Question I: Concerning Sins Against the Internal Goods of Life and Body

I. General view. - Charity and justice command that the right of the neighbor to the internal goods of life be preserved unharmed, and the opposite sins are prohibited by the fifth precept of the Decalogue. We call the internal goods of man the goods both of the body and also of the soul, namely, the natural use of reason and liberty, and moral and supernatural life. To the good of moral and supernatural life scandal is opposed; to natural good, whatever harms bodily life, or natural reason or free will. Concerning these things it is necessary to recall that not man but God alone has dominion over human life and over the human body, just as over the soul with its natural powers; and therefore:

1. an action directly killing, against the life of an innocent person, is never lawful, and consequently the life of an innocent person can in no case be directly taken away, as would happen in every species of embryotomy or direct abortion, that is, direct expulsion of an immature fetus;

2. likewise direct mutilation is illicit, not only for the sake of utility or profit, but even for the sake of virtue, unless it is for preserving the life or health of the whole body, insofar as the part is for the whole, and the good of the part ought to yield to the good of the whole, lest this be corrupted. Wherefore operations which render sterile or impotent, such as vasectomy, ovosectomy, sterilization, must of themselves be held intrinsically and gravely illicit, as being grave mutilations, unless otherwise health could not be hoped for;

3. likewise harmful actions are illicit unless at the same time and immediately, or not by means of the evil effect, they procure a greater good which compensates the evil and harmful effect;

4. a fortiori it is illicit directly to intend harm to the moral or supernatural life of the soul; likewise to posit an act which can harm it, unless it is done for a proportionately grave reason.

These principles come to be considered more attentively, as regards natural goods, in the actions of physicians generally, in the use of hypnotism, in surgical operations, in the use of certain narcotic medicines, in the use of chloroform and anesthetic means, in actions, potions, and incisions which bear relation to the procreation of the human race.¹ As regards spiritual goods, which are harmed by scandal, it will be said in the following question.

¹ Concerning all these matters especially may be consulted Capellmann, Medicina Pastoralis; Noldin, Tanquerey, Vermeersch, and Prummer in their manual of moral theology; Saesmans, Geneeskundige Plichtenleer, i.e., medical deontology.

II. Concerning the actions of physicians. - The following rules bind under grave obligation:

1. The physician must always use the safer means, i.e., those which, according to what science teaches, are certain; but if such means are not known, that is to be preferred which is more likely and, other things being equal, more quickly conduces to health. There also comes to be attended to, according to the diverse circumstances of persons, the great utility or necessity of a quicker cure, for example in a laborer; likewise also whether the remedies cause less pain or are of less price, so that that is to be preferred which, all things considered, is more profitable and less burdensome.

2. It is illicit for a physician to seek experience from a man by those means concerning which he himself is ignorant whether they are harmful or truly useful, as for example by vaccination from secretions of syphilitic ulcers for the diagnostic end concerning the existence of syphilis;² however, he can employ means which he certainly knows cannot harm, although it is not established for him whether in the present case they will be useful. Nevertheless Noldin adds, Th. M., II, n. 744: it would be lawful to test a remedy with the consent of the sick person, if the matter concerned slight harm which can easily be repaired.

² It is lawful in animals; likewise in malefactors condemned to death, if the civil power establishes this.

3. To a sick person whose recovery now cannot be hoped for, even such a remedy can be provided, when it is not established for the physician whether it will be harmful or useful for curing the health of the sick person: not in order to take an experiment for other sick persons, for it is illicit to seek an experiment in another's life, since evils are not to be done, even to one, so that goods may come to others, even many; but because it is more conformable to prudence and to the will of the sick person to apply that doubtful remedy than to omit it with the certainty of death. For such a remedy, as also for other extraordinary means to be employed, consent generally is to be sought from the sick person, and, if he is not able to consent, from relatives, especially if there is much fear of the danger of great and perpetual harm.

