Author: Nihushi Bhardwaj

After much thought and research, I believe that funding for amniocentesis should be provided to women, however, in certain conditions. For example, if the women is over a certain age, such as over 37, or has a genetic predisposition on either her side of the family or her significant other’s. I don’t believe that funding for amniocentesis or invasive genetic screenings should be provided to couples just because they want to see if their child is going to be “normal” or not. Looking through the lens of American, Japanese, and Israeli culture, I hope to show how this technology has both positive and negative consequences during pregnancy.

Tsipy Ivry’s Embodying Culturecompares how pregnancies are in Japan versus Israel. The Japanese have a very different approach to amniocentesis, as well as a lot of biomedical technology, from what is commonly seen in the Western world. This has a lot to do with their history on eugenics. The Japanese went through several periods in the twentieth century where they were restricted on the number of kids they could have or they were encouraged to have lots of children (Ivry 81). However, over the past couple of decades, they have now reached a problem where the majority of their population is older and there are less children being born. Hence, Japanese officials are encouraging couples to have more kids. One of the consequences of that was making abortion illegal. After abortion became illegal in 1996, the uses of biomedical technology, such as obstetrical ultrasound and amniocentesis, for the purpose of abortion greatly diminished. As Ivry describes there is “no clear guidance from the health ministry” (Ivry 105). She goes on and describes the guidelines that were issues by the health ministry in 1999, which stated that “an ob-gyn has no obligation to inform the patient of the existence of the triple marker” (Ivry 105). This differs significantly from the United States and Israel where the patients have to be informed of what the results are. Due to the Maternal Body Protection Law that came into place in the late 1990’s, as well as the desire to increase Japan’s population, the ministry and the medical insitutions simply had a “formal lack of enthusiasm to use it [genetic testing]” (Ivry 105).

The guidelines set by the government are also interpretive. For example, some institutions state that amniocentesis should be offered as a choice to patients above the age of 35. Whether that means all 35 year olds and older or individuals above the age of 35 seems to be up to discretion of the doctor. As Tsipy Ivry goes on to describe, it has a lot to do with the culture of pregnancy within Japan. Doctors are more reluctant to tell their patients about the test or its meaning. They also don’t want to add more stress towards the mother or the baby. In Japan, a meaningful bond between the mother and baby is created from the day that she knows she’s pregnant, through means such as writing in a notebook, talking to the baby, etc. Thus, for the mother to want to abort the baby due to genetic abnormalities, whom she considers as a full child and not a fetus, is a more stressful ordeal than it would be if this bond hadn’t been created. Additionally, the idea of statistics in amniocentesis, like “the 3:1000 chance of losing the child versus the 1:300 probability that the child would be born with Down’s” (Ivry 112) is inconvenient due to its lack of definitivity and a burden to the parents. If the parents decide to go forward with an amniocentesis and the result comes back negative, there is still a chance that their child could be born with a genetic or chromosomal abnormality. Thus, in Japan, amniocentesis is weighted more heavily, if undertaken, because of all the additional hospital visits, hospitalization time after amniocentesis, antibiotic prescriptions to avoid infection, as well as ultrasounds every few hours after the test (Ivry 120). This may be due to the change in culture after eugenics, the reluctance of the doctors to interfere in a natural process or the indecisive nature of statistics, but Japanese are less likely to use amniocentesis for checking abnormalities. Furthermore, Japanese women are more focused on other anxieties and pressures during pregnancy, like weight-gain, than they are on what the genetic outcome of their child will be (Ivry 172).

Ivry then showed us a look at Jewish Israel, where the use of biotechnologies for checking abnormalities in pregnancy are used more than they were in Japan. Couples that decide to undergo amniocentesis usually have to go to classes to understand the statistics, risks, and what the test results mean. However, as described by Ivry, the couple focuses less on the numbers and “important information” and more on the cultural implications, as well as the practicality of living with a child with Down’s, for example. Because of the liberty of these genetic tests in Israel, women are able to make a decision on whether or not they would be able to live with a child that has a genetic or chromosomal abnormality. There are many reasons for not wanting an unhealthy child: new life stability, the amount of care, fear, etc. Unlike the Japanese who stressed about weight and other allergies, the pregnant women in Israel focused and stressed a lot more on whether their child was going to be normal or not, due to this increased access to genetic screenings, such as amniocentesis. Additionally, amniocentesis in Israel doesn’t require all the medical institutional time, like it did in Japan. Instead, women “must sit in the waiting room following the same test before they are sent home” (Ivry 120). In general, more information is given to pregnant couples. How they interpret and use this information is influenced by doctors, family, friends and personal views. It is less about what diseases the child may have and more about how that child would fit into the couple’s current life story.

