This may seem a very obvious question, but actually it is not. This article explores some of the complexities of objectively defining what ‘animal suffering’ is. In this article, for conciseness, the term ‘human’ is used to identify human animals and the term ‘animal’ is used to identify non-human animals. In addition, the terms ‘she’ and ‘he’ are used, rather than ‘it’, because companion animals have names and therefore a gender.
To begin, let’s consider another term – ‘animal abuse‘. While animal suffering is the consequence to the animal of receiving a physical and/or psychological negative experience (as perceived by the animal), animal abuse is the act of delivery of that experience upon the animal. But we can, and should, refine this definition further. Is a cat that attacks and injures another cat ‘animal abuse’? Most, I think would argue that it is not, on the grounds that the aggressor is a cat and, as far as we know, cats are incapable of understanding the concept of perpetrating an act with the specific intent of causing pain and suffering on another. Such an act would require that cats have a ‘theory of mind’, which is a form of empathy meaning that cats would have the ability to spontaneously understand the mental states of other cats and, possibly, other species as well. In other words, in order for one cat to ‘abuse’ another cat, the aggressor would need to plan his attack with the knowledge that a deep, ripping bite would cause more damage and suffering than a soft, half-hearted bite that causes little physical damage. The reward, and therefore the reinforcement, for the aggressor would be the pleasure he gets from that knowledge as he watches his victim scream in pain.
Now consider this
An old lady has recently lost her much-lived husband and is deeply lonely. All she now has for company is her 15 year-old cat. Her cat has been off her food for some weeks and has lost considerable weight. One day, she turns up at her local vets with her cat, and it is immediately clear that the cat is very unwell. The lab tests confirm that the cat is suffering from advanced chronic renal failure. The vet asks the owner why she did not bring the cat is much sooner. The owner bursts into tears and replies that she was frightened that the vet would tell her that her cat had to be put to sleep. The vet has known this little old lady, her late husband and their now-ancient cat for many years. She and her husband have been kind and gentle folk, and had taken in many rescue cats over the decades, nursing them back to good health. The little old lady pleads with the vet not to put her only companion to sleep. What should the vet do?
- Tell the owner off and report her to the RSPCA for cruelty and animal abuse?
- Tell the owner that the cat is very ill and is suffering, and will die within week, she can’t take it home and she needs to be put her to sleep now?
- Or tell the owner that the cat is very ill and suffering and she will die within the week, but it’s OK for her to take the cat home now so she can say goodbye, and that the vet will then visit the next day and put the cat to sleep at home?
This scenario also raises a number of further questions
- By denying the cat a quick exit from her obvious suffering and letting her go home with the owner, is the vet guilty of animal abuse? Or is the vet’s compassion for and empathy towards the owner, and attempt to mitigate her suffering, justifiable in this case?
- Is the owner guilty of animal abuse? Or is her lack of understanding of her cat’s grave condition, coupled with her own grief from the loss of her husband, enough to explain why she did not take her cat to the vets sooner?
- Had the vet told the owner that she had caused her cat much suffering, what good would that knowledge have done in the longer term for the lonely old lady’s physical health and emotional wellbeing?
These are difficult ethical dilemmas that veterinarians and veterinary nurses face every day in their professional lives, especially with the ever-growing aging population of both humans and their pets.
What ‘animal abuse‘ is – and is not – is also the subject of contention among well-meaning companion animal trainers. Trainers that use electric shock collars to train dogs would not consider their methods abusive. On the other hand, exclusively ‘positive reinforcement’ trainers may consider any kind of negative punishment, such as withholding a food reward in order to shape a behaviour, as abuse. Is an owner who leaves his dog at home alone for an hour a day, 5 days a week an abuser? What about 4 hours a day, or 8? Is never letting your dog off-lead abuse? An owner who never takes her dog for walks? What about a wheelchair- house-bound owner? How overweight must a much loved, but overfed pet be before you would consider the owner abusive?
