CCAR RESPONSA

In Vitro Fertilization and the Mitzvah of Childbearing

5758.3

She'elah

A couple in my congregation have been trying without success to conceive a child. They have consulted a specialist about the possibility of in vitro fertilization (IVF). They have been told that this procedure will likely involve extensive and uncomfortable testing and great financial expense. They wish to know whether Jewish tradition would require or urge them to undertake the personal, physical and monetary burdens of IVF in order that they may fulfill the mitzvah of procreation. (Rabbi Mark Glickman, Tacoma, WA)

Teshuvah

I. Childbearing, Jewish Tradition, and Reform Judaism. Our tradition indeed considers procreation to be a mitzvah, and Reform Judaism affirms this mitzvah as one of the highest values of Jewish life.

In biblical literature, children are a palpable sign of God's blessing (Psalm 128). Infertility, by contrast, is viewed as a tragedy. Children signify hope; childlessness is a synonym for despair; and the birth of a longed-for and prayed-for child is grounds for great exultation and joy.[1] The very Hebrew word which denotes the infertile person-`a-q-r/h, "the barren one"[2]-suggests the sadness and emptiness of a life without children. Infertility is the occasion of profound sorrow, a grief so vividly expressed by Rachel, who cries "give me children, or I shall die" (Genesis 30:1), and by Abraham, who declares that in the absence of children all other blessings are worthless (Genesis 15:2).[3] It is with these sentiments in mind that the prophet utilizes the language of infertility to depict the sacred history of Israel. Jerusalem, lifeless in exile, is portrayed as a childless woman, while God's redemption is heralded in the call: "rejoice, O barren one, who has not given birth...for the children of the desolate one will outnumber those of the one who is married" (Isaiah 54:1). Fertility, among the rewards we are promised for observing God's commandments (Exodus 23:26; Deuteronomy 7:14), will insure the future of Israel; barrenness is the end of the chain which links generation to generation in the transmission of Torah.[4] It is little wonder that our sages, reading these texts, could declare that "one who is without children is considered as though dead."[5]

It is understandable, then, that procreation (periyah ureviyah) becomes a mitzvah, a religious obligation for the Jew, derived from Genesis 1:28: "God blessed (the man and the woman) and said to them: Be fertile and increase, fill the earth and master it."[6] Technically, this obligation is fulfilled when one has produced a son and a daughter;[7] nonetheless, "a man who has already fulfilled this mitzvah is forbidden by way of rabbinic ordinance to desist from procreation so long as he has the power to engage in it."[8] Traditional halakhah, based upon a contentious interpretation of the language of the verse, regards procreation as a mitzvah for the man and not for the woman.[9] This distinction may seem a curious one; after all, both a male and a female are needed to procreate. Still, since childbirth has always involved significant medical risks for women, the predominant halakhic view may have been motivated by the desire to protect those women for whom pregnancy might pose an unacceptable danger to life and health.[10] Whatever its medical origins, this distinction is simply a way of saying that it is the man and not the woman who bears the legal responsibility imposed by the commandment. Thus, a man who has not yet become a father must marry a woman capable of bearing children, and the court (beit din) is empowered to compel him to do so.[11] In addition, a husband whose wife cannot conceive is entitled-and may even be required--to divorce her in order to marry a woman who can.[12] A woman is exempt from these requirements. This imbalance is remedied, however, by three factors. First, by long-standing custom, communities do not exert their coercive legal powers to force men to meet their procreative duties.[13] Second, although women are not considered exempt from the terms of Genesis 1:28, some authorities hold that they do partake in the related requirement, derived from Isaiah 45:18 (lashevet yetzarah And third, even if women are not technically "commanded" to bear children, the rabbis acknowledge that they, no less than men, are entitled to the blessings of parenthood. For this reason, the halakhah permits a childless woman whose husband is infertile to demand a divorce in order to marry a man who can give her children.[15]

