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Paper

Ethical dilemmas encountered by small

animal veterinarians: characterisation,
responses, consequences and beliefs
regarding euthanasia
Barry Kipperman,1 Patricia Morris,2 Bernard Rollin3

Small animal veterinarians’ opinions were investigated regarding the frequency and nature of ethical dilemmas
encountered, beliefs regarding euthanasia and balancing client and animal interests, prevalence and value of
ethics training and proposals to mitigate the stressful effects of ethical dilemmas. The majority (52 per cent)
of 484 respondents in the USA indicated via an online survey experiencing an ethical dilemma regarding the
interests of clients and those of their patients at least weekly. Scenarios involving client financial concerns were
commonly reported causes of ethical conflicts. While only 20 per cent of respondents indicated that other prac-
titioners prioritise patient interests, 50 per cent of respondents characterised their own behaviour as prioritising
patients. Most respondents (52 per cent) reported that ethical dilemmas are the leading cause, or are one of many
equal causes, of work-related stress. Less experienced practitioners, general practitioners and associate veteri-
narians were more likely to encounter situations they defined as ethical dilemmas, and female respondents were
more likely to find ethical dilemmas stressful. Most small animal veterinarians experience ethical dilemmas regu-
larly, which contribute to moral stress. Results suggested that most small animal practitioners believe that greater
awareness of moral stress and providing training in ethical theories and tools for coping with ethical dilemmas
can ameliorate moral stress.

Introduction Ethics4 are also ambiguous regarding professional advo-

Small animal veterinarians in practice encounter cacies asserting as the first principle that, 'The choice
conflicts between satisfying the interests of the pet of treatments or animal care shall not be influenced by
owner and those of the animal.1 2 The American Veter- considerations other than the welfare of the patient,
inary Medical Association (AVMA) Veterinarian’s Oath3 the needs of the client, and the safety of the public’, yet
provides no guidance in prioritisation of a veterinar- declaring under supporting annotations that ‘Veteri-
ian’s varied obligations: “…I… swear to use my scien- narians should first consider the needs of the patient’
tific knowledge … for the benefit of society through the (American Veterinary Medical Association Principles).
protection of animal health and welfare,…the promo- In contrast to these US codes of conduct, the UK code
tion of public health, and the advancement of medical of conduct more explicitly advises an animal advo-
knowledge" (American Veterinary Medical Associa- cacy position: 'On occasions, the professional respon-
tion oath). The AVMA Principles of Veterinary Medical sibilities in the Code may conflict with each other and
veterinary surgeons may be presented with a dilemma.
In such situations, veterinary surgeons should balance
Veterinary Record (2018) doi: 10.1136/vr.104619 the professional responsibilities, having regard first to
animal welfare’ (Royal College of Veterinary Surgeons
1
Department of Veterinary Medicine E-mail for correspondence:
and Surgery, College of Veterinary ​kippermanb@​missouri.​edu (RCVS) Code of Professional Conduct for Veterinary
Medicine, University of Missouri, Provenance and peer review Not
Surgeons and Supporting Guidance).5
Columbia, Missouri, USA commissioned; externally peer Ethical dilemma arise when there are competing
2
Department of Sociology, California reviewed. interests of equal moral weight, and there is no obvi-
State University, Sacramento,
ous way to prioritise one responsibility over others.6 In
California, USA Received July 18, 2017
3
Department of Philosophy, Colorado a study of ethical dilemmas, 57 per cent of veterinari-
Revised December 17, 2017
State University, Fort Collins, Colorado, Accepted January 28, 2018 ans in the UK reported facing 1–2 ethical dilemmas per
USA week, and 34 per cent of practitioners encountered an

Vet RecorD |  1
ethical dilemma 3–5 times per week.7 Moreover, 78 per
cent of the veterinarians in that study felt that they were
not given enough, or in many cases any, ethics edu-
cation during their training. Results of another study8
indicate that only 30 per cent of AVMA Counsel On Ed-
ucation accredited veterinary schools in the USA that
responded to a survey, reported offering a formal course
in ethics. The non-specific attributions within the US or-
ganisational principles (AVMA oath, AVMA principles)
regarding how to prioritise satisfying the interests of an-
imals, pet owners and the veterinarian, and the global
dearth of ethics instruction in training programmes,7–11
provide little direction to veterinarians in navigating
ethical conflicts.
Bernard Rollin12 13 defines a unique type of angst
experienced by veterinarians as a result of ethical di-
lemmas as moral stress. Moral stress arises from the
tension between what one feels one ought to be doing
or the ideal of the professional, and reality. Kipperman
and others14 documented that 49 per cent of small ani-
mal practitioners in the USA reported moderate-to-sub-
stantial burnout. In a survey in the UK, 83 per cent of
veterinarians agreed that veterinary medicine was a
stressful occupation.15 Decisions regarding euthanasia
are common causes of moral stress for veterinarians,
especially if economic considerations are perceived to
be the basis for these determinations.14 16–23 A veterinar-
ian may choose to comply with euthanasia requests,
dissuade the client or decline such requests.17 21 Yeates
and Main24 identified that 97 per cent of veterinarians
in the UK reported refusing euthanasia requests less
often than yearly, suggesting that such decisions are
uncommon.
With regard to the responsibility of the veterinarian
when faced with ethical conflicts, Main25 has argued
for a patient advocacy position: "… The obligation to
the animal’s best interest is greater than a concern for
the psychological well-being of the client. If we placed
a higher value on clients’ sensitivities, then our duty
as animal advocates would not be fulfilled". However,
results of a US survey26 demonstrate that as veterinar-
ians age, willingness to comply with client’s wishes
increased relative to the interests of patients. Given the
importance of decisions associated with ethical dilem-
mas to animal welfare, animal owners and veterinari-
ans, there is limited scientific literature examining how
veterinarians balance or prioritise client and animal in-
terests when these are at odds, the relationship between
specific clinical situations veterinarians encounter and
stress7 27 or the opinions of small animal veterinarians
regarding the ethical context of euthanasia.22 24 28 29
The purpose of the small animal practitioner survey
reported here was to assess the frequency with which
ethical dilemmas between client and patient interests
occur; identify some of the common circumstances that
cause ethical dilemmas; determine the degree of mor-
al stress elicited by these conditions; characterise the
2 | Vet Record
views of practitioners regarding euthanasia decisions;
determine the methods veterinarians use to resolve eth-
Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
ical dilemmas; determine which interest veterinarians
prioritise when client and patient interests conflict; as-
sess measures that might reduce the impact of ethical
dilemmas; document the prevalence of ethics training
and the influence of such training on managing ethical
dilemmas and evaluate differences among veterinari-
ans regarding ethical dilemmas on the basis of gender,
practice role (owner vs associate), practice type (refer-
ral vs other), years of practice experience, age or num-
ber of veterinarians in the practice.
Materials and methods
Survey design
A pilot survey was developed and administered to
a select group of 12 small animal practitioners who
evaluated the survey for clarity and completeness,
and the survey was revised and refined on the basis of
their feedback. The Human Ethical Review Committee
at the University of Edinburgh approved the survey
in May 2016. The final survey consisted of 5 sections
and 29 questions and took approximately 20 min to
complete. The first section provided a number of clin-
ical scenarios which were selected because they may be
associated with ethical dilemmas, and focused on how
often these situations are encountered; the percentage
of these encounters that would be classified as ethical
dilemmas; the degree of moral stress these cause and
how often any type of ethical dilemma between satis-
fying the interests of clients and patients is encoun-
tered. The second section posed questions regarding
use of euthanasia as an aid or method to resolve ethical
dilemmas or difficult cases when this may not be in
the best interest of the patient; whether euthanasia of
animals using acceptable methods is always an ethical
procedure regardless of reason or circumstance; the
frequency with which client requests for euthanasia
are declined and reasons for reluctance to decline
euthanasia requests. The third section focused on the
values of respondents via ranking of varied interests
when making decisions that involve ethical dilemmas,
and which interests are prioritised when animal and
client interests are at odds. The fourth section posed
questions regarding methods used to address ethical
dilemmas; the prevalence of approaches to address
ethical dilemmas in training programmes and the value
of such training in addressing ethical dilemmas. The
final section focused on the impact of ethical dilemmas
on work-related stress, and the potential of varied
proposals to ameliorate the consequences of such
stress. The questionnaire is available on request to the
corresponding author.
Survey distribution
An email containing an invitation to participate in
the survey and a link to the survey was distributed to
4100 members of the California Veterinary Medical TABLE 1: Frequency with which small animal veterinarians encounter an
Association, 4400 members of the Humane Society

