- Top of page
- The Israeli context
- IVF in Israel
- The Knesset discussion
- Conclusion: the medicalised narrative and the politics of IVF in Israel
This paper explores the shaping of health policy in terms of power relations and group interests, as enacted in Israel's IVF policy. A comparison with the principles of IVF provision in other countries (UK, Canada, USA) shows Israel's policy to be substantially more ‘liberal’. In order to explain this exception, the policy is initially located within the context of the state's pro-natalist reproductive policy, women's impaired equality and a complex system of healthcare provision. A Parliament Committee discussion on the subject is then analysed in greater detail, revealing three narratives that are used to account for the state's IVF policy: a nationalised narrative of reproductive medicine as a source of international acclaim, a personalised narrative of compassion for anguished women, and a medicalised narrative of experts as being best capable of regulating IVF. All three narratives have merged within the local IVF discourse, enabling the creation and maintenance of consensus among the participating politicians, physicians, consumers and women activists. Of significance is the muted argument regarding the state's interest in enlarging its Jewish population, which dominated other discussions on this topic. I argue that it is the demographic interest which crucially underlies the state's willingness to sustain its costly IVF policy, and that it is this interest which has enabled the various participants – who all shared an interest in unlimited IVF provision – to present a unanimous agreement. State representatives then used this consensus as a firm civil ground for the development and maintenance of Israel's exceptional IVF policy. The paper concludes with several implications regarding women's health and wellbeing.
- Top of page
- The Israeli context
- IVF in Israel
- The Knesset discussion
- Conclusion: the medicalised narrative and the politics of IVF in Israel
The controversies that have surrounded assisted reproduction technologies (ARTs) over the past two decades have by now, to a large extent, been routinised within health policies. These policies reproduce local attitudes towards key issues such as biotechnology, the family and social order, as well as power relations and state interests. Moreover, measures that are initially imposed from the outside eventually influence people's subjectivities and their indigenous norms of conduct so that they themselves contribute, not necessarily consciously, to a government's model of social order. Of major importance in enabling this dynamic is the effectiveness of policies as a mechanism for disguising the goals that their makers seek to advance (Shore and Wright 1997: 5–6, 11). The interests and goals that underpin ART policy, the discourse through which the policy is produced and legitimised, and its eventual consequences, are the subject of this paper.
In the following, I explore the social production of IVF1 policy in Israel. The analysis is contextualised by two main frames of reference. First, in comparison with principles of IVF provision in the UK, Canada, and the USA; and secondly, with reference to broader aspects of the Israeli reality: a pro-natalist reproductive policy, women's rights, and the structure of health service provision. A more detailed analysis of a Parliament Committee discussion on the subject reveals three IVF narratives – nationalised, personalised and medicalised – which are all integrated so as to create a consensus among politicians, physicians, consumers and women activists. I view the narratives, the ensuing consensus and the resulting policy of unrestricted public funding of IVF as being intimately related to the state's interest in extensive ART use to increase fertility among Jewish Israelis. Several potential implications of these policies and narratives on women's status are then briefly considered.
ART policies reflect these technologies’ complex implications. At the societal level is the issue of allocating scarce resources for the benefit of a few; the overshadowing of social causes of infertility (Blank and Bonnicksen 1992, Crowe 1985, Weir and Habib 1997); and the promotion of the social preference of genetic parenthood, and of the white, heterosexual, middle class family through recruiting procedures (Corea 1985, Summey and Hurst 1986, Powledge 1988, Klein 1989, Spallone 1989). Another concern addresses women's readiness to sacrifice their careers and savings for prolonged treatment that might well result in disappointment (Crowe 1985, Franklin 1990, 1997, McNeil 1990, 1992, Stacy 1992, Steinberg 1997). The high costs ($7000–$20,000 per cycle2), frequently not covered by insurers (Guzick et al. 1998), and the low rates of ARTs success (5–20 per cent per cycle; Clarke 1998: 248) are regarded as an additional source of class inequality (Birenbaum-Carmeli forthcoming).
At the clinical level, IVF and its derivatives have yet to be fully evaluated in terms of both effectiveness and risks (Stephenson and Wagner 1994). The increased risk to treated women of developing cancer has not been ruled out (Venn et al. 1995), nor has the risk of increased incidence of congenital malformations (Ericson and Källén 2001 vs. Hansen et al. 2002). More general concerns address the potential consequences of handling gametes and embryos in the laboratory (Vines 1998), the insufficiently-grounded protocols, and the experimental nature of many treatments, which has not always been disclosed to all participants (Wagner 1996). At the same time, ARTs are in high demand from infertile persons, and are strongly supported by many physicians and the pharmaceutical industry.
ART policies, which have had to reconcile the concerns with consumer and expert demand, differ considerably between countries. In some places, critics have dominated the scene and hindered routinisation (e.g. in Canada; Birenbaum-Carmeli, Carmeli and Cohen 2000), whereas in others (e.g. Britain, Australia, Israel; Koch 1998), IVF was implemented before having undergone full clinical testing. The criteria for eligibility for treatment form an important element in these policies, especially state-funded treatment, which influences uptake patterns (Soules 1996, Tarun, Harlow and Hornstein 2002). I precede my discussion of the Israeli case with a brief outline of the principles that govern ART provision in the UK, Canada and USA.
