Reverend Kevin 0’ St. L&s Unimsity Medical Center,St. Lnh, Missouti

study patient carej-om the ljmspective ofCatholic ethics o?ateback four centuries. In the course of this history, a prominent issue has always been management of pain and the e&is to avoid pain. Thus, Catholic theologians were concerned about the eflects of pain medication upon &psychic function and considered whether or not hastening okath for suffering people nd the ethical norms /br us2 when death is immi er, the issue of “overmed patients has been a President 3 Commission Human Research has utilized many of the principles d-eve when considering the matter of pain relieffw dying pers 1992;7:485-491.

euthanasia, Catholic ethics, do

When caring for a sick person, a p seeks to cure the person by eliminating or aheviating the ihness, disease, or injury that causes dysfunction on the part ofthe patient. But the physician also assumes the responsibility to alleviate the pain that results from the original disease or injury, or tiom the therapy that is directed toward cure. For several centuries, physicians were more able to assuage pain than they were able to remove or alleviate the source of pain. In the latter half of this century, however, remarkaAddresswjnint reqzmtsto: Reverend Kevin O’Rourke, OP, Center for Health Care Ethics, Saint Louis University Medical Center, 1402 South Grand, St. Louis, MO 63104. Acc~~dfipubEc&on: May 12,1992. 0 U.S. Cancer Pain Relief Committee. 1992 Published by Ekevier, New York, New York

has been made in nagement is now a s dication, particularly opioid drugs, to relieve the pain of patients with progressive medical disease gives rise to two ethical issues: (a) pain medication may impair a patient’s cognitive function, thus making it difficult for the person to prepare for death, and (b) pain medication may hasten death. This presentation will study ,d-re two ethical issues in light of the tradition of the Catholic Church and exp ing ~derl~~g this teaclning. as been develope teat theologians over the past 400 years. The thoughts of Catholic theologians in regard to pain control have served as a basis for action in regard to pain in Western society,1g3and recently, the teaching of the theologians has

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been accepted as the official pastoral teaching of the Catholic Church.4*5

The Issues Painis anything that causes distress

Or

and may occur at many different levels of human function. For example, people experience spiritual pain as they conternplate the guilt they have incurred through sin of the past, even though these sins have been forgiven. They may experience emotional pain, such as may occur from removing life support from a friend or family member, even though the person’s debilitated condition was so severe that death, with relief from suffering, was a welcome event. In this essay, however, the subject of consideration is neither spiritual nor emotional pain, per se. Rather, the subject is the type of pain that arises from disease, injury, or illness; that is, pain that has a root cause in the body of the person.6*7This is the type of pain that physicians qua physician are called upon to treat. The pain in question may not terminate in the body; the physical pain may give rise to spiritual or emotional pain, but the fundamental cause of the pain under consideration is the physiologic system of the person. The International Association of the Study of Pain defines this type of pain as “An unpleasant sensory or emotional experience associated with actual or potential tissue damage as described in terms of such damage.“8 Pain medication may involve anything from an aspirin to morphine. In itself, pain relief is a beneficial action, one of the principal means people have for caring for one another. Therefore, if proximate or long-term injury does not result from the effort to relieve pain, ethical problems are not associated with pain relief. The use of opioid chugs, however, which may suppress the activity of the central nervous system, does present a problem because of the proximate and long-term effects of these drugs. Opioid analgesics, such as morphine, maysedatea person to the extent that he or she loses consciousness. Relatively large doses may also depress the central nervous system to the extent that death is hastened bv respiratory compromise.’ It is difficult t& predict accurately how opioid drugs will suffering,

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affect people; each patient is different insofar as tolerance of pain and reactions to opioids are concerned.g*10 Hence, it is erroneous to generalize and maintain that the ethical issues under discussion arise every time an opioid such as morphine is used to quell pain. Sometimes even severe pain may be relieved sufficiently without the cognitive function of the patient being impaired significantly, or for long periods of time.6 However, sometimes the very purpose of the pain medication is to render the patient comatose as death appr0aches.l 1 For example, Schneiderman and Spraggt* maintain: “If the decision is made to end the use of mechanical ventilation in a patient whose life depends on it, all participants in the decision should realize that the patient’s death will follow. We believe it is important to medicate such patients before ventilation is withdrawn to eliminate the discomfort of agonal efforts to breathe. As an unavoidable side-effect to the medication, survival may be shortened by minutes or hours.“‘* If the use of pain medication either impairs the cognitive function of the patient or hastens death, why would this present a problem as long as the pain is relieved? There are two concerns, both drawn from the teaching of the Church in regard to stewardship of life. 1. In the Catholic tradition, acceptance of suffering, of which physical pain is a prototype, is a means to spiritual growth. “The joy and the suffering of this life have a Christian meaning; its joys are signs of the hope for everlasting life in His kingdom, which is already present here on earth in promise; and its sorrows are a sharing in His cross through which a victorious res-uraction is to be achieved.“rs “Suffering, especially suffering during the last moments of lie, has a special place in Cod’s saving plan: it is in fact a sharing in Christ’s passion and a union with the redeeming sacrifice which he offered in obedience to the Father’s will.“14 Clearly, if as a result of the medication to alleviate pain, the patient is unable to think clearly or lapses into a coma, there will be reduced opportunity to “share in the sufferings of Christ.” Thus, the opportunity for expiation of the guilt of sin and for spiritual progress may be lost.

