We all see an awful lot of clever things done in the veterinary world, in the media. We've got Facebook and we've got Twitter, and we've got Instagram and all the others, and they come across as the great thing to do. Look at this, we've got.

A world first, impossible surgery, life saving brain surgery. And so it goes on. We're all used to it.

Is it a good thing? It comes across as a good thing. Why have we got to this now in this beginning of this century?

A lot of it is due to the technological advances that have occurred really relatively recently in our world's history. And in the veterinary and the medical world, we've got huge progress in diagnosis and in treatment. We've got things like surgical techniques, we've got skilled anaesthesia, we've got better pain relief.

We've got fantastic collection of new materials. We've got incredible computer power, and so it goes on. So we've got a lot of technology that supports terrific developments.

Oh, come back. As veterinary surgeons, we all in this country have made this declaration. We've got the beginning of it and the end of it.

And the capitals above all, are not mine, they are in the guide to professional conduct. My constant endeavour will be to ensure the health and welfare of animals committed to my care. We've all promised that.

Are we actually doing that? Are we getting carried away with this cool stuff that we can do now? Looks good, gets on TV, gets in the press, gets plastered all over Facebook.

Are we really doing our patience any good through this? And the old one, just because we can, doesn't mean we should. The animal's best interest should be at the top of the list when we are carrying out veterinary treatment.

OK, so what about these new treatments? Shouldn't we be pushing forward the frontiers of science? And yes, I, as having worked in the research and academia for quite a lot of my career, yeah, I've been, I hope, pushing forward the frontiers of science, so I can't be completely down on this.

But we do need to balance the development of new techniques against the tried and tested ones. And we want to make those developments not at the patient's expense. We want to treat the patients in terms of developing the new.

But not to their. Definite disadvantage. Now let's look at the laws relating to this.

Our laws are decided by our society. It might not look quite like it at the moment, but that's how they really are. And in in the UK and it's European law at the moment, we are forbidden to be cruel to animals.

We are forbidden to do anything nasty to animals, and it comes out in this country as the Animal Welfare Act. And there are 2 major exceptions to this, that you can do something nasty to an animal. I you can make a surgical incision, for instance.

We've got the Animal Scientific Procedures Act, often known as ASPA. And that is where a procedure is done on an animal, not to the benefit of that animal, but to benefit others in terms of scientific research. And in being allowed to do that under a range of licences, the harm benefit is balanced and there are constraints applied so that the animals used do not suffer.

And the other exception to the Animal Welfare Act is the Veterinary Surgeons Act. We are incredibly privileged to be able to do those nasty things to animals when it is to their benefit in order to treat their disease. And this comes out as recognised veterinary practise.

So I'm sorry, you've got lots of TLAs around here, or one of them's got is a 4. There's ASA for scientific procedures. We've got the VSA, the Veterinary Surgeons Act, under which we do recognise veterinary practise, RVP.

Now, the distinction between APA and the Veterinary Surgeons Act is quite important, and I'm afraid to say that my profession isn't always very good at understanding that. The procedure that is carried out may be exactly the same, some piece of surgery, hopefully rather better than the person in this effort. If it is for the benefit of the animal, it's under the and it's carried out by a veterinary surgeon, it's under the Veterinary Surgeons Act and it's recognised veterinary practise.

If it's for scientific research and it's not for the animal's own benefit, it must be done under APA. And this is where it is important. Vets are not exempt from APA.

If they are doing the very same procedure that they would do in on Mrs. Smith's cat to treat Mrs. Smith's cat, but they're doing it on an animal in order to carry out some scientific research.

The latter must be under Asper. So the Veterinary Surgeons Act allows registered veterinary surgeons to do these acts of veterinary surgery or regulated procedures in order to treat animals because they are trained and qualified to do so. And any regulated procedure outwith the Veterinary Surgeons Act or ASPA infringes the Animal Welfare Act and is a criminal act.

And regulated procedure is basically anything that may cause pain, suffering, distress, and lasting harm, and there are certain thresholds set as to what one might consider to be something that causes pain, suffering, distress, and lasting harm. Now when it comes down to clinical treatment, we're all now hopefully under direct surgeons Act. It is carried out for the welfare of the patient.

