Allocution To Doctors On The Moral Problems Of Analgesia
Pope Pius XII
Professor Mazzoni, secretary of the Italian Society of anesthesiology, had submitted to the Sovereign Pontiff three questions concerning analgesia, at the end of the Congress of Italian anesthesiologists, held in Rome in October, 1956. The Pope agreed to treat these questions from the religious and moral point of view at the time of a special audience granted on February 24, 1957 at an international assembly of 500 doctors and surgeons. Here is this significant speech that Pie Xll pronounced in French. The translation is from ACIM-ASIA. (The original French text of the moral section follows the English text.)
Outline of the Allocution
Question 3: ABOUT THE USE Of ANALGESICS FOR THE DYING
The IX National Congress of the "Società Italiana di Anestesiologia", which was held in Rome from October 15 to 17, 1956, by the intermediary of the president of the organizing committee, professor Piero Mazzoni, has asked Us three questions, which relate to the religious implications and morality of analgesia in relation to the natural law, and especially to the Christian doctrines contained in the Gospel and proposed by the Church.
These questions, of an undeniable interest, do not fail to raise men of today to intellectual and emotional reactions; among Christians in particular, there appear in this respect extremely divergent tendencies. Some approve without reserve the practice of analgesia; others would be inclined to reject it without nuances, because that would contradict the ideal of Christian heroism; others still, without sacrificing this ideal, are ready to adopt a position of compromise. This is why We are asked to express Our opinion about the following points:
1. NATURE, ORIGIN AND DEVELOPMENT OF ANESTHESIA
The advent of modern surgery was marked by two decisive facts in the middle of last century: the introduction of the antisepsis by Listing, after Pasteur had proven the role of germs in the outbreak of infections, and the discovery of an effective method of anesthesia. Before Horace Wells had thought of using nitrogen protoxide to deaden the patients, surgeons were obliged to work quickly, summarily, on men who struggled in prey with atrocious sufferings. The practice of the general anesthesia was going to revolutionize this state of affairs and to allow long, delicate, and sometimes astonishingly audacious interventions; it ensured, indeed, to the expert as well as to the patient the paramount conditions of calm, peace and "muscular silence" essential to the precision and the safety of any surgical operation. But it imposed at the same time an attentive monitoring on the essential physiological activities of the organism. The anesthetic, indeed, invades the cells and reduces their metabolism, it removes the reflexes of defense and slows down the life of the subject more or less already seriously compromised by the disease and the operational traumatism. Moreover, the surgeon fully absorbed by his work, was to hold into account at every moment the general condition of his patient: heavy responsibility especially in the case of particularly serious operations. Also, one has seen in the last few years a developing new medical specialization, that of anesthetist, called to play a growing role in the organization of a modern hospital.
This role is often unobtrusive, almost unknown to general public, less brilliant than that of the surgeon, but it is essential too. It is in his hands, indeed, that the patient entrusts his life, in order to pass through the painful moment of the surgical operation with the greatest possible safety. First of all, the anesthetist must medically and psychologically prepare the patient. He informs himself carefully of the characteristics of each case, in order to envisage the possible difficulties, which the weakness of such or such organ would cause; he inspires confidence to the sick, requests his collaboration, gives him medicine intended to calm him and prepare the organism. It is he, who, according to the nature and the duration of the operation, chooses the anesthetic which is the best adapted and the means of applying it. But especially, during the intervention, it falls on him to supervise keenly the state of the patient; he remains, so to speak, at the look-out for the lightest symptoms, to know exactly the degree reached by the anesthesia and to follow the nervous reactions, the rhythm of the respiration and the blood pressure, in order to prevent any possible complication, larynged spasms, convulsions, cardiac or respiratory troubles.
When the operation is terminated, the most delicate part of his work starts: to help the patient to recover his senses, to avoid incidents, such as the obstruction of the respiratory tracts and the demonstrations of shock, to manage the physiological liquids. Thus, the anesthetist must unite with the perfect knowledge of the techniques of his art, the great qualities of sympathy, comprehension, and devotion, not only in order to support all the psychological provisions useful for the good state of the patient, but also by a feeling of true and deep human and Christian charity.