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ethical dilemma between satisfying the interests of their clients and those
Veterinary Medical Association, 93 members of the of their patients
Society for Veterinary Medical Ethics and 1309 small Frequency Percentage

animal specialists of the American College of Veteri- Multiple times daily 13.1
nary Internal Medicine. Those who belonged to more Once a day 5.8

than one organisation received multiple invitations to
the survey. Veterinarians without small animal experi-
ence were excluded from participation. The survey was
conducted from September 30, 2016 to November 3,
2016, and participation in the survey was voluntary
and anonymous.
Data analysis
Responses to survey questions were tabulated and
descriptive statistics (number and percentage) were
generated. Responses were compared on the basis of
year of graduation from veterinary school, practice role
(owner vs associate), respondent gender, practice type
(referral vs non-referral), year of birth, number of veter-
inarians in the practice and self-reported patient advo-
cacy. The Wilcoxon rank-sum statistical test and Mann-
Whitney U test were used for comparisons between two
groups in which the dependent variable was ordinal,
and Spearman's correlation coefficient was used to
quantify the magnitude of the relationship between
ordinal variables. Independent samples t tests were
used for comparisons between two groups in which the
dependent variable was continuous, and the Pearson's
correlation coefficient was used to quantify the magni-
tude of the relationship between continuous variables.
Logistic regression was performed when multiple inde-
pendent variables were used to predict the value of a
dichotomous dependent variable. All analyses were
performed with statistical software (IBM SPSS Statistics
for Windows, V.22) and values of P<0.05 were consid-
ered to be statistically significant.
Results
Study participants
Responses were received from 600 veterinarians; 116
respondents were excluded because they failed to
answer at least 50 per cent of the survey questions.
Thus, responses from 484 veterinarians were evalu-
ated. One hundred and eighty (37 per cent) respond-
ents were members of the Humane Society Veterinary
A few times a week 25.6
Once a week 7.7
A few times a month 23.9
Once a month 6.0
A few times a year 14.1
Once a year 2.1
Every few years 1.2
Never 0.4
cent), mixed animal (1.2 per cent) and academic prac-
tice (1 per cent); 4.5 per cent of respondents reported
work in a non-listed category.
Of the 484 respondents, 31 per cent were categorised
as referral practitioners (RP: defined as practitioners
in emergency, specialty or academic type), and 69 per
cent were categorised as general practitioners (GP). Of
481 respondents, 33 per cent identified themselves as
practice owners and 67 per cent identified themselves
as associate or relief veterinarians (ie, non-owners),
and 80 per cent were female and 20 per cent were male.
The median number of years in practice for the re-
spondents was 20 (range, 0–53 years). The median age
of respondents was 50 years (range, 25–86 years). The
median number of full-time practitioners affiliated with
each respondent’s practice was 3 (mean=8).
Frequency of ethical dilemmas
The frequency with which veterinarians encountered
any type of ethical dilemma between satisfying the
interests of their clients and those of their patients is
shown in Table 1. The median frequency with which
practitioners encountered ethical dilemmas was
once a week, and 19 per cent of respondents reported
encountering such an ethical dilemma at least once a
day. Female respondents (21.4 per cent) were more
than twice as likely as males (9.3 per cent) to report
experiencing frequent (at least once a day) ethical
dilemmas. A logistical analysis (Table 2) was performed
TABLE 2: Logistic regression model on the likelihood of a respondent
experiencing ethical dilemmas at least once per day.

Medical Association, 135 (28 per cent) were members OR

Variable B se Sig. Exp(B)
of the California Veterinary Medical Association, 127
  (Intercept) −0.805 0.343 0.019 0.447
(26 per cent) were members of the American College of
Gender (ref: male) 0.078 0.332 0.814 1.082
Veterinary Internal Medicine and 23 (5 per cent) were Female
members of the Society for Veterinary Medical Ethics. Ownership (ref: yes) 0.618 0.299 0.039 1.855
The largest proportion (45 per cent) of respondents No

reported working in small animal general practice, while Practice type (ref: RP) 1.057 0.304 0.001 2.882
General practitioners
27.5 per cent reported working in specialty or referral Years of experience (ref: >15) 0.911 0.301 0.002 2.487
practice; other practice types included shelter medi- <15 years
cine (6.2 per cent), relief (5.6 per cent), mobile (3.9 per Model χ2=32.576, df=4, P<0.001.

cent), emergency (2.9 per cent), feline only (1.9 per RP, referral practitioner.

