The Ethics of Medicating Dogs with Behavior Issues in a Shelter Setting
Each year, millions of pets are surrendered to humane societies, county pounds, and private rescue groups. While a survey of the research shows broad variation nationally, it is fairly well accepted that somewhere between three and four million dogs per year are admitted to one of these types of rescue associations (throughout this article I will refer to them collectively as “rescue”). Of the dogs surrendered or entering rescue as strays, as many as 30 percent are eventually euthanized, presumably because they are either too difficult to place or have been deemed to be unlikely to be successfully rehabilitated. Many rescues, though, have worked very hard to lower their euthanasia rates—the Animal Humane Society reports that their euthanasia rate for dogs had dropped to two percent for the year July 2014 – June 2015. At least part of this drop may be attributed to their greater outreach to breed rescues and private rescues for placement of dogs that are not immediately adoptable.
Many studies have been published that seek to shed light on the reasons behind owner surrenders—this is one example. This paper summarizes a number of articles published in recent years looking at various causes/effects of surrender. The authors found that in some comparative analyses, dogs surrendered versus those who are kept by their owners have the same rate of attendance at obedience classes. However, the dogs surrendered are more likely to be outdoor dogs exclusively, older, male, and intact. Leading causes of owner surrender include behavior problems such as hyperactivity, destruction of house furnishings, biting, fearfulness, and barking. It is not known, as far as I could determine, if the owners in these studies had tried behavior modification or medical treatment.
Regardless of the specific background in cases of owner surrender, a large number of dogs entering rescue are diagnosed with behavior issues. Indeed, the very act of coming into rescue disrupts a dog’s known world and is a cause of stress. That stress may itself create or aggravate behavior problems. With the understandable reluctance to euthanize otherwise healthy dogs, rescues may exhaust their capacity unless they can place these dogs. “Filling up” causes rescues to close to new intake. So rescues are motivated on several levels to successfully adopt out dogs with behavior issues. Creating space in the kennel or foster homes, remaining open to intake, and financial health are all logical reasons a rescue needs to ensure that dogs flow through intake, into foster care, and out to successful placements as fast as possible.
The reality that all rescues face, regardless of size, is that funds are never unlimited. I would posit that even the largest and best-funded rescues must weigh the cost of care against the ability to place dogs successfully in a new home. Placing a dog who then “bounces back” into the rescue results in even more stress (including financially) on the rescue, and may well worsen the dog’s behavior issues. Resources devoted to behavior problems may take away from resources that could be devoted to addressing solvable medical problems (for the sake of brevity I’m including treatable diseases of a physical nature in the medical category, to the exclusion of behavior or psychological issues). Additionally, most rescues will not accept a dog with a bite history. A dog who cannot be adopted out or who has a bite history that would ethically preclude that dog being placed will either have to be cared for by its current rescue for the remainder of its life, or be euthanized.
So what then is the ethical obligation of the rescue to treat the behavior symptoms the dog presents with effectively in the short term, versus deeper testing and investigation to rule out organic causes of the problem behavior?
This article looks at the ethics and practical application of the use of anti-anxiety and other pharmaceutical forms of intervention as a way of stabilizing a behavior case. The stabilization must be enough that the dog can be placed in a permanent home safely—for both the dog and the family. Because many rescues do not have the resources to consult board-certified veterinary behaviorists on an ongoing basis, some have begun to use medications without a supervising veterinarian. When a veterinarian is consulted in a general practice setting, that veterinarian may or may not have the most recent understanding of a drug’s effect on that specific behavior case. Lastly, the most troubling ethical issue in my opinion is the case in which dogs grouped under the heading of “behavior issues” may have an underlying physical cause, which a private owner with more funds and time would be able to identify through ongoing and extensive testing by a veterinarian. Testing for thyroid issues, irritable bowel syndrome, Cushing’s disease, and diabetes are all logical parts of a veterinarian’s work up that may be beyond the financial reach of a rescue.
My own practical experience as a volunteer behavior consultant with several rescues in the northeast, along with experience fostering and adopting dogs with behavior issues would indicate that many times (certainly a large majority of the time) severe behavioral issues such as dog- or person-directed aggression are not tied to a discrete physical cause. As the costs of lab tests may run in the hundreds to thousands of dollars, very difficult decisions must be made regarding the ability to continue to pursue a physical cause for the observed behavior.