As described earlier about baby bonding in Japan, that is not a concept typically seen in Israel. Instead, “through birth, the fetus becomes a baby” (Ivry 216). This fundamental difference in when a fetus is thought to be a baby also significantly influences the use of invasive genetic screenings. As Ivry states, “such techniques of detachment…devised to defend women from threatening catastrophe…underpin the trivialization of pregnancy, as well as the enthusiastic embrace of PND” (Ivry 216). This can be seen through their everyday life. Most women who become pregnant in Israel continue to work until a week or so before their due. They don’t believe that they should be given any special treatment or start worrying about the child just because they are pregnant. This detachment of baby from body is contradictory to the Japanese women who leave their jobs as soon as their know their pregnant and prepare for the child. This cultural difference between Japan and Israel demonstrates the views of a two nations that have opposing views on genetic testing.

Compared to Japan and Israel, the United States is a melting pot of individuals. Because there is not one major ethnic group, the views and uses of genetic testing depends greatly on factors like SES, religion, physical and emotional environment. Rayna Rapp describes three different hospitals in three different parts of town in New York City to demonstrate this to us: Elite, Middle and City. The way information is presented, received and understood all depends on the women’s location, education, status, and so much more. For example, Rapp describes how genetic counselors would describe statistics to clients who don’t know how to handle numbers, aren’t scientifically educated but are attentive, or those who are scientifically sophisticated (Rapp 67-68). The importance of the genetic counselors and the influence they had on these patients was crucial, in comparison to what was seen in Japan and Israel, due to this difference in diversity. Because of this diversity, genetic counselors have to compensate by translating, using metaphors or phrases that mean something similar in that client’s language, simplifying numbers, etc. (Rapp 68). A problem that was encountered in City Hospital and some clients of the Middle Hospital, was obtaining a genetic record of the patients. For example, what was the cause of a family death? What was the medical name for a problem that a close family member had? (Rapp 74). Things like that which may not seem important to name for the patients, play a huge role for the counselors. However, due to the differences in culture, it was not important back home, so it shouldn’t matter here. Yet, when it comes time to potentially screening for these genetic tests, how does the counselor know if they should let the client undergo that risk or not? Another problem due to cultural difference was silence due to misinterpretation or not knowing what to say that the doctors would understand. As Rapp describes, medical etiquette could mean the doctor explains everything to the patient and they don’t need to explain everything; that is why they go to the doctor (Rapp 75). This change in medical environment where they have to exchange information that doesn’t seem relevant or that the patient doesn’t know, leads to problems.

These communication problems result in misconceptions and differences in light of “genetic and socially gendered contributions to a pregnancy’s health and well-being, and between medical and experiential understandings of what specific disabilities entail” (Rapp 79). Middle-class, educated (usually scientifically) couples have an easier time understanding what they are doing at the genetic counselors and what their future plan is for testing. However, the formality to which they understand what the testing is for and why they are undergoing it, usually decreases as SES and scientific education decreases. That doesn’t mean that they don’t understand what they are going through; it’s because of the complexity of their situation usually means that there are things that might be understood between both parties both not with 100% certainty that a middle-class, American-raised couple would have. Another problem, that was seen in both Israel and Japan, is the increased anxiety that mothers have if they need to undergo genetic testing or if they’ve already undergone it (Rapp 106). However, the women that Rapp interviewed that had undergone amniocentesis reported that they were very glad that they had undergone the test. Even though it did cause them a lot of anxiety, they said “it was better to know than not to know” (Rapp 116).