To accomplish his task, he has today a very rich range of products, of which some are known for a long time and have successfully underwent the test of experience, while others, fruit of recent research, contribute their particular share to the solution of this difficult problem: to remove pain without causing damage to the organism. The nitrogen protoxide, of which Horace Wells did not manage to make known its merits during the experiment carried out at the Hospital of Boston in 1845, always preserves a honorable place among the agents commonly used in the general anesthesia. With ether, already used by Long Crawford in 1842, Thomas Morton experimented in 1846, in the same hospital, but with more success than his colleague, Wells. Two years later, the surgeon James Simpson proved the effectiveness of chloroform; but it will be the Londoner John Snow who will contribute more to the propagation of its use. The initial period of enthusiasm once passed, the defects of these first three anesthetics appeared clearly; but it behooved to await the end of the century so that a new product appear, ethyl chloride, which is insufficient when a prolonged narcosis is wished. In 1924, Luckhardt and Carter discovered ethylene, the first anesthetic gas which is the result of a systematic search in laboratory, and, five years afterwards the use of cyclopropane entered into use, thanks to the work of Henderson, Lucas and Brown; its quick and deep action requires of him who uses it a perfect knowledge of the method in close circuit.
If the anesthesia by inhalation has a well-established supremacy, it meets for the last quarter of a century with the increasing competition of intravenous narcosis. There were several attempts done earlier with chloral hydrate, morphine, ether, ethyl alcohol, which only gave very discouraging if not at times disastrous results. But since 1925, barbiturate compounds have entered in the clinical experiments and are clearly affirmed, after the evidence had shown the undeniable advantages of this type of anesthetic. With them, one avoids the inconveniences of the method by the respiratory tract, the unpleasant impression of suffocation, the dangers of the period of induction, nausea upon waking up and the organic lesions.
The Pentothal sodium, introduced into 1934 by Lundy, ensured definitive success and the broadest diffusion of this kind of anesthesia. From now on barbiturates would be used, either only for operations of short duration, or in " combined anesthesia " with ether and the cyclopropane, of which they shorten the period of induction and permit to reduce the dosage and inconveniences; sometimes one uses them as the principal element and compensates for their pharmacological defects by the use of nitrogen protoxide and oxygen.
Cardiac surgery, which has recorded spectacular progress in the last few years, poses particularly difficult problems with anesthesia. Indeed, it supposes in general, the possibility of stopping the blood circulation during a more or less long period. Moreover, as it interests an extremely sensitive organ, and whose functional integrity is often seriously compromised, the anesthetist must avoid all that would burden the function of the heart. In the case of mitral stenos, for example, he must prevent the psychic and neuro-vegetative reactions of the patient by a preliminary sedative medication. He must avoid tachycardia, thanks to a major pre-anesthesia with a small parasympathetic block; at the time of the commissurotomy, he may reduce the danger of anoxia by an abundant oxygenation and may supervise the pulse and the course of cardiac action.
But, to be well accomplished, other operations require the possibility for the surgeon to work on a bloodless heart and to stop the circulation of the blood well beyond three minutes, which, normally, mark the appearance of irreversible lesions of the brain and cardiac fibers. To cure one of the most frequent congenital defects, which was the persistence of the hole of Botal, they used since 1948 the surgical technique called "covered sky", which presented evident risks of any blind operation. Now, two new methods, hypothermia and the use of an artificial heart make it possible to operate under direct vision, and thus open in this field brilliant prospects. It was noted, indeed, that hypothermia is accompanied with a lessening of the uptake of oxygen and the production of carbon anhydride proportional to the fall of the body temperature. In practice, one does not go down below 25 degrees, in order not to deteriorate the contractibility of the cardiac muscle, and especially not to increase the excitability of myocardic fiber and the danger of determining a ventricular fibrillation, which is reversible but with difficulty. The method of hypothermia makes it possible to stop the circulation, which lasts from eight to ten minutes without destroying the nervous cells of the brain. This duration can still be prolonged by the use of cardiopulmonary machines, which take venous blood out, purify it, bring oxygen to it and return it into the organism. The functions of these apparatuses demand that the operators have a rigid training accompanied by multiple and meticulous controls. The anesthetist then, accomplishes a heavier task, more complex and whose perfect execution is an essential condition of success. But the results already achieved make it possible to hope for the future a broad extension of these new methods.
