financial motive at play. More moral hazards abound So many more… I’m in the process of setting these down now that I’m training a new medical director and taking on a new associate (a new grad, no less), so feel free to opine on the many ways in which veterinary medicine offers moral and ethical traps, especially when these are best brought up throughout the training and mentorship process. All thoughts are welcome! Patty Khuly, VMD, MBA, owns a small animal practice in Miami and is available at drpattykhuly.com. Columnists’ opinions do not necessarily reflect those of VPN Plus+.

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Caution: Eight moral hazards to beware of in vet life

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