Print version ISSN 0021-2571
Ann. Ist. Super. Sanità vol.47 n.4 Roma Dec. 2011
ANIMAL-ASSISTED INTERVENTIONS IN MENTAL HEALTH
Problemi connessi con l'uso degli animali a scopo terapeutico. il Documento del Comitato Nazionale per la Bioetica
President, Bioethics Veterinary Committee, Rome, Italy
The Italian Ministry of Health, in 2002, instructed the National Committee for Bioethics to carefully review and ultimately provide evidence for future legislative bills in various aspects. One such matter was that of the subject of "Pet Therapy", generically viewed as a "man-animal" relationship, with the purpose of proving beneficiary to both human health and welfare. The necessity of a bioethical approach was deemed important in establishing the concrete benefits for mankind (and the research required to demonstrate this) whilst also considering any possible malaise inflicted on those animals participating. The final recommendations decided upon, took into consideration effectiveness, cost, suitable alternatives, discussion of the intervention with the patient.
Key words: bioethics, health, humans, animals.
Nel 2002 il Comitato Nazionale per la Bioetica fu incaricato dal Ministro della Salute di approfondire vari temi per fare valutazioni utili a una futura produzione legislativa. Uno dei temi era relativo alla pet therapy, intesa genericamente come relazione tra uomo e animale col fine di produrre un beneficio per la salute e il benessere umani. La rilevanza bioetica fu indicata soprattutto nella individuazione dei reali benefici per l'uomo e nella ricerca per dimostrare questi e i possibili malesseri degli animali coinvolti. La dimostrazione dell'efficacia, i costi, le alternative, la condivisione delle scelte con il paziente e gli interessi attribuibili all'animale furono presi in considerazione contemporaneamente nelle raccomandazioni finali.
Parole chiave: bioetica, salute, uomo, animali.
The National Committee for Bioethics, appointed in 2002 and remaining in office until 2006, was commissioned by the Italian Ministry of Health to contemplate the area of "pet therapy" from a bioethical point of view. The subject of "pet therapy" i.e. the use of animals in providing a beneficial effect on the health and welfare of humans has aroused great public interest. Nevertheless, solid scientific data on the real efficacy of this therapy are seriously lacking and still under acquisition. A major difficulty envisaged in transferring this therapy to the medical classes is due to the present lack of scientific data on a) the beneficiary effect on the human being and b) the welfare of the animal employed. A strong conviction felt by most, is that whilst facilitating the human being, the outcome for the animal must also be advantageous.
A working party on animals was appointed in 2002 and had, as its first assignment, that of studying the area of "pet therapy".
Experts in this specific field of activity were employed to carry out a series of interviews, the result of which saw various rough drafts of the final document being drawn up. These were dealt with in several assembly discussions before final approval of the document was given. This decision was reached, unanimously, on October 21st 2005 in an assembly comprised of doctors, lawyers and a veterinary surgeon.
The work proceeding realization of the document saw the Coordinator of the group on animals invited to a hearing on the bill, by the Commission of Social Affairs, of the Chamber of Deputies.
The title of the document, "Bioethical problems related to the use of animals in activities correlated to human health and welfare. Man-animal therapeutic alliance" serves to highlight the fact that the CNB did not wish to deal exclusively with "pet therapy". Two other aspects, closely correlated, were the case of assistance animals and that of those patients who are hospitalized and desire to have their pets acompany them during their stay.
The term "pet therapy" is unquestionably recognizable and undoubtedly the reason for selection of this title. Despite this, the critics may be moved to selection of an arguably more apt title, employing the use of more precise and careful terms. Some of these include: assisted therapies with/through animals (AAT), assisted activities with/through animals (AAA) and so on, including the use of animals for educational/social purposes.
Assistance animals were also taken into consideration, as in the case of guide-dogs for the blind, for the deaf, for the motor disabled, for those affected by epilepsy etc. The aforementioned case of those patients who are hospitalized and desire to have their pets accompany them during their stay was also discussed.
On reflection of all of these cases, there are two considerations. The first is in the search for the benefit of using animals in ameliorating human health, the second, the use of animals as elements of this relationship.
The moral implications for both parties involved are analogous. The human beings involved are ultimately weak; they are in need of assistance/therapy. The animals themselves are also deserving of moral consideration. These moral implications are particularly important, considering the non-traditional and in part unknown nature of these interventions, which involved physical and psychological aspects.
It has been felt by professional organizations and public institutions alike, the necessity for adequate definition of guidelines and utilization of a code of ethics. In response to this, the CNB has felt the need to provide answers not only to these requests but also to the requests of the Ministry.