Vet RecorD |  3
TABLE 3: Frequency with which the respondents encounter clinical scenarios associated with ethical dilemmas

Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
Financial limitations compromise Euthanasia based on lack of Euthanasia based on Therapeutic trial elected instead
Frequency patient care (%) means (%) unwillingness to treat (%) of testing (%)
Multiple times a day 36.4 1.0 0 23.4
Once a day 11.8 2.5 1.2 9.5
A few times a week 27.7 7.9 2.1 28.6
Once a week 6.6 8.3 2.9 8.1
A few times a month 9.7 17.8 12.4 18.0
Once a month 2.9 13.2 10.1 4.5
A few times a year 3.3 33.5 40.1 4.8
Once a year 0.0 4.8 11.0 1.0
Every few years 0.4 7.4 12.6 0.2
Never 1.0 3.7 7.6 1.9

to determine whether gender or career trajectory varia-
bles best predict the probability of reporting frequent
ethical dilemmas. Associates, GP and those with less
veterinary work experience were each associated with
an increased probability of reporting frequent ethical
dilemmas. Maintaining all other covariants constant,
the odds of reporting frequent ethical dilemmas were
1.855 times greater for associates as compared with
owners (P=0.04), 2.882 times greater for GP relative
to RP (P=0.00) and 2.487 times greater for less experi-
enced (under 15 years) veterinarians as compared with
their more experienced counterparts (P=0.00). Gender
was analytically and statistically insignificant after the
inclusion of these other variables.
Commonly encountered ethical dilemmas
The frequencies with which veterinarians encounter
specific clinical scenarios, which may be associ-
ated with ethical dilemmas are presented in Table 3.
Scenarios involving owner financial concerns were the
most commonly reported causes of potential ethical
conflicts. Client financial limitations compromising
patient care and having to perform empirical ther-
apeutic trials instead of diagnostic testing because
of costs or owner preference, were reported to occur
most often, both with a median reported frequency of
a few times a week. Approximately three-quarters of
respondents reported encountering economic limita-
tions compromising patient care at least a few times
per week, and 48 per cent reported experiencing these
limitations at least once or multiple times per day.
Euthanasia requests perceived to be based on lack
of financial means occurred with a reported median
frequency of once a month, followed by euthanasia
requests where the respondent believed this decision
was due to client unwillingness to pay for treatment,
with a median frequency of a few times a year.
The percentage of clinical scenarios which veterinar-
ians classified as ethical dilemmas is shown in Table 4.
While 29 per cent of respondents reported that econom-
ic limitations compromising patient care were consid-
ered an ethical dilemma at least 50 per cent of the time,
39 per cent considered having to perform an empirical
therapeutic trial instead of diagnostic testing because
of costs or owner preference was considered an ethical
dilemma at least 50 per cent of the time, 51 per cent of
respondents felt that euthanasia requests which were
perceived to be based on lack of financial means were
considered an ethical dilemma at least 50 per cent of
the time and 66 per cent of respondents reported that
euthanasia requests believed to be due to client unwill-
ingness to pay for treatment were considered an ethical
dilemma at least 50 per cent of the time.
Comparisons between RP and GP regarding ethical dilem-
mas
Regarding client financial limitations compromising
patient care, GP reported significantly (P=0.011) greater
median frequency of such encounters (once a day) than
RP (a few times a week), GP indicated significantly

TABLE 4: The percentage of clinical scenarios which respondents classified as ethical dilemmas.
Percentage classified as ethical Financial limitations compromise Euthanasia based on lack of Euthanasia based on Therapeutic trial elected instead
dilemmas patient care (%) means (%) unwillingness to treat (%) of testing (%)
90%–100% 5.8 19.3 36.5 3.6
80%–89% 3.8 8.3 6.4 2.9
70%–79% 6.5 10.0 9.8 7.4
60%–69% 3.5 4.0 4.0 6.5
50%–59% 9.2 9.1 8.9 18.7
40%–49% 5.2 4.4 3.8 7.2
30%–39% 10.0 5.5 5.3 11.4
20%–29% 12.1 7.6 4.7 14.3
<20% 39.0 26.9 14.6 23.4
Never 4.8 4.9 5.9 4.6

4 | Vet Record
(P=0.001) more encounters of this nature as an ethical
dilemma (median=20 per cent–29 per cent) than did
RP (median=<20 per cent) and moral stress ratings for
this circumstance for GP were significantly (P=0.001)
greater than the corresponding ratings for RP (median
response for both groups was ‘moderate’). In general,
GPs were more likely to report greater moral stress
from the presented scenarios causing ethical dilemmas
compared with RP.
Beliefs regarding euthanasia
When asked to indicate their level of agreement on
a 5-point Likert scale with the statement, 'Veterinar-
ians sometimes use euthanasia as an aid or method
to resolve difficult cases when this may not be in the
best interest of the patient’, 45 per cent of respondents
agreed and 37 per cent disagreed. The level of agree-
ment did not differ significantly between male (agree)
and female (neutral; P=0.16) respondents, based on
years of experience (P=0.45, Spearman’s r=0.035), or
between RP (agree) and GP (neutral; P=0.08). When
respondents were asked whether they had ever used
euthanasia as an aid or method to resolve difficult
cases when it may not be in the best interest of the
patient, 42 per cent of practitioners reported that they
had done this at least once in their career. Most (83 per
cent) respondents did not agree that the euthanasia of
animals using acceptable methods is always an ethical
procedure regardless of reason or circumstance. Opin-
ions regarding whether the euthanasia of animals
using acceptable methods is always an ethical proce-
dure regardless of reason or circumstance did not differ
significantly (P=0.20) between male (agree=22 per
cent) and female (agree=16 per cent) respondents,
between RP (agree=15 per cent) and GP (agree=18 per
cent; P=0.42) or based on years of experience (P=0.13,
Pearson’s r=0.079).
The majority (80 per cent) of respondents reported
to have declined a euthanasia request at some point in
their career; of these, 52 per cent reported that they de-
cline euthanasia requests every few years, while 32 per
cent reported to decline such requests at least a few
times a year. The most common reasons respondents
provided for reluctance to decline euthanasia requests
were fear that the client may seek other options which
could worsen the animal’s welfare (65.3 per cent), diffi-
culty declining such requests once a client had reached
this decision (50.8 per cent) and concern that declining
euthanasia requests may jeopardise respondent rela-
tionship with the client (15.1 per cent). Respondents
who reported prioritising patient interests relative to
client interests were significantly (P<0.00) more likely
to decline euthanasia requests.
Balancing client against animal interests
When asked for their opinion regarding which interest
is prioritised by other small animal practitioners when
Vet RecorD | 
the interests of clients and animals conflict, 57 per
cent of respondents characterised the client as being
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prioritised, whereas 20 per cent reported clients and
patients were equally prioritised, 20 per cent reported
the interests of the patient as being prioritised and 3 per
cent felt the veterinarian’s interest was prioritised. Half
of the respondents characterised their own behaviour
as prioritising the interests of the patient when the
interests of clients and animals conflict, whereas 32 per
cent reported prioritising clients and patients equally,
16 per cent reported prioritising the client’s interest,
while only 2 per cent reported to prioritise their own
interests.
There was no significant (P=0.15) difference between
RP (patient=24 per cent) and GP (patient=17 per cent)
regarding the perception of which interest is prioritised
by colleagues when the interests of clients and animals
conflict. There were no significant differences regard-
ing which interest respondents prioritised when the
interests of clients and animals conflict between male
(patient=46 per cent) and female (patient=52 per cent;
P=0.34) respondents, between owners (patient=52 per
cent) and associates (patient=50 per cent; P=0.77), be-
tween RP (patient=52 per cent) and GP (patient=50 per
cent; P=0.82) or based on years of experience (P=0.44,
Spearman’s r=0.035). Respondents who characterised
their own behaviour as prioritising patient interests
were significantly (P=0.03) more likely to report eutha-
nasia requests perceived to be based on lack of finan-
cial means as an ethical dilemma (median response was
50 per cent–59 per cent) and were significantly (P=0.01)
more likely to rate these situations as stressful (median
response was ‘high’), compared with respondents se-
lecting all other advocacy behaviours (corresponding
median responses were 40 per cent–49 per cent, and
‘moderate’), respectively.
Resolution of ethical dilemmas and ethics training
Using a 6-point ordinal scale from 1=never to
6=very frequently, respondents reported how often
they used the following methods to address ethical
dilemmas; my gut instinct based on my personal value
system (median rating was 6), consultation with friends
or colleagues (median rating was 5), guidance from
my training (median rating was 5), examples set by
my colleagues (median rating was 4), guidance from
written policies of state or national veterinary organ-
isations (median rating was 4) and consideration of
varied ethical theories (median rating was 3) was
used least often. The proportion of respondents who
reported having received training in their curriculum
regarding approaches to address ethical dilemmas
was nearly evenly split, with 51 per cent of respond-
ents receiving ethics training. Those respondents who
reported receiving ethics training were asked whether
they believed such training adequately prepared them
to address ethical dilemmas in practice. On a 5-point
5
 TABLE 5: Moral stress ratings of respondents regarding clinical scenarios associated with ethical dilemmas.

