Pope Pius XII addresses the religious, moral and medical issue of preventing pain—when is it justifiable to be relieved of pain and what about pain's salvific effects?
This address was given by Pope Pius XII to the Ninth National Congress of the Italian Society of the Science of Anesthetics on February 24, 1957.
Religious and moral aspects and pain and prevention in medical practice
The Ninth National Congress of the Italian Society of the Science of Anesthetics, held at Rome on 15th-17th October, 1956, submitted three questions to Us, through the President of the Organizing Committee, Professor Piero Mazzoni—questions which deal with the religious and moral implications of pain prevention in the light of the Natural Law, and especially of Christian doctrine as contained in the Gospel and taught by the Church.
Three religious and moral questions concerning pain prevention (analgesia)
These questions, of unquestionable interest, do not fail to awaken intellectual and emotional reactions in men today. Among Christians especially, there is evidence of many and various trends. Some approve unreservedly of the practice of analgesia; others would be inclined to reject it outright as contradictory to the ideal of Christian heroism. Others without the least sacrifice of that ideal, are ready to take their stand midway. That is why We are being asked to voice Our thoughts on the three following points:
- Is there a universal moral obligation to refuse analgesia and to accept physical pain in a spirit of faith?
- Is it in accord with the spirit of the Gospel to bring about, by means of drugs, the loss of consciousness and of the use of a man’s higher faculties?
- Is it lawful for the dying or those in danger of death to make use of drugs if there exist medical reasons for their use? Can one use drugs even if the lessening of pain is probably accompanied by a shortening of life?…
Question 1: On the general moral obligation to endure physical pain
In the first place, then, you ask whether there is a general moral obligation to endure physical pain. In order to give a more precise answer to your question, We shall treat of various aspects of the matter. And first, it is evident that in certain cases the acceptance of physical suffering is a matter of serious obligation. Thus a man is bound in conscience to accept suffering whenever he is faced with the inescapable alternative of enduring suffering or of acting contrary to a moral obligation, either by positive action or by omission. The martyrs could not avoid either torture or death without denying their faith or without avoiding the serious obligation of bearing witness to it when the occasion was given. But it is not necessary to go back to the martyrs. At the present time there are found magnificent examples of Christians who, for weeks, months, and even for years, endure suffering and physical violence in order to remain faithful to God and to their conscience.
Free acceptance and the desire of suffering
Your question, however, does not refer to this situation; it has in mind rather the free acceptance and the desire of suffering in itself and for itself. To recall at once a definite example of this, We refer to the Address We gave on Jan. 8, 1956, with reference to new methods of painless childbirth. There it was asked whether, by virtue of the text in Scripture: "In sorrow shalt thou bring forth children," the mother was obliged to accept all the sufferings and to refuse relief from pain by either natural or artificial means. We answer that there was no obligation of this kind. Man, even after the fall, retains the right of control over the forces of nature, of employing them for his own use, and consequently of deriving benefit from all the resources which it offers him either to suppress or to avoid physical pain. We added that, for the Christian, suffering is not something purely negative, but on the contrary, is linked with lofty religious and moral values, and hence can be desired and sought even if no moral obligation to do so exists in a particular case. Continuing, We said:
The life and sufferings of Our Lord, the pains which so many great men have endured and even sought, and by reason of which they grew to maturity and rose to the highest point of Christian heroism, the daily examples which We have before Our eyes of the acceptance of the Cross with resignation—all this reveals the meaning of suffering, of patient acceptance of pain in the present working out of salvation during the period of this earthly life."
The duty of renunciation and interior purification
Moreover, the Christian is bound to mortify his flesh and to strive after his interior purification, for it is impossible, in the long run, to avoid sin and to carry out all one’s duties faithfully, if this effort at mortification and purification be neglected. Physical suffering becomes a necessity and must be accepted to the extent that, without its aid, mastery over self and disorderly tendencies is unattainable; but in so far as it is not required for this purpose, one cannot assert that there exists a strict obligation in the matter. The Christian, then, is never obliged to will suffering for its own sake: he considers it, according to circumstances, as a means more or less suited to the end which he is pursuing.
Invitation to a higher perfection
One can consider what is of strict obligation; but it is also possible to look at the demands of the Christian faith, the invitation to a higher perfection, which is not imposed under pain of sin. Is the Christian obliged to accept physical pain so as not to set himself in contradiction to the ideal which his Faith proposes to him? Does not a refusal in this matter imply a lack of the spirit of faith?
That the Christian experiences this desire to accept, and even to seek, physical pain in order the better to share in the Passion of Christ, to renounce the world and the pleasures of the senses, and to mortify his own flesh, is beyond dispute; but, at the same time, it is important to give a correct interpretation of this tendency. Those who manifest it exteriorly do not necessarily possess genuine Christian heroism; but it would also be a mistake to declare that those who do not manifest it are quite devoid of it. This heroism can, in fact, reveal itself in many other ways.