It is normal that, before so varied resources which modern medicine offers to avoid the pain, and the desire which is so natural to benefit from them to the maximum, some questions of conscience emerge. You have decided to propose some of them to Us, which interest you particularly. But before answering them, We would like to remark briefly that other moral problems also claim the attention of the anesthetist; especially that of his responsibility with regards to the life and health of the patient; because those things sometimes do not depend less on him than on the surgeon. In this connection, We have already noted on several occasions, and in particular in the allocution of September 30, 1954 at the VIII Assembly of the World Medical Association, that man cannot be for the doctor a simple object of experiment, on whom he would test the methods and new medical inventions.
We now pass to the examination of the proposed questions.
Question 1: ON THE GENERAL MORAL OBLIGATION TO SUPPORT PHYSICAL PAINS
Thus you asked initially, if there is a general moral obligation to support physical pain. To answer with more exactitude to your question, We will distinguish several aspects there. Firstly, it is obvious that in certain cases, the acceptance of the physical pains is a serious obligation. Thus, every time that one is put before the inescapable alternative to bear suffering or to transgress a moral duty by action or omission, he is bound in conscience to accept suffering. The "martyrs" could not avoid tortures or death, without disavowing their faith or escaping the serious obligation to confess it in a given time. But it is not necessary to come to the "martyrs"; We find presently splendid examples of Christians who support pains and physical violence, during weeks, months and years, in order to remain faithful to God and to their conscience.
Your question however does not refer to this situation; it rather refers to the free acceptance and the search for pain because of its meaning and own finality. To immediately quote a concrete example, let us remember the allocution, which We pronounced on January 8, 1956 in connection with the new methods of painless childbirth. It was asked then if, under the terms of the text of the Scriptures: "You shall give birth in pain" (Gen. III, 16), the mother was obliged to accept all the sufferings and to refuse analgesia by artificial or natural means. We have answered that there was no obligation of this kind. Man keeps, even after the fall, his right to dominate the forces of nature, to use them in his service, and thus to make profitable all the resources that it offers him to avoid or remove the physical pain. But We have added that, for a Christian, this does not constitute a purely negative fact, that it is associated on the contrary with religious values and high morals, and can thus be wanted and sought, even if there exists for that no moral obligation in such or such particular case. And We continued: "The life and the sufferings of the Lord, the pains that so many great men supported and even sought, thanks to which they matured and grew up to the heights of Christian heroism, the daily examples of resigned acceptance of the cross, which We have under Our eyes, all that reveals the significance of suffering, the patient acceptance of pain in the actual economy of salvation, during the time of this terrestrial life.
Moreover, a Christian is bound to mortify his flesh and to work to purify himself internally, because it is not possible in a long run to avoid sin and to discharge accurately all his duties, if he refuses this effort of purification and mortification. In the measure where the mastery of one self and one’s untamed tendencies is impossible to conquer without the assistance of the physical pain, this thus becomes a need and it should be accepted; but in so far as it is not necessary for this purpose, one cannot affirm that there exists on this subject a strict duty. The Christian is never obliged to want it for itself; he regards it as a more or less adapted means, according to the circumstances, with the end that he pursues.