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Financial limitations compromise Euthanasia based on lack of Euthanasia based on Therapeutic trial elected instead
Moral stress rating patient care (%) means (%) unwillingness to treat (%) of testing (%)
Very high 9.0 18.9 35.2 2.6
High 14.9 26.0 20.4 7.2
Moderate 37.2 28.3 24.2 34.8
Low 23.9 13.0 7.3 33.7
Very low 11.6 9.6 5.8 15.6
None 3.4 4.3 7.1 6.2

ordinal scale ranging from strongly agree to strongly
disagree, 39 per cent of respondents agreed that
such instruction prepared them to address the ethical
dilemmas they encounter, 38 per cent were neutral
regarding the benefits of ethics instruction in addressing
ethical dilemmas and 23 per cent of respondents disa-
greed that ethics training prepared them to address
ethical dilemmas.
Effect of ethical dilemmas on moral stress
Respondents were asked to rate the degree of moral
stress elicited by varied clinical scenarios associated
with ethical dilemmas (see Table 5). Most respond-
ents characterised the clinical scenarios associated
with client economic concerns as causing at least a
moderate degree of moral stress, except for the scenario
of having to perform therapeutic trials based on cost or
client preference. Slightly less than half (45 per cent) of
the respondents reported moderate to very high stress
scores (median response was ‘low’) when having to
perform empirical therapeutic trials instead of diag-
nostic testing based on cost or client preference; 61 per
cent of respondents reported moderate to very high
stress scores (median response was ‘moderate’) when
encountering economic limitations compromising
patient care; 73 per cent of respondents reported
moderate to very high stress scores (median response
was ‘moderate’) when encountering euthanasia
requests believed to be due to lack of financial means
and 80 per cent of respondents reported moderate to
very high stress scores (median response was ‘high’) for
the scenario where euthanasia is requested because the
respondent believes that the client is unwilling to pay
for treatment.
Opinions regarding the effect of ethical dilemmas
on work-related stress included attributing ethical di-
lemmas as ‘the leading cause’ (9.1 per cent), as ‘one of
many equal causes’ (42.4 per cent), ‘moderate contribu-
tion, but other things affect stress more’ (32.3 per cent),
‘minimal contribution, many other things affect stress
more’ (16.0 per cent) and ‘no effect’ (0.2 per cent).
Logistic regression was used (Table 6) to examine the
factors that predict when ethical dilemmas were consid-
ered a leading source of stress, that is, when respond-
ents considered ethical dilemmas as either ‘the leading
cause’ or ‘one of many equal causes’. Variables includ-
ed respondent gender, career-related variables such as
ownership status, work experience and whether the
respondent is RP or GP, whether or not the respondent
reports to experience ethical dilemmas at least once a
day and whether or not the respondent prioritises the
patient when client and patient interests conflict. Re-
sults were statistically significant for gender (P<0.00),
years of experience (P=0.04) and frequency of ethical
dilemmas (P<0.00). Maintaining all other covariants
constant, the odds of considering ethical dilemmas a
leading source of stress were 3.041 times greater for
females relative to males, 1.565 times greater for less
experienced veterinarians relative to more experienced
and 2.87 times greater for those who report to expe-
rience ethical dilemmas at least once a day relative to
those who report experiencing them less often.

TABLE 6: Logistic regression model on the likelihood of respondents defining ethical dilemmas as a leading cause of work-related stress
OR
Variable B se Sig. Exp(B)
 (Intercept) −0.889 0.318 0.005 0.411
Gender (ref: male) 1.112 0.260 0.000 3.041
Female
Ownership (ref: yes) −0.228 0.233 0.216 0.750
No
Practice type (ref: RP) 0.178 0.216 0.408 1.195
General practitioners
Years of experience (ref: >15) 0.448 0.223 0.045 1.565
<15 years
Frequency of dilemma (ref: <1/day) 1.054 0.263 0.000 2.870
Greater or=once per day
Conflicting interest (ref: client) 0.228 0.195 0.243 1.256
Prioritising patient
RP, referral practitioner.

