Full Title Name:  Detailed Discussion of Veterinarian Client Issues

I. Introduction to the Veterinarian-Client Relationship

            When you take your pet to your veterinarian to be examined, you become the veterinarian’s client. As the client, you are bound by any conditions in your agreement with the veterinarian. But, what about the veterinarian? The veterinarian is already bound by the rules of the veterinary accrediting agency for the state where he or she practices. [1]  
            This paper will examine the policies set by the American Veterinary Medical Association (AVMA) that provide a general guide of the ethical duties veterinarians have to both their animal patients and their human clients. There are three main sets of rules governing the relationship between veterinarians and their clients:  professional ethics, criminal law, and civil law (or malpractice suits). This paper will examine only the professional ethics governing veterinarian-client relationships. The concept of “informed consent” will also be examined as it relates to the practice of veterinary medicine. Veterinary duties with regard to prescription medicines and medical feeds will also be discussed. Finally, this paper will discuss the disciplinary process, with examples from two states’ statutes. Having knowledge of the policies of the AVMA can help one to understand the boundaries of the veterinarian-client relationship. 

II. The Principles of the American Veterinary Medical Association

            The Principles are an established set of veterinary guidelines, set up to create a basis from which state veterinary accrediting agencies can create their state rules and regulations. Many issues that potential clients may have with veterinarians are addressed within the Principles, including what constitutes a veterinarian-client-patient relationship, and what the rules regarding that relationship are.

A. Continuing Veterinary Education, Specialty Identifications, Non- Veterinarians, and Substance Abuse 

            For each state, the rules regarding veterinarians are a little different. However, the Principles of Veterinary Medical Ethics of the AVMA (“Principles”) provide a general guide for state regulations, and most states follow those guidelines. Every state has its own licensing requirement. [2] Many of these licensing requirements derive from ethical principles that guide veterinary practice. The Principles make it unethical for veterinarians to identify themselves as members of an AVMA specialty organization when they are not members of that organization. [3] The Principles also make it unethical to assist non-veterinarians with the practice of veterinary medicine. [4] This particular Principle protects veterinarians, clients, and patients from the unauthorized and dangerous practice of veterinary medicine by persons without a veterinary license. The Principles also recommend that veterinarians continue their veterinary education after they receive their licenses. [5] In some states, veterinarians are required to continue their veterinary education in order to renew their license. [6] Additional protection can be found in the provision that recommends that veterinarians impaired by alcohol or other substances should seek help from qualified organizations or individuals. [7]  

          Although the Principles are very important to understanding the veterinarian-client relationship, they are simply guidelines and policies that are suggested for the veterinarian to follow. Further, veterinarian membership within the AVMA is voluntary. While acting with disregard for these guidelines and policies may indicate that the veterinarian is in violation of his or her ethical duties, they do not create a cause for a legal action. A veterinarian who disregards these guidelines and policies may be subject to disciplinary proceedings by the veterinary board in his or her state; however there is not a cause for legal action just because there is a violation of the Principles.

B. Veterinarians Actions towards Patients and Clients

            In discussing professional behavior, the Principles state “Veterinarians should first consider the needs of the patient: to relieve disease, suffering, or disability while minimizing pain or fear.” [8] Additionally, the Principles require veterinarians to obey the laws of the jurisdiction where they reside and practice veterinary medicine. Veterinarians are also prompted to be honest and fair when they relate to others. [9] These requirements and recommendations are also designed to protect the clients and patients of veterinarians. 
 

C. The Licensing Process 

            State veterinary accrediting agency requirements typically include submitting an application for licensing, passing a state licensing exam, and providing the board of examiners with transcripts from the applicant’s veterinary school. [10] State accrediting agencies may also require licensed veterinarians to renew their licenses through a process which includes an application, payment of fees, and continued veterinary education. [11]  
 

D. Disciplinary Proceedings 

            In addition to licensing and license renewal, state veterinary accrediting agencies are also involved in disciplinary proceedings against veterinarians and in determining which actions taken by veterinarians are acceptable, and which are not. [12] The definitions of acceptable and unacceptable actions vary from state to state. [13] However, in general, the actions of a veterinarian are considered unacceptable if the veterinarian engages in false or misleading advertising, misrepresents the services rendered, or is convicted of a crime. [14]  
 

E. Display of License, Disclosure, and Medical Records 

            State veterinary accrediting agencies may also regulate where the veterinarian displays his or her license and when the veterinarian can disclose information on which animals he or she has treated. [15] The Principles also require veterinarians to keep medical records. [16]
            The Principles go on to mandate several other important factors in the practice of veterinary medicine, including defining terms, discussing influences on the judgment of the diagnosis and possible treatment of the patient, and determining the therapy options for the patient. [17] The Principles also discuss medical records, fees, advertising, and euthanasia. [18] One of the most vital portions of the Principles is the discussion of the veterinarian-client-patient relationship. 

