Pain and the Saint

Hardly have news of Mother Theresa of Calcutta’s beatification reached around the world, the age-old criticisms have been wheeled out once again and dusted off like it befits the tired tropes they are. Many of them are somewhere on the road between Ridiculousville and Obscenetown, and of course some are just plain exaggerations. There is one that is a little more complex, and that hits a little closer to home.

This one goes somehow along the following way: “Mother Theresa, because of her beliefs, glorified pain, and therefore let poor people die without adequate pain relief”. The first part is pure speculation, based on the second part, which derives from a letter by the surprisingly undistinguished Dr Robin Fox, editor of the Lancet between 1990-1995, that examined the state of medical care in Mother Theresa’s Calcutta institution.1http://www.sciencedirect.com/science/article/pii/S0140673694923531 Four things before all:

  • One, it’s what is called a ‘letter to’, and as such not subject to peer review before publishing. Especially not if it’s by the editor. It is not a peer reviewed study. It is not scientific evidence. It is not science. It is a travel report, presented without corroboration.
  • Two, Dr Fox is not an anaesthesiologist, a specialist in palliative care or an expert in terminal care analgesia. He did not bother to take one along, domestic or foreign.
  • Three, and most problematically: Dr Fox did not compare what he saw in Calcutta with what he would have seen at any other Indian hospital. The third of these is the most condemning, because if he had, he might have learned a little about the difficulties of obtaining adequate pain medication in India.
  • Four, saints are not perfect, and neither is the Lancet. In recent years, the Lancet has committed a lot of fairly egregious sins against good research, viz. the Burnham Iraq mortality paper,2http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69491-9/abstract the Bristol Cancer Centre study3http://www.thelancet.com/journals/lancet/article/PII0140-6736(90)93402-B/abstract and more than a few other blunders. These are just the biggies. And these were actual papers, i.e. peer reviewed. Imagine the non-peer reviewed stuff. Non-scientists tend to have an elevated image of journals, especially those well-known and with a high Impact Factor, like Science, The Lancet or the NEJM, ignoring that they, too, are fairly flawed products of fairly flawed human institutions.

The religious angle

Let’s dispose of one of the more pernicious arguments right here. It is sometimes argued that Mother Theresa intentionally let people die in pain because suffering is great and Catholics hate adequate analgesia. That’s false on both counts.

There’s a difference between saying ‘suffering is meaningful’ and ‘suffering is great’. There’s nothing positive about avoidable suffering. Consider §2279 Cathechism of the Catholic Church:

Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged.

The above is completely in line with modern medical ethics, which permits ‘terminal sedation’ or ‘terminal analgesia’, administering adequate pain medication (which often can mean rather high doses), even if this will almost inevitably hasten death (due to the respiratory suppressive effects of opiates/opioids), but not intentional use of pain medication to kill. There is a whole realm of ethics, medical and otherwise, on the doctrine of double effect that is involved here,((As a good starter, interested readers should consider Gillon (1986)) but what is clear without a doubt is how far this position of the Church, binding on Mother Theresa and, insofar as one can tell, flawlessly applied, does not oppose proper analgesia at any point. As such, she was not getting kicks out of people dying in pain. In the first place, she started her work to do what she could to keep people from dying an undignified and horrible death on the streets, and instead spend their last days or hours in dignity. The cost of this were, as her own writings reveal, extreme emotional distress, nightmares and what could without doubt be diagnosed as a severe anxiety disorder. If anything about dispensing medicine at her house is strange, it is that she did not start dipping into the Xanax jar.

The medical angle

Perhaps it deserves mention that Mother Theresa’s order did not run a hospital, or a hospice in the modern sense of the world. In fact, hospices in the Western sense, which Dr Fox seems to compare Mother Theresa’s institutions with, did not exist in India at the time and remain fairly scarce. She ran an institution with very modest means and staffed by volunteers that aimed at giving dying people some dignity. None of them were forcibly picked up on the street by jack-booted nuns and told they’re going to go to Mother T’s, or else. It was up to those who did so to decide whether they wanted to or not.