Take, for example, a Christian who carries out, day after day, from morning till night, all the duties of his state or profession, the laws of God and of men: one who prays with recollection, does his work wholeheartedly, resists his evil passions, shows his neighbor the charity and service that is his due; endures bravely, without murmuring, whatever God sends him: that man is always living beneath the sign of the Cross of Christ whether physical suffering is present or not, whether he endures it or avoids it by means which are lawful. Even if one considers only obligations binding a man under pain of sin, he cannot live or carry out his daily work as a Christian without being ever ready for sacrifice and, one may say, without constantly sacrificing himself. The acceptance of suffering is only one way, among many others, of indicating what is the real essential: the will to love God and to serve Him in all things. It is, above all, in the perfection of this voluntary disposition that the quality of the Christian life and its heroism consists.
Motives which allow the avoidance of physical pain
In specific cases, which are the motives which allow avoidance of physical pain without involving any conflict with a serious obligation or with the ideal of the Christian life? One could list quite a number: but, in spite of their variety, they are finally summed up in the fact that, in the long run, the pain is preventing the obtaining of some good or advantage of higher worth. It is possible that suffering may be preferable for a particular person in a definite situation; but, in general, the harm caused forces men to protect themselves against it. Beyond doubt, suffering will never be completely banished from among men, but its harmful effects can be kept within narrower limits. And so, just as one masters a natural force to draw advantage from it, the Christian makes use of suffering as a spur to his effort to mount higher and purify himself in the spiritual life, in order to carry out his duties better and answer the call to a higher perfection.
In keeping with the abilities or dispositions above-mentioned, it is for each one to adopt solutions suited to his own case, without at the same time hindering other advantages and other greater benefits. The value of each solution will be measured according as it is a means of progress in the interior life, of more perfect mortification, of more faithful accomplishment of the individual’s duty, of greater readiness to follow the prompting of grace. In order to be sure that such is really the case, a man will look to the rules of Christian prudence and the advice of an experienced spiritual director.
Conclusions and answer to the first question
From these replies, you will easily draw useful directives for practical application.
The fundamental principles of the technique of anaesthesia, a science as well as an art, and the end pursued, give rise to no difficulties. It combats those forces which, in a great many respects, produce harmful effects and hinder a greater good.
The doctor who accepts its methods is in no way acting against the natural moral order nor against the specifically Christian idea. He is seeking, in accord with the ordinance of the Creator, to bring suffering under man’s control, and to do so he makes use of the conquests of science and of technical skill in keeping with the principles We have set forth and which will guide his decisions in particular cases.
The patient desirous of avoiding or of soothing the pain, can, without disquiet of conscience, make use of the means discovered by science and which, in themselves, are not immoral. Particular circumstances can impose another line of conduct, but the Christian’s duty of renunciation and of interior purification is not an obstacle to the use of anesthetics, because it is possible to fulfill that duty in another manner. The same rule applies also to the demands of the Christian ideal which go beyond the call of duty.
Question 2: The state of insensibility (narcosis) and the total or partial deprivation of consciousness
Your second question concerned the state of insensibility and the total or partial deprivation of consciousness in the light of Christian morals. You expressed it thus:
The complete abolition of sense perception in all its forms (general anesthesia), or the diminution to a greater or less extent of the perception of pain (partial anesthesia and analgesia), is always accompanied in the one case by disappearance, in the other by the lessening, of consciousness and of the highest intellectual faculties (memory, process of association, critical faculties, etc.). Are these phenomena, which enter into the normal framework of insensibility during surgical operations, and of the analgesic practice, before and after an operation—are they compatible with the spirit of the Gospel?"
The Gospel tells us that, immediately before the Crucifixion, Our Lord was offered some wine mixed with gall, doubtless to mitigate His sufferings. After having tasted it, He would not drink it, because He wished to suffer fully conscious, thus fulfilling what He had said to Peter at the time of the arrest: "The chalice which My Father has given Me, shall I not drink it?" So bitter was this chalice, that Jesus had pleaded in the agony of His soul: "Father, let this chalice pass from Me! But not as I will but as Thou wilt!" Does the attitude of Christ towards His Passion, as revealed in this and other passages of the Gospel, permit the Christian to accept the total or partial state of insensibility?
Since you arc considering the question under two aspects, We shall examine successively the suppression of the pain, then the lessening or the total suppression of consciousness and of the use of the higher faculties.
Disappearance of pain
The disappearance of pain depends, as you say, either on the suppression of general sense-perception (general anesthesia), or on the lowering, more or less noticeable, of the capacity for suffering (partial anesthesia and analgesia). We have already stated the essential point on the moral aspect of suppression of pain. It is of little consequence, from the religious and moral point of view, whether it be caused by a state of insensibility or by other means; within the limits indicated, it gives rise to no objection and remains in accord with the spirit of the Gospel. However, one must neither deny nor underestimate the fact that the acceptance of physical suffering (whether obligatory or not), even on the occasions of surgical operations, can reveal a lofty heroism and frequently gives genuine testimony to a heroic imitation of the Passion of Christ. Nevertheless, that does not mean that it is an indispensable part of it; in major operations, especially, it is not unusual for anesthetics to be essential for other reasons, and the surgeon or the patient could not omit them without a lack of Christian prudence. The same holds good for analgesic practice before and after the operation.
