Culture as Shaping Public Policy: Public Funding of IVF in Israel
The regulation of IVF is a complex and sensitive matter in every country. The ever rising cost of healthcare forces countries with national health insurance systems to make tough choices about which services deserve public funding. In light of the need to prioritize, IVF often raises difficult issues.
On one hand, the desire to have biological or genetic children is a fundamental aspect of being human and procreation is therefore a basic human interest. On the other, the question of whether infertility is a disease is being constantly debated. The inability to have biologically related children is devastating for those who wish to have them, but infertility does not involve morbidity or mortality. It is therefore perceived by some as not deserving the same priority in public funding as conditions that are physically debilitating or life threatening.
The decision whether to fund IVF relies heavily on cultural considerations such as the social and cultural meaning of biological parenthood and of infertility in a given society. With one cycle of IVF costing about $10,000, and more than one cycle usually required to achieve a live birth, many cannot afford to pay for IVF out-of-pocket. As a result, cultural considerations become the basis for public policy decisions that shape the lives of tens of thousands of individuals and families.
Israel's Experience: Cultural and Historical Background
Israel is a fascinating case in point, since it provides a powerful example of the way culture can shape public policy in the area of reproductive technologies. Defining itself as a ‘Jewish and democratic state’, it seeks a cultural fusion of Jewish and democratic values. Reproduction and fertility are very salient in Jewish culture. “Be fruitful and multiply” is a fundamental imperative of the Jewish religion and the desire for biological offspring is a profound element of Jewish tradition. The Biblical plea of Rachel to Jacob “Give me sons, or else I die”, is a cultural symbol that captures the tragedy of infertility. Furthermore, the genetic component of parenthood is strongly emphasized in Jewish law (“Halakha”). Even though in some instances the Rabbis acknowledged the social reality of adoption, the prevalent Halakhic position perceives parenthood as a natural given (Zohar, 1997).
These ancient perceptions of infertility as a ‘curse’ and of fertility as a ‘blessing’ pervade Israeli culture even today. Community life is centered on children and the cultural emphasis on parenthood is not exclusive to the religious population. Although ultra-orthodox Jewish families tend to be larger, the secular Jewish population and the Muslim population have similar attitudes regarding the necessity of reproduction. The average fertility rate of about 3 children per woman is high in comparison to other countries with similar economic and social features (Central Bureau of Statistics, 2000).
In addition, a sense of threat regarding the future existence of the Jewish people after the extermination of 6 million Jews in the Holocaust creates a sentiment of ‘demographic duty’ to the nation and underlies an official pronatalist population policy. While this policy is evident in every aspect of Israel’s legal and regulatory framework (for example, incremental social security benefits which are awarded for each child), it also underlies the public funding of IVF.
Public Funding of IVF in Israel
Israel’s National Health Insurance Law of 1994 provides every Israeli resident with a ‘basic basket’ of health services. This basket covers “infertility diagnosis and therapy” and “artificial fertilization” for the purpose of “bearing a first and second child, for couples who do not have children from their current marriage, and also for a childless woman who wishes to establish a single parent family”. Under the law, Health Funds are required to provide IVF treatment without limitation of treatment cycles, unless medical grounds justify restrictions.
It is worth noting that under the law, single women are entitled to public funding of IVF with donated sperm in order to establish a single-parent family (Kahn, 2000), which - as some critics argue - makes IVF a treatment for ‘social’ rather than ‘clinical’ infertility. Individuals are also entitled to public funding of IVF even if they already have biological children from a previous relationship. This makes the ‘right to biological parenthood’ a right held by the couple, not just by the individual.
Such extensive level of public funding is unparalleled in any other country in the world. Furthermore, labor laws compensate working women for absences resulting from infertility treatment. This policy provides partial explanation for the fact that Israel has the highest rate of per-capita-consumption of IVF in the world (Shalev and Gooldin, 2006).
This strong pronatalist culture raises serious ethical concerns. First, it raises difficult questions regarding priority setting in resource allocation, as economic constraints currently force Israel to consider the rationing of even basic and life-saving services.
Second, some argue that this cultural atmosphere creates a ‘national obsession’ with biological parenthood, encourages individuals to over-consume IVF, and raises questions about the indoctrination of women towards motherhood ‘at all costs’. When the realization of biological parenthood - and motherhood in particular - is a societal expectation as well as an emotional imperative (Fogiel-Bijaou, 1999), childless woman often perceive themselves as ‘flawed’ and nurses in IVF clinics talk about an ‘addiction’ to treatment.
While individuals in other countries may perceive Israel’s public policy as a reproductive paradise, it is important to remember that this policy is grounded in unique cultural assumptions and that it does carry its own ethical and social price tag
|Author :||Vardit Ravitsky, Ph.D.
Center for Bioethics
University of Pennsylvania
Central Bureau of Statistics 2000. Birth rate in Israel: 28.6 / 1000 in the 80’. 18.4 / 1000 in the 90’. Still, double the average of European countries. Statistical Abstract of Israel, No. 51.
Fogiel-Bijaoui S 1999. Families in Israel. In: Izraeli D. et al. Sex Gender Politics: Women in Israel. Tel Aviv: Hakibbutz Hameuchad Publishing House Ltd, 107-166. (In Hebrew).
Kahn, S.M. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press.
Shalev, C. and Gooldin, S. The Uses and Misuses of In-Vitro Fertilization in Israel: Some Sociological and Ethical Considerations. Nashim: A Journal of Jewish Women's Studies & Gender Issues, 12: 151-176.
Zohar N 1997. Alternatives in Jewish Bioethics. New York: State University of New York Press.