Authentic Compassion: Pain Treatment at the End of Life

In 1994, Dr. Charles Cleeland authored a study that found that 42% of cancer patients with pain were receiving inadequate therapy for their pain. This led to the Health and Human Services (HHS) guidelines for more aggressive pain management and the ubiquitous question about your level of pain “on a scale of 1 to 10” every time you visit the doctor for any reason.

The interest in pain management was actually a response to the push for legalized assisted suicide. Advocates of assisted suicide claimed that uncontrolled pain justified aiding cancer patients to end their lives. At the time, there were proclamations by medical experts that 90% of pain could be easily treated and there was no risk of addiction for those who were actually in pain.

So where are we nearly two decades later? A new study just published in the Journal of Clinical Oncology finds that while pain management has improved, a significant number of cancer patients are still suffering. Dr. Michael Fisch and his colleagues looked at over three thousand patients with breast, lung, prostate, or colorectal cancer. Of the two thousand patients who complained of pain, roughly one-third were receiving inadequate therapy for their pain. The reasons for this failure to adequately alleviate pain are varied and complex. Physicians cited concerns about raising red flags for excessive use of pain relievers monitored by the Drug Enforcement Agency (DEA) as a reason for using suboptimal doses of opiod analgesics. Patients resisted the use of pain medicine, fearing these powerful drugs would adversely affect their level of functioning. Some patients had a cultural stoicism that made it difficult for them to admit they had pain and needed medication. Many patients did not speak English well and had a difficult time communicating their need for pain relief to their physicians. In 50% of all patients with inadequate pain relief, oncologists treating the patient did not deem the pain to be related to cancer and therefore, did not aggressively pursue therapy to alleviate the pain.

Those who promote assisted suicide and euthanasia no longer limit their justifications to simply dealing with chronic pain; they now include depression and other mental illnesses, loss of cognitive abilities, and loss of independence as reasons for ending life. In light of this recent study, however, one wonders if these purveyors of death were correct twenty years ago to claim that intractable pain in cancer patients made life not worth living and gave rise to the need for legalization of assisted suicide?

Clearly, the Fisch study is not an indictment of life with cancer. The presence of suffering does not make death preferable to life. What this study does tell us is that in a significant number of patients with cancer, relief of pain is not a simple issue. Both physicians and patients create obstacles to optimal pain therapy. The answer is not to get rid of the patients in order to get rid of the pain: The answer is to address the impediments that hinder successful pain management.

Even more importantly, this study tells us is that in spite of the best efforts of medicine, there are still people among us who are suffering. Seeing others who are ill or hurting often makes us uncomfortable because it brings our own mortality to the forefront of our consciousness. Yet as Christians, we are called to suffer with those who are in pain – literally, to be compassionate. Someone you know may very well be hurting. He needs you to comfort him, listen to him, pray with him, or at least pray for him.

I remember the first time I got sick after leaving home to go to medical school. I was alone in my apartment. The fever, the aches, and the general misery were magnified by my isolation. My mother was not there to offer a cool cloth for my brow or soothing words to help me sleep. While it is important to offer and utilize medical treatments that ease suffering, no pill will ever replace the consolation provided by human presence.

Turning to assisted suicide or euthanasia as a solution for suffering says that we as a society cannot be bothered with authentic compassion. It says that we want what is easy and expedient rather than what requires effort and time. It says the healthy and powerful can decide whether the weak and vulnerable live or die. Therefore, legislative efforts to protect the disabled, the sick and the suffering from becoming victims – particularly given certain ominous elements of the Affordable Care Act – are necessary. But legislation alone will not build a culture of life.

Each of us must take the time to recognize the pain and suffering of our child, our spouse, our neighbor, and even the strangers who momentarily cross our paths each day. Compassion may mean sitting at a bedside. It may mean an unrushed conversation over coffee or taking a casserole to the family next door. It may just mean a kind word or a smile for someone who looks like they are having a bad day. Each of these small acts affirms that we are a community instead of just a collection of individuals. An authentically compassionate community desires that no one ever suffers alone, and does not seek death as the solution to pain.

LifeNews Note: Denise Hunnell, MD, is a Fellow of HLI America, an educational initiative of Human Life International. She writes for HLI America’s Truth and Charity Forum.

There is no support in Christian tradition for your assertions and scriptural interpretations.

