Over the next few blog updates, we will be spotlighting new articles from our June 2016 issue, which you can access in full here. The theme of this special issue is The Clinic in Crisis: Medicine and Politics in the Context of Social Upheaval. In addition to articles that address the topics of societal unrest, political change, and human health, this installment also turns to how people navigate change and decision-making within the contexts of their own lives. Specifically, one article questions whether individual autonomy over medical decisions is a characteristic of medical care across cultural contexts. In Teman, Ivry, and Goren’s article “Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control,” we learn that the notion of reproductive choice and control does not cleanly map onto the procreative experiences of Haredi (ultra-Orthodox Jewish) women. To access this article in full, click here.
Reproductive technologies have expanded the range of procreative choices a woman and members of her family confront: should birth control be used to limit the number of children she wishes to have? Should assisted reproductive technologies (ARTs) be used to facilitate conception, or should a woman abort a fetus that has tested positive for a developmental or congenital ailment? The authors of this article suggest that in these discussions, another question has emerged. Are these decisions truly reflective of individual choice, or do individual mothers and members of their community perceive the reproductive course as one over which no person has ultimate control?
Amongst Haredi (ultra-Orthodox Jewish) women in both the United States and Israel, the authors observed another way that individuals framed their reproductive experiences. Rather than describing their procreative choices as a form of individual control over one’s life course, the Haredi women referenced hishtadlut, or obligatory effort: the notion that they were obliged to God to try to become pregnant, but not responsible for the outcome if they were unable to do so. In hishtadlut, women have “room for effort” in that they may flexibly interpret and enact what constitutes a serious attempt to become pregnant or maintain a healthy pregnancy per their religious duty to God to have children. In this explanatory framing, women recognize that they must consciously make choices that would enable God to enact a divine plan for them: however, they are not accountable for the outcome if, having invested the “effort,” God’s plan does not come to fruition or leads to the birth of a child with a developmental disability or congenital condition.
The concept of hishtadlut extended to the use of various reproductive technologies. For instance, there are many concerns about hereditary genetic illnesses like Tay-Sachs disease within the Haredi community. To ameliorate this issue, blood samples from young Haredi men and women enrolled in high school are collected and catalogued into an anonymous database. If two families are arranging a marriage between a son and a daughter, they are able to consult the database to confirm whether or not both individuals are genetic carriers of an illness. This prevents unions between two carriers who would have a greater likelihood of having a child with a genetic illness; thus a genetic carrier would be paired with a non-carrier spouse. Most women interviewed for the article agreed that this technological system facilitated the will of God, as it reduced the chance that a couple would face the difficulty of raising a disabled or an ill child. Here the technology is seen as a “blessing” from God, as it allows families and couples to avoid “heartbreak,” while bolstering a couple’s ability to have healthy children per God’s divine plan.
In other instances, technology is viewed as irrelevant out of the hishtadlut principle. For example, the Haredi women perceived genetic testing for fetal developmental or other congenital illnesses as having little purpose. In Jewish law, abortions beyond 40 days after conception are prohibited, and all fetal diagnostic testing occurs after this point in a woman’s pregnancy. Thus, the women held that the test was inconsequential, as God’s will for them and their fetus had already been ordained. If a baby was born with a disability, this was part of their fate as decided by God. Here “choice” is viewed as God’s choice for the mother and baby, rather than the mother’s own control over whether or not to give birth to a child with potential developmental or congenital conditions.
As Teman, Ivry, and Goren’s research illustrates, “choice” and “control” do not necessarily apply to the reproductive experiences of women and their families across cultures. Indeed, in a deeply religious community such as the Haredi Jews, “choice” is attributed to God while individual reproductive decision-making is cast as a means to allow God to work through individuals to enact divine will. Haredi women did not describe themselves as accountable for becoming pregnant (or having a healthy child), but they did feel obligated to use technologies and consciously make reproductive decisions or avoid certain interventions. These actions, they held, would enable God to direct their journey to motherhood and to fulfill their purpose as parents.