JOURNAL
ISSUE 4
2001/2002
Involuntary
Childlessness in Israel: The Need to Cope with Discriminating
Family Policies
Zmira
Laufer, Ph.D.
Ron Laufer, M.D., M.P.H.
ABSTRACT
Involuntary childlessness is a social problem shared by different
societies and cultures. The twentieth century has witnessed
advanced fertility treatments being added to more traditional
solutions such as foster care and adoption. In Israel, childless
people are presented with a variety of welfare and medical
solutions, which are offered under an inconsistent social
policy. This policy, which reflects the complex social and
professional environment in Israel, engenders various professional
dilemmas among different disciplines, including the social
work profession.
Among the issues that the social work community must address
are the built-in inequalities in policies intended to provide
assistance to childless people and securing the best interest
of children. These biases point to new directions for professional
intervention not just on the previously studied clinical level
but more importantly, on the macro policy level.
INTRODUCTION
One of the most complex struggles which can be seen recurring
throughout human history is the pursuit of couples and singles
to achieve the status and fulfill the role of a parent. This
struggle has been propelled primarily by two basic motivational
forces: first, existential physical needs, as parenthood guarantees
a "next generation" that can supply for individuals
the food and protection they need in their old age. Second,
the individual's emotional need to belong to society through
parenthood, which means belonging to the normative club of
parents and preventing the need to cope with the stigma of
being childless (Miall, 1989), or through motherhood in a
social environment in which social norms dictate that women
are fulfilled only by motherhood (Shalev, 1989a; Blyth, 1993;
Yishai, 1998).
It is no wonder
that this very important human struggle has been documented
in every era. Among the oldest and most well-known experiences
of coping with the inability to become a parent is in the
Biblical story of Abram, Sarai and Hagar: "Now Sarai
Abram's wife bore him no children; and she has a handmaid,
an Egyptian, whose name was Hagar. And Sarai said unto Abram:
'Behold now, the Lord hath restrained me from bearing; go
in, I pray thee, unto my handmaid; it may that I shall be
builded up through her.' And Abram hearkened to the voice
of Sarai. And Sarai Abram's wife took Hagar the Egyptian,
her handmaid, after Abram had dwelt ten years in the land
of Canaan, and gave her to Abram her husband to be his wife"
(Genesis 16:1-3). Even today, certain cases of childlessness
have received international attention, especially those involving
surrogate mothers as in the stories of "Baby Cotton"
in England (1) (Cotton and Winn, 1985) and "Baby M"
(2) in the US.
At the close of
the twentieth century, the world of childless people has become
more and more complex in the presence of rapid social and
medical developments which have provoked a series of ethical,
professional, theological, philosophical, judicial and economic
dilemmas. Because of its complexity, the issue is still very
much in the public eye and has awakened the need for more
activism among the relevant disciplines.
The first part
of the paper is a short overview designed to clarify the essence
of the problem on involuntary childlessness (IC) and provide
an acquaintance with the available social and medical solutions
to the problem. Next, we present the current social policy
regarding IC in Israel, which raises a range of dilemmas among
different disciplines. The discussion focuses on the unique
status and commitment of the social work profession in relation
to this social problem and in particular, to aspects of intervention
on the macro level.
INVOLUNTARY CHILDLESSNESS
IN AN ERA OF CHANGE
Involuntary childlessness (IC) may be defined as a situation
in which individuals or couples desire to become parents and
have difficulties realizing it.
This definition
emphasizes two basic elements of this paper's ideational perception.
First, the problem affects couples and single persons alike,
and second, couples and singles may be perceived as involuntarily
childless only if they desire to change the situation.
Present policies
on IC are the outcome of two major processes of change that
took place in the second half of the twentieth century. The
first process, of a social nature, is characterized by a sharp
decrease in the number of children available for both foster
care and adoption - two traditional, acceptable and common
ways for dealing with childlessness. Today, statistics show
a continued increase in the number of couples registered at
adoption agencies as well as in the number of years these
people must wait (Miall, 1989; Jaffe, 1995). This significant
decrease can be seen to be the result of:
- the development
of effective means of birth control (e.g., the pill) and
their widespread use;
- liberalization
of abortion laws to allow more women to decide for themselves
or with the assistance of health and welfare practitioners
to stop unwanted pregnancies; and
- the creation
of openness and support for nontraditional parental patterns
such as unmarried single mothers, or single-sex parents.