Reform Jewish teaching is in substantial accord with that of our sacred texts. Though many cultural differences separate our world view from that of our ancestors, we still hold that "it is a mitzvah for a man and a woman, recognizing the sanctity of life and the sanctity of the marriage partnership, to bring children into the world."[16] Indeed, given our commitment to gender equality in the realm of religious observance, we would apply the terms of this mitzvah to women and to men alike.[17] And just as our tradition understands periyah ureviyah as an essentially Jewish obligation,[18] Reform Judaism admonishes us to bear in mind the Jewish dimensions of this subject. We may be rightly concerned about the problem of world overpopulation. And human beings in any case have the right to determine the number of children they should have. On the other hand, "Jews have seen their progeny...as an assurance of the continued existence of the Jewish people."[19] "In considering family size...parents should be aware of the tragic decimation of our people during the Holocaust and of the threats of annihilation that have pursued the Jewish people throughout history." Therefore, "couples are encouraged to consider the matter of family size carefully and with due regard to the problem of Jewish survival."[20]

None of this implies that procreation is an absolute requirement for every person. As Reform Jews, we place a high value upon personal freedom in the realm of religious observance. Phrases such as "absolute requirement" are conspicuous by their absence from typical Reform Jewish religious discourse. With respect to this particular observance, there have always been those who could not and did not have children; similarly, "there are people who, for a variety of reasons, will be unable to fulfill this mitzvah." Like other mitzvot, this one is incumbent only upon "those who are physically and emotionally capable of fulfilling it. Those who cannot are considered no less observant and no less Jewish."[21] Yet this understanding attitude should not be taken to mean that we are somehow neutral as to the decision of a Jewish couple to have children. To say that "procreation is a mitzvah" is to say that it is a positive good and that, barring truly extenuating circumstances, it is the choice that Jews ought to make for their households and families.

For this reason, our she'elah is an especially profound one. The couple who submit it clearly take their Judaism seriously. As such, they regard children not only as the fulfilment of a personal desire but also as the realization of a mitzvah, an act by which we Jews constitute ourselves as a people and as a religious community. The procedure of in vitro fertilization (IVF) may offer the only hope for them to conceive a child. They wish to know whether Jewish tradition and Reform Jewish tradition, both of which stress the importance of having children, teach that they ought to undergo this procedure despite their aversions to it. It is to this issue that we now turn.

II. Artificial Techniques of Human Reproduction: A Reform Jewish View. In ancient times, the accepted response to barrenness was prayer. Since it was natural to regard infertility as a divine punishment, an "act of God,"[22] the proper course of action was to turn to God in supplication, as did Abraham (Genesis 20:17), Isaac and Rebecca (Genesis 25:21)[23] and Hannah (I Samuel 1-2). Indeed, a refusal to pray on behalf of the infertile was considered an act of grave moral insensitivity. Thus, the rabbis criticize Jacob's angry response to Rachel ("Can I take the place of God, who has denied you fruit of the womb?" Genesis 30:2) with a question of their own: "is this how one responds to those who suffer?"[24] Significantly, these episodes are cast in a therapeutic context. Infertility is a disease, an ailment that can be "cured" by the correct remedy. And as is generally the case in biblical and much rabbinic literature, the best available "therapy," for childlessness as with all other diseases,[25] is prayer.

Since then, much has changed. Where healing was once effected primarily by means of prayer, Jewish tradition has for many centuries accepted the practice of medicine (refu'ah) as the correct therapy, the right response to disease. Medicine, our sources tell us, is a mitzvah; it is the way in which we most often fulfill our obligation to save life (pikuach nefesh). While it is surely a good thing to ask God's blessings upon those who are ill--and we do so in our liturgy--prayer is no longer sufficient therapy. As the talmudic saying puts it, "one who is in pain should go to the doctor":[26] when we are ill, we must avail ourselves of the remedies devised through human wisdom and scientific knowledge and not place our exclusive reliance upon the hope that God will intervene into the workings of nature.[27]

From all of this, it follows that the various technologies which enable the infertile to conceive ought to be understood as medicine. Our Committee has indeed taken this position with respect to artificial reproductive techniques in general[28] and IVF in particular.[29] Human infertility is a disease, not because it threatens the life and health of the infertile but because it frustrates our attainment of the goal--the mitzvah--of bringing children into the world.[30] The scientific tools developed to cure this disease are therefore advances in medicine and should be welcomed, as we welcome other medical advances, as a positive good. The question we must answer at this juncture is the extent to which this particular kind of medicine ought to be regarded as obligatory. Medical treatment, after all, is a mitzvah, understood in our tradition as a religious duty. And in cases where the medical procedure indicated for a specific condition is a tested and proven one (refu'ah bedukah or refu'ah vada'it), offering a reasonably certain prospect of successful treatment, the tradition holds that a patient is obligated to accept the treatment and can even be compelled to do so.[31] Does IVF, which we clearly regard as medical treatment for disease, fall into this category of "tested remedy"? If it does, then we would have strong grounds on which to urge the couple who bring this she'elah to undertake the procedure despite its discomfort and its cost.

