Cruel to be kind

Advanced medical techniques give animals a new leash on life, but owners -- and their pets -- are often feeling the strain

by Chris Wright

We in New England pride ourselves on our pragmatism, our no-nonsense frugality, our suck-it-up austerity. All of this goes out the window, however, when it comes to our animals. We preen, parade, and pamper our pets to a near-ludicrous degree, and spend gobs of money in the bargain. A local outfit called Pet Companions offers a daily Doggie Camp, complete with a swimming pool, air conditioning, and piped-in classical music. A new cookbook, My Children Don't Eat Dogfood, provides recipes for home-baked pet fare such as McCloud's Meaty Muffins ("mix ground chicken with potatoes, add milk and eggs and carrots and peas . . . "). Brookline recently became home to the newest branch of Bone Appetit, a "bakery and boutique" that features Down Boy bagels, Puppa's pizza, Bark-Assure breath mints, and "It's a Puppy" cigars.

But even in this climate of shameless pet pampering, it is safe to say that Bob the greyhound is one of the most well-treated dogs in the country at the moment. Not that Bob's in particularly good shape. Amid banks of high-tech gadgetry, surrounded by a tangle of wires and tubes, the seven-year-old greyhound lies etherized on a table, receiving treatment for a cancerous tumor on his front leg. Bob is inside the linear accelerator at Angell Memorial, the MSPCA's state-of-the-art pet hospital in Jamaica Plain. A team of radiation therapists hovers about, tending to the equipment, checking the patient's vital signs. Lasers pinpoint the spot on his leg where radiation will be directed. You might think you were in a NASA facility if it weren't for the gangly, hairy limb protruding from the gleaming machinery.

Oh, and for the little heap of poop in the lobby.

It seems fitting that Boston, a city renowned for its level of human medical care, should be home to Angell Memorial, the largest, oldest, and best-equipped animal hospital in the country. Every year, Angell treats more than 50,000 patients, from dogs and cats to chickens and lizards. It has 22 board-certified specialists -- neurosurgeons, plastic surgeons, orthodontists, ophthalmologists. You can get Prozac for your pooch, a kidney transplant for your kitty, reconstructive surgery for your rabbit, acupuncture for your hedgehog, or a root canal for your rat. The hospital boasts a cancer center that could hold its own at Dana Farber. "There are human facilities that don't have the equipment we have," says radiation oncologist Sheri Siegel.

It's a far cry from the initial vision of Boston attorney George Thorndike Angell, who, in 1886, founded the Massachusetts Society for the Prevention of Cruelty to Animals after watching a two-horse race in which both animals dropped dead. Angell's goal was merely to prevent this kind of cruelty, not to revolutionize animal health care. Even when the MSPCA opened Angell Memorial in 1915, no one could have envisioned the kinds of treatment that are available at the hospital today.

Neither could anyone have anticipated the kinds of knotty ethical questions that arise from offering human-quality medical care to animals. Human medicine has been struggling to deal with advances that drastically increase end-of-life expectancy, raising the financial stakes just as dramatically. But human doctors, at least, have long-standing ethical guidelines to go by. In advanced animal hospitals like Angell, the technology isn't far behind its human counterpart, but the ethics are. Doctors are performing big-ticket surgery on four-legged patients with six-year life spans. If the patients are in pain, they can't tell their doctors. And animal medicine, unlike human medicine, has a utilitarian tradition of putting sick or injured patients down. If high-tech medicine is a thorny issue for doctors who treat humans, it's a tangle of barbed wire for veterinarians. Guidelines, where they exist at all, are being established simply through practice, and pet owners are often the ones who pay the price. As for the pets, if they could talk, they might just ask: "Whose life is it, anyway?"

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Angell's linear accelerator, under which Bob the greyhound now lies, looks like a 12,000-pound food mixer. But it's the hospital's pride and joy, able to direct radiation to a specific spot, thus minimizing damage to healthy cells. It's also extremely expensive. Any veterinarian hoping to buy one had better plan one hell of a bake sale: a linear accelerator will set you back about $300,000.

