Analgesia

Allocution To Doctors On The Moral Problems Of Analgesia

Pope Pius XII
24 February 1957

Introduction

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. Is there a general moral obligation to refuse analgesia and to accept physical pain in a spirit of faith?
2. Is the deprivation of consciousness and of the use of higher faculties, caused by narcotics, compatible with the spirit of the Gospel?
3. Is the use of narcotics licit for the dying or for patients in danger of death, supposing that there exists for that a clinical indication? Can one use them even if the attenuation of the pain is probably accompanied by a shortening of life?

Historical Section

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.

2. Role of the anesthetist

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.

3. Variety and progress of the anaesthetics

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.

4. Cardiac surgery

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.

Moral Section

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.

1. Free acceptance and the research of pain

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.

2. On the duty of renouncement and interior purification

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.

3. On the invitation to a higher perfection

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.

4. Reasons which make it possible to avoid physical pains

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.

Conclusions and answers to the first question

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 selfdenial 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.