The Corpus Christi Sunday bulletin in Nairobi on June 7, 2015 had a short article that read in part as follows: “The very earliest Christians, when celebrating the Eucharist, would send a fragment to the sick and the dying people who were unable to be present. Records dating back to AD 100 also tell us that a portion of the Eucharist would be carefully preserved in a safe place to be given to those in danger of death as viaticum or “food for the journey”. […] In the twelfth century, the Church legislated that the Blessed Sacrament was to be reserved in a “skilfully constructed and safely locked tabernacle.”
I couldn’t help but think about morphine when I read the passage in the bulletin: about how appropriate doses for the sick and the dying, are also “food for the journey” across the River Styx and must also, under civil law, be locked in a tabernacle, or small chest.
The word eucharist comes from the Greek “eukaristos,” which means “grateful” and is now usually translated as “thanksgiving.” It refers to the Christian sacrament of the Lord’s Supper, and has become synonymous with “Communion” or “Holy Communion. Morphine, like the blessed sacrament, can be the best medicine for the dying, and people in severe pain and terminal distress. Morphine, too, must be kept in a locked container, since a dense thicket of rules springing from fear of ‘diversion and abuse” surround its manufacture, distribution, and dispensing. Only certain people, usually doctors, are allowed to prescribe it (like only priests are allowed to consecrate the host). The many restrictions surrounding the use of morphine, most of which derive from politically induced moral panic and subsequent lack of medical education around pain management, mean that the majority of people in the world who need it for pain relief, can’t access it.
When I was in Uganda going on home visits to hospice patients in the countryside around Kampala with a nurse who was trained to prescribe morphine (Uganda is the only country in the world that allows nurses to prescribe opioids), I asked her what it was like to bring pain relief to people who had been without any for a long time, who had been told they had to live in excruciating pain before they die. Her whole face shone when she replied that when the morphine takes away the agony they have been enduring, often for months or weeks, they hold the bottle in both hands and say “this is my God…now I am at peace”.
Back in 1680, the English Hippocrates, Physician Sir Thomas Sydenham attributed the gift of the opium poppy — the biotic source of pharmaceutical morphine — to divine benevolence, stating famously that “Among the remedies which it has pleased almighty God to give to man to relieve his sufferings, none is so universal and efficacious as opium.” And indeed the WHO calls morphine, derived from the opium poppy, “the gold standard of medication for pain management.”
Beginning in the early twentieth century, the world’s “great powers” decided, in their infinite wisdom, advised by Episcopal Bishop Charles Brent, to designate morphine, opium, and certain other psychotropic substances as “narcotic drugs.” Decades later diplomats classified these drugs into “schedules,” each of which entail a specific degree international control. Parties to that first UN treaty, the Single Convention on Narcotic Drugs, agreed to place morphine in Schedule I, penalising non-medical use, which they feared would cause serious harms to public health. The end result of endowing opium and morphine with this property to potentially cause such “evils” (the word used in the treaty) as addiction and premature death, has meant that few medical schools train doctors or nurses to use it, and most countries, succumbing to the moral panic, have enacted laws and regulations that harshly punish diversion, misuse, or the suspicion of either.
As a result, God’s own medicine, considered by the WHO as “essential,” is unavailable in most of the world, particularly in the poorest countries, which need it most, and can make it up as a liquid from inexpensive imported powder. Prevention and treatment programs available in the global north are non-existent in many low and middle income countries, and most cancer patients only present very late at rural health clinics or distant hospitals, which send them home saying “nothing more can be done” in terms of treatment. Of course much more can always be done where palliative care services exist, but providing palliative care is challenging where morphine is inaccessible, and currently it is unavailable in less than 10% of the world http://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf.
The UN Economic and Social Council — the institutional “parent” of the Commission on Narcotic Drugs, has been passing resolutions on the problem of lack of access to opioid medicines in much of the world, since 1995 — for twenty years! ECOSOC has been joined by other UN bodies, global and regional palliative care and pain associations. USAID, DfID, and European development corporations are working on the ground to improve training and access, but progress is excruciatingly slow, change is not reflected at a systems level, and morphine remains bound in its scheduling straitjacket.
The Catholic church, which treats millions of persons every year in its clinics and hospitals, and trains tens of thousands of students in its schools, and preaches to tens of millions of people in its churches, could help restore God’s own medicine to her people, now! Pope Francis has already articulated his support for palliative care for older persons and children, but has stopped short of saying that Catholic medical institutions must make rational use of morphine routine for patients suffering from severe pain. He too, as his public statements about drug addiction reveal, remains spellbound by the time-worn ideological narrative that focuses on substances as inherently dangerous, rather than recognising that it is the vulnerability of persons that predisposes them to self-destructive behaviours, only one of which may be substance dependence.
The author with Dr. Anne Merriman, Hospice Africa Uganda Founder, and Dr. Amandua Jacinto Uganda Ministry of Health, visiting Archbishop Michael Blume Papal Nuncio, in June 2015 (Missing Rose Kiwanuka, RN. Palliative Care Assn. of Uganda, ED)
Some colleagues and I had a very good meeting in Kampala recently with Papal Nuncio Monsignor Michael Blume, who supported the idea of encouraging the Holy See to speak out at the UN on the need to improve access to essential controlled medicines such as morphine. The Vatican could do a lot to support Uganda’s mission to train nurse prescribers and palliative care providers all over Africa. I sent Mons. Blume a fact sheet, available at https://www.scribd.com/doc/269347667/Fast-Fact-Sheet-Global-Morphine-Availability-for-Papal-Nuncio-Kampala, which I hope will serve as food for thought, reflection, and further research on the topic. Ensuring that “God’s own medicine” is available to all God’s people who need it, no matter how far away they are from a clinic or hospital also aligns with Catholic catechism, which states “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 an end or a means, but only foreseen and tolerated as inevitable.” (CCC, n. 2279) It goes on to call palliative care “a special form of disinterested charity.” Archbishop Blume quoted that line to us from memory!
Catholic medical institutions I visited in South India earlier this year, also host palliative care programs that care for terminally ill, abandoned, and mentally ill. Rural palliative care might not exist without the church in India. Their sisters do wonderful work, and their medical staff need to be encouraged to learn to use morphine and other opioids when indicated. The theology is there, the infrastructure and staff are there, so it would be great to have some informed leadership from the top. Our enlivening visit with Monsignor Michael Blume contributed to that effort in East Africa.