Bob can't appreciate any of this. He's out cold, tongue lolling, drool flowing -- probably chasing rabbits across a meadow somewhere or having sex with Lassie. Even when he finally comes out of the anesthesia, Bob seems oblivious to the ordeal he's been through, staggering around and snapping up treats with doggie abandon.

In fact, the treatment will hurt Bob's owners, Julie and Matt Kopser, a lot more than it hurts their dog -- at least when they get their bank statement. Bob's three-week course of radiation therapy is going to cost them about $2000, not including incidentals such as medication and examinations, which add up faster than you can say "Down, boy."

The linear accelerator might represent the most expensive treatment available at Angell, but it's by no means the only expensive treatment. A cardiac procedure called "balloon dilation of pulmonic stenosis" has a price tag of $850. It costs $425 to insert a permanent pacemaker, and $215 for a temporary one (plus hospitalization, anesthesia, etc.). A night in intensive care averages $200 to $250. An EKG is $65. An x-ray runs from $45 to $65. A simple check-up is $40. A "blood profile" is $36. An Elizabethan collar -- the little plastic dish that prevents an animal from chewing on its stitches -- is $18.

It's easy to see how a sick dog can get expensive in a hurry. Debbie Peneranda, whose 11-year-old English bulldog, Jimbo, has a heart-based tumor and congestive heart failure, spent thousands of dollars at another area hospital, where the staff finally advised her that euthanasia was her best option. Unconvinced, Peneranda took Jimbo to Angell, where doctors promptly drained six pounds of fluid from his abdomen before getting down to the job of trying to treat his condition.

Peneranda's bill from Angell is $4000 and climbing. Jimbo still goes to Angell every three weeks for check-ups, and will do so for the rest of his life -- which could be a few more years. But he's alive, and that's what's important to Peneranda. She hasn't a single quibble about the money she's paid to Angell so far. "I'm more than happy to spend it," she says. "No one thought Jimbo would last a month. That was in October '98."

Meredith Hobart is equally effusive. Her adventures began when her cat, Marco Polo, fell to the floor one morning, "jerking and screaming." After a harrowing taxi ride, they made it to Angell -- Hobart hysterical, Marco Polo's heart flicking on and off like a light. "He was rushed from my arms into ICU," says Hobart, "where he was placed in an oxygen tent, put on a heart monitor. I didn't know what was going on."

Today, fitted with a pacemaker, Marco Polo is "back to his old self, playful, beating up his brother." The price tag for his care was $5000. Hobart didn't blink. "My cat is my baby," she says.

Not everyone, of course, has that kind of money -- or is so willing to part with it.

Zoë Agnew took her dog, Molly, to Angell when Molly "fell on her butt" and couldn't move. Agnew found herself faced with an arsenal of high-tech medicine, and rapidly withering willpower.

"It's overwhelming," she says. "Your first instinct is to say yes to everything. They're pretty good at `This is what we're doing and this is why we're doing it,' but there's no saying no." And so, she says, "Suddenly my dog's getting neurology tests, all these crazy tests." Molly's condition ultimately healed itself. "She made a miraculous recovery," Agnew says. "A $600 recovery."

There was certainly no saying no for Hannah Adams. When she went on vacation a few years back, her roommates accidentally let her cat, Max, out into the street, where he was promptly bitten in the leg. Max's real problems, however, started en route to the emergency room. "He didn't like the car ride," explains Adams. "He was having anxiety attacks." Adams says that the staff at Angell interpreted Max's panting as a sign he was having heart trouble. Max was put in an oxygen tent overnight and given a battery of tests.

"My roommates believed that the cat was about to die," Adams says. "I arrived the next day and went and got him. I just thought it was complete bullshit. My cat was fine." The hundreds of dollars that Max's trip to the hospital cost Adams left her somewhat bitter about the experience. "It sort of reaffirmed rumors I'd heard that they have fancy equipment and they like to use it, even if it's not necessary," she says. "I've heard they like to charge a lot of money for things that don't need to be done. I have a lot of questions."