Suppression or lessening of consciousness and of the use of the higher faculties
You then speak of the diminution or suppression of consciousness, of the use of the higher faculties, as of phenomena which accompany the loss of sense-perception. Ordinarily, what you wish to obtain is precisely, this loss of sense-perception; but often it is impossible to produce it without bringing about at the same time total or partial loss of consciousness. Outside the sphere of surgery, this process is often reversed, not only in medicine, but also in psychology and in criminal investigations. Here it is claimed that a lowering of consciousness is brought about, and, through it, of the higher faculties, in such a way as to paralyze the psychic control mechanisms which a man constantly makes use of for self-mastery and self-direction. He then gives himself over without any resistance to the play of association of ideas, and of feelings of volitionary impulses. The dangers of such a situation are evident; he can even reach the point where he sets free instinctive urges which are immoral.
These manifestations at the second level of the state of unconsciousness are well known, and, in practice, one tries to avert them by means of drugs previously administered. The stopping of the mechanism of control is declared to be particularly dangerous when it evokes the revelation of secrets of private or social life, affecting the person or the family. It is not enough that the surgeon and his assistants are all bound not only by the natural secret (secretum naturale), but also by the professional secret (secretum officiale, secretum commissum) with respect to all that takes place in the operating-theatre. There are certain secrets which ought not to be revealed to anyone, not even, as the technical formula says, "uni viro prudenti et silentii tenaci." We have already underlined this in Our Address of 15th April, 1953, on clinical psychology and psychoanalysis. Hence one can only approve of the use of drugs in the treatment before the operation in order to avoid these disadvantages.
Let Us note first of all that in sleep, nature itself interrupts more or less completely intellectual activity. If, during light sleep, the use of reason ("usus rationis") is not entirely abolished, and the individual is still able to enjoy the use of his higher faculties, as St. Thomas had already noted, sleep nevertheless excludes the "dominium rationis," that power in virtue of which reason freely commands human activity. It does not follow that if a man gives way to sleep, he is acting contrary to the moral order in depriving himself of consciousness and mastery over himself through the use of his higher faculties. Yet it is also certain that there may be cases (and it often happens) in which a man cannot permit himself sleep, but must remain in possession of his higher faculties in order to perform a moral duty which is obligatory. Sometimes, without being bound by a strict duty, a man deprives himself of sleep so as to render services of his free choice, or to impose some self-denial for the sake of higher moral interests.
The suppression of consciousness, then, by natural sleep, does not, of itself, raise any difficulty; but it is not lawful to accept it when it impedes the carrying out of a moral duty. The giving up of natural sleep can also, in the moral order, be an expression and a realization of a voluntary striving towards moral perfection.
But consciousness can also be reduced by artificial means. It makes no difference from the moral standpoint whether this result is obtained by the administration of drugs or by artificially produced sleep (hypnosis)—which can be called a form of psychic pain prevention. However, hypnosis, even considered exclusively in itself, is subject to certain rules. May We recall a brief reference We made to the medical use of hypnosis, at the beginning of the Address of 8th January, 1956, on natural painless childbirth?
In the matter which engages Us at present, there is question of hypnosis practiced by the doctor to serve a clinical purpose, while he observes the precautions which science and medical ethics demand from the doctor as much as from the patient who submits to it. The moral judgment which We are going to state on the suppression of consciousness applies to this specific use of hypnosis.
But We do not wish what We say of hypnosis in the service of medicine to be extended to hypnosis in general without qualification. In fact, hypnosis, in so far as it is an object of scientific research, cannot be studied by any casual individual, but only by a serious scholar, and within the moral limits valid for all scientific activity. It is not the affair of some group of layman or ecclesiastics, who might dabble in it as in some interesting topic for the sake of mere experience, or even as a simple hobby.
The lawfulness of the suppression or lessening of consciousness
To appreciate the lawfulness of the suppression or lessening of consciousness, one must consider that reasonable and freely controlled activity is the characteristic mark of the human being. The individual will be unable to carry out, for example, his daily work if he remains habitually plunged in a twilight state. Moreover, he has an obligation to relate all his actions according to the demands of the moral order. Since the natural energies and the blind instincts, left to themselves, are incapable of guaranteeing a regulated activity, it follows that the use of the reason and of the higher faculties is indispensable both for seeing clearly the precise terms of the obligation, and for applying them to particular cases. Hence derives the moral obligation of not depriving oneself of this consciousness without true necessity.
It follows that one may not confuse consciousness, or suppress it, with the sole object of gaining pleasurable sensations, by indulging in drunkenness and injecting poisons intended to secure this state, even if one is seeking only a pleasant state of well-being. Beyond a certain dose, these poisons cause a disturbance, more or less pronounced, of consciousness and even its complete darkening. Facts show that the abuse of drugs leads to the complete neglect of the most fundamental demands of personal and family life. It is, therefore, entirely reasonable for the public authorities to intervene to regulate the sale and the use of these drugs, so as to remove from society serious physical and moral harm.
