DIFFICULT MORAL QUESTIONS

Question 53: May a woman whose uterus is badly damaged have a hysterectomy?

I have been pregnant seven times, have had four miscarriages, and have three children, all delivered by caesarean section. Now I am pregnant again. I am being cared for by Dr. Brown, the same obstetrician who cared for me last time, when the pregnancy went to term and we had our first son. Like all the earlier pregnancies, this one has been difficult, but now there are only six weeks to go.

Yesterday Dr. Brown, who is a devout Catholic and prolife, told my husband and me that he thinks my tubes should be tied when he delivers the baby. He knows that we have followed the Church’s teaching and used natural family planning (NFP), and that I quit my previous doctor when he insisted I be sterilized or find another doctor. But Dr. Brown says he thinks tying my tubes would not go against the Church’s teaching.

He explained it to us this way. My uterus, he said, is in such bad shape that another pregnancy might well end in disaster, and so removing it would be in order. But to remove it, he would have to tie and cut my tubes. Once that was done, however, pregnancy would be impossible, and so actually removing the uterus would be unnecessary. Dr. Brown says even theologians who accept the Church’s teaching against sterilization have said that tying the tubes in such a case is something different, called “uterine isolation.”

My husband and I have talked this over and are not sure it makes sense. Something else also has occurred to me. If it would be morally acceptable to remove my uterus, I think I might prefer that anyway. I plan to take estrogen after menopause, and I understand it is simpler for a woman whose uterus has been removed. Also, my eldest sister and two other relatives on my mother’s side of the family have died of cancer of the uterus and, while there is no sign that I have cancer, I would just as soon not run the risk. Therefore, I think I’d rather have my uterus removed, if Dr. Brown agrees.

What do you think about both things. Do you consider “uterine isolation” different from sterilization? If so, would it be morally acceptable for me to go all the way and have my uterus removed rather than just having my tubes tied?

Analysis:

This question calls for the application of moral norms and a judgment regarding the acceptability of a hysterectomy. Recently, the Church has taught that so-called uterine isolation is direct sterilization. But since the questioner’s purposes are entirely distinct from preventing conception, she could choose to have a hysterectomy while only accepting sterility as a side effect. The health benefits she hopes to gain ordinarily would not warrant accepting sterility and the burdens of having a hysterectomy. But she could rightly accept sterility inasmuch as she has a good and perhaps obligatory reason no longer to exercise her capacity to procreate. The prospective benefits of the hysterectomy will not be offset by such surgery’s usual burdens, most of which will be entailed by the caesarean section.

The reply could be along the following lines:

As Dr. Brown told you, some faithful theologians have said that so-called uterine isolation differs from other sterilization and is morally acceptable.¹⁹⁴ However, the Congregation for the Doctrine of the Faith has issued a document, approved and ordered published by John Paul II, in which both this procedure and hysterectomy in the same circumstances are judged to be direct sterilization.¹⁹⁵

The Church’s teaching on this matter is easily explained. The damaged condition of your uterus does not in itself medically indicate that it needs to be removed. If it did, Dr. Brown would be saying you need the hysterectomy rather than proposing uterine isolation. Tying your tubes will forestall a possible disaster, not by improving the condition of your uterus, but only by preventing conception. Therefore, in uterine isolation, the chosen means of forestalling disaster is preventing conception, and the choice to prevent conception by tying the tubes is contraceptive sterilization.

Nevertheless, in my judgment you could choose to have your uterus removed without choosing to prevent pregnancy and without violating any moral norm. Your concerns—to simplify estrogen replacement therapy and to eliminate the risk of uterine cancer—are in themselves grounded in the intelligible good of health. For most women, of course, it would be unreasonable to have major surgery for those purposes alone. In your situation, however, satisfying these concerns by choosing hysterectomy could be reasonable, because the operation would involve few additional burdens. You would already be undergoing the major surgery required for a caesarean delivery, and the loss of your capacity to procreate would be insignificant inasmuch as you have a good, and perhaps even obligatory, reason no longer to exercise that capacity. So, I think you may tell Dr. Brown that, provided he sees no medical indication against a hysterectomy, you wish him to do it in order to eliminate the risk of uterine cancer and facilitate estrogen replacement therapy after menopause.

I must point out, though, that if the advice I have offered you is regarded legalistically, it is likely to be abused by others. Your question makes it clear that you and your husband have followed the Church’s teaching and withstood your previous physician’s insistence that you be sterilized. Plainly, in raising the possibility of hysterectomy, you really are motivated by the concerns you state, which provide reasons for choosing a hysterectomy, and these concerns are entirely separate and distinct from preventing conception. Indeed, if you already were past menopause and undergoing abdominal surgery for some other reason, those same concerns could motivate you to have a hysterectomy. Others, however, desiring a hysterectomy for the purpose of sterilization, might insincerely use such considerations as an excuse, rationalizing their choice rather than justifying it. So, I do not say any woman whose uterus is so seriously damaged that another pregnancy might end in disaster and who is about to undergo a caesarean section may rightly use such considerations as a ground for having a hysterectomy. Rather, I am saying only that you—or a woman in your situation and with your ends in view—may choose a hysterectomy unless her physician judges that there are medical indications against it.

Finally, if the hysterectomy is performed, you and your husband probably will be glad you no longer need practice NFP. Someone might say such gladness either is wrong in itself or a sign that the hysterectomy was contraceptive. Neither will be true. With your purposes, the hysterectomy will not be contraceptive, though sterility will result as a side effect. And it will no more be wrong for you to rejoice over the advantageous aspects of that sterility than it is wrong for couples to rejoice over the advantageous aspects of the normal sterility during each cycle and after menopause.

194. See Thomas J. O’Donnell, S.J., Medicine and Christian Morality, 2nd ed. rev. (New York: Alba House, 1991), 138–44; but see the same author’s “‘Uterine Isolation’ Unacceptable in Catholic Teaching,” Linacre Quarterly, 61:3 (Aug. 1994): 58–61, in which he retracts that opinion in view of the judgment of the magisterium on the matter.

195. See Congregation for the Doctrine of the Faith, “Responses to questions proposed concerning ‘uterine isolation’ and related matters” (31 July 1993), AAS 86 (1994) 820–21, OR, 3 Aug. 1994, 2.