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"Expense is a huge issue," says Siegel, the radiation oncologist. "It's unfortunate that that's what it comes down to, but that's the business. It takes money."

As its staff members never tire of telling you, Angell Memorial is "a state-of-the-art hospital, with care as good as you can get anywhere." Indeed, walking through the doors at Angell, you'd swear you'd wandered on to the set of ER. White-coated physicians skitter about, stethoscopes swinging. In myriad operating rooms, masked surgeons huddle; frowning technicians attend to bleeping, flickering machinery.

As Hannah Adams discovered, all this polished professionalism can be a problem. Adams's assertion that "they have expensive equipment and they like to use it" might not be the most charitable way to put it, but it's easy to see why a doctor with a lifetime of training and a battery of high-tech medical equipment at her fingertips wouldn't be gung-ho for euthanasia. All too often, the juggernaut of advanced animal health care collides with clients' drastically different senses of how much an animal is actually worth.

At one extreme is Meredith Hobart, happily opening her pocketbook to her cat's health-care providers. On the other is a man who once came to Michael Pavletic, a reconstructive surgeon, with a badly injured dog. When Pavletic told the man how much it would cost to fix the animal, the man said, "Gee, Doc. For that I can buy a new dog."

In his book Veterinary Ethics, Jerrold Tannenbaum, an associate professor at Tufts University School of Veterinary Medicine, writes:

Many clients who say, or have convinced themselves, that they "cannot afford" an alternative to euthanasia can afford it in the sense in which they would literally be able to pay for it if they made financial arrangements to do so. What they really mean is that they do not regard saving the animal to be worth the economic burden.

The dilemma Tannenbaum articulates is a new one: owners of sick pets have always been able to put animals down, but they haven't always had the option of angioplasty. The availability of expensive, high-tech treatments may open up a realm of possibilities, but it also places an enormous burden of responsibility on hard-up pet owners.

"Heck, it's very sticky," says Angell chief-of-staff and orthopedic surgeon Paul Gambardella. "It can be extraordinarily expensive to maintain humane care. There's no right or wrong answers that can be pulled out of a hat." Gambardella believes that, as much as possible, veterinary doctors should steer clear of the decision-making. Those choices are for the owners to make. And yet, he says, "my job is to go full force to try to save the animal."

Faced with the sophisticated medical technology available for animals, the decision for owners of sick pets becomes less about the possibility of treatment than about financial prudence. The choice becomes: pay up or put down.

It may seem strange -- grotesque, even -- to think of the life of a so-called family member in terms of cost value, but sometimes you have to: if it's going to cost $8000 for a year's worth of cancer treatments for your pet, and the benefit is going to be seven months of additional life, then you have to ask, "Is it worth it?"

Not surprisingly, many find choices like this difficult to make.

"Unfortunately," says Jeanne Baravella, department head of client services at Angell, "we have to contend with the fact that some people just can't put finances and making a decision about their animal together."

For some people, having invested so much -- financially and emotionally -- makes stopping treatment a real problem. "It's almost like being in Las Vegas," says Pavletic, the reconstructive surgeon. "You lose a certain amount of money and you're continuing to lose. When do you decide enough is enough?"

For others, of course, "enough" comes right away -- not because the owner doesn't care, but because not all animal lovers can afford the kind of treatment that Angell provides.

"Finances are a real hot point in the organization," says Baravella. "Bills not only become very high, but people are paying out of pocket. We get a lot of people who are needy."