It should be noted that the latter development may act in
two directions. On the one hand, it may reduce the number
of children available for adoption since women will be raising
their children by themselves rather than giving them up
for adoption. Yet on the other hand, same-sex couples may
put pressure on the available children by demanding the
right to adopt a child themselves, since they may also suffer
from the general population's infertility problems or because
the couple's gender makes procreation an impossibility.
The second process
of change, scientific by nature, has to do with the treatment
of infertility problems. The medical options offered to infertile
persons are the result of significant scientific progress,
both in the understanding of different pathologies that may
cause infertility and in the diagnostic and therapeutic techniques
for these pathologies.
The scope of possible
therapies offered to men and women range from hormonal medication
up to assisted reproductive techniques (ART). The most well-known
ART is "in vitro" fertilization (IVF) in which the
oocyte is fertilized by sperm in the lab and is then implanted
back in the woman's body.
The new medical
technologies available today enable doctors to expend greater
efforts in order to help specific people express their potential
to give birth, by either manipulating sperm or ovum. These
abilities also permit other people to participate in the birth
process, by donating sperm, ovum or even a womb, if surrogate
motherhood is needed.
At present, the
possible solutions for IC can be divided into three groups:
non-biological, biological which do not require an additional
partner and biological which do require an additional partner
(Table 1).
Table 1: Solutions
for childless couples and individuals (3)
- Non-biological
options
- Short-term
foster care
- Long-term
foster care
- Open adoption
- Confidential
adoption
- Biological
options
- Hormone
therapy requiring another party
- Assisted
fertilization
- Biological
options - requiring another party
- Sperm
donation
- Ovum donation
- Sperm
and ovum donation
- Ovum donation
and surrogacy
- Sperm donation
and surrogacy
- Sperm
and ovum donation and surrogacy
It can be argued
that in purchasing a pregnancy, sperm and ovum are essentially
identical to the biological process that occurs in adoption
except for the fact that this is a type of "reservation
ahead of time" of the child to be adopted. However, due
to the lack of data about the frequency of people opting for
this solution, and since massive biological interventions
are required, this solution was included in the group of biological
options.
INVOLUNTARY CHILDLESSNESS
IN ISRAEL
Israel is a state with two prominent social features. First,
it is a society of immigrants, having absorbed massive waves
of immigration of different cultural groups from developed
and developing countries. Second, modernity and tradition
co-exist in Israel. On the one hand, Israel is an industrialized,
urbanized country, yet on the other hand, religious and traditional
values play a central role in it (Shalev, 1989b; Kurazim,
1997).
Today, the pluralistic
and diverse Israeli population has before it a wide range
of social and medical alternatives and the complexity of the
Israeli society have transformed the country into a living
laboratory for all these alternatives.
INVOLUNTARY CHILDLESSNESS
AS A SOCIAL PROBLEM IN ISRAEL
A sociological definition states that a social problem is
"an alleged situation that is incompatible with the values
of a significant number of people who agree that action is
needed to alter the situation" Rubington and Weinberg,
1989, p.4). Examining the problem of IC in Israeli society
shows that all four characteristics exist and hence we can
speak of this issue as a social problem.
a.) An alleged
situation - It seems that the problem of IC is unable to disappear
from the public agenda in Israel. In the mass media (newspapers,
television, cinema and radio), the problem has been widely
reviewed. The combination of family issues, ethical dilemmas
and biotechnology, together with dramatic personal stories
make the topic an "all-time favorite."