The concept of when one believes the fetus is a baby was important in the United States, as well. For some mothers, it only increased their anxiety for wanting to undergo amniocentesis, while for others it didn’t matter. As Rapp describes later on, “this anxiety invokes dread because it confronts the issue of ‘choice’; a diagnosed fetus is potentially an aborted fetus. And the fear of taking the responsibility for ending a desire pregnancy is substantial” (Rapp 128). All these beliefs of abortion, fetus-baby, along with the diversity already present, makes amniocentesis in America a much more complex and individualistic choice than in the previous cultural contexts. Like seen with some women in Israel, some pregnant women that Rapp interviewed also expressed how they’d be able to handle a disabled child, along with their current life. Some expressed how it was selfish of them to do so, how they couldn’t imagine daily life no matter how much they wanted a kid, how much their life would center on their child instead of themselves, and how they wouldn’t want to burden any siblings (Rapp 137-139).

After looking at amniocentesis in 3 different cultural settings, there were both arguments for and against having amniocentesis. In Japan, Tsipy Ivry showed us a world where genetic testing wasn’t the most important thing. There were other things to worry about in a pregnancy, such as weight, bonding with the baby, cultural allergies, etc. Israel, on the other hand, is a very pro-biomed technology country. Thus, it was no surprise that the government and the people were not against amniocentesis. It was a way to make sure that the pregnancy was a good one, that, considering personal circumstances, the couple would be able to make their own decision on whether they needed to know if they had a disabled child and if they would be able to handle that child. If not, they were able to make that decision. In the United States, a nation where biomedical technology is used greatly, it was a mix. Rayna Rapp helped show that due to a cultural diaspora, there were so many factors that genetic counselors had to consider when counseling their clients, while making sure that they didn’t sway their decisions based on personal (genetic counselor) views. These could be things like, how abortion or disabilities were handled in the client’s native country, current life, SES, religion, etc. Because of this, it was important for the genetic counselor to make sure they were giving the clients specific important information about genetic testing, like amniocentesis. However, the level to which they gave the clients the information and the level to which the clients actually understood the information varied, which is a problem. Lastly, the United States is not currently worrying about population growth, unlike the other two nations, so the choices made by couples were purely individualistic, in regards to genetic testing.

Through this range of views, I have chosen to advocate for a restricted amniocentesis; amniocentesis only in situations in which there is a known genetic predisposition on either side of the couple’s family or if the woman is above a certain age (that will be decided by a counsel). I believe that amniocentesis, as mentioned early on, should not be used as a tool in which couples can choose whether they want to have an “abnormal” child or not. While I do think that biomedical technology is great, especially for bringing a closer view of the child like sonograms, it also increases genetic selection, to an extent. By being able to choose what kind of child we think deserves to live in this world, based on our living conditions, lifestyle and morals, we are intentionally creating a normal vs abnormal child. Furthermore, because the United States is so diverse, there are unfair circumstances in pregnancy to women and their significant others that don’t understand the complexity of testing, like scientifically-educated, middle-class couples do. If there was a way to the communication and understanding portion of genetic testing/amniocentesis easier for both the counselor and the client, then it would be better and funding for amniocentesis could increase. However, because there is so much diversity and inequality in the medical institutions, it would be best to restrict amniocentesis. Finally, in a period that is already stressful enough, having these added, dangerous tests, like amniocentesis, puts even more pressure on the pregnant woman. During a time when they should be focusing on the well-being of themselves and the child, increasing stress and anxiety will only make it worse. Therefore, I believe, that we should become a little bit more like the Japanese that Tsipy Ivry described: less focused on genetic testing and more focused on oneself and the baby.

Citation:

Ivry, Tsipy. Embodying Culture : Pregnancy in Japan and Israel, Rutgers University Press, 2014. ProQuest Ebook Central

Rapp, Rayna. Testing Women, Testing the Fetus : The Social Impact of Amniocentesis in America, Routledge, 1999. ProQuest Ebook Central,

 

In looking at the way both authors approached reproductive technology, I think it’s important to remember that Broyde approaches Judaism from an already well-established perspective towards reproductive technology and argues certain perspectives within this. Bhattacharya, on the other hand, is trying to build up Hindu bioethics. Up until this point, there hasn’t been a defined bioethics for Hinduism, specifically one that is in the Western world or that fits the Western world’s views. Thus, in looking at the two approaches the two authors take, they seem steps behind: one is building upon something that has been built upon for centuries, while the other is starting to build the foundations for a, basically, non-existent perspective.