Policy wonks Although pet insurance has been available in the US for about 10 years, it hasn't yet proven hugely popular. According to Trina Theall, executive vice-president of Preferred Health Insurance, which insures pets, that's at least partly because many owners just don't know it exists -- and if they do, they don't take it seriously. "Many people don't look at it as real insurance," Theall says. "They insure other prized possessions: their houses, their cars, boats, lives, and families, yet they don't insure their pets." Veterinarians, too, are skeptical. "They're leery of it," Theall says, "afraid it's going to cause more paperwork, afraid they're going to have to wait for reimbursement." And insurance companies don't see pet insurance as being particularly lucrative. "The premiums are so low," says Theall. "If the average premium is $150, it's going to take an awful lot of customers to make that cost-effective." There are, however, a few pet-insurance companies out there, and Theall predicts that the industry will blossom as animal heath-care becomes more extensive -- and expensive. Three major companies offer insurance to pet owners in the Massachusetts area; premiums vary according to the age, species, breed, and health of the insured pet, plus other variables. (Call or log on to the companies' Web sites for details; be sure to ask about fee schedules and whether policies cover congenital or hereditary disorders.) The following chart compares policies and basic costs for a young, healthy animal. Premier Health Insurance (877-PPI-CARE; www.ppins.com) Basic   Plus   Ultimate Per-incident limit: $1500 $3500 $5000 Annual limit: $7500 $10,000 $12,000 Annual deductible: $100 $100 $100 Annual premium: $83 $160 $312 Veterinary Pet Insurance (800-USA-PETS; www.veterinarypetinsurance.com) Gold Plan   Advantage Plus Plan Per-incident limit: $2000 $4000 Annual limit: $7500 $12,000 Per-incident deductible: $40 $40 Annual premium: $109 $191 Preferred Heath Insurance (888-424-4644; www.pethealthplus.com) Basic plan Per-incident limit: None Annual limit: $2500 Lifetime limit: $5000-$10,000 per lifetime Per-incident deductible: $40 Major-surgery deductible: $200 (covers 80 percent of bill) Annual premium: $95 and up

Unlike many animal hospitals, Angell is a nonprofit facility, and the hospital does attempt to lessen the financial burden of treating a sick animal. For pet owners with very low incomes, Angell offers subsidies in the form of cut-price treatments. For others, there is an interest-free monthly payment plan, in which qualified owners can extend payments for up to 12 months. There's also animal insurance (see "Policy Wonks," right), an option that is sorely overlooked in the New England area, says Baravella.

Some pets, however, run out of time before their owners run out of money. Robin Belair took her six-year-old cat, Rhubarb, to Angell, suspecting liver disease. Despite the $1500 or so that Belair spent, Rhubarb died in the hospital. "Next time, I'd probably let him die at home," Belair says. "I think people go way too far, spending way too much money. I spent my vacation money on my cat." But, she hastens to add, "He did feel like my kid. I felt like I had to try. I would have gladly spent the money if he had lived." And now, on top of the financial burden, she says, "I feel guilty."

Who wouldn't? For most pet owners, the very idea of putting money before a pet feels like an enormous betrayal.

"Many people feel embarrassed and ashamed not to be able to do the max for their animal," says Jane Nathanson, who works as a counselor at Angell. "People feel a lot of guilt, and they need not. Money's a horrible reason to have to decide on euthanasia, because you're haunted by the thought you've destroyed a life by your own limitations. But that's reality. It's no reason to feel guilty."

Jerrold Tannenbaum takes a firmer position. "When a client wants to euthanize the animal because treating it is not worth it to him," he writes, "the client should know that this is the reason behind the decision." Besides, he asks, "Do social workers possess special expertise in dealing with the many ethical questions that can arise when clients must contemplate various alternatives for their animals?"

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Tannenbaum is about as close as the industry gets to a certified animal ethicist, but even he seems bogged down by questions. In attempting to put his finger on some of them, he raises two seemingly contradictory problems. One is "the inability of some patients to pay for procedures." The other: "the insistence by some clients that an animal be kept alive when euthanasia would be in its best interest."

The increasing availability of advanced treatments for pets has more than just practical implications for animal welfare; it marks a shift in the very definition of animal welfare. Whereas the prevention of pain and suffering has long been the cornerstone of veterinary medicine, that is quickly and quietly being supplanted by another, more-human model: the preservation -- and the sanctity -- of life. Human death has long been viewed as a kind of failure; the better animal care gets, the more we invest in our animals, the more a pet's death can feel the same way. Treat animals like people, and you start thinking of them as people -- which, legally, they are not.