Instead of considering it from the point of view of a strict obligation, we can also consider that of the exigencies demanded by the Christian faith, the invitation to a higher perfection, which is not under pain of sin. Is the Christian bound to accept the physical pain in order not to put itself in contradiction with the ideal, which his faith proposes him? Does refusing it imply a lack of spirit of faith? If it is undeniable that the Christian proves his desire to accept and even seek physical pain for better participation in the passion of Christ, to renounce the world and its sensible pleasures and to mortify his flesh, it is important however to interpret correctly this tendency. Those who express it externally do not necessarily possess the true Christian heroism; but it would be as erroneous to affirm that those, who do not manifest it, are deprived of it. This heroism can, indeed, be interpreted in other ways. When a Christian, day after day, from morning to evening, discharges all the duties imposed on him by his state of life, his profession, the commandments of God and men, when he prays with recollection, works with all his strength, resists his bad passions, manifest to his neighbor the charity and devotion that he owes him, supports manfully without murmuring all that God sends to him, then his life is always under the sign of the cross of Christ whether physical suffering is present or not, whether he suffers it or avoids it by licit means. Even if We consider only the obligations falling on him under pain of sin, man cannot live nor accomplish his daily work as a Christian, without being constantly ready for the sacrifice and, so to speak, without sacrificing himself continuously. The acceptance of physical pain is only one expression, among many others, of what constitutes the essential: the desire to love God and to serve him in all things. All the quality of the Christian life and its heroism consists above all in the perfection of this voluntary disposition.
What are the reasons, which make it possible to avoid physical pain in concrete cases without entering into conflict with a serious obligation or with the ideal of Christian life? One could enumerate a great number of them; but, in spite of their diversity, they are finally reduced to the fact that in the long run, pain prevents the obtaining of goods and higher interests. It can be that it is preferable for such a person and in such concrete situation; but in general, the damages that it causes forces men to defend themselves against it; undoubtedly it will never disappear completely from humanity; but one can put its harmful effects in narrower limits. Thus, like one controls a natural force to benefit from it, the Christian uses suffering as a stimulant in his effort of spiritual ascension and purification, in order to better discharge his duties and to better answer the call of a higher perfection; it is up to each one to adopt some solutions concerning each personal case, according to the aforesaid aptitudes or provisions, insofar as - without preventing other higher interests and other goods - they are a means of progress in the interior life of more perfect purification, of a more faithful achievement of duty, of greater promptitude to follow the divine inspirations. To make sure that such is the case, one ought to consult the rules of Christian prudence and the opinions of an experienced spiritual director.
You will easily draw from these answers useful and practical orientations for your action.
1. – The fundamental principles of anesthesiology, as science and art, and the end that it pursues, are not objectionable. They struggle with forces that, in many ways, produce harmful effects and block a greater good.
2. - The doctor, who accepts these methods, enters in contradiction neither with the natural moral order, nor with the specifically Christian ideal. He seeks, according to the order of the Creator (Gen. 1, 28), to subject pain to the capacity of man, and uses for that the acquisitions of science and technology, according to principles which We have stated and which will guide his decisions in particular cases.
3. - The patient desirous of avoiding or calming the pain can, without anxiety of conscience, use the means found by science and which, in themselves, are not immoral. Some particular circumstances can impose another line of conduct; but the duty of self-denial and interior purification, which falls to the Christian, is not an obstacle to the use of the anesthesia, because one can fill it by another way. The same rule also applies to the supererogatory exigencies of the Christian ideal.
Your second question concerned narcosis and the total or partial deprivation of consciousness in comparison with Christian morals. You stated it as follows: "the complete abolition of the sensitivity in all its forms (general anesthesia), or the more or less large reduction of the painful sensitivity (hypo and analgesia), is always respectively accompanied by the disappearance or the reduction of consciousness and of the highest intellectual faculties (memory, processes of association, critical faculties, etc.) : are these phenomena, which occur within the usual framework of surgical narcosis and pre and postoperative analgesia compatible with the spirit of the Gospel? "
The Gospel reports that immediately before the crucifixion, they offered to the Lord wine mixed with gall, undoubtedly to attenuate his sufferings. After having tasted it, he did not want to drink it (Matth. xxvii, 34), because he wanted to suffer in full knowledge, thus fulfilling what he had said to Peter during the arrest: " The chalice which my Father hath given me, shall I not drink it? "(John xviii, 11). The bitter chalice that Jesus had begged with the anguish of his heart: "My Father, if it is possible, let this chalice pass from me! Nevertheless not as I will, but as Thou wilt!” (Matth. xxvi, 38-39; Luke xxii, 42-44). Does the attitude of Christ towards his passion, such as this account reveals it and other passages of the Gospel (Luke xii, 50), make it possible for the Christian to accept total or partial narcosis?