Is surgery, in practice, compelled to produce a lessening or even a complete suppression of consciousness by means of the state of insensibility (narcosis)? From a technical point of view, the answer to this question lies within your competence. From the moral point of view, the principles previously stated in answer to your first question apply substantially to the state of insensibility as much as to the suppression of pain. In fact, what matters to the surgeon in the first place is the suppression of painful sense-perception, and not that of consciousness. When the latter remains fully awake, the violent and painful sense-experiences easily arouse reflexes and reactions which are often involuntary, but capable of bringing undesirable complications in their train and even terminating in a fatal collapse of the heart. To preserve the psychical and organic balance, to prevent its being violently disturbed, is an important objective for both doctor and patient; and the state of insensibility alone allows them to obtain it. It is hardly necessary to draw attention to the fact that, if one suspected that others might interfere in an immoral manner while the sick person is unconscious, this state of induced insensibility would evoke serious difficulties which would be calling for adequate safeguards.
The teaching of the Gospel
To these rules of natural morals, does the Gospel add details and further demands? If Our Lord on Calvary refused the wine mixed with gall because He wished to drink to the dregs in full consciousness the chalice which His Father offered Him, it follows that man ought to accept and drink the chalice of suffering whenever God wills it. One need not, however, believe that every time an occasion to endure pain presents itself, God wills it, whatever be the conditions and circumstances. The words of the Gospel and the attitude of Our Lord do not indicate that that is God’s will for all men and at every moment, and the Church has in no way given this interpretation to them. Yet the actions and suggestions of Our Lord hold a deep meaning for all men. In this world there are countless people who are weighed down by sufferings (sickness, accidents, wars, natural disasters) to the bitterness of which they can bring no solace. The example of Christ on Calvary, His refusal to give relief to His pain, are for them a source of consolation and strength.
Besides, Our Savior has warned His followers that this chalice awaits all. The Apostles, and after them the martyrs in their thousands, have borne witness to it, and do not cease to bear glorious testimony to it down to the present day. Often, however, the acceptance of unrelieved suffering involves no obligation and corresponds to no rule of perfection. The case occurs quite regularly when serious reasons for this decision exist and the circumstances do not impose the contrary. It is then possible to avoid the pain without putting oneself in opposition to the teaching of the Gospel.
Conclusion and answer to the second question
The conclusion, then, of the exposition of the matter up to this point can be stated thus: within the limits laid down, and provided one observes the required conditions, the state of insensibility involving a lessening or a suppression of consciousness is permitted by natural morality, and is in keeping with the spirit of the Gospel
Question 3: On the use of pain-relieving treatments of those who are dying
We have now to examine your third question:
Is it permitted in general, and during the period after an operation in particular, to use analgesic treatments (the employment of which invariably dulls consciousness), even in the case of the dying and of patients in danger of death, when there is a medical reason for this use? Is this permitted even in certain cases (inoperable cancers and incurable diseases) where the lessening of the unbearable pain is achieved probably at the cost of the duration of life, which is thereby shortened?"
This third question is fundamentally only an application of the two preceding to the special case of the dying, and to the particular effect of a shortening of life.
To declare that the dying have a greater moral obligation than others—whether from Natural Law or from Christian teaching—to accept suffering or to refuse its alleviation, is in keeping neither with the nature of things, nor with the sources of Revelation, just as, in accord with the spirit of the Gospel, suffering helps towards the expiation of personal sins and the gaining of richer merit, those whose life is in danger have certainly a special motive for accepting it, for, with death quite near, this possibility of gaining new merits is likely soon to disappear. This motive, however, directly concerns the sick person, not the doctor who is engaged in relieving the pain—for We are supposing that the sick person is assenting to this relief or has even expressly asked for it. It would clearly be unlawful to make use of anesthetics against the expressed will of the dying person (when he is sui iuris).
Some clarification would seem to be needed then, for it is not uncommon for the explanation to be presented in the wrong manner. Attempts are sometimes made to prove that the sick and the dying are obliged to endure physical sufferings in order to acquire more merits; the reason adduced is the invitation to perfection which Our Lord addressed to all: "Be ye perfect as your heavenly Father is perfect," or the words of the Apostle: "This is the will of God, your sanctification." Sometimes an argument based on reason is put forward. According to this, no indifference would be permissible with respect to the obtaining (though gradual and stage by stage) of the final end towards which man is moving; or, again, the precept of well-ordered self-love which would insist on one’s seeking advantages for eternity in the measure in which the circumstances of daily life permit their attainment; or, even the first and greatest commandment, of the love of God above all things, which would allow no choice in profiting by the particular occasions offered by Providence.