Nevertheless, there are other fundamental differences between their approach to reproductive technology. Broyde focuses a lot on the definition of kinship-who’s the correct mother, what about if it was the father, how would the child be considered a Jew and through whom, how could this be done so it is not problematic for any of the parties. This is something that we saw in Susan Kahn’s book on IVF in Israel. Judaism focuses a lot on making sure that a child that is born, is born properly as a Jew. Bhattacharya, on the other hand, approached reproductive technology by basing it off 6 basic Hindu principles. She uses these principles to show how they would be used in a case-to-case situation. Additionally, she used one of the texts of Hinduism to base her reasoning off. Broyde didn’t necessarily base his arguments from any scriptures, however, the ideals discussed were based off rules that had been established by interpretations of the first and second chapters of the Genesis.

There were a lot more differences between the two approaches the authors took, yet, it would be difficult to properly compare the two when Broyde is looking at reproductive technology from a specific aspect, whereas, Bhattacharya is looking at a more general perspective of it. Again, as I mentioned before, this isn’t necessarily a difference in the religions, but a difference in how well established the ideologies on this topic are. Bhattacharya is trying to make a very diverse religion into something that can be understood simply, which is very difficult. By defining these six principles, she is trying to define a set of fundamentals for the religion, as seen with Christianity and Judaism. However, that isn’t really possible. From a personal point of view, Hindus come from one God. From this God comes all beings, including the other common forms of Brahman, like Vishnu, Shiva, etc. When God comes to Earth, He takes on different forms, as seen in the Mahabharatawith Krishna (a form of Lord Vishnu). Wherever He comes, that area of India is more likely to worship that form of Him. This makes Hinduism a very diverse and complex religion. For Bhattacharya to try to put all that diversity into a box by only talking about Mahabharatais bold but terribly difficult. In a religion where there is no one set scripture, like there is with other monotheistic religions, trying to find one scripture that can be interpreted for a topic that isn’t talked about is challenging. Bhattacharya does a good job at it, however, throughout her book, it seemed like she was explaining what Hinduism was more than how it significantly differed in bioethics compared to Judaism or Christianity.

Nevertheless, that doesn’t mean some of the differences in reproductive technology weren’t due to religion. Judaism has a more stricter view on the use of reproductive technology than does Hinduism. The six elements of Hindu thought – emphasis on centrality of societal good, a firm belief in the underlying unity of all life, the expectation and requirements of dharam, the multivalent nature of Hindu traditions, a theory of Karma and a commitment to ahimsa- are all ideas that are not concrete; there is no one right way to interpret them. Thus, grouping things into categories is difficult. Judaism, on the other hand, has a set of principles that one needs to keep in mind and abide by when conceiving. For example, Broyde talks about whether the “process is permissible (mutar), prohibited(asur) or a good deed( mitzvah)” (Broyde 296). This is brought up when he discussed activities that were obligatory, like having 2 kids or acts that were permissible, like getting artificial insemination with sperm other than the husband’s (with his consent). Cloning, though not the best option, would be something that would be permissible. The problem comes when defining who the mother is. Here we see a fundamental difference between Hindu thought and Judaic thought. While Hindu principles seem to be up to the interpretation of the individual, for Jews, though it is case-by-case, their principles are more concrete and distinct.

In looking at a specific example of this difference, one can see this underlying distinction through motherhood. Broyde, when looking at cloning, said that motherhood could either go to the gestational mother or the clonor. He agreed with it going to the gestational mother because she was the one who had “conceived” the baby, although the clonor was genetically related to the mother. This is an idea that aligns with was discussed in Susan Kahn’s book, in regards to an IVF. Bhattacharya didn’t necessarily disagree with this idea, but she believed it depended on the situation. The first-born of Kunti, for example, was conceived and genetically-related to Kunti but he didn’t think of her as a mother-figure because she didn’t raise him. Additionally, in the Jaycee case, the surrogate parents wouldn’t be considered the parents and neither would the individuals who donated their egg/sperm; it would be John and Luanne. These two cases do align with Jewish thinking as well, if everything is planned so that the child is Jew and not related to either the husband’s family or the wife’s. Through the stories talked about by Bhattacharya, it is important that the child is related to either parent, but does not necessarily have to be from both parents if one of them cannot procreate. Nevertheless, the extra details of making sure the child is Jew and relatedness aren’t emphasized in Hinduism.