Since you consider the question under two aspects, We will examine successively the suppression of pain and the diminution or total suppression of consciousness and of the use of higher faculties.
The suppression of pain depends, as you see it, either on the suppression of the general sensitivity (general anesthesia), or on a more or less marked lowering of the capacity to suffer (hypo and analgesia). We have already said the essential on the moral aspect of the suppression of pain; In relation to the religious and moral judgment, it matters little whether it is caused by a narcosis or by other means. Within the indicated limits it raises no objection and remains compatible with the spirit of the Gospel. In addition to this, it should not be denied and underestimated that the fact that the voluntary acceptance (obligatory or not) of physical pain, even at the time of surgical operations, can manifest a high degree of heroism, and indeed often testifies of a heroic imitation of the passion of Christ. However this does not mean that it is an essential element. It is not rare that anesthesia is essential for other reasons, such as when the surgeon or the patient could do without it without failing in Christian prudence. The same applies to pre and postoperative analgesia.
You speak then of the reduction or the suppression of consciousness, and of the use of higher faculties, as some phenomena accompanying the loss of senses. Usually, what you want to have is precisely this loss of sensitivity; but often it is impossible to cause it without producing at the same time total or partial unconsciousness. Outside the surgical domain, this relation is often reversed, not only in the medical field, but also in psychology and in criminal investigations. In these other domains,, one pretends to determine a fall of the consciousness and, thus, of higher faculties, so as to paralyze the psychic mechanisms of control, that man continually uses to control and direct himself. Then, he is given up without resistance to the play of associations of ideas, feelings and volitive impulses. The dangers of such a situation are obvious; it can even happen that his immoral instinctive impulses are let loose. These manifestations of the second stage of narcosis are well known. Actually one endeavors to prevent them by the preliminary application of narcosis. The stopping of the control faculties proves to be particularly dangerous, when it causes the divulgation of secrets of the private, personal or familial, and of social life. It is not enough that the surgeon and all his assistants be bound with the natural secrecy (secretum naturale), and with the professional secrecy (secretum officiale, secretum commissum) with regard to all that occurs in the operating room. There are certain secrets, which should be revealed to nobody, not even, as the technical formula says: uni viro prudenti and silentii tenaci. We have already underlined this in our allocution of April 13, 1953, on clinical psychology and psychoanalysis. We can also approve the use of narcotics in preoperative medication in order to avoid these inconveniences.
Let us note initially that during sleep, nature itself stops more or less completely the mental activity. In a sleep not too deep, the use of reason (uses rationis) is not entirely eliminated and the individual can still enjoy his higher faculties - which St. Thomas d' Aquinas had already affirmed (S.Th. Ia, q. 84, a. 8). However, sleep excludes the dominium rationis, in virtue of which reason commands freely the human activity. It does not follow that if man gives himself up to sleep, he acts against the moral order while being deprived of consciousness and self-control by the use of higher faculties. But it is certain also that there can be cases (and it happens often times), in which man cannot go to sleep, but must remain in possession of his higher faculties, to discharge a moral duty, which befalls on him. Sometimes, without being held by a strict duty, man renounces sleep to render nonobligatory services or to deny himself for higher moral interests. Thus the suppression of consciousness by natural sleep does not offer in itself any difficulty. However it is illicit to accept it, when it blocks the accomplishment of a moral duty. To renounce natural sleep can be in the natural order of things an expression and voluntary execution of a tendency towards moral perfection.
But consciousness can also be affected by artificial means. That one may obtain this result by the application of narcotics or by hypnosis (which one can call a psychic analgesic) that does not make any essential difference in the moral point of view. Hypnosis however, even considered only in itself, is subject to certain rules. may We be allowed on this matter to recall Our short allusion to the medical use of hypnosis which We made at the beginning of the allocution of January 8, 1956 on painless natural childbirth.
