Does the Nation's Survival Depend on a New End-of-Life Conversation?

Rescue medicine is a staple of U.S. health care. As a defensive strategy for individuals, advance care planning (ACP) has arisen partly in reaction to the primacy of a rescue ideology in our health care system. The impetus to snatch life from death's very jaws is tied to prominent themes in American ideology such as self-reliance and overcoming adversity. The relentless medical pursuit of rescue from death reflects this ideology. As overall health policy, however, rescue medicine is ruinous to the nation's future. The classical citizen virtues of civic friendship, honesty, and courage are embodied in the modern ethics and practice of hospice and palliative care. A metaethic of palliative care provides a positive counterpoint to the ideology of rescue and sets up the coordinates for a new national EOL conversation, including ACP. Rescue recedes as a central goal within the worldview of chaos theory, which comprehends turmoil and progress, living and dying, overcoming and succumbing. In this chapter, we describe the dynamics of a health care delivery system that reflects the classic virtues of citizenship.

THE MAJOR KEY: RESCUE AS NATIONAL IDEOLOGY

Since the invention and proliferation of CPR in the 1960s, rescue has become the central paradigm of health care in the United States. More dollars go toward acute care than to prevention, rehabilitation, long-term care, mental health, or public health combined (U.S. Department of Health and Human Services Public Health Service, 1994). Why have rescue and stabilization come to dominate health care delivery in the United States? To understand why overcoming imminent peril resonates so strongly throughout the health care system, it is instructive to consider how well rescue embodies the dominant U.S. ideology. It is also helpful to ask what the general public wants to be rescued from, and therefore, how the mainstream culture views death and dying.

Respiratory or cardiac collapse is a dramatic event, signaling imminent death. But with the application of speed, intensity, and complex technology, it is potentially reversible—in some cases, under the right conditions. The juxtaposition of imminent death with its potential reversal through tools of human design is irresistible to the American imaginary. Rescue embodies many of the themes of the dominant U.S. ideology, what we are calling the “major key” emphasized in media messaging. Other values built into American citizenship, which seem to command less media attention, form a “minor key.”

The United States was founded on a shared ideology rather than a shared history. That circumstance serves as a source of ongoing insecurity for its citizens regarding the stability of its foundations and the viability of its future (Cavell, 1976). As a result, many people in the United States cling tenaciously to nationalizing narratives as a stronghold against perceived threats (Nichols & Mathewes, 2008). Themes of triumph, heroism, and overcoming adversity through determination and innovation run deep. Never give up, never say die. Drama and display are also important in the United States (Nye, 2001), making technological innovations in health care settings especially salient, particularly if they can delay death. When individualism, entitlement, and choice are paired with the idea of equal opportunity for all, they become legitimized as national aspirations (Bauman, 1992). Francis Hsu (1972) has summed up American psychology as self-reliance, noting its corollary, the abhorrence of dependence. Yet there is a tension here, because many Americans think of themselves as altruistic, always ready to extend a hand to those in legitimate need.

Rescue from calamity fits with this ideology of heroism and triumph, especially if it involves technology and drama. Body trauma television programs capitalize on the appealing combination of a high stakes threat, intensity, urgency, and valiant intervention. Rescue is individualized, customized care made available to anyone, as long as she or he is in extremis. As rescue is understood as being universally available, privileged access to health care can exist in an egalitarian society. In fact, rescue may be the one part of health care in the United States that the system attempts to guarantee to everyone. (The problem is that those who have inadequate insurance must collapse and have the collapse be witnessed before they will become eligible to have “everything done.”) Excellence in the intensity and complexity of
rescue medicine implies overall excellence in U.S. health care delivery. It is clear that this display of fervor, intricacy, and speed is perceived as the gold standard of medical care, the apex of medicine as it is understood and delivered in America. The most cultural value accrues to conquering the highest perceived threat. In the United States, that threat is death.

 
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