If a dog passes an initial medical exam, and traditional diseases or causes of pain are ruled out, a rescue then needs to focus on how to handle the behavior issues the dog is presenting. From an ethical perspective (do no harm) treating the dog with a behavior modification protocol is a logical next step.
In my experience with behavior consulting in rescue situations, specifically focusing on aggression and reactivity, I have found that up to half the dogs presenting with these kinds of issues in rescue do not respond to behavior modification alone, or their response is minimal and levels off early in the protocol. It is at this point that many rescues then consider the most appropriate use of medication to treat the observed behavioral symptoms. The rescue must evaluate whether medicating the dog short term or long term is necessary, which medication is most suited for the behavior observed, and whether the observed behavior reported is a reliable metric of the dog’s issues.
This last point is crucial to understanding the challenges faced by rescues. Many rescues use at least some level of placement in foster homes as a way of both creating more space and increasing the dog’s chance of being successfully adopted. Foster homes offer a lifesaving option for dogs who are not immediately adoptable. The vast majority of foster homes, however, do not have advanced training in behavior issues. Rescues must rely on the foster family to accurately describe the antecedents to the behavior and any consequences. That’s a fairly high degree of insight expected from a lay population. If it is not possible from a geographical or resource perspective to have an assessment performed when behavior issues are reported, the rescue must rely on the foster family’s observations when evaluating whether to medicate and which medications to consider.
Some rescues use a kennel environment to hold dogs who are waiting for adoption. While some behaviors can be attributed to the stress of the kennel environment (barrier aggression, fearfulness), it is difficult if not impossible to parse what is due to the environment versus what may already have been present in the dog. To some extent, the distinction may not matter. The dog is not adoptable as it presents currently, so medicating based on the symptoms is necessary.
To illustrate the ethical considerations of treating behavior issues medically, I’m including two case studies. Both cases focus on Dobermans coming into rescue. In both cases, the dogs fit the typical profile discussed at the beginning of this article—they were both intact males, one found as a stray and the other from a situation in which he was living outdoors exclusively, all year round. Both dogs were referred to me, and fostered in my home, for evaluation after troubling behaviors were observed. Both cases also demonstrate the issue of limited resources and difficulty in placing the dogs. I would also describe both cases as extreme examples (as will be noted below) but useful in illustrating the ethical issues weighed by the rescue involved to place the dogs safely and avoid euthanasia.
Case study 1: Captain
A 2-year-old emaciated intact male Doberman and his littermate brother were surrendered by the owner because of significant fighting between the two dogs. Both entered rescue with a body score of 3 to 4, one with Lyme disease and both with skin problems Their background included initially living indoors as young puppies, rapidly transitioning to running free outdoors in a rural area. After neighbor complaints, the dog warden required the owner to confine and maintain control of the dogs. As a result, the owners elected to chain both dogs outdoors continually in all weather, in Ithaca, New York. A simple wood doghouse was the only shelter available, and no apparent socialization or training had been provided. Upon surrender to the rescue, no foster homes were open and so both dogs were housed in a reputable kennel to treat their health issues, neuter, and observe them further.
Within a few months, the shyer of the two was put into a foster home, then rapidly adopted. The remaining dog, Captain, struggled with skin issues and developed/revealed behavior issues that worsened during boarding over the next few months. He was reported to exhibit increasingly aggressive behaviors towards other dogs (across barriers) and towards people he did not know; the owner of the kennel, having considerable breed experience, spent a lot of time with him trying to socialize him and establish some basic manners.
Despite a considerable amount of time spent on him, Captain’s behavior was reported as aggressive and deteriorating. Reports included lunging at strangers and often at people he’d previously met and seemed to accept. While no actual bites occurred, he did at times bump the person hard with his nose, and bark and attempt to lunge at the person (up on rear legs, straining against the prong collar that was used at all times). The kennel owner found that she could not find any staff to care for him and was herself fearful of losing control of him. The rescue then asked that I take Captain for an evaluation.
During the evaluation, I observed the aggressive lunging and hard nose-bump when he was introduced to me. However, a slow introduction with classical conditioning enabled him to settle and eventually accept my presence. When Captain first arrived at my home, he had a great deal of trouble settling, as exhibited by continual anxious pacing and roaming in the back yard.
He appeared to be uncomfortable with direct eye contact, even after three weeks in my foster home with a familiar handler and familiar environment. He also continued to struggle with introductions to people he didn’t know, exhibiting the lunging and barking previously noted. Although the kennel and original owner did report dog-focused aggression, Captain settled in with my well-socialized senior male Doberman, my 6-month-old female Doberman, and a male Dachshund mix.