Now, the growth in the love of God and in abandonment to His will does not come from the sufferings themselves which are accepted, but from the intention in the will, supported by grace. This intention, in many of the dying, can be strengthened and become more active if their sufferings are eased, for these sufferings increase the state of weakness and physical exhaustion, check the ardor of soul and sap the moral powers instead of sustaining them. On the other hand, the suppression of pain removes any tension in body and mind, renders prayer easy, and makes possible a more generous gift of self. If some dying persons accept their suffering as a means of expiation and a source of merits in order to go forward in the love of God and in abandonment to His will, do not force anesthetics on them. They should rather be helped to follow their own way. Where the situation is entirely different, it would be inadvisable to suggest to dying persons the ascetical considerations set out above, and it is to be remembered that instead of assisting towards expiation and merit, suffering can also furnish occasion for new faults.
Let Us add a few words on the suppression of consciousness in the dying in the circumstance where it is not suggested by the pain. Since Our Lord willed to submit to death fully conscious, the Christian wishes to imitate Him in that also. In addition, the Church gives to priests and to the faithful, an Ordo Commendationis Animae, a collection of prayers which should help the dying to leave this world and to enter into eternity. But if those prayers keep their value and meaning even when they are spoken beside a sick person who is unconscious, to one who is able to take part in them they ordinarily bring light, consolation and strength. And so the Church lets it be understood that the sick person should not, without serious reason, be deprived of consciousness. When this state is produced by natural causes, men must accept it; but it is not for them to bring it about unless they have serious motives for so doing. There is, in addition, the desire of the persons concerned when they have the faith. They wish to have the presence of their kindred, of a friend, of a priest, to help them to die well. They wish to preserve the possibility of making their final arrangements, of saying a last prayer, a last word to those around them. To disappoint them in this is contrary to Christian, nay, to ordinary human sentiment. The use of anesthetics at the approach of death with the sole purpose of depriving the sick person of consciousness at the end, would not be a notable gain in the art of modern healing, but a practice truly to be regretted.
Your question was proposed rather on the supposition that a serious medical reason existed (e.g., violent pains, pathological states of depression and of agony). The dying person cannot allow, still less ask the doctor to make him unconscious if he thereby renders himself incapable of fulfilling some serious moral duties, for example, the settling of important business, the making of his will, going to confession. We have already said that the intention of gaining greater merits, taken by itself, is not an argument sufficient to make the use of drugs unlawful. To judge of this lawfulness, the question must also be asked whether the state of insensibility will be relatively short (during the night or for a few hours) or prolonged (with or without interruption); one must also consider whether the use of the higher faculties will return at certain moments for a few minutes at least or for several hours—and enable the dying person to do what his duty imposes on him (e.g., to make his peace with God). In addition, a conscientious doctor, even if he is not a Christian, will not yield to the urgings of those who, contrary to the will of the dying person, would wish to make him lose his clarity of mind in order to prevent him taking certain decisions.
When, in spite of obligations still binding on him, the dying man asks for the state of insensibility for which there exist serious reasons, a conscientious doctor will not countenance it, especially if he is a Christian, without having invited the patient, either personally or, better still, through some others, first to carry out his obligations. If the sick man refuses obstinately, and persists in asking to be made unconscious, the doctor can consent to it without rendering himself guilty of formal co-operation in the sin committed. That sin does not really depend on the fact of unconsciousness, but on the immoral will of the patient; whether or not he obtains the relief from pain, his behavior will be the same: he will not carry out his obligation. Granted that the possibility of repentance is not excluded, there is yet no serious probability of it; and who knows even that he will not be hardened in evil?
But if the dying man has fulfilled all his duties and received the Last Sacrament, if medical reasons clearly suggest the use of anesthetics, if, in determining the dose, the permitted amount is not exceeded, if the intensity and duration of this treatment is carefully reckoned and the patient consents to it, then there is no objection the use of anesthetics is morally permissible.
The case of the sick who are inoperable and incurable
Would it be necessary to give up its use if the actual effect of the drug was to shorten the span of life? First, all forms of direct euthanasia, i.e., the administration of a drug in order to produce or hasten death, is unlawful because, in that case, a claim is being made to dispose directly of life. It is one of the fundamental principles of natural and Christian morality that man is not the master and owner, but has only the use, of his body and life. One is putting forward a claim to a right or direct control every time one wills the shortening of life as an end or as a means. In the hypothesis which you are considering, there is question only of ridding the patient of unbearable pains, for example, in a case of inoperable cancer or of incurable diseases.
If there exists no direct causal link [and usually there is—because morphine causes respiratory suppression and subsequent pulmonary infection—Ed.], either through the will of interested parties or by the nature of things, between the induced unconsciousness and the shortening of life—as would be the case if the suppression of the pain could be obtained only by the shortening of life; and if, on the other hand, the actual administration of drugs brings about two distinct effects, the one the relief of pain, the other the shortening of life, the action is lawful. It is necessary, however, to observe whether there is, between these two effects, a reasonable proportion, and if the advantages of the one compensate for the disadvantages of the other. It is important also to ask oneself if the present state of science does not allow the same result to be obtained by other means. Finally, in the use of the drug, one should not go beyond the limits which are actually necessary.