III. IVF as a Medical Procedure. The technology of in vitro fertilization, first developed over fifty years ago, led to a live human birth in 1978.[32] It is a "medically indicated" treatment for infertility resulting from blockage of a woman's fallopian tubes, male infertility, endometriosis, and "other multiple causes."[33] The procedure may be summarized as follows.[34] The woman's ovaries are stimulated with fertility drugs to produce multiple eggs.[35] The woman's response is monitored by means of urinalysis, blood samples, and ultrasound. Once the eggs are released, the physician may retrieve them through laparoscopy, done under general anesthesia, in which a surgeon inserts a hollow needle, guided by an optical instrument called a laparoscope, into the woman's abdomen. Alternately, the needle may be inserted into the vagina, guided by ultrasound. This latter method requires only a local anesthetic. Upon retrieval, the eggs are placed in glass dishes and combined with semen collected from the woman's partner or a donor. The dishes are placed into an incubator for twelve to eighteen hours. If an egg is fertilized and develops into an embryo, it is transferred into the uterus by means of a catheter inserted into the vagina. Should the embryo become implanted in the uterine wall, pregnancy will be detected about two weeks later.

The medical effectiveness of this complicated procedure might be measured in one of two ways. First, given that "tens of thousands of embryo transfers are carried out each year internationally, and thousands of babies have been born" as a result of this therapy,[36] we might well say that in vitro fertilization works, that it has been tested and found to be a "successful" response to the disease of infertility. Yet if we consider the figures from the standpoint of IVF's rate of success, we find much less ground for encouragement. Estimates range from a rate of 16.9% to 27.9% live births for each group of eggs collected in fertility clinics in the United States, a number which "remains lower than one would like and has not improved much during the last five years."[37] This rate, moreover, declines further when it is calculated from the beginning of the IVF process, from the point of hormonal stimulation rather than from the collection of the eggs.[38] Such numbers do not suggest a therapy which offers "a reasonably certain prospect of successful treatment." We might well expect them to improve as IVF techniques are refined in coming years. At present, however, this less-than-heartening success rate virtually begs us to conclude that, while in vitro fertilization offers much hope to those who seek children, it cannot be considered a "cure" for the disease of infertility.

IV. IVF--An Obligation? Given these facts, we are in a better position to address the question: does Jewish tradition require an infertile couple to undergo in vitro fertilization if that procedure is seen as the only means by which they might conceive a child?

We cannot deny, first of all, that in vitro fertilization counts as one of the "miracles" of modern medicine. We would be ungrateful indeed should we fail to acknowledge our good fortune to live in an age which has devised such a means for overcoming a condition that for many centuries has brought great sadness to women and men. Rabbis who counsel infertile couples should not fail to emphasize this blessing offered us by science, the wonderful possibilities it opens for those who yearn to fulfill the mitzvah of procreation. Still, there is a crucial difference between possibility and reality, and the reality of IVF's success rate suggests that the procedure does not qualify as a "tested and proven" treatment (refu'ah bedukah) for infertility. We have written in connection with other medical conditions that, if a particular treatment cannot be considered a refu'ah bedukah, "if its therapeutic effect upon the disease is uncertain at best, then the patient is not required to accept it."[39] That reasoning, we think, most certainly applies to this case.

To say that a person is "required" or "obligated" to accept a particular medical treatment means as well that, as best as medical opinion can determine, the therapeutic benefits of the treatment significantly outweigh its potential risks and side-effects. To be sure, the benefits of IVF are obvious, in the form of the "thousands of babies" it has brought into the world, and its untoward side-effects are not as clear. Physicians, for example, report that the general risks of surgery to the infertile woman "have been minimized with careful medical practice... (and) the birth defects that have been observed (in children born of IVF) occur in frequencies and types not significantly different from that found in the general population." On the other hand, "these comforting results are... all short term." There is some evidence that the use of fertility drugs for ovarian stimulation may significantly increase the risk of contracting ovarian cancer later in life. In addition, little is known about the long-term potential for introducing genetic defects that become manifest later in the child's life. The increased frequency of multiple births, resulting from implantation of several embryos in the uterus at a time, is another source of health risk, as is the use of cryopreservation (freezing of embryos for later implantation.[40] It is understandable that some women do not wish to accept these potential health risks for themselves or for the children they might conceive.[41] And however we ourselves might draw that fateful balance between the possible blessings and the potential risks of IVF, the dubious success of this procedure makes it difficult in the extreme for us to assert that a particular woman is somehow "required" to undertake the procedure.

