Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

Service Animal Versus Emotional Support Animal: Navigating an Ethical Dilemma to Ensure State and ADA Compliance While Providing Patient Care

By Hilary Hawthorne, O.D., and Audrey Seaton-Bacon, Ph.D.

Case Study No. 18

Scenario: Patient arrives at the office of a doctor of optometry five minutes before her appointment, accompanied by an animal. She tells the staff that she experiences stress, fear and terror while visiting doctors’ offices, and since she fears that the eye examination will be a traumatic experience, she wants her dog present during the entire visit. Patient insists that she wants to receive services at your office as it is closest to her home, and she has not been examined by a doctor of optometry in years. She made arrangement for her insurance to cover her visits with you. You have patients in the waiting room observing the conversation exchange; some of their cell phones are poised to record the incident.

Dilemma: What do you do? Do you or don’t you provide her with care? Are you and your staff trained to effectively handle this situation? What are the potential legal and ethical issues in this case?

Legal Discussion

What does the law dictate? Under Americans with Disabilities Act (ADA) regulations, businesses can ask only two questions when trying to determine whether an animal entering a public facility is truly a service animal: 1

  • Is the animal required because of a disability?
  • What work or task has the animal been trained to perform?

Specifically, a covered entity’s employees may not seek documentation for the animal, request that the animal “demonstrates” its task, or ask “about the nature of the person’s disability.” 2 The Department of Justice, Civil Rights Division, Disability Rights Section has provided a provision in the ADA document related to service animals that requires the following: “State and local governments, businesses, and nonprofit organizations that serve the public generally must allow service animals to accompany people with disabilities in all areas of the facility where the public is normally allowed to go.” 3, 4

State Law

The ADA does not preempt state law. If state law provides greater protections to owners of service animals than the ADA, business owners must adhere to state law. If applicable, follow any state laws regarding emotional support animals and therapy animals, too. If in doubt about state requirements, it is always safer to conform to laws that permit greater protection to the individual with the animal.

In one stipulation of the law related to service animals, a helpful policy guidance from the Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, indicates that "service animals are to accompany the individual with a disability, unless the animal's presence or behavior creates a fundamental alteration in the nature of a facility's services in a particular area or is a direct threat to other persons in a particular area." Neither of these two exceptions are likely to apply in the context of an optometry practice.


Service Animals: A service animal (almost always a dog) is trained to perform specific tasks for a person with a disability and helps its owner attain safety and independence. 5 Service animals are viewed as a medical resource, as in life or death situations, thus service animals are protected under federal law. Examples of tasks performed by service animals are as follows: 6

  • Guide Dog or Seeing Eye® Dog serves as a travel tool for persons who have severe visual impairments or are blind. Hearing or Signal Dog alerts a person who has a significant hearing loss or is deaf when a sound occurs, such as a knock on the door.

  • Psychiatric Service Dog performs tasks that assist individuals with disabilities to detect the onset of psychiatric episodes and lessen their effects, such as reminding the handler to take medicine and keeping disoriented individuals from danger. 7
  • SSigDOG (sensory signal dogs or social signal dog) alerts a person with autism to distracting repetitive movements common among those with autism, allowing the person to stop the movement (e.g., hand flapping).

  • Seizure Response Dog assists a person with a seizure disorder, like standing guard over the person during a seizure or going for help. A few dogs have learned to predict a seizure and warn the person in advance to sit down or move to a safe place.

  • Mobility Assistance Dog serves an individual with an impairment in mobility, such as pulling a wheelchair.

Therapy Animals: Therapy animals (commonly dogs, but not in every instance) receive formal training in providing therapeutic contact in the form of a social, emotional and psychological interaction with individuals, usually within a clinical or professional setting (such as hospitals, schools, hospices and nursing homes) and during a designated time. Although their responsibility is to improve the recipient's physical, social, emotional and/or cognitive functioning, therapy dogs are not limited to working with individuals with disabilities and are not protected by ADA's regulations; therefore, federal laws do not mandate therapy dogs be admitted into physician offices.

Emotional Support Animals: Emotional Support Animals (ESAs) are used by their owners to alleviate distress and/or create a sense of well-being. Usually ESAs are the owner's pet with whom there is a significant level of comfort, attachment and sense of security. Due to the already established emotional and psychological bond between owner and animal, the ESA is often used as an adjunct to the patient's psychotherapy and may be incorporated as part of a medical treatment plan.

As with therapy dogs, emotional support animals are not life dependent and are not considered service animals under the ADA's Title II and III guidelines. 8 Emotional support animals are not legally required to be allowed access to all places of public accommodation because they are not required to perform any specific tasks needed to aid a person who is limited by a disability. 9, 10

Accommodating Service Animals

Distinct Uses for Animals: Ordinarily, under ADA guidelines, the rights of service animals are limited to dogs. However, businesses must make reasonable modifications in policies to allow the disabled individual's use of miniature horses as service animals if trained to do work or perform tasks for individuals with disabilities. 11

Given the current understanding and distinct uses of these animals in ADA rulings, and the psychological and/or medical provisions available, we return to the original questions posed by this ethical dilemma. Are practitioners required to provide care for individuals with animals? The answer is...It depends on whether the animal is a service animal, therapy dog or emotional support animal.

Individuals seeking optometric care in practical terms must be allowed to have their service animal present in every case. Whereas, the decision to permit patients to bring therapy dogs or emotional support animals into the facilities would be left up to the practitioner and office policies.