From Historical and Biblical References in Physician-Assisted Suicide Court Opinions:

Patristic Sources on Suicide

In contrast to Judge Reinhardt's assertion, no evidence appears to exist of any Christian during the patristic period committing suicide, in the ordinary sense of the word, to accelerate entrance into heaven. Furthermore, suicide was clearly condemned by church fathers before and contemporary with Augustine (354-430). Some examples will suffice here to show the consistency of this position. Justin Martyr (second century) insisted that suicide opposed the will of God.^[74] "It is not lawful," maintained the anonymous author of the Epistle to Diognetus (second century).^[75] Both authors employed a Christianized version of the Platonic argument that suicide is tantamount to desertion from one's divinely assigned post. "Suicides are punished more severely than others," the anonymous Clementine Homilies (late second or early third century) asserted.^[76] Clement of Alexandria (ca.155-ca.222) argued that suicide "is not permitted"^[77] for Christians. "[N]othing," according to Lactantius (ca.240-320), "can be more wicked than suicide."^[78] Basil of Caesarea (ca.329-379) declared that the sin of abortion is compounded by the dangers of the procedures that render it virtually an act of attempted suicide.^[79] Jerome (ca.345-419) stated categorically that Christ would not receive the soul of a suicide.^[80] "Scripture forbids Christians to lay hands on themselves," averred Augustine's mentor, Ambrose (ca.339-397).^[81] "God punishes suicides more than homicides," John Chrysostom (349-407) proclaimed, "and we all justly regard them with horror."^[82]

Both Ambrose and Jerome make one exception to their otherwise inclusive condemnation: suicide done to preserve chastity. The small minority of patristic sources prior to Augustine who mention this category of suicide approve of it.^[83] Augustine's rejection of the probity of suicide to preserve chastity led him to engage in a thorough analysis of suicide in the City of God (1:16-28). The first installment of this massive work was published in 414, four years after the Goths captured and ravaged Rome, raping pagan and Christian women alike.

Augustine condemned the following motivations for suicide: 1) because of guilt over past sins; 2) because of a desire for heaven; 3) to avoid or escape from temporal problems; 4) to avoid or escape from another's sinful actions (including doing so to preserve chastity); and 5) to avoid sinning. The only conceivably justifiable cause for suicide, Augustine said, would be the last, yet even the sin of such a well-motivated suicide would be greater than any sin that one might avoid by killing oneself. The basis for his condemnation was fourfold:

1. Scripture does not expressly permit, much less command, suicide as a means of achieving heaven or as a way to escape or avoid evil.

2. A prohibition of suicide is explicit in the sixth commandment ("Thou shalt not kill").

3. Since no private party has the authority to kill a criminal who deserves capital punishment, those who kill themselves are homicides.

4. Suicide allows no opportunity for repentance.

His only reference to martyrdom in this digression on suicide was his refutation of pagan approval of suicide to avoid captivity. He argued that the patriarchs, prophets, and apostles did not commit suicide to escape persecution or martyrdom. About a decade before he published the first installment of the City of God, Augustine addressed martyrdom, but not that of Christians persecuted by pagans. Rather, he condemned the courting of martyrdom by, and the theatrically spectacular suicides of, the Donatists, a schismatic, heretical group.^[84]

The Donatist movement began in the early fourth century when rigorists condemned the church's accepting back into fellowship those who had apostatized during the "Great Persecution." Donatists viewed themselves as upholders of the purity of discipline in the face of "compromise with the world." From its beginning, the movement was a thorn in the flesh for the church leadership, resulting in persecution by the church and the imperial government in 317. In 415, the death penalty was enacted for Donatists who continued to assemble. It was especially then that some Donatists, primarily a fringe group known as the Circumcellions, increased their indiscriminate as well as systematic acts of violence against orthodox Christians (even once attempting to ambush and kill Augustine) and even provoked the authorities to put them to death.

For nearly twenty years, Augustine periodically composed anti-Donatist treatises. A frequent focus of these was the Donatists' attitude toward and practice of suicide, which was sometimes sensationalistic. Space permits only a brief summary of the major themes in his anti-Donatist writings that do not occur in the City of God:

1. Provoking martyrdom is a form of suicide and hence a sin.

2. "Heroic" suicide by those who fail to provoke others to martyr them is a sin.

3. The Donatists' suicides violate the foundational Christian principle of patient endurance (presented in one of his last anti-Donatist writings (Letters 204) composed in 420).

In 415 Augustine wrote a treatise chiding the Donatists with the example of Job:

At him let those men look who bring death upon themselves when they are being sought out to be given life, and who, by taking away their present life, reject also the life to come. For, if they were being forced to deny Christ or to do anything contrary to justice, they ought, as true martyrs, to bear all things patiently rather than to inflict death upon themselves in their impatience. If he could have done it righteously to escape evil, holy Job would have destroyed himself so that he might have escaped such diabolic cruelty in his own possessions, in his own sons, in his own limbs.^[85]

Patient endurance will prove to be the climax of Augustine's final statement on the subject of suicide, in book nineteen of the City of God, published in 426 or 427.

Patristic Sources on Suffering

Patient endurance was not, of course, a theme unique to Augustine. Even a cursory reading of the church fathers shows that they viewed suffering as an indispensable feature of God's sanctifying processes. This conviction, along with an unwavering belief in divine sovereignty, and an equally solid confidence that God does all things for the ultimate good of his people endued them with a sense of responsibility to practice endurance in the face of all afflictions.

