Becket Gremmels, Ph.D. 
System Director, Ethics
CHRISTUS Health
Irving, Texas
[email protected]

I have previously argued that, based on some of Pius XII's speeches, a simple application of the principle of totality is insufficient to argue that sex reassignment surgery (SRS) for gender dysphoria is intrinsically evil.¹ Here I provide more insight on the principle of totality from Pius XII as it applies to plastic surgery, and I clarify my previous conclusion. I also reply to responses to my previous article by E. Christian Brugger and John Brehany.

More Insight from Pius XII
While speaking to the Italian Society of Plastic Surgery, Pope Pius XII discussed how Christian ethics and anthropology might view surgical intervention for aesthetic or restorative purposes rather than curative.² Granted this is in the context of plastic surgery and not SRS, but some of Pius' comments are quite telling of his thoughts on surgical intervention done to benefit the patient in a way that is not physiological. According to Pius, Christian morality holds that physical beauty is "a good, but a physical one, ordered to the whole person and, like other goods of the same category, is susceptible to abuse."³ He gives the example of someone who asks for plastic surgery to perfect their physical features even though they do not have any major imperfections or injuries because they "already conform to the rules of normal aesthetics."⁴ Pius says that such surgery "is in itself neither good, nor evil, but only the circumstances ... will give the moral significance of good or bad, licit or illicit."⁵ In these cases, Pius says the primary circumstances to consider are "that the intention is right, that the general health of the patient be protected by the considerable risk, [and] that the motives are reasonable and proportionate to the 'extraordinary means' to which one must resort."⁶

Pius goes on to say that in some circumstances, plastic surgery is not merely justified but strongly advised. For example, "Some deformities, or even merely imperfections, are prone to psychological disturbances in the patient, or become an obstacle to social and familial relations, or impediment — especially in people dedicated to the public or artistic life — to the conduct of their business."⁷ Sometimes physical deformities can even lead to feelings of inferiority which "take root and establish themselves in complexes which can also lead to profound anomalies of character and behavior, to the point of psychosis, and sometimes (God forbid) crime and suicide."⁸ Helping people with such situations involves much more than a plastic surgeon, including friends, family, psychologists, priests, and others. Yet if the plastic surgeon is involved, Pius says that such a procedure is not done simply for medical reasons but also for "spiritual motive[s], suggested by the charity of Christ."⁹

In a different speech to the Collegium Internationale Neuro-Psycho-Pharmacologicum, Pius says that "man has the right to use his body and his higher faculties, but not to use them as master and lord, because he received them from God his Creator."¹⁰ Yet someone who "mutilates or destroys a part of himself, because it is necessary for the good of the whole organism ... does not impose on Divine rights" as long as he "acts to safeguard a higher good, to preserve life, for example."¹¹ Yet, Pius also says that just as individual organs are subordinate to the organism and its final end, so "the organism is subordinate to the spiritual end of the person itself."¹² Any damage to organs or bodily functions caused by physical or psychological medical interventions may be licit if "they are aligned with the good of the person and do not transgress the limits posed by the Creator on the right of man to dispose of himself."¹³

"The Whole Person"
In both of these speeches, Pius again touches on that idea of "the whole person" in reference to the principle of totality, which I have discussed previously. It seems that, for Pius, the reason for justifying physical surgical alteration is not limited to physiological benefit. Rather, they also include other higher goods, such as the good of the whole person, especially the spiritual ends of the human person. This is particularly evident in his discussion of plastic surgery performed to relieve the psychological implications of a physical defect, or even merely a physical imperfection.

Fr. Scaria Kanniyakonil provides a brief summary of theologians who have found this concept within the principle of totality, what he calls an "integrated concept of the principle of totality."¹⁴ Arthur Vermeersch, Bert Cunningham, and Gerald Kelly are among those who he identifies as holding this view. In fact, Kelly clearly agrees with this interpretation of Pius XII.¹⁵ To be clear, Kanniyakonil also names many theologians who disagree with this integrated concept and prefer what he calls a "physicalist concept of the principle of totality", yet the concept remains.

