Question Three: Concerning Incisions Which Injure the Mother

I. The incisions which injure the organs not of the fetus but of the mother are:

a) Caesarean section (keizersnede, so called because Julius, called Caesar, i.e., cut out, was thus born), or hysterotomy (baarmoedersnede): it consists in an incision of the abdomen and of the maternal uterus in order to extract a living fetus who, on account of the narrowness of the mother or other causes, such as death, irreducible retroversion of the uterus (onherstelbare omkanteling van de baarmoeder), placenta previa,¹ cannot be brought forth by the natural way;²

¹ The placenta is called previa when it adheres over the internal mouth of the uterus or near this mouth. This occurs when the ovule descends as far as the mouth of the uterus, and there the decidua serotina and then the placenta are developed.

² You will find the manner of performing the Caesarean operation among certain theologians, such as Dens, Theol. Mechlin., Aertnijs, and in Antonelli, c. c., t. I, n. 446.

b) symphysiotomy³ (schaamboogdoorsnijding), by which the cartilage, or symphysis, which joins the two bones of the pubis is cut. This operation is done if the impossibility of birth arises from narrowness of the pelvis (bassin, bekken), provided, however, that the narrowness is not excessive; for thus the breadth of the pelvis is increased so that the fetus can pass through it more easily;

³ It is the operation which Dr. Sigault first employed, in the year 1768; it is more dangerous than Caesarean section: in the latter, indeed, the section is deeper, but in the former harder; yet, in a particular case, it can be judged safer.

c) pubiotomy (schaambeendoorsnijding), by which, for the same end, one or both bones of the pubis are cut;

d) combined operations⁴ (vereenigde behandelingen): that is, symphysiotomy together with artificial premature delivery; thus the Caesarean operation is avoided, and the mother is healed after a few days.

⁴ They are of Dr. Iacolucci, in the year 1867.

II. The aforesaid operations are not illicit, unless they are done in such circumstances in which, on account of the weakness of the mother, the inexperience of the operator, or a certain danger of infection, they appear destructive of the mother and equivalent to killing. For Saint Thomas says (III, q. 68, a. 11, ad 3): "Evils are not to be done that goods may come about (Rom. IV, 8), and therefore a man ought not to kill the mother (or the infant) in order to baptize the child"; whence Caesarean section is illicit if it brings with it, as it were necessarily, the death of the mother or of the infant.

Nevertheless, in fact it is almost always licit, if the fetus is viable,⁵ and birth cannot be obtained in any other way. Formerly it often brought great danger and was an extraordinary means; today, because of the progress of surgical art, if it is done by an expert, it often is not very dangerous, nor is it a means so extraordinary, but for the most part it includes a rather remote danger of death for the mother, especially if precautions by antiseptic means are employed; but by an inexperienced person, e.g., by a priest, while the mother is living, it cannot be done. The same is to be said a fortiori of a less dangerous incision, which they call the vaginal Caesarean operation,⁶ namely, by which the opening of the female genital canal (moederscheede) is widened, which is the natural way by which the infant is born.

⁵ It is said: "if the fetus is viable"; for, as De Smet notes (De Sacramentis, n. 316): "If the infant is in danger before mature birth, seven months, because the pregnant mother is sick even unto death, and therefore it is to be feared lest the offspring die with her, regularly the death of the mother is to be awaited, and when she has died, the fetus is to be cut out from the maternal womb... And indeed: a) there can scarcely be a question of conferring Baptism in the uterus, both because before mature birth the uterus is penetrated with greater difficulty, and because for rightly administering the sacrament the membranes enclosing the fetus would have to be perforated; and this perforation would inevitably bring with it the effusion of the amniotic fluid and the expulsion of the immature fetus; but the expulsion of a fetus not yet viable would constitute abortion, and seems gravely illicit. (See nevertheless below, II, q. 3, n. IV.) b) Regularly there will be no place for Caesarean section, inasmuch as, the weakness of the mother being supposed, it would be deadly in the case."

⁶ It is the operation of Dr. Hubert, who was professor at the University of Louvain. This is done if birth is impeded not from narrowness of the pelvis, but from closure or perverse disposition of the fleshy parts, which cannot otherwise be overcome.

III. The mother is also bound (of herself under grave obligation) to undergo an operation, even Caesarean section, if 1) she cannot give birth naturally; 2) in the judgment of an expert the infant cannot otherwise be baptized; and 3) the safety of the mother and of the infant can prudently be hoped for by means of the section; for the mother cannot be killed, nor the fetus himself, so that this latter may be baptized before he dies.

