Rabbinic Supervision

Rabbinic supervision in assisted reproduction: Help your patients navigate a complex issue

Director, Division of Reproductive, Endocrinology and Infertility, Maimonides Medical Center, Brooklyn, New York

Department of Jewish Philosophy, Yeshivah of Flatbush, Brooklyn, New York

Orthodox Jewish couples who desire assisted reproduction often must obtain rabbinic supervision for their procedures. The stresses associated with fertility treatment may be exacerbated by community concerns. Their religious authorities may be suspicious of the procedures, signal their discomfort, or be opposed to common procedures.

Although requirements for rabbinic supervision are most widely known through association with kashrut (or kosher) dietary laws, they reflect a community-wide philosophical construct: a key objective is to ensure that foreign or impure substances are not introduced into natural products; hence, kashrut requirements extend into any activity that involves biologic products or specimens. Judaism also requires accurate reporting of a child’s parentage; the use of donor sperm, for example, presents a complicating factor that may necessitate input from religious authorities.

This article reviews the challenges faced by Orthodox Jewish patients and describes elements of Jewish law that may affect patients and their healthcare providers. Our goal is to help fertility specialists better address patient needs. Clearly, both contemporary medical education and medical practice emphasize the importance of understanding each patient’s individual concerns and values.¹ The World Health Organization has included the word “responsiveness” as a major criterion to assess medical care systems around the world.²

Halakhic Judaism and fertility treatment

Orthodox Jews are committed to Halakhah, the traditional body of Jewish law and ethics based on the Bible and authoritative texts of Judaism: the Mishnah, the Talmud, and universally accepted codifications. However, no central authority or formal structure exists. Contemporary issues—such as those associated with assisted reproduction—are addressed through a process in which questions are posed to various rabbinic authorities. The responses are circulated as responsa (rabbinic rulings). Eventually, a dominant, authoritative opinion emerges, thus providing overall guidance. Still, this does not imply a universal consensus. A local authority may serve as the final decision-maker in all matters affecting the community. Thus, patients may need to respond to varying interpretations of rules related to fertility treatment.

The role of rabbinic supervision

For non-Jews, rabbinic supervision is most often thought of in terms of its association with kashrut dietary laws, which call for communal supervision of public establishments and institutions. Even the most pious, well-respected restauranteur will arrange for this communal supervision of his or her establishment. Although kashrut supervision ensures compliance with complex dietary laws, exceptions are sometimes made. In 1954,³ some authorities determined that the United States government’s supervision of milk and dairy products was sufficient to permit their consumption. Other rabbinic leaders disagreed and continue to require supervision.

Similarly, opinions differ concerning assisted reproduction. The federal government’s enforcement of its rigorous standards to ensure the integrity of gamete transfers satisfies many in the community. However, some religious authorities insist that separate rabbinic supervision is required.

Clinicians should note that a patient’s request for rabbinic supervision does not imply a lack of confidence in medical professionals. Even if a couple has confidence in laboratory procedures, they may not be able to proceed comfortably without rabbinic approval.

Differences of opinion for fertility treatment

Grazi⁴ describes the major issues in the interface of fertility medicine and religion for observant couples. In general, new opportunities to help couples overcome infertility are welcomed, although ethical concerns may limit acceptance of specific therapies or protocols. In general, procedures that are allowed include intrauterine insemination (IUI) and in vitro fertilization (IVF) that uses the gametes of a married couple to overcome fertility problems.

The use of donor gametes, especially donor sperm, is controversial. Some authorities believe that this violates the exclusivity of marriage and therefore resembles adultery. Others see the process as ethically neutral because no physical sexual contact occurs. However, even those who permit donor gametes do so hesitatingly.

Donor eggs provoke other controversies, specifically in terms of whether the genetic or gestational parent should be considered the Halakhic mother. This affects not only familial relationships but it also raises other questions. For instance, if one “mother” is Jewish and the other is not, will the child require a religious conversion?