In the UK, ARTs are regulated by the Human Fertilization and Embryology Authority3, but the country as a whole has no national ART policy. Rather, each Local Health Authority decides the scope of its ART funding and the eligibility criteria. Local variations thus abound. In 1998 the National Health Service (NHS) funded an average of 10.8 IVF cycles per 100,000 persons4. Within this, however, local provision ranged from 21.5 to 0.3 per 100,000 (National Survey of the Funding and Provision of Infertility Services, College of Health). In over half of the Local Health Authorities, waiting times were greater than a year. Almost a quarter of UK Health Authorities did not fund ARTs at all. While the pattern evoked critical responses on behalf of politicians and ART advocates, little change appears to have occurred. Since 2000, Cambridgeshire Health Authority, for instance, has not provided ART services, and its Board has openly declared that ‘Assisted conception remains a low priority for resources’5. On the whole, approximately 25 per cent of IVF treatments in the UK are state-funded6, subject to various local criteria7. Given the absence of official information on this issue I quote data published in the popular press8. The most prevalent criteria are said to be the woman's age (the age-limit ranged from 32 to 40), the man's age (40–51), normal Body-Mass Index, and no history of sterilisation for any of the partners. Some Health Authorities added a minimum period of infertility (two to three years) as well as normal sperm count, and excluded applicants who had previously undergone IVF, even if this had been funded privately. All Health Authorities also applied social criteria: applicants should have been in stable relationships for at least two or three years and have no existing children9. Additional requirements included the proven ability to provide a caring environment for the child and an absence of child-related convictions or offences related to domestic violence. Eligible couples were covered for up to two or three cycles, with few exceptions offering one or five cycles. In 1999, most Health Authorities treated several dozens of couples each (36–119). The average cost of each cycle was £4,200–£5,100, and £9,000–£11,000 per ongoing pregnancy (Sykes et al. 2001).
Other countries with public healthcare systems also restrict access to IVF. In Ontario, Canada, since 1994, public funding for IVF treatment has been confined to women with blocked fallopian tubes, who have not undergone tubal ligation. All other IVF indications were not province-insured. Treatment has been limited to three cycles in one's lifetime10. More recent information provides a broader list of IVF indications, all being of a medical – rather than social – nature11. Eligible patients are still obliged to pay an Annual Fee as well as laboratory charges (500–2000 Canadian Dollars). Drug coverage may be obtained from private insurers12. In Australia, the Federal Government has tried to restrict IVF to heterosexual couples despite court rulings that this is discriminatory and substantial public and professional protest (Farrant and Douez 2002, Zinn 2002).
Different rules govern IVF provision in the USA, where health services are privately funded. Four states require full insurer-coverage of IVF, and several others mandate partial coverage. (e.g. in Arkansas – a lifetime limit of $15,000 for fertility treatment; in Hawaii – one IVF cycle; in Illinois – four cycles for primary infertility, and two additional cycles for patients who gave birth in the initial attempt; Ryan 2001: 143). In most other US states, IVF coverage is negotiated with insurers, 80 per cent of whom exclude all ART services (Millsap 1996). The majority of users thus pay for the treatment themselves (Tarun, Harlow and Hornstein 2002). A relatively recent arrangement is that of risk-sharing, in which a fixed number of treatment cycles is offered for a predetermined cost (Stassart et al. 1997).
A major cause for the exclusion of ART from insurance policies is the high cost. Cost estimates, however, vary dramatically. At the higher end of the scale is the oft-cited figure of $50,000–$800,000 per ‘IVF child’ in the USA (Neuman, Gharib and Weinsten 1994). At the lower end are studies of the actual costs, which quote an increase of $0.67–$1.71 per person per month (Griffin and Panak 1998, Stovall et al. 1999). A different articulation equated the cost of three IVF cycles to that of a hip replacement (Bertarelli Foundation Scientific Board 2000). The total expenditure for IVF in the US was $200 million during the year 1997 (Ryan 2001), mostly paid by individual users.
In comparison with these rationed funding patterns, Israel's IVF policy emerges as substantively different. Publicly-funded IVF is provided practically without limitations, for a wide range of indications, with minimal payment at the point of delivery. Women of all ages13, marital status and sexual preference are entitled to treatment, until they have two children from the present relationship14. If required, couples/women may combine IVF with egg/sperm donation, and counselling is not mandatory. In 1996, the Embryo Carrying Agreement Law was passed, making Israel the first country in the world to legalise surrogate mother agreements (Shalev and Lev 1999). Further IVF-related allowances were made by Israeli courts that licensed exceptional provisions such as embryo transfer despite a divorced man's objection or post-mortem sperm aspiration. This exceptional policy needs to be located within the broader context of Israel's pro-natalist reproductive policy, women's status and the structure of the healthcare system.
IVF in Israel
- Top of page
- The Israeli context
- IVF in Israel
- The Knesset discussion
- Conclusion: the medicalised narrative and the politics of IVF in Israel
IVF was introduced to Israel in 1981 and an IVF pregnancy was first obtained in 1982. Since then, numbers of IVF centres have mushroomed, rising from eight in 1985 to 16 in 1989, and 26 at present. These clinics serve Israel's six million citizens, comprising a world record ratio of 1:230,000. Israeli women undergo more IVF cycles than women in any other country. In 1990, 1,800 IVF cycles were conducted per million Israelis, compared with 240 in the USA and 416 in the UK (Shalev and Lev 1999). Indications for IVF have always been broad. As early as 1985, when knowledge of IVF long-term consequences was necessarily scant, IVF was indicated in Israel for endometriosis, mechanical infertility, unexplained, immunology-related, male infertility and ‘other indications that are accepted in the medical literature’ (MoH circular 9.9.85). Since the early 1990s, micromanipulation has been added to many treatments. In 1996, 2,562 babies, comprising 2.1 per cent of the births in the country, were born following IVF. The average success rate is roughly 10 per cent live births per cycle (Ifrah 1999) for women under age 40, and five per cent for older women (Report of the Committee for the National Collection of ART data 1999). The average cost per IVF cycle was estimated at $2,560 and the cost of a ‘take home (IVF) baby’ at $19,267 (Stern et al. 1995), making Israel's annual IVF expenditure roughly 40 million dollars. This expenditure was by and large covered by the state.
