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Analysis: What to make of the CDF’s hysterectomy ‘responsum’?

By Carl Bunderson

Spanish Archbishop Luis Ladaria Ferrer, the prefect of the Congregation for the Doctrine of the Faith, in a Sept. 8, 2015, file photo. (CNS photo/Paul Haring)

Denver, Colo., Feb 26, 2019 / 03:01 pm (CNA).- The National Catholic Bioethics Center issued a commentary this month in response to a December Vatican document on the moral liceity of hysterectomies in certain medical situations.

The commentary affirmed what other theologians have observed in recent weeks: that it is difficult to understand what situations the Congregation for the Doctrine of the Faith’s hysterectomy guidance intended to address, and that in the often-complex world of speculative bioethics, considering the concrete applications of theoretical reasoning is essential to giving clear and helpful moral guidance.

When the Congregation for the Doctrine of the Faith issued in December a ‘responsum’ saying that hysterectomy is a licit act when a woman’s womb is not suited for procreation and medical experts are certain an eventual pregnancy will bring about a spontaneous abortion before viability, many moral theologians expressed among themselves the need for clarity about the document’s purpose.

Considered narrowly and on its face, of course, the CDF response is true: a hysterectomy is not, of itself, illicit.

However, to say that the response’s implications are difficult to reconcile with the preceding Magisterium and with moral theology would be an understatement.

The CDF was asked if, “when the uterus is found to be irreversibly in such a state that it is no longer suitable for procreation and medical experts have reached the certainty that an eventual pregnancy will bring about a spontaneous abortion before the fetus is able to arrive at a viable state, is it licit to remove it”?

In its Dec. 10, 2018 response, published Jan. 3, the congregation responded “yes, because it does not regard sterilization.” The response bears the signatures of Cardinal Luis F. Ladaria Ferrer, S.J., prefect, and Archbishop Giacomo Morandi, secretary of the congregation.

The National Catholic Bioethics Center wrote that “while the response affirms that removing a uterus that is incapable of carrying a child to viability is not per se a direct sterilization, it does not offer a comprehensive rationale and explanation – including a full and specific medical scenario – under which performing such a hysterectomy would, in practice, be morally legitimate.”

The CDF said its response regards “situations in which procreation is no longer possible,” and that it completes responses, “which retain all of their validity,” given in 1993 to questions proposed concerning “uterine isolation” and related matters.

The 1993 responses stated that hysterectomy is licit when there is a grave and present danger to the life or health of the mother posed by the womb – e.g., it is chosen for a therapeutic reason, to curtail a serious present danger such as hemorrhage which cannot be stopped by other means.

However, the responses also said that hysterectomy and tubal ligation are illicit when they are intended “to prevent a future possible danger deriving from conception” or to avert “the risks of a possible pregnancy” when the womb is “foreseeably incapable of carrying a future pregnancy to term without danger to the mother,” because these are direct sterilization. The NCBC’s commentary summarized the 1993 responses as stating that hysterectomy “is not legitimate for the purpose of avoiding potential risks or dangers that would arise only if the woman were to conceive a child.”

In an illustrative note accompanying its 2018 response, the CDF said the question it sought to answer is different from the cases of direct sterilization discussed in the 1993 responses because of “the certainty reached by medical experts that in the case of a pregnancy, it would be spontaneously interrupted before the fetus arrives at a state of viability.”

The congregation added that the “object of sterilization is to impede the functioning of the reproductive organs, and the malice of sterilization consists in the refusal of children.”

The CDF argued that hysterectomy in the case under recent consideration is different because in the recently considered scenario “it is known that the reproductive organs are not capable of protecting a conceived child up to viability,” or that the reproductive organs “are not capable of fulfilling their natural procreative function.”

Further, the CDF asserted that “The medical procedure should not be judged as being against procreation, because we find ourselves within an objective context in which neither procreation, nor as a consequence, an anti-procreative action, are possible. Removing a reproductive organ incapable of bringing a pregnancy to term should not therefore be qualified as direct sterilization.”

The CDF’s response would seem to say in effect that “procreation” has not occurred at the moment of fertilization, nor at any point prior to the possibility of the live birth of a child, and says directly that “the objective of the procreative process is to bring a baby into the world.”

By defining procreation as the live birth of a child, the CDF seems to have allowed for a creative appropriation of its own 1975 document Quaecumque sterilizatio, which said that “any sterilization which of itself, that is, of its own nature and condition, has the sole immediate effect of rendering the generative faculty incapable of procreation, is to be considered direct sterilization … Therefore, notwithstanding any subjectively right intention of those whose actions are prompted by the care or prevention of physical or mental illness which is foreseen or feared as a result of pregnancy, such sterilization remains absolutely forbidden according to the doctrine of the Church.”

