A follow-up article by Fr. James F. Keenan, S.J. (November 2000) argues that contraceptive sterilization can be licit under indicated circumstances when a Catholic hospital merges with another. He cites "approved authors." Yet I believe that his appeal to these authors is a misapplication, and that we are finally left with the inescapable mandate: "Ye shall not do evil in order to achieve good."
I shall first treat about the heart of the matter, why it is in all circumstances intrinsically evil. Thereafter I will expand with up to date information about what sterilization is doing to society.
Fr. Keenan had presented the following hypothetical case as fairly typical when mergers are negotiated between Catholic hospitals and other hospitals in the area (LQ August 1997):
In an American city of 100,000 inhabitants there are two hospitals, one community and the other Catholic. In the field of obstetrics, the former provides a full selection of services which the latter for ethical reason does not. The latter, instead, tries to protect and promote the values of its tradition. In renegotiating their contract with the Catholic administration, the obstetrics team demands a new proviso: they want permission to do tubal ligations on those women who want ligations while having their infant delivered through cesarian section. The team estimates that the number of direct sterilizations would be very limited. Their reasons for the proviso are simply that they believe it is unethical and medically ccontraindicative (sic) to "open" the patient twice. This team is well respected by the administration and is well established in the community. They are prosperous enough that they could move out of the facility, if they were not to receive the proviso. In all other matters they have acceded to the hospital and have regularly observed ERD. If they were to leave the Catholic health care facility, the facility believes it would not be able to deliver any obstetric services and thus would provide no alternative to the community facility.
Without pausing here to test whether the case be authentic, we pass on immediately to his claim that approved authors of the past would agree:
For centuries moralists have occasionally asked, whether, when there is something we definitively oppose because it is counter to church teaching, must Church members always refrain from cooperating in that activity even when their failure to do so would mean the demise of their life, facility, or department?...
I found it, as most moralists find traditional insights, in the writings of "approved theologians" in the casuist and manualist traditions. That location is where, normally, we find complicated methodological principles.
Moreover, I think that critical reflection helps us to recognize that these theologians were right. Logically speaking, we could imagine as others in previous times have, that immediate material cooperation could be distinguishable under extreme duress from formal cooperation. The insight enjoys both internal and external certitude. Regarding the former, the claims are evidently cogent; regarding the latter, the claims have been supported by significant voices both historically and contemporaneously...
As representative of the "casualist and manualist" theologians, we consult our old favorites of seminary days, Noldin, Merkelbach, and Zalba. They indeed approve immediate cooperation in an evil act as Fr. Keenan states, but not in an action which is itself intrinsically evil. There lies the difference. Let us hear them out. Noldin, Schmitt, Heinzel (Editio XXXI, 1955, Vol 2, No. 118 #3) teach that, with the exception of doing damage to someone's property, "Cooperatio materialis immediata illicita est..." So does Benedictus Henricus Merkelbach (Editio IX, 1954 , Vol I, No. 489b:" Cooperatio immediata etiam mere materialis est illicita." He also allows the exception of Noldin, but adds that to cooperate immediately in an act which is itself intrinsically evil, is tainted with the same specific malice as that of the principle agent (Merkelbach loc. cit.). Marcellinus Zalba, S.J. states that when in the concrete circumstances one's action cannot but be a part of the sin, then it is necessarily formal cooperation, always illicit (Theologiae Moralis Compendium, II, Madrid, 1958, No. 249 and 244). The authors would not have written so didactically had there been a controversy at their time.
Then what about the exception? Noldin explains as follows: Immediate material cooperation is illicit except in certain cases of sins against justice. For immediate cooperation is ordinarily evil from the nature of the act, therefore in itself; therefore it is never licit to cooperate immediately in killing another. However, in certain actions which are against justice, sometimes the nature of evil (ratio mali) ceases. So for a very serious reason it is permissible to cooperate immediately in bringing harm to a neighbor in regard to goods of fortune (in bonis fortunae.) Noldin continues, explaining in finer print: It is permissible, for example, to help in the burning of another's house out of fear of death: a) provided the cooperator wants to make up for the damage later; b) if the damage would be inflicted even without his cooperation; c) if by cooperating he can prevent an even greater harm to the neighbor; for in all these cases the neighbor cannot be opposed reasonably.
