Introduction

Approximately 10 per cent to 25 per cent of couples will experience infertility, defined medically as the involuntary failure to conceive that lasts over one year (Simonstein 2010). Fertility treatment, considered to be part of the Assisted Reproductive Technologies (ART), and particularly In Vitro Fertilization (IVF), offer a chance for infertile couples to conceive with a success rate of up to 30 to 35 per cent, even though this rate obviously varies considerably with age (Mladovsky and Sorenson 2010, Seidman 2007). For example, according to the Israeli Ministry of Health in 2015, the success rate of IVF treatments among women under the age of 35 was 31.3 per cent. In contrast, this rate drops among women aged 40 to 42 to 11.4 per cent, and further decreases to less than 4 per cent among women who are over 42 years old (Eliraz 2017).

Interestingly enough, IVF treatments are given in Israel in significantly higher numbers than in other countries in the world. During 2002, 15,000 cycles of IVF were undertaken in Israel at a rate of 2,500 cycles per one million people, a ratio five times higher than in other countries such as the Netherlands, England, and Sweden (Eliraz 2017, Simonstein 2010). A more updated figure shows that in 2016, the Israeli market consumed nearly 38,000 cycles of IVF, manifesting as a ratio of cycles per one million people that is eight times higher than in the rest of the world, thus making Israel the country with the highest IVF treatment per capita worldwide (Eliraz 2017). These numbers are explained by the fact that in Israel, IVF treatments are substantially more funded as part of basic public health benefits than any other country (Dunn, Stafinski, and Menon 2014, Schuz 2013, Simonstein 2010). As such, Israel provides an important case in point for examining the justification underlying the most generous public funding of ART treatments (and particularly IVF cycles) at the policymaking level (Birenbaum-Carmeli 2009).

To be sure, previous studies have already examined this Israeli phenomenon of generous public funding with respect to IVF treatments in Israel from cultural and feminist perspectives. Such studies offered critiques of this generous public funding by mainly focusing on the devaluation of women through emphasizing their main role in society as mothers (feminist critique) (Birenbaum-Carmeli 2007, 2009, Remennick 2008, Shalev and Gooldin 2006, Teman 2010). These critiques are further supported by other studies in the Israeli cultural context that have stressed the main role that maternity and having children play in the Israeli society (Donath 2015, 2017, Kahn, Farquhar, and Appadurai 2000). Alternatively, the critiques focused on the possible cultural-societal underpinnings of the generous funding policy (Birenbaum-Carmeli 2004, Gooldin 2008, Hashiloni-Dolev and Shkedi 2007, Ivry 2010, Newman and Inhorn 2015, Teman 2010, Boas et al. 2018). Some of these critiques focused on the holocaust as creating an exaggerated urge to compensate for the six million Jews who were annihilated. Other studies placed the ongoing Israeli-Palestinian conflict as a strong social force positioning Israeli-Jewish and Palestinian women in “the battle of wombs,” whereby fertility plays a key role in sustaining a demographic lead of Israeli Jews over Palestinians. Additional studies pointed to another possible cultural influence underlying the generous funding of IVF treatments: the emphasis on having a family as a key value in Israeli society. Such studies link the emphasis on family in the Israeli society to some of the abovementioned narratives like the “battle of the wombs” and the urge to compensate for the Jews annihilated in the Holocaust. However, the high value placed on the family in Israel is also associated with traditional-religious influence, as well as with the Zionist perspective stressing the wish to create a “new Jew” as opposed to “diaspora Jews” (Almog 2000, Birenbaum-Carmeli and Carmeli 2002, Hashiloni-Dolev 2007, Nahman 2006).

However, none of these studies examined major moral claims as they were echoed within a key framework of policymaking in Israel for justifying the continuance of Israeli generous public funding of IVF treatments from a general bioethical model perspective (e.g., American Principlism, European Principlism, virtue ethics, care ethics, etc.) (Ashcroft et al. 2007, Beauchamp and Childress 2008, Häyry 2003, Hursthouse 1999, Rendtorff 2002). In fact, in a previous study conducted by Sigal Gooldin, she has pinpointed two pivotal discussions taking place at the Knesset (the Israeli Parliament) in which the justifications for generous public funding were highlighted (Gooldin 2013). Furthermore, she already noted the central role that vulnerability of the childless plays in these discussions. According to Gooldin, in these discussions, a substantial justification for the generous public funding granted to IVF treatments was based on the idea that “distinct forms of suffering shape a distinct population of vulnerable subjects (‘the childless’), who in turn are entitled to extensive state provided care” (Italics added). Such emphasis on the concept of vulnerability seems to resonate with the principle of vulnerability within the European Principlism model.

Interestingly, though, Gooldin’s paper does not make the linkage to this Principlism model and certainly does not focus on philosophically examining the validity of the justifications for public funding of IVF treatments as they appear in the pivotal discussions regarding this matter at the Knesset. Instead, Gooldin focuses on the triumph of a liberal-individual perspective over a collective-national in the arguments used by those who were engaged in the policy making in support of the generous public funding of IVF. Still, against the backdrop of her paper, the discussions at the Knesset may constitute an intriguing case in point for examining the validity of justification for a generous public funding of IVF particularly through the lenses of the European Principlism model. Hence, these discussions in the Israeli parliament, and mainly relevant fragments from it that pertain to key principles in the European Priniciplism model such as vulnerability, may serve as the basis of a philosophical examination, including thought experiment regarding their validity, applying this model’s perspective. In fact, such examination of the justification for a particularly generous public funding of IVF treatments at the Israeli public policy level discourse is both important and novel for three interconnected reasons.