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arist are more e

euthanasia, or is in keeping with the teaching of th Church?

Though it may sou istic in the written

while the traditio ideal that suffering ma e a way of joinmg oneself more closely to the sufferings of Christ, it also states: ‘“It would be imprudent to impose a heroic way of acting as a general rule. Hence, human and Christian prudence suggest for the majority of sick people the use of medicine cap pressing pain, even those secondary effect, semi-con duced lucidity. As for those who are unable to express themselves, one can reasonably presume that they wish to take those pain killers and have them administered according to the doctor’s advice.“14 Though certain assumptions may be made when caring for incapacitated patients, patients who are capable of making health-care decisions for themselves should be consulted before pain medication is given. If possible,a person should have the opportunity “to moderate the use of pain killers, in order to accept voluntarily at least sufferings and thus associate t conscious way with e su Hence, no blanket judgments should be made that would treat all patients indiscriminately insofar as pain relief is concerned. Knowing that the capacity to endure pain differs from one person to another, pain such a way as to relief should be provide enable each person to family obligations. For exa approaches, the patient should be fortified

emotional strain as a loved 0

means of “controlling” patients.16 The attitude may lead to overmedication as approaches. Helping the patient to maintain some degree of awareness as death approaches em to be unnecessary and even brutal. r the person of faith, death is the last act, not a penalty to be grudgingly endured. Catholic tradition does not present ring or death as a human good but r as an inevitable event which may be transformed in

stiering and death be considered a passive process. In their attempt to specify more clearly what it means to suffer and die, modem theologians have concentrated on death as a personal act of a human being, an act that terminates earthly existence but also

the view of Karl Rahner,” a view accepted and developed by many theoiogians, death is an active consummation, a maturing selfrealization that embodies what each person has made of himself or herself during life. Death becomes a ratification of life, not Amerelyan inevitable process. It is an event, an action in which the freedom of the Ferson is intimately involved. Dying with cclrist is an

488

adventure; it is a consequence of, but not a condemnation for, sin. This is a new approach to death, yet it is thoroughly in keeping with the Christian tradition. Indeed, this view of death seems to describe more clearly the experience of Christ, who offered his life rather than have it taken from him, who completed his love and generosity in the final act of cbedience to the Father: “It is consummated” Uohn 1930). The presence of loving caregivers and family members will help a dying person to perform the act of death. “What is therefore important, is to protect vigorously against any systematic plunging into unconsciousness of the fatally ill, and to demand on the contrary, that medical and nursing personnel learn how to listen to the dying.“15 In sum, the teaching of the Catholic Church in regard to the use of pain medication which may impair cognitive function was expressed aptly by Pope Pius XII in 1957. When asked by anesthesiologists: “May narcotics be used at the approach of death even if the use of narcotics may shorten life?” he responded: “If no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties: Yes. In this case, of course, death is in no way intended or sought, even if the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using for this purpose pain killers available to medicine.“4 In this statement, Pius XII indicates that the principle of double effect underlies the teaching of the Church in regard to the use of pain medication.

Traditional Teaching in Regard to Hastening Death Ethical confusion occurs more often in regard to the proper treatment of persons approaching death than in any other phase of patient care. Some physicians and theologians and lawyers wish to prolong life unless death is inevitable and unavoidable. According to this theory, even life without the potential for cognitive function must be ;rolonged as long as possible.18 For some, hastening death as a result of pain relief is morally unacceptable. Others believe that using pain medication with the risk of impeding respiration and thereby hastening