Looking for a definition of ‘animal suffering’
The UK Animal Welfare Act, 2006 (Animal Welfare Act, 2006) defines animal suffering as meaning both ‘physical and mental suffering’. Physical suffering is clearly the easiest to identify. Mental suffering is much less clear. Veterinarians are the professionals who examine suspected cases of animal abuse and so often become expert witnesses when a prosecution of the animal’s owner is launched. A recent paper looked at how veterinarians negotiated the complexities of being an expert witness in court cases of ‘unnecessary suffering’ of animals in the UK (Baumgaertner et al., 2016). Of the 42 reports examined retrospectively, most of them were accurate in their observations of fact. However, significant variations were found in how the expert witnesses described the actual suffering and also what the owners of the animals involved had or had not done in the process. Disagreements of what constituted ‘suffering’ were also apparent. The paper recommended that “…expert witness reports should include a systematic consideration of the animal’s mental and physical states, severity of harm, duration of harm and a commentary on the necessity of suffering as defined by legislation”.
The best place to start is with the term ‘suffering‘ itself because we know and accept that humans experience it and most of us know what it feels like. Suffering is a private and personal experience to the sufferer in that different people may experience it differently when subjected to exactly the same cause. This makes suffering a highly subjective experience that makes it difficult, if not impossible to measure and quantify in an objective and scientific way. In humans, several methods are used to identify suffering (Dawkins, 2008), including –
- Verbal report: Ask the person how they feel. Terms such as hunger, thirst, pain, fear, boredom, exhaustion etc. all imply that the feeling is not pleasant. But pain is clearly more unpleasant than boredom, and a state of starvation is clearly more unpleasant than just being hungry. Yet, verbal report is considered to be the most accurate method of identifying suffering in humans.
- The individual’s perception of what constitutes a positive vs. a negative reinforcer: For example, when someone takes heroin, initially the experience is highly rewarding and this acts as a powerful positive reinforcer to repeat the experience. However, the highly addictive nature of heroin on repeated use is an adaptive, physiological mechanism that quickly blunts the initial highly rewarding subjective experience, while at the same time, causing a highly negative physiological and subjective experience as the drug is cleared from the receptors between repeated doses.
- Physiological changes: Physiological changes such as hypothalamic-pituitary-adrenal axis activation during stress, which can be objectively measured via heart rate, blood pressure and levels of stress hormones such as adrenaline and cortisol in the blood stream. However, such measurements are an indirect and crude representation of suffering. For example, high autonomic arousal could indicate fear, or pain, or both.
- Observation and measurement of brain activity of the sufferer: Again, this is and indirect and crude representation of the subjective experience of suffering.
- Observation of behaviour: Behavioural observations such as escape behaviours and body language indicators such facial expression.
- Physical health of the individual: Chronic disease, starvation, neglect, painful wounds etc. all indicate a degree of suffering.
All of the above tools, except the first one (verbal report), can be used in animals to identify suffering. However, a surrogate for verbal report can be used to ‘ask’ an animal how she feels, by ‘asking’ her what she likes and does not like, and in the longer term, whether she is content or discontent. How an animal behaves on the presentation of a benign, neutral, but ambiguous stimulus is a reliable indicator of contentedness or discontentedness (see Harding et al., 2004). A content animal will tend to approach and investigate the stimulus, with an apparent expectation that it may signal something she may find rewarding.
On the other hand, a discontented animal will tend to ignore or avoid the stimulus, with an apparent expectation that it may signal something she may find unpleasant. These 2 measurable behavioural outcomes are called optimistic and pessimistic biases, the bias arising as a consequence of the animal’s expectation. This expectation is the product of the animal’s changing emotional states over a period of time, which ultimately shape the animal’s consequent mood state. Unlike emotional states, mood states are stable affective (feeling) entities and therefore much easier to evaluate. In short, an animal that is suffering will have a depressed mood state, while an animal that is not suffering will have a normal and balanced mood state.
Animal abuse: at the heart of the veterinary profession itself?
2 recent papers (Lees et al., 2017a; 2017b) comparing conventional veterinary drugs with homeopathic remedies is a ‘must-read’ for all animal lovers, whatever your particular opinions and believe systems might be. These papers are open access so please do download and read them for yourself. They are long and contain a great deal of useful and interesting background information. Here is a brief summary of what the authors have to say.
First, the conclusion
Given the discussion of animal suffering and abuse presented above, the practice of homeopathy on animal patients within the veterinary profession constitutes animal abuse because it potentially leads to their unnecessary suffering. Worse is that both the veterinarians and owners involved are unaware of this because they have the best interests and wellbeing of the animals involved in their care at the heart of the decisions they make.
