PUBLIC HEALTH PERSPECTIVES ON THE PARSHAH: LEKH LEKHA
When Hashem reassures Avram that “your reward is very great” (15:1), Avram seems somewhat incredulous – מה תתן לי ואנכי הולך ערירי—”What can You already give me, seeing that I am childless!?” (15:2). Wealth, victory, and Divine favor all ring hollow without a child of his own.
That deep rooted sentiment is something that has resonated with the Jewish people throughout the ages. In modern times, it has adopted a very practical and public face in the possibility of publicly supporting fertility treatments. The State of Israel currently performs more IVF cycles per capita than any country in the world. That is due in no small part to one of the most generous public funding policies anywhere. National health insurance covers fertility treatment, including IVF, until a couple has two children together, even if each spouse already has children from a previous marriage.((According to the State Comptroller’s November 2024 report, about 61,000 IVF cycles were performed in Israel in 2021, an increase of roughly 60% since 2011. That comes to 27 cycles per 1,000 women of reproductive age, compared with 6 in the UK, the highest of all the countries examined. Public spending on IVF reached about NIS 450 million in 2023. The report confirms that funding continues until age 45 (for new egg retrievals) with a nearly unlimited number of cycles, whereas other countries cap funding between ages 35 and 43 and between one and six cycles. According to the Taub Center, IVF accounted for 9,176 births in 2019, about 5% of all live births.))
Most discussions of fertility in medical halakhah focus on the individual couple. What is permitted? What is required? Whose child is it? The public health question is different: why should the public pay? Every shekel spent on IVF is a shekel not spent on something else in the health basket.
Two Answers to One Plea
Avram’s complaint is entirely personal. He has no heir and Eliezer is set to inherit his household (15:2–3). God’s response comes in two stages.
The first answers the plea on its own terms: לא יירשך זה כי אם אשר יצא ממעיך הוא יירשך—”this one will not inherit you; only one who comes from your own body” (15:4). This is a promise to an individual. Avram will have a son.
Then the frame shifts. ויוצא אותו החוצה—God takes Avram outside and has him count the stars: כה יהיה זרעך—”so shall your seed be” (15:5). This is no longer about an heir. It is about a people. Rashi reads “outside” as “outside your astrology.” Avram had seen in the stars that he would not have a son. God tells him that Avram will not, but Avraham will.((Rashi to Bereishit 15:5, s.v. va-yotzei oto ha-hutzah.)) The prognosis is real, but it is not the last word.
A personal plea was answered with a national promise, and the two were never fully separated again.
The recently published Sefer Yoshveha Aleha, edited by Rav Neriyah Gutel and Rabbi David Stern of Merkaz Torah U-Medinah, devotes chapter 13 to “Public Funding of Fertility Treatments” (while it lists multiple contributing authors, it does not identify a particular author for each chapter). It frames the question of public funding as relevant to two different tracks:
- Support for a mitzvah: Funding fertility treatments manifests the public’s support of an individual’s mitzvah of peru u-revu. Because of its importance, Halakhah has given a public dimension to fulfilling what would otherwise be a personal mitzvah.
- National need. The public, through its government, decides that additional births serve a collective national interest: demographic, social, or even security-related. In this view, funding fertility treatments is good public policy.
The First Track: A Private Mitzvah Made Public
Peru u-revu is, at first glance, the most private of mitzvot. And while that is undoubtedly true, the authors place it among a handful of unique mitzvot for which Hazal added a communal responsibility component. The most classic example of such a mitzvah is Talmud Torah. While the obligation to teach one’s child belongs to the father, Yehoshua ben Gamla is praised for having saved the Torah itself by establishing publicly funded teachers in every town, so as to ensure that all children had access to a Torah education (Bava Batra 21a). This frameshift to a communal responsibility is credited with preserving Torah from being lost.
There are several indications that peru u-revu belongs in the same category.
A Sefer Torah is one of our holiest objects and selling one is generally forbidden, with only two exceptions: funding Talmud Torah or enabling a marriage. The Gemara (Megillah 27a) justifies the latter based on the pasuk – לא תהו בראה לשבת יצרה—”He did not create it to be a waste; He formed it to be inhabited” (Yeshayahu 45:18). Interestingly, the Gemara does not say that doing so enables additional personal fulfillments of the mitzvah of peru u-revu, but rather focuses on the broader notion of the settlement of the world. It’s this broader notion that Sefer Ha-Hinukh (mitzvah 1) gives as the rationale behind peru u-revu. It’s specifically this larger focus, the element that not only universalizes but broadens peru u-revu to attain a more communal aspect that justifies the sale.((Rambam, Sefer HaMitzvot, aseh 212, likewise speaks of the intent to perpetuate the species, though he does not cite the pasuk in Yeshayahu.))
