Dr. William E. May's article condemning sterilization for contraceptive purposes (HPR, August-September 1977) rings clear and sweet for the most part, like a church bell. But towards the end, when he allows "material cooperation" by Catholic hospital administrators in some cases, there is only dissonance and confusion, I think, as though the bell had sprung a crack. I will try, in this short article, to tune up the last part of his article with the first part.
Along the same lines, the USCC Administrative Board has recently issued a Directive entitled "Sterilization Policy for Catholic Hospitals," leaving the door just slightly ajar for the practice in some instances. Salva reverentia, that door must be closed completely, I believe. [Note, July 2000: It is my understanding that both Dr. May and USCC have corrected their position since this was written in 1978.]
The theoretical section of Dr. May's article is balm for wounds suffered from "dissenting theologians" and a feast for the heart. Sterilization for contraceptive purposes, he maintains, is intrinsically evil, with intrinsic malice, and the Church teaches so. He lists some of the important people who defend this teaching.
The teaching of dissenting theologians cannot be our norm for morality, continues Dr. May; it is the teaching of the Church which remains as our norm for practice; and that teaching clearly excludes sterilization for contraceptive purposes, so we must follow it. Agreed. I would only contest the propriety of labeling the dissenters as "theologians"; a man who is a theologian is supposed to bring to us the word of God. Dissenters from authentic Church teaching in such important matters should be called "autologians"; they produce artifacts, not God's word. It must be an offense to the Lord even to name such people theologians, since, by implication, we make him responsible for their counterfeit products.
On page 18, Dr. May wrestles with the problem of applying the moral principle, which excludes contraceptive sterilization, on a practical level in Catholic hospitals. He does not believe that there is. a justifying reason for what he calls "material cooperation" in localities where "decent non-Catholic hospital facilities exist in which sterilization is common" (italics mine). He continues:
The problem becomes critical in localities where the Catholic hospital is the only medical facility within reasonable distance of persons who for conscientious reasons believe that sterilization is the "right" thing to do. Here the grave cause allowing material cooperation would be a respect for the consciences of others and a desire to avoid even greater evils, such as public outrage and a climate in which the Catholic hospital could no longer bear witness to evangelical ideals in the care of the sick . . . .
In such instances, one can argue that the conditions exist in which a Catholic hospital can materially cooperate by providing space, equipment and personnel for sterilization . . . .
He goes on to warn that scandal must be avoided by making it known that the conviction of the Catholic hospital remains that the "operation is truly immoral and is being merely tolerated" (p. 18).
Very similar, I believe, is the teaching published late last year by the USCC Administrative Board; in this document entitled "Sterilization Policy for Catholic Hospitals" we find the following:
Direct sterilization is a grave evil. The allowance of material cooperation in extraordinary cases is based on the danger of an even more serious evil, e.g., the closing of the hospital could be under certain circumstances a more serious evil.
When the Board of Administrators of a hospital, which has the moral responsibility to decide what medical procedures it will provide services for, makes a free decision to "provide space, equipment and personnel for sterilization" (Dr. May); when the Board of Administrators agrees by free decision that direct sterilization procedures can be performed within its premises and with use of its equipment in extraordinary cases in order to avoid an even more serious evil (cf. USCC directive), then the members of that Board have freely given their authorization to the practice of intrinsically evil acts in the hospital. The government did not commandeer the rooms and facilities against their will; the police did not occupy the rooms against their protest; the doctors did not force their way in with a band of violent tresspassers; the Board was not under the influence of drugs which deprived the members of rational responsibility. The Board sat in Council, cast their vote, and took the responsibility for the act. Now if the Board can licitly authorize the intrinsically evil procedure of contraceptive sterilization in some cases, then what principle can be adduced to prohibit the Board from also authorizing other intrinsically evil acts in the hospital? Say abortion; say use of facilities for infanticide "in order to avoid public outrage" or to keep the hospital from having to close its doors? And why can it not provide facilities to euthanatize our aged relatives and our troublesome incapacitated subjects?