In evaluating him over the course of four weeks, I was able to identify that he did offer calming behaviors prior to escalation (lip licking, turning head, attempt to turn around); however, they were subtle and very quick. The time between signaling he was uncomfortable and reacting was on the order of 5 to 10 seconds. At the end of four months in rescue (three in a kennel, one in foster care with me), he still struggled to stay focused on a handler he knew and accepted; I was not able to bring him outside the house or out of my yard without him going over threshold within a few minutes.
Physically, Captain had gained weight and was close to a normal body weight. He continued to have skin issues (dry coat, sores present at intake still not completely resolved) and he was not able to come off of an antibiotic for that reason. Parasite infection was ruled out, as were tick-borne illnesses. At that point, chicken and beef were dropped from his diet at the advice of my veterinarian; both she and I had noticed that some dogs with behavior issues improved when chicken and beef were eliminated. We discussed a thyroid panel; however, his skin was improving, and the cost was prohibitive for the rescue. So at that time the rescue elected not to pursue the thyroid testing (recall they had already absorbed initial vetting on intake, skin treatment, and boarding for three months). At this point, the rescue would typically have asked a general practice vet for Prozac. My veterinarian preferred not to put Captain on Prozac based on her survey of the literature and experience with side effects. Because he still exhibited a lot of anxiety that resulted in the behavior displays described above, my general practice vet consulted with a veterinary behaviorist and started him on trazodone (100 mg once a day), after he redirected on me while reacting to an outside stimulus (no bite).
I rethought the behavior modification techniques being used (by the way, the IAABC Animal Behavior Consulting: Principles & Practice course was tremendously helpful in this re-evaluation!) and started with a new protocol based on simple impulse control exercises and limited time off my property with the goal of keeping him under threshold. While he improved, there were still observable behaviors indicating significant anxiety and trouble settling. Working with the vet, we increased the dosage of trazodone to twice a day.
Over the next few weeks, I was able to successfully introduce Captain to six people who help with caring for the dogs in my care. The introductions “stuck” in that he did not revert to displays of aggression if a few days or weeks had passed since they were introduced. At 60 days into the trazodone therapy, he was able to walk more calmly in a known neighborhood with a trusted handler (me or one of my assistants). At this point, I elected to discontinue operant conditioning, as he didn’t seem to be progressing in offering positive behaviors. I instead used classical conditioning —offering a treat each time he noticed something he tended to react to. After two weeks of classical conditioning on our walks, he progressed to the point that he could walk within 8 to 10 feet of people he had never met, including in loud environments such as construction sites.
Currently, Captain remains under my care as a foster. It is unclear, despite his progress, whether he will be able to be adopted or have to remain in foster care permanently. At two and a half years old he is behaving well in my home living with three cats, two other Dobermans, and a foster Miniature Pinscher. His coat and other symptoms that might be consistent with thyroid problems have resolved, and the behavior issues have improved. He still requires ongoing vigilance, however, and we are still working on consistency in his greetings of strangers. With two years of poor nutrition and likely use of aversive handling techniques by the original owners, there is a lot of trust that needs to be built between this dog and humans.
Based on his history of poor nutrition and little or no socializing during critical development periods, he may never be successfully adopted and thus remain in foster care permanently despite medication. However, I believe he needs a further 8 to 12 months with medication and behavior modification before that determination can be made. This case study poses the question: Is partial success with medication good enough to justify the lack of further extensive medical testing for underlying issues? I believe it is, though the long-term outcome is still to be determined.
Case study 2: Kai
Kai was an intact male blue-coated Doberman admitted into rescue after intake at the county pound as a stray. No owner claim was made, and he appeared to be very fearful in the kennel environment. Within four days of admission to the pound, Kai was admitted to rescue and brought to an emergency vet with physical symptoms of shock (poor capillary refill, dehydration, failure to eat). His fearful behavior included refusal to look at the human handling him, turning away from the handler, cowering in the back of the kennel, and refusal to leave a crate or kennel. He was observed trying to eat his bedding, so all bedding was removed from his run. He was hydrated, but no cause to the physical symptoms of shock was found, and he was released to me in foster care.
I elected to keep Kai separate from my dogs because he was previously a stray and then had spent time in the county pound; he had tested positive for whipworms, and he also seemed reactive to my dogs, growling and showing teeth when he encountered them despite a slow introduction.