If Bhattacharya and Broyde were to discuss genetic testing, I believe it would have some similarities and differences. Bhattacharya would deal with it based on the 6 elements. If the results of the prenatal testing came back positive for something like Down’s Syndrome, not only would it be analyzed in terms of how to deal with it, but it would also be looked at to see what had the parents done through their actions or practices that they had gotten a child with problems. Using those same elements, they would then make their decision about what to do with that information, such as should the child be aborted or should the child live. If a Jew couple went through this same test with the same result, they would probably go ahead with the child because of the emphasis on having kids to fulfill your duty. Broyde would see how well it fit in with the halakhah. Both of them would agree that aborting the child would be seen as a sin. The reasoning behind each is complex, nevertheless, the common idea that life begins at conception and that having a child is part of one’s duty in life holds greater value than does (or should) the problems the child has been screened for.

After reading Bhattacharya’s work, it was interesting to see how she was trying to fit Hindu bioethics into Christian and Jewish bioethics.  By attempting to westernize Hindu principles, she was able to build a basis for bioethics. However, it was a very broad base that was very similar to Christian and Jewish ones. While she was trying to show how straightforward and simple their bioethics was, she was also trying to simplify Hindu’s bioethics by attempting to mimic it. This is seen through her use of one scripture, as well as defining a set of thoughts/principles that guide Hindu decisions. Through defining Hinduism as a very interpretive religion, it’s important to recognize that all religions can be interpreted in different ways. Broyde’s work helped emphasize this point by looking at the rules we see in Judaism on who the rightful parents, which depended interpretation of who the rightful mother or mothers are. Additionally, by looking specifically at Roman Catholicism, it diminishes the broadness of the Christian view to a specific, orthodox sect. So, while her work attempts to show Hindu bioethics like the Western religions, it is done at the expense of a more constrained view on all 3 religions.

Works Cited:

Bhattacharya, S. (2006). Magical Progeny, Modern Technology: A Hindu Bioethics of Reproductive Technology. Suny University Press.

Broyde, M. J. (2005). Modern Reproductive Technologies and Jewish Law. Marriage, Sex, and the Family in Judaism, 295-328. Rowman & Littlefield Pub, Inc.

Throughout time, the importance of reproduction and kinship has been viewed in the light of religion. For Jews and Christians, the Genesis serves as a basis by which God directly tells them how and who to consider as their kin. The way they interpret what is said, especially in the first two chapters of the Genesis, significantly affects their views on who is kin and how that person is kin. The first chapter of the Genesis talks about how God created mankind in his likeness (1:26) so that they could, essentially, rule over the Earth in place of him. After God had created everything, he gave man a “helper suitable for him” (2:18). Eventually, this helper literally came from man himself, to show the inseparable union between man and woman. The man and woman now have this bond through which there were able to fulfill God’s blessing of being “fruitful and increasing in number” (1:28).  This has been interpreted to mean that mankind was given the gift of reproduction, and one way or another, had to fulfill this purpose. Human reproduction is seen as something that God directly told man had to be done in order to increase their presence in this world. And this reproduction had to be done between a man and woman that were fortified together by a very strong bond, which is usually seen as marriage.

This interpretation of reproduction and kinship in the Genesis, as mentioned earlier, differs between Jews and Christians. As mentioned in Dr. Seeman’s article on “Reproductive Technologies among Jewish Israelis”, Jews use both the Genesis and the Leviticus. The Genesis is used for their idea of marriage, the traditional marriage that is typically seen. The Leviticus, on the other hand, is used to focus on “claims about permitted and forbidden reproductive practices” (Seeman 346). Based on this, the Leviticus is seen to be what is referred to for the legality of reproduction. Christians, on the other hand, use the Genesis to understand both marriage and reproducing. As later described in Seeman’s text, Catholics use the text to “focus on what can be derived from narrative rather than legal portion of the biblical text” (Seeman 348). Thus, one of the reasons behind the differences in interpretation is through how the Genesis itself is used by religions: legality versus narrative. In general, the Genesis gives us the idea of creating a family, however, what to do with that information is up to interpretation by the two religions. This is why there is a major difference in the understanding of a fundamental life concept between Jews and Catholics.