The legal-religious framework
Initially approved by the High Committee of Medical Experiments in Human Subjects, IVF was broadly accepted in Israel as morally and socially legitimate and has not been called into question in any significant way. In 1984, the application of IVF was expanded to include single women, although for a limited period and only when using their own eggs19 (MoH letter 5.11.84). Interestingly, the professional committee that recommended making single women's eligibility permanent, justified its view by the needs of dozens of infertile women ‘whose partners agree to marry only after pregnancy has been achieved’ (21.7.85). Lesbian women have also been admitted under the ‘single woman’ clause. Use of donated sperm, which had been regulated earlier (1979), was extended to IVF. Egg donation and surrogacy were initially more disputed, but were eventually licensed, subject to medical, ethical and religious restrictions (Kahn 2000: 112–58). Also licensed was the transfer of embryos to widowed20 and divorced women (subject to the estranged partner's consent; MoH regulations 1986). With the exception of the Embryo Carrying Agreement Law, these rulings are formalised as MoH regulations that have the force of law.
Israel's IVF regulations have been forged in collaboration with religious authorities. Both practitioners and politicians consulted Rabbis and experts and made considerable effort to accommodate their concerns (Israel Medical Association Members Bulletin, September 1985). On the whole, with a few disapproving exceptions (e.g. Jacobowitz, professional committee report 198521, Golinkin quoted in Kahn 2000: 188–90, Ha’aretz 23.1.89), most Rabbis took a pragmatic supportive approach to introducing measures that guaranteed the Jewish and ‘marriageable’22 status of the resulting children (e.g. inspectors in IVF laboratories; Halperin 1988, Kahn 2000: passim). The Rabbis’ acceptance was made known to the general public through the media (e.g.‘it turns out that the Jewish Orthodoxy is more liberal than any other religion when it comes to IVF’, Ha’aretz 18.3.88).
Whilst supportive of women's procreativity, Israel's IVF regulations were not without patronising elements. Thus, a widowed woman is required to wait a year after her partner's death, in order ‘to avoid fertilization in a state of excitement or depression or unbalanced mental response’. She would then need to obtain a social worker's approval that would still have to be ratified by the head of the department (IVF committee member to the MoH General Manager Women 14.09.87). This requirement doubted not only the widow's discretion, but also the competence of the social worker (nearly always a woman), and bestowed the authority for final decision making with the senior gynaecologist (practically always a man), who lacked any training in the domain of mental health and welfare23. Single women, too, were required to undergo a similar evaluation. (In 1996 this requirement was challenged by a lesbian woman who applied for a sperm donation, on the grounds of infringement of single women's bodily autonomy; Kahn 2000: 82). At the same time, the construction of the right to reproduce as an individual right, detached from a prerequisite of a nuclear family, was welcomed by many Israeli women (Kahn 2000: 83).
The demographic concern
Infertility services have always been viewed as part of the country's pro-natalist policy. On the 19th of June 1986, the MoH summoned the country's leading gynaecologists to discuss measures to ‘improve fertility’. Among the experts’ recommendations was a two million dollar allocation to 10 IVF centres, which would perform 1,600 treatment cycles per year, resulting in the birth up to 180 babies (Discussion Minutes). Several months later, when the Inter-Ministerial Demography Team submitted its recommendations (16.2.87), the first one was ‘helping women who wish to obtain fertility treatments’. The team proposed a higher IVF allocation, aimed at the birth of 1,000 ‘test tube babies’ (p. 5). Though the money has never been transferred, the recommendations clearly illustrated that certain policy makers viewed IVF as being an effective solution for infertility. At the same time, the fact that the money has not been transferred also points to the limitations of this notion. In the following years, however, practitioners and activists who attempted to expand ART funding have repeatedly quoted the figure suggested by the Inter-Ministerial Demography Team.
IVF was again considered in the context of demography in an interpellation to the Minister of Health. Referring to the fee that some IVF patients had to pay at that time (up to US $1,000), a right-wing MK24 queried: ‘In this period, when we have an interest in increasing the Jewish population in the land of Israel, what does the Minister intend to change in the health care system in order to avoid a situation that a person may be prevented from bearing a child because of health care costs?’ (5.7.89). The Minister agreed that IVF should be fully state-funded and placed the responsibility for the inadequate funding with the Ministry of the Treasury.
Another explicit tie between IVF and the state's demographic concern was made by Israel's former Chief of Staff and former Minister of Health, MK Mordechai Gur. Bearing the authority of both a security and a health expert, Gur openly contended that ‘IVF is anyway cheaper than bringing in a newcomer’ (January 1987 Olam Ha’isha).
Media coverage of IVF has been extensive and highly supportive, particularly in earlier years, when it presented IVF ‘success stories’ as national accomplishments and symbols of local scientific excellence (Birenbaum-Carmeli 1997). A predominantly positive approach has been retained in later years. Journalists constituted IVF as a sphere of internationally-recognised local pre-eminence (‘Within a short period of time Israel has turned into one of the world's largest fertility empires’, Ma’ariv 30.9.89; ‘[Israel is] one of the five leading countries in the world: USA, UK, Australia and France’, Ha’aretz 7.12.87). Whenever possible, they reported world records (‘World's first: natural delivery following IVF’, Yedioth Aharonoth, not dated; ‘World record: woman aged 60 gave birth to girl’, Yedioth Aharonoth 22.2.94) and glorified the technology and its practitioners (equating IVF with ‘man's first steps on the moon’, Ha’aretz 23.1.89; an article entitled ‘Correcting God's shortcomings’, contrasted IVF with ‘adoption and placing a wish note in the Wailing Wall’, which were traditional methods of coping with ‘God's mistakes,’Ha’aretz 4.2.88). The resulting children were celebrated as ‘more intelligent than the average population’ (Olam Ha’isha January 1987), and the country's ‘first IVF girl’ was depicted on her 10th birthday as ‘a very tall, attractive and intelligent girl, who alleviates any concerns regarding IVF children’ (MoH bulletin 16.04.92).