Kai continued to refuse most food, although I was able to tempt him to eat at times. He rapidly formed a close attachment to me, following me at all times when he was not crated. After I returned from a four-day business trip, he began vomiting and again was refusing food, and had also begun to have diarrhea. A visit to a general practice vet included X-rays, which showed a thickening of the stomach but no definitive diagnosis. This second visit resulted in a bill of $1,300. After four days of hospitalization, IV antibiotics, metronidazole, and fluids, Kai was released. He had lost 8% of his body weight.
I elected to assume he had irritable bowel syndrome and switched him to a home-cooked diet with the recommended supplements. He stabilized, began to gain weight, and was somewhat less reactive, so I allowed him to interact with my dogs. He also was strong enough to repeat the treatment for whipworm, and we completed that protocol.
Within three weeks of the last hospitalization, he again started vomiting and was brought to a different veterinarian. On examining Kai, the vet noticed that there was a blockage in his stomach. An ultrasound revealed a mass, and he was immediately admitted to surgery, where the vet found what looked to be socks and hard red plastic blocking the passage of food through his stomach. The blockage had likely had been there for some time, causing intermittent obstruction.
The vet noted that Kai had “significant lesions throughout his large and small intestines,” indicating that he had likely had these gastrointestinal issues for some time, and would be susceptible to future blockages. Also, Kai had evidently already undergone stapling of the stomach, a procedure used for dogs who had, or were considered high risk for, blockage and subsequent torsion of the stomach.
Because the problem was found to be a blockage and not a cancerous mass, we elected to have Kai neutered at the same time, hoping that would address some of his behavioral issues. This second vet bill was lower because the vet, having a close working relationship with the rescue, performed the surgery at cost.
Kai returned home the next day, continued on his home-cooked diet, and over the next six weeks healed and apparently rebounded physically. He was also able to be fully introduced to my resident dogs and began to play and take an interest in his surroundings. However, I did observe that he obsessively ate almost anything in the house or yard if left unsupervised. Because of the risk of another blockage, he was conditioned to a basket muzzle and wore one at all times outside as well as whenever he wasn’t directly supervised inside.
Despite these precautions he again blocked six weeks after his surgery. At this point, the rescue had put $6,500 into his care. He was taken to my vet who x-rayed him and found the blockage was large but of unknown origin (we later determined it was a result of him eating some potting soil from a houseplant —the vermiculite showing up on x-ray).
Although the vet offered to do the second surgery at cost, the rescue was faced with a very difficult decision. Despite vigilant care and muzzling, he had blocked a mere six weeks after the last surgery. A continued history of obsessive eating (likely pica) meant that he would most likely continue this pattern. That risk made him most likely unable to be adopted. Ethically the rescue would have to disclose his history; very few potential families have the emotional or financial resources to accept the risk of ongoing surgeries.
The rescue elected not to have the surgery performed, and recommended we take him home and walk him as much as possible, returning that evening for another x-ray. Later that night the second x-ray indicated the blockage had slightly broken up, and all parties agreed to have him return home. If he deteriorated I was to bring him in immediately; otherwise I would return in the morning. He did make it through the night, and the x-ray the following morning showed that the blockage had continued to break up. The vet felt there was a physical gastrointestinal condition occurring that was causing the blockages and the adhesions. However, pursuing a diagnosis was likely to run to an additional $2,000 to $4,000.
After consulting with the general practice veterinarian, and because of his seemingly compulsive obsession with eating foreign objects, we started Kai on Prozac. After four weeks, he had progressed enough and seemed relaxed enough to begin leaving the muzzle off outside as long as he was under supervision. Six weeks after initiating Prozac, he had progressed to the point where the rescue was able to place him in a traditional foster home. The foster family reported that he still tried to eat things at times, but felt it was much reduced and manageable. They later adopted him, and six months out he has still not had a further blockage.
So, in looking at these two case studies, what are the ethical issues at hand? At a minimum we must weigh:
1. Is it appropriate, in cases where resources are limited, to bypass conclusive medical testing before starting pharmacotherapy? Would Kai, for instance, have had fewer blockages if we had started Prozac earlier (which would have saved the rescue a few thousand dollars)?
2. Does the rescue have an obligation to inform potential adopters about the reason for medication and the chances of being able to discontinue medication in the future?
3. Should psychoactive drugs be prescribed in the absence of behavior modification?
4. Is it ethical for a rescue to put a dog on a drug in the absence of ongoing veterinary supervision (“borrowing” the drug from another dog, thereby eliminating the cost of a veterinary workup)?