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death is “passive euthanasia.“r6 Still others, thinking that medicine has no intrinsic goals or values, tend to refer all decisions concerning “hastening death” to families of the patient, or what is worse, to the courtsls In order to understand clearly Church teaching in regard to the difference between intending to hasten death (euthanasia) and intending to relieve pain even if death occurs more swiftly, certain distinctions must be considered briefly. uman life is a gift from God, “‘beI. stowed in order to accomplish a mission. Thus the right to life is not of foremost importance, but rather directing oneself toward the end of perfecting oneself according to God’s plan.“15 IIuman beings have been called to make their lives useful, but they may not destroy life at their own will. Murder and suicide are contrary to God’s providence for human beings. However, because our mission in life is to love God, love ourselves, and love our neighbor, a person need not take positive action to prolong human life if the therapy to prolong life would be ineffective or impose a grave burden insofar as achieving one’s mission in life is concerned. “A person’s duty is to care for his body, his functions, its organs; to do everything he can to render himself capable of attaining to God. This duty implies giving up things which of themselves may be good.“‘5 In Catholic teaching, then, one has a moral obligation to eschew murder and suicide because these actions bespeak a power over human life, which is in God’s providence and is not given to human beings. Insofar as taking positive steps to prolong life is concerned, however, a person should not prolong life if prolonging life would interfere with the person’s mission in life. In Catholic tradition, the moral obligation to prolong life is usually expressed by saying that when faced with a fatal pathology, one should use the means to prolong life, unless these means impose a grave burden upon the patient or the therapy is futile. If the therapy that would prolong life imposes a grave burden or is futile, then there is no moral obligation to use it. 2. In Catholic teaching, euthanasia is an action or omission which of itself or by

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Pain ~l~~an~

caregiver. Euthanasia Euthanasia is active i

direct killing of an innocent person. Euthanasia is passiveif the cause of death is present en there is a but is not resisted obligation to do so. sia occurs when a p ogy is allowed to die even though th cure the illness would not impose ine the term passive support is removed from a example, removing ar cial hydration and nutrition from a person in a persistent vegetative state is often called passive euthanasia. Actually, this withdrawal is not a form of euthanasia because there is no moral (ethical) obligation to continue lie support for people with these sympto euthanasia is ethically unacceptable because it intends and causes the death of another (by intentionally omitting acts) when a moral obligation to prolong person in question

holding therapy from a person with a fatal pathology) and withholding therapy from a person with a fatal pathology because the therapy would be burdensome or useless occurred in the case of Baby Doe in Indiana.*O Baby Doe was a child with Down’s syndrome suffering from duodenal atresia Without a simple surgery, he would die due to an inability to ingest food and to receive nourishment. Would the surgery impose a grave burden on Baby Doe? No, because it is a surgery performed on normal chil the time and never thought to be burden. Would the surgery have so because it would have tive? It oe to pursue his purpose in enabled life. Down’s syndrome ch impaired but they are able to know, love, and

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cause his death.

court were

in e ot constitute a

have been performed. In sum, the direct of the parents was to hasten th, not to avoid useless or bu t moral difference er active or passive, on with the direct

leviating pain as death apif the pain medication hastens death for a dying person, if the direct iuten don of the act is to remove hastening death is an accidental In euthanasia, the intention is to cause in order to relieve pain. Even in the face of severe suffering, the intention to ta of another is not in accord with intention of dence of God. However, r-son is within removing pain from a dyin the providence of God. Thus, if the death of e person is hastened by reason of the fact at strong pain medication is used, it is an undesired side effect. If there were therapy at would remove the pain without hastening death, such a therapy would be utilized.4~5 Notice that when stating the teaching of the Church in regard to pain relief, it is not enough to state that pain relief may be utilized even if a side effect is to hasten the death of the patient. Rather, the statement must be more specific; the teaching of the Church is conveyed accurately only if the moribund condition of the patient is stated.4 The need to limit the hastening of death by pain medication only to the moribund is clear from the following example. A young man breaks a leg while skiing and is in serious pain from the injury and the surgery necessary ta mend the compound fracture. The amount of pain medication necessary to relieve the pain would seriously impair respiratory function. The risk associated with this much pain medication would not be

