On December 10th, the Congregation for the Doctrine of the Faith released a new statement on the liceity of hysterectomies in extreme cases. The statement was a response to questions posed to the CDF “in recent years.”
The CDF’s latest statement adverts to an earlier statement from 1993. In that earlier statement, the CDF addressed two questions related directly to the procedure of hysterectomy:
- May a hysterectomy be performed when the uterus is so gravely injured or diseased that it poses a risk to the life of the mother?
- May a hysterectomy be performed when a uterus does not pose immediate threat to the mother but may pose a future threat in the case of pregnancy?
The CDF responded that a hysterectomy is licit in the first case since it “has a directly therapeutic character” which has only as an unintended and secondary consequence that the patient become sterile.
The CDF gave a negative response to the second question, however, stating that in this case the hysterectomy would be a direct act of sterilization. Here, sterilization is not an unintended consequence of a therapeutic procedure but the very means by which the intended good effect (removal of future risk) is obtained. Since sterilization is itself an inherently evil act, and since inherently evil actions cannot be utilized licitly even to bring about a good effect, performing a hysterectomy to prevent future pregnancy is illicit.
The new question which the CDF has answered is as follows:
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 (hysterectomy)?
The CDF’s immediate response is: “Yes, because it does not regard sterilization.”
At the outset, this immediate response may be confusing, especially as it could appear to contradict the CDF’s earlier response to Q2. Accordingly, the response to the statement among Catholics online has been mixed, with some worrying that the CDF has now endorsed direct sterilization.
However, a careful examination of the issue ought to be sufficient to explain the rationale of the CDF and to recognize the important difference between this ruling by the CDF and its earlier statement.
First and foremost, it ought to be noted that the cases being addressed here are “extreme.” The essential difference which distinguishes these current cases with the cases addressed in 1993’s Q2, however, is the assurance of medical experts that a future pregnancy would be “spontaneously interrupted before the fetus arrives at a state of viability.” These new cases refer to a uterus which renders a couple to be in a state where “it is not possible to procreate” due to this spontaneous interruption before viability.
The statement does not explicitly define what it means by these terms medically. As such, I inquired with an OB/GYN Jason Phillips, MD what condition would allow for conception but interrupted viability. Dr. Phillips stated that he could not think of a medical condition which would allow for conception but not implantation. This leads him to believe that the CDF is likely speaking about extreme cases of uterine fibrosis wherein the uterus is unable to maintain the life of the baby up to the age of viability (usually 23–24 weeks gestation, with fetal lung development being the common limiting factor). Uterine fibrosis can, however, permit implantation and development up to a certain point. Unfortunately, that point is simply antecedent to the point of viability.
The aforementioned 1993 cases concerned the removal of a uterus which was viable for the implantation of an embryo and its growth into a viable baby. There the concern was that implantation and ensuing pregnancy might cause harm to the mother as the fetus grows. Obviously, that is a different case than the present one. Removal of a uterus in the 1993 case would be a direct act of sterilization insofar as the act itself is the removal of an organ necessary and capable for providing fetal viability.
The new case, however, seemingly concerns the removal of a uterus which is not capable of gestating a child to viability. Since the uterus is incapable of providing viability, its removal is in no way an act of sterilization. In short, the CDF says, “Therefore, we are not dealing with a defective, or risky, functioning of the reproductive organs, but we are faced here with a situation in which the natural end of bringing a living child into the world is not attainable.”
As such, the CDF is not re-describing the act of sterilization, nor is it affirming a consequentialist ethic, justifying sterilization for the sake of a good consequence. Far from negating or changing its teaching on sterilization, this new statement reaffirms that direct sterilization “is and remains instrinsically illict as an end and as a means.” Drawing upon an earlier definition of sterilization from the CDF from 1976 (and re-cited in the 1993 ruling), sterilization is an act “whose sole, immediate effect is to render the generative faculty incapable of procreation.”
Removal of a uterus which is already and in itself inefficacious for pregnancy could not be an act of sterilization since this act in no way renders one to move from being capable of procreation to being incapable of procreation. In other words, this new case speaks to situations in which the retainment of the uterus does not affect in any way the ability to bring children into the world. The removal of an inefficacious organ does not remove the power which that organ usually provides precisely because the damaged quality of the organ already entails the loss of that power through defect or disease.
On the other hand, the case from 1993 involved situations where the uterus was capable of procreation but posed a risk should the patient become pregnant. Removal of the uterus in those situations would indeed move the patient from being capable of procreation to being incapable of procreation, i.e. sterilization. It is true that this new case seemingly deals with a uterus which is partially capable of its natural function but one which is not capable enough to achieve its most proper end, i.e. the gestation of a child long enough to insure its living outside of the womb. The uterus in this case may allow for a period of fetal development, but not a period long enough to permit the survival of that fetus. In short, the uterus is not sterile simply, but it is sterile effectively.
What Does It Mean to Procreate?
There is one concern which may remain for Catholics. Why does the statement assert that a uterus incapable of fetal viability renders a couple to be in a state for which it is “not possible to procreate”? As we have already noted, the couple is able to conceive. If they were not able to conceive, the state of the uterus vis-à-vis fetal viability would be of no concern. There would simply be no embryo in need of gestation in the first place. And yet, does not procreation mean the same thing as conception?
The statement seems to be using the term “procreate” in a different sense than we often use it. Frequently we use the word “procreate” as interchangeable with “conceive.” Since the Church teaches that life begins at conception, this is a natural word choice. The first moments of conception bring a new and truly human being into the world. Calling this “procreation” is thus coherent.
However, the CDF clearly intends to use this term in a more limited sense stating that “the objective of the procreative process is to bring a baby into the world.” Why does it use procreation in this more narrow sense, applying it only to pregnancies capable of viability and birth? It seems that the CDF is wanting to stress that these cases are incapable of “bringing a child into the world,” probably because this is a major difference with the 1993 cases, where a child could presumably be brought into the world, as it were. In both cases, conception is possible, but only the 1993 case speaks to a situation with the possibility of viable pregnancy. It seems natural to assume that “procreation” is used in this sense so as to better differentiate the cases and to highlight precisely why they are different.
The word choice is perhaps unusual, but not problematic when viewed in this light. The only other possible reading would be that the CDF wishes to imply that conception is not procreation in any way, necessitating that the Church has reversed its stance on life beginning at conception. There is simply no reason to believe that the CDF is attempting to assert that conception is not procreative in the sense of bringing a human life into existence, and any confusion to that effect is clearly unintended by the CDF. We can thus distinguish between two definitions of procreation: 1) causing a new human being and 2) causing a new human being capable of life outside of the womb and “in the world.” The CDF utilizes the term according to the second definition but obviously without negating the first.
The CDF responds to new cases as they arise and as modern technology results in new progress in medicine. Still, the principles governing this particular ruling are those which have governed previous rulings and which are always operative and unchangeable in Catholic biomedical thought, i.e. the principle of double effect and the status of direct sterilization as an intrinsic evil.
 Quaecumque Sterilizatio, AAS LXVIII 1976, 738-740, no. 1.