In response to a “dubia,” or doubt, posed about the moral implications of a woman getting a hysterectomy, the Vatican’s doctrinal office said Thursday the removal of the uterus is licit in “extreme cases” where health risks are imminent and where sterilization is not an issue.

In a Jan. 3 statement, the Vatican responded to a question on whether a hysterectomy is valid 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.”

The brief response from the Vatican’s doctrine chief, Jesuit Cardinal Luis Ladaria, head of the Congregation for the Doctrine of the Faith, ruled that in this case, it is licit “because it does not regard sterilization.”

Ladaria’s answer is an affirmation of longstanding Church teaching forbidding intentional sterilization with the goal of removing the possibility of procreation. It also upholds a July 31, 1993, ruling from the Vatican’s doctrine office titled “Responses to Questions Proposed Concerning Uterine Isolation and Related Matters,” which held that while intentional sterilization was forbidden, a hysterectomy was permitted “when there is a grave and present danger to the life or health of the mother.”

The 1993 document also approved “the removal of the uterus and tubal ligation (uterine isolation) with the intention of making impossible an eventual pregnancy which can pose some risk for the mother,” so long as sterilization was not the primary objective.

In an illustrative note accompanying the response, Ladaria said the question received was in regard to “some extreme cases” recently submitted to his office “that constitute a different issue from that which was given a negative response” to hysterectomies in the 1993 document.

While Vatican teaching prevents direct sterilization, it has long approved of procedures when there are health complications and sterilization is not the primary objective. Another way of putting the point is that what the Vatican has opposed is not the procedure of hysterectomies, but the direct use of them as a means of birth control.

In Ladaria’s letter, signed Dec. 10, 2018, he outlined that position, saying the essential element in the cases his office has received is when medical experts reach the conclusion that the uterus would not be able to carry an unborn child to viability during pregnancy, making procreation impossible and a hysterectomy licit, since the couple is, in a sense, already sterile.

“The precise object of sterilization is to impede the functioning of the reproductive organs, and the malice of sterilization consists in the refusal of children: it is an act against the bonum prolis,” or the good of offspring, Ladaria said, stressing that in the case in question, “it is known that the reproductive organs are not capable of protecting a conceived child up to viability, namely, they are not capable of fulfilling their natural procreative function.”

Since in this case bringing a child into the world is not possible, Ladaria said a hysterectomy should not be seen as an act against procreation, because “neither procreation, nor as a consequence, an anti-procreative action, are possible.”

“Removing a reproductive organ incapable of bringing a pregnancy to term should not therefore be qualified as direct sterilization, which is and remains intrinsically illicit as an end and as a means,” he said, adding that the ability of the uterus to carry a child to viability is a medical question. From the moral perspective, the question is whether the “the highest degree of certainty that medicine can reach has been reached” and that the decision taken is made in good faith.

Ladaria clarified that his office is not saying a hysterectomy is always the best decision, and Thursday’s approval applies only to the cases mentioned.

Ultimately, he said, “it is the decision of the spouses, in dialogue with doctors and their spiritual guide, to choose the path to follow, applying the general criteria of the gradualness of medical intervention to their case and to their circumstances.”