The paper starts with a summary of why any kind of therapy for a disease may appear to work, when in fact it does not. For example –
- Coincidence: Many common diseases get better on their own, for example a muscle sprain causing a limp, or the common cold. Taking a flu remedy may be wrongly accredited with curing the cold, therefore its apparent efficacy is just a coincidence. In statistics, this is called regression to the mean. In biological terms it occurs because most diseases have a predictable time line of progression where they either get worse or they get better. Some chronic diseases, for example many skin diseases, tend to wax and wane – they go through phases of remission followed some time later by another flare-up. Apparent positive responses to medication may sometimes be mere coincidence because it happens to coincide with a period of remission. In addition, the state of the patient’s immune system plays a significant role in the natural healing cycle, and this in turn is affected by the patient’s mood state, as discussed above.
- Placebo effect: The placebo effect occurs when a patient responds positively to a treatment for a condition using a medical intervention that itself has no known therapeutic value for that condition. In humans, the placebo affect is thought to be the result of ‘mind-over-matter’ where, if the patient thinks she should feel better, she does. In some countries human doctors routinely prescribe placebo medicines to their patients for mild, common conditions, and they get better. The existence of placebo effects in animals is problematic as it requires that the patient holds the belief that the medicine being taken is actually effective. Any cat owner will testify how difficult – and dangerous – it can be to persuade their patient to swallow an antibiotic tablet for a cat bite abscess. The cat is incapable of making the decision to consume the bitter pill in the knowledge that it will help the abscess heal in the longer term.
- Observer bias: There are many examples in human medicine of doctors wrongly attributing benefits to medicines they are using, some leading to serious health scandals. The same thing occurs in veterinary medicine. Observer bias is a natural phenomenon that results as a consequence of how the human mind works, and it is linked to the coincidence effect discussed above. If a patient’s condition improves while being given a particular treatment, the clinician is biased toward attributing that improvement on the treatment she prescribed, and less inclined to consider the possibility of other factors, such as coincidence.
Homeopathy was invented by Samuel Hahnemann, a medical doctor, in 1796. To put this into some kind of perspective, the practice of medicine at this time was primitive compared to our understanding of it now, and included practices such as bleeding, blistering, purging, sweating and vomiting, along with brutal and primitive surgery without anaesthesia or pain relief, and no understanding of germ theory and sterilisation. There was no such thing as ‘medical science’; medicine was taken and therapies, such as bleeding, was administered. The patient either got better, or in many cases worse and died. There was no interest in exploring what was actually going on inside the body during this process. Being ill was a very risky, and often an unnecessarily painful, business in those days. Any prospect of an ‘alternative’ approach would have been widely popular.
Hahnemann was also a translator and was responsible for translating into German the original Materia Medica (‘the use of plant parts or their actives’), used by doctors as their medical textbook at the time. The Materia Medica, originally updated from the original ancient Greek version by William Cullen in 1789, was the definitive pharmacological encyclopaedia that catalogued everything that was known at the time about medicines and their use in the treatment of disease. It was while translating this book that Hahnemann came up with the idea of homeopathy as an alternative approach to the primitive medical practices he was involved with. What Hahnemann proposed in 1796 remains the cornerstone of homeopathic practice today, and it is based on 3 key principles: the Law of Similars, the Law of Infinitesimals and the Law of Succession.
- The Law of Similars: ‘like cures like’. In other words, the things that cause a disease can also cure that disease. For example, a cold makes your eyes and nose run, onions also make your eyes and nose run, therefore onions cure the common cold.