IVF may be more disruptive than IUI in terms of normal marital relations, but it is also less likely to be associated with adultery: third-party sperm is not introduced into the reproductive tract of a married woman.

Differences within 2 schools of contemporary observant Judaism result in differing requirements for assisted reproduction.

Modern Orthodox Judaism features extensive interaction between secular and religious authorities. Many religiously observant medical professionals have rabbinic training, and many rabbis have a university education. Constant dialog exists between the secular and religious. These observant communities, and their rabbis, are generally comfortable with medical procedures and technologies.

Ultra-Orthodox, or Hasidic, communities rarely encourage secular studies beyond high school. Few professionals are trained in both rabbinic studies and medicine. Rabbis who lead these communities take a very conservative view of assisted reproduction. Many rabbis, for example, view donor gametes as anathema to Jewish values.

The limited interaction between rabbinic and medical professionals often leads to suspicion and even animosity between the groups. Distrust builds with media reports of physicians who achieve successful pregnancies “at any cost” or experience innocent mishaps.⁵ As a result, these authorities tend to place significant restrictions on the use of IVF or insemination, even when the husband’s sperm is used.

Laboratory protocols

Many Orthodox rabbis in both camps typically require strict independent supervision of all aspects of the lab work, including sperm washing, egg retrieval, and embryo culture, transfer, and freezing. Samples often must be locked in dedicated incubators and storage tanks or placed in a closed and locked section of a larger unit. Generally, an embossed seal is affixed to vials containing frozen gametes or embryos to ensure that no mistakes can be made.

Clinicians should, however, realize that these procedures have little effect on the workings of the lab, once requirements are explained to the lab technicians and supervisors.

It also may be helpful to put this requirement into perspective. No laboratory supervisor can ignore the possibility of human error—even though the probability is extremely low, thanks to the strict supervision in place at all labs. The presence of the rabbinic supervisor addresses the Halakhic concern for—and awareness of—the possibility of human error. This supervision sets in place processes to confirm that human error has not occurred. Typically, the patient is responsible for the costs associated with rabbinic supervision.

Medicine, faith, and the patient

The fertility specialist can do much to help patients negotiate the complexities of treatment and the demands of their faith and reduce the stress associated with assisted reproduction.

A good working relationship with clergy will be helpful. Clinicians should offer to meet with a couple’s rabbi and discuss the assisted reproduction services and sensitivities. Rabbis who are familiar with—and become comfortable with—reproductive technologies can be essential allies to the heathcare team.

Acosta et al⁶ reported, in a limited study, that providing rabbinic oversight resulted in highly successful IVF outcomes. The study authors speculated that the patients’ lowered stress levels may have contributed to the extraordinarily high success rates achieved.

Establishing a good working relationship with religious leaders also may lead to referrals. Religious leaders may be comfortable referring patients directly to centers that accommodate the cultural and psychological needs of community members.

An important resource is available to aid clinicians. The Puah Institute in Israel (www.puahonline.org) bridges the gap between rabbinic groups and the medical community. It provides guidance to couples seeking fertility therapy within an Orthodox framework, develops educational programs, and trains and credentials laboratory supervisors. (The supervisor must be a woman because of modesty issues at the time of insemination or embryo transfer.) To date, over 100 institute-trained supervisors have worked in 80 fertility labs in 10 countries. As a result of their efforts, rabbinic authorities who had previously been unwilling to allow fertility therapy have granted permission.

Conclusion

Many Orthodox couples experience intensified stresses of fertility therapy because of lack of rabbinic support. Even if these couples themselves are perfectly content with government supervision of the labs, and have complete confidence in the integrity of medical professionals, they cannot proceed comfortably without the approval of their rabbinic authorities. Allowing the required independent rabbinic supervision accommodates the cultural, spiritual, and psychological needs of Orthodox couples. Clearly, responding positively to a patient’s request for rabbinic supervision constitutes good medicine.

Sexuality, Reproduction & Menopause ©2010 Quadrant HealthCom Inc.