And for the benefit of the patient, and it must be recognised for any practise. And I'm gonna highlight two particular situations that we come across. Treatment within the Veterinary Surgeons Act.

So it's a procedure that you might do as a perfectly recognised procedure, a piece of surgery, for instance. You've still got to decide does it benefit the patient, or is it over treatment? Obviously, we're going to come back to that one.

But there's also, what about new treatment? It's designed to benefit the treat the patient. We don't know yet whether it really will benefit the patient.

We think it will. And actually it might harm the patient. So those are the two scenarios I'm looking at.

Now, the Royal College of Veterinary Surgeons guides professional conduct, gives us a lot of guidance on what is recognised veterinary practise and so forth. And I picked out some pieces here that are pertinent to this. Veterinary surgeons must provide veterinary care that is appropriate and adequate.

And the, the, the colouring is, is mine, but it's appropriate and adequate. And we are now encouraged very much to use evidence-based medicine. So we use treatments for which there is evidence, how to do them and whether they work.

So it looks as though the best treatment is indeed make a diagnosis and do everything you possibly can to make that diagnosis with all the available technology we've got. Then you should do everything you possibly can to treat that diagnosis. And you should use all the available evidence as to what that treatment should be.

And Somewhere along the lines, you've got an owner involved and that owner should be informed of what is involved and what is likely to be the outcome. Now I would argue that the correct or the best treatment is not always the right treatment. And I'm now going to quote a lovely presentation made by Steinel Neeson at the London Vet Show last year.

He was talking about Mrs. Tibbles and her cat. This is an old cat with chronic renal failure and arthritis.

We've all seen them. The right treatment for this cat is that it goes on to the kidney diet. It hates it, so it doesn't eat.

It must have regular visits to the vet for blood samples to see how it's doing. Has it, gets very stressed. And then it has numerous different pills to treat all the various disease process going on.

And it hates it. It bites the owner, it scratches the owner, and they fall out. So you've got, you know, the pill that treats this bit and the pill that treats that bit.

And so it goes on. And it can't have its honey flavoured meloxicam for its arthritis anymore cos that's bad for its kidneys. So it's now painful, it doesn't move about.

And the owner and cat have fallen out completely, so they've lost their relationship. The cat hates the owner and the owner feels guilty, but that's the right treatment. So how about a life that isn't quite as long because it didn't get pill see that prolonged its life by 3 weeks, according to that study.

Let him eat the food that he likes. Let him stay on the meloxicam. And never mind the blood samples, and if he doesn't last quite as long but he's happy, isn't that better?

I would argue that it is. So in answer to an earlier question that I had had up there, yes, I think the profession is getting carried away with apparent clinical excellence, doing the things that we think we're meant to be doing. And it's back to just because we can.

Does it mean we should? Think about major surgery on an old animal. It's got numerous comorbidities and it's now got a lung tumour, and if you take out that lobe, well, it'll remove the lung tumour.

But will it really prolong good life? We're treating the disease and not the patient. I'm afraid we're teaching our students that this is diagnosis A and the treatment is ECD straight on.

What about the quality of life of that animal? This animal lying in intensive care cannot understand that feeling lousy now is gonna make him feel better later. We can.

And we still don't much enjoy that sort of care treatment. Pain relief may be marvellous, but it isn't just about pain. And there's the other question here, will life really be better later anyway?

OK, so what about these new treatments? Or what are we going to do about them? Surely we should be pushing forward the frontiers of, of science.

These are the ones that are often talked about as heroic and life saving. We're often told there was no alternative. And I'm afraid to say it is often that the clinician wants to have a go.

There's a certain amount of tunnel vision comes in here that you're determined that this is the process that that should be gone through, this is the treatment. And it's very difficult to see other arguments when seen just through that tunnel. And I'm arguing here that we need peer review, what I would call a sanity check.

Is this really sensible? Does this really make sense that you do this particular treatment for this animal? We'll hear a little bit more shortly about the Declaration of Helsinki, which is from the medical world, that research protocols should be reviewed by an independent committee.

So somebody's completely unconnected and can stand back and think outside the box a little bit and say, is this really the right thing to do? So we need ethical review and we also need premeditated and recorded constraints to protect the welfare of the patient. And in fact, if you think about it, all this bit in the bottom half of the slide is what AA does for scientific procedures.