What if the conditions a,b,c are not present, continues Noldin. Authors are then divided: some argue that cooperation would then be illicit because the one who is harmed would not agree to the damage. Cooperation in that case would be intrinsically evil they state. Others, more correctly, argue that it would be licit because in extreme necessity one is allowed to steal from a neighbor, or even destroy property, if that is necessary to save one's own life.
However, continues Noldin, cooperation in a sin which tends toward the destruction of the Church or of the republic is never licit. Hence no reason whatsoever, not even fear of the greatest evil, even of one's life, would excuse one to cooperate. For that kind of evil, since it is public, is such that every private person is held to prevent it also at the danger of his own life. (End of para-translation of Noldin.)
The classical case cited by Noldin and others, is immediate cooperation in damaging a neighbor's property to save oneself from grave harm. The evil of so cooperating is extracted from his action by the fact that every person gains a right to the neighbor's property when life or grave harm is at stake. Such stealing is not theft, is not sinful.
The Catholic hospital, when negotiating for a merger, weighs whether it be licit to allow contraceptive sterilization in order to prevent its own foreclosure, the loss of jobs by the staff, the loss of providing health care for members of the community. The cases differ.
There is no question here of cooperation. Once the Catholic hospital is in charge, it operates, without having to cooperate. The hospital initiates the act. "The buck stops here" President Truman reminded himself by the sign on top of his desk. There is no wiggle room. The hospital becomes guilty of evil as a unit - of evil not only because the Church considers it to be so, but because it is in fact a misdeed seriously offensive to God and unworthy of man who is God's image. The operation mutilates not only the body of the patient. It collapses the personal integrity of the patient, of the operating team, and of the entire hospital: bonum ex integra causa; malum ex quocumque defectu. A hospital is good if good all the way; it is evil if it embraces but one defect. In no manner is contraceptive surgery a "service" to a neighbor or the community.
Christ, a steady-handed Manager, was so certain that His Peter would make no confusing mistakes to mislead the Church, that He promised to obey in heaven whatever Peter decided on earth. He knew absolutely that Peter would never betray that trust. "Whatever you bind on earth, shall be bound in heaven" (Mt 16:19). Christ didn't even keep the keys but turned them over to Peter. In the Encyclical Letter Veritatis Splendor the successor of Peter turned the keys against doing what is intrinsically evil when he wrote:
80. Reason attests that there are objects of the human act which are by their nature "incapable of being ordered" to God, because they radically contradict the good of the person made in his image. These are the acts which, in the Church's moral tradition, have been termed "intrinsically evil" (intrinsece malum): they are such always and per se, in other words, on account of their very object and quite apart from the ulterior intentions of the one acting and the circumstances...
With regard to intrinsically evil acts, and in reference to contraceptive practices whereby the conjugal act is intentionally rendered infertile, Pope Paul VI teaches: "Though it is true that sometimes it is lawful to tolerate a lesser moral evil in order to avoid a greater evil or in order to promoter a greater good, it is never lawful, even for the gravest reasons, to do evil that good may come of it" (cf. Rom 3:8)...
Man, who is an image of God, distorts his own mirror image if he decides differently than God does. When the space telescope Hubble's mirror needed fixing, a shuttle was dispatched to do the repair work. The distorted image, which had been an eyesore, now straightened out and became beautiful. More recently Professor Joseph K. Nariai managed the construction of the largest telescope in the world called Subaru. You can enjoy the majestic image of Jupiter, and the rings of Saturn so sharp they make you gasp, by clicking on http://www.asahi-net.or.jp/~uy2h-trt/lsnetj/Subaru/index.html. I printed out the images to enjoy them all the more. The least flaw in the mirror would have distorted this beauty. Like Hubble, like Subaru, so also may every Catholic hospital mirror the beauty of God.
The elegance of God so fascinates the angels that their speech turns into song, their joy leaps into the hearts of the shepherds, the night turns to day: "Glory to God in the highest, and on earth peace to men of good will," even so did they sing.
Bathed in the glory of God, hastening to Bethlehem with the joy of shepherds, flourishing as communities of love - such are those faithful Catholic hospitals strung from Maine to California, from Florida to Washington, from Alaska to Hawaii, with their priests, their sisters, doctors, nurses, auxiliaries, volunteers, patients and visitors, their surgery rooms, their pharmacies, their flower shops. They are a presence of God, a warmth of heaven's love, a dance of angels wherever their banners fly: St. Luke's, Mercy, Providence, St. Mary's, St. Martha's. Let not surgical contraception "black out" these shining cities on the hill. May Catholic hospitals flourish, their staffs make music to the Lord, their presence radiate His glory into the communities round about them.