If sterilization for contraceptive purposes is "intrinsically evil" then it is evil, it is evil, IT IS FOREVER AND ALWAYS EVIL! It is not a sheep in wolves' clothing. It is a flint-eyed wolf, with fangs bared, saliva dripping, whose bite is mortal. And if the Board permits this operation to be performed in its own hospital, the Board members are responsible. They chose evil in preference to death, to closing of the hospital or whatever temporal harm they feared or whatever "scandal" of the ignorant they wanted to avoid (but they in fact only scandalize the ignorant still more).
The labeling of the Board decision as "material cooperation" does not change the nature of the action itself. In fact, moral theologians do not use the terms "material" and "formal" cooperation in the same way at all. St. Alphonsus limits formal cooperation to the cases where the cooperator concurs with the evil will of the principle agent either by his own intention, or by the nature of his action; i.e., he concurs with the evil will of the principle agent either explicitly or implicitly (cf.S. Alphonsus 11, no. 59 and 63). That is different from the reasoning of the USCC Directive, which describes formal cooperation only from the viewpoint of the intention ("if done for medical reasons"). The USCC Directive does not explain, as St. Alphonsus did, that the nature of the act of cooperating may implicitly make it formal cooperation, without need of explicit intention.
Canon 2209 #3 states that those cooperators, without whose cooperation a crime would not have been possible, share the same degree of guilt as the principle agent:
Non solum mandans qui est principalis delicti auctor, sed etiam qui ad delicti consummationem inducunt vel in hanc quoquo modo concurrunt, non minorem ceteris paribus, imputabilitatem contrahunt, quam ipse delicti exsecutor, si delictum sine eorum opere commissum non fuisset.
#4 of the same Canon explains that if the cooperation only served to make it easier to commit the crime, so that it would also have been committed without such cooperation, then there is less imputability.
Marcellinus Zalba, S.J., cites this Canon when explaining formal cooperation. He states that there is formal cooperation, always illicit, when in the concrete circumstances one's action cannot but be a part of the sin. He explains that there is participation in the sinful action itself when one contributes actions, whether in the same category or whether of another kind, whether on the same level or whether subordinate to the principle action, if these actions contribute towards the production of an effect which has only one single total cause (Theologiae Moralis Compendium, II, Madrid, 1958, No. 249 and 244.)
In the case brought up by Dr. May, .the cooperation of the Catholic hospital is necessary as a condition that the crime of sterilization for contraceptive purpose can be committed; since there is no other place for the people to go for the operation, as he describes the case, except the Catholic hospital, the crime would not be committed unless the Board of Administrators of the Catholic hospital allow the use of their facilities. The conclusion seems inescapable that the administrators then incur the guilt of the crime together with the principle agents (c. 2209 #3); that their action is one part of the total cause of the crime (Zalba) and is therefore formal cooperation in the sense of Canon Law and according to the explanation of Zalba.
Leaving terminology aside, and allowing that some authors may wish to label the action of the Board of Administrators of a Catholic hospital as material cooperation, and some may wish to call it formal, let us do without the labels and look at the action itself. When a Catholic hospital provides space, equipment and personnel for sterilization, it does not merely tolerate an action which it cannot prevent; it contributes its necessary share of the whole action so that the sterilization can be performed. The hospital decides to provide the rooms, the electricity, the equipment and it permits the technicians to perform the operations. As Truman said: "The buck stops here" and in this case the buck stops right at the desk of the hospital administrators. If they say yes, the operations will be performed; if no, they will not be performed, at least not in that hospital. Even if they say yes reluctantly, they nevertheless say it effectively. Their agreement is a part of the operation.
Pilate's cooperation in the crucifixion of Christ - was it material or was it formal? Let us examine the question by applying the standards of Dr. May and of the USCC Directive.
The Jews believed, for apparently conscientious reasons, that Christ must be put to death, and that was the right thing to do because Christ was "pretending to be the Son of God" (John 19:7) which was considered to be blasphemy. It probably cannot be said that Pilate cooperated out of respect for their consciences, which is one of the reasons for material cooperation as given by Dr. May. But he did so for other reasons similar to those of Dr. May: "fear of even greater evils, such as public outrage" and a closing of the hospital. Pilate feared a riot, and feared loss of his job and head if he fell into disfavor with Caesar.