- The Law of Infinitesimals: ‘less is more’. In other words, the more a medicine is diluted, the more potent it becomes. For example, many cold remedies come in sachets of powder that you dissolve in a glass of water and then drink in order to benefit from the medicine. Now, instead of emptying the sachet into a glass of water, if you emptied it into an Olympic-size swimming pool of water instead, and then scooped your glass into the pool and drank a glassful of that, the medicine would work better. The degrees of dilution involved in the preparation of homeopathic remedies is staggering, and is indicated by the suffix ‘c’, or ‘d’, where ‘c’ = units of x100 dilution, and ‘d’ = units of x10 dilution. ‘c’ is the most commonly used in over-the-counter homeopathic remedies, and most of these are 30c. This is how the math works. A remedy labelled as 6c indicates that it has gone through 6 successive dilutions of 100x by liquid volume; 30c means 30 successive dilutions of 100x by liquid volume. To put this into some kind of context, we need to consider this dilution effect on the number of ‘active’ molecules originally present in the remedy before dilution started. The actual number of the ‘active’ is immaterial, what matters is how it behaves during successive dilutions. It is possible to work backwards and figure out how much water it would take to have just 1 molecule of the ‘active’ left in the water at a given dilution. For a homeopathic remedy of 30c (a common dilution for over-the-counter remedies), the mass of water required in kilograms would be more than 15,000 times the mass of the sun. In chemistry, the mole is an important universal unit of measurement as it describes the number of particles (molecules, atoms, or whatever) present in that volume of liquid. This number is called the Avogadro constant and it is 6×1023. Dilution of a liquid quickly strips out these particles and, at a homeopathic dilution of 12c (=1×10-24), it is beyond the Avogadro constant. In other words, it is unlikely that any molecule of ‘active’ actually remains in the liquid at this dilution.
- The Law of Succession: Dilution of the ‘active’ alone is not enough to create a homeopathic remedy. At each dilution phase of the Law of Infinitesimals, the remedy needs to be agitated in a very specific manner. Hahnemann came up with this Law whilst travelling around the bumpy, pothole-ridden streets in his horse-drawn carriage with his remedies. He decided that agitation was required to pass on the ‘healing power’ of the ‘active’ from one dilution to the next to make it more potent. He called this process ‘potentising’, or ‘dynamising’ the remedy. To carry out the ‘potentising’ process, Hahnemann invented a special board of leather stuffed with horse hair (made by his saddle-maker) that he claimed was ideal for the ‘succession’ process through a series of ritual shakings and 10 to 50 tappings of the container storing the liquid within against the leather. The ‘potentising’ process continues today, albeit in various forms, as a vital part of the homeopathic remedy production process.
So, homeopathy is the brainchild of one man living in the 1700’s, a time when medical practice was cruel and primitive.
Hahnemann believed that disease was a disruption of the ‘vital life force’, or ‘life energy’, which was ‘spirit-like’ and ‘animated’ the entire human body. Homeopaths still refer to these ‘forces’ and ‘energies’ existing in their patients today. Homeopaths also belief that just about anything can be used as an ‘active’ because it also holds some kind of ‘vital force’, which can be captured in a homeopathic remedy. For example, there are remedies available that are based on the dilution and succession of the Berlin wall, Hadrian’s wall, car exhaust fumes, electricity, magnetic fields, light from the planet Venus and rays coming from TV sets.
Along with the 3 Laws described above, Hahnemann also laid out how homeopathic remedies should be tested, and this method was used by Hahnemann himself when writing his homeopathic Materia Medica to give what he called the ‘symptom picture’ (i.e. what the remedy should be used for) along with each remedy he listed. The ‘symptom picture’ for a particular remedy is created by using ‘provings’ (or ‘pathogenetic trials’), and to a lesser extent, by observing the response of the patient. The ‘proving’ process uses volunteers (in some cases, just 1 volunteer) who take the remedy being investigated and record in a diary how they feel along with any physical changes they notice. The diaries (or diary) are then handed over to a ‘master prover’ who uses the information provided to come up with the ‘symptom picture’.
This raises a bit of a problem when it comes to ‘provings’ in animals. How on earth can animals ‘report’ how they feel? Only humans experience ‘symptoms’, these are verbal reports that human patients relate to their doctor, such as ‘I always feel tired’, ‘I get frequent headaches’, etc. Both humans and animals have ‘signs’, these are indicators observed by a third party (usually the doctor/veterinarian) such as temperature, respiratory rate, nystagmus, swelling, etc.
Putting animals aside for a moment, the ‘symptom picture’ tells the homeopath that each remedy has specific healing powers that will only work for certain signs/symptoms and/or only patients with certain ‘characteristics’. This approach to treatment of disease would appear to rely on a mystical belief system, based on spirits and supernatural forces. In short, homeopathy has more in common with magic and religious beliefs than it has with mainstream science.
Back to animals. With the exception of the horse that Hahnemann cites as responsible for his idea for the ‘Law of Succession’, animals are not represented at all in his homeopathic model. Homeopathy is therefore an exclusively anthropocentric belief system (humans are the centre of the universe and everything in it is there exclusively for human benefit) with veterinary homeopaths tacking animal on only recently.