4. It is illicit to take away or notably shorten the life of those lethally wounded, the old, the sick, the dying, lest they suffer longer, even with their consent, by an action directly tending to this, because one must not use an evil means for a good end, nor are evils to be done that goods may come: for all these retain the right to life, and must be committed to God, who alone is Lord of life and alone can dispose directly of their life.

5. Consequently it is illicit in the article of death to provide morphine or a similar soothing means to a sick person directly so that the painful exit of his life may be shortened and be terminated in quiet euthanasia, i.e., a happy death. Indeed, also so that the dying person merely be deprived of reason and depart without the sense of pain; for for this there is not present, at least regularly, a sufficient proportionately grave reason, and certainly not if he is not yet prepared for death, since thus he would be deprived of the opportunity of doing penance and so perhaps would be placed on the way of eternal damnation. Concerning this more will be said below, under n. IV.

6. Puncture of the heart or artery (ponction du coeur, steek door het hart, Herzstich), which sometimes relatives or connections of the deceased, sometimes on account of the testament of the deceased himself, ask for lest perhaps he be buried alive:

a) cannot be done by a physician, if he does not have indubitable signs of death but seriously doubts concerning it, because this is to expose oneself to the danger of killing a man;

b) but if there are certain signs of death, of itself it is not illicit,³ since this is done only to free the relatives from fear and vain anxieties;

³ If it were illicit, by equal right it would be illicit to bury the deceased.

c) nevertheless the relatives cannot licitly ask for it, because they do this from an evil intention of shortening life if it were still present and of hastening death if it had not yet supervened; with which, therefore, it is not lawful for the physician to cooperate. Wherefore let him try to lead them away from this useless purpose; and if they are unwilling, let him declare to them that he will by no means perform the puncture, unless because he is wholly certain concerning death and solely to dissipate their vain anxiety.

7. The physician is bound, by himself or through others, efficaciously to warn the sick person concerning the proximate danger of death, so that he may dispose concerning temporal affairs and provide for spiritual necessities.

That office of charity is personal; hence, if others are lacking who can or will efficaciously persuade the sick person, the physician himself is bound to warn him by himself. Nevertheless he can be excused if the warning is certainly useless, whether because the sick person certainly does not need the warning, or because the warning certainly will in no way be useful, which nevertheless can rarely be affirmed with certainty.

III. Concerning the use of hypnotism. - Hypnotism is usually described thus: the induction of a peculiar state, analogous to sleep, which is called hypnosis, in which state the man who has been placed in it merely undergoes the suggestions of the hypnotizer. It is induced by very diverse means, which nevertheless probably are all reduced to one, namely the suggestion of sleep; but it has several grades, from simple sleepiness to perfect somnambulism. Concerning this it is useful briefly to note that its practice sometimes is illicit, namely, as often as it is employed unjustly or without a grave cause and great caution. For:

1. The hypnotized person is deprived of the ready use of reason and of dominion over the lower powers, which ordinarily by his own powers he will recover with difficulty without the nod of the hypnotizer; he hands himself over to the judgment of the hypnotizer, by whom he can be led sufficiently efficaciously and often invincibly to perpetrating illicit things, and ordinarily he can be reduced to the same state even while resisting. But such a deprivation of the use of reason and abdication of liberty, involving of itself a grave danger for morals, is illicit as often as a proportionately grave cause and cautions are lacking to remove the danger.

2. Hypnotism, unless it is employed with great prudence, exposes the health of soul and body to grave harm; hence there is required the removal of such danger, or at least a founded hope of obtaining a greater good.

3. But if someone by abuse of hypnotism subjects a non-consenting person to his commands, or exercises the art in circumstances in which it is harmful, he commits grave injury, and from justice is bound by apt means to restore that person to his own right and to repair all damages.