Prepare to Accommodate Service Animals and Develop Policies for Nonservice Animals: In order to lawfully address permitting animals in an optometric setting, the healthcare office should develop and refine policies, educate staff and advise patients. Suggestions to consider:

  • Have policies and procedures that effectively communicate the current ADA guidelines for accessibility that require staff to admit service animals. 12, 13
  • Train office staff to utilize two questions used to determine whether an animal qualifies as a service animal.
  • Post signage that clearly delineates that ADA regulations apply only to service animals.
  • If the office wants to go beyond service animals, affix signage stipulating whether nonservice animals (i.e., emotional support animals and therapy animals) are allowed.
  • If necessary, consult legal advice to define a way to enforce policies before prohibiting nonservice animals. Local and state optometric associations may have information about this subject.
  • If applicable, develop resources that promote interdisciplinary collaboration when caring for patients with nonservice animals.

Ethical Considerations

Although this case provides the reader with key information and legal obligations regarding accommodating service and nonservice animals, business owners considering whether or not to permit nonservice animals into a practice should also consider the therapeutic effect these decisions have on patients. In order to function, patients may be dependent upon animals to assist them for a distinct purpose, which may include a wide range of medical services or psychological support. An emotional support animal may serve both as a temporary bridge to recovery and play a role in minimizing a patient's anguish and suffering, which is critical to the therapeutic process and in supporting the health and welfare of the patient.

It is important to remember the use of a true ESA is not offered in isolation. Nonservice animals may be a part of a larger treatment regimen. Other forms of treatment typically include psychotherapy and medication. For some patients with psychiatric disorders classified in the current Diagnostic and Statistical Manual of Mental Disorders (DSM), such as generalized anxiety disorder (GAD), the collaborative effort of health professionals is a powerful intervention for the overall treatment process.

Coordination of care may assist both patients and other health providers in clarifying the need for an emotional support animal. For example, a doctor of optometry might receive a letter from other provider(s) communicating that a patient has a disability and ongoing treatment.14 These letters may also disclose that a support animal is recommended to accompany the person in public settings. Note that this only applies to nonservice (emotional support and therapy) animals. Therapy animals do not require a DSM diagnosis.


Achieving the patient's improved quality of life is an important clinical outcome. As clinicians who seek the best overall health outcomes for their patients, doctors of optometry may wish to take this into consideration when developing policies for nonservice animals. Unless outweighed by other considerations, the decision to permit nonservice animals in certain cases may prove extremely beneficial to certain patients.

Animals have no certification or official national registry that exists to verify whether an animal has undergone training to become a service animal. Rather, enforcement laws are largely symbolic, and meant to educate people who bring nonservice animals into public spaces. , Individuals who wish to pass off their pets as service animals in order to take them into offices, restaurants, libraries, sporting events and stores are a real problem for business owners, patrons and disabled people who genuinely rely on the help of qualified service animals.

For true service animals, the ADA permits businesses to ask only two questions. The ADA prohibits businesses from asking for documentation. Do not ask for documentation regarding the animal just in case it is a service animal. Alternatively, a good standard of practice might be to provide patients with a questionnaire form on which they can state whether their animal is a service, emotional support or therapy animal.

Psychologists sometimes provide a letter to medical professionals explaining the necessity of the patient's emotional support animal. It is recommended that this letter state that the patient is in treatment, their psychiatric disorder according to the current DSM classification and an expiration date, which is then revisited based on treatment progress.

As a liability concern, business owners are generally not subject to liability for the actions of animals brought onto their premises by patrons, unless the business owner has reason to know a particular animal is dangerous. However, consider contacting your insurance broker or premises liability carrier to make sure your legal representation is covered in the event you or your business is named in a lawsuit; even if you are not liable, it may take some time to get yourself removed from a suit.

By establishing office policies for service and emotional support animals and training staff, doctor's offices diminish the risk for ethical concerns or legal consequences. If the situation encountered in an optometrist's office is not handled effectively, there may be hard feelings, bitterness, ill will or emotional anguish. Taking active steps to address this subject serves to remind doctors of the commitment to the human aspects of care that often bring meaning to the practice of optometry.

2 https://ada.gov/regs2010/service_animal_qa.html
12https://www.salus.edu/getattachment/About/University-Policies/University-Policies/Service-Animals-on-Campus-Policy Updated.pdf.aspx

About the Authors

Hilary Hawthorne, O.D., is a member of the AOA Ethics and Values Committee and works at Community Eye Center Optometry in Los Angeles, California. She has maintained her certification as a Diplomate of the American Board of Optometry since 2011. As a past president of the California Optometric Association, Dr. Hawthorne is in the association's Distinguished Member category and has also served as a member of the AOA Board of Trustees. Currently, she is an executive committee member on the Great Western Council of Optometry.

Dr. Audrey Seaton-Bacon is a licensed clinical psychologist in private practice at the ASB Psychological Services and Training Center in Whittier, California. She is the developer of Don't FADE: Reclaim Your Life, a tool for individuals to identify and interrupt four areas of thought which cause them to withdraw or disengage from healthy relationships, as well as inhibit their bringing their true, authentic and vibrant selves to life. She is also one of several contributing authors in the book Terrifying Transferences by Dr. Lawrence Hedges.