Nurses may increasingly find themselves having to address situations with patients whose ethics conflict with the need to stay healthy.
For the more than 1.5 million Americans who follow a vegan diet, taking prescription medication can be a bit of ethical roulette. Many medications today contain ingredients that are derived from animals and therefore go against a vegan’s preferences, whether those preferences are based on religious, cultural, or personal lifestyle choices. Even when part of a life-sustaining regimen, these medications, and the thought of taking them, can represent a harsh irony that asks individuals to chose their own clinical well-being over a fundamental principle by which they live their lives. The decision to avoid the consumption of animals as well as any product of animal origin is additionally challenged by the fact that federal regulations related to disclosure of the use of animal-derived ingredients in medications and healthcare products does not seem to be well defined. While medical product manufacturers are expected to disclose the presence of animal-derived materials in medical labeling “when the information is necessary for a healthcare provider or patient to safely use the device” per the U.S. Food & Drug Administration, this speaks nothing of any expectation to generally inform providers and the general public about the mere presence of animal-derived properties for any other reason.
This loosely established parameter poses challenges not only to practicing vegans, but to the healthcare providers who actively seek to keep their patients informed of when their preferences may be at risk of being compromised.
This represents a healthcare problem and a communications problem.
“The United States as a whole is getting more diverse, and so we are taking care of more diverse patients. The demographics are changing, and with that we have to be more careful about how we care for and communicate with patients,” said Jayesh B. Shah, MD, MSc, UHM (ABPM), CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP, medical director for two wound centers based in San Antonio, TX. As a wound care physician, Shah, the president of the American College of Hyperbaric Medicine, is familiar with the quagmire of trying to be proactive for his patients who would want to avoid animal-derived treatment while offering suitable alternatives when possible with an increasing number of products that treat chronic wounds utilizing animal properties.1 Still, wound care is hardly the only area of healthcare impacted by this issue. A small sampling of other medications that reportedly contain animal ingredients (or excipients, which are inactive properties) includes CREON®, a pancreatic enzyme replacement therapy for patients living with exocrine pancreatic insufficiency; and cholecalciferol, a vitamin D3 tablet.2 Additionally, gelatin, a protein typically obtained from cows or pigs that’s obtained by boiling skin, tendons, ligaments, and/or bones with water, according to PETA (People For The Ethical Treatment Of Animals), is used for various reasons in medications, including the production of gel capsules. According to Shah, animal-derived products are regularly used in all fields of medicine and surgery, which means practitioners are likely to encounter a situation in which the use of a product conflicts with a patient’s religious beliefs.1
A devoted follower of Hinduism, which discourages the killing of animals and ingesting food that is derived from animals, Shah is hopeful that in time regulations will become more stringent and clear about the expressing of animal-based properties on medical packaging, but until that occurs his best option is to try to remain informed through research. He encourages nurses to attempt to do the same.
“Hopefully manufacturers will be required to include this information [on packaging],” he said. “Right now there are minimum requirements for them to list where their products are derived from, so the only way to know this type of information could be to read the [medical] literature.”
While Shah admits that having the conversation with patients who would prefer to not consider ingesting an animal-based product or having one applied to their body, he does offer tips that nurses and other healthcare providers can follow. “The way I navigate it is by explaining that this [medication or product] is something that they need, just like any other medication that they might be taking, and that we don’t have any other option. And I try to help [everyone] understand that whatever religion they might practice, if something is lifesaving then it is ok to use. “Luckily, most religions give you a little leniency for medical purposes. The conversation (about ethics) becomes easier for us as healthcare providers because of that. That said, research shows that in some cases, there will be a risk of nonadherence or lack of compliance if there are conflicts between religious and/or ethical beliefs and prescribed treatments.3 One study reviewed the position of religious and spiritual leaders of the six largest religions worldwide (18 branches) in 26 different countries and found that Hindus and Sikhs did not approve of the use of bovine (cattle)- or porcine (pigs)-derived products; Muslims did not accept the use of porcine-derived products.4 However, Christians (including Jehovah’s Witnesses), Jews, and Buddhists accepted the use of all animal- and human-derived products4 (with an exception among Jews who follow a kosher diet and do not eat pork or shellfish). Additionally, a report claims that Jehovah’s Witnesses do not approve of the use of blood-derived products and the same report found that all religions allowed the use of animal-derived products if there were no alternatives or an emergency situation existed.4 To learn whether a drug contains animal content, the manufacturer or a national medicines agency can be contacted, but Shah suggests that uncovering facts in medical literature, perhaps by extensively searching or by stumbling upon the evidence, will remain the most trusted source of information. However, in many situations, information related to animal-derived products is not going to be accessible.4
Shah suggests that nurses and other healthcare providers consider asking the following questions to help gain an understanding of patients’ spiritual and lifestyle preferences and to foster appropriate communication about concerns that may arise:1
- Are there foods that you do not eat for religious or spiritual reasons?