Looking at the first question, I would argue that yes, it is ethical. Failure to address significant behavior issues either absorbs foster care capacity or results in euthanasia. Being able to relieve or eliminate behavior symptoms early on, which then makes the dog adoptable, offers a lower risk of failure and a higher likelihood of a successful adoption. If the dog fails to progress on medication, the rescue then must decide if they have the resources to invest in further testing. There is, of course, the risk that you are medicating and addressing symptoms instead of their underlying physical cause, which leads us to the second question.
There is always the possibility that a medical condition is present and not yet advanced enough to be diagnosed and treated. So medicating to address the behavior issues without further testing could overlook possible medical illness, and in those instances the medical condition of the dog may deteriorate after adoption. The more challenging question here, I believe, is to what extent the adoptive family should be educated about the reasons behind medicating and the possibility that there is an undiscovered medical condition. This touches on issues of informed consent not unlike those humans face, for example when trying to decide between surgery and medication. Just as with informed consent in humans, I would argue that potential adopters are due a full disclosure. To the best of their ability they should be given all the facts, including that there may be medical conditions present that have not been diagnosed.
As to the question of whether psychoactive drugs should be prescribed in the absence of behavior modification, I would have us look at the ultimate goal and the practical reality. Most foster homes and many kennel workers are not trained in the nuances of behavior modification. Although I always develop and implement behavior modification for my fosters, I have spent years and a considerable sum of money on continuing education. It is difficult to find enough foster homes, and most rescues cannot require that behavior modification is used beyond “common sense” management techniques. While it is not ideal, if the medication alone results in improvement and the rescue is able to successfully re-home a previously unadoptable dog, a life has been saved, and space in a foster home or kennel has been created. This enables the rescue to take in another dog and allocates financial resources in a sustainable way.
The last question in this discussion speaks to a practice of many rescues; given that many dogs throughout a community are already on Prozac, it is very easy to access and make this medication available to a dog with behavior problems. This can be done in the absence of a veterinarian following the case; though that is illegal. I would also posit it is unethical, and it is here that rescues might examine their own practices carefully. The drugs prescribed for behavior issues in dogs are very complex in their effect. The side effects may be low, but can be disastrous if not identified—Prozac, for example, occasionally results in increased aggression. Based on my experience with a variety of veterinarians in my community, I would also posit that there is an additional side to this question regarding taking a dog to a veterinarian who is not conversant with behavior therapy involving these drugs. It typically takes several weeks of trying to find the right drug and dosage. Additionally, new research is being published all the time in this field, and the first-line use of drugs is evolving. A veterinarian who is not conversant with the latest studies risks an escalation of the problematic behavior if the medication does not work or causes risky side effects—sometimes with tragic results when a dog must be euthanized after an escalation of aggressive behavior and a resulting attack or bite incident.
What can we as animal behavior consultants do in this last example of an ethical dilemma? At a minimum, we can reach out to all community veterinarians in our area and understand how they treat such issues. As much as possible, we should remain current on the thinking of board-certified veterinary behaviorists. The intent of this call to action is not to offer veterinary advice. Rather, we can help our clients develop a list of symptoms and observations both before and after administration of the drugs. While it’s important never to criticize a veterinarian (as most of us are not in fact veterinarians), it’s also important to be able to recommend another vet if our clients ask for one, or we gently suggest a second opinion. Many general practice vets are in fact very up to date; these same vets are also likely to call on their colleagues who are certified in behavior for an informal consult.
For those of us working in the shelter or rescue setting, the balance between resources and unmet need will continue to present a challenge for all those involved. In trying to help as many dogs as possible, it’s very important to continue to develop ethical guidelines for the situations we encounter. It’s also my hope that the IAABC Foundation Journal may serve as a place for wider discussion of the ethical issues involved. I truly look forward to comment, criticism, and debate on the ethical issues raised in this article.
Shortly after publication, Captain exhibited further behavior issues, primarily developing conflict aggression with my senior Doberman with whom he had previously interacted well. Because Captain was designated as not adoptable due to his behavior, we could not place him in another foster home. As a result, Captain had to be euthanized. A very difficult and sad decision but one made for the safety of my senior Doberman.
A lifelong dog, cat and horse lover, Susan Cullinan MS, MSTS, KPA-CTP has been teaching group classes for four years. Over the last two, she has moved into behavior consulting with a focus on reactivity and aggression cases.