The issue which occupies us now concerns hypnosis practiced for clinical purposes by the doctor, while keeping the precautions that medical science and ethics require from the doctor who employs it as well as from the patient who subjects himself to it. On this given use of hypnosis, will apply the moral judgment, which We will formulated on the suppression of consciousness.
But we do not want that We extend purely and simply to hypnosis in general what We are saying on hypnosis at the service of the doctor. This, in as much as it is a scientific object of research, cannot be studied by any person indiscrimately, but only by a serious scientist within the moral boundaries valid for any scientific activity. It is not the case of any circle of laymen or ecclesiastics, who would occupy themselves with it as with interesting subject by way of pure experiment, or even by simple pastime.
To appreciate the liceity of the suppression and the reduction of consciousness, it should be considered that to act reasonably and freely towards an end constitutes the characteristic of the human being. The individual will not be able, for example, to complete his daily work, if he remains constantly plunged in a twilight state. Moreover, he is bound to conform all his actions to the exigencies of the moral order. Given that the natural dynamism and blind instincts are powerless by themselves to ensure an ordered activity, the use of reason and higher faculties proves to be essential, both for the perception of the precise standards of the obligation, and for their application to particular cases. From there rises the moral obligation not to be deprived of consciousness without true need.
It follows that the consciousness cannot be disturbed or suppressed merely with the aim of enjoying pleasures while devoting oneself to intoxication and by absorbing poisons intended to arrive at that state, even if one only seeks a certain euphoria. Beyond a determined quantity, these poisons cause a more or less remarkable disorder on the consciousness and even its complete obscuration. Facts show that the abuse of drugs leads to the total forgetfulness of the most fundamental exigencies of personal and family life. It is not thus without reason that the authorities intervene to regulate the sale and the use of these drugs, in order to keep society from serious physical and moral damage.
Is surgery found in the practical necessity to cause a diminution and even a total suppression of consciousness by narcosis? From the technical point of view, the answer to this question comes under your responsibility. From the moral point of view, the principles formulated previously in answer to your first question apply essentially as well to narcosis and to the suppression of the pain. What counts most for the surgeon in the very first place is the suppression of the painful sensation, not that of consciousness. When one is awake, violent painful sensations easily cause reactions and reflexes which are often involuntary. They may bring about undesirable difficulties and lead even to mortal cardiac attack. To preserve the psychic and organic balance, to prevent him to be violently traumatized, constitutes for the surgeon as well as for the patient an objective importance, that only narcosis makes possible to obtain. It is hardly necessary to point out that, if others intervened in an immoral way while the patient is unconscious, narcosis would cause serious difficulties, which would impose adequate measurements.
Does the Gospel add further details and requirements to these rules of natural morality? If Jesus-Christ on Calvary refused the wine mixed with gall, because he wanted to drink in full knowledge to the dregs the chalice which the Father presented to him, it follows that man must accept and drink the chalice of pain every time God wishes it. But one must not believe that God wishes it each time a suffering arises, whatever the causes and circumstances. The words of the Gospel and the behavior of Jesus do not indicate that God wants that for all men and at all times and by no means has the Church given them such an interpretation. But the facts and actions of the Lord keep a profound significance for all. Numberless are in this world those who are oppressed by sufferings (diseases, accidents, wars, natural plagues), of which they cannot alleviate the bitterness. The examples of Christ on Golgotha, his refusal to soften his pains, are for them a source of consolation and force. Moreover, the Lord has warned his disciples that this chalice awaits them all as well. The Apostles, and after them the martyrs by thousands, testified to this and continue to testify gloriously unto this day. Often however the acceptance of suffering without lessening is not obligatory and does not signify a higher perfection. The case arises regularly, when there are some serious reasons for that and the circumstances do not impose the opposite. One can then avoid pain, without putting himself at all in contradiction with the doctrine of the Gospel.
The conclusion of the preceding considerations can thus be formulated as follows: within the indicated limits and if one observes the proper requirements, narcosis involving a decrease or a suppression of consciousness is allowed by the natural moral law, and is compatible with the spirit of the Gospel.