6 | Vet Record
 TABLE 7: Percentages of small animal practitioners who indicated
effective or very effective opinions regarding various proposals for
reducing moral stress from ethical dilemmas.
Proposal
Training and tools for coping with ethical dilemmas
Greater awareness of moral stress and burnout
Increased access to support services
Greater awareness of costs of veterinary care among pet owners
Greater acceptance that it is ethical to decline euthanasia requests
Greater acceptance that veterinarians are limited by wishes of pet owner
Ethical guidelines from veterinary organisations
Proposals for mitigation of moral stress
Opinions regarding various proposals for reducing
moral stress are presented in Table 7. The proposals that
most respondents indicated would be effective or very
effective in reducing moral stress among veterinarians
were greater awareness within the profession of moral
stress and burnout (83.9 per cent), modify veterinary
school curricula to include specific training in ethical
theories and tools for coping with ethical dilemmas
(83.9 per cent), increased access to counselling and
support services (77.8 per cent) and greater aware-
ness of the costs of veterinary care among pet owners
(74.9 per cent); 38 respondents cited other options.
Discussion
The majority (52 per cent) of the small animal practi-
tioners in the USA that responded to the present survey
reported experiencing an ethical dilemma between
satisfying the interests of their clients and those of their
patients at least once a week, with 19 per cent reporting
encountering ethical dilemmas at least daily. Among
the clinical scenarios provided, the two most common
dilemmas respondents encountered included client
financial limitations compromising patient care and
having to perform empirical therapeutic trials instead
of diagnostic testing because of costs or owner prefer-
ence, with a median response for both of a few times a
week. These results concur with studies that found that
Danish and the US small animal veterinarians encoun-
tered economic limitations regularly.14 23 Although
only 29 per cent of respondents considered financial
limitations to patient care to be an ethical dilemma
the majority of the time, the absolute number of these
conflicts is still high given the frequency with which
this type of encounter was reported. Moreover, financial
limitations to care may lead to economic euthanasia at
a later time, which most respondents considered to be
an ethical dilemma at least 50 per cent of the time these
situations are encountered.
Regarding the frequency with which small animal
practitioners encounter economic euthanasia, results
were mixed. The median frequency of requests for eu-
thanasia where the respondent perceived this to be
based on lack of financial means was once a month,
and the median response for euthanasia requests where
Vet RecorD | 
the respondent believed this decision was due to client
unwillingness to pay for treatment, was a few times a
Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
year. However, 22 per cent of respondents reported ex-
Percentage periencing one or both types of economic euthanasia at
83.9 least once a week.
83.9 Female respondents were more likely than males to
77.8 report experiencing ethical dilemmas, and were much
74.9
more likely to experience them at least once a day.
66.2
However, almost all of this relationship was explained
57.7
by the lower rate of practice ownership, fewer years of
53.9
work experience and decreased probability of being a
referral veterinarian, among females. In the present
survey, more experienced practitioners were less likely
to report the scenarios we provided as an ethical dilem-
ma. It is reasonable to presume that with experience a
practitioner would develop improved moral reasoning
skills, which is the process by which people determine
that one course of action is morally right and another
course of action is morally wrong. However, moral rea-
soning scores among veterinarians in the UK did not
improve with years of experience, which disputes this
assumption.30 Alternatively, experienced practitioners
over time may become desensitised to circumstances
that novice colleagues may find ethically problematic.
Contrary to the findings of previous research of small
animal veterinarians in the USA14 where RP were more
likely to encounter financial limitations than GP, refer-
ral practitioners in this survey encountered financial
limitations affecting patient care less frequently and
were less likely to consider these situations an ethical
dilemma when encountered, compared with GP. One
explanation for this finding is that RP may encounter
fewer financial limitations because they may see a se-
lect subset of clients who are more motivated, and may
be more capable of committing financial resources to-
wards veterinary care. GPs were more likely to report
greater moral stress from the presented ethical dilem-
mas compared with RP. As GP often have long-standing
relationships with their clients, it is possible that they
empathise more with the plight of the client compared
with RP.
More respondents in the present survey agreed
(45 per cent) than disagreed (37 per cent) that veteri-
narians use euthanasia as an aid or method to resolve
difficult cases when this may not be in the best interest
of the patient, and 42 per cent of practitioners report-
ed that they had done this at least once in their career.
Rollin13 suggests that euthanasia is a double-edged
sword, referring to its potential benefit in ending termi-
nal suffering, but noting that it can also be performed in
circumstances that when scrutinised, appear less com-
pulsory. The AVMA Guidelines for the Euthanasia of
Animals31 are ambiguous regarding the basis of eutha-
nasia decisions, noting, 'Impacts on animals may not
always be the center of the valuation process, and there
is disagreement on how to account for conflicting inter-
specific interests'. The RCVS Code of Conduct5 is more
7
specific on this issue: 'The veterinary surgeon's primary
obligation is to relieve the suffering of an animal, but
account must be taken not only of the animal's condi-
tion, but also the owner's wishes and circumstances’
(Royal College of Veterinary Surgeons Code of Profes-
sional Conduct for Veterinary Surgeons and Supporting
Guidance).
Convenience euthanasia refers to circumstances
where the primary rationale for this request is based on
human needs such as economics, changes in personal
circumstances, lack of time, capacity or desire to care
for the animal, rather than animal welfare.7 28 32 Results
of a study of Canadian practitioners by Rathwell-Deault
and others32 indicate that decisions regarding conveni-
ence euthanasia were made mostly by considering the
veterinarian's and the client's/owner's interests. Our
findings suggest that small animal practitioners some-
times perform euthanasia when this is not justified
based on animal welfare considerations.
Although practitioners admitted performing eutha-
nasia when this may not serve animal interests, only
17 per cent of respondents believed that euthanasia of
animals using acceptable methods is always an ethical
procedure regardless of reason or circumstance. Eutha-
nasia derives from the Greek roots of ‘a good death’ and
in human semantics is restricted to circumstances of
mercy killing, in which death is viewed as a respite from
inevitable suffering.33 The AVMA Guidelines on Eutha-
nasia in 200734 defined euthanasia solely by method
and outcome: ‘…The act of inducing humane death in
an animal’. In 2013, the AVMA Guidelines for the Eu-
thanasia of Animals31 expanded this limited designa-
