Book Review

For the Sake of the Children: The social organization of responsibility in the hospital and the home

N Engl J Med 1999; 341:620-621August 19, 1999

Article

For the Sake of the Children: The social organization of responsibility in the hospital and the home
By Carol A. Heimer and Lisa R. Staffen. 419 pp. Chicago, University of Chicago Press, 1998. $18. ISBN: 0-226-32505-9

Increasing knowledge and technological sophistication have led to remarkable advances in the care of critically ill newborns. These advances have resulted in increased survival among such infants, even those with extremely low birth weights. Successful outcomes depend on the organization and effectiveness of the neonatal health care team and the parents who will continue to care for an infant after discharge from a neonatal intensive care unit (NICU). Increasingly, there is interest in the role of the parents, both in the NICU and in the home.

For the Sake of the Children, coauthored by two sociologists, examines the social organization of responsibility, focusing particularly on parents. In this empirical report, the authors also examine others who take responsibility — namely, the neonatal health care team — and the role of the state in its responsibility to these vulnerable infants. The authors recognize that responsibility is a moral issue as well as a practical one, and although their investigation is empirical, they appropriately claim that such an investigation leads one to see more clearly what is morally acceptable and what is not.

Field observations were carried out in two NICUs — one in a city and the other in a suburban setting. The interviews with the parents were conducted a year or so after the infants had been discharged, leading to a matching of categories of events rather than the actual events witnessed by the interviewers. The authors acknowledge that parents who were less devoted to their children were probably less willing to be interviewed and therefore may be underrepresented in this study. In addition, this study reflects experience at only two specific NICUs.

The book opens with a discussion of why we need a sociology of responsibility. It then details the personal experiences of parents whose infants were treated in the NICU. It describes the variation in the degrees of responsibility the parents took on by examining the conditions under which they embraced or rejected responsibility for their newborn infant. Acceptance of this responsibility is critically examined according to the ways it was undermined or supported by the institutions caring for the infant and how the parents met their obligations. For parents, responsibility entailed concern not only for the present welfare of the infant but also for the future — a time when the complex organizational structure of the NICU would no longer be there to guide them through the trials and tribulations of caring for their dependent infant. In some cases, this dependency involved sophisticated technological assistance.

The authors discuss responsibility in terms of a joint enterprise, pursuing the state's responsibility in the NICU and in the home through standards that it sets and enforces. The social control of parenting in the NICU by the organization of the NICU is followed by a discussion of the parents as agents of social control in the NICU. The authors note that although parents have ultimate responsibility for their child, they have little ability to intervene while the child is hospitalized. Parents who “intervene too much” may be viewed as difficult, although the staff of the NICU recognizes that these parents may shoulder appropriate responsibility once the infant is discharged home. The authors address the subject of labeling of the parents — a form of social control that can affect the way responsibility is perceived or assessed — as “appropriate” or “inappropriate.” This practice has the potential to affect considerably the way the staff reacts to parents.

The authors address the issue of sex inequality, by which the burden of care of the infant falls predominantly on women, limiting their ability to seek more highly rewarding responsibilities. They report that more responsible people tend to take into account the interests of others as well as their own, consider long-term outcomes, define their roles more diffusely, use more discretion, and cope with whatever controversies arise.

The authors have done a creditable job of examining the theme of responsibility in the context of neonatal care. Their book will be of interest to physicians, social workers, and organizations that have a shared responsibility for the total care of these vulnerable infants.

I. David Todres, M.D.
Massachusetts General Hospital, Boston, MA 02114