III. Veterinarian-Client-Patient Relationship and Informed Consent

            A veterinarian-client-patient relationship (“VCPR”) begins when the veterinarian takes responsibility for the animal. [19] The Principles state that a VCPR exists when all three of the listed conditions are met. [20] The first condition basically requires the client to allow the veterinarian to see and treat the animal. [21] The second condition is the basic requirement of informed consent. [22] The third condition is to have back-up measures set in place, in case the treatment fails or in case the patient has a bad reaction to the treatment. [23]  
           Informed consent in a veterinarian-client relationship is vastly different from informed consent in a medical doctor-adult human patient relationship. Where in a veterinarian-client-patient relationship, the patient is not capable of making a decision for him or herself.  By contrast, in a relationship between a medical doctor and an adult human patient, the patient can make the decision him or herself. Veterinarian-client informed consent is more like informed consent in a medical doctor-minor patient-caregiver situation since both require an adult human to make the final decision on the proposed treatment.
            Termination of a VCPR, under the Principles can and should be done by the veterinarian in certain situations. [24] One situation is when the patient no longer requires medical care. [25] The other situation is when there is an ongoing condition for which the patient should be referred to a different veterinarian for diagnosis, care, and treatment. [26] This could include possible problems with internal organs, skeletal issues, or any issues that generally require the care of a specialist. Clients, on the other hand, may terminate a VCPR at any time. [ 27]
            The Principles require “informed consent” from the client before the patient is treated. [28] Getting this “informed consent” typically means the veterinarian explains both the risks and benefits associated with a particular treatment method. [29] Then the client signs a document which states the client understands the risks and benefits. [30] By giving informed consent to a procedure or treatment, it is assumed that the client both read and understood all of the terms in the statement. Once informed consent has been given, the patient-animal may be treated according to the conditions listed within the statement.
            According to the Journal of the AVMA, part of informed consent means that client information sheets provided to the veterinarian must be handed out with the drug(s) to which they pertain. [31] These client information sheets have information on risks associated with that particular drug. [32]
            A standard AVMA consent form includes the name and address of the client (Owner) and the name, species, breed, sex, and date of birth of the patient. [33] Additionally, a standard AVMA consent form includes a clause indicating that the person signing the form is the legal owner of the patient and has the authority to consent to treatment. [34] Following that clause, another clause has spaces to identify the veterinarian, the veterinary hospital or office, and the treatment(s) being administered to the patient. [35] Next, is a clause indicating that the client has been informed of the possible risks and complications of the treatment, and indicating that the client is aware that unforeseen problems may arise and require further treatment. [36] Then, there is a clause which authorizes the use of anesthesia or pain medications as needed before or after the procedure(s). [37] After that, a sentence indicates that the client is aware that other personnel may be required in order to assist the veterinarian. [38] Finally, the signature lines are provided for the client and/ or a person acting as an agent on behalf of the client. [39]  
            When a client decides to forgo treatment, there is also a standard AVMA form for that waiver. [40] The waiver of treatment(s) or test(s) form is similar in structure to the consent form. The waiver form begins with spaces to insert the name and address of the owner and the name, species, breed, sex, date of birth, and color/ description of the patient [41] Following those spaces, there is a space to indicate the treatment(s) or test(s) that the client is waiving. [42] Then a short statement indicates that the client has been made aware of the treatment(s) or test(s) which he or she is waiving, as well as the consequences of not getting the recommended treatment(s) or test(s). [43] At the end of this statement, the client absolves the veterinary practice from all liability associated with the lack of care given at the client’s discretion. [44] Finally, there are signature lines for the client and a witness. [45]
            Informed consent is an important concept to the veterinarian client patient relationship because it is part of what defines the boundaries of that relationship. In addition to defining how the veterinarian and the client together make decisions regarding the care of the patient, informed consent also defines how the veterinarian deals with the client. If the veterinarian does not give the client enough information to allow the client to give informed consent, the veterinarian has failed to uphold one of his or her duties to the client and to the patient. Informed consent is rooted in the idea of protecting both the client and the veterinarian. The concept of informed consent is important as it relates to prescription veterinary drugs as well. 