tion and define euthanasia by method (‘A good death is
… the humane termination of an animal’s life’), and by
intention (‘… ending the life of an … animal in a way that
… eliminates pain and distress'). Our finding that most
respondents reject the notion that euthanasia is always
an ethical procedure regardless of rationale, suggests
that small animal veterinarians in the USA repudiate
method-based, value-free definitions of euthanasia. An
intention-based definition of euthanasia that centres on
benefiting the recipient may provide clearer guidance to
veterinarians as they confront euthanasia decisions.
While 80 per cent of practitioners in this survey in-
dicated having declined a euthanasia request, these
decisions were uncommon (median frequency was
every few years). The most common reason cited by re-
spondents for reluctance to decline euthanasia requests
was fear that the client may seek other options, which
could worsen the animal’s welfare. Studies by Yeates
and Main24 and Morris21 confirm our finding that fear
may be the main reason why some veterinarians are re-
luctant to decline euthanasia requests, and suggest this
concern acts as a rationalisation to help practitioners
cope with difficult end-of-life decisions in which they
may feel guilt or another negative emotion. A potential
consequence of such reasoning is that veterinarians
8 | Vet Record
may change their attitudes towards euthanasia over
time, coming to perceive it as more acceptable.20 21 35
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Corroborating this theory, a study by Ogden and oth-
ers28 in the UK suggests that tolerance of convenience
euthanasia may increase over time as students in their
early stages of study were found to score lower on an
acceptance scale of convenience euthanasia compared
with students in their clinical years and recently gradu-
ated veterinarians.
The second most common reason cited by the re-
spondents in this survey for reluctance to decline eu-
thanasia requests was the difficulty in doing so once a
client had reached this decision. The AVMA Guidelines
for the Euthanasia of Animals31 encourage deliberation
and discussion rather than acquiescence: 'There may
be instances in which the decision to kill an animal is
questionable, especially if the animal is predicted to
have a life worth living…In this case, the veterinarian,
as…animal advocate, should be able to speak frankly
about the animal’s condition and suggest alternatives
to euthanasia’. In accord with other research on US
veterinarians,21 multiple respondents commented that
they felt discouraged in exercising their discretion re-
garding refusal of euthanasia requests and sensed peer
pressure from employers or hospital administrators to
comply with euthanasia requests that conflicted with
their personal values. These findings suggest there may
be benefit to training in veterinary curricula emphasis-
ing navigating challenging end-of-life decisions, and in
particular, encouraging students to feel comfortable ad-
vocating for alternatives to euthanasia when this may
not be in an animal’s interest.
A fundamental ethical problem is whether veterinar-
ians should give primary consideration to the animal or
to the client.18 36–38 However, a barrier discouraging the
animal advocacy position is economic; the veterinarian
is dependent on the pet owner who pays for veterinary
services.25 Results of a survey39 of Australian veterinary
students supported an animal advocacy posture, as
96 per cent agreed that, "My primary focus as a veteri-
narian should be the interests of all animals in my care".
In the present survey, only 20 per cent of respondents
indicated that they believed other practitioners priori-
tise the interests of the patient, and only 50 per cent of
respondents described their own behaviour as prioritis-
ing patient interests. These findings raise questions re-
garding whether the majority of small animal veterinar-
ians in the USA see their professional role as primarily
advocates for animals.
In attempting to explain the disparate findings be-
tween self-reported advocacy behaviours in contrast
to the perception of the same behaviours of their col-
leagues, research by Bazerman and Gino40 has docu-
mented an inconsistency in the way we judge our own
dubious behaviours relative to those of others, a ten-
dency known as moral hypocrisy. A study by Batson
and others41 on moral hypocrisy demonstrated that
individuals perceived their own transgressions to be
less objectionable than the same transgression enact-
ed by another. Research also suggests that although we
recognise others’ conflicts of interest, we fail to recog-
nise conflicts of interest that we face that may lead to
unethical behaviour.42 In addition, Joseph and others43
found that self-reporting of one’s own ethical behav-
iour is significantly correlated with exaggeration of re-
sponse. These theories may apply to our findings if our
respondents perceived animal advocacy as inherently
more ethical than client advocacy. Our findings raise
the need for additional study on this subject perhaps
requiring ethnographic investigative techniques.21 37 We
were surprised to find no statistically significant differ-
ence in self-reported advocacy pattern based on years
of experience; we had surmised that patient advocacy
would decline with experience, as studies by Paul and
Podberscek,44 Schoenfeld-Tacher and others45 and Co-
lombo and others46 have indicated declining empathy
for animals as veterinary students progress through
training programmes.
When asked to consider methods they rely on when
encountering ethical dilemmas, respondents indicated
that gut instinct based on their personal value system
was the most common method used, while guidance
from written policies of state or national veterinary
organisations, and consideration of varied ethical the-
ories, were least often used. These findings are inter-
esting in that they tell us something about how veteri-
narians approach ethical dilemmas, but how much one
technique influences another is unknown. For example,
neither the researchers nor the respondents can easily
separate out how much ethics training influences a vet-
erinarian’s ‘gut instinct’ or personal approach to resolv-
ing ethical dilemmas.
We were surprised to find that only 39 per cent of
respondents who had received ethics instruction in vet-
erinary school agreed that such training prepared them
to address ethical dilemmas. These findings suggest a
need for future studies to further explore veterinarians’
opinions about ethics training, as it seems reasonable
to assume that veterinarians are influenced by such in-
struction, but our data suggest that the training is not
necessarily seen as especially salient to ethical deci-
sion-making. While the majority of our respondents
who received ethics instruction were skeptical of its
effectiveness for resolving dilemmas, it is important to
note that we did not inquire about the nature and ex-
tent of ethics training respondents received, why our
respondents found their training ineffective at this task
or how they would evaluate the merits of their ethics
training.
Most respondents in the present survey character-
ised all clinical scenarios associated with client eco-
nomic limitations as causing at least a moderate degree
of moral stress, except for having to perform therapeu-
tic trials based on cost or client preference. Moderate to
Vet RecorD | 
very high stress ratings were reported by 45 per cent of
respondents who encountered having to perform em-
Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
pirical therapeutic trials instead of diagnostic testing