A sufficient cause for exercising hypnotism is not a cause of recreation or of profit alone; but:

a) sometimes the cause of scientific investigation (Holy Office, 26 July 1899), provided that the expert chooses a person to whom hypnosis appears not harmful but rather useful;

b) more frequently the cause of medication, whether for putting the senses to sleep in a surgical incision, or for curing a disease of the nerves or rheumatism; nevertheless let it be noted that in more recent time the salutary effects of hypnotism are now more restricted or called into doubt;

c) also the cause of removing or diminishing evil propensities, for example to suicide, drunkenness, lust, theft, etc., when in an extraordinary case they as it were take away liberty or weaken the will. In an extraordinary case, we have said; otherwise the proportionately grave reason is lacking. The ordinary means, namely, of formation, education, and self-mastery is the exercise of one's own reason and liberty; otherwise suggestions weaken the will more than they strengthen it.

In the aforesaid cases caution is to be employed: let there be employed only a physician very expert and prudent and supremely trustworthy, who uses only honorable and harmless suggestions and only for the intended end; let a trustworthy witness also be joined, who assists present or at least remains nearby: thus for the good reputation of the hypnotizer himself, but especially on account of the good of the hypnotized person.

IV. Concerning the use of morphine and other narcotic medicines. - The matter concerns not only physicians but also nurses, indeed patients who can administer medicines to themselves, for example as a remedy for sleeplessness or against the pains of rheumatism.

For in modern times narcotics (νάρκωσις, i.e., sleep, stupor) are often employed, whether for soothing pains or for provoking pleasure, as opium, morphine, cocaine, or for putting the senses to sleep, as ether and chloroform; their effects can be harmful or even intercept the use of reason for a time, and therefore their use can be illicit.

Soothing or stupefying means (calmants, stupefiants; verzachtende, verdoovende, bedwelmende middelen), concerning which we are here treating exclusively, are medicines which cause a temporary suppression or diminution of the activity of the nerve centers, from which there arises a certain state of physical and moral inertia. They are opium, morphine, cocaine, and other derivatives or mixtures of this sort.⁴ These are taken not only by way of absorption or chewing, by smoking or inhalation, but also by subcutaneous injection, and they are very efficacious for soothing pains; indeed they provoke a certain sense of cheerfulness and pleasure, but at the same time they weaken the nerves.

⁴ The International Geneva Conference, 17 Nov. 1924 - 19 Feb. 1925, reserved exclusively the name stupefiants to certain things. They are: opium, or the latex collected from the immature fruits of the white sleep-bearing poppy, which is cultivated in Asia Minor, India, China, Egypt, Persia; morphine, which is a certain principal alkaloid extracted from opium, and heroin obtained from it by chemical operation; coca naturalis, or erythroxylon coca, which is a certain plant from the Peruvian region; cocaine, or a certain alkaloid derived from coca; hashish, or cannabis from India, which secretes a toxic resin or oil enjoying excitatory properties. Very recently also peyotl is denounced, a certain Mexican cactus plant, of which a certain extract comes into use in the United States of America and is called "mescal buttons." This first effects alacrity and vigor, but then nervous languor and depression, with illusions and disturbances, yet without loss of consciousness, so that the man knows his state to be fictitious. Nor does the use of this remedy render a man dull as the others are apt to do. Concerning these see Dupre and Logre, Intoxications par l'opium, l'ether, la cocaine, in Nouveau Traite de Medecine, fasc. VI, Paris 1922; Dr. De Block, Toximanies, Liege 1927; Dr. Lewin, Paradis artificiels, Paris 1928; Mgr. Beaupin, Le Probleme des Stupefiants, in Vie intell., 1930; Brouillard, Stupefiants et Anesthesiques, in Etudes, 1929; Dr. Vervaeck, Le Peril des Toximanies, in Dossiers de l'A. C., 1930. Likewise the periodical La Cite Chretienne, 1928; S. Luc medical, 1934; Kothen, Les Toximanes, in Coll. Mechl., 1931-32; St. Willems, in Coll. Brug., 1932; Meunier, Les stupefiants et la morale, in Rev. Eccl. de Liege, 1934.