It remains for Us now to examine your third question: "Is the use of analgesics, of which the use always blunts consciousness, allowed in general, and for the postoperative period in particular, even among the dying and patients in danger of death, when there is a clinical indication for that? Is it allowed even in certain cases (inoperable cancers, incurable diseases), to attenuate intolerable pain even if it entails the shortening of life? ".
This third question in reality is only an application of the first two with to the special case of the dying and with the particular effect of shortening life.
That the dying may have more than others a moral natural or Christian obligation to accept pain or to refuse its diminution, arises neither from the nature of things nor from the sources of revelation. But as the suffering according to the spirit of the Gospel, contributes to the expiation of personal sins and the acquisition of greater merits, those whose life is in danger have certainly a special reason to accept it, because, with death so close, this possibility of gaining new merits may likely disappear soon. But this motive interests the patient directly, not the doctor who practices analgesia, tsupposing that the patient has agreed or even has asked for it expressly. It would be obviously illicit to practice anesthesia against the express will of the dying (when he is sui iuris).
Some clarifications are necessary here; because it is not rare that one puts forward this reason incorrectly. Sometimes one tries to prove that the sick and the dying are obliged to support physical pains to acquire more merits, according to the counsel to seek perfection, that the Lord addresses to all: Estote ergo vos perfecti, sicut et Pater vester coelestis perfectus est” (Matth. v, 48), or on the words of the Apostle: Haec est voluntas Dei, sanctificatio vestra (I Thess. IV, 3). Sometimes a principle of reason is put forward, according to which no indifference would be allowed with regard to the attainment (even gradual and progressive) of the last end, towards which man tends; or the precept of the well ordered love of self, which would impose to seek the eternal goods insofar as the circumstances of everyday life make it possible; or even the first and greatest commandment that of the love of God above all, which would not leave any choice in profiting from the concrete occasions offered by His Providence. However, the increase of the love of God and the abandonment to His will do not proceed from the sufferings themselves, that one accepts, but from the voluntary intention supported by grace. This intention, for the dying, can be strengthened and become more vivid and alive, if their sufferings are attenuated, for the pains worsen the state of weakness and physical exhaustion, block the impulse of the heart and undermine the moral courage instead of supporting it. On the other hand, the suppression of pain gives organic and psychic relief, facilitates prayer and makes possible a more generous gift of oneself. If the dying embraces suffering as a means of expiation and source of merits in order to progress in the love of God and in the abandonment to His will, let anesthesia be not applied; let him be helped rather to follow his own way. In the contrary dispositions, it would not be convenient to suggest to the dying the ascetic considerations stated above remembering that instead of contributing to the expiation and merit, the pain can also be an occasion of new faults.
Let us add some words on the suppression of consciousness in the dying, insofar as it is not motivated by the pain. Since the Lord wanted to undergo death in full knowledge, the Christian desires to imitate Him in that. Besides, the Church gives to priests and faithful alike the Ordo commendationis animae, a series of prayers, which must help the dying at the very portal of eternity. But if these prayers preserve their value and their meaning, even when one pronounces them close to an unconscious patient, they normally bring to him who can understand them light, consolation and strength. Thus the Church asks that the dying should not be deprived of consciousness even if they fall into the state of unconsciousness. When nature does it, men must accept it; but they must not do it in their own initiative, unless they have serious reasons for that. It is also the desire of the dying who have the faith to have their loved ones, a friend, a priest near them to help them die well. They want to avail the chance of making their ultimate provisions, of saying a last prayer, a last word to those present. To frustrate them is an act repugnant to Christian sentiments. It is even simply inhuman. The anesthesia employed at the moment of death with a sole aim of avoiding from the patient a conscious death, would be a remarkable acquisition of therapeutic modern, but a really deplorable practice.