First, since the Israeli case represents an exceptionally favorable stance regarding public funding of IVF treatments, it provides a unique opportunity to examine the “purest” and most adamant justification for such funding, at the public policy level. Indeed, as we shall see in the next section, the justifications brought in the Israeli case in-point are not “distorted” by any financial considerations or constraints. Rather the whole discourse is focused on explanations as to the unique importance of IVF treatments, thereby superseding any budgetary considerations. Therefore, if these justifications are found to be self-contradictory in the abstract and specific thought experiments that will be offered in the current paper, it may assist in better envisioning a possible better moral framework for discussing public funding of IVF treatments not based on economic grounds.

Second, by critically examining the main justifications articulated at the Israeli public policy level through European Principlism bioethical model, the article offers a novel approach that has not been used before in the context of IVF public funding. By showing that the arguments underlying the generous public funding for these treatments are self-contradictory from the perspective of the European model of Principlism, the current article offers a new method for scrutinizing this subject in a manner that reaches beyond a particular cultural context or critique. Indeed, this general bioethical model, often overshadowed by the so-called “American Principlism” model (i.e. autonomy, non-maleficence, beneficence, social justice), has never been used before in order to examine and question the issue of publically funding IVF treatments.

Third, based on and following the previous two points, using a general bioethical model, such as the European Principlism model, the current article moves beyond the particular socio-cultural critiques and discussions with respect to the Israeli society in the context of IVF. As such, this article demonstrates a philosophical investigation that is less tied to a particular socio-cultural (including feminist) context as previous discussions have been, and therefore may be applicable beyond the Israeli particular case. While our analysis may support some of these critiques, it does so from a different and more general perspective, since the European Principlism is a general (or “grand”) model in bioethics, not situated in the Israeli socio-cultural context. For this reason, in what follows, we also mainly refrain from linking our discussion to previous socio-cultural critiques, as we wish to give the general European Principlism model its full proper weight.

More specifically, in this paper, we argue that an examination of the discussions held in the two Knesset committees shows that two key concepts were used by advocates of generous public funding for IVF in Israel. These concepts are “emotional vulnerability” and the “worthlessness of the childless.” We then explain, analytically, how these two concepts at first may seem to correspond to the principles of vulnerability, integrity, and dignity as defined by the bioethical European Principlism model. However, we shall show that a deeper analytical exploration of these principles actually points to the possibility that they are undermined by the concepts of emotional vulnerability and the worthlessness of the childless. Finally, based on showing the undermining of the vulnerability, dignity and integrity principles by the “emotional vulnerability” and the “worthlessness of the childless,” we offer two “take home” messages informed by our analysis of the Israeli case, but potentially reaching beyond it.

The paper uses theoretical-philosophical approach, based on an analytical philosophy method.(Beaney 2016). This method is characterized in setting the focus on positioning, examining and either corroborating or refuting arguments based on their logic by employing a thorough and meticulous testing of their content(s). In the current paper, this examination will concern both the coherence and consistency of the arguments supporting the generous stance adopted towards IVF public funding at the policy level, when examined through the lenses of the European Principlism model.

Setting the Stage: About the Israeli Discourse and Key Concepts in European Principlism

As far as policymaking is concerned, a crucial period in the discourse on the funding of IVF treatments in Israel occurred between September 2003 and January 2004. Following a suggestion by the Ministry of Finance to reduce public funding for fertility treatments, the Finance Committee (henceforward, FC) of the Knesset thoroughly discussed the overall state of funding for these treatments (Gooldin 2008, 2013). At the same time, the Committee for Advancement of Women Status (henceforward, CWS) also held discussions on this matter.

To be sure, the Ministry of Finance’s request for reduction in the public funding for IVF treatments was made against the backdrop of an existing public funding policy since 1994 when the National Health Insurance law was enacted, allowing unlimited IVF treatment cycles for up to two children. Admittedly, four years later (1998), based on the recommendation of a professional medical advisory committee, the public funding of IVF treatments was limited to women up to the age of 45 (Birenbaum-Carmeli 2004), yet none of the other developed countries that possess the knowledge and technology allowing such treatments has provided this generous public funding policy. Hence, other countries had a cap of no more than 4 cycles of treatments (and on average 2-3 cycles), and none of them provided funding for more than one child or to women over 40 years old (Birenbaum-Carmeli 2004, Collins 2002).

While the Ministry of Finance eventually withdrew its proposal to reduce public funding for IVF treatments, the discussions in both committees marked a pivotal point in this discourse at the policymaking level. Indeed, despite the fact that more than a decade has passed since 2004, no further discussion at the level of public policy has taken place. In fact, the deliberations in the FC and CWS of the Knesset in 2003-2004 constitute the sole instance of such multiple deliberations at the public policy level since the enactment of the National Health Insurance law. The only other known instance in the research literature of discussing the issue of public funding of IVF at the national public policy level occurred in 1998 at the CWS within a single meeting (Birenbaum-Carmeli 2004). Furthermore, unlike the deliberations held at the FC and CWS of the Knesset in 2003-2004, the single discussion of the CWS from 1998 was not held in the context of directly deliberating the national policy regarding the financing of IVF in Israel.

It might be argued at this point that there were other decisions pertaining to the subject of IVF treatments’ public funding, such as the decision made by the Ministry of health in 2014 to limit the number IVF treatment cycles to 8 (Health-Minestry 2014). However, this sort of decisions was reached based on a medical-professional advisory committee focusing on the medical aspect of the issue, rather than at the public policy level. In fact, a letter written by the legal counselor of the Ministry of Health two weeks after the publication of the aforementioned decision emphasized that the threshold of 8 cycles does not necessarily refer to a limitation on the number of funded cycles. Rather, this threshold simply pointed for the need to reconsider individually for each patient whether and how the IVF treatments should be continued (Hibner-Harel 2014).

