Indirectly intended life-shortening analgesia: clarifying the principles.

• Author: Barry, Robert

One of the most widely accepted and least criticized doctrines of medical ethics is that which allows painkillers to be given to patients in such doses that the patient's life is unintentionally shortened. Because this doctrine is rather vague and ambiguous as it now stands and has not been studied closely, it could readily be subjected to some abuse. The authors will examine the context of the development of this doctrine in Catholic moral teaching and determine what precise actions this doctrine was initially proposed to permit. Catholic moral teaching is utilized because it is the classic statement of the conditions under which toxic analgesia may be provided a patient. This is necessary because, in its primitive form, the teaching was in fact quite precise and restrictive, but that precision has never been made fully clear. The authors also wish to review the medical and clinical options now available to practitioners who might have to confront situations where they previously had to give potentially lethal doses of analgesia to patients in great pain.

On February 24, 1957, Pope Pius XII received an audience of physicians ans surgeons, on which occasion he gave answers to three questions concerning the alleviation of pain.(1) The three questions presented to him were: (1) may indirectly lethal doses of painkillers be given? (2) may patients in great pain be reduced to unconsciousness? and (3) is there a duty to accept pain and suffering?(2) In his answer to these questions, he denied that there was a general moral obligation to endure pain.(3) This view referred to his statement of January 1956 on "Painless Childbirth," when he held that a woman was not morally required to endure the pain and anguish of childbirth.(4) His teaching held that pain and suffering were to be accepted to promote one's spiritual growth, but it was legitimate to take measures against them:

We answered 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.

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.

. . . 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 higher

perfection.(5)

The Pope also stated that if a nonterminal patient was in great pain, the possibilities open to an anesthesiologist would be to reduce the level of pain to an acceptable level or to reduce the patient to unconsciousness.(6)

It follows that one may not confuse consciousness, or suppress it,

with the sole object of gaining pleasurable sensations, by indulging

in drunkenness or injecting poisons to secure this state, even if one

is only seeking 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 . . . .

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 quite 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

for them to obtain it?(7)

In answer to the question of whether it was permissible to use analgesia even though it might result in the shortening of life, he answered:

To declare that the dying have a greater moral obligation than

others--whether from the Natural Law or from Christian

teaching--to accept suffering or 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. The 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 at least 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 juris').

When, in spite of obligations still binding on him, the dying

man asks for the state of insensibility for which there exists 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.

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 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 to

the use of anesthetics as morally permissible.

If there exists no direct causal link, either through the will of

the 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 lawful 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 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 case of the use of the drug,

one should not go beyond the limits which are actually necessary.(8)

It is clear that potentially toxic analgesia was allowed because it was permitted by the principle of the double effect. In its classical form, this principle held that:

1. The action itself is good or indifferent;

2. the good effect and not the evil effect is the one sincerely

   intended by the agent;

3. the good effect is not produced by means of the evil effect; and,

4. there is a proportionate reason for permitting the foreseen evil

   effect to occur.(9)

   Administering toxic analgesia in accord with the principle of double effect demanded that it be administered with the proper intention and that the pain be so grave as to require it. However, even if giving toxic analgesia would be in conformity with the requirements of this principle, the action would also have to meet other demands as well and would have to be prudent, respectful of the common good, and in harmony with other authentic types of indirect killing. Pius also warned of the possibility of analgesia slipping over the edge and becoming primarily lethal rather than therapeutic, which would make its use impermissible.

   This trilogy of statements implies that there are both positive and negative aspects to pain and suffering, and that benefits are involved in permitting or treating pain and suffering. Pius did not hold that there is a moral right to live without pain, but only that it was not unjust to request indirectly intended life-shortening analgesia. While there was a value in suffering and pain, this value could be lost when it was so severe that one could not fulfill one's spiritual obligations.

   At the time this teaching was proposed, Reverend Aidan Carr asserted that the allocution was issued to steer people away from total rejection of analgesia for the dying on the one hand and the indiscriminate use of it on the other hand.(10) And John Lynch later said that the medication in question had to be truly analgesic in nature and could not be merely a lethal agent.(11) Also, he noted that the pain had to be serious enough to compensate for the incidental shortening of life, meaning that the pain had to be serious and beyond the control of any less harmful treatment.(12) Lynch believed that one might only provide doses that increased the risk of death,(13) but that is not entirely clear from the teaching. Lynch contended that there was nothing theologically novel about this doctrine,(14)...