In contrast, the history of the development of pharmacology followed a different path. Like homeopathy, its origins lie in the Materia Medica, but then it took a very different path 200 years ago. In parallel with the developments in anatomy, biology, chemistry, physiology, microbiology, pathology, etc., pharmacology followed the rational development of the scientific method involving many different individuals sharing their ideas and findings. This ultimately lead to the development of randomised controlled clinical trial as a tool to ensure better accuracy of the data collected and the avoidance of errors arising from phenomena such as bias. Animals and their veterinary treatment was an initially small, but integral part of the development of pharmacological science from as early as 1816.
Where does this leave us now? Whether you believe in homeopathy as a valuable therapeutic tool or not, there are 2 inescapable hypotheses that we should all consider very carefully.
- Hypothesis A: Homeopathy is an effective therapeutic modality and homeopathic remedies are genuinely effective.
- Hypothesis B: Homeopathy is an ineffective therapeutic modality and homeopathic remedies have no effect whatsoever beyond placebo.
Only 1 of these hypotheses can be correct.
Homeopathy is a top-down system based effectively on magic invented by 1 man. Its basic principles have remained unchanged and unchallenged (by homeopaths) right up to the present day.
In contrast, conventional medicine is a bottom-up modality that has systematically evolved through the endeavours of many thousands of individuals (and continues to do so) and their critical analyses of the known facts that continuously shape and further our knowledge and understanding of how the mind and body really work.
Even if you are sceptical about the effectiveness of homeopathy, you may think that, because the remedies actually contain no active ingredients, their use must be harmless. Well, you are wrong, especially in the context of where they are used in animals.
First, as homeopathic remedies are not regulated, it is possible that over-the-counter products may contain toxic contaminants, possibly introduced in the production process, such as heavy metals and pathogenic fungi and bacteria.
But there are much more serious problems in relation to animal welfare and suffering.
Although the placebo effect can be very useful in human medicine, this is not the case for animals, where it is – at best – rare in everyday animal life. Where it does exist, it needs to be specifically conditioned in order for the animal to respond. Even then, its use as an aid to therapy is limited. These problems are listed below –
- Caregiver placebo effect: As discussed above, bias is a very important factor in human perception. When an owner seeks veterinary care for their sick pet, all they want is for their pet to feel better. This is indeed the driving desire of the veterinary team engaged in treating the animal as well. The problem is that this shared desire can – and does – lead to a bias that influences the outcome of the objective assessment of the effectiveness of that treatment. This phenomenon has been reported in several recent studies (see Conzemius and Evans, 2012; Gruen et al., 2014; 2017) and it has caused major concern for the veterinary profession where the implications of the animal’s suffering going unnoticed, and therefore inadequately treated, are profound. Would you be concerned if your cat or dog was silently suffering from chronic pain while you believed she was fine?
- Homeopathy may prolong animal suffering: The Academy of Veterinary Homeopathy Standards of Practice in the United states says this – “Our patients often present under the influence of previously prescribed drugs or after numerous medical and surgical interventions. Concurrent treatment with many drugs, herbs, acupuncture and other types of intervention can reduce the effectiveness of homeopathic medicines and often makes it difficult to evaluate the response to the homeopathic medicines, a crucial parameter for accurate prescribing. While it is desirable to treat susceptible problems with only homeopathic medicines, it is not always safe to discontinue other treatments until the patient is stable.” They go on to say “Concurrent drugs, herbs, and electromagnetic applications should be avoided, when possible, to prevent the possibility of interfering effects on the life force and the patient’s responsiveness.”. As discussed above, we now understand the difficulties in recognising suffering because of the care-giver placebo effect etc. Who decides “…to… discontinue other treatments …when… the patient is stable”? Does the veterinary homeopath comprehensively discuss the implications of this with the owner?
- Violation of informed consent: Veterinarians are obliged to adhere to the rules of informed consent laid down by the Royal College of Veterinary Surgeons (RCVS, 2017). The RCVS states – “Informed consent, which is an essential part of any contract, can only be given by a client who has had the opportunity to consider a range of reasonable treatment options, with associated fee estimates, and had the significance and main risks explained to them.”. How many veterinary homeopaths explain the clash of homeopathy with conventional scientific understanding, as discussed above? Part of the process of informed consent is that the veterinarian needs to have a conversation with the owner and satisfy herself that the client understands all the points being discussed. Simply handing the client a pile of documents (for example, printed copies of the 2 review papers discussed here) does not adequately constitute the client’s consent.