Conclusion and answer to the third question
To sum up, you ask Us:
Is the removal of pain and consciousness by means of drugs (when medical reasons suggest it) permitted by religion and morality to both doctor and patient (even at the approach of death, and if one foresees that the use of drugs will shorten life)?"
One must answer:
Yes, provided that no other means exist, and if, in the given circumstances, that action does not prevent the carrying out of other moral and religious duties."
As We have already explained, the ideal of Christian heroism does not require, except in a general way, the refusal of a state of insensibility, which is justified on other grounds, not even at the approach of death; all depends on the particular circumstances. The most perfect and most heroic decision can be present as fully in acceptance as in refusal.
We venture to hope that these considerations on the technique of pain prevention, looked at from a moral and religious point of view, will help you to discharge your professional duties with an even keener sense of your responsibilities. You desire to remain completely faithful to the demands of your Christian faith and to abide by it in all your activity. But far from thinking of these demands as restrictions or as shackles on your liberty and initiative, regard them rather as an invitation to a life immeasurably higher and more excellent, which can be won only by effort and renunciation; for the fullness and joy of that life are already a matter of experience here below for any one who knows how to enter into communion with the Person of Christ living in His Church, quickening it with His spirit, diffusing through all His members His love as the Redeemer Who alone will finally triumph over suffering and death.
To the end that Our Lord may impart to you His gifts in full measure, We earnestly pray to Him for you, for your families and fellow-workers, and with all Our heart, We grant to you Our fatherly Apostolic Blessing.
A health profession which faces increasing challenges to adhere to Catholic moral and religious compunctions is the pharmaceutical field. Since the landmark analyses of the pharmaceutical industry in 1989 (Pharmaceutical Companies: The New Abortionists) and 1994 (Infant Homicides Through Contraceptives), the public has witnessed the proliferation of chemical and mechanical abortifacients within the profession which boasts that it is the "most trusted."
Fewer and fewer opportunities to practice a "life-saving" profession present themselves as larger and larger retail chains and hospital centers swallow up what is left of small, independent practitioners. With that decimation comes the attitude for less and less "toleration" for those who profess the Faith through the corporal and cognitive works of their training.
We see more and more retail and institutional pharmacists either reprimanded or dismissed for refusing to dispense contraceptives / abortifacients (many times they are one and the same) or refusing to refer women where such poisons may be had. Certainly all is not lost, but the masonic-minded masters continue to tighten the screws and squeeze those brave souls who adhere to and practice the Catholic Faith in their profession. There are pockets of opportunities for those who seek to practice their profession of work and the Faith, but they must be pursued or initiated by pharmacists who wish to maintain their moral scruples.
For more information contact the author at: Bogomir Kuhar, PharmD, Pharmacists For Life International, PO Box 1281, Powell, OH 43065-1281 614-881-5520.
Medical and moral problems in the practice of resucitation
An Address to an International Congress of Anesthesiologists (November 24, 1957)
By Pope Pius XII
Dr. Bruno Haid, head of the Anesthesiology Department at the University of Innsbruck’s surgery clinic, has submitted to Us three questions of medical morality concerning what is called resuscitation. We are pleased, Gentlemen, to respond to his request, which manifests the keen consciousness you have of your professional duties, and the desire to resolve the delicate problems which you face in the light of the principles of the Gospel.
According to the presentation of Dr. Haid, modern anesthesiology is not limited to problems of analgesia and anesthesia strictly speaking, but includes resuscitation as well. In medicine, and especially in anesthesiology, this word designates the techniques capable of remedying to certain life-threatening incidents, especially asphyxias which, formerly, when modern technology was not available, would lead in just a few minutes to heart failure and death. The task of the anesthesiologist thus extends to acute respiratory difficulties caused by strangulation or occasioned by open thoracopulmonary wounds. He intervenes to prevent asphyxia due to the internal obstruction of the respiratory passages caused by stomach ailments, or by drowning; to remedy total or partial respiratory paralysis in case of grave tetanus, infantile paralysis, poisoning by gas, hypnotics, or drunkenness, or even in cases of respiratory paralysis provoked by serious cranial traumas.
When a doctor practices resuscitation and the treatment of persons with head injuries, and sometimes persons undergoing brain surgery or those who have suffered cervical traumas caused by anoxia and remain plunged in a deep coma, he often is faced with questions which pertain to medical morals and which call upon the principles of natural philosophy more so than those of analgesia. Thus it happens that, in cases like the accidents and illnesses listed above in which the treatment offers sufficient hope of success, the anesthesiologist can ameliorate the general condition of patients suffering from serious brain lesions, whose case initially appeared hopeless: he can re-establish respiration, either by manual intervention or with the help of special equipment, free the respiratory passages and provide for feeding the patient. Thanks to this therapy, and especially by the administration of oxygen by means of artificial respiration, the failing circulation resumes and the patient’s condition improves, often very quickly, so much so that the anesthesiologist, or any other doctor who, relying upon his own experience, would have given up, continues to entertain a slight hope of seeing spontaneous breathing return. Usually the family considers this improvement as an astonishing result, for which it is grateful to the doctor.