Pilate did not agree with the idea of the Jews that Christ must be killed for pretending to be the Son of God. He therefore satisfies the requirement of the USCC Directive for material cooperation, namely that "if the cooperation is to remain material, the reason for the cooperation must be something over and above the reason for the sterilization itself." In the case of Pilate, the reason had to be something other than that brought forward by the Jews, namely blasphemy. And Pilate's reasons were other: fear of riot, fear for his own future.
Finally, Pilate clearly told everyone that "It is plain that he has done nothing which deserves death" (Luke 23:15) and he washed his hands to signify that he disagrees. So he satisfies the requirements of Dr. May and the USCC Directive to publicly explain disagreement with the deed, to avoid scandal. It seems then that Pilate's case would have qualified as material cooperation by the criteria of Dr. May and the Directive.
"Pilate sent for water and washed his hands in full sight of the multitude saying as he did so: 'I have no part in the death of this innocent man; it concerns you only... (Matt. 27:24). Finally, "he gave Jesus up into their hands to be crucified; and they, once he was in their hands, led him away" (John 19:16).
Whether we call it material or formal cooperation, history does not judge Pilate kindly. "Crucifixus sub Pontio Pilato, passus, et sepultus est" is the judgment of Christians for nineteen centuries. Pilate's washing of hands has become a folklore symbol of a futile attempt to dispossess oneself of the responsibility which one really possesses. Christ did not hold Pilate as responsible as he held the ones who had delivered him to Pilate; but Christ did hold Pilate responsible: "That is why the man who gave me up to thee is more guilty yet" (John 19:11).
A Catholic hospital Board of Administrators, if it votes to permit the use of its facilities for contraceptive sterilization, even for the very best of reasons, is it not Pilate in action once more? And will the people not see that?
But I do not believe that a Catholic hospital is going to die when it gives witness to the truth that sterilization is bad for the people. This is especially so if the Catholic hospital "is the only medical facility within reasonable distance," since this would indicate that the hospital enjoys great influence, that it has the confidence and good will of the people in the area, that perhaps it was largely the Catholics of the area who built the hospital and who use it now. (And if people feel such a need for a sterilization clinic, let them prevail upon the local government to build one for them.) Just 400 meters from my room is Holy Spirit Hospital in Nagoya, Japan. Like other struggling hospitals in Japan, it has a very clear line, which is known to all the people: no abortions, no sterilizations, no artificial inseminations. The non-Christian doctors and personnel cooperate. The non-Christian patients fill the hospital, and the maternity ward beds are always reserved fully five months ahead! The people expect that the Catholic hospital will stick to its Catholic rules; and it seems that they not only respect this policy - they love it, the ones who go there, that is. The women know that they will be treated with dignity.
A Catholic hospital does no real service at all when it agrees to perform sterilizations out of "respect for the consciences of others and a desire to avoid even greater evils" (Dr. May). It is too easy to lose sight of the fact that the provision of sterilization is not at all a favor done to the people. Sterilization is not a box of good chocolates camouflaged under a wrapper which states "Forbidden by the Pope." It is an inhuman and stupid thing to be sterilized for contraceptive purposes. Even if people do not know now that it is stupid, they will learn it eventually, whether in this life or in the next.
God does not give people grace to help them to do such intrinsically evil, such improper things to their bodies; neither should Catholic hospitals offer a chance to people to do what is not good for them. Just because we know that God can overlook actions which people perform when misinformed, when ignorant, we nevertheless also know that God wants people not to be dull-witted, nor to harm themselves physically, culturally and spiritually even in "good conscience." Admittedly, Christ on the cross prayed to the Father to forgive his crucifiers because "they do not know what they are doing" (Luke 23:35). But he did not ask Mary to hand the hammer and nails to the executioners who were doing this "in good conscience." Neither should Sisters and administrators of Catholic hospitals help people to do so stupid a thing as to have themselves sterilized, to go through with an intrinsically evil act. The victims will see their own foolishness some day, at least by the time they reach the presence of the "Father of Lights" where all shadows flee and all fogs are lifted. If they meet the Board of Administrators there who allowed them to go through with the sterilization, will they thank them?