If the community may liquidate its most sacred and most restricted asset to enable people to have children, the authors argue that ordinary public funds may certainly be used for the same end. Most Poskim hold there is no individual obligation to pursue fertility treatment. But many hold that the mitzvah is fulfilled through artificial insemination and IVF.((Sefer Puah, vol. 2, ch. 25 (no obligation to pursue treatment); ch. 48–49 (mitzvah fulfilled through insemination and IVF). In ch. 42, Sefer Puah also surveys whether fertility treatment counts as refuah at all. It concludes that infertile couples are, at the very least, holim she-ein bahem sakanah, so their treatment is medicine and its cost should fall on the public. We will take up this argument in the next post.)) If so, publicly funded fertility treatment fits comfortably within the framework of communal support for peru u-revu.
The Second Track: “Your People Need Sustenance”
The second justification is broader and independent of any mitzvah performance. It applies both to people who already have or yet to fulfill peru u-revu and would be relevant even according to those opinions that maintain that IVF does not necessarily fulfill the mitzvah.
The Gemara describes the Hakhamim approaching King David at dawn (Berakhot 3b), entreating him: אדוננו המלך, עמך ישראל צריכין פרנסה—”our master the king, your people Israel need sustenance.” When his first suggestion of supporting each other meets fierce economic opposition, he authorizes a military campaign to secure bounty from elsewhere.
The Rambam describes the king’s core roles as administering justice and waging war (Hilkhot Melakhim 4:10), strongly implying that maintaining the economy is not his domain. Yet when there is a genuine national need, the sovereign may step beyond his core responsibilities and commit public resources, even lives, to address it.((See also Rambam, Hilkhot Melakhim 5:1: a discretionary war may be waged “to expand the borders of Israel and increase its greatness,” even absent mortal danger.)) If the king may go so far as to send soldiers into battle to sustain his people, the authors argue that surely a government may take the far less drastic step of funding fertility treatment, when increasing births is a genuine national need.
The process that David then followed is instructive: יועצים באחיתופל ונמלכין בסנהדרין ושואלין באורים ותומים—”they consult Ahitofel (his expert advisor), seek guidance from the Sanhedrin, and inquire of the Urim ve-Tumim.” National-need decisions are not made by instinct. They first require expert assessment and legitimate authority.
This second track rationale for publicly funding fertility treatments is similarly conditioned. Israel’s fertility rate is already the highest in the OECD by a wide margin. In 2020, Jewish Israeli women averaged about three children each, compared with an OECD average of roughly 1.6.((Fertility rate figures are from the Yoshveha Aleha chapter, which cites CBS and OECD data for 2020.)) Whether Israel needs more births is a question for demographers and economists—if the experts conclude that there is a national need, the state may, and perhaps must, invest. If they conclude there is none, the national-need justification disappears and, according to these authors, only the mitzvah track remains.
Why the Distinction Matters
In an earlier post, we contrasted two ways of thinking about “the public.” On one view, the public is simply a collection of individuals, and public policy aggregates their individual concerns. On the other, the whole is greater than the sum of its parts; the public has needs and interests of its own. We argued that Halakhah adopts the second approach.
The two tracks map neatly onto those two views. The mitzvah track treats the public as a collective helping each individual fulfill his or her obligation. The national-need track treats the public as an entity with an interest of its own in the next generation. It is, in the fullest sense, a public health rationale.
The reason we fund will shape whom we fund.
The distinction has practical consequences. The two tracks will give different answers to the hard allocation questions: who should be prioritized, whether funding should depend on income, and what might justify ending it. Those questions deserve their own treatment, and we will return to them once all three justifications are on the table. For now, the point is simpler: the reason we fund will shape whom we fund.
At the same time, bearing children has an outsized impact on the psyche of the Jewish people, both as individuals and as a collective. As Rabbi Jonathan Sacks notes (Koren Sacks Humash, Bereishit 15:3), the very first recorded conversation about our covenant with God is Avram’s concern for his legacy. “The first Jew is worried that he may also be the last.” Our subsequent history, of which Avram was given a glimpse in the ברית בין הבתרים later in this very chapter (15:13), has made that concern all the more real. But far beyond fear, having children and leaving a legacy speak to something deeper within the Jewish soul: a tradition of ensuring that the Tradition continues. Until quite recently, that longing had no real public expression. The State of Israel’s fertility policies give it one, translating the inner yearnings of Jewish souls into concrete public policy.
From Stars to Spreadsheets
Avram asked for an heir and was shown the stars. A personal plea was answered with a national promise, and the two were never fully separated again. Public funding of fertility treatment lives in the same tension. It is both help for individuals in a mitzvah and an investment in the people as a whole.