It could also be argued at this point that, examining the arguments at the public policy level in favor of keeping the generous public financing of IVF in Israel from a professional bioethical perspective would be comparing apples to oranges. Public policymakers are neither philosophers nor bioethicists, and therefore examining their justifications from a professional bioethicist perspective by utilizing the European Principlism model is inappropriate for examining such justifications. Alternatively, it may be claimed that examining these justifications at the public policy level is wrong and futile because such justifications were not intended to be philosophically sound.

However, these sorts of claims might be ignoring the fact that bioethical models were conceptualized so that they would be accessible to non-professional bioethicists involved in the application of bioethics (e.g., policymakers, physicians, scientists, etc.) (Bulger 2007, Hine 2011). Furthermore, the justifications used at the policy level are of primary interest since they constitute the actual claims used to justify this policy. In other words, these claims are not merely made by a generic group of people, who may present more or less valid arguments regarding the need for generous public funding of IVF. Rather, the focus here is on the group of people who was responsible directly for this generous public funding policy regarding IVF since they were practically engaged in policy making regarding this matter on the Israeli national level. Indeed, examining the merits of the justification offered by policy makers for a given policy related to health or medicine is hardly odd to or exceptional in the bioethics research literature. The purpose of such examinations is often precisely to test the validity of a given policy using a normative-philosophical perspective. At the same time, the deliberations at the two Knesset committees (FC and CSW) were exceptional as well. These deliberations, as noted above, provided a unique opportunity at the Israeli public policy level for the stakeholders involved in them to submit to “the imperative of justification” namely articulate moral justifications for the generous pubic funding of IVF in Israel (Boltanski and Thévenot 2000, 2006). As such the discussions at the two Knesset Committees offered an area of transparency “on the otherwise opaque surface of regular, uneventful social life” (Mitchell 2006, p. 29).

Therefore, the deliberations held between September 2003 and January 2004 at the FC and CSW of the Knesset still constitute a unique and fundamental opportunity for examining the justifications offered at the public policy level for the most generous publically funded scheme of IVF treatments. That is, these deliberations at the policy level provide a special opportunity for a sort of a thought experiment aimed at examining the validity of the arguments in favour of such funding.

As already noted in the introduction, vulnerability means that the human condition is prone to be hurt or distressed, resulting in suffering, abnormality, and disability (Kemp and Rendtorff 2008, Rendtorff 2002, 2014). Supposedly, this principle compels state and society to alleviate as much as possible these conditions, based on the acknowledgment of the human condition as encapsulated in the vulnerability principle. Vulnerability refers both to bodily vulnerability, where the physical body is hurt or distressed, and to emotional vulnerability, emphasizing that humans are considered to be a unity of body and soul (Rendtorff 2002, 2014).

The concept of “dignity” stresses the intrinsic value and the unique place that every human being has simply due to his or her humanness (Rendtorff 2002). Therefore, dignity may be regarded as “a property by virtue of which beings possess moral status” (Kemp and Rendtorff 2008, p. 247). Such moral status in turn can also be understood to be an essential foundation of the development of human rights as moral obligations and their derived privileges belonging to all human beings (Rendtorff 2014). While dignity can be identified with the capacity for autonomous action, its essence reaches beyond the mere autonomy of human beings, since dignity is also identified with “the capacity for experiencing pain or pleasure” (Kemp and Rendtorff 2008, p. 247). In fact, according to Rendtroff, the identification of dignity with the latter capacity renders the domain of dignity to be a sense of self-esteem, being proud or ashamed, or feeling inferiority or degradation.

Finally, according to the suggested European model of bioethics, the principle of “integrity” revolves around a narrative of wholeness, totality, or completeness of the person or human being. Integrity therefore also corresponds to a core that is untouchable, namely, the personal sphere of any human being, which should never be subject to external intervention (Rendtorff 2002). This core represents the immunity of the human being (Kemp and Rendtorff 2008).

The Worthlessness of the Childless and Emotional Vulnerability as Justifying IVF Funding

As mentioned in the introduction, during the period between September 2003 and January 2004 and against the backdrop of the proposal made by the Ministry of Finance to cut public financing for IVF treatments in Israel, several discussions were held at the FC and CSW of the Knesset. Examining these discussions shows that two concepts played a key role in justifying generous public funding for these treatments since 1994. These concepts were the “worthlessness of the childless” and “emotional vulnerability.”

The “worthlessness of the childless” means that the childless are worthless, supposedly in their own perception. Children are viewed as invaluable, namely, they have an infinite value from this perspective. Therefore, people that are childless are perceived as worthless in the sense of being deprived of something (or rather someone) that is taken to have an infinite value. For example, a member of the Shas religious party described the childless in the following manner: “If you don’t have children you’re as good as dead. No one knows what such couples are going through, the life they lead. Everything is extinguished. There’s no happiness, just sadness”(Knesset 2003b; Gooldin 2013, 95).

