'Morphine cases'

'Morphine cases' are an established part of the philosophical debate on double effect. It is worth reminding ourselves that medical practice has moved on from the kind of case philosophers have in mind, which in described by the Rev Billings in the radio talk described below. Hat-tip to 'Care not Killing'.

The use of Morphine

"We remain deeply concerned that some media reports are giving the misleading impression that doctors are administering morphine to dying patients in the knowledge that it will kill them.

The latest of these came on Radio Four's 'Thought for Today' on 23 February, when the Rev Dr Alan Billings, Director of the Centre for Ethics and Religion at Lancaster University, addressed the case of Kelly Taylor, a 30 year old woman, who is currently seeking legal permission to be heavily sedated with morphine and then dehydrated until she dies.

In the broadcast, Rev Billings referred to the so-called 'double effect' of high doses of morphine – a misconception that has become pivotal in Kelly's case. He said, 'Every day we allow doctors to end the lives of some people by making a distinction between intention and outcome. A doctor increases the morphine of a terminally ill person in great pain to the point where they die. The morphine kills. That's the outcome, but the doctor is not thought culpable because his intention is the relief of pain, not the death of the patient.'

Rev Billings here was expressing two popular misconceptions about morphine: that it frequently ends the lives of terminally ill people, and that it causes sedation when given in doses necessary to relieve pain. We strongly refute the statement that doctors are ending lives by giving their patients large doses of morphine to control pain.

Morphine, if deliberately given in very high doses to people who are not in pain, does cause respiratory depression and death. It was indeed the drug used by Dr Shipman to kill his victims, and this has undoubtedly heightened public anxiety about its use. However, when correctly used to relieve pain in a patient who is terminally ill, morphine should never cause death. By contrast it usually lengthens life and improves its quality. This is because the therapeutic dose of morphine, which relieves pain, is virtually always well below the toxic dose which ends life and because the relief from pain which it brings removes stress factors in the patient's condition. In addition, toxic doses risk causing increased agitation in some patients- hardly what is intended by those advocating this approach. In modern medicine, and especially in palliative medicine, doctors can kill the pain without killing the patient.

So-called 'terminal sedation' is very rarely necessary; and when it is, it is used to control severe agitation, rather than physical pain, in patients whose conscious level is diminished by their illness. Even when used for the management of agitation, it is very seldom necessary to sedate any patient continuously until they die, but usually only for periods of 12 or 24 hours at a time. Whatever the circumstances, morphine is not the drug of choice used for this sedation since sedation wears off rapidly, which is good for patients taking it for pain relief, but it makes it a poor sedative."

The same mismatch between philosophical examples and medical practice applies to the 'craniotomy case': the procedure at issue (crushing the head of a baby during childbirth in order to remove it quickly from the birth canal) is simply no longer used. The really 'hard' cases often turn out to extremely rare. It is unclear, for example, whether a 'therapeutic' abortion would ever be needed to save the life of a mother.

Philosophers usually aren't medically qualified, and for us an imaginary situation is as good as a real one, for the purposes of testing intuitions and proposed policies. But perhaps we should be more careful about allowing pro-abortion medical myths publicity.

Marriage, anulments and liturgy

(The following has been published by CFNews, here. For a report on the Pope's speech, see here.)

This week's Catholic Herald carries a front-page story on a recent speech by the Pope condemning over-easy annulments. In part:

In a speech to the Roman Rota, the Church’s highest court of appeal for annulments, the Pontiff pointed to a “crisis” in the way marriage was understood.
He said that Catholics and even tribunal judges were affected by the secular idea of marriage as merely the “formalisation of emotional bonds”.
In “some ecclesiastical realms” this idea has caused annulments to be granted for the sake of the couple’s well-being rather than because the marriage was invalid.
“The crisis over the meaning of marriage has affected the way many faithful think,” the Pope told judges and officials of the Roman Rota last Saturday. “The indissoluble conjugal bond is denied because it’s treated as an ideal that cannot be made ‘obligatory’ for ‘normal Christians’.

The Pope has correctly identified a specific misunderstanding of marriage as a cause of the decline in the ability of marriage tribunals' capacity to apply the correct principles to determining the validity of marriages. The misunderstanding is the replacement of the notion of the 'indissoluble marriage bond', as the central concept of marriage, with the notion of a 'formalisation of emotional bonds'. It seems clear that the same false understanding of marriage is behind the decline of marriage itself: in fewer people being willing to make the commitment of marriage, and ever more people who have married, getting divorced.

Where might we find such a view expressed? Well, here is the opening prayer of the revised marriage ceremony, promulgated in 1969:

"Dear friends, you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community. Christ abundantly blesses this love. He has already consecrated you in baptism and now he enriches and strengthens you by a special sacrament so that you may assume the duties of marriage in mutual and lasting fidelity. And so, in the presence of the Church, I ask you to state your intentions."

Now look at the Latin:

Dilectíssimi nobis, in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur. Amórem vestrum coniugálem Christus abúnde benedícit et ad mútuam perpetuámque fidelitátem et ad cétera Matrimónii offícia assuménda eos peculiári ditat et róborat Sacraménto, quos ipse sancto iam Baptísmate consecrávit. Quare vos coram Ecclésia de mente vestra intérrogo. (For the full texts, see here.)

There are many problems with the translation, but let's just look at the key phrases:

you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community.

in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur.

The highlighted Latin phrase means literally '[you've come together so that] the Lord my establish the sacred bond [of matrimony]'. The official translation has removed the notion of matrimony as a sacred bond, established by the Lord, and replaced with the notion of the couple's love merely being strengthened by the Lord. In other words, the correct view of marriage, as an indissoluble bond, is expressed in the Latin, but in the English this view has been replaced by the false view, that marriage is the formalisation of an emotional bond.

So what is His Holiness saying? That the view of matrimony put forward in the scandalously inacurate official English translation of the new order of matrimony is responsible for a misunderstanding of marriage among even the higher echelons of the Church, which has dangerously undermined the institution of marriage itself.

Posted by Joseph Shaw