In fact, the idea that surgical interventions can be justified for non-physical purposes is also found in the distinction between proportionate and disproportionate means. Gerald Kelly, Charles McFadden, and others argue that some treatments might be proportionate due to the patient's responsibility to the common good or spiritual welfare.¹⁶ For example, amputating a gangrenous limb might be disproportionate for a patient and thus not morally obligatory. However, if that patient had not been to confession in ten years and is competent enough to confess, she might be morally obliged to undergo the surgery so she can survive long enough until a priest can arrive to hear her confession. The non-physiological good of her spiritual welfare justifies the intervention. Similarly, a king might be obliged to undergo such a procedure if his death would plunge the kingdom into civil war due to the lack of an heir, or perhaps a president whose vice president is uniquely unqualified to lead the country. The physiological benefits of these surgeries are not the primary reason for their justification, rather the non-physiological benefits are.

Ultimately, the question of whether the principle of totality can only justify physical surgical alterations for physiological benefit, or also includes higher goods like the good of the whole person, is not tied to gender dysphoria and SRS.¹⁷ Thus, even though this understanding of the principle of totality has implications for SRS, one can consistently hold this view while still holding SRS to be morally unjust by intention or even in its very object.

Implications for SRS
With this view of the principle of totality, and with Pius' understanding that I describe in the previous article, it is clear that an overly simplistic rejection of SRS as a violation of the principle of totality because it either (1) involves the surgical alteration of tissue that is not pathological, or (2) results in sterilization, is insufficient. SRS might be unjustified based on other arguments or for other reasons, but by themselves these two arguments are insufficient.

It might then appear that the integrated concept of totality could justify some forms of SRS in some circumstances if empirical research substantiates the view that gender dysphoria is caused by some physiological defect or anomaly in embryological development. One might then be able to argue that the principle of totality could justify some form of SRS in some circumstances. Pius' mention of the risk of suicide due to psychoses that stem from physical deformities is especially poignant given the rates of attempted suicide among patients with gender dysphoria. One study found that 41 percent will attempt suicide over their lifetime.¹⁸ Another found that to be 31 percent.¹⁹ Even those who have undergone SRS still have a rate that is 4.9 times higher than the general population.²⁰ These numbers are extremely high considering the rate is 2.7 percent in the general population.²¹

However, even an integrated concept of totality is insufficient, by itself, to justify SRS, regardless of the empirical data. While the question of what constitutes "the good of the whole person" certainly differs for each individual, the general answer lies not in totality or empirical data, but in metaphysics and anthropology. Thus, to justify SRS solely by the principle of totality would be circular. The integrated concept of totality might allow for such a justification depending on the empirical data, but only if a justifying context can be found in metaphysics and anthropology. I am not confident that such a context can be found, but exploring how these fields apply to SRS is outside the scope of this article. I leave that to others to do.

Reply to Brugger and Brehany
In response to my previous article, E. Christian Brugger notes that I did not acknowledge "that changing our biological sex is impossible", nor did I consider special obligations of those with gender dysphoria who might have responsibilities to spouses or children.²² This was intentional. As I noted, as "even a cursory review of gender dysphoria itself and its origins are outside the scope of this article."²³ I agree with him that these questions are relevant, but addressing them was not the point of the previous article or this one. The articles' scope is intentionally very narrow surrounding the principle of totality (especially as expressed by Pope Pius XII) to SRS for gender dysphoria.

More to the point, Brugger in part begs the question when he says, "to participate in SRS following the assumptions about sex and gender held today by secular culture would be intrinsically evil."²⁴ This assumption, that it is intrinsically evil, is one of the issues in question. He goes on to provide an answer to the relevant question, viz., can one ever participate in SRS without following these cultural assumptions? Is it possible to justify SRS while not agreeing with the tenets of gender theory that seem at odds with traditional Catholic anthropology and metaphysics? Given Pope Francis' recent comments warning against gender theory, this is an especially poignant question.²⁵ Answering it is, again, outside the scope of this article. Yet I would again point out that the answers lie in metaphysics and anthropology, not in the principle of totality.