Nevertheless, these differences also come from the importance of how one determines what kinship means. Does kinship come from genetics? Or is everything passed down matrilineally? How does one define a child that meets the religion’s requirements, as well as the reproductive needs of the parents? From the “Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation”, it is clear that the view of the Catholic Church on kinship comes strictly from marriage. A child must come from the egg of the wife and the sperm of the husband. If the couple is having reproductive issues, like infertility, then the only option that is acceptable to the Catholic Church is homologous artificial insemination or IVF with the husband’s sperm. They understand that some couples do not have the ability to procreate and would like to, but the main point they emphasize is that having a child is not “an object to which one has a right…. rather, a child is a gift, ‘the supreme gift’ and the most gratuitous gift of marriage” (Shannon and Cahill, 168). Basically, even though it seems like one must have children in marriage, they don’t necessarily have to. For Catholics, the emphasis on procreation isn’t on creating children; it’s more on valuing the life they are about to bring into the universe, from the moment of conception. Thus, the Church is looking at reproduction and kinship from a moralistic/ ethical view. For this reason, they have very stringent regulations on reproductive biotechnology. Homologous IVF is seen as the only viable option because it uses the egg and sperm from both parents, so the child will be genetically related to both. The other options are either not morally righteous or the child will be related to only one of the parents, which brings about its own problems. So, from the view of the Catholics, kinship emphasizes and depends on genetics and being able to trace your lineage from both parents.

Jews, on the other hand, seem more open-minded to the idea of using reproductive biotechnology. One reason is because they don’t focus as much on the Book of Genesisfor reproduction, like Christians do. However, it is mainly due to how they interpret kinship. For them, family comes matrilineally. Likewise, there is a huge pressure placed on women to have children, even if they are not married. In Susan Kahn’s book Reproducing Jews, we saw this emphasis on creating a family, and the support the country of Israel gave these women. Kahn looked at reproduction from the viewpoint of single, older-aged women who were not married to show how the laws of religion played a role in their reproduction. Overall, though, the rabbis say that it is okay for women to bear a child if done through artificial insemination. How strict the rabbi is on whether the sperm comes from the father, or a Jewish sperm-donor or from a non-Jewish sperm-donor, depended on the women and how strictly of a Jew she was. Ideally, married couples who were having reproductive issues could get IVF done. However, Susan Kahn was looking at this from a non-ideal perspective of unmarried women who needed to fulfill their duty of producing another Jew. Compared to the Catholics, the Jews placed an emphasis on having children, whether or not they were completely genetically related to both parents or completely Jew. This was because the way a Jew was defined differed from the way Christians or Euro-Americans see kin. Hence why it seems that the Jews were more lenient towards reproductive biotechnology. Something important to note, however, is that Jewish women and couples didn’t prioritize using artificial insemination or other reproductive technologies for having kids; instead, they used as a last resort after having flushed out all other options.

After comparing the views on this topic between Judaism and Christianity, one could see how there are multiple factors at play here besides the interpretation of the Genesis. How strict one is in their faith, how progressive they are with their religion, the emphasis on carrying on one’s lineage versus the importance of life, the importance of culture along with many other factors played an important role in the views of the religious priests and followers of both these religions. Looking at these topics through an ethnographic perspective allowed for a more humanized understanding of the problems these people were going through and why (or why not) using these reproductive technologies would be important. By just reading religious texts, it is up to interpretation of the individual. But through analyzed understandings of the culture, religion and people, it allows for various perspectives to be shown that emphasize different factors important for one religious group versus another. Additionally, it allows for comparisons to be drawn between varying groups to show how practices in one may or may not be the same as in another. It is through these ethnographic approaches that some of the religious decisions can be brought about, in regards to a heavy topic like reproduction and kinship.

 

Citations:

Don Seeman, “Ethnography, Exegesis and Jewish Ethical Reflection: The New Reproductive Technologies in Israel.” In Daphna Birenbaum-Carmeli and Yoram S. Carmeli editors, Kin, Gene, Community: Reproductive Technologies Among Jewish Israelis(Berghahn Books, 2010), pp. 340-362.

Donum Vitae In Shanon, Thomas A. and Lisa Sowle Cahill, Religion and Artificial Reproduction: AnInquiry into the Vatican “Instruction on Respect for Human Life in its Origin and on the Dignity of Reproduction.”(Crossroad, 1988).

Susan Martha Kahn, Reproducing Jews: A Cultural Account of Assisted Conception in Israel(Duke University Press, 2000).