Vetnuus | December 2024 11 be in their best interest. Some similarities may be drawn between equine clinical decision-making and clinical decision-making for child athletes,5 where decisions and consent are provided by a parent. However, children generally gain competence over the course of their athletic careers. A key difference for ESMVS is the extreme vulnerability of the patient who lacks agency and, in extreme cases, is expendable. Having to meet the interests of others (owners, riders, trainers) when providing care is common in many aspects of veterinary medicine and is a component of shared decision-making. However, the pressure for a horse to compete and the conflicts of interest that may arise in this situation were the primary challenges identified by respondents (and previously identified in an equine sports medicine scoping review1). This can occur when the owner’s interest conflicts with the best interests of the horse. Such conflicts are common in veterinary practice, however, the nature and degree of the conflict in equine sports medicine makes this distinct in its prevalence and severity. At stake for the veterinary surgeon, trainer, owner, and rider will routinely be professional success, both reputational and financial. Furthermore, the context of equine sports is competitive, introducing a potentially overriding reason to seek positional advantage over competitor equine athletes. This is a situation of competitive escalation, which marks it as distinct from the routine stakeholder conflicts in veterinary care. Challenges for veterinary surgeons in clinical decision-making should be supported by the development or use of ethical codes,6,7 ethical standards in decisionmaking8 and ethical frameworks.9,10 These will also require ethical reflection that considers the particular features of clinical situations, allowing nuanced case-by-case decision-making. Trying to balance competing obligations can lead to moral distress for ESMVS. We define moral distress as when the ESMVS knows the appropriate action to take but is unable to do so due to some constraint. These constraints can include competing obligations and professional or personal values. The questions were not set up to fully explore the moral distress experienced by the respondents, but words such as ‘hard’, ‘wrestle with’, ‘difficult’, ‘challenging’ and ‘horrified’ were used by respondents along with the repeated references to feeling pressured, for example, ‘the pressure on them [veterinary surgeons] is immense’. These ethical issues and the resulting moral distress may influence veterinary students considering a career in equine sports medicine, as well as negatively affecting retention within the profession. Our results also revealed pressures upon veterinary surgeons not previously identified in the scoping review.1 In particular, this includes providing veterinary services at competitions/races, which is a pressured environment requiring rapid decision-making in view of the public and spectators. Second, the responsibility of providing a good outcome for the horse was a pressure not previously identified. This can come from having to meet the expectations of owners and trainers while also meeting an ESMVS’s personal values. When rating the degree of responsibility veterinary surgeons feel towards various stakeholders, the responsibility towards the RCVS was lower than may be expected, considering this is the regulatory authority in the UK. This may indicate that the weight of competing obligations is such that professional obligations are diminished. Regulations that can be used to support and protect an ESMVS from undue influence should be considered. Some of these findings will be concerning for governing bodies. Of particular concern is that half of all veterinary surgeons were aware of a horse being given a banned substance. Although the questionnaire did not explore whether veterinary surgeons had any involvement in this practice, the findings do indicate the presence of doping in equestrian sports. A quarter of veterinary surgeons were aware of horses being subjected to procedures banned by the RCVS and over half were aware of a horse undergoing a veterinary procedure that is not permitted by a sporting governing body thus suggesting that the governing bodies and ESMVS at the coalface are not well aligned. A high proportion of participants knew that a horse had received a controlled medication too close to a competition, that a horse continued in training against veterinary advice and that a horse had competed with an underlying disease process that was likely to be worsened by competition. Although this survey offered anonymity, underreporting of sensitive information may still occur.11 It appeared that few veterinary surgeons reported illicit practice when they were aware of it. The reasons were multifactorial and included conflict with client confidentiality. Similarly, sports doctors will also often choose to keep sensitive information confidential, likely from a perceived overriding responsibility to the athlete.12 The challenges of confidentiality could be eased by clearer guidance on the professional expectations when faced with these situations.12 There appears to be a lack of clarity on the process of reporting and where the veterinary surgeon’s professional obligations lie. Some respondents were concerned that there was a lack of penalty for performing a banned surgical procedure. Collectively, these concerns appear to indicate that the professional bodies may lack safe reporting mechanisms and deterrence. The survey confirms that at least some UK veterinary surgeons have ethical concerns about the use of particular treatments. Those that were most commonly identified as being ethically unacceptable were: intraarticular medications, upper airway surgeries and firing. The high prevalence of lameness in the performance horse during training and competition is clearly a concern for many. Thus far, there has not been a format for these concerns to be raised, discussed, and potentially addressed. A previous paper also suggested that governance around treatments/procedures may be less regulated than the administration of medication.1 This is an area that the governing bodies could consider how best to address. Looking to human sports medicine could be a useful source for specific agencies tasked with detection, policy, working with and coordinating stakeholders, and administering penalties (one such agency that demonstrates the all-encompassing function is the World Anti-Doping Agency). Good regulation requires a good understanding of what is being regulated. The potential flaws in regulation and consequent illicit activity support our earlier findings1 that it may be useful to clarify conceptually and distinguish practically, between therapeutic (optimal), excessive, and performance-enhancing veterinary provision. Defining the line between appropriate proactive veterinary intervention and excessive prophylactic veterinary intervention seems important in equine sports medicine. Furthermore, a better understanding and separation between an intervention with a justifiable veterinary rationale and one aimed at performance enhancement appears necessary. Regulation of veterinary procedures for performance horses can fall between the veterinary governing bodies and the sporting governing bodies. Only the RCVS has regulatory jurisdiction for the veterinary profession. The BEVA is the largest member organisation for equine veterinary surgeons in the UK. It produces extensive guidance and resources but is non-regulatory. The sporting governing bodies are regulatory and can enforce regulations about veterinary procedures and veterinary medications, but should the onus and responsibility be left with the sporting organisations to debate and decide upon veterinary regulations? Veterinary and
RkJQdWJsaXNoZXIy OTc5MDU=