So there's really no reason that we can't apply the same sort of process in the clinical world. Now, I've to make it sort of hopefully a bit simpler, I've I've tried to break this down and I call it three types of research. We've got pure science, which is not for the individual animals benefit, which clearly goes under Asper.

That's, that's easy. We've got a clinical trial, so it's using recognised veterinary practise and so it falls under the Veterinary Surgeons Act. It's a clinical trial, so it may involve randomization, it may involve controls, it might even involve placebo treatment.

It's got to go through ethical review, and it's got to go through peer review to check the science. Now drug trials in this country fall under the an animal test certificate, ATC, which is administered and provided by the Veterinary Medicines Directorate. So drug trials, in fact, get fairly well looked after in this respect.

But surgical procedures. And of any form in implants, there is no regulation. If you think that this is a good idea and you're doing it for for that animal, there's nothing really to stop you doing it, even though you've no idea whether it's gonna work or not.

And this sort of pushes it on to the life saving heroic stuff, pushing forward the frontiers of science, but is it really recognised veterinary practise? It is allegedly for the animal's benefit. But it is not evidence-based medicine, and if it's a go ahead, it needs to have the same sort of constraints that are there under AA, that there is somebody from the outside looking at it.

There are stop points. If it all goes pear shaped, you've got to plan what happens to that animal. And it's premeditated.

It's known about beforehand. And I would point out that ethical review doesn't stop the process. It simply makes sure that the patients are not injured on the way by thinking out all the possible things that might go wrong and deciding what to do about them.

So my little flow diagram on, on the right outlines this really a new idea for treatment. Must have peer review, it must have scientific review, and it must have ethical approval. And then included within that there are planned stopping points and audit.

Audit is where you get the evidence from to see what happened afterwards and how often does a clinical study not end up with the answer that you thought it was going to have. So it's particularly important that we stand back and look and say, well, that one didn't work, did it? But by the way, that one did.

So all this is extremely important. And the the British College of Veterinary Specialists is just beginning to look at guidelines for audit that we can all do in clinical practise that should make us stop and look at some of the more innovative treatments that are being carried out. Now when it comes down to the Individual animal that you think that this heroic piece of surgery might save, how do you look at those?

It it it's not going to be a full clinical trial. It's not under ASA because it's not a scientific experiment, but it is an experiment of some sort or another because it hasn't been done before or it hasn't been done in its entirety before. And there is the beginnings of the way to help those in clinical practise to stand back and look at the procedure.

And we need to look at all the stakeholders, and the stakeholders are clearly the animal. We've got to think of its quality of life, we've got to think about the harms versus the benefits. We've got an owner involved here.

Who's this procedure really being done for? Where do the finances come into it? What about the aftercare?

Quite a, quite a an effort there. And then there's the clinician, again, who is it really for? Is it kudos?

Is it furthering the career? Is it getting those last cases for that case series for the diploma? Finance maybe.

And we have a huge responsibility to our profession. Things that appear on TV, Facebook. And in the papers, All come back to how the general public and the world sees our profession.

Women to be caring profession. So that's just as important as for the individual clinician. Now the paper that was published in the veterinary Record, and I'm sorry, I'm completely biassed because I am one of the authors.

But I nonetheless, I'll stand up and say it, it's there. It is a prototype. It contains a prototype of a tool, a veterinary ethics tool, conveniently spelled vet.

To help those stakeholders decide whether a particular procedure is going to be good for the animal. And clearly the the animal can't speak for itself. It must include an advocate for the animal, and this is not always the owner.

So it balances the stakeholders' points of view, it has an advocate for the animal and it ensures that the owner's consent really is informed. I often wonder. How well an owner understands what their pet is going through when it's in the hospital or the intensive care for hours, days, weeks, dare I say, months.

I don't think they know that that really isn't much fun. I know about what goes on in intensive care wards, and I can't bear it seeing one of my own animals with tubes lined up all over the place. I don't think the owners really understand what's actually going on.

So, to finish. We may have a procedure that's legal. It's veterinary, it's recognised veterinary practise.

It's clinical excellence, but is it ethical and is it in the patient's best interest? My final comment is we as veterinary surgeons are privileged to be able to apply euthanasia. It's not failure.

Thank you