The National Center for Health Statistics states on the web (http://www.cdc.gov/nchs) that "between 1965 and 1988 surveys, the prevalence of surgical sterilization rose dramatically among married women 15-44 years of age in the United States, from 16 to 42 percent. In 1995 the prevalence remained about the same at 41 percent." A news release issued on June 5, 1997 by NCHS states that the leading method or contraception remains female sterilization (10.7 million women), followed by the oral contraceptive pill (10.4 million women), the male condom (7.9 million), and male sterilization (4.2 million). Among couples with at least one child, in which women were in the age category of 35-44 years, 68.3% were surgically sterile (figure for1988, see Advanced Data issued by NCHS Dec. 4, 1990).
During the past three decades a major shift is evident toward female rather than male sterilization. In 1970, for example, the cumulative total of sterilizations was reported to be 2,750,000 of which 52% were male and 48% female. By 1983 the trend have reversed, being 46% male, and 54% female (see report by Association for Voluntary Sterilization based on government figures). By 1995, it was 28% male vs. 72% female (NCHS, June 5, 1997).
The USA figures contrast sharply with those of Japan where I live, and where sterilization is minimal, 5.0% of women contraceptors and 1.2% of men (Mainichi Survey 1992). Anecdotal evidence from conversations with doctors indicates that physicians are decidedly against sterilization, and even more decidedly against sterilizing their own wives.
Why this overwhelming use of sterilization in the USA (68% in families with at least one child) and why so low in Japan? For myself I draw the conclusion that sterilization in the USA is a landslide vote against the Pill. The figures bear this out. At age 25-34 the Pill is still on top: 23.7% Pill vs. 23.6% surgically sterile. Ten years later at ages 35-44 the Pill plummets to 6.3% vs. 54.0% surgically sterile. Worse: at age 44 the rate is higher than that average; and if there is at least one child, we see the rate of 68% of couples sterilized.. In Japan no similar passage from Pill to sterilization exists. The Pill had been outlawed until 1999; currently its sales are sluggish, about 140,000-180,000 users, about the same as before approval (Yomiuri, March 1, 2002). Summarized simply: sow Pills, harvest sterilization; ban Pills, few sterilizations.
Planned Parenthood enthuses on the Internet that tubal ligation is simple, quick, and safe (click on http://pplm.org/fs.html). The procedure requires a small incision near the navel and sometimes a second small lower down. The doctor inserts a laparoscope and seals the fallopian tubes preventing future fertilization. The procedure takes about 20-30 minutes. Local anaesthesia and sedation is given to help the patient relax. Patients rest in a recovery room for 1-2 hours. Most can return to normal working schedules within one or two days. The operation does not affect sexual feelings and many find sex more enjoyable because there is no fear of pregnancy. [An alternate method is resection of a small part of each tube and sealing of opened tubes.]
Other information is easily available on the Internet. The cost for a tubal ligation is $1,000-$2,500. For attempted reversal the standard charge at one advertised center is $6,500 with results of 95% open tubes and 70% who become pregnant.
Approximately 500,000 vasectomies are requested annually, costing about $240 and up to $520. About 5% request reversal which is reported to be 95% successful for men who had sperm at the time of the operation (see e.g. malereproduction.com/). One party advertises repair of vasectomies @$2,400.
Nearly 25 percent of women with an unreversed tubal ligation in 1995 expressed a desire for reversal of the operation, on the part of herself, her husband or partner, or both. About 11 percent of married or cohabiting women whose partner had a vasectomy reported some desire for reversal.
In a real-life situation, the case would not be as desperate as Fr. Keenan states it. For example, if the Catholic hospital already had an Obstetrics department before the merger, it can continue the the services thereafter with the same team in its own facilities and a new team in the acquired section. If the Catholic part did not have an Obstetrics section before, it should not be difficult to find replacements for the merged section if its team walks out. With 29,900 OB/GYN's in the nation (1995), and the prevailing low birth rate, finding replacements promptly may be exactly what the hospital wants to do anyway to forestall conflict. The team of the merging hospital that had been doing abortions and sterilizations would tend to be a cause of conflict in the newly merged unit under Catholic control.