Presentations of doctor-woman relations have tended to be hierarchical, portraying anguished women seeking help from knowledgeable male experts (‘That woman who keeps knocking on my door day by day, asking me for an egg donation, I can provide her with the redeeming salvation, but someone [i.e. religious restrictions] is binding me’; Doctor Information November 1984). Treatment failure was often attributed to the woman, either by doctors (‘the patients [literally “the sick women”, Haholot] did not respond to treatment’, Shenker November 1954), or by themselves. (‘Every time the pregnancy did not implant, I felt I let myself down’, Hadashot 16.5.88). Impairment was often located in the woman's body, even when referring to problems that were not clearly female-anchored. Immunology-related infertility then became: ‘the woman producing antibodies against her husband's sperm’ (Doctor Information November 1984). Unexplained infertility was re-designated in terms of ‘healthy women, whose tests are all normal but who cannot achieve pregnancy’ (November 1984). Several years later, micromanipulation was presented as a means to overcome ‘the thickness of the egg-surface [that] does not allow the sperm to break through it’ (Ha’aretz 26.6.91). (But –‘A tiny cut in a woman's egg will enable a barren husband to fertilize her’, Ha’aretz 29.5.90). Personal stories portrayed women who gave birth after exceptionally long fertility treatments. (Title: ‘After 44 failed test-tube fertilizations, a woman gave birth to a girl’, Yedioth Aharonoth 1.5.94; a women's magazine praised the resolve of women who underwent treatments for 17 and 20 years, Olam Ha’isha January 1987). At the same time, women's fears of the increased long-term risk of cancer were dismissed as groundless by the country's most senior gynaecologists (Hadashot 23.7.93). Although some criticism has also been voiced, the dominant approach – especially during the 1980s and early 1990s – was clearly supportive of IVF.
Provision and funding of IVF
IVF is provided free of charge, or with relatively affordable fees (up to a maximum of several hundred US dollars), to all Israeli citizens. However, Jewish Israelis tend to make greater use of IVF than their Arab counterparts, who are religiously prohibited from taking up certain procedures (e.g. to donate or receive eggs; Kahn 2000: 132), and are possibly less actively encouraged to undergo treatment (Portugese 1998).
Funding of IVF was initially provided by the Kupot and the Demography Unit, and has since been included in the National Health Law (1995). In 1994, before the National Health Insurance Law came into effect, the Kupot differed somewhat in the services they provided. Two Kupot limited the number of IVF cycles to seven and set a maximum on the woman's age (40 and 47). Additional cycles could be covered by a basic private supplementary insurance. One Kupah required a one-year membership period for eligibility (Shalev and Lev 1999). Generous as they were, these limits were habitually infringed and members could in practice obtain as many cycles as they desired. Moreover, both the state's Ombudsmen and the Supreme Court admitted all challenges to restrictions on access (Shalev and Lev 1999). The most generous IVF provider was Klalit, which practically placed no restrictions on usage. Though this policy derived from its faulty computer infrastructure (that could not trace women's treatment and entitlement efficiently) rather than from professional or social conviction, Klalit's policy became standard provision by the National Health Insurance Law. It is noteworthy that this move has taken place even though all four Sick Funds, including Klalit, wanted to ration IVF.
An MoH attempt in the early 1990s to limit state coverage of IVF to seven treatment cycles resulted in an outburst of intense resentment. In the country's widest-read newspaper, a woman who had undergone four unsuccessful cycles was quoted as saying: ‘No one in the world, including the Minister of Health, has the right to decide how many times I shall try. No one will take away from me the hope to become a mother, even if it takes 20 IVF treatments or more’ (Yedioth Aharonoth 31.08.93). The case of a 45-year-old woman, who delivered a boy after 25 IVF cycles that spanned a decade, was also retold in this context (30.08.92). The plan to limit state coverage has never materialised.
On 21 December 1998, the Knesset Committee for the Advancement of Women's Status conducted a discussion on ‘Fertilization, pregnancy and pregnancy-related social rights in the National Health Insurance Law’. At that time, before the Al-Aqsa Intifadah had begun and the hi-tech bubble had burst, Israel's economy was booming. Although the political turmoil went on, the discussion was conducted within a comparatively stable climate. The discussion sheds light on the inscription of power relations and interests into policy making and, in particular, on the diversity of narratives that were used in the making of Israel's IVF discourse and policy.
The Knesset discussion
- Top of page
- The Israeli context
- IVF in Israel
- The Knesset discussion
- Conclusion: the medicalised narrative and the politics of IVF in Israel
Twenty-five people participated in the discussion under consideration: nine representatives of women's organisations, four MoH officials, four Kupot representatives, three Knesset members (MK), two representatives of the IVF Consumers Association, one gynaecologist, one representative of Israel's Social Security Institute and an MDA25 representative, the author of a comprehensive work on surrogacy.
The three MKs were all women, as were the representatives of the women's organisation, the IVF Consumers Association and MDA. The six male participants were all physicians of which five were gynaecologists. Three were listed as ‘Dr’ and three were ‘Prof’. (only two women were listed as ‘Dr’) With the exception of one woman, the medical establishment was represented by men. Among the MoH representatives, three were physicians. The discussion was chaired by an MK of the Russian immigrant party, a doctor of political history who had not been particularly involved in health or women's issues in the past. In practice, MK Dayan, a veteran Labour activist for women's rights, often took the lead. For the sake of the analysis I present each IVF narrative separately.
The nationalised narrative of IVF
The nationalised narrative played a seemingly marginal role in the Knesset discussion. It was introduced by MK Dayan, who opened the meeting. Dayan praised the progressive nature of Israel's Health Insurance Law and the social enlightenment that was encapsulated in the comprehensive state funding of IVF. The ‘exceptionally high success rate’ was presented by Dayan as exemplary of the country's scientific excellence. The second MK, representative of Israel's civil rights party Meretz, a professor of political sciences, asserted that ‘there is no doubt in this room concerning the principal decision made by the State of Israel regarding the very high priority of pregnancy and fertility’.
