Response to John Lantos

In response to my essay on cultural metaphors and pain relief in neonatology, John Lantos shifts emphasis to a significant, related, but ultimately distracting topic, the NICU’s life-saving mission, thus launching a defense of neonatal intensive care units not really central to my critique of inadequate pain relief for the preterm baby. I neither celebrate nor condemn neonatal intensive care per se but mainly focus on cultural metaphors as an influence on clinical practice. The desire to save babies’ lives is indisputably primal and unassailably “moral”—but isn’t that just the problem in a modern, technologically complex world? Moreover, some of the medical studies I cite indicate that pain relief enhances survival, so is this really the issue? Instinct may or must be our field guide, especially in the emotionally sensitive area of neonatal care, but a cartography of cultural metaphor and means helps us identify and refine our human obligations beyond it. However, the respondent does pose a number of provocative questions pertinent to my premises and argument, and we remain in agreement on several points. Let me begin, then, with the latter.

The respondent and I both accept that Western medicine “works its magic by causing harm,” and, like him, I am aware that good and bad are not always extricable from one another. To think otherwise would be to adopt the puritan fallacy that one can eliminate evil without affecting good. Correspondingly, cultural metaphors like those I describe both enable and disable. That said, I think we would agree that some evils, such as causing unnecessary pain, can and should be limited as much as possible. We do not equally value exploring cultural metaphor as a means for effecting pragmatic changes in medical care, however; and, by implication, the respondent distrusts the representational nature of my writing, which he sees as replicating the very metaphoric transactions I critique. Like the neonatologists and parents who both want babies to survive, the respondent and I agree only generally, but otherwise perceive according to differing motivations and arrive at different evaluations of the same phenomena.

The primary purpose of my essay is to encourage people—laypersons and medical professionals alike—to look into and, as necessary, past the cultural metaphors contextualizing NICU care in order to locate themselves more consciously as participants or witnesses, with an end to relieving all the kinds of pain in the NICU zone. We need to refine our assessment of the “balance of benefits to burdens,” in the respondent’s words. This is not to say that immediate remedies always result from conscious awareness. The respondent rightly claims that my critique “stops short of particular proposals for reform.” I indeed diagnose more freely than I prescribe, in part because practical remedies to the infliction of pain in neonatology are emerging, as physicians such as K. J. S. Anand, his colleagues, and others research neonatal suffering from both a clinical and humanitarian standpoint; and because changing whole institutions strikes me as a Herculean, if not arrogant ambition, just as replacing major cultural metaphors with others is a Utopian one. (Nevertheless, we should not abandon the imagination of “other worlds” of medicine, since one of the disadvantages of cultural metaphor is that it limits research possibilities.) What is more, as a literary person writing across disciplines, I have never felt a sense of trespass but have sometimes suspected that I was jaywalking past complexities I did not see. In medical situations, people often have to act and react quickly, without the luxury of a long exposition like my essay. Perhaps my words, reaching the minds of readers at a calm time, when there is space for reflection, may enlarge those deeper sensibilities from which our trained and/or spontaneous actions spring. Perhaps someone actively struggling with the issues I raise will feel, if not enlightened, less isolated as a witness. I confess also that I value consciousness for consciousness’s sake. If, as I hope, my essay offers readers a new perspective on the relationship between metaphor and practice, whether in NICU care or in any of the other venues the respondent designates, such...