IV. Veterinarians and Prescription Drugs

            The use of prescription drugs to treat veterinary problems is common. Most people expect that if their pets are ill and they take them to the veterinarian, they will get a prescription of some sort. Most people do not think about what rules, if any, govern whether or not they get a prescription for medications or medicated feed. The AVMA does have policies regarding the prescription and use of veterinary medications. [46] The use of veterinary medications, once outside the veterinarian’s office, is hard to determine and regulate. However, the way that veterinarians and veterinary technicians prescribe and use veterinary medications is regulated under the policies of the AVMA, as well as the general regulations incorporated into the Food and Drug Administration’s regulations on animals used for human consumption. [47]
             The policy requiring prescriptions includes Veterinary Feed Directive medicated feeds for food producing animals. [48] These medicated feeds must not be prescribed for use that do not meet the terms of the label. [49] In food producing animals, “extra-label” use of prescription drugs by veterinarians or non-veterinarians is strictly prohibited. [50] In non-food producing animals, the extra-label use of drugs is recognized as necessary. [51] Veterinarians may prescribe drugs to non- food producing patients for extra-label use as long as they follow the guidelines for the use of prescription drugs. [52]
            Under the Principles, a veterinarian must form a VCPR prior to prescribing veterinary medications. [53] Also under the Principles, veterinarians must write a prescription for medications that can not be obtained over-the-counter. The requirement of a written prescription is beneficial to both the client and the veterinarian. This policy is particularly helpful when a client files a complaint against a veterinarian. If the veterinarian can prove that he or she provided the proper medication, or attempted to provide the proper medication, then he or she has a better chance of prevailing in any disciplinary proceedings. On the other hand, if the client can prove with a copy of a written prescription (or the lack of a written prescription) that the veterinarian did not follow the AVMA policy of first considering the needs of the patient, “to relieve disease, suffering, or disability while minimizing pain or fear”, [54] then the client has a better chance of prevailing at any disciplinary proceedings.