As such, the criticism that the institution did not distinguish between the terminal and non-terminal is rather strange, because 1) they were not a hospital or hospice in the modern, Western sense of the word, 2) their care was not specific to the dying – the sick can derive significant help from being in a clean, safe environment, 3) they lacked the medical resources.

In an alternate universe, Mother Theresa had to her avail the suns needed to run a properly staffed medical institution, with doctors and referrals and all the drugs in the world. In that perfect universe, perhaps the abject poverty that meant the alternative would be dying on the streets would not have existed, either. Of course the care she administered was, when judged from the perspective of a hospital, inadequate. But she was at no point running a hospital. Much as you don’t expect your hairdresser to have an M.D., her institution was what it was. Equally, canonisation is what it is – it is not a medical doctorate, or the Church sending ‘atta girls’ for a hospital well run.

The personal angle

There’s a reason while this story hits home to me. I tend not to speak about this publicly, but I have been living a long, long time now with extremely severe, often interminable, pain. The international politics of pain medication and its availability, closely linked with narcopolitics, is one of my pet topics I can bore people with into a stone cold stupor. What it boils down to is this: proper pain relief is an integral part of human dignity. Being in unmanaged or inadequately managed pain means the patient is inadequately treated, and ignoring pain relief is the worst kind of non-profitary medical malpractice.

With that said, I’ve also been at the forefront of research into pain, both as a subject and as a participant. I have had the pleasure to try quite a few modern approaches to pain management. I’m hoping to be able to find some better ones. Throughout this, I was aware by the risks and complexity of pain analgesia. With a frail, terminal patient, it gets even more complicated.

Strong pain medication is not like Tylenol that you can simply pop a few of and things get better. In general, patients are started on a low dose PRN (‘as needed’) oral opioid in conjunction with an NSAID, then eventually the PRN oral opioid is increased (a process called ‘titration’) until it manages their needs. Then, the PRN opioid is converted into a long-term opioid, such as a matrix patch, which releases the drug into your fatty tissues over time (usually three to five days) or a long-lasting time-release opioid formulation, together with low doses of the PRN opioid for ‘breakthrough pains’, pain spikes that are no longer treated adequately by the long-term pain medication. Alternatively, severely ill/bedbound patients may be offered a solution like PCA, which injects a constant stream of an opioid with the option of the patient to add a given number of ‘bolus’ doses for pain spikes – these are used e.g. in the post-surgical context, for the first day or so after a surgery. More complex pain management issues exist for chronic complex pain, such as spinal catheters, neurosurgery, implantable pain pumps, implantable spinal cord stimulators and so on. This is the state of the art, today, in the West, in 2016. In Mother Theresa’s days, pain patches were barely existent and certainly not available. The only thing they could have had was oral morphine sulphate or IV morphine.

Pain medicine is one of the most expensive branches of medical care, despite the fact that most pain medications are cheap as chips. The reason for that is the incredible attention required and the risk involved in pain medication. Especially before antagonists like naloxone became widely available and financially feasible, it would have taken a host of highly qualified doctors to appropriately dispense pain medication in Mother Theresa’s institutions. Dr Fox admonishes her for not stocking strong opioids, but really, should she be not praised instead for not stocking potentially fatal pain medicine that takes specialist care to administer, specialist care that their people lack and that legally requires doctors their houses did not have and could not afford to have on staff?

Perhaps the more appropriate angle to this is immense personal gratitude that in our world, we have ways of managing pain that the poorest of Calcutta have no access to. Truly, we are blessed. As were they, when Mother Theresa gave them the small mercy of giving them a modicum of care and respect for their dignity in their last hours.

One should never stop hoping and demanding for the world to improve. But nor shall one confuse a desire for a better world with a blanket condemnation of those who made do with the world they were handed. In a demanding and dire situation, so dire that it drove Mother Theresa herself to anxiety and insomnia in the beginning, she made the best she could with what she got. The cost of aspiring to a better world should not be the denigration of those who had to live in this one.

References   [ + ]

1. http://www.sciencedirect.com/science/article/pii/S0140673694923531
2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69491-9/abstract
3. http://www.thelancet.com/journals/lancet/article/PII0140-6736(90)93402-B/abstract

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