Furthermore, national averages imply that 162 physicians in a typical city of 100,000 have an office-based practice (calculated from Statistical Abstract of the USA, for 1996). The typical 35 tubal ligations per year, (calculated from the national average), can be done at one of the clinics in town or elsewhere. For example, in 1983, 41,000 tubal ligations were performed in clinics (Association for Voluntary Sterilization).The women can drive to a clinic in this city, or to a string of hospitals down the highway. Furthermore, the author's mention that it would be necessary to "open" the patient twice is an exaggeration. Only one or two small incisions are needed. The claim of a medical need for sterilization in Catholic hospitals is a mountain created from a mole hill.
If the media nevertheless agitate for surgical sterilization in the merged venture, what can be done? Some of the opposition might be even "in odium fidei," a sign to the Catholic party to stand firm in the Faith. Each case will be different, but Catholic negotiators might hone their skills, and media professionals might get the facts to the public in a balanced perspective. And if worse comes to worse, wait. As the Japanese proverb says: Isogaba maware: "When in a hurry, take the detour." Yes, delay the merger. Or merge with another party.
What should be done if administrators themselves of the Catholic hospital insist on sterilizations? It is then the turn of the Bishop to give witness to the Faith. And if the Bishop fails? Then the one who was commissioned by Christ to "confirm the brethren" is charged with the responsibility. And if despite Rome's opposition the merged hospital performs operations? Like Esau, it loses its birthright. It should no longer term itself "Catholic." Hopefully it will not come to that.
Surgical sterilization, whether coerced or voluntary, degrades women and men by physical and spiritual mutilation. Japanese men and women who were sterilized under a sweeping eugenics program during 1949-1996 feel only anger today. Their resentment against a wrong done by public authority finally brought an end to the program. Health Ministry statistics indicate that 844,939 people were sterilized during the almost 50 years for mental or physical handicaps including Hansen's Disease.
The case of Yasuji Hirasawa made headlines. Just weeks before he was to get married he was given an ultimatum to be sterilized or the government will stop the marriage. "I was sterilized just like an animal is castrated. It was so humiliating. I just want the government to apologize and to have my dignity as a human being restored" (Mari Yamaguchi, Associated Press, Dec. 19,1997).
The fact that Americans request the operation voluntarily does not prevent its damage to body and soul. Clinical Psychiatrist Bernharda Meyer (Canada, recently died) communicated to me what she had learned from the many couples who visited her clinic in order to heal their marriages. Sterilization had done to their marriages what they had neither foreseen nor anticipated. She was successful with healing many of them by counsel, by advising religious practices, and by having them impose upon themselves a regime of periodic abstinence, similar to what couples do when they practice natural family planning. May her testimony put the "service" of sterilization into proper perspective. A service it is not.
If we include vasectomized male spouses, the number of sterilized couples may reach as high as 60% or 70%. More than half the couples actually live neuter gender sex, having excluded their heterosexual humanness of being men or women. Why have so many done it? Many decide on this permanent form of unnatural birth control because they have that choking fear of "needing an abortion." Or they may dread that if they lack physical love-making during abstinence time when following natural family planning, their marriage may break up.
These fears are not necessary, and are entirely out of touch with reality, if we view what is going on in the field of natural family planning, where couples are well adjusted. People who do not know NFP, however, are probably not going to bo convinced. Before living it, they don't believe. It is a no-win situation: they won't believe it until after they live it; but they won't live it either because they don't believe it works. Stuck in their prison of self-imposed ignorance, they mis-opt for that tragedy of sterilization.
Bearing and rearing their children, they may admit, sadly, that they no longer have sexual relations since frigidity or impotence have become a problem.
In some cases there is a restless search for "satisfying sex" which can almost take the form of rape if done with the spouse; or there is incest, a hidden affliction about which reports are increasing. Or the search for sex may be done outside, especially because "one is protected in any case."
The divisive psycho-sexual consequence of sterilization is something which even love cannot prevent or neutralize, because the very core of a human being is an inseparably interlocked unity of body + psyche. Because of sterilization, spouses cannot accept each other as intact human beings in their male and female sexuality. There always remains an awareness about the rejection of the essence of the spouse in his/her total self, even if this is only felt subconsciously (and nine tenths of our feeling and thinking is subconscious).
