Tag Archives: medical ethics

Pregnancy Ethics in Israel and Japan—Updated by AS

I have heard from both rabbis and doctors about the different approaches in America and Israel on the view of the fetus and the role of therapeutic abortion. But the contrasts were always framed as US versus Israel or different schools of halakhah neither of which provided a useful focal point to articulate the differences, since America is diverse and halakhhah is ideal-not reality.

Here is a book on Israel compared to Japan that offers much to think about. What is the role of the medical model in the construction of modern Judaism? How is Israeli medical ethics very different than American medical ethics? Is it practice or ideal? (From what I hear, American MO are aggressive in feeding tubes in a way that Israelis are not.) How Jewish views of birth and death may at this point be less in harmony with nature than other cultures. How do views of secular Israel and religious America effect Orthodox practice. How did Centrism halakhah and ideology has adapt the views of the evangelical era? How and why do the actual ethics in the community not follow the rabbis- Modern Orthodox Jews do not usually take pride in and raise severe birth defect children, but American Catholics do. [And American MO HS girls do indeed get pregnant out of wedlock but we dont see corresponding numbers of unwed mothers- practice is not matching theory.] Or I am told by OBGYNs that Hungarian Hasidim in the US take an Israeli approach and rebbitzens can and do decide on ad-hoc terminations of fetuses. I know this introductory paragraph is over-generalized and needs breakdown by demographics and era.

Nevertheless, read this review and ask: what it imply about Israel or Judaism?

The Meaning of (Gestating) Life -Pregnancy in Israel and Japan.
Elrena Evans | posted 4/23/2010

“What’s the book about?” “It’s about pregnancy,” I’d say. “In Japan and Israel.”
This impression in turn led to a developing interest in the lived experience of pregnancy and how it is socially and culturally constructed in different societies.

Although both Israeli and Japanese women experience pregnancy as a highly medicalized event, much as in the United States, the forms that medicalization take differ greatly. And these differences, Ivry argues, are deeply rooted in distinctive cultural contexts: in Israel, a struggle to stay alive amidst constant military conflict; in Japan, an emphasis on the betterment of society through the long-term maternal efforts of child-raising.

If we think of each culture’s implicit understanding of pregnancy as a narrative, Ivry contends, we’ll find that the “protagonist” of the Japanese narrative differs sharply from the protagonist of the Israeli narrative:

In the Japanese arena the protagonist of pregnancy is the interconnected entity of the mother-baby, whereas in the Israeli case the protagonists are the pregnant woman and her suspect fetus.

Pregnancy is conceptualized as an early stage of parenting in Japan and is all about the interdependence of mother and baby and their ongoing relationships. The Israeli model defines pregnancy as a state “in limbo” that involves two separate individuals (of whom only one is a person).

Japanese pregnancies are understood through a lens Ivry refers to as “environmentalism,” by which she means the notion that the mother’s body (and thus her actions, both physical and mental) are responsible for the outcome of the pregnancy—in other words, the baby. To this end, Japanese ob/gyns place strict boundaries on the body of the pregnant woman: she must not gain too much weight, nor allow herself to become chilled, nor submit herself to the bumps and jerks of public transportation.

This assumption that a woman seeking prenatal care intends to keep her pregnancy does not hold true for the Israeli experience. Israeli pregnancies, Ivry argues, are understood through the lens of “geneticism,” whereby the random assemblage of genetic material is the dominant factor in determining pregnancy outcome. The role of the Israeli mother is to try and determine the fetus’s genetic makeup through a battery of prenatal diagnostic tests, and then to act according to the information she receives. Prenatal diagnosis is both widespread and aggressive, and in the event of an “abnormal” diagnosis, abortion is expected.

Ivry categorizes pregnancy for Israeli women as a “risky business.” Unlike the mother-baby dyad of Japanese pregnancies, Israeli pregnancies are strictly woman (not mother) and fetus. “When a woman walks into my office and says ‘I’m pregnant,'” Ivry quotes an Israeli ultrasound expert as saying, “I don’t touch her. I don’t say anything to her, I open a new card, and I write that I recommend an abortion. Then I sign her up on a paper that says that she is aware of all the testing that exists. Now we can begin to talk.”