based on cost or client preference, and 61 per cent of re-
spondents indicated moderate to very high stress when
faced with economic limitations compromising patient
care. Higher levels of stress were reported to be asso-
ciated with economic euthanasia, as 73 per cent of re-
spondents reported moderate to very high stress associ-
ated with euthanasia requests believed to be due to lack
of financial means, and 80 per cent of respondents in-
dicated moderate to very high stress associated with cir-
cumstances where euthanasia was requested because
the practitioner believed that the client was unwilling
to pay for treatment.
Although respondents reported encountering eco-
nomic euthanasia infrequently (once a month to a few
times a year), our findings suggest that the moral con-
text of euthanasia requests as perceived by the veteri-
narian may be associated with degree of reported stress,
as practitioner belief that the client can afford treatment
but instead chooses euthanasia generated more moral
stress than the perception that the client is unable to
afford treatment. The comparatively lower prevalence
of reported stress when confronting economic con-
straints not associated with euthanasia may reflect an
acquiescence that such circumstances are accepted or
considered as normal within small animal practice,
economic limitations may be perceived as the sole re-
sponsibility of the pet owner rather than a consequence
of the veterinarian’s actions, fees or hospital policies,7
or stress may simply be perceived as more significant
when economic limitations are directly associated with
a patient’s death.21
The majority (52 per cent) of respondents in this
survey reported that ethical dilemmas were the leading
cause, or were one of many equal causes of work-relat-
ed stress. Female respondents were significantly more
likely than males to report ethical dilemmas as a source
of stress. The reported impact of ethical dilemmas on
stress decreased with increased experience. These find-
ings are consistent with those of other studies,7 47–53
which indicated that female and less experienced vet-
erinarians had a higher prevalence of serious psycho-
logical distress or found ethical dilemmas more stress-
ful compared with all veterinarians. Given that the vast
majority of those entering the veterinary profession in
the USA and the UK are female,54 55 the findings that
women were more likely to experience ethical dilem-
mas and were more likely to report such dilemmas as
stressful, warrants efforts to mitigate these detrimental
experiences, especially early in their careers. Most re-
spondents indicated that they support modifications to
veterinary school curricula to include specific training
in ethical theories and tools for coping with ethical di-
lemmas, and efforts to increase awareness within the
profession of moral stress and burnout. This finding is
9
interesting in that it represents a paradox, when most
respondents also felt that their ethics training had not
prepared them well to address ethical dilemmas.
One of the limitations of this study was that the vol-
untary nature of the survey might have biased respond-
ents towards those feeling more affected by ethical
dilemmas. The proportion of female respondents was
higher than that in the US veterinary population.56Fe-
males in the general population report a higher prev-
alence of psychological distress,57 so our moral stress
results might have been skewed. There are two potential
sources of misleading information in behavioural stud-
ies: conscious lying and self-deception.58 We attempted
to minimise the former by assuring respondents that
their responses would remain confidential and that
their participation was voluntary. The possibility of re-
sponse bias through self-deception can be inherent in
any research in which people are asked to discuss their
values.
Results of the present study confirmed that small an-
imal practitioners in the USA regularly experience ethi-
cal dilemmas involving client and patient interests, and
these contribute to moral stress. Results revealed that
small animal veterinarians perform euthanasia when
this is not justified based on animal welfare considera-
tions. While the majority of respondents indicated that
other practitioners prioritise client interests, 50 per
cent of respondents characterised their own behaviour
as prioritising patient interests. Moral stress from eth-
ical fatigue and lack of consensus regarding animal
advocacy among small animal veterinarians may have
detrimental consequences for animal welfare. On the
basis of the results of this study, concerted efforts to ed-
ucate veterinary students and veterinarians about ethi-
cal dilemmas unique to the profession and their roles as
animal advocates are warranted, and may help to miti-
gate one of the major causes of moral stress.
Acknowledgements The authors thank Dr Jim Clark, Dr Christine Kim and Pam
Runquist for their contributions towards shaping the survey; all of the respondents
and anonymous referees for their useful comments. This manuscript represents a
portion of a dissertation submitted by Dr Kipperman to the University of Edinburgh as
partial fulfillment for a Master’s degree.
Funding None declared.
Competing interests None declared.
© British Veterinary Association (unless otherwise stated in the text of the article)
2018. All rights reserved. No commercial use is permitted unless otherwise expressly
granted.
References
1 Rollin BE. Veterinary and animal ethics. In: Wilson J, ed. Law, ethics and the veteri-
nary profession. Indiana: Priority Press, 1988:24–49.
2 Tannenbaum J. Veterinary medical ethics: a focus of conflicting interests. J Soc Issues
1993;49:143–56.
3 American Veterinary Medical Association (AVMA). Veterinarian’s oath. https://www.​
avma.​org/​KB/​Policies/​Pages/​veterinarians-​oath.​aspx (accessed 23 Jun 2017).
4 American Veterinary Medical Association (AVMA). Principles of veterinary medical
ethics. https://www.​avma.​org/​KB/​Policies/​Pages/​Principles-​of-​Veterinary-​Medical-​
Ethics-​of-​the-​AVMA.​aspx (accessed 23 Jun 2017).
5 Royal College of Veterinary Surgeons. Code of professional conduct for veterinary
surgeons and supporting guidance. http://www.​rcvs.​org.​uk/​advice-​and-​guidance/​
code-​of-​professional-​conduct-​for-​veterinary-​surgeons/​pdf (accessed 23 Jun 2017).
6 Morgan CA, McDonald M. Ethical dilemmas in veterinary medicine. Vet Clin North
Am Small Anim Pract 2007;37:165–79.
10
7 Batchelor CE, McKeegan DE. Survey of the frequency and perceived stressfulness
of ethical dilemmas encountered in UK veterinary practice. Vet Rec 2012;170:19.
Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
8 Shivley CB, Garry FB, Kogan LR, et al. Survey of animal welfare, animal behavior,
and animal ethics courses in the curricula of AVMA Council on Education-accredited
veterinary colleges and schools. J Am Vet Med Assoc 2016;248:1165–70.
9 Self DJ, Pierce AB, Shadduck JA. A survey of the teaching of ethics in veterinary
education. J Am Vet Med Assoc 1994;204:944–5.
10 Colonius T, Swoboda J. Student perspectives on animal-welfare education in
American veterinary medical curricula. J Vet Med Educ 2010;37:56–60.
11 Magalhães-Sant'Ana M. Ethics teaching in European veterinary schools: a qualita-
tive case study. Vet Rec 2014;175:592–7.
12 Rollin BE. Putting the Horse before Descartes. 58. Pennsylvania, USA: Temple
University Press, 2011.
13 Rollin BE. Euthanasia, moral stress, and chronic illness in veterinary medicine. Vet
Clin North Am Small Anim Pract 2011;41:651–9.
14 Kipperman BS, Kass PH, Rishniw M. Factors that influence small animal veterinar-