A Catholic hospital, especially if it is the only hospital in the area, should be a light on the mountain for the people around it, a beacon to warn them about hidden rocks and shoals and to light up the channel which leads them safely into the harbor. Catholic hospitals are splendid witnesses and instruments of evangelization if they influence people to do what is right, and do not open the way for them to follow a fashion which is intrinsically evil. Christ can point to them with pride, as he pointed to John the Baptist, saying: "And what did you go out into the desert to see - a reed swaying in the wind?" (Matt. 11:7)
Dr. Nobuo Ojima, gynecologist and assistant director of Seibo Hospital in Tokyo, under the direction of the Franciscan Sisters of Mary, is now a strong promoter of Natural Family Planning in Japan. He is not a Catholic, and only a very small percentage of the people he teaches are Catholic. But he argues persuasively that NFP is God's way for regulating conceptions. For example, on December 14, 1977, at the opening ceremony of the "School for Natural Family Planning" which is being formed by our Family Life Association, Dr. Ojima told the doctors, nurses and midwives that a woman's body might be compared to a very wonderful and expensive camera which can do excellent work if the user studies the directions about use of the camera and observes them carefully; with some care she can get results which justify the nature of the machine. But foolish people might jam the mechanisms and use it like a box camera that any fool can play with - and the results will be poor. Well, said Dr. Ojima, a woman's body is a marvelous piece of work put together by God and the monthly cycle is a beautiful thing. "All of you and all of your clients," he said, "should learn about your cycles, and be thankful for them; and don't stuff pills into the body to jam the mechanisms; and don't wreck that fine piece of work by some fool sterilization operation."
Dr. Ojima is popular with the press as well as on TV, so NFP is getting national advertising now through him. Also he is giving an NFP course to students at the Japan School of Nursing and to 80 at the Red Cross Medical Center. And our "school" in Tokyo will enroll 68 initially; in Nagoya it is expected to go over 100. Famous doctors, well known in Japan, will teach there. The Japan National Nursing Association, with a membership of 150,000, has indicated through its governing board that it is much interested in learning and promoting NFP.
The basic system being taught is the Roetzer-Keefe approach. Both doctors have been in Japan, and their work is translated into Japanese. Dr. Roetzer of Voecklabruck, Austria, has over 26 years of experience in teaching NFP, is a member of the World Health Organization's Task Force on the Determination of the Fertile Period, is a marvelous teacher, a warm-hearted and good Catholic with six children. His records of success in teaching NFP are impressive: a study of 380 of his clients, covering 12,323 cycles, indicated that there were only 7 surprise pregnancies; the Pearl Rate is 0.7, which stands up to the very best records of pill users, the IUD and even sterilization.
Dr. Keefe has equally long experience in New York, and although he has not been making studies of his success, one senses that he knows very well what he is teaching; and the Japanese appreciate his guidance. It should also be mentioned that Dr. Claude A. Lanctot was in Japan in the fall of 1976 and gave impetus to the establishment of the national organization of the Family Life Association. Before that, Dr. Kevin Hume had been here from Australia, and before that, Fr. Paul Marx, O.S.B. Director of the Human Life Center at St. John's University Collegeville, Minnesota. All helped to introduce natural family planning to Japan.
All the major daily newspapers in Japan have had articles favorable to NFP during the past five months; magazines are also picking it up. So the beginnings of promotion for NFP in Japan have been made; the work of training competent teachers is being organized nationally. We are taking our materials from the USA, Europe, and Australia. Our teacher doctors - nonChristians - tell the nurses, midwives and audience in simple words that NFP is better than all other methods of birth control.
Catholic hospitals in the USA can also offer, with confidence, an alternative to sinful and debasing sterilization; they can offer to teach NFP to couples instead. It is a far better service to the clients, and it enables the Catholic hospital to bear sure, unwavering witness to Christ.