It is unclear that Cardinal Franjo Šeper, who was prefect of the CDF in 1975, intended to say that “any sterilization which of itself, that is, of its own nature and condition, has the sole immediate effect of rendering the generative faculty incapable of protecting a conceived child up to viability, is to be considered direct sterilization.”

Yet, as it defines procreation in this way, that is how Cardinal Ladaria’s CDF seems to have retroactively read Quaecumque sterilizatio.

The difficulty in reconciling the 2018 response with the preceding magisterium lies in the object chosen when a woman whose womb is “irreversibly in such a state that it is no longer suitable for procreation and medical experts have reached the certainty that an eventual pregnancy will bring about a spontaneous abortion before the fetus is able to arrive at a viable state” seeks to procure a hysterectomy.

The question posed to the CDF in 2018 asked about the physical act of hysterectomy in a certain kind of scenario, but did not give the purpose of the hysterectomy. Ultimately, though, knowing the purpose is necessary for understanding what the moral object is.

On the other hand, the questions submitted to the congregation in 1993 all included the purpose of the hysterectomy, enabling identification of the moral object, by using the phrase “in order to …”

The act of performing or procuring a hysterectomy is not per se evil – an organ, even a reproductive one, may be removed to preserve the life or well-being of the human organism of whom it is a part, as demonstrated by the liceity of hysterectomy when a woman faces a life-threatening hemorrhage which can be prevented by the womb’s removal.

In that case, the moral object of the act is a directly therapeutic hysterectomy to preserve the woman’s life, because the very existence of the womb – independent of any possible future pregnancy – is a threat to her life. The sterilizing effect of this act is foreseen, but not chosen.

In the case presented to the CDF in 2018, the end is not posed; rather, only the physical aspects of the act are presented.

However, the case presents a potential mother who could conceive, but not carry to viability, a child. In seeking a hysterectomy while not pregnant, what end could she be pursuing except to prevent a certain future danger to herself or to a child who is conceived? The womb is not described as itself posing any risk to the woman’s health, which would necessitate its therapeutic removal, and indeed the CDF noted that in these conditions there are other options alongside hysterectomy, noting in particular “recourse to infertile periods or total abstinence.”

The NCBC commented that its ethicists are not aware at this time “of concrete cases that would fit” the criteria given in the 2018 question submitted to the congregation, and noted that “the phrasing of the question and its response, as well as several linguistic formulations in the introduction and illustrative note, raise questions about how to interpret and apply the document.”

According to the NCBC, the 2018 response “does not overturn any previous Church teachings on direct contraception and direct sterilization or on the circumstances in which hysterectomy is immoral as a form of direct sterilization,” nor does it “reject the medical reality of the existence of human beings from the moment of fertilization.”

Nor does it “reject the moral reality … that ‘the human being is to be respected and treated as a person from the moment of conception,’” or say that “women who are unable to carry a child to the point of viability are, by that fact, unable to conceive or gestate a new human child in the womb.”

“By reaffirming the validity of the 1993 responsa, the 2018 document also reaffirms the Church’s perennial condemnation of direct sterilization,” the NCBC wrote.

The 1993 response “identified the nub of the moral problem: one may not perform any action that results in sterility in order to prevent dangers that would arise only in the event of pregnancy.” Commenting on this response, the NCBC said that “The lack of a pathological problem in the uterus itself (apart from future pregnancy) thus implies that its removal is a direct sterilization when the goal is to avoid risks associated with pregnancy. The operative words are not ‘risks to the mother’ but ‘risks … deriving from a possible pregnancy’: avoiding risks to the possibly conceived child would not change the moral assessment, since those risks are, by definition, ‘deriving from a possible pregnancy.’”

“Causing sterility in order to prevent” dangers that would arise only in the case of a pregnancy “constitutes direct sterilization,” wrote the NCBC.

“Given this, the 2018 responsum does not allow for hysterectomy in cases where its purpose is to prevent dangers, whether physical or psychological, whether to the mother or to the child, that would be expected to arise as a result of a possible future pregnancy.”

The NCBC added that “the removal of the uterus only serves the end of preventing danger to a child by impeding the natural effects of the sexual act: the conception and gestation of a child. A hysterectomy in order to avoid dangers to the child that would arise during pregnancy is therefore immoral in accordance with the 1993 responsa and the broader moral tradition.”