Then, too, we cannot ignore the matter of cost. As of a few years ago, the estimated expenditure for a couple in the United States achieving a successful delivery by IVF ranged from $44,000 to $211,940, the costs rising (and chances of success diminishing) with each failed cycle of treatment.[43] True, we might say that "money is no object" and that successful medical treatment ought to be regarded as a "priceless" commodity. But how "successful" is this treatment? Given that failure is the probable outcome of each IVF treatment cycle, it is again difficult to justify an "obligation" to undertake its extraordinary expense.

Finally, let us not lose sight of what our she'elah terms the "personal" burdens associated with IVF. Any surgery is an invasive procedure which by its nature inflicts physical discomfort and psychological distress upon the patient. This particular form of surgery, an arduous process which offers uncertain prospects of success and which touches upon some of the most sensitive aspects of personality and marital life, may well cause even greater suffering. Infertile women and couples who have reached the point of considering IVF have already travelled a difficult and painful road in their lives. To tell them that they are "required" to submit to this procedure--especially when it does not offer them a prospect of probable success--is but to increase to no good purpose the anguish they have already suffered. In cases such as this, we think it better to follow instead the counsel of compassion, of rachmanut; let us listen to the voice of those who suffer rather than insist they hearken to ours.

Conclusion. Jewish tradition regards the bringing of children into the world as a mitzvah, a religious duty. At the same time, it does not require or oblige this couple to undertake in vitro fertilization. How can an act be both a mitzvah and yet not obligatory? One way of thinking about this question is to remind ourselves that the word "mitzvah" can indicate a general religious requirement, one that applies to most of us, even the preponderant majority of us, most of the time, but which exempts particular individuals depending upon the circumstances of their lives. For example, Jewish law recognizes that, in general, we all bear the duty to save human life, to rescue those who are in danger, but this obligation does not apply to the individual who for some reason is "unable" to perform the rescue.[44] With respect to our issue as well, while it is true that as a species and as a people we are "required" to bring children into the world, it is also true that Jewish law accepts that there are exceptions to the general rule. Thus, it neither compels individuals to marry nor infertile couples to divorce.[45] And, significantly, it does not demand that a woman sacrifice her health for the sake of this mitzvah; as one emiment authority has put it, "one is not required to lay waste to one's life in order to 'settle the world.'"[46]

We might also keep in mind that our tradition draws a distinction between mitzvot which are defined as chovah and those which are not. A chovah, or "obligation," is a religious duty that one is required to perform, regardless of the expense or inconvenience involved. At the same time, there are a number of mitzvot which do not impose absolute requirements; "one who performs this act receives a heavenly reward for doing so, but the one who does not perform it is not punished thereby."[47] We might say that the decision to undertake IVF falls into this latter category. Reform Jewish teaching would endorse this distinction. It is certainly a mitzvah to have children, and couples considering IVF or similar procedures deserve our full encouragement and support. Still, if this couple decides against IVF, we must pay the highest deference to their freedom, human dignity, and unique experience.

Finally, we should note that IVF and other artificial techniques of reproduction are not the only means whereby this couple might hope to fulfill the mitzvah of bringing children into the world. They may create their family by way of adoption, for as we have noted elsewhere, the relationship created by adoption is equivalent in every respect to that between parents and their biological children.[48] Should the couple choose to take this path to parenthood, they are entitled to all the assistance and encouragement which our community can offer them as they continue to build their Jewish household.