If the damage to the brain is so serious that it is probable, and even practically certain, that the patient will not survive, the anesthesiologist begins to ask himself the anguishing question of the worth and meaning of the attempts to resuscitate the patient. To gain time and to make with greater certitude the final decisions, he immediately resorts to artificial respiration, alimentation, and the cleaning of respiratory passages. But then he can find himself placed in a delicate position if the family considers his efforts as inconvenient and comes to oppose them. Most of the time, this happens, not at the beginning of the attempts at resuscitation, but when the patient’s condition, after a slight initial improvement, does not progress and when it becomes clear that the only thing keeping him alive is artificial respiration. It is at this point that the doctor wonders if he must, or if he can, continue the attempt at resuscitation, even though the soul may have already left the body.
The solution to this problem, already difficult in itself, becomes even more so when the family—perhaps even a Catholic family—compels the physician in charge to remove the artificial respiration apparatus in order to allow the patient, already virtually dead, to go in peace. Thence flows a fundamental question from the point of view of religion and of the philosophy of nature: According to the Catholic faith, when does death take place in patients on whom modern resuscitation techniques are used? Is Extreme Unction valid at least as long as cardiac activity can be observed, even if all vital functions properly so-called have ceased, and if life depends entirely upon the use of artificial respiration?
The problems raised by the modern practice of resuscitation can be formulated in three questions:
- First, has one the right, or even the duty, to use modern artificial respiration apparatus in every case, even in those which, in the judgment of the doctor, are considered as completely hopeless?
- Secondly, has one the right or the obligation to remove the artificial respiration apparatus when, after several days, the state of deep coma does not change, while, if it were removed, circulation would cease in a few minutes? What should one do in the case where the family of the patient who has received the last sacraments, urges the doctor to remove the apparatus? Is Extreme Unction administered at this stage still valid?
- Thirdly, should a patient plunged in a coma because of "central paralysis," but whose life—that is to say, whose circulatory system—still functions thanks to artificial respiration, and in whom no signs of improvement have been seen for several days, be considered as dead de facto, or even de jure? In order to declare him dead, is it not necessary for the circulatory system to cease despite the use of artificial respiration?
We shall reply to each of these questions, but before doing so, We should like to set forth the principles which will enable Us to formulate the reply.
Natural reason and Christian morality say that man (and whoever is responsible for taking care of his brother) has the right and the duty, in case of grave illness, to take the measures necessary to conserve life and health. This duty, which he has towards himself, to God, and even to the human community, and most often towards specific persons, flows from well-ordered charity, from submission to the Creator, from social justice and even from strict justice, as well as from filial piety. But usually the obligation is limited to the use of ordinary means (according to the circumstances of person, place, era, and culture), that is to say, means which impose no extraordinary burden on either oneself or another. A more severe obligation would be too heavy for most men, and would render the acquisition of more important higher goods too difficult. Life, health, all temporal activity, are, after all, subordinate to spiritual ends. Moreover, it is not forbidden to do more than the strictly necessary to conserve life and health, on the condition that higher duties are not neglected.
As for administering the sacraments to a person in a coma, the answer flows from the doctrine and the practice of the Church, which, for its part, follows the Lord’s will as a rule of action. The sacraments are destined, by virtue of divine institution, for men in this world, during the course of their terrestrial life, and, with the exception of baptism itself, suppose that the ones who receive them have been baptized. One who is not a man, one who is not yet a man or who is no longer, cannot receive the sacraments. Also, if someone manifests his refusal, the sacraments cannot be administered against his will. God forces no one to receive sacramental grace. If it is not known whether someone fulfills the conditions required for valid reception of a sacrament, the attempt must be made to remove the doubt. In case of inability to do so, the sacrament can be conditionally conferred, at least tacitly (with the clause "si capax est," which is broader). The sacraments were instituted by Christ for men in order to save their souls; thus, in case of extreme necessity, the Church tries extreme solutions in order to communicate to a man grace and sacramental aid.
The questions about the fact of death, and about its recognition, whether by the fact itself (de facto), or by legal criteria [de son authenticite juridique] (de jure), have by their consequences, even in the domain of morals and religion, a still broader scope. What We have just said about the essential suppositions for the valid reception of a sacrament has shown it; but the importance of the matter also extends to questions concerning inheritance, marriage and matrimonial cases, to questions of benefices (e.g., the vacancy of a benefice) and to many other questions pertaining to private and public life.
It is incumbent upon the doctor, and especially the anesthesiologist, to give a clear and precise definition of "death" and of "the moment of death" of a patient who dies in a state of coma. In order to do this, one could begin by the usual concept of the complete and definitive separation of the soul from the body; but in practice, one must take into account the impreciseness of terms like "body" and "separation." One can leave aside the possibility of a man being buried alive, because the removal of the respiratory apparatus brings on the cessation of circulation after a few minutes, and then death.