• Do you have any restrictions related to receiving blood and/or blood products?
• Do you have any restrictions related to the use of products that are made from animals (or from specific animals)?
In March 2019, the FDA issued nonbinding industry guidance regarding medical devices containing materials derived from animal sources, which the FDA notes “may carry a risk of transmitting infectious disease when improperly collected, stored, or manufactured.” But PETA officials are inclines to want to see more transparent communication for this patient population and their providers. “Patients who are concerned about potential disease transmission from animal-derived medical devices, as well as those who ethically oppose the crude use of animals and animal parts for human medical devices, deserve the right to know if a medical device contains any animal-based components, PETA officials told ADVANCE. “The FDA does recommend documentation of information regarding animal-derived materials in medical device companies’ premarket submissions that undergo review by regulators, but we suggest that this information should be made clearly and plainly available in layman’s terms to patients so they can make informed decisions about their healthcare,” said Shalin Gala, vice president of international laboratory methods at PETA. “PETA feels that the FDA should require transparency from manufacturers of medical devices, who currently don’t have to disclose animal-derived materials to consumers. Patients who are concerned about potential disease transmission from animal-derived medical devices and those who ethically oppose the crude use of animals and animal parts for such devices deserve to have the opportunity to make informed decisions about their healthcare.”
Animal-Derived Product Policies Adopted by AMA1
The American Medical Association’s (AMA’s) House of Delegates approved policies this past winter that intend to help increase awareness of animal-derived medical products among healthcare providers. According to a statement by AMA officials, the new policies urge manufacturers to include all ingredients and components present in medical products on the product’s label, including both active and inactive ingredients, and to denote any ingredients derived from an animal source. The policies also encourage cultural awareness regarding patient preferences associated with medical products containing active or inactive ingredients or components derived from animal sources. According to Jayesh B. Shah, MD, MSc, UHM (ABPM), CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP, there is a lack of awareness about the impact that use of animal-derived products can have on certain segments of the population, including vegans, who avoid consumption of animals as well as animal-based products (whereas a vegetarian’s diet avoids the eating of animals only). “I think we really need more awareness for this, for sure,” Shah said. “Even with the internet and Google, and all the information that’s out there – somehow people really don’t know about this topic. There really is a lack of awareness.” Beyond dietary preferences and religious and/or cultural differences, a person’s decision to go without animal consumption and the avoidance of animal-based products in their daily lives may also be tied to social significance, such as a stance against the potential of animal cruelty. “There’s a lot of vegan movement in this country, and people do talk about [the issue of animal cruelty],” Shah said. “And for these patients, it is definitely important to try to use products that are not animal-derived.” Shah also said that it is probably safe to assume that animals may have been killed specifically for medical use when they are used in products and/or medicines, even though there will be instances in which the animals used for a product or a medication had previously died, much like with human cadavers and organ donors. “But it is not necessarily true that every animal that is used for a product or a medication had already died,” Shah said.
It is often the patient’s nurse who will be made aware of lifestyle and religious or cultural belief systems that are strictly against the use of animal-derived products, and in these instances the role of advocate is as important as ever, Shah said. “Nurses might be the first to recognize that a patient has a conflict [with a prescription or treatment], and having nurses educated about the product and the conflict really helps,” he said. “Just as with anything else, nurses are excellent advocates for their patients and they are educated on how to handle conflict. They can point out that the treatment might be lifesaving. They can let the patient know that there may not be better options out there. Most people, when it comes to medicine, if they don’t have other options they are going to understand [that they need to comply] despite the conflict.
The AMA policies are enacted following a report by the AMA’s board of trustees that found that 70% of physicians were unaware that several medications contained animal-based ingredients.1 However, 70% of physicians also thought it was important to inform patients who might object if such medications are prescribed, the report claims. According to the AMA, manufacturers are not required to declare on labels how an ingredient is sourced, which means it is not present in drug databases and clinical decision-support systems for physicians.
- Shah JB. Ethically administering animal-derived products to wound care patients. TWC. 2019;13(1):18-21.
2. Is my medication vegan? The Vegan Society. 2017. Accessed online: www.vegansociety.com/whats-new/blog/my-medication-vegan
3. Sattar SP, Ahmed MS, Madison J, et al. Patient and physician attitudes to using medications with religiously forbidden ingredients. Ann Pharmacother. 2004;38(11):1830-5.
4. Erickson A, Burcharth J, Rosenberg J. Animal derived products may conflict with religious patients’ beliefs. BMC Med Ethics. 2013;14:48.