This view of the utter worthlessness of the childless was expressed in more detail at the CSW by Professor Shlomo Mashiach, one of the most prominent obstetricians and fertility experts in Israel, a pioneer in IVF treatments. Note that while Professor Mashiach is not a policymaker but is rather part of the medical profession, the following quote was said in the context of a Knesset Committee deliberating on the right policy regarding public funding of IVF treatments. Professor Mashiach, a non-religious physician, supposedly speaking from his experience in treating childless couples and childless single women, made the following statement:

The disease of sterility or fertility is no less fatal than cancer. It burrows in and spreads throughout everybody in the childless family. The woman is ostracized, the man cannot be part of the community, and the family ceases to exist. That’s what’s special about the family in Israel, both Jewish and Arab families... Israel is different from the rest of the world. In Israel, the most important thing about family is the children. In Israel, the family is special. Who among us can say that he would forgo a child? No one. Maybe a tiny proportion of the population, and they’re disturbed. Both Jewish and Arab families must have children, and they’ll do anything for it (Knesset 2003a italics added).

To be sure, the sense of worthlessness to the extent of feeling tortured was also expressed by non-Jewish speakers at these two Knesset committees, namely by speakers representing minority ethnic groups in Israel like the Arabs and Druze. Hence, not only religious or alternatively Jewish spokespersons give voice to the framing of the childless as worthless. Therefore, attributing this stance to a cultural Jewish or religious-Jewish viewpoint seems to be inaccurate. Thus, Ayoob Kara, a Druze Minister of the Knesset (MK), emphasized the agonizing nature of being childless and, conversely, the joy given to parents by their children.

“I would like to thank these couples, who have come here and represented thousands of couples around the country who are going through this torture... We won’t give up on children. Children are a joy for everyone” (Knesset 2003b italics added).

Moreover, this view of childless couples (or single women) in Israel as worthless echoes previous studies conducted in Israel on the attitudes among the “simple citizens.” For example, Birenbaum-Carmeli summarizes the feeling of the childless in Israel as having “the shared experience of being a zero” (Birenbaum-Carmeli 2004). Other studies focusing specifically on the narratives of Israeli childless women who at one point were completely consumed with trying to have a biological child showed that these women expressed anxiety, loneliness, and frustration to the extent that they avoid events where children were present (Haelyon 2005, Remennick 2000). These women’s lives as childless were experienced as worthless to the extent that they were put “on hold” and would completely devote themselves to the purpose of having a biological child, especially for those women who used IVF (Birenbaum-Carmeli 2004).

Furthermore, these studies offer further understanding of what such “worthlessness” may entail in this particular context. These studies portray Israeli childless women’s attitudes as reflecting loss of their identity in two ways. First, these women are completely obedient to their gynaecologists. Second, the childless women’s attitudes reflect an internalization of the idea that maternity is part of their femininity and sexuality. Simply put, a sense of being a “whole” woman can only be achieved if you are a mother, thereby positioning these childless women as having incomplete identities.

From this perspective, the presentation of the Israeli childless couples and particularly childless Israeli women as worthless and helpless during the discussions held at the policy level seems to resonate with a wider public sentiment, as the quoted studies demonstrate. Note that the possible cultural roots for this phenomenon are both beyond the scope of the current paper and, as indicated in the introduction, have already been addressed in previous studies. Rather, the point is that perception of Israeli childless couples and single women as worthless was used at the policy level to argue against any cuts of IVF public funding, and that such justification appears to represent wider public sentiment in Israel.

At the same time, the emphasis on the sense of worthlessness attributed to childless couples and single women in Israel also seems to accompany another key idea used during the discussions at the FC and CSW of the Knesset. This is “emotional vulnerability,” another concept justifying the need to sustain the generous public funding of IVF in this country. In contrast to the sense of worthlessness by the childless that was expressed directly by the speakers at the public policy level, the idea of emotional vulnerability is offered by Gooldin’s analysis of the discourse at the Knesset’s two committees.

Specifically, Gooldin builds on the following key statement made by Ahmad Tibi, an Arab MK who is also a gynecologist, during the discussions held at the FC of the Knesset.

There is something malignant about infertility because it spreads emotionally, socially and through the family. As we have heard during some very emotional testimonies, the entire family unit and environment suffer. It [becomes] the everyday ultimate thing; people think only about how to have children both as a fundamental right, because every man and woman want to be a parent, and because they want to get out of [a situation in which they are susceptible to] social and emotional distress. So many families have broken up because of this. This has malignant social and emotional consequences of the highest level...Therefore...funds must be allocated to terminal cancer patients as well as to the possibly terminal state of the family … (Knesset 2003a, italics added)

Gooldin illuminates the idea of “emotional distress” as it appears in MK Tibi’s statement in order to contrast it to the emotional well-being gained by IVF in order to bypass such distress. She then uses the idea of “emotional distress” as expressing “distinct forms of suffering [that] shape a distinct population of vulnerable subjects (‘the childless’), who in turn are entitled to extensive state provided care” (Gooldin 2013, p. 95).

In fact, the emphasis on emotional distress reflecting unbearable emotional vulnerability appears in the discussions of both policymakers and professional consultants in both committees of the Knesset (FC and CSW). For example, Professor Dor, another prominent gynecologist who was invited to the discussions held at the CSW, stated that “Perhaps the Ministry of Finance’s bureaucrats are not always sensitive to suffering...This is an injury that the public cannot endure” (Knesset 2003a italics added). In a similar vein, Gooldin mentions “several MKs [who] reported that they were convinced to vote against cutbacks after hearing extremely moving and heart-rending appeals from fertility patients” (Gooldin 2013, p. 96).

Furthermore, note that the two ideas playing a key role in keeping the generous public financing of IVF treatments are interconnected and possibly complement each other. Childlessness in the aforementioned deliberations at the Israeli policy level entails unbearable emotional vulnerability precisely because the childless are depicted as having a deep sense of worthlessness. Alternatively, it may be claimed that the emphasized sense of worthlessness among the childless in Israel is based on perceiving childlessness as entailing unendurable emotional distress and vulnerability. Indeed, the reciprocal and complementary nature of the “worthlessness of the childless” and “emotional vulnerability” is summarized by the member of the Shas religious party quoted above. Before presenting the utter worthlessness of the childless (“If you don’t have children you’re as good as dead”), he frames his whole argument in the emotional distress and therefore emotional vulnerability domain. In his words: “I’ll start with the emotional question [...] If you don’t have children you’re as good as dead” (Knesset 2003b italics added).

