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Many end-of-life issues involve the relief of pain and discomfort brought about by terminal illnesses. We have been blessed that among the contemporary medical breakthroughs are treatments and interventions used to relieve pain and promote comfort effectively. These measures help persons go through the effects of illness in a dignified way. They also provide an atmosphere where patients and their families are able to explore other important values at the end of life. Providing opportunities to pursue spiritual preparation, the celebration of the Sacraments and other religious rituals at the end of life are helpful in coping with illness and loss.
Healthcare providers should offer measures to alleviate pain. To say that everything has been exhausted to relieve pain is not an excuse. There are undoubtedly other options that have not yet been exhausted if a patient continues to suffer from pain.
Opioids like morphine sulfate are effective in treating severe pain.
Some conditions require strong medications to manage or relieve pain. Opioids, like morphine sulfate, are effective in treating severe pain that is brought by terminal illnesses like cancer.[1] The administration of a specific dose should be carefully titrated to achieve adequate pain relief. Dosages must also be adjusted to a level sufficient and effective enough to relieve symptoms. Dosages can vary widely among patients. A physician can increase the dosage until the patient obtains a satisfactory response.[2] It is imperative that physicians inform patients and family members of the possible unintended effects when giving or increasing the dosage of opioids.
Family members raise moral questions of their use because of undesirable side effects that include loss of consciousness and respiratory depression, which may hasten death.
Administration of opioids to relieve pain is morally acceptable if the intention is not to end life.
The Catholic Church teaches that with careful and special considerations, the administration of opioids to relieve pain is morally acceptable even if they have known undesired effects such as the shortening of life. We can apply the Church’s principle of double effect to situations in which one action is followed by two results, one good (intended) and the other is evil (foreseen but not intended).
The principle of double effect generally has to do with the intention and the nature of the action. The action should meet four conditions to satisfy the requirements in the application of the principle of double effect. The administration of morphine to a patient who experiences unbearable pain has met these conditions:[3]
- The act itself must be good– The administration of medication is a good act;
- The intention must be good. One intends the good effect and not the bad effect– The intention of giving the medication is to relieve pain;
- The act must first achieve the good. The good effect is not produced by bad effect— The relief of pain is achieved first. The evil, which is diminished consciousness follows;
- There is a grave reason for doing the action and for permitting the bad effect to happen–Medication is given to relieve unbearable pain.
It is morally permissible to give opioids if the intention is to relieve unbearable pain, and not to eliminate life to stop the pain, if there are no “other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties.”[4] A person has the right to prepare for his or her death while fully conscious. He or she should not be deprived of consciousness without a compelling reason.[5]
There are cases when physicians consider the possibility of palliative sedation due to the severity of pain during a patient’s final days. Palliative sedation relies on the “monitored use of sedatives, barbiturates, neuroleptics, benzodiazepines or other anesthetic medications, entirely deprives the patient of consciousness as he or she enters into deep comatose state until death.”[6] The decision to submit a patient to palliative sedation must be taken with careful and serious discernment even as we acknowledge the significance of palliative and other comfort measures to ease severe pain. This decision requires the gravest of motives.[7]
The Pontifical Council for Pastoral Assistance to Healthcare Workers states the criteria for deep palliative sedation as follow:
In the presence of unbearable pain that is resistant to typical pain management therapies, if the moment of death is near or if there are good reasons for anticipating a particular crisis at the moment of death, a serious clinical indication can involve, with the sick person’s consent, the administration of drugs that cause a loss of consciousness. This deep palliative sedation in the terminal stage, when clinically motivated, can be morally acceptable provided that it is done with the patient’s consent, that appropriate information is given to the family members, that any intention of euthanasia is ruled out, and that the patient is able to perform his moral, familial, and religious duties.[8]
It is morally permissible to use pain medications if the intention is only to relieve pain and not to kill or to render the patient unconscious to remove pain. Death should not be intended or sought, even if the risk of it is reasonably taken.[9]
Each patient responds differently to pain.
A patient’s choice on how to manage pain shall be respected. On the one hand, if a patient decides that it is better to stop the pain and accept the side effects of pain medications, than to be in constant agony, that wish must be followed. On the other hand, if a patient wishes to endure the pain rather than lose the capacity to complete tasks, that wish must be followed as well.[10]
Christians believe that suffering is a way of sharing or participating in Christ’s saving act. There are Christians who voluntarily accept their sufferings, including pain brought about by illness and associate them in the redemptive suffering of Christ. This belief (redemptive suffering) leads some patients in the refusal or moderate use of painkillers. A Christian may freely accept pain without alleviating or mitigating it by the use of painkillers.[11]
However, this should not be the norm for everybody; it would be imprudent to impose a heroic way of acting as a general rule.[12] On the contrary, human and Christian prudence suggests the use of medicines capable of alleviating or suppressing pain, even though they may have undesired effects of diminishing consciousness or reducing lucidity.[13] For unconscious patients who are unable to express themselves, we can reasonably presume that they would prefer to receive pain medications based on their physician’s moral and professional judgment. It is morally acceptable to administer a well-titrated pain medication in this case even if it may hasten death.[14]
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[1] Morita T, Tsunoda J, Inoue S, Chihara S. “Effects of High Dose Opioids and Sedatives on Survival in Terminally Ill Cancer Patients,” Journal of Pain and Symptom Management. 282, No 9 (April, 2011). https://www.ncbi.nlm.nih.gov/pubmed/11312042
[2] Moira Mc Queen, Bioethics Matter, A Guide for Concerned Catholics, (London: Burns and Oates, 2009), 282.
[3] Edward J. Furton and Rev Albert S. Morazeski, OP, “Double Effect,” in Catholic Healthcare Ethics: A Manual for Practitioners (Philadelphia, PA: National Catholic Bioethics Center, 2009), pp 23-29.
[4] Declaration of Pope Pius XII, as cited by CDF, Declaration of Euthanasia, Sec III.
[5] CDF, Declaration of Euthanasia, Sec III.
[6] Fr. Tad Pacholczyk, Palliative Sedation While Approaching Death in Making Sense of Bioethics, The National Catholic Bioethics Center, September 2019.
[7] Fr. Tad Pacholczyk, Palliative Sedation While Approaching Death…
[8] NCBC, Pastoral Council for Pastoral Assistance to Healthcare Workers, New Charter for Healthcare Workers, No 155.
[9] CDF, Declaration of Euthanasia, Sec III.
[10] David Kelly, Medical Care at the End of Life, 19.
[11] CDF, Declaration of Euthanasia, Sec III.
[12] CDF, Declaration of Euthanasia, Sec III.
[13] CDF, Declaration of Euthanasia, Sec III
[14] CDF, Declaration of Euthanasia, Sec III.
HELPING FAMILIES PROJECT 