Your question was rather on the case of a serious clinical indication (for example, violent pains, morbid states of depression and anguish). The dying cannot allow and even less ask the doctor to give him the state of unconsciousness, if by that he puts himself incapable of accomplishing serious moral duties, for example, to transact important affaires, to make his testament, to confess himself. We have already said that the reason for the acquisition of greater merits is not enough in itself to make illicit the use of narcotics. To judge its liceity, it should be asked whether the narcosis is relatively short (for a night or a few hours) or is prolonged (with or without interruption). Also one should ask whether the use of higher faculties will come back at certain moments, for a few minutes at least or for a few hours, and whether the dying has the possibility of complying with his duty imposed on him (for example to reconcile himself with God). In addition to this, a conscientious doctor, even if he is not Christian, must never yield to the pressures of him who would like, against the will of the dying, to make the dying lose his lucidity in order to prevent him from making certain decisions.
When in spite of the obligations which fall on him, the dying demands the narcosis for which there are serious reasons, a conscientious doctor cannot give it to him, especially if he is a Christian, without having asked him first to fulfill beforehand his duties either by himself or better still by the intermediary of others. If the patient refuses obstinately and persists in asking for a narcosis, the doctor can give his consent to it without making himself guilty of formal collaboration to the fault. This, indeed, does not depend on the narcosis, but on the immoral will of the patient; to give it or not, does not make any difference; his behavior will be the same: he will not do his duty. If the possibility of repentance is not excluded, there is however no serious probability of it; moreover who knows if he will not become hardened in evil?
But if the dying has done all his duties and received the last sacraments, if clear medical indications suggest anesthesia, if one does not exceed in the quantity of the dose, if one carefully measures the intensity and the duration and that the patient consents to it, nothing then is opposed to it: the anesthesia is morally allowed.
Would it be necessary to give it up, even if the action of the narcotics would shorten life? Let Us say firstly that any form of direct euthanasia, i.e. the application of narcotics in order to cause or hasten death is illicit, because one then pretends to have dominion over one’s life. It is one of the fundamental principles of natural and Christian morality that man is not a master and owner, but only usufructuary of his body and of its existence. He pretends to have a direct dominion every time he wants to shorten his life as an end or a means. In the case that you consider, it is only a question of parrying from the patient unbearable pains, for example, in the event of inoperable cancers or incurable diseases.
If between the narcosis and the shortening of life there is no direct causal bond, decided by the will of the parties or by the nature of the things (what would be the case, if the suppression of pain could be obtained only by the shortening of life), and if on the contrary the administration of narcosis has by itself two distinct effects, on the one hand the relief of pain, and on the other hand the shortening of life, it is licit; however there it would remain to be seen whether there were between these two effects a reasonable proportion, and if the advantages of the one compensate for the disadvantages of the other. It is also important to ask whether the current state of science does not allow to obtain the same result, by employing other means, then, not to exceed, in the use of norcosis, the limits of what is practically necessary.
In short, you ask Us: "is the suppression of pain and of the consciousness by the means of narcosis (when it is demanded by a medical indication), allowed by the religion and morals to the doctor and to the patient (even with death approaching, and with the knowledge that the use of narcosis will shorten life)? "
The answer will be: "If there are no other means and, if, in the given circumstances, that does not prevent the fulfillment of other religious and moral duties: Yes "
As We already explained, the ideal of Christian heroism does not impose, at least generally, the refusal of a justified narcosis, not even with the approach of death; all depends on the concrete circumstances. The more perfect and more heroic resolution can be as well in the acceptance as in the refusal.
We dare to hope that these considerations on analgesia, considered from the moral and religious point of view, will help you to discharge your professional duties with an even acuter sense of your responsibilities. You wish to remain entirely faithful to the requirements of your Christian faith and to conform to it in all your activity. But far from considering these requirements as restrictions, or obstacles to your freedom and to your initiatives, see rather in them the call to infinitely higher and more beautiful a life, which cannot be conquered without efforts nor self-denials, but of which plenitude and joy are already felt here below for whomever can enter in communion with the person of Christ living his Church, animating it of his Spirit, spreading in all its members his redeeming love which alone will definitively triumph over suffering and death.
That the Lord may fill you with his gifts, We beseech it for yourselves, for your families and your collaborators and, of wholeheartedly, We grant you Our paternal apostolic blessing.