Connecting Emotional Vulnerability and Worthlessness of Childless to European Principlism

Now that the manner in which the concepts of “emotional vulnerability” and the “worthlessness of the childless” were used in order to justify the generous Israeli public funding of IVF policy, this section will show how these concepts are connected to the European Principlism model. For the bioethical European Principlism model, a key version is manifested in The BIOMED II project, “Basic Ethical Principles in European Bioethics and Biolaw” that took place from 1995–1998 (Kemp and Rendtorff 2008). The project was based on cooperation between 22 partners in most EU countries aimed at identifying key ethical principles of bioethics from the European (as opposed to the American) perspective and social and cultural heritage. The project yielded four fundamental principles: autonomy, dignity, integrity, and vulnerability. These reflected the key ideas or values of European bioethics (Rendtorff 2002). It should be noted that while there is acknowledgment of the principle of autonomy, this principle is not prioritized over other principles, as with the American model (i.e., autonomy, beneficence, non-munificence, justice). In addition, note that the remaining principles in the aforementioned European version of bioethical principles completely differ from the American version. Accordingly, in what follows. We shall show various linkages from the principles of vulnerability, dignity, and integrity to the concepts of “emotional vulnerability” and “worthlessness of the childless.” Then, the next section will explain why such linkages may actually be misleading in that the two concepts used in Israeli discourse actually undermine the essence of vulnerability, dignity, and integrity.

Emotional Vulnerability as a Type of Vulnerability

As already noted in the introduction, vulnerability means that the human condition is prone to be hurt or distressed, resulting in suffering, abnormality, and disability (Kemp and Rendtorff 2008, Rendtorff 2002, 2014). This conceptualization of vulnerability is built, on the one hand, upon an ontological perspective of vulnerability (Mackenzie, Rogers, and Dodds 2014). While an ontological viewpoint of vulnerability may lead to quite different conclusions, its fundamental basis is common, namely the idea that humans are susceptible to being hurt by their very nature. It is this susceptibility or being prone to be hurt that is part of what defines us as humans. On the other hand, setting the focus on the possible results of vulnerability such as disability and suffering introduces the other facet of vulnerability in the European bioethical Principlism. This other facet revolves around the need to care for those who are least advantaged, namely most vulnerable such as the disabled (Rogers, Mackenzie, and Dodds 2012, Mackenzie, Rogers, and Dodds 2014, Brock 2002). Supposedly, this latter facet of the principle compels state and society to alleviate as much as possible the conditions of those who are the least advantaged. It should also be noted that vulnerability refers both to bodily vulnerability, where the physical body is hurt or distressed, and to emotional vulnerability, emphasizing that humans are considered to be a unity of body and soul (Rendtorff 2002, 2014).

Supposedly, the latter attribute of the vulnerability principle is also expressed in the Israeli discourse at the public policy level regarding “emotional vulnerability” and its justification for public funding of IVF. As we have seen, the concept of emotional vulnerability stresses the unbearable distress or suffering attributed to childless Israelis, thereby depicting them as being the least advantaged. The particular concept used in this Israeli discourse also relates to the suffering of the childless. In addition, the Israeli deliberations in the two Knesset committees regarding public funding of IVF stressed the emotional facet of vulnerability, thereby perfectly fitting with one of the two facets of vulnerability. Finally, the principle of vulnerability compelling society and state to alleviate people’s distress, especially those who are the deemed the most disadvantaged seems to be echoed in the justification for the need of the State of Israel to be involved in relieving these vulnerable people from their distress through funding IVF treatments.

Dignity, Integrity, and Worthlessness

The concept of dignity emphasizes the intrinsic value and the unique place of every human being, while also being depicted as “a property by virtue of which beings possess moral status” (Kemp and Rendtorff 2008, 247). Therefore, dignity is regarded as an essential foundation for the development and justification of human rights belonging to all human beings (Rendtorff 2014). Since dignity is also identified with “the capacity for experiencing pain or pleasure” (Kemp and Rendtorff 2008, 247), human dignity may be associated with a sense of self-esteem, being proud or ashamed, or feelings of inferiority or degradation (Rendtorff 2002).

There are at least two reasons for the combination of worthlessness attributed to the childless at the deliberations of the two Knesset committees and the principle of dignity. These conflicts between the sense of worthlessness and the principle of dignity can be interpreted in turn as justifications for resolving the sense of worthlessness through the state’s commitment to publicly funded IVF. Indeed, this sort of justification seems to underlie the emphasis on the sense of worthlessness supposedly experienced by the Israeli childless couples and childless single women to explain why public funding for IVF should not be cut back.

The first reason for this conflict is that a sense of worthlessness undermines the intrinsic value and unique place any human being has according to the dignity principle. Hence, if childless Israelis experience a sense of worthlessness attributed to them in the committees’ deliberations, then it stands to reason that their intrinsic sense of dignity is infringed. The second reason for the conflict between the worthlessness of the childless and the principle of dignity has to do with the status of being childless and the right to parenthood. The principle of dignity is depicted as a key foundation of human rights, and the right to parenthood is often perceived as a human right. Therefore, when the childless are designated and emphasized as a group entitled for help from the state in order to have their own children, as in the case in Israel at the policy level, such an emphasis corresponds with the dignity principle. Hence, the right of parenthood is asserted based on the principle of dignity against the backdrop of the worthlessness of the childless.