NOTES

  1. Such as Hannah's prayer of thanksgiving (I Samuel 2) and Sarah's happiness (Gen. 21:6-7).
  2. While the Bible refers more often to female than to male sterility, the latter is not unknown; see Deut. 7:14 and Rashi ad loc.
  3. Other examples include Sarah (Gen. 16:2; see Rashi ad loc., from Bereshit Rabah 45:2), Isaac and Rebecca (Gen. 25:21); Hannah (I Samuel 1-2), and the Shunamite woman (II Kings 4).
  4. See the comment of Sforno to Ex. 23:26. 
  5. BT Nedarim 64b; Rashi to Gen. 30:1. The Torah Temimah comments upon that verse: "the Talmud teaches here that the course of life is a thread that stretches from parents to children. When one has no children, the life-thread of that individual has been severed, and he is as though dead." See also Bereshit Rabah 45:2, cited in note 3: one who is without children lines in a state of "ruin" (harus; a play on the biblical term ibaneh in Gen. 16:2).
  6. The midrash which derives the law from Gen. 1:28 is found in M. Yevamot 6:6. On the law itself, see Yad, Ishut 15:1 and SA EHE 1:1. It is interesting that although this verse is addressed to Adam and Eve and therefore to all humankind (and compare Gen. 9:1), the halakhah does not count procreation as one of the "Noachide" mitzvot: it is an obligation for Jews alone (BT Sanhedrin 59b). For this reason, a Gentile who has children and then converts to Judaism has fulfilled the obligation to procreate provided that the children convert as well (Yad, Ishut 15:6; SA EHE 1:7). Although some poskim disagree, holding that a proselyte's Gentile children do "count" toward fulfilment of the mitzvah (Resp. Maharil, no. 223), others note that this has to do with the issue of relationship (yichus: Jewish law recognizes the legal relationship between members of Gentile families), and we should not infer from this dispute that either side holds procreation to be a mitzvah for Gentiles as well as for Jews (Tosafot, Yev. 62a, s.v. beney.
  7. M. Yevamot 6:6, according to the position of Beit Hillel, who derive the "male and female" standard from the precedent of Adam and Eve, as opposed to Beit Shamai, who rely on the precedent of Moses, who fathered two sons. Yad, Ishut 15:4; SA EHE 1:5.
  8. Yad, Ishut 15:16, from the statement of R. Yehoshua, BT Yevamot 62b.
  9. See M. Yevamot 6:6 and BT Yevamot 65b. The setam mishnah assigns the mitzvah of procreation to the man, while R. Yochanan b. Beroka, noting that the language of the verse is in the plural voice, holds that both the male and the female are obligated under the commandment's terms. The Talmud explains the setam position by the text's word vekhivshuhah, "and master it", literally, "and conquer it": just as it is the way of the male, and not the female, to "conquer," so does the rest of the verse, including the words peru urevu ("be fruitful and increase") apply exclusively to the male. The meaning of "conquest" here is ambiguous: while the term may well refer to warfare, a traditionally male pursuit, some sources suggest that it deals with the husband's mastery or dominance in the marital home; see Bereshit Rabah 8:12 and Bartenura to the mishnah. The Talmud, continuing the debate, replies on behalf of R. Yochanan b. Beroka that the word vekhivshuhah, like the rest of the verse, is written in the Hebrew plural; thus, it applies equally to the woman and to the man. The response to this is that while the word is vocalized in the plural, it is written chaser, "defectively," as though it is a singular word, indicating that the Torah limits the obligation of this verse to the male alone. The later halakhah, beginning with the talmudic sugya at BT Yevamot 65b, accepts the setam position as authoritative (Halakhot Gedolot, ed. Hildesheimer, 2:240-241; Yad, Ishut 15:2; SA EHE 1:13).
  10. The talmudic discussion does not mention these medical considerations. Later authorities, however, might well take them into account in their understanding of a woman's religious obligation with respect to childbearing. See Resp. Chatam Sofer, EHE 20, discussed below at note 45: a woman is not obligated to conceive under the terms of Isaiah 45:18 when the pregnancy poses more than the usual health risk.
  11. BT Yevamot 64b; Hilkhot HaRosh, Yevamot 6:16; SA EHE 1:3.  
  12. BT Yevamot 65a-b and Ketubot 77a; Yad, Ishut 15:7-8; SA EHE 154:6.
  13. Resp. R. Yitzchak b. Sheshet, no. 15, and Isserles to EHE 1:3.
