The Difficulty of Being Anti-NICU

Steven Spielberg’s recent movie, Saving Private Ryan, was interpreted by most critics as an “anti-war movie.” It was hailed for its graphic and horrifying depictions of the grotesque and senseless brutality of modern combat. Nevertheless, as film critic Jonathan Rosenbaum pointed out, the end result is to glorify war. ¹ The heroes were handsome, we were led to admire them and to identify with them, and we hoped that, in similar circumstances, we would act like them. In similar ways, it is hard to write an anti-NICU book or paper.

Many sensitive observers of neonatal intensive care units (NICUs) are troubled by the attitudes and beliefs of the people who work there. One question that arises is whether the attitudes are extricable from the milieu. That is, do you have to be like that in order to like working there? In their book Mixed Blessings: Intensive Care for Newborns, sociologists Jeanne Guillemin and Lynn Holmstrom focus upon “the complex organizational imperatives that have directed the growth of newborn intensive care.” ² They believe that the moral dilemmas of neonatal care are so inextricably intertwined with the organizational structures of NICU care that people’s responses are less individual and moral than they are collective and professional. The doctors all act like doctors, the nurses like nurses. In the NICU that these sociologists studied, “the most fundamental decision—whether or not to ‘go all out’—was easily and routinely made, and the answer was in the affirmative.” ³ They note that “the decision to be aggressive did not involve long discussion, reflection, or emotional agonizing. On the contrary, such decisions were virtually automatic.” ⁴ They quickly see that physicians would rather err on the side of treating someone who will ultimately die than of not treating someone who might have ultimately survived.

Interestingly, in many cases, the authors note that the parents seem to think very much like the doctors. They also have a bias towards aggressive treatment. Given the sociologic mindset of the authors, this seems puzzling. The authors note, “Parents’ sheer dermination coupled with their commitment to the survival of their infant also contributed to the aggressiveness of treatment in the n.i.c.u.” ⁵ The puzzling aspect is that parents are not, it would seem, embedded in the same way in the dense sociologic matrix of professional hierarchies and world views, yet it seems that they also “err” on the side of overtreatment rather than undertreatment.

The authors don’t explain why they think such a response by doctors and parents should be considered a “bias” rather than a “moral commitment” or a “program.” This is a curious judgment for a social scientist to make. It is as if a sociologist would point out that parents “are biased” on the side of picking up their crying infants rather than letting them scream, or that lifeguards have a bias to rescue people who appear to be drowning. The description encodes a moral judgment without acknowledging or arguing it. In dissecting the underlying rationales for aggressive treatment, the authors implicitly convey their own biases that these are “strange” ways of thinking, that is, that they need to be explained.

It is impossible to avoid personal moral sentiments in an analysis of a place that is as morally charged as the NICU. Gayle Whittier should be commended for not even trying. Far better to wear one’s morals on one’s sleeve than to hide them in the vain hope that they will not be noticed and recognized. There is nothing morally neutral about a NICU. NICUs are horrible, wonderful places. They are the best and the worst of pediatrics. They save many lives and they cause much pain and suffering. They may or may not increase morbidity from chronic neurologic and pulmonary conditions. The question that has hovered around these units since they were first developed in the late 1960s is whether we can have the good without the bad or, if not, whether the current balance of benefits to burdens is worth it.

It is not difficult to frame an argument that the...