Hence there is required a) that the fetus be viable, ordinarily of seven months; otherwise he would be killed; b) that the mother be robust; c) and that there be an expert surgeon. For then, by the law of charity, the mother must, under grave obligation, prefer the eternal salvation of her neighbor, namely of the infant, to temporal good and life.

Hence generally the obligation of the mother does not exist, because a) more often the fetus survives the deceased mother, or there is serious hope that he will survive; b) generally, by means of an instrument, he can be baptized in the uterus; c) for preserving her own life, and a fortiori for preserving the life of the fetus, the mother probably is not bound to have recourse to a means which perhaps is, or at least is still reputed to be, extraordinary.

For practice, even in the case in which she is bound to undergo the incision, prudence generally forbids warning a mother who is in good faith about the grave obligation, because of the danger lest perhaps, by refusing consent, she die in the state of sin. Nevertheless, the priest, and likewise the physician and relatives, ought to exhort her to the section. The physician is obliged to perform it, if it is asked of him, and he is bound to exhort the mother to undergo it, because from justice he must employ safer means for preserving the life of the mother and of the offspring; whence the priest should induce the physician to furnish this office.

IV. When a pregnant woman has died, immediately after death the Caesarean operation is to be done, as the Roman Ritual prescribes, tit. II, c. I, n. 17: "If a pregnant mother has died, let the fetus be extracted cautiously as soon as possible, and if he is living, let him be baptized" (Can. 746 § 4; S. Off., 15 Feb. 1780). But that the life of the infant may more easily be preserved, the uterus of the deceased mother is to be covered with cloths, so that it may retain heat; however, to open the mother's mouth, lest the infant perish by lack of respiration, is of no utility, because he does not breathe through the mother.

To this section, of themselves all are bound by the grave precept of charity, because all are bound to provide for the eternal salvation of the infant even with the greatest temporal inconveniences; and, if the fetus is viable, there is added another reason, that of preserving his temporal life.⁷ They are bound, however, provided three conditions are present:

⁷ "The obligation," says De Smet (De Sacramentis, n. 313), "begins from the death of the mother, known with moral certainty, and perseveres until the morally certain death of the offspring... But how long life can be preserved for infants in the uterus of a dead mother cannot be determined: this depends much on the character of the disease from which the pregnant mother died; but there is no doubt that the fetus can survive the mother for an hour, indeed for several." Namely, in the placenta there remains a sufficiently great amount of blood that from it he can assimilate the necessities of life; and this is the greater because little suffices for sustaining that tender life.

1. the mother is morally certainly dead; whence the section is not to be done except after the testimony of an expert concerning death;

2. it is probable that the fetus is living; hence no one is bound to it at the beginnings of pregnancy, in the second or third month, because then the fetus is almost always dead, or at least it is very uncertain whether he will emerge living; nevertheless it is to be done in the fourth month, especially if the woman has perished by sudden or very rapid death, unless there are grave reasons for judging that the fetus died before the mother or with her;

3. those acting are suitable and have sufficient skill so that they can accomplish the section without danger to the fetus; nevertheless no one is bound beforehand to learn the art or manner, because, in order to satisfy a precept, no one is bound to employ remote means, namely when the precept does not yet urge. Hence:

a) the operation first falls upon the physician, who is to be induced to perform it even if he says that the offspring is already dead, because in this matter they are accustomed to proceed more lightly and to speak thus lest they perform the section; and yet there is no doubt that the fetus can survive the mother for an hour, indeed for several;

b) but if he is unwilling, let another, e.g., a midwife, who is suitable for this, approach; the priest should warn such a person concerning this, unless very grave inconveniences are feared;

c) if others are lacking, the priest is not certainly bound to this, both because of frequent inexperience, and because of indecency, and especially because of the danger of scandal and of greater evil from the hostile talk, hatred, and calumnies of the enemies of religion; for the scandal of many is to be avoided more than the salvation of one infant is to be procured (S. Off., 15 Feb. 1780; 13 Dec. 1899). Nevertheless, these reasons do not hold for all circumstances, e.g., if there is a discreet Catholic family, or in missions, the Chinese nevertheless excepted; whence, according to several authors, of himself he would be bound: although this is perhaps more probable, nevertheless it is not certain.⁸

⁸ Many teach that the priest is bound, such as Cangiamila, Debreyne, Th. Mechl., Vering, Konings, and Behmkuhl; nevertheless others deny it, such as Bouvier, Gousset, Marres, and Berardi.