No matter how much people think of their pets as kids, any animal -- cat, horse, rat, chicken, or dog -- is ultimately a piece of property, like a car or a television set. And while it's still legal to kill a pet and illegal to torture it, it's perfectly legal to submit a pet to potentially torturous procedures in the interest of saving its life. But is that in the pet's best interest, or the owner's? The animal certainly has very little say in the matter.

Dr. Tracey Ritzman, a specialist in avian and exotic-animal medicine at Angell, recalls fitting a ferret with a pacemaker a while back. The animal didn't survive the procedure, says Ritzman, but a pacemaker was what the ferret's owner wanted, and a pacemaker was what the ferret got.

"If people are honest," says Mary Beth Sweetland of People for the Ethical Treatment of Animals (PETA), "most will admit that keeping an animal alive is mostly for our benefit. I think if the prognosis is poor and the veterinary doctor tells you that physical suffering will occur, you have to make a decision. Once you're adding to suffering because you can't stand to let go, that's where you draw the line." To do anything else, she says, is "selfish, unconscionable."

Paul Gambardella also uses the word "selfish" in describing this scenario. "If an animal is suffering too much," he says, "then the owner has crossed the line, and that animal ought not to live. We have to counsel, we have to get them turned around."

Sheri Siegel agrees. "You want to make sure that the treatment isn't worse than the disease itself," she says. The problem is, a dog might yowl when you step on its tail, but unlike humans, animals can't really express chronic pain -- which means we're often guessing about their quality of life.

In her field, Siegel explains, there are some guidelines to follow, such as the type and severity of the cancer. "What's the prognosis? A year? Several years? A few months?" she asks. "A year is a lot. A few months, you have to question." It ultimately boils down to a decision of when, exactly, killing becomes the most compassionate treatment.

"When there's a decision to think about something like open-chest surgery," says cardiologist Nancy Laste, "we try to weigh risk benefit and cost benefit, we try to get owners to consider the pain involved. We try to evaluate carefully as far as overall health, see if there's anything else on the horizon." Even though variables abound, Laste says, "Most people make good decisions."

But what is a good decision? This is a question that keeps cropping up, and one that remains impossible to pin down. We cannot assess a dog's quality of life based on its mental status, as we can with humans. Humans think, therefore we are, and when we stop thinking -- it's time for others to think about pulling the plug. But what constitutes dogness? The ability to fetch a stick, perhaps. So a legless dog is no longer a functioning dog, right? Wrong. An outfit called K-9 Carts in Montana offers little strap-on wheelchairs for handicapped pets. Even with one of these things attached to him, Rover won't be jumping over any more fences, but at least he'll enjoy a somewhat active -- if somewhat weird -- life.

But what about dogs who have chased their last sticks, yet still are kept alive? "People for whom money is no object may leave an animal on a respirator," says Gambardella. "Yes, the animal is not very functional and not very conscious, but it's not in pain. Is it wrong to do that? Maybe you and I might think so, but if [the owners] don't think so and they've got the money to pay for these machines, you can interject views, but they have to make the decision." The bottom line is that without strict ethical guidelines, decisions must be made on a case-by-case basis. And yet, says Gambardella, "the line is different for different people."

For the owner of a sick pet, even one in extreme pain, walking into Angell Memorial -- with its flashy machinery, its air of scrubbed efficiency -- makes it easy to succumb to a sort of magical thinking, to believe that science might deliver a miracle cure. Even devout observers of animal welfare fall into this trap.

"To tell the truth, I made that mistake," says PETA's Mary Beth Sweetland. "I took my dog Oscar to a specialist. I have absolutely no doubt that he was suffering terribly. I put this dog through living hell, I dragged him through every test, and in the end they couldn't save him. I know now I was doing it to assuage my own sorrow. So call me selfish." Sweetland says she learned her lesson, though. "I've euthanized two dogs in the last four years," she says.