The problem also
continues to be a "burning topic" on professional
levels. The medical developments, which occur with such high
frequency, engender situations requiring extended efforts
to resolve contradictions between these developments and ethical
codes. These efforts can be seen by the quantity of publications
in professional journals relating to different aspects of
childlessness.
b.) Incompatibility
with the values - Different sociological studies have established
that Israel is characterized by being a "family society"
in which children are highly valued, not only by their families
but also by the community, and which the children's welfare
considered to be the responsibility of society as a whole
(Peres-Katz, 1981, 1990; Shamgar-Handelman, 1986, 1990).
The last Declaration
of Intentions published by the Ministry of Labor and Social
Affaires (LASA) complements these findings. The Ministry's
declaration, which is characteristic of social positions that
have appeared consistently since the 1920s, states that "the
Ministry of LASA believes that a strong and modern society
is obligated not only on a moral level to protect, nurture
and strengthen its child population. A strong society perceives
its children as its most important resource and places the
area of children in a central place on its national priority
list" (Korazim, 1997, p. 12).
This background
explains why childlessness in Israeli society is considered
incompatible with its values.
c.) The scope
of childlessness - The problem of childlessness in Israel,
as in other Western countries, has become in the last few
decades the concern of a large section of the population.
As has been found in surveys conducted throughout the world,
about 15 percent of the population that is of fertile age
suffers from fertility problems (Zigler, 1998). It has been
estimated that in the U.S. alone, every sixth couple encounters
difficulties in reproducing (Greenfield, 1997).
In Israel there
is available data only on married women. 19 percent reported
difficulties in becoming pregnant and one percent reported
an inability to conceive even after fertility treatments.
It can be assumed that similar figures apply to unmarried
women.
d.) A need for
an organized intervention by society - The existence of a
demand for change in a situation is the fourth condition for
a social problem. As Rubington and Weinberg (1989) explain,
the actual absence of the public's satisfaction with a certain
situation does not transform a situation into a social problem.
Only a clear demand to find a solution indicates a social
problem.
The call for change
in Israel comes from three directions at the same time. First,
there are the childless people who demand help. Second, there
is the general population, which is publicly pressing for
"something to be done." The third source of pressure
comes from the professional disciplines dealing with different
aspects of the situation that are petitioning for changes
that would resolve their professional dilemmas. Their dilemmas
arise from having to resolve complex issues such as the rights
of the embryo as a patient, the ownership of sperm or ovum
which belonged to people who died or couples that separated,
the ethics of removing fetuses (embryo reduction) in a multi-fetal
pregnancy (Vilichek, 1987; Shamgar, 1989; Shenkar, 1990; Daor,
1993; Davis, 1995).
AVAILABLE SOLUTIONS
FOR CHILDLESS PEOPLE IN ISRAEL
A. Non-Biological Options
Short and Long-Term Foster Care
Foster care is a monopoly, held by the Ministry of LASA, executed
only by social workers. It is implemented selectively both
among childless couples and among couples and singles who
already have children. All candidates go through a process
of recruitment and training. The selection of candidates focuses
on parental skills and the ability to cope with a diversity
of biological parents. The economic, education and health
status requirements for foster parenthood are lower than those
demanded from people who are interested to adopt a child confidentially.
In a retrospective
survey of 4,500 former foster care children, it was found
that 50 percent of them continued in foster or residential
care until they were adopted by either their foster parents
or by other families (Segev, 1997).
At the moment
there are about 1,600 foster families in Israel caring for
approximately 3,600 children. The procedures for operating
this system are based on regulations established by the Ministry
of LASA, and in addition to some of the laws regarding placement
in residential care. At present the Knesset (Israeli parliament)
has before it for first reading a Foster Family Law which
that will determine the legal framework of the issue (Laufer,
1997).
The average cost
of keeping a child in foster care is NIS 3,550 per month (about
$905 US). Special expenses such as psychological care, participation
in enrichment programs, etc. are paid for separately. The
Ministry of Labor and Welfare generally bears the expense
of raising foster children (in rare instances birth parents
also contribute).
Confidential
Adoption
a.) Intracountry adoption - In this option, children are given
selectively according to the principle of the child's best
interest. Potential parents must go through a strict recruitment
process in which they are required to prove an above average
economic, educational and health status as well as the ability
to be parents. This policy takes advantage of the fact that
demand exceeds supply. As fewer children are available for
adoption, the standards of prospective parents become higher.