In this issue, John Brehany responds to my previous article.²⁶ He points out that Pius says "in order to apply [the principle of totality] correctly, one must always explain certain presuppositions first…The answer to these questions cannot ever be inferred from the principle of totality itself."²⁷ For SRS, Brehany says that these questions (and answers) are primarily metaphysical, and I completely agree. The primary conversation that is needed is in metaphysics and anthropology, and only secondarily in totality. The same applies to Brehany's comments that, for Pius, natural law is necessary to provide context to the principle of totality.

Brehany also disagrees with my interpretation of Pius XII's phrase "good of his being as a whole." Brehany argues that a full reading of Pius XII's comments undermines my claim that this phrase can be understood in a non-physiological sense. The unofficial English translation that Brehany cites reads as follows:

the patient can allow individual parts to be destroyed or mutilated when and to the extent necessary for the good of his being as a whole. He may do so to ensure his being's existence and to avoid or, naturally, to repair serious and lasting damage which cannot otherwise be avoided or repaired.

Brehany argues that the second sentence is Pius XII's explanation of what he means by the phrase "good of his being as a whole." Based solely on how this text reads, I agree with Brehany that the second sentence could be a clarification of that phrase. I hesitate to base an argument solely on translation, but this phrase is vital to the discussion and the unofficial English version that Brehany cites takes liberties with the translation that alter the meaning of the text.

The official text from the Vatican is in French, which is the original language of the speech. It does not lend itself to Brehany's interpretation, and it reads as follows:

il peut disposer des parties individuelles pour les détruire ou les mutiler, lorsque et dans la mesure où c'est nécessaire pour le bien de l'être dans son ensemble, pour assurer son existence, ou pour éviter, et naturellement pour réparer des dommages graves et durables, qui ne pourraient être autrement ni écartés ni réparés.

In the original French, there is no second sentence but rather a comma. Moreover, Pius repeatedly uses the word "pour", meaning "for", before "the good of his being as a whole", "to ensure his existence", and "to avoid, and, naturally, to repair grave and lasting damage." These two factors, the comma and the repeated use of "pour", mean that "good of his being as a whole" is simply the first in a list of reasons why a patient "may use individual parts, destroy them or mutilate them." The only other official translation of this address is in Spanish, which conveys the exact same meaning as the original French.²⁸

Despite the fact that Brehany's reading of the unofficial English translation is reasonable, it seems more reasonable to me to defer to the official French translation since Pope Pius XII originally gave the speech in French and since it reads similarly to the only other official translation, which is in Spanish. Thus, Brehany's claim, that Pius provides an explanation of "good of his being as a whole" immediately after saying it, cannot be supported. Therefore, my original suggestion, that this phrase could be understood to refer to non-physiological goods or the good of the whole person, is a reasonable interpretation of Pius' teaching. Pius also discusses this on several other occasions, some of which I mention above. Thus, this interpretation of Pius' phrase "the good of his being as a whole" is not merely proof texting. Granted that Pius is not explicit, it seems legitimate to say the phrase is an acknowledgement of our obligation to care for the whole person.

A Clarification
I believe some clarifications of my previous article, and this one, are warranted. First, I do not intend to suggest anything contrary to Church teaching. Rather, I wish to think with the Church as she works to apply the metaphysical, anthropological, and moral insights of our faith to the empirical data and scientific understanding regarding the etiology of and treatments for gender dysphoria. Should the magisterium determine that this is not in accord with Church teaching, especially that the principle of totality can justify physical surgical alteration for non-physical goods including the good of a person's being as a whole, then I will faithfully submit and withdraw the argument.