When pregnant Israeli women contemplate amniocentesis, a diagnostic test that can identify chromosomal abnormalities but carries with it the risk of miscarriage, Israeli ob/gyns routinely frame the decision thus, Ivry tells us: women must weigh the grief of losing a healthy child against the grief of bearing a child with a disability. Nowhere is the grief over losing a disabled child so much as even mentioned; it is taken for granted that a disabled child is unwanted. As for the disabled community in Israel, Ivry notes that “Israelis with disabilities are often quoted in the media as supporting the diagnostic endeavor to prevent the birth of other people who would suffer the kind of life that they endure.”

Update – Serious and Thoughtful Comment by AS

First, I tend to bristle at the term therapeutic abortion when applied to cases where the only risk involved is having a child with a disability. We generally refer to this as selective abortion because it fits in the general category of abortion based on the projected traits of the child. The term is either a deliberate euphemism or a projection of the mistaken idea that anything done in a medical context on the basis of medical information is therapeutic.

In any event, to understand the relevance to Orthodoxy in Israel and America this study should probably be put into the context of three other books:
1) The Tentative Pregnancy by Barbara Katz Rothman
2) Testing Women, Testing the Fetus by Rayna Rapp
3) Reproducing Jews by Susan Martha Kahn
The first two describe how prenatal testing has changed pregnancy in America, the last how technically mediated reproduction in Israel reflects a preoccupation with the need to increase the population of Jews and a reflection of how the fraught “who is a Jew” question gets translated into medical culture. I believe that what the abortion data from israel show is that there is not just a concern with producing Jews, but producing healthy able bodied Jews, and this likely reflects some of the ideals of the halutzim and the like.

Talking with Israeli midwives and doctors as well as other anecdotal evidence (and somewhat confirmed here at the blog a mother in israel is that in the religious Zionist community selective abortion for disability occurs at a pretty high rate. It is also likely that Both R. Waldenberg’s and R. Aviner’s positions contribute to this phenomena.

When we come to American Orthodox communities I can offer the following observations/theories:
The uptake of preconception genetic testing is quite high. and the overall medicalization of pregnancy and childbirth is high as well
While ACOGS pushes for prenatal testing to be offered as a matter of course for younger and younger women, their is widespread recognition among doctors that there are many people who will not abort fetuses with chromosomal abnormalities on principle and therefore refusal of amnio is not completely out of the ordinary. Refusal of ultrasound is unusual.

Medical ethics in America is an established discipline with widely accepted ideas of patient autonomy and “non-directedness” on the part of genetic counselors. Medical ethics in Israel as a distinct discipline is pretty inchoate.

The disability rights critique of routinized testing and selective abortion is unknown to most orthodox Jews, and this reflects the fact that to my knowledge, adult orthodox Jews with disabilities may be reluctant to bring disability rights identity politics into the dialogues they have within their religious communities (the orthodox deaf community is not surprisingly a bit of an exception to this rule)

As far as raising children with disabilities: Modern Orthodox Jews like their larger socioeconomic cohort, have fewer children and tend to share concerns that a disabled child will disrupt their family in various ways and create a situation that is unfair to their other children and that impinges on their lifestyle. American Hareidim have more children but their concern is that a disabled child – especially if it is a genetic trait – will harm their other children’s ability to marry well.
As this is an area that I study I could say more, but don’t have too much time.

One thing I read recently that was interesting and perhaps relevant is Shalom Carmy’s review in the inaugural Jewish Review of Books. I recall the article ending with a claim that while Orthodox Halakha tends to ignore larger ethical motifs (like human dignity/created in God’s image) the way that Christians do, becuase its casuistic approach is more sensitive to the needs of people in particular situations. I take issue to this claim given the actual data on abortion. In short, without a larger conversation about how society views the disabled and how the medical model of disability tends to point toward the elimination of disability by eliminating people with disabilities, one fails to see how the supposed case-by case analysis of Halakhah that ignores larger social questions ends up simply reflecting whatever values tend to dominate. This is especially true when those values become invisible components of what is passed as objective medical information.