V. Disciplinary Actions 

            Under the Principles, a veterinarian needs to follow certain guidelines to avoid undergoing disciplinary proceedings. [55] Disciplinary proceedings can be filed for any number of reasons, including failure to follow state and local regulations regarding medical records, failure to adhere to the ethical requirements like those of the Principles, and for knowingly using false or misleading advertising. [56]  
            Although disciplinary actions may be undertaken if a veterinarian is found to have committed malpractice, the opposite is not always true. If a veterinarian is not found to have committed malpractice, he or she can still be disciplined by his or her state or local veterinary disciplinary board or committee. A disciplinary action undertaken by a state or local disciplinary board does not mean that a veterinarian was necessarily negligent in his or her actions. A disciplinary action simply means that the action(s) of a veterinarian do not comply with the Principles of the AVMA or the state or local policies regarding veterinary actions. If a veterinarian failed to display his or her license according to the state and/or local licensing authorities, that veterinarian could have to deal with a disciplinary action. A malpractice action, however, alleges that the veterinarian was actually act fault (usually through negligence) for injury to the patient. (For more on veterinary malpractice, see the Center's Veterinary Malpractice Topic Area .) 
            Most ethical requirements under the Principles allow for self-regulation and self-discipline of veterinarians. [57] Some requirements, like ones on medical records, defer to the state and local standards for regulation and discipline of their rules. [58] In most states, a separate disciplinary committee or board is set up to deal with problems. [59] The process of taking a case through the disciplinary proceedings committee or board typically involves several steps. [60] In Arizona, for instance, after a client feels a perceived wrong has been done, he or she is expected to talk with the veterinarian, and then with any superiors that veterinarian may have. [61] After doing this, the client can file a complaint with the Arizona State Veterinary Medical Examining Board, Division of Complaints and Investigations. [62] Along with the complaint, the client should send in any documents pertaining to the incident in question, including bills, medical charts, and any notes they have on conversations with the veterinarian(s). [63] The Board is generally made up mostly of veterinarians. [64] The Board will take some time to take a look at all the paperwork and the Board will contact the veterinarian(s) in question. [65] Once the Board has taken a look at the paperwork sent in by both the client and the veterinarian, the Board will schedule a hearing where both the client and the veterinarian can present their sides of the story. [66] At the hearing, the two sides are heard separately. [67] Once the Board has heard both sides, it makes a determination on whether or not to pass the case on to the next level of the process. [68] If the Board decides not to pass the case on, it will be dismissed. [69] If it decides to pass the case on, the case will be fully investigated and the Board may determine whether or not they believe the veterinarian can be held accountable for any perceived wrongdoing. [70] Following this step of the process, the case may be either dismissed or turned over to the disciplinary committee which will make a final determination on whether the veterinarian should be punished and what the punishment should be. [71]  
           To determine if a veterinarian is criminally liable, one must look to the laws of the state where the veterinarian practices. [72] In only a very few jurisdictions, veterinarians are criminally liable when they do not report suspected cases of animal abuse. [73]  (See the Table of Veterinary Reporting and Immunity Laws ). These jurisdictions then usually limit civil and criminal liability when the report of suspected abuse is made in good faith. [74] When veterinarians are not held criminally liable, they may still be subject to discipline from their state veterinary accrediting agency. [75]  
               In Oregon, veterinarians are required to report cases of aggravated animal abuse in an effort to limit the instances of human abuse. [76] Although the penalty for failure to report aggravated animal abuse is not detailed in the statutes, it can be assumed that there are some legal ramifications, including but not limited to disciplinary proceedings being undertaken by the veterinarian accrediting agency of Oregon. [77] In most instances, failure to follow the regulations set forth by the state accrediting agency result in fines and other similar penalties. [78] The same can be said of penalties for failure to follow the regulations set forth in other states. [79]  
            Veterinarians are not generally required to cross-report potentially criminal situations to other state agencies. However, veterinarians may be required to report suspected cases of spousal or child abuse. Or, as in Oregon, veterinarians may be required to report cases of aggravated animal abuse, which could indicate future cases of aggravated spousal or child abuse according to the Legislative Assembly. [80]   Traditionally, veterinarians are immune from liability for reporting suspected or known cases of animal cruelty. Veterinarians are also traditionally immune from criminal animal cruelty statutes for actions that are traditional veterinary practices. So, for example, if an animal is injured during a common examination, the veterinarian will probably be immune from any cruelty to animals statutes in his or her state. On the other hand, if the veterinarian’s actions are not within the scale of traditional veterinary practices, the state or municipality will be able to hold that veterinarian criminally liable for his or her actions.
            In addition to the Principles, the AVMA approved the “Prevention and Resolution of Grievances” policy. [81] This 2004 policy consists of 5 policy statements. [82] The first policy statement requires veterinary colleges continue to emphasize “professionalism, ethics, practice management, and veterinary-client-patient relations” in their studies. [83] The second policy statement requires schools for veterinary technicians to emphasize professionalism and veterinary-client-patient relations. [84] The third policy statement speaks to those who plan continuing education classes. [85] This policy statement asks that those planning continuing education courses include courses on professionalism, ethics, client relations, and the art of practice. [86] The fourth policy statement is that complaints should be handled by veterinary medical associations and their designated committees before going to the state veterinary medical examining board. [87] And, the fifth policy statement indicates that whenever possible, there should be an ethics-grievance committee or a peer-review committee in place to handle complaints. [88]
            Taken together, the Principles and the Prevention and Resolution of Grievances policy create a fairly solid basis for solving disputes over the quality and effectiveness of veterinary care. Together, the Principles and the Prevention and Resolution of Grievances policy give veterinarians, their clients, and state veterinary accrediting agencies guidelines for dealing with the conflicts that may arise during the normal course of veterinary-client-patient relationships. When there is a conflict between veterinarian and client, having knowledge of the process through which the client’s claims and the veterinarian’s actions are investigated can be very essential for the client. If the client has knowledge of what the process is, the client can fill out and take all of the proper paperwork to the hearings. The client can also use this information to make sure that he or she does not waste the time of the committee or board that will be hearing these cases, as well as their own time, by filing a complaint with the committee or board. 
            While the requirements for bringing a grievance action against a veterinarian may seem insurmountable to those attempting to seek retribution for a veterinarian’s actions, the requirements actually do create a balance which helps to prevent veterinarians from actions brought by clients who were simply unhappy with the actions of the veterinarian.

VI. Conclusion

            Veterinarians are bound to help both their clients and their patients by an ethical duty. This duty is extended to the care of the public under ethical guidelines illustrated by the AVMA Principles. Through their actions, veterinarians help people and our beloved pets. The relationships of veterinarians and their clients and patients are governed by state rules and regulations as well as ethical duties. These governing rules generally require the veterinarian to behave professionally with regard to his or her patients and clients. The rules also require the veterinarian to be honest and forthcoming in all of their dealings with both their clients and the public at large. Failure to follow these rules means that a veterinarian may be punished in one of many ways. Some punishments are fines, others are more severe, including the possibility of license revocation or even criminal liability for the actions taken (or not taken, in some instances) by the veterinarian. In a veterinary medical care situation, the veterinarian is often dealing with a pet that is considered to be a member of the family. Disciplinary provisions are put into place by the AVMA and state and local veterinary practice governing bodies to protect the relationship of a family pet as patient and a veterinarian as caregiver. The existence of disciplinary policies and procedures serves as a balance between the emotions and desires of the pet owner and the standards and practices of the veterinarian.