Second, in my previous article, I did not make a definitive argument that SRS is justified or that it is unjustified. Rather, I argued that a simplistic application of the principle of totality to SRS is insufficient to claim it is unjustified. While I did previously conclude that SRS is not inherently unjustified (or intrinsically evil), that conclusion was limited to the context of the principle of totality. If other concepts are in play, especially metaphysical and anthropological ones, SRS could be argued to be inherently wrong, by intention or in its object, regardless of the circumstances. I do not make a definitive argument about SRS in this article either. Rather, I show how the principle of totality, as understood to include the good of the whole person and not just a physiological benefit, might justify some forms of SRS if the metaphysical, anthropological, and scientific pieces fall into place.

Finally, and hopefully the above discussion has made this clear, my aim is to push the conversation towards metaphysics and anthropology. This is where applicable theological insights remain to be had; for example, Bedford and Eberl provide just such metaphysical analysis, while Mayer and McHugh provide a social, biological, and anthropological critique.²⁹ Combined with empirical evidence regarding the efficacy of treatment for gender dysphoria, these fields create a context and framework in which the principle of totality can work, just as Brehany points out. Only within this context does the principle of totality make sense, especially the integrated concept of totality. Hopefully such a discussion will lead to definitive answers to whether or not SRS is inherently wrong, or if some portions of SRS may be licitly done in some circumstances, as Brugger suggests.