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In a way, the logical extension of the urge to preserve animal life is the so-called Missiplicity Project at Texas A&M University, which, for a price, will offer your pet eternal life -- sort of. Shell out $1800, and you can have your animal's cell tissue stored in a "doggybank" in preparation for a time (slated for around 2004) when the pet can be cloned. That procedure will cost about $12,000. Interested owners, though, will have to take a ticket and stand in line. Thanks to the $3.5 million donated to the university by her owners, a border collie cross named Missy will be the first dog cloned. There has already been a clamor of interest from other pet owners, including, reportedly, celebrities such as Elizabeth Taylor and Snoop Dogg. "It's the ultimate in sick," says PETA's Sweetland. "There are 22 million unwanted animals euthanized each year, and these jokers are trying to clone dogs so people can pretend their dog is still there."

And that's the nub of the matter: questions regarding high-tech animal procedures often hinge less on what's ethical, practical, or even humane than on the owner's sentimental attachment to a pet. In a sense, what's scientifically accurate doesn't matter half as much as what people feel. Hence Angell's last stop for pet owners: therapy groups.

"The loss of a pet is a traumatic event, a real crisis," says Jane Nathanson, a rehabilitation counselor at Angell. "People feel overwhelmed with grief." Nathanson leads two support programs at the hospital: one for people whose pets are nearing the end, and one for people whose pets have already died. Like traditional group therapy, Nathanson's sessions consist of people sitting in a circle and sharing their feelings with one another. Tears and self-recrimination are commonplace. Nathanson, who is a licensed social worker, directs the sessions by drawing on what she's learned in her 12 years in the pet-loss business.

"People are seeking guidance and education along with group support," she says. "They want a sense of direction. How do you cope?"

Owners' grief is often infused with large doses of guilt: guilt over not having been able to afford treatments, guilt over having followed an unsuccessful course of treatment, and guilt over the sheer level of grief they are experiencing.

"People may feel more grief than they did for the death of a family member," Nathanson says. "They don't understand: `My own father died, and this means more to me.' Sometimes I'll pick up the phone and someone will be sobbing, and the first words out of their mouth will be `I'm sorry.' " But, says Nathanson, "we need to grieve, and respect ourselves with our grief." And this isn't always so easy.

Despite our society's increasing humanization of its pets, there remains an abiding "it's only a dog" attitude, and a sort of snickering scorn for people who shed tears over the loss of an animal. There are still many who hold animal ownership to strict utilitarian standards. Go to rural Maine and suggest the linear accelerator for a cancerous dog, and you're likely to get laughed out of the state.

If the "heck, take it out back and shoot it" approach is at one extreme of the attitude toward animal treatment, Michael Pavletic has seen his share of the other extreme. He recalls somebody who asked him to put a diamond stud in a dog's ear (he refused). "You have to educate them that this is not a legitimate reason to treat an animal," Pavletic says.

Legitimacy in this world, though, is highly subjective. Isn't it also absurd to spend hundreds of dollars to treat a chicken that might just as easily have found its way into a McCloud's Meaty Muffin? Isn't it verging on the frivolous to fork out thousands on futuristic canine cancer treatments? What's next, medical marijuana? A dog is a dog is a dog, right?

The point is that it isn't so much a dog, but someone's dog, our dog. Pavletic describes the "intense joy and euphoria" he feels when watching a once-sick dog "wagging its tail, joining its family." Sentimental, yes. But attempting to remove sentiment from the matter is like trying to discuss marriage in purely contractual terms.

As Bob the greyhound dodders out of Angell's radiation lab -- munching on biscuits, happily weathering a barrage of affection -- it's easy to see what Pavletic means. Bob won't be able to sidestep his mortality forever, but that doesn't seem to matter right now -- at least not to him.

"They're so different than we are," says Sheri Siegel, who was Bob's oncologist. "Other than the dirty word of cancer, they're so happy. They don't know they're sick."

And then she moves on to her own pets, two cats named Elbe and Emma. "They think I'm crazy," she says. "Every day I pick them up and give them a little squeeze."

If she were to find a tumor, would Siegel put her own animals through cancer procedures? "I don't know what I'll do if and when that day comes," she says. "What do you do when it's your own pet? I don't know."

Chris Wright can be reached at cwright[a]phx.com.