490

proportionate to the overall well-being of the patient. In the case of a person who will die soon, however, provided there are no spititud or familial obligations to be fulfilled, there is no great benefit to extending the person’s life for a few hours or days. Thus, pain medication, even if it would hasten death, could be utilized when there is no moral obligation to prolong life. A growing number of physicians and medical ethicists speak out in favor of euthanasia, either active or passive.** Some maintain that active euthanasia or suicide is the ultimate act of the autonomous person. 22 Some of these proponents of euthanasia are confused, either about the criteria that allow withholding or withdrawal of life support or about the ethical use of pain medication at the time of death.23 Others, however, simply deny the consistent and customary teaching of medical ethics and religion. In the Netherlands, for example, euthanasia is tolerated by the legal system (Welie, unpublished, 1989). In face of these actions and allegations, the teaching of the Catholic Church has been reiterated: “It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself sometiling to be rejected.“4 In sum, the tradition of the Catholic Church clearly renounces euthanasia, whether active or passive, but does allow the use of pain medication that hastens death if there is no moral obligation to prolong the life of the suffering person: “Human and Christian prudence suggests for the majority of sick people the use of medicines capable Of alleviating or suppressing pain even though these may cause a secondary effect of semiconsciousness and reduced lucidity.4 In this case of course, death is in no way intended or sought, even if the risk of it is reasonably taken, the intention is simply to relieve pain effectively. ‘”

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the campaign to approve and legalize euthanasia in contemporary society, the traditional teaching of the Catholic Church in regard to pain relief, especially as death approaches, is extremely important. There is no doubt that euthanasia, whether passive or active, has an attraction for people imbued with pragmatic, consequentialist, and cost-effect philosophies of life. But these philosophies are short-sighted. In the long run, they betray human dignity and the bonds of community and the profession of medicine. On the other hand, the Catholic tradition presents a deeper and transcendent appreciation of the human person in community. Only if the human dignity of persons in pain is respected will they receive pain relief in accord with their mission in life. The teaching of the Church in conjunction with the practice of ethical physicians gives hope for the future insofar as care of the sick and dying is concerned.

1. Bonica J. History of pain concepts and therapies. In: Bonica J, ed. The management of pain. Philadelphia: Lea and Febiger, 1990:2-18. 2. Ioeser J, KellyJ, eds. Managing the chronic pain patient: theory and practice at the University of Washington Multidisciplinary Pain Center. New York: Raven, 1989. 3. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behaw ioral Research. Deciding to forego life-sustaining treatment. Washington, DC: US Government Printing Office, 1983:80. 4. Congregation for doctrine of the faith. Declaration on euthanasia. Washington DC: United States Catholic Conference, 1980:6. 5. Pope Pius XII, 194.4. Christian principles of the medical profession: 1957. Address to anesthesiolo gists. In: O’Rourke X, Boyle P, eds. Medical ethics sourees of Catholic teaching. St. Louis: Catholic Health Association, 1989217-302. 6. Twycross R, Lack S. Symptom control in far advanced cancer: pain relief. 1983. 7. Brescia FJ, Approaches to palliative care: notes of a death watcher. In: Foley K, Bonica J, eds. Advances in pain research and therapy proceedings of the second international congress on cancer pain. New York: Raven, 1990: 393-397.

8. ~~te~adon~ Association for Pain terms: a list with definitions and notes e. Pain 1980;8:249-252.

16. Coldbar I?. The right to die: the case for and against passive euthanasia. isability Handicap Sot 1987;2:21-29.

ko R Foley I& Inturissi C. Clinical analgesic studies and sources of variation in analgesic responses to morphine. In: Foley K, Inturrisi C, eds. in the management of clinical en, 1986~1424.

On the theology of death. NewYork:

10. Ventafridda V, Tamburini M, Caraceni A. A 8 method for cancer pain validation study of the relief. Cancer 1987;59 11. Hyers T, Sriggs DD, l-Imison L. Wi~holding and withdrawing ventilation. Am Rev Respir Dis 1986,143:1327-1331.

se 0. Criteria for withhol treatment, Linacre 19. Robinson R, oran DE. Termination of medical treatment: imminent legislative issues. Cam Lawyer 1987;31:99-111. 20. Pless J. The story of Baby Doe. N Engl J ,Med 1983;309:604.

12. Schneiderman LJ, Spragg R Ethical decisions in discontinuing mechanical ventilation. N Engl J Med 1988;318:934-988.

21. AngelI M. Euthanasia. N Engl J Med 1988;319: 1348-1350.

13. Pope John Paul ll. The Christian meaning of suffering. Ch-igins1984;13:609-619.

et al. The physician’s responsibility ill patients: a second look. N Engl J Med 1989;320:844-349. 23. I-Iumphrey Il. Aid in dying: the right to die or the right to kill-a public forum. Int Rev NatI Pam Plann Spring 1988.

15. PondfIcaI Council Cor Unum 1980. Qnestions of ethics regarding fatally Q’Rourke IS, Boyle P, eds. edical ethics: sources of Cathohc teaching. St. Association, 1989.

The rigbt to die: understanding euthanasia. New York: 25. Welie J. Euthanasia in the Netherlands. Unpub lished article, 1989.