The nationalised framing of IVF was not confined to politicians. Professor Dor, a senior gynaecologist, started out by recalling Ben Gurion's26 historic decision to fund fertility treatments directly from the budget allocated to the Prime Minister's Office. While he did not make any further explicitly political allusions, Dor maintained a nationalised overtone by borrowing charged idioms and metaphors from the rhetoric of local politics:
All of a sudden, a tremendous rupture (Shever Atsum) has occurred in Israeli society: the taps have shut down. And they shut down not for medical reasons but for economic reasons. Tomorrow Mekorot27 would turn off the water supply to the whole country because we drank enough! [At the same time], state allowances are granted to certain people who walk around various state institutions, take advantage of state resources and use them cynically for futile ends. Surely futile socially, though very fruitful politically.
Dor's metaphors evoked several sensitive public issues: ‘A tremendous rupture’ sounded alarming in a society concerned about ‘national unity’; in drought-struck Israel, shut down taps conjures up the actual problem of water deficiency; the ‘people who walk around various state establishments’ conjured up images of ultra-orthodox communities who have been heavily funded for decades by all Israeli governments28. Referring to the allocation of public resources to this population, which has long been resented in secular circles, thus constituted the participants as belonging to one and the same ‘camp’, while also suggesting that state resources were available but allocated to other purposes. Other terms which Dor later used had traditionally been associated with collective Jewish predicaments. Such was the depiction of infertile women as ‘beaten by destiny’ (Mukot Goral), the requirement to attend committees – a glaring wrong (‘Avel meshave’ah’), and IVF regulations became decrees (Gzerot), some of which were obviously illegal (Bilti hukiot be’alil29). Still on a collective note, Dor generalised the pain of childless Israelis as more devastating than that of others:
Our public is thirsty for children. In this country, gentlemen [sic!], a childless couple is a beaten couple, socially as well as personally. Each partner in this couple feels himself30 utterly disabled, unable to concentrate on his work. People do not realise their ability to contribute to society because they are so preoccupied with this difficulty and with their bodily defect. I have worked in the US and know American society. There, a couple may undergo one cycle or two but they will not destroy their normal lives. At the most, they will adopt a child, because treatment is very expensive. We are an enlightened state and allow unlimited treatment according to medical indications, but in the US, a couple has to spend $10–15,000, so how many cycles can they afford?
The comparison between ‘our public’ and ‘enlightened state’ to the American scene thus further enhanced the nationalist perspective, while suggesting a moral superiority of Israelis’ craving for children. It also associated childlessness with a diminished personal contribution to the national collectivity. One should note that although these last comments clearly crossed the boundaries of his area of expertise, Dor's opinion has nevertheless carried the authority of his professional prestige.
Still within the nationalist narrative was Dor's representation of the contribution of fertility experts to the country's international prestige.
New technologies are mushrooming like crazy . . . And we have to spend whole days writing letters for this woman. The professional quality deteriorates only because of the forms we have to fill in. The field of reproduction has turned Israel into a medical empire [admired by] colleagues from England and France, from very enlightened countries. But if we don't work on breakthroughs, then colleagues abroad will overtake us, and believe me, Israel's prestige, promoted at an international conference, is not less important than attending committees and trying to convince some people that we are right.
Dor then constituted administrative requirements as a hindrance to medical research. Utilising the image of a rapidly progressing technology (a claim which some experts contest, Wagner 1996), he foresaw the erosion of the country's medical standards and prestige, which would affect its reputation more generally. It is noteworthy that the speaker never mentioned doctors’ own interests. Also significant is the absence of any explicit reference to the demographic issue, which prevailed in official documents, especially in previous years.
The personalised narrative of IVF
The personalised narrative of IVF dominated much of the discussion. Participants endorsed the general image of female vulnerability, which also prevails in other spheres of Israeli culture (Sered 2000: 4–6), as well as in foreign IVF contexts (Franklin 1990, 1997: 88–93), and dwelt on the agony of infertile women (always women), whom they depicted as requiring patronage and medical treatment. The first to use personalised language was MK Dayan, who opened the discussion:
It is heartbreaking. Some women who apply for IVF after the fifth cycle, are being told that ‘it is too expensive, you are not entitled to additional treatments’. And then the woman has to implore, or if she has money, she tries to obtain it privately.
Two elements in Dayan's presentation are of significance. First is the contention that finance-driven restrictions on IVF provision exacerbated women's agony and were therefore unacceptable. This statement was the first note in a long series that de-legitimised such measures as inhumane. Second is Dayan's reference, in her last sentence, to the ambiguity that surrounded treatment provision at the time. The Kupot, attempting to economise, often tried to contain treatment (e.g. to confine the woman to a specific clinic). Women were, however, well aware of the ambiguity and therefore negotiated the terms of provision. These patterns resulted in women requesting and receiving treatment as personal favours. Although such a negotiation of one's entitlement also prevails in other contexts of service provision in Israel (Handelman 1981, Sprinzak 1993), in the sphere of fertility treatment it enhanced the image of helpless women as depending on male officials and professionals. Treatment then became a gesture towards the weak rather than a woman's legitimate right. In this respect, the personalised narrative of IVF used a language of vulnerability and compassion rather than a language of rights.
Women's helplessness vs. the Kupot was soon concretised by the gynaecologists, all men, who had ample examples to present. One doctor described a woman who had received treatment following a legal suit against her Kupah. The woman was informed, however, that if the Kupah's appeal was successful, she would have to reimburse the costs. Using dramatic language, the speaker described the woman's vulnerability:
The Kupah's sword is threatening that, God forbid, if she fails [in court], she will be charged for the treatment and will have to mortgage her home.
In another example presented by a gynaecologist, the personalised narrative of compassion merged with that of nationalism:
There is this woman, a police officer who works day and night for the country. She is 42, dressing up as an old woman in order to catch rapists and murderers who threaten to kill their wives. Day and night for the country, risking her body and soul, and she is standing weeping at the door of some committee, and finally reaching psychiatric treatment. A commander in the Israeli Police, 42 years old, whose sandglass is running out, and she needs to go to a committee! Why? Because someone has taken the law into his hands in a way that cannot go on! I am telling you that the pain of these women hurts me, and I think it must stop.