  14. This theory is developed by the Tosafot (Gitin 41b, s.v. lo; Bava Batra 13a, s.v. shene'emar). The requirement of leshevet yetzarah, because it is derived from a prophetic source (divrey kabalah), is considered less stringent than that of periyah ureviyah, which is based upon a verse in the Torah. Nonetheless, the fact that women may be subject to this requirement makes a difference in traditional halakhic thought. Thus, the permit to sell a sefer torah in order to raise the funds needed to marry applies to women as well as to men, since women, though they are not obligated under Genesis 1:28, are nonetheless "covered" by Isaiah 45:18. See Magen Avraham to SA Orach Chayim 153, no. 9; Beit Shmuel to SA Even Ha`ezer 1, no. 2; and Resp. Tzitz Eliezer 10:42.
  15. BT Yevamot 65b; Yad, Ishut 15:10; SA EHE 154:6. Should the husband refuse this demand, the court may compel him to issue a get
  16. Gates of Mitzvah, A-1, 11. 
  17. In this, we would follow the position enunciated by R. Yochanan b. Beroka in M. Yevamot 6:6 and BT Yevamot 65b; see note 8. His midrash, that the biblical verse speaks in the plural, is surely more compelling than that which supports the opposing view. We would categorically reject any attempt to determine religious obligation based upon some "tendency" of males toward conquest or domination.
  18. See note 6. 
  19. Gates of Mitzvah, 9.
  20. Ibid., A-2, 11. 
  21. Ibid., note. See also the sources cited in note 12: the "long-standing custom" in traditional Jewish practice "is not to coerce on this matter." The community, that is to say, does not intervene into the lives of couples who for any reason do not have children.
  22. See Genesis 20:18 ("for God had closed fast every womb of the household of Avimelekh"; Genesis 29:31 and 30:3 ("Can I take the place of God, who has denied you fruit of the womb?"); I Samuel 1:5-6 ("for God had closed her womb").
  23. While according to the literal sense of the verse Isaac prayed alone, the rabbis understand the words lenokhach ishto to mean that both husband and wife offered prayers; Rashi ad loc, from Bereshit Rabah 63:5.
  24. Bereshit Rabah 71:7. The midrash continues: "by your life, your (Jacob's) sons will one day pay fealty to her son" (i.e., Joseph; see Gen. 50:18-19, especially Joseph's repetition of his father's words: "can I take the place of God?").
  25. The idea of disease as a divine recompense for our misdeeds and of healing as a sign of God's favor appears throughout our texts. See, for example, Ex. 23:25; Lev. 26:16; Deut. 7:15; BT Berakhot 60a (bottom, the prayer which suggests that human beings have no business engaging in medicine in response to illness); and especially the comment of Nachmanides (Ramban) to Lev. 26:11.
  26. BT Bava Kama 46b.
  27. As Ramban writes (to Lev. 26:11), once Israel chose to live its life in accordance with the laws of nature, rather than according to God's special providence, "the Torah will not make its laws depend upon miracles." That is to say, if pikuach nefesh is a mitzvah (see BT Yoma 85b to Lev. 18:5), then the correct way to fulfill that obligation is through the practice of medicine, which unlike prayer does not require a special intervention by Heaven. For a more detailed discussion see Teshuvot for the Nineties (TFN), no. 5754.18, 373-375. 
  28. See American Reform Responsa (ARR), nos. 157-159. 
  29. See our responsum no. 5757.2, "In Vitro Fertilization and the Status of the Embryo." 
  30. On this, see responsum 5757.2 at note 7: "by 'disease' we mean a condition in which some aspect of our biological or psychological systems does not function properly." And in the note itself: "This suggests that the definition of 'disease' is largely a matter of social construction: that part of our biological or psychological systems is functioning 'improperly' is a judgment we make based upon a conception of what 'proper' functioning is. Accordingly, we may define human infertility as a disease and the procedures designed to correct it as 'medicine'."
  31. See our discussion in TFN, no. 5754.14, 348-349, at notes 38-40.
  32. J. Rock and M. F. Menkin, "In vitro fertilization and Cleavage of Human Ovarian Eggs," Science 100:105 (1944); P. C. Steptoe and R. C. Edwards, "Birth After Reimplantation of a Human Embryo," Lancet 2:336 (1978).