Finally, we turn to the principle of integrity, which is based upon a narrative of wholeness, totality, or completeness of the person or human being and corresponds to a core that is untouchable: the personal sphere of any human being, which should never be subject to external intervention (Rendtorff 2002). Once again, the worthlessness of the childless as a key justification for keeping the generous public funding of IVF treatments stems from the infringement of the integrity principle by the sense of worthlessness attributed to the childless, specifically childless women.

To illuminate this infringement, we simply need to go back to the studies cited as expanding our understanding of the meaning of worthlessness in the context of being an Israeli childless woman. These studies presented the loss of identity of Israeli childless women, whether because complete obedience to the gynaecologist resulted in an infringed self-determination, or since motherhood was depicted as a key condition for being a “whole” woman. However, such a loss of identity as encapsulated in the sense of worthlessness attributed to Israeli childless women can also be seen as an infringement on their integrity. A woman who abdicates her decision and preferences to a gynaecologist’s orders in effect loses part of her self-determination, where the latter is associated with preserving her integrity. In a similar vein, if a childless woman depicts the ideal of a “whole” woman as including motherhood, her self-narrative of wholeness is obviously damaged, thereby undermining her capability to realize her integrity.

Can “Emotional Vulnerability” and the “Worthlessness of Childless” Justify Public Funding of IVF from a European Principlism Perspective?

Does the justification from emotional vulnerability fit with the essence of vulnerability?

In healthcare systems, the systematic protection of vulnerability is actualized in public health policies that aim at improving resistance to bodily injury, thereby enhancing human adaptation to social and physical environments as manifested in the IVF policy in Israel (ICDC 2011). The tasks of public health may thus be defined as those protecting physical or emotional vulnerability and reducing this vulnerability (Kottow 2004).

However, reduced human vulnerability seems to conflict with other core statements on the essence of vulnerability such as “human fragility, vulnerability and finitude that determine our longing for beauty and meaning” (Kottow 2004, 285). Hence, vulnerability is also an important reason propelling the quest for beauty and meaning. In other words, the meaning of acknowledging human vulnerability is more complex and two-sided. On the one hand, realizing the proneness and susceptibility of all human beings to suffering, distress, abnormality, and disability compels society to alleviate people’s distress as much as possible through medical care. On the other hand, acknowledging vulnerability also implies accepting its ontological facet that emphasizes the existence of vulnerability as a significant factor of human beings as a species. Conversely, the presumption to completely eradicate vulnerability is unwarranted, since vulnerability is the driving force behind a unique feature of being human, separating us from other animals, which is the quest for beauty and meaning in our lives.

From this perspective, honouring the vulnerability engrained in infertility and being childless cannot only revolve around reducing infertility by publicly funding IVF treatments but should also be achieved by respecting this vulnerability in the first place. Clearly, respecting and accepting infertility is hardly the case, insofar as the adamant use of emotional vulnerability in the Israeli discourse depicted here on the public funding of IVF treatments is concerned. As we can recall, the emphasis on emotional vulnerability in this particular discourse, introduced childless persons as being “worthless,” lacking happiness, and even undergoing torture. In other words, the manner in which emotional vulnerability was utilized and referred to in the context of the deliberations at the two Knesset committees between September 2003 and January 2004 reflected a rather one-sided depiction of the principle of vulnerability. If a person is deemed as only “worthless” or “helpless” as emphasized in the aforementioned Israeli discourse at the policy level, these are not characteristics that can be easily accepted.

Furthermore, in stressing the two facets of acknowledging vulnerability, the European Principlism model suggests that truly respecting vulnerability is about striking the right balance between the struggle for immortality and the obvious finitude of human beings (Kemp and Rendtorff 2008; Rendtorff 2002). If such a need for striking a balance is applied to funding IVF treatments, one may argue that defying infertility through generously funding IVF treatments may align with defying immortality as encapsulated in the principle of vulnerability. Similarly, recognizing the medical limitations of these treatments as well as their potential negative psychological and social ramifications represent the recognition of the ontological facet of vulnerability: the idea that humans are susceptible to being hurt by their very nature. From this perspective, therefore, a balanced justification for IVF public funding cannot be achieved if the limitations and negative ramifications of IVF treatments are ignored or marginalized in favour of focusing only on defying infertility through seeking justifications for unlimited financial support for these treatments. Such a more balanced viewpoint that the European Principlism model may be understood to support in the IVF context is also supported by Sarah Franklin’s account of the tendency to ignore the medical limitations of IVF in public discourse (Franklin 2002).

However, the deliberations of the two Knesset committees were precisely aimed at articulating justifications for provision of almost unlimited financial funding for IVF treatments, while largely ignoring the medical limitations of IVF, whether in terms of the utterly varied success rates in accordance with age, as mentioned in the introduction, or the risks and agonizing pains women have to undergo as part of the treatment. In addition, setting the focus on the “emotional vulnerability” and the “worthlessness of the childless,” these committees’ deliberations interpreted the emotional distress of the childless in only one direction, which depicts the distress of the childless as simply fixable by a medical intervention (IVF treatments) without looking at the possible psychological and social distresses caused by this medicalized intervention. Indeed, studies showing the loss of identity and infringement on the sense of integrity of Israeli childless women who underwent fertility treatments demonstrate the potential psychological and social distresses associated with IVF treatments that both committees seem to have ignored. These distresses are also pointed out in a report by the WHO from 2002 (Daar and Merali 2002).