OBJECT AND LIMITS
In the execution of "pet therapy" and thus correlated activities, the primary preoccupation is undoubtedly in ensuring an advantageous outcome for the human beings involved. The importance of ensuring the protection (and where necessary, the improvement) of the welfare of those animals involved must not be however be underestimated or overlooked.
In order to definitively reach any conclusions and thus recommendations, it is important to consider all aspects of moral importance. The decision was thus made to analytically consider the various points of view that could potentially emerge in this type of debate.
As a result, four parties of interest have been recognized: the patient, the animal, the working party and the community. Finally, the legal aspects surrounding the matter under investigation have been analyzed. Without doubt, the most innovative aspect of this approach has been deliberation on the hypothetical "point of view" of the animal.
In this regard, certainly, a full and comprehensive interpretation of the requests/needs of the animal cannot be achieved. Nevertheless, with the intention of recognizing a real moral status for animals, the artifice has been used of interpreting their presumable interests through the filter and elaboration of the bioethical committee. The requisite for considering the point of view of the animal comes not only from ethical consideration but also from legal and practical aspects.
The "animal question", in other words, the caring for protection of animals, has transformed from being a somewhat small phenomenon of the elite to being a popular social-cultural need, at least in Western civilization. This ethical "need" however, has led to repercussions in the legal systems of those countries in the European Union that provide for the protection of animal welfare. Furthermore, we can hypothesize that the efficacy of the therapeutic process comes in part, from the belief of those involved in the process that the animal involved is in fact actively participating and profiting itself from the interaction. So much so that it is possible to identify some sort of inter-specific "therapeutic alliance".
The ethical consideration, or rather the bioethical consideration (so called as the reflections require biological as well as ethological considerations) is particularly required as practices such as those of "pet therapy" are novel with respect to the historical and traditional uses of animals in human activities/ practices.
THE INTEREST OF THE COMMUNITY AND OF THE PATIENT
The primary interest of the human community fully concurs with that of the patient – the search for legitimate benefits for their own fellow beings, those with a pre-requisite for care and assistance.
The augmentation of any innovative practices still unknown to the medical world/social systems fundamentally rely on the production of scientific data that demonstrates irrefutable efficacy of the intervention. A widespread community interest, which has now also been established by law, is that of safeguarding the welfare of the animal.
The institutions involved have to face the difficult task of considering a plurality of concomitant elements: the health and welfare of the animals, the health of the public, the management and distribution of resources, the investment in the development of knowledge, the provisions of information for citizens and informed consent in these practices. Despite all the difficulties envisaged in this genre of practice, one element that could provide some order in this situation would be to put into effect a protocol of research that enables examination and comparison of all the elements, concentrating on the single clinical or social case.
One particular problem envisaged is that of expenditure. Given the current economic climate whereby great attention is directed towards public expenditure, it is imperative that a "pet therapy" working party encompasses a multidisciplinary group. That is, a group that is competent in satisfying all the imminent needs of both parties, in providing assistance to the patient whilst also ensuring the management and protection of the animal.
A protocol of "pet therapy" incorporating professional staff could essentially involve high cost. At the same time, it would ensure greater accuracy in the collection of results and production of scientific data. On the contrary, incorporation of those individuals working on a voluntary service, although may extend the base of intervention with no particular costs, may produce less objective data.
THE INTEREST OF THE ANIMAL
The practices of "pet therapy" in most cases would probably be better pursued through activities closer to those for which the animal has been originally domesticated.
The attempt to express the interest of the animal, without anthropomorphic attributions or reifications, whilst filtered by a bioethical committee, may be contradicted. It does however, underlie the search in practice for the acknowledgement of the moral importance of the life of the animal. The sheer fact that the animal is in some way involved in a "pet therapy" practice requires that a permanent condition of welfare (if not an improved condition of welfare) is guaranteed.
The responsibilities toward the animals must not be implemented during practice alone; it must be realized even during phases of inactivity, at termination of the protocol and for the remainder of its life thereafter.
The animal species that have not undergone the laborious and millenary biologic process of domestication and are therefore "wild", should, as a precaution, be excluded from these practices of "pet therapy". Despite individual processes of tameness, they could suffer the close contact with humans.
Another interest of the animal is that of being subjected to training practices that are characterized by gentle methods. These methods should not be physically or psychologically forceful, thus respecting the dignity and welfare of the animal.