Thus, even seemingly powerful women, who succeeded in operating the legal system or contributed to the country's welfare through a non-traditional career, were still portrayed as essentially powerless vis-à-vis the system. They, too, were frightened and weeping, and needed a male doctor to advocate for them. Again, it was compassion, evoked by the particularities of each case (fear, agony, contribution to the country), rather than generalised civil or human entitlement, that were constituted through the personalised narrative as justifying unlimited fertility treatment.
Female participants shared this narrative. The MDA representative conjured up the image of a passive, helpless woman whilst describing her cousin's ‘dreadful anxiety’ that she might not be granted the next treatment. The representative of the IVF Consumer Association generalised her own sense of worthlessness to all IVF patients.
All women – lawyers, psychologists and others – with fertility problems, share the feeling of being zero. Professionally, I am the head of a welfare department, but the moment I walk into the Kupah, I feel like a zero. I must struggle with bureaucracy, I have to explain to my boss why I miss so many workdays, why I spend so much time in the Kupah. I cannot go on living my life normally. The intensity, the extreme dependence on the health care system and the non-human bureaucracy just annihilate us.
Here again, a mixed message was conveyed. On the one hand, the speaker put forward a professional identity and took the liberty of criticising IVF procedures as failing to accommodate the needs of employed women. On the other hand, emphasising and generalising a sense of worthlessness to all childless women reproduced the notion of motherhood as the paramount source of meaning, even in the lives of professionally accomplished women. Indeed, the speaker's claim that all IVF patients shared the experience of ‘being zero’ explicated the patriarchal approach that had been implicit in the male experts’ presentations.
The founder and head of the IVF Consumer Association voiced a more pro-active, somewhat defiant stance. Speaking of a woman who had had to start medication three days before her referral form was due, the speaker claimed that such bureaucratic impediments were unacceptable, and flaunted her defiant advice to the woman: ‘buy the expensive medication now, and make the Kupah pay for it later’. Thus, rather than dwelling on the woman's stress, this female activist offered a more resistant response. Given the country's supportive attitude towards IVF, which was – and continues to be – manifested, amongst other ways, in the courts’ tendency to approve women's requests, the recommended strategy was likely to be fruitful. This approach stood, however, in contradistinction to a gynaecologist's presentation of women's law suits against their Kupot as indicating the extent of their suffering: ‘Where did it happen in this country that a woman went to court? What happened?’
The disempowering attitude towards childless women was facilitated by the elimination of men from the scene. Neither as infertile persons, nor as the treated women's partners, were men mentioned in the Knesset discussion. While male infertility is responsible for approximately half of all infertility cases, and although IVF has been applied to resolve male infertility in Israel since the mid-1980s, the speakers all referred to infertility and IVF as female problems and interests. Such a feminisation of infertility and its medical treatment was easy for the participants to produce, given the broader local view of women as fragile, and in need of male protection. It also reflected the dichotomised notion of maleness/health as the normative human condition, vs. femaleness/illness as requiring supervision and treatment (Sered 2000: 2)31. Within this context, the consensus regarding unrestricted provision of IVF carried the meaning of healthy men alleviating the suffering of impaired women. However, having said that, in the analysed discussion, I view the personalised narrative of IVF and the image of women's vulnerability sustained by this narrative as a means, not less than an end in itself. I elaborate on this point further in the concluding section.
Consensus and criticism in the Knesset discussion
Throughout the discussion all the participants agreed that IVF advanced the country's reputation, and that infertile women endured great suffering and should therefore be granted unlimited state-funded treatment. Challenges to the policy were construed as challenges to the principles that underpinned it (Shore and Wright 1997: 11). In the present context, this meant a challenge to the country's international acclaim, and even more so, to the utmost significance of childbearing in women's lives. Bureaucratic restrictions that interfered with women's hope to accomplish this goal could therefore be rendered unacceptable. The articulation of this consensus in a policy-making discussion, which was to be documented and made available to the general public, was an important ritual of democracy that endowed the local narratives of IVF with institutional authority. It demonstrated that officials across the board, beyond political, professional and gender identities, all shared the same view of IVF and its appropriate provision. The technology, as well as the country's exceptional policy, was thereby ethically and socially de-problematised, constituted as a service that required proper budgeting.
Interestingly, the consensus was sustained even through criticism, used by the participants in the Knesset discussion as one more mode of displaying their agreement. On the part of physicians, consumers and activists, criticism was exclusively directed towards the Kupot. The doctor ‘lamented’ the time he and his colleagues wasted filling in forms. The consumer representative blamed the Kupot for ‘playing God’. The women activists claimed that they had taken the law into their own hands, and the MDA representative contended that the clients had paid and were therefore entitled to service.
The Kupot representatives, in their response, whilst being the major target of criticism, actually joined in the consensus. The most senior Kupah official was also the head of the Gynaecology division in Jerusalem's main hospital. In his response, he fully agreed that women were entitled to unrestricted state-funded IVF. Moreover, he elaborated on the Kupot's discomfort when facing the women empty-handed, unable to provide a service, which they considered justified. The Kupot themselves, so he claimed, were victims of ‘the total collapse of the health care system,’ for which he blamed the state. (i.e. the Ministry of Treasury, rather than the MoH). This line was reiterated by the representatives of all the Kupot.
At this point, when the charges were openly directed towards the state, the MoH representatives, both gynaecologists, responded. The first speaker made the single comment in the meeting that called attention to the risks of IVF:
We must not live in a dream that IVF is risk-free . . . in two per cent of the cycles serious complications may occur, and may be life threatening . . . Doctors must calculate the risk/benefit ratio for every case. If we take a 45-year-old woman, her chance to conceive and give birth to a child by IVF, according to all the surveys in the world, is zero.