Sex, done for its own sake and not as an inter-relation of persons, is not love. Sex from which the natural openness to life has been blocked out lacks any glory and splendor. The fun eventually ceases to be real fun and no longer brings contentment. Contraceptive sex is distant, a gap between the two. It is not a heterosexual relationship because the partner's opposite and complementing sexuality is neutralized. The much touted method to allow uninhibited sex, blissfully free from fear of pregnancy, has in reality mis-developed; it now causes friction and/or flat, dead, or broken-up marriages.
Couples who have been sterilized can tell about this experience most clearly. Initially there is relief, and this time varies in duration. But the time comes when the husband can no longer perform well sexually; ejaculation praecox or impotentia coeundi may occur. This has roots in the subconscious, the abiding awareness of the non-reversible mutilation of their fertility which constitutes the essence of their sexual identity, male or female.
On the other hand, the woman may be the first to find the sex act boring, routine, flat. She may no longer "need" conjugal sexual intercourse. Increasingly she may remain dry, not perceiving any desire for the act, resenting the man who wants intercourse. She may detest his penis, she may feel physically nauseated by her man, may come to hate him. (This is reported to happen after abortion too by some women.) She may feel a revulsion when he touches her, since it is a suggestion of the sexual act, even when the husband may intend a non-genital caress. The situation keeps deteriorating, becoming distressful to the extreme for both. Living together is troublesome, irritating, unrewarding. They slip into the "sad" marriage, or the "dead" marriage, where they may still be fond of each other, or may be perseveringly committed to the upbringing of their children but they have no longer any hope left that they will ever be able to melt in marital oneness in the unique way of the intimate marital act.
Might her experience be exceptional, perhaps anecdotal? I think not. If fifty percent of marriages now end in divorce, the underlying cause must be quite universal. Look at USA statistics: only 393,000 divorces in 1960 before the Pill but 1,036,000 after (1975). That's a blockbuster explosion of broken marriages by 264%. The explosion continues to roll on and on. We would need ideological blinders to avoid seeing in the lock-in-step sequence a suggestion of a causal connection.
I think that contraceptives, and then surgical sterilization, damages marriages as surely as a blinding flash of lightning detonates a house-shivering thunder crash a split second later. Society needs to stop this destructive paroxysm of marriage much as it needs to devise protection against AIDS. Doctors and Catholic hospitals must help us. Because we trust our doctors we allow them to write our prescriptions, to prick us, to stick us, to use knife and scalpel while we are sedated, to prescribe hair-uprooting chemo-therapy. The basic rule for doctors is: "First, do no harm." Then, please doctor, do no harm to this couple.
A pseudo-ideology that the earth is overpopulated is public-sponsored pistol-whipping of our women, conditioning them for the rape of sterilization. The media degrades mothers, makes them wicked polluters of the earth, old-fashioned grannies who know not how to have sex without children. Why else would 54% of our gentle mothers meekly allow their tubes to be cut or tied? Public opinion has created a fashion - nay, a cult - whose bewitching charms few escape. The call to contraceptive surgery is a contemporary Song of the Sirens which ship-wrecks half of our marriages. Ulysses sailed safely past the jagged rocks only because he stuffed wax into the ears of his crew, then listened to the enchantment while he was bound helplessly to the ship's mast. Catholic hospitals might borrow wisdom from Ulysses by using modern strategy: natural family planning. They might steer their clients safely past the sterilizing knife by positively promoting natural family planning. Such is the program so dear to Pope John Paul II, who knows NFP inside out and outside in. He asks Bishops to give high priority to the pastoral work. I conclude with his pastoral exhortation:
The promotion and teaching of the natural, methods is; then, a truly pas-toral concern, one that involves cooperation on the part of priests and religious, specialist and married couples; all working in cooperation with the Bishop of the local Church and receiving support, and as-sistance from him...
The Church does not. claim that responsible parenthood is easy, but - the grace of the sacrament of marriage gives Christian couples a readiness and a, capacity to live out their commitments with fidelity and joy. At the same time, the use of the natural methods gives a couple an openness to life, which is truly a splendid gift of God's goodness. It also helps them deepen their conjugal communication and draw closer to one another in their union Ð a closeness that lasts throughout their lives...
At the heart of this work in natural family planning must be a Christian view of the human person and the conviction that married couples can really attain, through God's grace and commitment to the natural methods a deeper and. stronger conjugal unity; that unity, mutual respect and self control which are achieved in their practice of natural family planning (Address to convention on natural family planning, Rome, On June 8, 1984).