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.

8 responses to “Pregnancy Ethics in Israel and Japan—Updated by AS

  1. The blurb is thought provoking. However, nowhere does the article indicate it is about religious Israelis.

    Additionally, it would seem that whereas in the US amniosynthesis is meant primarily as a way for the mother to know some crucial facts about the health of her baby (she may want to keep a disabled child but wants to be prepared and informed), the Israeli scene painted in the article shows that obstetricians performing amniosynthesis already assume that there may be something wrong and that that will lead to an abortion. That surely impacts who chooses amniosynthesis, and skews the results of any poll of women seeking that test.

    I am now also less surprised at R’Eliyashiv’s view prohibiting amniosynthesis outright. The Israeli medical establishment is obviously strongly tilting in favor of aborting disabled foetuses.
    However, quite a number of MO rabbinical figures, particularly the noteworthy poskim (not to make a judgment call, let’s just define these as those who are commonly perceived as those one turns to with the difficult halakhic issues), harbor serious intellectual reservations regarding these lenient views. In YU, R’ Moshe Feinstein’s view on abortion was given much more consideration than R’ Eliezer Waldenberg’s. The same goes for end of life issues.

    While you may reasonably posit cultural osmosis regarding the incorporation of experiences in reaching practical psak, I think that regarding the academic analysis of the sources, the process is a lot more (but not entirely) objective, biased only to tradition (i.e., what was done in recent historical memory). Hence, I believe it is an error to consider possible cultural influence from Evangelicals, but to leave the academic convictions of internal opinion leaders out.

    • Sorry, I am not implying anything at all about pesak. Wrong blog. I know the book is not about religious Israelis, that is why it provides a great starting window on society.

      Your insight about Rabbi Eliyashiv is correct.
      I am now also less surprised at R’Eliyashiv’s view prohibiting amniosynthesis outright. The Israeli medical establishment is obviously strongly tilting in favor of aborting disabled foetuses.
      On the contrary about theoretical discussion, we have witnessed a move from the 1970’s where MO argued how different it was than the Christians to the current approach is how close we are despite the halakhic exceptions. The articles by the talking heads in journals have changed the most and reflect the culture wars.
      If there is a gap, it is between pesak and actual practice, and one gets a sense that it runs counter the pesak- but we will never get a truthful statistic.

      • about theoretical discussion, we have witnessed a move from the 1970′s where MO argued how different it was than the Christians to the current approach is how close we are despite the halakhic exceptions.

        True. That should be right up your current professional alley. Would the reason not be that once upon a time, for the Western Jew, the threatening other was a Christian, while nowadays it is the hypersecular <insert popular cause> rights activist?
        Nowadays, interfaith activity may increasingly be seen as a way to stem the tide of secularism.

  2. AS-
    Thank you so much for another wonderful comment- I am debating whether to make it into its own post. It does not read like one but it has the gravity of a post.
    Update- It became part of the post.

  3. Amnio is refused much more than ultrasound because of the high risk (relatively speaking) of it inducing abortion. Ultrasound has no such risk, or an immeasurably small one.

  4. A friend of mine was doing an OB rotation at a hospital frequented by chassidim. A doctor she was working for was apparently very pro-abortion and prided herself on, e.g., creative interpretations of statutes to allow abortions later in pregnancy. Said doctor explicitly told my friend she thought disabled babies should be aborted, and that she would lie to chassidic women about the severity of their fetus’ birth defects so that the women would get abortions.

    At some point I began to wonder (pure speculation) whether there was some complicity on the part of the chassidim. Something like, they see abortion as permitted if the fetus is X, but not Y. But they might also want to abort for Y, so if the doctor says X they don’t ask too many questions about whether it really might be only Y. Or even collusion – that they may know it’s Y, but the doctor says what she knows they need to hear to “allow” abortion.

    I have no basis for believing this occured in the context of abortions, but I wondered because the general idea of privileging the words of the doctor over the factual situation they do or do not represent does happen. Example: I also had heard the folowing from another friend, a grandmother: when she was having her kids (presumably in the 70s) the way to “get a heter” for contraception was for the husband to tell the doctor that his wife was so stressed out she was hitting the kids (or maybe that the husband was afraid she would). The doctor would say she had to stop having kids, and the husband would bring that “psak” back to the rabbi.

    By outsourcing a lie to a doctor people can invest it with enough “expert” authority to feel that the psak that results from the lie is legitimate. This is related to to AS’s point about the unconscious reflection of dominant values – perhaps just a more exteme example of how it occurs.

    On AS’s point re: able bodied jews, it seems to me that rav aviner’s psak is about as explicit on that as it could be

  5. MBG= I have heard that besides the outsourcing, the Hasidic community itself has a vision of the fetus that encourages it. There is lots of good material in the “mother in Israel” post. As long as we speak about axiological ideas we avoid the actual reality of the porcess, we also obscure the conceptions of motherhood, fetus, and childbirth.

    • I don’t know if this responds to your interests, but here are some of my own anecdotes…

      My experience has been that there is a profound lack of any distinct conceptions of childbirth, and probably pregnancy also, in the so-called MO world. The model of childbirth was the standard American medical model (again I think this helps rabbis avoid having to fully answer, and take responsibility for, difficult questions) and I was really at a loss to see any vision of gestation at all. Pregnancy talk among the women I know from shul was about ultrasounds, prenatal yoga, and eating sushi while pregnant, and was very much like pregnancy talk with other yuppies. I basically never heard about any of the (alleged) minhagim one can read about in yeshivish pamphlets, and nothing about introspection or self-improvement for the baby’s spiritual sake.
      Perhaps I just didn’t know where to look, but i think the MO adoption of what was previously a male model of religiosity (e.g., learning and synagogue attendance) as a quasi-gender-neutral norm has really cut off thinking about a lot of woman-specific ideas.
      The only area in which i felt any push-back against the standard conceptions of my secular counterparts was the idea that halacha can still ask physically difficult things of pregnant women (eg, fasting) – whereas i found in secular society a horror that (white, non-poor) pregnant ladies, especially in the third trimester, could be asked to do anything other than sit on the couch gestating.

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