If they are taken in great quantity, they are deadly by acute intoxication in the same way as poison; in lesser quantity they cause a sleep of the senses and privation of the use of reason, which effect differs in nothing from drunkenness; in moderate quantity but taken repeatedly for a long time they gravely harm health by slow and progressive intoxication, notably shorten life, and provoke a most vehement desire, for example for repeated use (morphomania), which can be overcome much more difficultly than even the habit of long-standing drunkenness, and scarcely can be cured except in hospitals erected for this end;⁵ indeed they cause abulia, or paralysis and as it were atrophy of the will, indolence, indifference toward the duties of state and negligence, dulling of the mind, irritability of spirit, perversion of the moral sense, and diminution of responsibility.

⁵ A moderate quantity of morphine is judged permitted at 0.1 gr., but not for a long time. One who uses 0.2 gr. or 0.5 soon comes to 1.0 and 3.0, which quantity equals 20 or 50 small bottles in a day. Thus Capellmann, o. c.

From all these things it is evident that the use of remedies of this kind is dangerous, and is to be avoided unless necessity requires otherwise; and therefore a physician cannot supply or leave with a sick person an injection syringe or morphine.

Certainly it is lawful to diminish pains, provided that by the remedies employed the healing of the disease is not delayed, or damage or danger is not directly brought to health or life. Hence in employing remedies someone can sin either from the fact that he takes too great a portion, harmful to health, or from the fact that he employs remedies too frequently.

In particular:

1. Transitory use, and so slight that it produces no other effect except restoration of strength and calming of the nerves, is lawful.

2. Use in greater quantity or frequency, employed without just cause, or for pleasure alone, or for quieting the desire for narcotics, is a grave sin if notable detriment of health and life can or probably will follow from it; venial if the detriment of health or abbreviation of life certainly is not notable; but it is lawful in decreasing quantity for him who has contracted so long-standing a custom of use, for example of opium, that he cannot abstain from it without grave detriment to health.

3. Use in such quantity that the senses are put to sleep and temporary privation of the use of reason follows: employed without just cause, it is a grave sin just as drunkenness is; but from a proportionately grave cause of necessity or utility it is lawful with the consent of the sick person, as if it is done so that he may not feel bitter pains, or in a major surgical operation so that the sick person may permit himself without resistance.

4. Especially in the article of death: a) to provide a remedy so that the sick person may be deprived of reason and depart without the sense of pain is gravely illicit, especially if he is not yet prepared for death, because he would be deprived of the opportunity of doing penance and would incur the danger of eternal damnation; also generally if he is duly disposed, because thus he would lack the opportunity of meriting and of immediately preparing himself for death and notably increasing heavenly glory. Hence a proportionately grave reason for permitting this is lacking; indeed, if there is danger that he will not return to the use of reason, this is equivalent to an abbreviation of life.

b) According to some, however, this could be tolerated, presupposing the consent and good faith of the sick person, who is already well prepared for death, namely on account of bitter pains,⁶ especially if he is very liable to movements of impatience, so that it can probably be feared that he may fall into grave sin; indeed, as has sometimes been said, even if at the same time an indirect abbreviation of life would follow in a sick person certainly soon to die. But this is more doubtful and rather to be omitted.

⁶ Not on account of agony alone, says Noldin, Th. M., I, n. 349.

c) Certainly, however, euthanasia properly so called, namely directly and in itself intended, or directly procured, is gravely illicit, namely a direct acceleration of death, so that insensibility and privation of the use of reason is only the effect of induced weakness and of abbreviation of life. For evils are not to be done so that goods may come. In the case there is rather intoxication than anesthesia.

Hence the Holy Office, 11 May 1852, declared the trade and use of opium, as they are exercised in the Chinese empire, to be illicit; and the S. C. P. F., 29 Dec. 1891, declared that in that region the cultivation and commerce of opium, likewise regular use, are to be prohibited to Christians, except in the case of avoiding graver harm.⁷

⁷ Consequently the Synod of Peking of the year 1880 commanded: 1. that absolution is to be denied to those who have not yet contracted the custom of smoking opium, if they are unwilling to renounce this; 2. that the customary users can be absolved if they promise to diminish the quantity; 3. that to those who do not keep the promise, absolution is to be deferred until they have fulfilled it; 4. that from those who exercise the cultivation and commerce of opium, it is to be required that they entirely leave it.