V. Case. It can happen that a woman or girl illegitimately pregnant, with no one knowing it, is in imminent danger of death. Now, after the fourth month of pregnancy, there is a well-founded hope of extracting a living fetus from the uterus of the dead mother. Whence the woman has a grave obligation to disclose the matter directly to some person, so that after her death the Caesarean operation can be done and the infant baptized. She can furnish this:

a) by writing letters in which she declares that she wills that after her death the uterus be opened and the offspring baptized, which signed and sealed letters she should hand to a trustworthy person, to be opened only after death. For thus, as far as can be done, provision is made for her reputation and for the salvation of the offspring;

b) if she cannot write, or does not wish to, let her manifest the matter orally to a wholly discreet person, who will reveal the fact only after her death;

c) other things being equal, for a duty of this kind the physician is to be chosen before others, who perhaps already knows the matter under professional secrecy, who can more fittingly provide for the reputation of the mother and of the family, and who, when necessity urges, can at once proceed to the section and baptism; parents are less suitable, who perhaps, from excessive fear of infamy, will abstain from revelation;

d) the confessor himself should only with difficulty and in the last place take upon himself the burden of revealing, especially if he fears lest from this the sacrament be rendered odious to the relatives of the girl.

But the confessor should induce the penitent to this by persuading and commending, not impose it as obligatory, if he finds that the penitent will certainly refuse it; for then he would uselessly disturb good faith, which in fact would not profit the infant and would harm the salvation of the mother. If, however, she doubts and asks concerning the obligation, the confessor must acknowledge the obligation.

VI. Observations. 1) To avoid the above-mentioned incisions by preventing conception, utero-ovarian amputation (the operation of Dr. Porro), or amputation of both ovaries, is often done; it is had without great hemorrhage or suppuration, and for that reason is said to be preferable to Caesarean section. But grave mutilation⁹ of the body is licit only (and indeed with the consent of the mother supposed) for preserving the life of the whole body, which therefore cannot otherwise be preserved, because the part itself is infected by disease and, from this very fact, even apart from pregnancy, brings danger to life; as with an arm and a foot. It is illicit if it is done in order never to conceive; indeed also, because evils are not to be done that goods may come about, in order to avoid the danger of a new pregnancy or of a new Caesarean section, the more so because a new pregnancy is doubtful and the danger is not yet imminent, and the Caesarean operation is not most grave, especially in a woman who has already undergone it, and this operation is as grave as Caesarean section.

⁹ Mutilation is grave not only by reason of danger or of the dimension of the member, but also by reason of function, e.g., if it deprives one of a power or function of great importance.

2. Oophorectomy, or ovosection (doorsnijding der eileiders), i.e., resection or ligation of the tubes of the oviduct, or of the canal leading from the ovary to the womb and carrying the maternal ovule to it, is gravely illicit for the same reason, as being a grave mutilation, except in the sole case in which the part labors under grave disease and constitutes a danger to life.

3. The same must be said of vasectomy¹⁰ in the man, or resection of the vessels or canals carrying the seed to the seminal vesicles (doorsnijding der zaadleiders), by which the way to ejaculation is broken off for the seed. Namely, it is gravely illicit, as being a grave mutilation, unless by reason of health it would be necessary for the good of the body, e.g., if a part of the deferent canal were infected with gangrene; whence it is not licit for obtaining sterility or impotence, even if perhaps the integrity of the canal and the power of inseminating could be restored, as some affirm, although in practice it is difficult; likewise, it is not licit for avoiding the multiplication of offspring or a dangerous birth, indeed not even for healing a great vicious inclination of lust: for the member, by its own nature, is immediately subordinated only to the good of the body, not to the good of the soul.

¹⁰ Concerning vasectomy, Nouvelle Revue Theologique 1910, p. 420; Revue Ecclesiastique de Liege, VI, 1910, p. 203; and Collationes Brugenses, XVII, 1912, p. 533, can usefully be read.

But public authority, since it does not have direct dominion over the life, liberty, and members of subjects, cannot take these away from them, and therefore cannot impose vasectomy upon innocent citizens, even the sick; to punish criminals in this way is incongruous, since it is not a suitable punishment, because the operation is little painful; finally, to use this means lest they harm others or lest, by entering marriage, they transmit disease by heredity, is not licit, because an evil means is not to be used for a good end, and also because other means are not lacking by which provision can be made for these things, e.g., prohibition by law under penal sanction, confinement, or abstinence from marriage.

It can also be noted that marriage, in the case of perpetual vasectomy, contracted, is invalid because of the impediment of impotence; but if the potency can be restored, it would also have to be restored when the consort demands it, yet then the end intended by authority would no longer be obtained. Moreover, bodily good is not the greatest common good of society; to this also pertains preserving human dignity, to which every species of animal selection is repugnant.

4. Likewise it is illicit to use the so-called X-rays or Roentgen rays, which, directed more intensely and with a greater dose upon the ovaries or testicles, can produce sterility, yet not always efficaciously and with fruit. For this is to be judged a grave mutilation, since it deprives one of a function of greater importance.