In case of insoluble doubt, one can have recourse to presumptions of right and of fact. In general, one will stop at that of the permanence of life, because it involves a matter of a fundamental right received from the Creator, and it is necessary to prove with certitude that it has been lost.
We come to the solution of the particular questions.
1) Has the anesthesiologist the right, or even the duty, in every case of deep coma—even those which are utterly hopeless in the judgment of the competent physician—to use modern artificial respiration technology, even against the will of the family?
In ordinary cases, it is granted that the anesthesiologist has the right to act thusly, but he does not have the obligation, unless it is the only means to fulfill another incumbent moral duty. The rights and duties of the doctor are correlative to those of the patient. In truth, the doctor has no rights that are separate from or independent of the patient; in general, he cannot act unless the patient authorizes him to, explicitly or implicitly (directly or indirectly). The technology of resuscitation, which is here in question, contains nothing that is in itself immoral; thus the patient, if he were capable of making the decision personally, could licitly utilize it, and, consequently, give authorization to the physician. Moreover, as these forms of treatment go beyond the ordinary means, which it is obligatory to use, it cannot be maintained that there is an obligation to use them, and, consequently, to authorize the physician.
The rights and duties of the family, in general, are dependent upon the presumed will of the unconscious patient, if he is a major and "sui juris." As for the family’s own duty independent of the patient, it usually only obliges them to use ordinary means. Consequently, if it seems that the attempt at resuscitation in reality constitutes for the family such a burden that one cannot in conscience impose it upon them, the family can licitly insist that the doctor cease his attempts, and the doctor can licitly obey. In this case there is no direct disposition taken against the life of the patient, nor euthanasia, which would never be licit; even when it brings about the failure of the circulatory system, the interruption of attempts at resuscitation is never more than indirectly a cause of the cessation of life, and it is necessary to apply in this case the principle of double effect and that of "voluntarium in causa."
2) Thus have We already answered the essential points of the second question:
Can the physician remove the respiratory apparatus before the definitive cessation of the circulatory system occurs? Can he do so at least once the patient has already received Extreme Unction? Is this sacrament valid when administered at the moment when circulation ceases, or even afterwards?"
It is necessary to reply in the affirmative to the first part of this question, as We have already explained. If the sacrament of Extreme Unction has not yet been administered, one must try to prolong respiration until it has been. As for knowing if Extreme Unction is valid at the moment of the definitive cessation of circulation, or even afterwards, it is impossible to answer by "yes" or "no." If this definitive cessation signified, in the opinion of the doctors, the certain separation of soul and body, even if certain organs continued to function, Extreme Unction would certainly be invalid, for the one receiving it would certainly no longer be a man. But that is the one indispensable condition for the reception of the sacraments. If, on the contrary, the physicians judge that the separation of body and soul is doubtful and that this doubt cannot be resolved, the validity of the Extreme Unction is also doubtful. But applying its usual rules: "The sacraments are for men" and "In cases of extreme necessity, extreme measures are tried," the Church allows the administration of the sacrament, conditionally, nonetheless, out of respect for the sacramental sign.
3) "When the circulatory system and the life of a patient in a deep coma caused by central paralysis are only prolonged by artificial respiration, and without any sign of improvement occurring for several days, at what point does the Catholic Church consider this patient as "dead," or is it necessary, according to natural laws, to declare death (question de facto and de jure)?"
(In other words, has death occurred after the serious brain trauma which caused the deep coma and central respiratory paralysis, the immediate fatal consequences of which have nonetheless been postponed by means of artificial respiration? Or does death occur, according to the current opinion of the doctors, only at the moment of the definitive cessation of the circulatory system, in spite of the prolonged utilization of artificial respiration?)
Regarding the determination of the fact in particular cases, the answer cannot be deduced from any religious or moral principle and, from this perspective, does not pertain to the competence of the Church. While waiting, she will remain open. But considerations of a general nature allow one to think that human life continues as long as the vital functions—as distinguished from the simple life of organs—continue to be manifest spontaneously or even with the aid of artificial assistance. A good number of these cases fall in the domain of unresolvable doubt, and should be treated according to the presumptions of right and of fact of which We have spoken.
May these explanations guide and enlighten you, when you attempt to resolve the delicate questions that occur in the practice of your profession. As a token of the divine favors which We implore for you and all those who are dear to you, We wholeheartedly grant you our Apostolic blessing.
1 Discorsi e Radiomessaggi, Vol. XVII, pp.465ff.
2 Gen. 2:16.
3 Ibid., p.478.
4 Cf. Gen. 1:28.
5 Mt. 27:24.
6 Jn. 18:11.
7 Mt. 26:38-39; Lk. 22:42-44.
8 Lk. 12:50.
9 Discorsi e Radiomessaggi, Vol. 15, p.73.
10 Summa Theologica, I, Q.84, A.8.
11 Discorsi e Radiomessaggi, Vol. XVII, p.467.
12 Mt. 5:48.
13 I Thes. 4:3.