V. Concerning incisions and surgical operations. - Surgical operations are those which are performed by vivisection, extraction, mutilation, amputation, resection, or another lesion of the body, done according to the rules of the surgical art for meeting some bodily defect.

Concerning these the following principles come to be attended to:

1. Operations which bring danger of life are lawful if they are a necessary means for averting an immediate or mediate certain danger of life, and in the place of foreseen death they set a probability or at least a possibility of safety;⁸ also when the danger of life is remote, provided that, if one waits longer, the power of resistance decreases in the body and therefore the hope of a successful operation is diminished. In this case, however, there must be proportion between the harm which is feared and the good which is hoped for. But dangerous operations are not lawful for removing evils in no way deadly, but only deforming or very troublesome, unless perhaps the evil is very grave and the danger of life minimal.

⁸ Even, for example, if according to statistical calculations there were 70 or 80 percent probabilities of death and only 20 or 30 possibilities of safety.

2. But to perform useless operations, as also dangerous ones, without true necessity, for example for the sake of profit or experiment, is illicit.

3. Nevertheless there is not always a strict obligation of undergoing an operation for preserving one's own life, namely if the means is extraordinary, for example if the operation is very painful or if it inspires great horror in the patient. Hence an operation is not to be done except with the consent of the sick person, if it can be requested.

Let it be noted that on account of the progress of the surgical art and on account of antiseptic remedies, several operations which formerly were extraordinary are now to be held as ordinary means. In this case let the priest recommend the operation; nevertheless, for the sake of prudence, let him not warn concerning a grave obligation, on account of the danger lest perhaps, by denying consent, the sick person formally sin and die in the state of sin.

VI. Concerning the use of chloroform and other anesthetic means. - Soporific, hypnotic, or anesthetic means (soporifiques, hypnotiques, anesthesiques, analgesiques; gevoelloosmakende, slaapwekkende middelen) are so called because they are apt to induce sleep or a certain insensibility and are customarily employed for this; although also if they are employed in great quantity or frequency, they can have harmful effects similar to those which were described above for narcotics. Means of this kind are: first of all chloroform, also ether and nitrous oxide (protoxyde d'azote, commonly: gaz hilarant, lachgaz), and various other similar things, for new ones can come forth from new combinations every day.⁹

⁹ Thus today are named: chloral, sulfonal, veronal, luminal, dial, alidial, sandophal, etc., which also cause deep narcosis and reduce into coma; others, as urethane, a weak narcosis. Some are truly analgesic, as chloroform and ether; others antispasmodic, as pyramidon, hypnal, chloral. Certain ones bring danger to those who suffer from disease of the heart. Concerning these see the periodical S. Luc medical, 1934.

Now:

1. Chloroform or another similar means employed in surgical operations induces sleep and insensibility, and from this head operations are completed much more easily and safely; but sometimes, although rarely, death is caused from it.¹⁰ Therefore this remedy is to be used only for a grave cause and cautiously, and indeed in such a way:

¹⁰ Prummer notes from Capellmann: according to a modern statistical review, in every 2907 times in which chloroform was employed, death occurred once. Therefore always some danger of life, although not so proximate, is joined with the use of medicines of this kind.

a) that before use diligent inquiry be made, lest perhaps the constitution of the sick person be such that, chloroform being employed, it would easily bring death;

b) nor let chloroform be employed except when it is necessary, i.e., only then when the manner and gravity of the operation, very vehement pains, or the duration of the thing make the use of chloroform very useful or necessary. Cf. those things which are said at the end of the number.

2. In childbirth, at least difficult childbirth,¹¹ even the moderate use of chloroform seems lawful, provided that there is no danger from it for the life of the mother or child, which belongs to an expert physician to judge.

¹¹ In ordinary childbirth, such as in the ordinary course of nature is had of itself, there seems to be lacking for this a proportionately grave reason.