Turning to “real-world situations and applications” of the response, the NCBC drew three conclusions from the document and the moral tradition on which it draws. These are: hysterectomy is licit if the womb itself poses a danger to the woman; if no danger arises from the womb in a non-pregnant state, and there is no physiological benefit from its removal, there is no therapeutic rationale to justify its removal under the principle of totality; and if a danger would arise only in the case of pregnancy, “whether to the woman or to the child, it would be unethical to perform a hysterectomy in order to avoid such a danger, following the second response of the CDF in 1993.”

Given these three conclusions, the NCBC found that the 2018 response “would seem to apply only in cases” in which the womb itself poses no danger to the woman; it is morally certain that a child would miscarry before viability; and there is not an intention to avoid dangers to life or health that would be expected in the case of a pregnancy.

“This means that any dangers to the health or life of the woman expected to arise as a result of future pregnancy, and any dangers to a potentially conceived child, should play no role in establishing a therapeutic rationale or ‘proportionate reason’ for performing a hysterectomy in the nonpregnant state,” wrote the NCBC, adding that this “leaves open the question about what medical conditions might satisfy the criteria of the 2018 responsum.”

The center said that among the scenarios that do not fit the response’s criteria are hysterectomy performed in order to avoid several kinds of potential damage to the womb, to avoid “serious congenital defects of a child”, or to avoid “prenatal loss of a child.” It added that it “looks forward to further clarification regarding medical cases that would unambiguously fulfill the criteria outlined in the responsum.”

“Nothing contained in the 2018 responsum can be properly understood as modifying previous Church teachings on the topics of contraception and sterilization,” the NCBC concluded, “and the document does not imply any rejection of the dignity of the human being from the moment of conception or any denigration of the real participation of the man and woman in the generation of a new human life starting from that moment.”

So, what to make of the response? It is undoubtedly safe to understand the document in light of the preceding Magisterium, knowing that an act with a sterilizing effect cannot be chosen for its sterilizing effect.

A matter of concern to some theologians, however, is how this response might be cited in the future, with its definition of procreation focused on live birth and its seeming opening of the door to a “pastoral” permission for women who can conceive children without being able to carry them to viability to procure hysterectomies to avoid further miscarriages.

Whether further clarity is forthcoming remains to be seen.

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  1. I have a great respect for the application of ethics to these medical situations, however, should not the power and grace of God also enter into the discussion. If the uterus is removed for a potential problem (for what is expected to occur in event of pregnancy) is this not illicit not only because it is a potential and not an actual event, but also because it prevents another potential event – a miracle or other intervention by God bringing healing to the womb and a child into the world through prayer. Is faith and hope to be excluded from the Church’s discussion with science.

  2. Hysterectomy wouldn’t resolve the issue of not being able to bring a baby to term because you wouldn’t even be able to conceive a child, much less bring it to term. Besides, you can’t really predict these things with definite certainty since many women who have suffered from miscarriages have gone on to give birth to a healthy baby later.

    • I think that the CDF is permitting this in specific cases where the doctors have confirmed over time that a viable pregnancy is beyond the realm of possibility — worse and more certain than a series of miscarriages. A miracle could change the permanent medical condition, but perhaps the church doesn’t want to expect her to rely on a miracle as her only hope for relief from repeated pain from the deaths of her unborn children.

      • Why should the Church permit (or desire) hysterectomy in the case of potential (or probable) miscarriages? Should it then permit vasectomy for the husband to prevent the hysterectomy? Or perhaps contraception to prevent the vasectomy? These other procedures are less of invasive and one could even argue sacrificial on the part of the husband. The Church doesn’t want its flock to rely on miracles! Does it want its flock to rely on the power of God? Church teaching should not be about every possible situation but about the enduring truth. It should speak the truth to guide pastors to guide their flock. From there “the Church” becomes the individual pastor who can work with his individual parishioner etc. in specific cases. Is the Church/pastor ever to be able to counsel the woman and husband to refrain from sex at fertile times to avoid pregnancy (or rather miscarriage) and the hysterectomy (Natural Family Planning has other uses) and to keep praying? (Or in the case of now permitting hysterectomy might the Church become complicit in facilitating the “sex life” of couples by encouraging infertile sex vs. the encouraging the hope of divine intervention). Please consider also that a miracle could allow the child to develop and be born without changing the “permanent medical condition” as the condition might be improved for a time (the term of the child).