This piece of information was altogether rejected by Dayan, who reframed it:
I am not talking about exceptions. I am talking about fertility age population in Israel, that does not receive the service it is entitled to and these are not the two per cent. I am not talking about the risk. I am talking about the population for whom – by all the statistics – it may work, if not within five cycles, then within 10 cycles, and sometimes on the 12th cycle. I am asking a simple question, and there is no point in complicating it: Why does not every woman entitled to IVF in Israel receive full funding for the treatment, for any number of cycles, in the best centres, why does she not get these treatments?
In the favourable climate regarding IVF in Israel, this female Parliamentarian, with a sound record in the sphere of women's rights, dismissed IVF-related risks as a marginal issue that the state representative possibly overstated. In fact, this response may itself be viewed as imprinted by the country's consistent pronatalist policy, to which Israeli feminists also subscribe. Determined to block a shift of focus, Dayan redirected the discussion to technical aspects of the issue32. The dismissal of IVF-related hazards is particularly significant given the fact that six weeks later (on 1.2.00), in a meeting on egg donation policy, the risks to women's health were the heart of the discussion. In fact, such risks were repeatedly highlighted in both professional and popular media, whenever the issue of egg donation was raised (e.g. letter by the Head of Gynaecology, Sheba Hospital to MoH, 23.9.85; letter of the Deputy General Manager of the MoH to the Minister, 2.7.95; Maariv 10.9.95). Dayan's approach thus illustrates how in Israel, unlike some other countries, local female activists helped construct IVF as a benign effective therapy. Dayan's reframing was apparently successful as no risks were mentioned further in the discussion.
Alongside the dismissal of health risks, the absence of ethical or social concerns is instructive. Moral issues that had for years troubled governments, feminists and consumers abroad, as well as arguments that public and private service providers had mobilised to justify restrictions on funding (that infertility was a social, not a medical problem, and that the clinical effectiveness of IVF was unproven; Hughes and Giacomini 2001) have never been raised by Israeli providers. Moreover, with the exception quoted above, no representative of the Kupot or the state tried to justify moderation in use of IVF in terms of women's health, or with reference to the glorification of biological motherhood/parenthood (as was the case in Ontario, Canada; Giacomini, Hurley and Stoddart 2000). This silence may indicate the unacceptability of ethical and social contestation of IVF in Israel's pro-natalist climate. It may also suggest, however, that owing to its demographic concerns – which were not raised in the meeting in question – the state of Israel did indeed have an interest in pervasive use of IVF and therefore did not try to rebut advocates’ arguments in the first place. If this was indeed the case, then even reluctant politicians and service providers, like the more critical speaker above, could only join the majority in privileging pro-natalism over ethical, economic and even health concerns. The second MoH representative thus restored the consensus by affirming the previously-aired view of IVF as an undisputable service that merely required proper budgeting and regulation:
There is no dispute in this room that [IVF] belongs to the health service basket and that every woman is entitled to treatment for up to two children. No one questioned it and there is no intention to change it. This is the basis, which remains. The question is how to obtain these two children and this is today's discussion, as are the differences among the Kupot.
One should, however, note that the unreserved consensus displayed by the participants also reflected the composition of the meeting participants, that is to say that none of the few officials who might have held different opinions were present. One such example is the previous Health Minister who suggested that a limit be placed on IVF provision. The others are two senior MoH officials who produced an internal paper exploring the option of IVF rationing during the same period. Neither was any Israeli Palestinian present. In other words, as broad as the IVF consensus in Israel may appear to be, it is not all-encompassing. The selection of participants for the discussion may thus be taken as yet another strategy used by the state in order to advance its interest in furthering the use of ART. From this perspective, the consensus that the participants displayed may be understood in terms of the active elimination of potential disagreement, fabricated beforehand by calculated recruiting.
Conclusion: the medicalised narrative and the politics of IVF in Israel
- Top of page
- The Israeli context
- IVF in Israel
- The Knesset discussion
- Conclusion: the medicalised narrative and the politics of IVF in Israel
Two main narratives have so far been identified as constitutive of Israel's IVF discourse: a nationalised narrative of procreative medicine as advancing the country's international acclaim, and a personalised discourse of IVF as a benign effective therapy offering hope to anguished women. These narratives, enhanced by the silencing of treatment-related concerns, presumably placed IVF beyond the confines of ordinary policy-making considerations. As in other policy-making contexts (Shore and Wright 1997: 9), experts were located in a more advantageous position than anyone else. They were the ones who advanced the country's reproductive science and the international prestige attached to it, as well as the ones who could allegedly alleviate women's suffering. The stage was set, then for the addition of a third, medicalised narrative of IVF.
The desirability of privileging medical experts in the context of IVF was agreed upon by all the female participants. MK Dayan preferred that ‘purely medical considerations’ should determine the age limit for IVF patients. The consumers’ representative asserted that ‘The lady's [geveret] doctors, and they alone should decide’33, while the Women's Organization's representative ascertained that she ‘would never leave this matter to politicians’. A (male) gynaecologist voiced a similar view:
We are not politicians. We have clear medical conclusions. These conclusions will solve, so I think, the problems of most women [sic] . . . Therefore, the medical element should prevail. The doctors have the same goal and it is a common goal and there are no conflicting goals.
The ability to present doctors’ considerations as superior to politicians’ relied on the formers’ alleged disinterestedness. Throughout the meeting, doctors’ special interests have been consistently overlooked, even when fairly obvious. (e.g. when the head of the obstetrics/gynaecology division in Jerusalem's main hospital suggested that smaller IVF units should be integrated into fewer larger ones, which was quite clearly in his interest.) The implications of funding structures on doctors’ careers and income prospects have never been mentioned.
