Address to an International Congress of Anesthesiologists
Pope Pius XII
24 november 1957
Dr. Bruno Haid, chief of the Anesthesia section at the surgery clinic of the University of Innsbruck, has submitted to Us three questions on medical morals treating the subject known as “resuscitation” [la réanimation]. We are pleased, gentlemen, to grant this request, which shows your great awareness of professional duties, and your will to solve in the light of the principles of the Gospel the delicate problems that confront you.
Problems of Anesthesiology
According to Dr. Haid’s statement, modern anesthesiology deals not only with problems of analgesia and anesthesia properly so-called, but also with those of “resuscitation.” This is the name given in medicine, and especially in anesthesiology, to the technique which makes possible the remedying of certain occurrences which seriously threaten human life, especially asphyxia, which formerly, when modern anesthetizing equipment was not yet available, would stop the heartbeat and bring about death in a few minutes. The task of the anesthesiologist has therefore extended to acute respiratory difficulties, provoked by strangulation or by open wounds of the chest. The anesthesiologist intervenes to prevent asphyxia resulting from the internal obstruction of breathing passages by the contents of the stomach or by drowning, to remedy total or partial respiratory paralysis in cases of serious tetanus, of poliomyelitis, of poisoning by gas, sedatives, or alcoholic intoxication, or even in cases of paralysis of the central respiratory apparatus caused by serious trauma of the brain.
The Practice of “Resuscitation”
In the practice of resuscitation and in the treatment of persons who have suffered head wounds, and sometimes in the case of persons who have undergone brain surgery or of those who have suffered trauma of the brain through anoxia and remain in a state of deep unconsciousness, there arise a number of questions that concern medical morality and involve the principles of the philosophy of nature even more than those of analgesia.
It happens at times — as in the aforementioned cases of accidents and illnesses, the treatment of which offers reasonable hope of success — that the anesthesiologist can improve the general condition of patients who suffer from a serious lesion of the brain and whose situation at first might seem desperate. He restores breathing either through manual intervention or with the help of special instruments, clears the breathing passages, and provides for the artificial feeding of the patient.
Thanks to this treatment, and especially through the administration of oxygen by means of artificial respiration, a failing blood circulation picks up again and the appearance of the patient improves, sometimes very quickly, to such an extent that the anesthesiologist himself, or any other doctor who, trusting his experience, would have given up all hope, maintains a slight hope that spontaneous breathing will be restored. The family usually considers this improvement an astonishing result and is grateful to the doctor.
If the lesion of the brain is so serious that the patient will very probably, and even most certainly, not survive, the anesthesiologist is then led to ask himself the distressing question as to the value and meaning of the resuscitation processes. As an immediate measure he will apply artificial respiration by intubation and by aspiration of the respiratory tract; he is then in a safer position and has more time to decide what further must be done. But he can find himself in a delicate position if the family considers that the efforts he has taken are improper and opposes them. In most cases this situation arises, not at the beginning of resuscitation attempts, but when the patient’s condition, after a slight improvement at first, remains stationary and it becomes clear that only automatic, artificial respiration is keeping him alive. The question then arises if one must, or if one can, continue the resuscitation process despite the fact that the soul may already have left the body.
The solution to this problem, already difficult in itself, becomes even more difficult when the family — themselves Catholic perhaps — insist that the doctor in charge, especially the anesthesiologist, remove the artificial respiration apparatus in order to allow the patient, who is already virtually dead, to pass away in peace.
A Fundamental Problem
Out of this situation there arises a question that is fundamental from the point of view of religion and the philosophy of nature. When, according to Christian faith, has death occurred in patients on whom modern methods of resuscitation have been used? Is Extreme Unction valid, at least as long as one can perceive heartbeats, even if the vital functions properly so-called have already disappeared, and if life depends only on the functioning of the artificial respiration apparatus?
The problems that arise in the modern practice of resuscitation can therefore be formulated in three questions:
First, does one have the right, or is one even under the obligation, to use modern artificial respiration equipment in all cases, even those which, in the doctor’s judgment, are completely hopeless?
Second, does one have the right, or is one under obligation, to remove the artificial respiration apparatus when, after several days, the state of deep unconsciousness does not improve if, when it is removed, blood circulation will stop within a few minutes? What must be done in this case if the family of the patient, who has already received the last sacraments, urges the doctor to remove the apparatus? Is Extreme Unction still valid at this time?
Third, must a patient plunged into unconsciousness through central paralysis, but whose life — that is to say, blood circulation — is maintained through artificial respiration, and in whom there is no improvement after several days, be considered de facto or even de jure dead? Must one not wait for blood circulation to stop, in spite of the artificial respiration, before considering him dead?
We shall willingly answer these three questions. But before examining them we would like to set forth the principles that will allow formulation of the answer.
Natural reason and Christian morals say that man (and whoever is entrusted with the task of taking care of his fellowman) has the right and the duty in case of serious illness to take the necessary treatment for the preservation of life and health. This duty that one has toward himself, toward God, toward the human community, and in most cases toward certain determined persons, derives from well ordered charity, from submission to the Creator, from social justice and even from strict justice, as well as from devotion toward one’s family.
But normally one is held to use only ordinary means — according to circumstances of persons, places, times, and culture – – that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities, are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, as long as he does not fail in some more serious duty.