  3. Regarding your point that the CDF appears to define procreation as viability — they refer to the procreative “process” rather than an event. The end goal of the procreative process is the birth of a live baby. As the 1975 quaecumque sterilizatio states, any procedure which prevents procreation would be sterilization. Because a live birth is an requisite condition of procreation, it follows that any medical procedure that prevents the possibility of live birth would be sterilization. Theoretically, any damage to the uterus (short of a hysterectomy) which would prevent a fetus from developing to viability would also be a sterilization. Therefore, a woman whose uterus is incapable of producing a viable fetus is already sterile, and a hysterectomy cannot render her any more sterile than she already is. I believe this reflects the CDF’s reasoning in the responsum, and by this logic, the 2018 responsum does not contradict the 1975 Quaecumque sterilizatio.

  4. My father used to say (I think he was quoting or paraphrasing someone else) that you could tell the death of an organization by the size of the rule book.
    God had Ten Commandments. The Church’s Catechism is how many pages? And all the magesterial documents besides. And now this.

    • I guess that’s why our Evangelical Protestant brethren and the megachurches do “land office business” so frequently and have so many in their congregations represented by former Catholics. That is why the “just the Bible” folks usually are wrong on contraception, wrong on the Sacraments, wrong on human nature as intrinsically depraved and frequently wrong on social justice (pace 2 Thes. 3: 10). And wrong on things like vasectomies and hysterectomies–since Scripture neither forbids nor enjoins them.

      Not everybody needs every answer, but every question deserves an answer. For those of us in communion with the Catholic Church, yes, life is complicated, especially in the 21st century, and that requires appropriate responses to hard questions. Otherwise, she is slack in making provision to “faithfully impart the word of truth.” (2 Tim 2: 15).

  5. While I understand the great care and attention to detail that went into this “responsum” I think it crucial in these days of scienticism to ask: what is it responding to? – It looks to me like some in the Church are being driven by the medical societies to find ways to pursue cosmetic care (all the rage and $ these days) rather than medical care. The medical profession these days has shown to be so afraid of malpractice, especially surrounding women’s reproductive capacities, they would prefer to remove anything that MIGHT be problematic in the future. Doctors are so revered beyond their capacities, that they know they can convince people of their clairvoyance and patients will obey their recommendations to disastrous results – witness the number of abortions because the doctor said the baby would be “disabled” or “abnormal”. And how many times they have been proven wrong. The kind of hair-splitting being used here is usually reserved for a morally problematic situation wherein the doctor feels constrained by morality and wishes to be free to do whatever he wants with no questions asked. Churchmen are too easily confused by these details and prefer to defer to the doctor. We have seen this operative in the bloody euthanasia wars using doctors words “nutrition, hydration” so people don’t see the denial of them as what they are – taking away food and water from a patient. See too, the use of “vegetative state”. How ANY Churchman can see a human being as “vegetative” is beyond Christ. The great concern of doctors (and their insurers) has also corrupted the noble ideal of palliative care and now makes the use of hospice like a Murmansk Run – be careful and check everything all the time. At THIS time in history, the Church should be far more circumspect with a corrupted medical establishment. They cost more lives than Big Oil every year.

  6. Here we go again playing God and physician. Women have been dealt a bad survival hand. Life threatening hysterectomy, miscarriage, ruptured uterus, still borne, ectopic pregnancy, placenta previa, etc. Now compare that mind boggling series of events to a man’s life threats. Oh. There are none!

    God bless all women who live a sacred life and who must attune to the teachings of the church. My real concern is that when a pregnant mother is suffering over her pregnancy in the hospital the clerics who apply such strict rules pay her a visit and say a prayer with her.

    • I’m not sure of your point here and to be honest pro-choice feminists make the same points about the complications of pregnancy as to why the Church should stay out of it and leave abortion to the woman’s conscience and her doctor. (And since God is the one who determines “survival” – is God the one whom you accuse of dealing women a bad hand?) In feminist fashion you seem to be focusing all the threats to women from her own body – I would say that women are under many more threats also, and sadly from men, and so she does deserve protection. As a Catholic man, I do a disservice to the woman by encouraging her to have a hysterectomy when she cannot bear children, to not encourage her and remind her that she is still precious as she is. You seem to be saying that it is her choice alone even without God since the Church does not “play God” but counsels the woman (pastorally) in love not to remove a part of her that is placed there by God which in this case is not itself a threat to her life (a uterus that is a threat to her life is an entirely different case). I agree with you though that formats/discussions such as this tend to make the female a laboratory case to be argued over and talked about like she is not in the room. It would be better to have conferences relate Church teaching with more compassion and understanding for the challenges and suffering of women in such situations as the Church also needs to do, say, in the subject of IVF.

  7. I wonder if perhaps the CDF’s proposal might address the incredibly rare but conceivable case where a woman with a womb incapable of carrying a child to term might have that womb removed in order to receive a transplanted one, capable of carrying a child? This is a very strange case, I am not sure what to think if it.

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