Concerning this we read in Damen in the more recent edition of the moral work of Aertnijs, I, n. 259: If "narcosis is neither too profound nor too prolonged, it does not seem to create danger for the child. Nor is the manner of employing the narcotic which is called chloroforme a la reine (because Queen Victoria is said thus to have undergone childbirth) harmful. This manner consists in this, that at the beginning of each pain (for the pains are interrupted), some chloroform or ethyl chloride is ministered, by which for the time of that pain the sense is diminished, without however the use of reason being taken away.

But chloroform employed imprudently, or by one not sufficiently expert, creates grave danger for the child. It is evident that in this case its use is wholly illicit."

3. Likewise, danger being excluded, Prummer says it is lawful "for soothing pains not so atrocious, at least if the matter concerns a very brief narcosis, such as that which is caused by means of weaker narcotics, e.g., Lachgas; or if the matter concerns an imperfect narcosis in which the use of reason is not completely taken away. Such narcoses seem lawful in the extraction of a tooth, in childbirth even ordinary."

Likewise also for calming pains or nervous digestive disturbances, or nervous affections, provided that it is done in lesser quantity and without danger of inconveniences.

On the contrary: a) immoderate, excessive, or frequent use of hypnotics, or use employed indiscreetly, for example without the prudent counsel of a physician, is wont to bring diminution of physical, intellectual, and moral life; now it is illicit even to weaken the body if from this the activity of the soul is impeded.

b) Use sought on account of pleasure alone is illicit, even if it were not harmful, because it is illicit to act exclusively for delight or pleasure alone.

c) Physicians sin who indiscreetly or imprudently, or without distinction to all, prescribe means of this kind.

d) Moreover they themselves and others can sin by cooperation, whether positive, for example by inducing to harmful or more frequent use or by ministering the remedy, or negative, by not impeding harmful use; which is altogether to be attended to by nursing sisters.

But since the use of hypnotics in certain cities has now increased unrestrainedly, it is altogether necessary that stricter and more efficacious vigilance be exercised on the part of public power, and that their public sale be subjected to the ordering of law and be able to be done only by prescription of a physician, and that pharmaceutical shops be submitted to due vigilance.

VII. Concerning operations which bear a special relation to the procreation of the human race, it was said in the little work: Questions concerning Embryology and the Ministration of Baptism.

VIII. Duties of the pastor and confessor. - Various obligations fall upon the pastor:

1. Let him induce physicians to perform their duties duly, namely to take diligent care for the bodily and spiritual health of the sick, and likewise to abstain from every harmful or illicit action or operation, such as the direct procurement of abortion and embryotomy.

2. Let him take care to have physicians as cooperators for himself, who may warn him about the sick, be willing to watch over their eternal salvation, and rightly instruct nurses and midwives concerning their duties.

3. Let him take care that physicians learn the right manner of baptizing in a case of necessity (can. 743), in particular when and how Baptism is to be conferred in the mother's womb, or on aborted fetuses, or, the mother being dead, a Caesarean section is to be done for this.

4. Let him oppose euthanasia with every effort, especially if the sick person is not yet prepared for death; outside this case, if warning does not seem opportune, the matter can be tolerated, provided that the silence of the pastor is not taken as approval; but if he is asked concerning the lawfulness of the matter, for example by a doubting physician, he cannot be silent, but must respond according to the truth.

5. Generally let him warn those physicians who do illicit operations or intend to do them, at least if fruit is probably hoped for; and also, even when fruit is not hoped for, if they frequently act thus or are a scandal to the faithful, or if they are not in good faith, as if they ask the pastor concerning this matter, or if silence would be equivalent to approval.

Similarly the confessor: 1. generally, opportunity being given, should induce physicians to perform their duties duly, just as was said concerning the pastor;

2. especially should warn a physician who in a particular case has done or is about to do an illicit operation, provided that fruit is hoped for; otherwise let him be silent, unless the physician frequently acts thus and is a scandal to the faithful, or if he is not in good faith, or if he would think the silence of the confessor equivalent to approval;

3. indeed let him deny absolution to a physician who refuses to do his duties, in particular to him who, lacking the due knowledge, is unwilling to acquire it or to abstain from the exercise of the art.