Affirming past indications as to when a hysterectomy would be morally acceptable, the doctrinal congregation, in a note published Jan. 3, said that "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," it would be licit to remove the uterus with a hysterectomy.

"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," it said.

The response and accompanying note by the congregation was dated Dec. 10 and signed by its prefect, Cardinal Luis Ladaria, and secretary, Archbishop Giacomo Morandi. Pope Francis approved the congregation's response and ordered its publication.

The congregation reaffirmed the three responses it gave in 1993 to questions concerning "uterine isolation" or tubal ligation and "related matters."

That document, signed by Cardinal Joseph Ratzinger, the future Pope Benedict XVI, said that because sterilization was not the primary objective it was morally licit to remove a "seriously injured'' uterus when it posed an immediate serious threat to the life or health of the woman even though permanent sterility would result.

However, it rejected the idea of performing a hysterectomy or tubal ligation ("uterine isolation") when uterine damage did not pose a present risk to the life or health of the woman but would pose a danger only in case of a future pregnancy. In those cases, it said, such medical procedures would amount to being direct sterilization, which remains illicit.

In the latest response to "a question on the liceity of a hysterectomy in certain cases," the congregation said, "in recent years some very specific cases have been submitted to the Holy See" concerning "a different issue from that which was examined in 1993, because they regard situations in which procreation is no longer possible."

What made the new question different was "the certainty reached by medical experts that in the case of a pregnancy, it would be spontaneously interrupted before the fetus arrives at a state of viability. Here it is not a question of difficulty or of risks of greater or lesser importance, but of a couple for which it is not possible to procreate," the congregation said.

"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 said.

But, in the cases referred to in the new document, "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."

"The objective of the procreative process is to bring a baby into the world, but here the birth of a living fetus is not biologically possible," it said. "Therefore, we are not dealing with a defective or risky functioning of the reproductive organs, but we are faced here with a situation in which the natural end of bringing a living child into the world is not attainable."

"The medical procedure should not be judged as being against procreation, because we find ourselves within an objective context in which neither procreation nor, as a consequence, an anti-procreative action, are possible," it explained.

Evaluating whether a pregnancy could or could not be viable "is a medical question," the congregation said, and "one must ask if the highest degree of certainty that medicine can reach has been reached" so as to recognize whether the medical response has been made "in good faith."

The congregation added that its note was not an endorsement of a hysterectomy as being the only or best option since there are other morally licit options in cases of severe uterine damage such as abstaining from sexual intercourse during fertile periods or total abstinence.

"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," it said.