  33. Joseph Schenker, M.D., "Medically Assisted Conception: The State of the Art in Clinical Practice," in Patricia Stephenson and Marsden G. Wagner, eds., Tough Choices: In Vitro Fertilization and the Reproductive Technologies (Philadelphia: Temple U. Press, 1993), 25-36. The citation is at p. 26. Dr. Schenker is Professor of Obstetrics and Gynecology at Hadassah Medical Organization, Jerusalem. At the time of this writing, he was chair of the department and president of the Israeli Society of Obstetrics and Gynecology.
  34. This description is taken from Andrea L. Bonnicksen, "In Vitro Fertilization and Embryo Transfer," Encyclopaedia of Bioethics (New York: Simon and Schuster MacMillan, 1995), 2221ff.
  35. Schenker, loc. cit., adds that the current trend is away from drug-stimulated menstrual cycles and toward "natural cycle IVF", which poses fewer risks to woman and child.
  36. Bonnicksen, 2222.  
  37. See Michael E. McClure, M.D., "The 'ART' of Medically-Assisted Reproduction: An Embryo is an Embryo is an Embryo," in David C. Thomasma and Thomasine Kushner, eds., Birth to Death: Science and Bioethics (Cambridge: Cambridge U. Press, 1996), 35-49. Dr. McClure is the Chief of the Reproductive Sciences Branch, Center for Population Research, National Institute of Child Health at the National Institutes of Health, Bethesda, Maryland. The citation is at p. 42.
  38. One such estimate, taken from a survey of several national registries, is a success rate of 9% to 13%. See Jean Cohen, "The Efficiency and Efficacy of IVF and GIFT," Human Reproduction 6 (1991), 5:613-618.
  39. It could be argued that 16.9% to 27.9% success rate ought to be accepted as a "proven treatment" because it raises the chances of conception to roughly equivalent with natural conception. But this is not what we think refu'ah bedukah means. The infertile couple do not measure medical success by the degree to which their attempts to conceive enjoy the same rate of success as that of other couples. For them, "success" means a successful conception leading to a live birth. Such is a reasonable definition, as it is the prospect of actually having a baby that brings them to IVF in the first place. And until the rates of conception and live birth significantly improve, we do not think the procedure currently qualifies as refu'ah bedukah.
  40. TFN, no. 5754.14, at pp. 348-349.
  41. McClure, 43-46.
  42. See Cynthia B. Cohen, "'Give Me Children or I Shall Die!' New Reproductive Technologies and Harm to Children," Hastings Center Report 26:2 (March-April 1996), 19-27, arguing that a decision not to have children is certainly ethical if we know we are subjecting them to significant risk by conceiving them through artificial technologies.
  43. McClure, 43. 
  44. See BT Sanhedrin 74a, from Lev. 19:16 ("do not stand idly by the blood of your fellow"), which declares that whoever sees his fellow in danger is "obliged" (chayav) to save him, and Yad, Rotzeach 1:14, where this obligation is formulated thusly: "whoever is able [emphasis added] to save (another) and does not do so violates the commandment 'do not stand idly by the blood of your fellow.'"
  45. And, again, see the sources at note 12: it has long been customary not to coerce over this very matter.
  46. Resp. Chatam Sofer, EHE, no. 20. 
  47. The quotation, taken from Mishnah Berurah 260, no. 1, is found as well in Isserles, Darkei Moshe to Tur OC 260; he in turn derived it from the 13th-century work Or Zaru`a, Hil. Erev Shabbat, par. 7. The talmudic source is BT Shabbat 25b: "the kindling of the Shabbat lamp is an obligation (chovah), while washing one's hands and feet in warm water on Friday afternoon (see Rashi ad loc.) is a voluntary act (reshut); but I [the transmitter of this statement] say that the latter is a mitzvah," meaning neither obligatory not entirely "optional". On this subject in general, see the article "Chovah, mitzvah, ureshut," Encyclopaedia Talmudit, vol. 12: 645-679.
  48. The quotation, taken from Mishnah Berurah 260, no. 1, is found as well in Isserles, Darkei Moshe to Tur OC 260; he in turn derived it from the 13th-century work Or Zaru`a, Hil. Erev Shabbat, par. 7. The talmudic source is BT Shabbat 25b: "the kindling of the Shabbat lamp is an obligation (chovah), while washing one's hands and feet in warm water on Friday afternoon (see Rashi ad loc.) is a voluntary act (reshut); but I [the transmitter of this statement] say that the latter is a mitzvah," meaning neither obligatory not entirely "optional". On this subject in general, see the article "Chovah, mitzvah, ureshut," Encyclopaedia Talmudit, vol. 12: 645-679.

If needed, please consult Abbreviations used in CCAR Responsa.