I am the chaplain at a Catholic hospital and serve on its ethics committee. At our next meeting, we will be dealing with an unusual case.
The patient, a girl of fourteen, has been shown through chromosome studies to be afflicted with a rare genetic disease. Though mentally deficient and incapable of speech, she has some mental capacity, has been able to communicate to some extent with her parents, is receiving special education, and has learned some sign language.
This patient, whose reproductive system is normal, began menstruating a year ago June. Her periods are normal and have become very regular. From the onset, it was clear that the young woman is very uncomfortable with menstruation, and, as time went by, she became increasingly upset and irritable during her periods. She expresses her anger by sign language and body language, sometimes kicking her parents and teachers. Often she must be taken home from school because of her behavior and discomfort. Her psychological reaction does not seem to result from premenstrual syndrome, but from cramps and, perhaps, local discomfort, since keeping her clean and dry while she is menstruating is difficult.
Our staff psychiatrists referred the case to a psychologist who has worked successfully with people who are severely mentally handicapped. He saw the young woman frequently, but gave up after two months, saying he did not think he could communicate with her sufficiently to be of any help. Now her parents have asked a gynecologist on the hospital’s staff to do a hysterectomy to eliminate her menstruation and the problems it leads to. He persuaded the parents to accept a delay and gave the patient an injection of a drug he hopes will suppress menstruation for a few months. In his opinion, if that treatment is effective, it probably can be continued indefinitely without serious side effects.
But, talking with me, the parents said they regard medical suppression of their daughter’s periods as a stopgap rather than a long-term solution. I suspected they might have mixed motives in seeking the hysterectomy, and pointed out that the young woman eventually might manifest enough maturity to marry and then would have the right to do so, despite what I understand to be a fifty percent chance that any offspring would inherit her affliction. The parents said they think it very unlikely that she ever will be able to marry. My impression is that they love her very much, are trying to do what they believe is best for her, and really do wish to end the distress and trouble her periods are causing her and them, rather than to eliminate the possibility that she will get pregnant.
I make every effort to advise other members of the committee in accord with the Church’s teaching. In this case, however, it seems to me that nothing in that teaching indicates what the hospital should do. What advice do you think I should give?
The question is whether doing a hysterectomy is morally acceptable in this case. If the intention to prevent pregnancy is excluded, the Church’s teaching does not answer the question. The judgment whether to use this means of eliminating the troublesome menstrual periods must be made by considering the reasons, grounded in prospective benefits and burdens, for and against doing the hysterectomy. In my opinion, the operation is not warranted at present. If developments strengthen the case for doing it, an effort should be made to determine whether the woman will eventually be capable of marital consent. If she will be, consideration must be given to whether it would be fair to deprive her of fertility.
I think you should test your impression that the parents are not trying to prevent pregnancy by gently but straightforwardly asking them, if you have not already, whether they are seeking the hysterectomy, at least in part, because they fear that their daughter eventually might either become pregnant due to rape or marry and transmit her affliction to a child. Intending the hysterectomy to prevent pregnancy within marriage, even if that were only one motive among several, would turn the act into contraceptive sterilization, which is always wrong. Intending it to eliminate the risk of pregnancy resulting from rape might not be contraceptive sterilization, but even so might be morally questionable (see q. 54, above). In any case, do your best to make sure the parents do not proceed with unexamined mixed motives, for if they were to act in bad faith they would incur guilt for a serious sin they might persist in rationalizing and never repent.
If their request for a hysterectomy is not motivated by a concern to prevent pregnancy, I agree with you that nothing in the Church’s teaching indicates what should be done in this case. It seems to me the gynecologist on the hospital’s staff acted rightly in persuading the parents to delay and giving the young woman a drug he hopes will suppress menstruation temporarily. If this treatment succeeds initially and can be continued for a time without undue side effects, the young woman might mature sufficiently and/or become receptive to psychological counseling, so that menstruation will not be a serious problem. Or other ways of treating her problem might become available. Thus, the alternatives are not necessarily limited to lifelong medical suppression of her periods by means of the drug or an immediate hysterectomy. Moreover, the costs and risks of a hysterectomy argue strongly against using this permanent and radical treatment to deal with a problem that might be transient, and for which a stopgap might be adequate. Therefore, I would tell the parents that it is unreasonable, and therefore morally unjustifiable, to do the hysterectomy if the problem can be dealt with medically.
They may well find it hard to accept this advice. Try to help them do so, but proceed carefully. While they, like any parents, would fail gravely to meet their responsibilities if they did not love their daughter and try to do what is best for her, their care for her is commendable because it is so demanding on them. You and I cannot imagine their grief upon learning of their daughter’s affliction, their years of struggle and frustration with her many unusual problems, and all the other sufferings she has brought them. Carrying so heavy a cross, they naturally experience each new problem as a great burden, so that anything that seems to offer a permanent solution to a problem has strong emotional appeal. Bear all this in mind and try to awaken their hope, so that they will realize as clearly as possible that this life as a whole is temporary, stopgaps often are appropriate, and heaven alone holds the lasting solution to their problems.
But what if the drug fails to suppress menstruation as the gynecologist hopes, or it has unexpected and unacceptable side effects, or eventual attempts to allow normal menstruation indicate that this patient is likely to have problems with her periods until menopause? Then, it seems to me, a careful study should be made to determine whether she ever will be capable of marital consent. If it is virtually certain she will not, if the intention to sterilize her is excluded, and if the costs and risks of a hysterectomy, including the possible psychological effects of the operation on her, seem warranted, I think the choice to perform a hysterectomy would be reasonable and appropriate.201If, however, there is some possibility that the young woman will become psychologically and morally mature enough to marry, that possibility must be taken into account. It must not be ruled out of consideration by assuming that mentally handicapped people cannot be good spouses and parents, though special support generally is needed. Moreover, as I said at the outset, a hysterectomy may not be chosen to prevent pregnancy within marriage, even if that were only one intention among others, because that would be sterilization. But even if the intention to sterilize is entirely excluded, it might be unfair to this woman to do the hysterectomy; for, if she eventually becomes capable of marriage, she will have the same right as anyone else to marry, and the hysterectomy would deprive her marriage of its appropriate fulfillment in children.
In judging whether doing the hysterectomy to eliminate her periods would be fair to her, I believe that, besides the degree of probability that she eventually will be able to marry, all the burdens and benefits to everyone concerned of both alternatives (that is, doing the hysterectomy and refraining from doing it in order to preserve her reproductive capacity) should be taken into account: the factors that weigh against continuing with medical suppression of her periods, the expected hardships for her and others due to her regular menstruation until menopause, the fulfillment children would bring to the marriage, the burdens parenthood would impose on the couple and on others, and so on. Having considered all the relevant factors, those making the judgment must imagine that the young woman eventually will marry, put themselves in her place, and ask whether they would understand what had been done, consider it reasonable, and accept it without resentment.202
201. Renée Mirkes, O.S.F., “Sex and Trisomy 21—Part One,” Ethics and Medics, 15:5 (May 1990): 2–3, discusses a similar case and also thinks that the hysterectomy could be morally acceptable.
202. This case illustrates a subtle point. It might seem that the preceding analysis falls into proportionalism insofar as it allows the burdens as well as the benefits of prospective parenthood to be taken into account in deciding whether to do something that, in fact, will eliminate a person’s reproductive capacity. However, provided the hysterectomy were not intended to prevent pregnancy, it would not be wrong in itself, and all the prospective burdens and benefits of parenthood would be considered solely as side effects, rightly taken into account in judging whether the act need be excluded as unfair or may be chosen for its genuine benefits to her and as fair to all concerned.