THE INTEREST OF THE WORKING PARTY
In the animal-assisted therapies, less so in the case of assistance animals, the working party must be necessarily large enough in order to include all the professionals required for all phases of the project and its realization. It could prove difficult to achieve and maintain a dynamic equilibrium between the various components especially in the case of activities involving professionals rather than volunteers.
The same relationships, within such a large group of people could therefore affect the relationship between the human patient and the animal co-therapist.
To quote only one code of conduct of only two of the involved professionals: "the Vet must interrupt a session even if very productive for the patient, if the animal shows any signs of malaise. The Doctor pursues the improvement of the clinical situation of the patient by documenting facts".
Even in this case, the acquisition of scientific data on the beneficial effects on human and on the welfare of the animal can create the conditions for a more efficient and stable communication within the working party, and with the Health Authorities (distribution of resources etc.), with patients and their families (informed consent etc.) and with the Veterinary Authorities that must check upon animal welfare (Veterinary vigilance etc.).
A THERAPEUTIC ALLIANCE
In addition to the scientific considerations and prior to attainment of data from research, one has to take into account that, for this discipline that we briefly define as "pet therapy", a fundamental presupposition is that of a truly genuine relationship with the animal, on the part of both the patient and of the working party.
Human-animal communication is mostly emotional and, although based fundamentally on the identification of an asymmetry of roles, it should rely on the respect of the dignity of the individual, the welfare of the animal and the recognition of the importance of biodiversity.
This attitude towards the animal can be a stimulus to the whole process of humanizing in medicine that wishes to recuperate with the paradigm of caring: transferring ones attention from the disease to the diseased, and from the diseased to the individual themselves seen in his or her physical/psychological entirety, may favor the study and use of such complementary therapies. These therapies intend to provide more integrated answers, considering not only the disease as an isolated fact but as a culmination of events including the individual's social history etc.
It is therefore hoped that:
a) research for the characterization of the real benefits for human health and the welfare of the practices that involve animals (and also the research for studying neurophysiological and cognitive parameters that can be used to interpret their "language") may be supported. This is especially important in the case of highly organised practices such as the activities carried out with animals for assistance, the assisted activities with animals (AAA) and above all, the assisted therapies with animals (AAT);
b) at the same time, research for the clarification of any alterations (in practices or in working procedures) that may lead to conditions of disease should be supported. As yet, the conditions of those animals utilised in therapy are not comprehensively understood and thus must be treated with a precautionary approach in order to exclude the possibility of stressful conditions;
c) wild animals are not involved since they are not accustomed either to living with humans or living in a restricted environment and therefore would inevitably undergo a condition of malaise;
d) efforts are put towards an improvement in the quality of life for those animals involved, using where possible, and without bias, animals from kennels, shelter homes, or those abandoned, as long as adequately selected and trained. It is necessary to take into consideration the conditions of life and welfare of the animal during all the stages of the project, even at its termination. It must be highlighted that in order to protect the interest of the animal, an adequate public vigilance must always be guaranteed;
e) a possibility to maintain a relationship with one's own animal is guaranteed in case of admission to a residential structure. This is so to prevent renouncing the assistance value of such a relationship of affection and to avoid the risk of abandonment or euthanasia. Furthermore, patients admitted to hospital structures should be permitted visits from their own animals, in appropriate spaces;
f) ethical committees should be entrusted with the responsibility for evaluation of the protocols and the projects of research and their realization procedure, in which to provide the involvement of the animals in activities different from their traditional utilization;
g) that the use of so-called "gentle" training techniques, the most possibly respectful for the dignity and welfare of the animal, should be promoted;
h) it is important for physicians to be aware of the possible effects, especially psychological, of these practices. For this reason, it is also recommended to not generically advise the presence of an animal in a domestic environment without having first considered two factors. The potential for the success of the relationship with the patient and the adequate knowledge required as regards the animal and its needs;
i) in the utilization of animals, the benefits alone must not be the only factor under consideration. The risks associated with their use must also be contemplated, risks such as allergies and infections (for example: the risk of toxoplasmosis transmission from a cat to a pregnant woman).
The CNB wishes to remind in short, that pet therapy (in the AAT form, that is, assisted therapy with animals) is at present, in many of its applications, still a hypothesis of work. This hypothesis is still awaiting adequate supporting evidence through scientific methods, which is deserving of public support, particularly when conducting scientific research.
The author was member of the National Committee for Bioethics from 2002 to 2006.
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
Address for correspondence:
Bioethics Veterinary Committee
Via S. Carlo a Palidoro 130
00050 Passoscuro, Rome, Italy
Submitted on invitation.
Accepted on 4 October 2011.