Cyprian (ca.200-258) is an excellent, but not atypical, example. Writing to his fellow Christians while their city was being ravaged by plague, he reminded them that, just like all others, they will suffer illness and adversity. He called his readers to endure with patience. This

endurance the just have always had; this discipline the apostles maintained from the law of the Lord, not to murmur in adversity, but to accept bravely and patiently whatever happens in the world. . . We must not murmur in adversity, beloved brethren, but must patiently and bravely bear with whatever happens.^[86]

Hence, "the fear of God and faith ought to make you ready for all things,"^[87] such as sickness and loss of loved ones. "Let not such things be stumbling blocks for you but battles; nor let them weaken or crush the faith of the Christian, but rather let them reveal his valor in the contest, since every injury arising from present evils should be made light of through confidence in the blessings to come. . . Conflict in adversity is the trial of truth."^[88]

Cyprian unfailingly stressed the activity of God and the passivity of Christians in death. He averred that Christians who died of the current plague "have been freed from the world by the summons of the Lord."^[89] Later he asserted that "those who please God are taken from here earlier and more quickly set free, lest, while they are tarrying too long in this world, they be defiled by contacts with the world."^[90] He then counseled that "when the day of our own summons comes, without hesitation but with gladness we may come to the Lord at His call."^[91] For "rescued by an earlier departure, you are being freed from ruin and shipwrecks and threatening disasters!"^[92] Hence, "Let us embrace the day which assigns each of us to his dwelling, which on our being rescued from here and released from the snares of the world, restores us to paradise and the kingdom."^[93] He encouraged them to contemplate their loved ones, who were already in heaven, and the bliss that was treasured up for them there. "To these, beloved brethren, let us hasten with eager longing! Let us pray that it may befall us speedily to be with them, speedily to come to Christ."^[94]

It is God who summons Christians home. God removes them from the world; God liberates them; God delivers them; God rescues them; God brings them to heaven. Christians are passive--they are being liberated; they are being delivered; they are being rescued; they are being brought. It is God who is the active party. Christians are to yearn for heaven and to pray for an early departure from life. Yearning for death and praying to die are categorically different from taking one's own life. There is no place for suicide here. Patient endurance of all tribulation, steadfastness to the end, final submission to God's will under those very afflictions that God is using to refine and perfect the Christian: such faith is antithetical to suicide. And such faith permeates patristic literature.

There is no evidence that before Augustine's time suicide stimulated controversy within the Christian community. Martyrdom, however, did. As we have seen, the probity of provoking or volunteering for martyrdom was hotly disputed before the legalization of Christianity. Why did suicide not stimulate controversy within the Christian community? Surely not because the church fathers were reluctant to condemn sin and to confront their fellow Christians for their moral failings. The absence of controversy regarding suicide does not suggest that Christians were indifferent to suicide as an ethical issue. It simply appears not to have been a sufficiently attractive and viable option for them to have regarded it as a threat to the moral integrity of the Christian community.

The condemnations of suicide that we encounter prior to Augustine's time are comparatively rare because they are not part of Christians' broad moral indignation against pagan depravity. Their outrage, especially against abortion and infanticide, was greatly stimulated by the perceived helplessness of the victim, whether a fetus or an infant. So also with gladiatorial combat and viciously cruel forms of torture and execution. Even acts of sexual immorality were more severely condemned when slaves were forced to be the objects of their owners' lusts or their greed when forced into prostitution for their owners' profit. The moral indignation of Christian authors was especially provoked by the helplessness of the victims of others' sins. Suicide, as practiced by pagans, simply did not arouse passionate condemnation, for it was not an act in which an innocent party was victimized.

Conclusion

Early Christians lived in a secular milieu in which suicide by the ill was frequently practiced and its probity seldom questioned. Yet patristic literature has no record of ill Christians committing suicide or asking others' assistance to do so. Neither do we have records of people requesting others to kill them to escape the grinding tedium of chronic illness or the severe suffering of terminal illness. Christianity introduced moral obligations that were altogether foreign to the Greek and Roman ethos. One of these was a duty to care--not a duty to cure, but a duty to care--an obligation to extend practical compassion to the destitute, the widow, the orphan, and the sick. This introduced a truly radical transformation in attitudes toward the sick.

Patristic literature addresses only three ethical issues raised by illness: the tendency of some Christians to seek medical care without first pondering the spiritual dimensions of their suffering; the use of pagan or magical healing alternatives; and the occasionally frantic struggles to find and cling to even meager hope of recovery. There is not a scintilla of evidence that the preferential position that Christianity gave to the sick included an expedited "final exit."

While the Bible does not explicitly condemn suicide, it nowhere explicitly condones it either. Those whose suicides are recorded in the Bible are clearly presented as characters not to be emulated. Their suicides may be understandable, but they are narratively structured as yet another in a series of wrong decisions made by unethical characters.

Suicide and assisted suicide are incompatible with a number of biblical teachings. So foundational are the goodness of God and his sovereignty in patristic theology, and patient endurance of affliction so stressed as an essential Christian virtue, that we should not be surprised that patristic texts are void of any reference to suicide by the ill. Scripture and early church history do not condone suicide or assisted suicide. They should not be distorted to provide support for the legalization of physician-assisted suicide.

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