- Veterinary homeopaths are treating the owner, not the animal: As discussed above, the placebo effect is a valid and valuable tool in human medicine, but this is not the case in animals. Veterinary homeopaths routinely spend a great deal of time just talking to the owner and of course listening to what they have to say, which is a really good thing. Owners of chronically sick animals are often, and understandably, worried and stressed about their pets’ condition and may have already exhausted much of what the conventional veterinary profession has to offer. Like conventional veterinarians, veterinary homeopaths are kind and empathic people and WANT to help their clients feel better. However, there is arguably no tangible benefit for the animal in this process.
Conclusions
The key point here is that we humans can make informed choices about how we are treated for illness. The pets we love cannot. They rely on us to make those choices on their behalf. Whatever your views about homeopathy, there is no getting away from the fact that it is a belief system, not a system based on universally accepted, tried and tested and well understood scientific principles.
As discussed above, it is not always straightforward to establish when a treatment is not working for our pets and, as a consequence, they suffer unnecessarily. The 2 key papers on homeopathy discussed in this article are a ‘must-read’ for all pet owners along with those working with animals professionally.
You may not agree with everything presented here, but please don’t let your own biases cloud your judgements.
Question everything.
Insist on satisfactory answers from the veterinary professionals treating your pets.
The animals in your care deserve nothing less from you.
LINKS TO THE OPEN ACCESS PAPERS REVIEWS IN THIS BLOG
© copyright Robert Falconer-Taylor, 2017
This article is an original work and is subject to copyright. You may create a link to this article on another website or in a document back to this web page. You may not copy this article in whole or in part onto another web page or document without permission of the author. Email enquiries to robertft@emotions-r-us.com.
Images:
1. A feral street dog photographed on the main road of the city of Gianyar, Bali, Indonesia, by Jack Merridew. Public domain, via Wikimedia Commons.
2. Dog on a chain near a kennel by Robert Falconer-Taylor. © Copyright Robert Falconer-Taylor, 2017.
3. Various homeopathic remedies. By Wikidudeman (Own work) [Public domain], via Wikimedia Commons.
References
Animal Welfare Act, 2006. http://bit.ly/1sxCoFL. Accessed August 31, 2017.
AVHSP. 2017. Academy of Veterinary Homeopathy Standards of Practice http://bit.ly/2wLwiHB. Accessed August 31, 2017.
Baumgaertner, H., Mullan, S. and Main, D.C., 2016. Assessment of unnecessary suffering in animals by veterinary experts. The Veterinary record, 179(12), pp.307-307.
Conzemius, M.G. and Evans, R.B., 2012. Caregiver placebo effect for dogs with lameness from osteoarthritis. Journal of the American Veterinary Medical Association, 241(10), pp.1314-1319.
Dawkins, M.S., 2008. The science of animal suffering. Ethology, 114(10), pp.937-945.
Gruen, M.E., Griffith, E., Thomson, A., Simpson, W. and Lascelles, B.D.X., 2014. Detection of clinically relevant pain relief in cats with degenerative joint disease associated pain. Journal of veterinary internal medicine, 28(2), pp.346-350.
Gruen, M.E., Dorman, D.C. and Lascelles, B.D.X., 2017. Caregiver placebo effect in analgesic clinical trials for cats with naturally occurring degenerative joint disease-associated pain. The Veterinary record, 180(19), p.473.
Harding, E.J., Paul, E.S. and Mendl, M., 2004. Animal behaviour: cognitive bias and affective state. Nature, 427(6972), pp.312-312.
Lees, P., Pelligand, L., Whiting, M., Chambers, D., Toutain, P.L. and Whitehead, M.L., 2017a. Comparison of veterinary drugs and veterinary homeopathy: part 1. The Veterinary record, 181(7), p.170.
Lees, P., Pelligand, L., Whiting, M., Chambers, D., Toutain, P.L. and Whitehead, M.L., 2017b. Comparison of veterinary drugs and veterinary homeopathy: part 2. The Veterinary record, 181(8), p.198.
RCVS. 2017. Royal College of Veterinary Surgeons; Communication and consent. http://bit.ly/2iKRdEQ Accessed August 31, 2017.