Equally important for the unproblematic privileging of experts’ views, was the construction of medical guidelines as both ‘pure’ and clear cut. The obviation of the political facets of the medical language itself (Seguin 2001), which this presentation entailed, can be illustrated via exchanges that took place during this very meeting. A women's organisation representative told the audience of her relative who had conceived after nine IVF cycles and then, for the second time, after eleven additional cycles. This line was reinforced by a gynaecologist, who mentioned two women who had conceived after 11 and after 24 IVF cycles and then generalised that the number of required IVF cycles was ‘a purely medical decision, to be made only by experts’. Yet, the gynaecologist who highlighted ‘belated IVF successes’ had himself headed a study a short period before the Knesset discussion, that illustrated the significant reduction in the effectiveness of the technology with every additional cycle (Dor et al. 1996)34. Whilst not fully contradicting his expressed stance, the doctor made no reference whatsoever to this knowledge in his Knesset presentations.
The prioritising of professional knowledge and authority in general, and in the field of IVF in particular, was obviously not the product of the Knesset meeting alone. Rather, the meeting seemed to reinvigorate a line that had advanced the interests of every participating group for quite some time. Doctors could obviously benefit from officially governing IVF, which could translate into greater freedom for experts, into some moderation of administrative requirements, and was in itself an accomplishment for professional politics. IVF consumers and women activists, who accepted the view that unlimited treatment was in women's best interests, could consider gatekeeping carried out by doctors as a guarantee for the continuation of generous provision. Other actors who would probably have been supportive of this mode of doctor-centred regulation were religious officials, who had obtained doctors’ collaboration in shaping IVF procedures so as to conform to even strict Orthodox requirements (Kahn 2000: 169–70).
One party that was more likely to be more reluctant were the providers, i.e. the state, which would have to continue funding the costly treatment. However, state representatives, too, expressed their support and flagged their continued reliance on medical recommendations for policy making35. This supportive approach can be understood on two inter-related levels. First, it may well be the case that the state representatives indeed agreed with the other participants regarding the importance of IVF. Being Israelis and doctors themselves, they probably shared the view of reproductive medicine being an important field of practice and of national excellence, and of childbearing as being a paramount goal in one's life (especially in women's lives). Secondly, however, one may suspect that given the chronic financial constraints on the state's healthcare budget, IVF provision would also have been rationed in Israel, had it not been for the demographic interest. In other words, the political interest in enlarging the state's Jewish population – which accounts for Israel's broader pro-natalist reproductive policy – has probably underpinned the state's unlimited funding policy as well.
Accounting for the silencing of this argument in the Knesset meeting seems fairly straightforward. Rather than raising a sensitive political issue, state officials could endorse the seemingly passive role of a consenting party. Establishing the state's position as appreciative of women's needs, of activists’ demands and of practitioners’ requirements, was a considerably less contestable route to accomplishing their goal. For most Israelis, the country's demographic concerns, whilst also present in popular consciousness, were quite removed from their personal quest to have children. In the climate of prosperous late 1990s Israel (and before the outbreak of the Al-Aqsa Intifada), individuals’ wishes to bear children were thoroughly private affairs. The idea that these unborn, much-desired children were pawns in the harsh reality of the regional conflict, might well have been resisted by many Israelis as well as by some of the participants present in the Knesset meeting. Thus, rather than declaring the state's readiness to invest public resources in increasing Jewish fertility, Israeli politicians shared the accepted language of national pride, human compassion and professionalism.
In this respect, the Knesset discussion regarding Israel's IVF policy exhibits some general characteristics of policy making. One may start with the very handling of the subject in the Committee for the Advancement of Women's Status, which may be understood as the removal of a politically intricate problem to a less politicised institutional context (Dreyfus and Rabinow, quoted in Shore and Wright 1997: 8–9, Luhmann 1982: 116). In this relatively marginal sphere of Israel's public life, the discussion could be narrowed down to the uncontested view of children being of utmost significance for women's lives. Having established this frame of reference, any challenge to the policy could be delegitimised as calling the underlying moral assumption into question. Given the strength of the family in all walks of Israeli society, and the added support provided by the alleged contribution of IVF to the country's international prestige and by experts’ recommendations, the personalised narrative of childless women's agony could qualify as the policy's motivation. As such, this narrative could not only veil the political quality of the goals that underlay it. It could also naturalise the exceptional policy in terms of women's desire for children, thus locating it beyond dispute or criticism.
In conclusion, one should consider the implications of Israel's ‘liberal’ IVF policy, and of the narratives used throughout the production of this policy, on Israeli women. On the one hand, many women (and men) benefit greatly from the state funding of IVF. This benefit should not be underestimated: the availability of treatment to persons of all classes, marital and sexual identities obviously serves the needs of people who could not have afforded it otherwise. The same funding structure also encapsulates a potential for some social change and the acceptance of less traditional family formations. (Indeed, the number of unwed mothers in Israel has grown over the past two decades, as has their social acceptance.) On the other hand, both the content of the policy and the narratives used for its production and legitimation also reveal fewer woman-friendly aspects of Israeli pronatalism. At the bio-medical level is the exposure of Israeli women to a record number of IVF cycles per capita, which coincides with the marginalisation of ART-related problems. Alongside the powerful influence of the family-centred climate and of state funding, women's readiness to undergo prolonged treatments is also forged by the near absence of an awareness of such risks, and of the decreasing odds of conception after several unsuccessful cycles. The dismissive response to the more cautious doctor in the Knesset discussion clearly illustrated this perception. On a broader societal level, the near absence of awareness or activism regarding the social implications of extensive ART use is instructive. As mentioned above, Israeli feminists are largely absorbed by the prevailing notions and hardly present any alternative, resisting voices. Both experts and the media tend to highlight stories of exceptional success, which praise the resolve of ‘heroic women’ who had refused to give up. All these factors seem to have contributed to the willingness of Israeli women to undergo prolonged drastic treatments, which may now be understood as partly exploitative, manipulating women's bodies, desires and life trajectories, (also) for the sake of the state's interests. After all, IVF is always ‘cheaper than a newcomer’.