The process of
adoption has its own specific law and its procedure is fixed
in defined regulations (Law of Adoption of Children 1981).
This law gives the Ministry of LASA the monopoly for all adoptions
of Israeli children.
According to the
latest data, 893 children were adopted between 1992 and 1995.
This group of children included 362 infants, 513 children
defined as having special needs and 18 children with Downs'
syndrome (Ben-Asher & Zionism, 1996).
According to informal
estimates, the Ministry of LASA has today a waiting list of
1,500 couples. The average waiting period for a couple is
approximately six years. Due to this long waiting period,
it happens that couples who are approved for adoption are
later disqualified and taken off the list because they are
over the age limit for adoption (Jaffe, 1994).
There is no available
data regarding the cost of the adoption process, not of the
cost of caring for children until they are adopted. All these
costs were covered by the Ministry of LASA.
b.) Intercountry
adoption - Up until 1997, and Israeli citizen with the necessary
financial means could acquire a child for adoption outside
of the state. This situation created religious and legal problems.
It was a threat to the principle of "the child's best
interest" and to the Israeli society's ability to take
responsibility for the welfare of these children. As a result,
the Law of Adoption (Law of Adoption, Amendment) was amended
to state that intercounty adoption can take place only through
a nonprofit association or through the designated service
in the Ministry of LASA. Only candidates who were assessed
and approved by the association as being able to fulfill a
parental role may adopt a child.
Unfortunately,
the current situation is that people who want to adopt are
caught in a trap. One on side, they cannot carry out independent
adoption arrangements. On the other side, there is as yet
no nonprofit association that has been authorized to provide
adoption services, and the Ministry of Labor and Welfare does
not provide adoption services at the moment. In practice,
couples and individuals continue to adopt children from abroad,
thereby becoming lawbreakers.
Official data regarding the extent of intercountry adoption
is unavailable, as is information about its costs.
Open Adoption
This alternative is relatively new in Israel. There are no
figures regarding its extent or its cost. The legal basis
for this adoption, at the moment, is the existing Law of Adoption.
The unique judicial aspects of this option have not as yet
been addressed.
B.) Biological
Options
Medical treatment is given in the framework of the National
Health Insurance Law which guarantees every citizen a basic
"health package," and for which every paycheck is
taxed. The actual services are given by any of the four sick
funds, which also provide a complementary health package paid
for privately and separately by their clients. The Israeli
Ministry of Health supervises the medical services that are
provided to the public, but also provides services itself
as a subcontractor for the sick funds through a net of government
hospitals and clinics.
Many medical centers
maintain fertility units and of these, 22 units provide IVF
treatments. The ratio of IVF units per population is about
four times that of the UK or the US, and the ratio of treatment
cycles which they provide is about four times that of the
UK and about ten times that of the US (Seidman & Lotan,
1998). These treatments, which began in Israel in 1982, are
responsible today for about two percent of all the births
in Israel.
Most of the treatments
for childless people are covered by the National Health Insurance.
Fertility treatments are given, up to two births, for couples
or single women who do not have children of their own. An
attending doctor who has suspicions about the ability of the
prospective parents to raise children, whether due to psychiatric
disturbances or mental retardation, is entitled to ask for
a social worker's evaluation prior to beginning treatment
at one medical center is able to apply at another one which
may give the treatment and not ask for such an evaluation.
Medical insurance
covers up to six therapy cycles. Additional attempts are given
in accordance to the different rules of each sick fund, with
the client having to cover some of the costs herself. The
cost of fertility therapy varies greatly from case to case
and may range from less than $1,500 to over $13,000 (in US
dollars).
C.) Biological
Options Requiring Another Party
Donation of Sperm and/or Ovum
Donations of sperm and ovum are regulated through laws and
regulations which determine who is allowed to be a donor,
how many times a donor may donate (for example, a man is allowed
to donate sperm up to three times) and who may receive a donation.
The regulations
do not mandate central registration of donors and recipients.