1. Becket Gremmels, "Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality," Health Care Ethics USA 24, no. 1 (2016).
2. Pope Pius XII, "Discourse of His Holiness Pius XII to the Participants of the 10th National Congress of the Italian Society of Plastic Surgery," October 4th, 1958. All translations are my own from the original Italian or French.
3. Ibid., Part III. "essa è un bene, ma corporale, ordinato a tutto l'uomo e, come gli altri beni dello stesso genere, suscettibile di abusi." NB: The phrase "tutto l'uomo" could also be read as "all humanity" or "all mankind" rather than "the whole person". I believe "the whole person" more accurately reflects Pius' intention here, especially given his comments below regarding the potential psychological repercussions of physical deformity. However, "all humanity" is also a legitimate translation. While that alternate translation does not support my argument here, it does not contradict it either.
4. Ibid. "già  conformi ai canoni della normale estetica"
5. Ibid. "non è in sé moralmente né buono, né cattivo, ma soltanto le circostanze, alle quali in concreto nessun atto può sottrarsi, gli daranno il valore morale di bene o di male, di lecito o di illecito"
6. Ibid. "che la intenzione sia retta, che la sanità  generale del soggetto sia tutelata da notevoli rischi, che i motivi siano ragionevoli e proporzionati al « mezzo straordinario » cui si fa ricorso."
7. Ibid. "Alcune deformità , od anche solo imperfezioni, sono fornite di turbamenti psichici nel soggetto, oppure divengono ostacolo alle relazioni sociali e familiari, o impedimento, — specialmente in persone dedite alla vita pubblica o all'arte, — allo svolgimento della loro attività."
8. Ibid. "tende a radicarsi e stabilizzarsi in complessi, i quali possono anche condurre a profonde anomalie del carattere e della condotta, fino alla psicosi, e talvolta (Dio non voglia) al delitto e al suicidio."
9. Ibid. "ma anche ad un motivo spirituale, suggerito da quella carità  di Cristo"
10. "To the first General Assembly of the Collegium Internationale Neuro-Psycho-Pharmacologicum," (September 9th, 1958). "l'homme a le droit de se servir de son corps et de ses facultés supérieures, mais non d'en disposer en maître et seigneur, puisqu'il les a reçus de Dieu son Créateur."
11. Ibid. "l'homme a le droit de se servir de son corps et de ses facultés supérieures, mais non d'en disposer en maître et seigneur, puisqu'il les a reçus de Dieu son Créateur, de qui il continue de dépendre. Il peut se faire qu'en exerçant son droit d'usufruitier, il mutile ou détruise une part de lui-même, parce que c'est nécessaire pour le bien de tout l'organisme. En cela, il n'empiète pas sur les droits divins, puisqu'il n'agit que pour sauvegarder un bien supérieur, pour conserver la vie, par exemple."
12. Ibid. "à  la subordination des organes particuliers envers l'organisme et sa finalité propre, s'ajoute encore celle de l'organisme à la finalité spirituelle de la personne elle-même."
13. Ibid. "Des expériences médicales physiques ou psychiques peuvent, d'une part, entrainer certains dommages pour des organes ou des fonctions, mais, d'autre part, il se peut qu'elles soient parfaitement licites, parce qu'elles sont conformes au bien de la personne et ne transgressent pas les limites posées par le Créateur au droit de l'homme à disposer de lui-même."
14. S. Kanniyakonil, Living Organ Donation and Transplantation: A Medical, Legal, and Moral Theological Appraisal (Oriental Institute of Religious Studies India, Department of Publications of Paurastya Vidyapitham, 2005), 171-89, especially 83-87. A version of this chapter is available here: www.lifeissues.net/writers/kan/kan_07totality1.html
15. Gerald Kelly, "The Morality of Mutilation: Towards a Revision of the Treatise," Theological Studies 17 (1956): see especially 331 and 43.
16. Daniel Cronin, Ordinary and Extraordinary Means of Conserving Life (National Catholic Bioethics Center, 2011), 162-64.
17. For example, see Janet Smith's discussion of Pius XII's, Cunningham's, and Kelly's concepts of totality with regard to living donor organ transplantation. Janet E. Smith, "Organ Transplants: A Study on Bioethics and the Ordinary Magisterium," in The Ethics of Organ Transplantation, ed. S.J. Jensen (Catholic University of America Press, 2011), 272-304.
18. Ann P. Haas, Philip L. Rodgers, and Jody L. Herman, "Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey," (American Foundation for Suicide Prevention the Willimas Institute, 2014).
19. Masahiko Hoshiai et al., "Psychiatric comorbidity among patients with gender identity disorder," Psychiatry and Clinical Neurosciences 64, no. 5 (2010).
20. Cecilia Dhejne et al., "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden," PLoS One 6, no. 2 (2011): 5.
21. Matthew K Nock et al., "Cross-national prevalence and risk factors for suicidal ideation, plans and attempts," The British Journal of Psychiatry 192, no. 2 (2008).
22. E. Christian Brugger, "Response to Bayley and Gremmels on Transgender Ethics," Health Care Ethics USA 24, no. 2 (2016).
23. Becket Gremmels, "Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the Principle of Totality," ibid., no. 1. See footnote 19.
24. E. Christian Brugger, "Response to Bayley and Gremmels on Transgender Ethics," ibid., no. 2: 15.
25. Inflight Press Conference of His Holiness Pope Francis from Azerbaijan to Rome, October 2, 2016 w2.vatican.va/content/francesco/en/speeches/2016/october/documents/papa-francesco_20161002_georgia-azerbaijan-conferenza-stampa.html. Meeting with the Polish Bishops: Address of His Holiness Pope Francis, July 27, 2016, w2.vatican.va/content/francesco/en/speeches/2016/july/documents/papa-francesco_20160727_polonia-vescovi.html.
26. John Brehany, "Pope Pius XII and Justifications for Sex Reassignment Surgery," Health Care Ethics USA 24, no. 4 (2016).
27. Pope Pius XII, "Address to the Participants of the International Congress on the Histopathology of the Nervous System." September 14, 1952. "Respect au principe de totalité en soi! Cependant afin de pouvoir l'appliquer correctement, il faut toujours expliquer d'abord certains présupposés .... La réponse à ces questions ne peut jamais être inférée du principe de totalité lui-même."
28. "puede disponer de partes individuales para destruirlas o mutilarlas cuando y en la pedida en que sea necesario para el bien del ser en su conjunto, para asegurar su existencia o para evitar y, naturalmente, para reparar los daños graves y duraderos, que no podrí­an ser de otra forma descartados ni reparados."
29. Elliott Louis Bedford and Jason T. Eberl, "Is the Soul Sexed? Anthropology, Transgenderism, and Disorders of Sex Development," Health Care Ethics USA 24, no. 3 (2016). Lawrence S. Mayer and Paul R. McHugh, "Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences," The New Atlantis 50 (2016): 99-126.

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