In fact, against the backdrop of the above arguments showing the problematic gap between the vulnerability principle and its application in the Israeli context of public funding for IVF treatments, we may offer a specific thought experiment demonstrating these arguments. As it may be recalled a comparison was drawn between cancer and infertility by two of the speakers during the Knesset committee’s discussion (MK Tibi and Prof. Maayan) in order to offer a justification for the need to provide generous (and limitless at the time) funding for IVF treatments. Yet if we shift the justifications offered by MK Tibi and Prof. Maayan from public funding of IVF to public funding of cancer treatment, by employing a thought experiment, it is quite clear that their use of emotional vulnerability with respect to the childless does not make sense.

Thus, for example, MK Tibi was quoted above as making the following statement.

… people think only about how to have children […] because they want to get out of [a situation in which they are susceptible to] social and emotional distress. So many families have broken up because of this. This has malignant social and emotional consequences of the highest level … Therefore … funds must be allocated to terminal cancer patients as well as to the possibly terminal state of the family … (Knesset 2003a, italics added).

Now if we reframe the same statement in terms of terminal cancer, then the statement would read something as follows.

… people think only about how to survive a terminal cancer because they want to get out of a [situation in which they are susceptible to] social, emotional and physical distress. So many families have broken up because of this. This has malignant social and emotional consequences of the highest level … Therefore … funds must be allocated to terminal cancer patients (Italics denote the changed text in comparison to the original statement).

Such an overreaching statement seems to justify any given treatment for terminal cancer, regardless of their actual rate of success in the name of emotional distress and vulnerability. Yet it is known that in public health policy, including in the Israeli “Drugs Basket” committee that oversees public funding for drugs in the country, the efficacy of suggested new drugs, some of which pertain to cancer treatment, plays an important role. When a drug or other treatment for terminal cancer is deemed to be not efficient enough, it will not be covered through public funding, even though the potential target population is likely to be clearly disadvantaged health-wise. In other words, justifying public funding of cancer treatment merely based on arguing for the need to address even an extreme emotional or physical vulnerability simply does not work. Indeed, in such cases, the other, ontological facet of vulnerability is bound to be acknowledged not less than the obligation to alleviate the pain, suffering, and distress of the most vulnerable like terminal cancer patients. Therefore, this thought experiment in which IVF treatment was replaced by terminal cancer treatment demonstrates that following only one facet of the vulnerability principle simply does not make sense.

The Complexity of Dignity

An unbalanced and one-sided sense of vulnerability in the Israeli discourse on IVF funding and the phenomenon of infertility seems to undermine the very concept and meaning of dignity. Hence, the partial and misleading sense of vulnerability entailed in the idea of emotional vulnerability used in this discourse also leads to an inapplicable concept of dignity.

Thus, according to Kottow, in a situation of disease or disability, the conceptualization of dignity in European Principlism differs from a situation of perfect health. In the former situation, it would be meaningless to forcefully maintain the dignity of steadfastness, of man entrenched in terra firma, when he has become sick, infirm, unable to remain in the original uprightness of the healthy human condition” (Kottow 2004, 285). Therefore, dignity in a situation of disease or disability, as in the case of infertility, revolves around experiencing suffering and disability with tolerance, and when not removable with acceptance. Due to this reason, for example, the idea of “dignity” is used repeatedly in bioethical discussions wishing to illuminate the moral problem entailed in unchecked genetic testing and editing (PGD, PND, CRISPR) in search of the “perfect baby,” also known as “new eugenics.” Hence, in such discussions, precisely based on cherishing the importance of human dignity (as well as human diversity), the need for truly accepting and respecting “imperfect babies” is recognized and fostered. In fact, these sorts of discussions are also known to have raised questions regarding whether and what are the definitions for “perfect” and “imperfect” babies as well as to who is entitled to make these definitions in the first place.

Yet, there is no place for tolerance or acceptance of infertility as an “imperfectness” of human life that should be respected as part of their dignity, when a distorted and partial sense of vulnerability is employed, as in the case of emotional vulnerability in Israeli discourse. There also appears to be no room left for even discussing why infertility is considered a state of “imperfectness” that should be corrected by default and what makes fertile women so “perfect” to begin with. In other words, a partial and one-sided account of vulnerability, as in the case of the Israeli discourse regarding the public funding of IVF treatments at the policy level, may be understood as potentially leading to a diminished definition of dignity. That is, a definition which neither allows for the acceptance of and respect for the “imperfectness” supposedly associated with infertility, nor permits any discussions regarding the conceptualizations of “perfect” and “imperfect” in the context of infertility.

State Intervention and the Infringement of Integrity

According to the suggested European model of bioethics, the idea of integrity corresponds to a core that is untouchable, namely the personal sphere, which should never be subject to external intervention (Rendtorff 2002). Meanwhile, the loss of identity as encapsulated in the sense of worthlessness attributed to Israeli childless women by some of the studies we already cited could also be taken as an infringement of the integrity of these childless women. Therefore, it was suggested that this infringement of integrity associated with the worthlessness attributed to Israeli childless women justifies publicly funding IVF treatments. In other words, the need to help these women escape the stigma of childlessness supposedly can be met by offering affordable and accessible IVF treatments.

However, one must wonder whether justifying public IVF funding, achieved through state intervention to supposedly amend or rectify infringed integrity is not a basic contradiction in terms. Such justification seems to lead to an internal inconsistency, since it is based on a principle (integrity) that is undermined by the very offered object of justification (state intervention).