This is in order to prevent the stigmatization of people involved,
taking advantage of the low probable risk for future marriage
between siblings (Shalev, 1996; Korinaldi, 1996). At present,
there is no data about the extent of the use of sperm and
ovum donations.
Surrogacy
Fertility treatments involving a surrogate mother are new
in Israel and a special procedure has been developed for them
under the "Law of Agreements for Carrying Fetuses."
The Israeli Ministry of Health established a committee designed
to specifically supervise this procedure and authorize each
case. In order to be eligible to be helped by a surrogate
mother, the woman must prove that she is medically incapable
of becoming pregnant or maintaining a pregnancy.
The National Health
Insurance covers the costs of medical treatments involved
in the procedure, as if the surrogate mother were a patient
requiring IVF treatments, through the surrogate mother's sick
fund. The expenses that are not covered by the insurance are
covered by the prospective parents. These would be the treatments
involved in an ovum donation (if the prospective mother is
unable to supply one), medical and psychological evaluations
of the prospective parents required by the supervising committee
and psychological counseling for the surrogate mother which
is required by law.
A monetary agreement
between the expected parents and the surrogate mother is allowed
by law, but the committee has to approve the agreement, making
sure that the payments are reasonable and that the rights
and needs of the surrogate mother are not compromised.
The new procedure of surrogacy can still be considered experimental
and will most likely change in the future. Up until today,
two cases of surrogate pregnancies have been successfully
concluded. It must be noted that each of the two pregnancies
received an unprecedented amount of media attention, and the
first one even reached the courts when the surrogate mother
claimed that her rights had been infringed upon.
INEQUALITIES AND
DISCRIMINATION IN THE POLICIES RELATED TO INVOLUNTARY CHILDLESSNESS
Analysis of the policies described previously clearly points
out a consistent priority given to certain population groups
and specific solutions for childless people. This preference
is most prominent when it comes to financial coverage and
criteria definition.
INEQUALITIES IN
FINANCIAL COVERAGE
Analysis of the welfare policy reveals an inequality in resource
allocation for the different types of adoption. Full funding
is provided for the adoption of Israeli children, while none
is given for intercountry adoptions. Bearing in mind that
the requirements from candidates for intracountry adoption
include an above average economic status, both adoption options
discriminate. People of lesser economic status who are interested
in adopting a child, although not proven to be less suited
for parenthood, are at a major disadvantage.
The existing medical
policy also creates inequalities in resource allocation. Sperm
and ovum donations are not covered, even though their actual
costs may be less expensive than some of the sophisticated
fertility treatments that are fully covered by the national
health insurance. Furthermore, in the case of surrogacy and
health care coverage, the state released itself from any financial
obligation beyond IVF procedure (Shifman, 1991).
INEQUALITIES IN
SELECTION CRITERIA
Analysis of the current policies reveals inequalities between
different population groups through the practiced criteria
for parenthood. Such inequality is the result of using familial
status for selecting parents for confidential adoption. For
example, single mothers are at a disadvantage when compared
to couples with the same economic, educational and health
characteristics. These women are generally offered children
with special needs and not infants, who are in much greater
demand (Jaffe, 1994). Single-sex couples or homosexual singles
may find themselves at an even greater disadvantage, though
such cases are still too few for a verifiable statement to
be made.
Another inequality
has to do with screening for parental abilities. Medical treatments
are given to anyone who demands them. The responsibility for
testing the parental ability of the candidates for treatment
falls on the attending doctor. In other words, the responsibility
is in the hands of personnel whose specialty is fertilization
and not parenting. Furthermore, in past cases in which fertility
treatments were provided for people whose inability to be
parents was patently obvious, the doctors involved were not
taken before a board of ethics or any other public body for
having gone ahead with the fertilization. In contrast, in
nonmedical solutions as well as in surrogacy, prospective
parents must, by law, prove their ability to be parents (Law
of Adoption, Foster Care Regulation and the Law for Carrying
Fetuses).
DISCUSSION
An attempt to examine the issue of IC in Israel from a general
perspective reveals a noncomprehensive policy, both on the
theoretical and practical levels.