ians' opinions and actions regarding cost of care and effects of economic limitations
on patient care and outcome and professional career satisfaction and burnout. J Am
Vet Med Assoc 2017;250:785–94.
15. Robinson D, Hooker H. The UK Veterinary Profession in 2006: the findings of a
survey of the profession conducted by the Royal College of Veterinary Surgeons.
London: Royal College of Veterinary Surgeons, 2006. www.​google.​com/​search?​
client=​safari&​rls=​en&​q=​The+​UK+​Veterinary+​Profession+​in+​2006:+​the+​findings+​
of+​a+​survey+​of+​the+​profession+​conducted+​by+​the+​Royal+​College+​of+​Veterinary+​
Surgeons&​ie=​UTF-​8&​oe=​UTF-​8. (Accessed 23 Jun 2017).
16 Fogle B, Abrahamson D. Pet loss: a survey of the attitudes and feelings of practicing
veterinarians. Anthrozoos 1990;3:143–50.
17 Sanders CR. Killing with kindness: veterinary euthanasia and the social construction
of personhood. Sociol Forum 1995;10:195–214.
18 Tannenbaum J. Veterinary medical ethics: animal welfare, client relations, competi-
tion and collegiality. 2nd ed. Mosby, 1995.
19. Swabe J. Veterinary dilemmas: ambiguity and ambivalence in human–animal inter-
action. In: Podberscek AL, Paul ES, Serpell JA, eds. Companion animals and us:
Exploring the relationships between people and pets: Cambridge University Press,
2000:292–312.
20 Bartram DJ, Baldwin DS. Veterinary surgeons and suicide: a structured review of
possible influences on increased risk. Vet Rec 2010;166:388–97.
21 Morris P. Blue juice: Euthanasia in veterinary medicine. Pennsylvania, USA: Temple
University Press, 2012.
22 Hartnack S, Springer S, Pittavino M, et al. Attitudes of Austrian veterinarians
towards euthanasia in small animal practice: impacts of age and gender on views on
euthanasia. BMC Vet Res 2016;12:26.
23 Kondrup SV, Anhøj KP, Rødsgaard-Rosenbeck C, et al. Veterinarian's dilemma: a
study of how Danish small animal practitioners handle financially limited clients. Vet
Rec 2016;179:596.
24 Yeates JW, Main DC. Veterinary opinions on refusing euthanasia: justifications and
philosophical frameworks. Vet Rec 2011;168:263.
25 Main DC. Offering the best to patients: ethical issues associated with the provision of
veterinary services. Vet Rec 2006;158:62–6.
26 Verdon D. Triennial report: generational differences: DVM Newsmagazine, 2009.
http://​veterinarynews.​dvm360.​com/​2009-​triennial-​report-​generational-​differences
(accessed 23 Jun 2017).
27 Graaf G. Veterinarians’ discourses on animals and clients. J Agric Environ Ethics
2005;18:557–78.
28 Ogden U, Kinnison T, May SA. Attitudes to animal euthanasia do not correlate with
acceptance of human euthanasia or suicide. Vet Rec 2012;171:174.
29 Sugita H, Irimajiri M. A survey of veterinarians’ attitudes toward euthanasia of
companion animals in Japan. Anthrozoos 2016;29:297–310.
30 Batchelor CE, Creed A, McKeegan DE. A preliminary investigation into the moral
reasoning abilities of UK veterinarians. Vet Rec 2015;177:124.
31 American Veterinary Medical Association (AVMA). Guidelines for the euthanasia
of animals. 2013 https://www.​avma.​org/​KB/​Policies/​Documents/​euthanasia.​pdf
(accessed 23 Jun 2017).
32 Rathwell-Deault D, Godard B, Frank D, et al. Conceptualization of conven-
ience euthanasia as an ethical dilemma for veterinarians in Quebec. Can Vet J
2017;58:255–60.
33 McMillan FD. Rethinking euthanasia: death as an unintentional outcome. J Am Vet
Med Assoc 2001;219:1204–6.
34 American Veterinary Medical Association (AVMA). Guidelines on euthanasia. 2007
https://​grants.​nih.​gov/​grants/​olaw/​Euthanasia2007.​pdf (accessed 23 Jun 2017).
35 Harmon-Jones E, Harmon-Jones C. Cognitive dissonance theory after 50 years of
development. Zeitschrift für Sozialpsychologie 2007;38:7–16.
36 Rollin BE. An introduction to veterinary medical ethics. 2nd ed. New Jersey, USA:
Blackwell Publishing, 2006.
37 Ashall V, Millar KM, Hobson-West P. Informed consent in veterinary medi-
cine: ethical implications for the profession and the animal ‘patient’. Food Ethics
2017;37:1–12.
38 Weich K, Grimm H. Meeting the patient’s interest in veterinary clinics. Ethical dimen-
sions of the 21st century animal patient. Food Ethics 2017;229.
39 Verrinder JM, Phillips CJ. Identifying veterinary students' capacity for moral
behavior concerning animal ethics issues. J Vet Med Educ 2014;41:358–70.
40 Bazerman MH, Gino F. Behavioral ethics: toward a deeper understanding
of moral judgment and dishonesty. Annual Review of Law and Social Science
2012;8:85–104.
41 Batson CD, Kobrynowicz D, Dinnerstein JL, et al. In a very different voice:
unmasking moral hypocrisy. J Pers Soc Psychol 1997;72:1335–48.
| Vet Record
42 Moore DA, Tetlock PE, Tanlu L, et al. Conflicts of interest and the case of auditor
independence: moral seduction and strategic issue cycling. Acad Manage Rev
2006;31:10–29.
43 Joseph J, Berry K, Deshpande SP. Impact of emotional intelligence and other
factors on perception of ethical behavior of peers. Journal of Business Ethics
2009;89:539–46.
44 Paul ES, Podberscek AL. Veterinary education and students' attitudes towards
animal welfare. Vet Rec 2000;146:269–72.
45 Schoenfeld-Tacher RM, Kogan LR, Meyer-Parsons B, et al. Educational research
report: changes in students' levels of empathy during the didactic portion of a veteri-
nary program. J Vet Med Educ 2015;42:194–205.
46 Colombo ES, Pelosi A, Prato-Previde E. Empathy towards animals and belief in
animal-human-continuity in Italian veterinary students. Anim Welf 2016;25:275–86.
47 Elkins AD, Kearney M. Professional burnout among female veterinarians in the
United States. J Am Vet Med Assoc 1992;200:604–8.
48 Reijula K, Räsänen K, Hämäläinen M, et al. Work environment and occupational
health of Finnish veterinarians. Am J Ind Med 2003;44:46–57.
49 Gardner DH, Hini D. Work-related stress in the veterinary profession in New Zealand.
N Z Vet J 2006;54:119–24.
50 Fritschi L, Morrison D, Shirangi A, et al. Psychological well-being of Australian
veterinarians. Aust Vet J 2009;87:76–81.
51 Hatch PH, Winefield HR, Christie BA, et al. Workplace stress, mental health, and
burnout of veterinarians in Australia. Aust Vet J 2011;89:460–8.
Vet RecorD | 
52 Mastenbroek NJ, Jaarsma AD, Demerouti E, et al. Burnout and engagement,
and its predictors in young veterinary professionals: the influence of gender. Vet Rec
Veterinary Record: first published as 10.1136/vr.104619 on 14 February 2018. Downloaded from http://veterinaryrecord.bmj.com/ on 20 May 2018 by guest. Protected by copyright.
2014;174:144.
53 Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward
mental illness, and practice-related stressors among US veterinarians. J Am Vet Med
Assoc 2015;247:945–55.
54 American Association of Veterinary Medical Colleges (AAVMC. Detailed look at admis-
sions cycle demonstrates demand, process improvement. 2017 ​http​://a​avmc​.org/​
VetMedEducatorJa​n2017.​​asp​x#​Progress (accessed 23 Jun 2017).
55 British Veterinary Association and the Association of Veterinary Students. Membership
and benefits BVA-AVS research report. 2016 https://www.​bva.​co.​uk/​uploadedFiles/​
Content/​Membership_​and_​benefits/​BVA-​AVS-​Research-​Report-​2016.​pdf (accessed
25 Jun 2017).
56 American Veterinary Medical Association (AVMA). Market research statistics: U.S.
veterinarians. 2016 https://www.​avma.​org/​KB/​Resources/​Statistics/​Pages/​Market-​
research-​statistics-​US-​veterinarians.​aspx (accessed 23 Jun 2017).
57 Reeves WC, Strine TW, Pratt LA, et al. Mental illness surveillance among adults in
the United States. Morbidity and Mortality Weekly Report 2011;60:1–32.
58 Herzog HA, Vore TL, New JC. Conversations with veterinary students: attitudes,
ethics, and animals. Anthrozoos 1989;2:181–8.
11