Note that the argument here is not generally against state intervention due to its possible infringement of integrity. Indeed, any instance in which the state “intervenes” to treat disease, save a life, or assist individuals in any way that corresponds to their needs may be considered to be an infringement of integrity. Clearly, claiming that such interventions are unwarranted due to supposed infringement of integrity would be absurd. The argument concerns the paradox generated by the internal inconsistency of justifying generous public funding for IVF treatments based on a principle (integrity) that is undermined by the object of justifications (state intervention). Hence, the logical problem here is that in the name of wishing to relieve childless women from an infringed integrity associated with the “worthlessness of the childless,” another form of infringing integrity (state intervention) is used.

In other words, illuminating this dissonance or paradox in the Israeli context through the lenses of the integrity principle, begs the question of whether the de-facto use of this principle in this context is reasonable. A loss of identity for Israeli childless women occurs, as some of the quoted studies suggest, and this loss can be understood as entailing an infringement of integrity. Therefore, using the latter as a justification for state intervention via public funding of IVF makes little sense since such funding constitutes in itself a breach of integrity.

Furthermore, Gooldin seems to touch on this paradox but from a different angle, building on other sources, while still referring to the discourse illuminated at the two Knesset Committees (Inhorn 2003). She stresses the disconnect between the discourse that suits the situation in developing countries where IVF treatments are mostly unavailable and the context in which this same/specific rhetoric is used in Israel, where it is used to justify state intervention in providing IVF treatments.

According to Gooldin, any emphasis on the suffering of the “childless” (especially childless women), expressed by stressing their emotional vulnerability, may also fit the situation in developing countries where “the material conditions … shape [this] suffering because in these environments identity, labor, and care-taking often takes place apart from the state” (Gooldin 2013, 95). However, such suffering in the Israeli context is actually an “acute object of the state intervention” (Gooldin 2013, 95). Therefore, the dissonance illuminated by Gooldin can be understood in terms of the same paradox of justifying public funding of IVF, constituting a state intervention through arguing for amending the infringed integrity of the individual childless person.

What Can be Learned From the Israeli Case? Two “Take Home” Messages

Thus far, it has been (hopefully) explained and demonstrated how the argumentations for the generous public funding of IVF treatments, extracted from the Israeli discourse at the national public policy level, reveal substantial inconsistencies with core values of the European Principlism model. However, the question remains whether it is possible to learn something from the depicted and analysed Israeli discourse on public funding of IVF that reaches beyond it. We think that the answer to this question is positive and entails two possible “take home” messages that may be applicable beyond the Israeli particular case. Notice that these limitations go beyond the economic or monetary concerns since, as stated in the “Introduction,” the aforementioned Israeli discourse did not revolve around such concerns.

First, the logical problems, entailed in the one-sided depiction of vulnerability and dignity in the Israeli discourse about public funding of IVF treatments, emphasize the need to refrain from such framing of justification in the context of funding these treatments. In other words, this Israeli discourse points to the necessity of examining the merits of funding IVF treatments based on a genuinely broad perspective regarding the vulnerability and dignity of the childless. Given the full meaning of the “vulnerability” principle, such an examination will also recognize the medical limitations of these treatments as well as their potential negative psychological and social ramifications. These limitations and ramifications are not less linked with “vulnerability” than the “emotional vulnerability” ascribed to the childless in the Israeli discourse. Similarly, with respect to the “dignity” principle, the Israeli discourse teaches us that, interpreting this principle only as implying the need to “restore” the dignity of the childless through providing them with free access to IVF treatments, would be wrong. Rather, any attempt to fully account for the “dignity” principle in the context of these treatments will also consider the possibility that the so-called “imperfectness” of the childless (biologically) should be dignified as well. Accounting for this principle will also mean that part of the moral framing for this discourse will include discussions of what is “perfect” and “imperfect” and who is qualified to decide on their definitions, insofar as being childless or not are concerned.

The second “take home” message that may be extracted from the Israeli discourse at the national public policy level regarding the funding of IVF treatments concerns the use, or rather misuse, of the “integrity” principle. As suggested from our analysis above, there seems to be a contradiction in terms when it comes to justifying this funding based on the presumed wish to amend the infringed integrity of the childless using another form of such an infringement through state intervention. Therefore, the use of “integrity” as a justification for public funding of IVF seems to be flawed and possibly should not be part of the arguments presented in favour of this funding. The potential absurdity of using the “integrity” principle for justifying the public funding of IVF is further corroborated and emphasized, once the full scope of “dignity” is considered. As stated in the previous point, accounting for this principle also implies the need to include discussions of what is “perfect” and “imperfect” and who is qualified to decide on their definitions, insofar as being childless or not are concerned. Yet if the image of “perfect” and “imperfect” is not as clear and determined as might be expected (at least according to the Israeli discourse), then what constitutes “wholeness” or “integrity” is unclear as well. This being the case, the ability to use the principle of “integrity” as a justification for public funding of IVF treatments may be questionable as well.

Conclusion

This article has offered a critique of the justification for public funding of IVF treatments as expressed in Israeli discourse at the national public policy level by exploring these justifications using key values associated with the European model of bioethical Principlism. The Israeli case was chosen because that nation is renowned for a (relatively) generous public funding of these treatments compared to other countries. Specifically, we explained why the claims for public funding of IVF, as shown to be based on the concepts of “emotional vulnerability” and the “worthlessness of the childless,” seem to be invalid when explored through the lens of the European Principlism model. It was suggested that these concepts are on the one hand both relying on and expressing the principles of vulnerability, dignity, and integrity. However, on the other hand, these concepts are also undermining the very principles of bioethics they allegedly express and rely on. That is, the manner in which these two key concepts in the Israeli discourse are used at the national public policy level in order to substantiate an exceptionally generous public funding of IVF treatments are self-contradictory.