Professional debates
that have not been resolved yet include issues such as the
right for parenthood. Should Israeli society assist any couple
or single to become a parent, not just by providing a legal
right, but by committing adequate funds for this purpose (Korinaldi,
1996)? Another such issue has to do with the state's right
to intervene in the process of becoming a parent. Does a financial
investment give the state the right to impose public norms
and perceptions on prospective parents (Shifman, 1991)? An
additional issue involves the possible use of the Law of Adoption
of Children, with its developed legal principles, for other
solutions to childlessness.
On the practical
level, IC is a social problem that is being addressed by two
very different medical establishments. This difference between
the medical and social work establishments can explain a large
part of the inequalities and discriminations that were described
previously. Each establishment has a different approach for
intervention. While the focus of the medical approach is the
infertile patient, the focus of the social work establishment
is the child who needs adequate parenting. The result of these
opposing approaches can explain the inconsistent criteria
for candidacy for different parenthood options.
The reality in
which government ministries provide the funds for different
parenthood options can explain the existing economic inequalities.
However, the problem of unequal budgeting has to do with more
than just the simple fact that the two ministries have different
resources. An important factor is the different public image
and appeal that the options have. The medical options are
perceived to be doctors who give children to childless people
while using exciting innovative technology (in spite of the
low success rate of 11 percent). The nonmedical options are
perceived to be social workers who take children away from
their biological families and place them in old-fashioned
arrangements.
In view of the
current situation in Israel, the social work profession has
a commitment to take a public stand on the issue of IC, followed
by active intervention on the macro level. This professional
commitment is based on two elements. The first one is inalienably
part of the code of ethics upon which the profession rests,
which demands that it work for the reduction of cases of discrimination
(Association of Social Workers, 1994). The second is the monopoly
that the profession has on dispensing nonbiological solutions
to the problem of IC and on the social aspects of biological
treatments.
It appears that
there are two directions for action in which social workers
must take the initiative. One direction would be to focus
more attention on childless people in the framework of nonmedical
options, not as a means of helping children, but as a way
to answer clients seeking help. This can be done by initiating
and encouraging the establishment of pressure groups of clients
and a social lobby to demand equal assistance for people choosing
or needing the solution of intercountry adoption. It should
be mentioned that today social workers in the public adoption
service are the ones implementing the discriminatory policy,
and so have the highest accessibility to the discriminated
segment of the applicant population.
The other direction
for action would be to implement the biological options under
the principle of "the best interest of the child."
This can be achieved by creating pressure groups and a social
lobby that would help settle the differences between the policies
guiding the adoption services and fertility units. As social
workers are committed to the welfare of children at risk due
to parental dysfunction, intervention at the fertility clinic
level should be an important preventative goal.
It can be summarized
that the social work profession has a unique obligation to
the problem of childlessness. The social mandate given to
the profession, as well as its ability to respond rapidly
to social change requires social work practitioners, educators,
researchers and policy makers to form the professional leadership
that would mediate the changing medical and social reality
and those seeking to become parents.
FOOTNOTES
1.) The first publicized case in England in which a surrogate
contract was drawn up and signed. In this case, Ms. Cotton,
the surrogate mother, was paid in installments by the childless
couple. In addition, she also received £20,000 by an
English newspaper for the sole rights to publish her story.
Public argument centered on the degree of fairness shown by
the courts to the surrogate mother when they had the baby
turned over to the prospective couple immediately after birth
and thereafter allowed them to leave the country.
2.) In this case,
a childless couple, S., contracted with a surrogate mother
through the services of an agency. Everything was fine up
to right after the birth. At this point the surrogate mother
declared that she regretted her previous decision and decided
that she was not prepared to give up the baby to the couple.
The matter reached the courts.
3.) It should
be emphasized that the scope of this paper is limited to involuntary
childlessness. However, these options may also serve people
who are fertile: women who desire to become mothers but are
not willing to go through a pregnancy, men who ask to freeze
their own sperm before starting a job that may jeopardize
their fertility, etc.
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