The Veterinary Profession has got itself into a fine mess over the issue of kidney transplants for cats. The full spectrum of human emotions is exposed: cant, compassion, cowardice, greed, honour, pomposity (I list them in alphabetical order to avoid any suggestion of ranking). In this column I shall try to use the tools of practical ethics to unravel some of this disorder.
The first important point to make is that most (not all) the ethical issues raised by the practice of kidney transplantation for cats are not unique, but apply to many complex and expensive procedures designed, in that crude but catchy phrase, ‘to prolong the suffering of geriatric pets’. Whenever a veterinary surgeon is presented with the decision whether to recommend treatment or euthanasia for a sick or injured pet s/he is inescapably faced with three conflicting issues:
How much will the animal suffer if I elect to prolong its life?
How much will the owner suffer from the death of the loved pet or, alternatively, the cost of the treatment?
How much will I gain in terms of money and/or professional satisfaction by seeking to prolong this animal’s life through radical surgery and/or prolonged medication?
All three questions need to be addressed. To ignore any one of them would be to neglect one or more parties whose welfare is worthy of respect. Any moral decision that addresses the conflicting priorities of different stakeholders (and this means most moral decisions) must give due regard to the rights of each. The decision may be that a particular act, such as kidney transplant surgery for cats, is unacceptable in any circumstances. If so, this must be because the harm done to the animals (donor and recipient) is so great that it overwhelms the needs of all other parties. However this is not a truly moral decision if the welfare of the cats is considered in isolation. Most decisions in most circumstances, involve compromise. Some may be a fudge, but a compromise can be a moral decision if it affords proper respect to the rights of all parties.
Costs and benefits
Let us now consider the good and harm that may be involved for the various parties concerned in the matter of kidney transplant surgery for cats. The issues are raised, but not answered in Table 1.
The Recipient Cat: Successful renal transplants have been reported to extend life for several years. However the survival rate after one month appears to be below 70% even in the best equipped of environments such as UC Davis, California. Complications thereafter include acute episodes of rejection, malignant hypertension (33%), and central nervous disorders (15%). Thus some recipient cats will enjoy years more high quality life but for a high proportion the operation will either fail or produce prolonged periods of distressing ill health. In a strictly utilitarian sense the operation does more harm than good to the day-to-day welfare of the greater number of cats. The justification for the recipient must therefore lie in its inherent ‘right to life’ and this, of course, must be considered quite separately from its value to the owner. My personal belief is that the desire for longevity per se is not something that much troubles a cat. It follows from this that euthanasia is not a welfare problem. If it curtails a good life, then this may be a moral problem for the owner, but death is always the end of suffering.
The Donor Cat: If kidneys are removed under proper surgical conditions, just before, or even immediately after the euthanasia of a cat that has already been condemned to death, then the procedure does not impose any added cost. (I stress, this does not make it ‘right’, it is simply part of the overall ethical analysis). If one has respect for the telos, or inherent value of every cat as an individual, then it is proper to question whether it is right to destroy the life of one cat to satisfy the wish, not of another cat, but of its owner. The alternative procedure adopted by the Feline CRF Information Center (USA) is to perform a transplant only on the basis of a contract whereby the owners of the recipient will adopt the donor. In this way, it is claimed, two cats are saved, not one. The subsequent medical prognosis for the healthy donor is good. Moreover, it is highly probable that owners prepared to spend a small fortune on one cat are likely to lavish care on another that they willingly allow to enter their home.
The Owner: Whether or not the owner has a form of pet insurance, the financial cost of agreeing to a kidney transplant will be large. Figures from UC Davis suggest an initial cost between $3,500 to $13,000 with a continuing annual cost of approximately $2,000 for immunosuppressive therapy, laboratory tests and back-up visits. I have three quite delightful cats in my house but I would not personally be prepared to pay that much for any of them, even if I thought (which I don’t) that it was in the interests of their welfare. Some people however are prepared to put that price on the sentimental value of their cat. Thus any veterinary surgeon who discusses the option of a kidney transplant with the owner of a cat should acknowledge that the prime object of the exercise is to make the owner feel better; and should say so! Since the owner is likely to outlive the cat, surgery will only defer the sorrow of loss. This principle applies to all cases where euthanasia is a proper option within our duty to ensure the welfare of animals in our care.
Having honestly explained the prognosis and all the complications of surgery, the veterinary surgeon should pose the question ‘Do you believe that it is fair to your pet to run the risk of prolonging its suffering simply to reduce your distress at this time?’
The Veterinary Surgeon: I come now to consider the moral position of the veterinary surgeon as a stakeholder in this exercise. I am, of course, aware that very many vets consider it to be completely unacceptable, possibly because they have carried out an ethical analysis similar to that which I describe or, more likely, from a gut feeling that ‘it is simply not right’. This paragraph is therefore really addressed only to those who might be prepared to give it a go but are prepared to consider the moral issues (if such complex individuals exist). There is a clear financial benefit and, when it works, there is also the satisfaction of success in a complex and delicate operation. Neither of these are inherently improper aims for a professional person working to support themselves and their family. However the only potential cost to the veterinary surgeon is the risk of ignominious failure. Thus implicit in any decision to proceed with kidney transplant surgery is a conscious or unconscious acknowledgement that self-interest has overridden all other concerns. In my opinion, a vet faced by a client desperate to save their cat with failing kidneys should never recommend a kidney transplant a priori but
attempt to persuade them that palliative therapy leading to euthanasia at the appropriate time would be the kindest solution for the animal. If the owners insisted upon a transplant, then the honourable decision would be to seek the ‘least worst’ solution. This would involve referring the case to a hospital with a proven record of success (should such a one exist). It would never be right to pocket the bill and hope for the best.
Finally, though not in conclusion
In this short article I have sought to examine the ethical issues attached to the practice of kidney transplants, considered not in isolation but as an extreme example of heroic surgery in veterinary practice. I set out the costs and benefits (if any) for all the stakeholders and invite you to make up your own minds. In this, as in all moral issues, I believe one should at least consider the interests of all parties before reverting to how you felt in the first place. In other words, it may be wrong to do it, but it is not wrong to contemplate doing it. I understand the reasons, at least in law, why RCVS have agreed to permit kidney transplants subject to (limited) ethical and clinical guidelines. Having contemplated it myself, I am back where I began. I wouldn’t. But that is easy for me to say because I never sought to make a living from small animal practice.