Reforming Ideology, Reforming Worldview, Reforming Health Care
Just as U.S. hospitals weave industry together with life and death drama, combining speed and technology with throughput and saving lives, the U.S. health care system combines major themes of ideology with the nation's underlying fear of non-survival (Cavell, 1976). Here the news of medical breakthroughs that seem to hold back death for individuals also reinforces national pride and legitimacy for the United States as a nation.
This particular ideology of progress is based on a mechanistic, linear worldview that hearkens back to Isaac Newton. The underlying assumption
FIGURE 19.2 Traditional Linear Understanding of U.S. Health Care.
is that a continuous investment of energy and treasure in the medical project can extend the line of continuous innovation and advancement forever. Such an understanding maps closely to the interest in expanding rescue and life support technology to avoid personal finitude. Unfortunately, a strategy of progress cannot erase the anxiety of a nation founded on ideology, since it cannot guarantee its future existence. Furthermore, chaotic events inevitably interrupt the assumed linear progress. Getting back on track restores credibility. Anything that encroaches upon the U.S. ability to lengthen its lifeline, therefore, must be rejected. Perhaps the salience of the concept of “death panels” expressed the anxiety that slowing technological progress in any way would shorten the lives of both individuals and the nation itself.
In fact, as Albert Jonsen and Daniel Callahan warn, the project of continuous rescue is itself ruinous to the nation (Callahan, 2003; Jonsen, 1986). Prolonging an unqualified pursuit of more time alive is untenable for both individuals and for national economies. A belief that honest striving will make future events break largely in favor of the United States, that no abyss yawns ahead, is bravado. No one nation can hope to escape the effects of global warming, pandemic flu, economic collapse, natural disasters, and/or other yet unknowable forms of chaos. The U.S. faith that unlimited growth will enable the nation to prevail over such adversity interferes with realistic preparations for adverse events and could actually accelerate their arrival. The negative externalities of market transactions, which seem irrelevant when the deals are struck, can be expected to backfire, as the 2008 economic collapse showed (Chomsky, 2012). Not only is the view of progress as a linear advancement untenable, it is also deeply flawed. It does not account for the actual
complexities of real-world phenomena, nor does it allow for the inevitability of chaos.
Taking Comfort in Complexity
There is good news, however. Now that computers analyze enormous sets of data, it is possible to appropriate more accurate depictions of reality that can incorporate chaos and complexity. Order can be created even without the luxury of predictability (Chinnis & White, 1999). In this more comprehensive view of the way things work, interconnectivity, creativity, and relationships become keys to thriving. Complex adaptive systems display openness, nonlinearity, self-organization, emergence, and the diffusion of local action to global effects (Anderson, Crabtree, Steele, & McDaniel, 2005; Malone & Tanner, 2008). Building social capital offers the resources to creatively manage bad times and the resilience to move beyond them (Campbell, 2006). Complexity science enables a revised view of reality as indicated below.
Those who have been working in the field of thanatology and EOL have long known that chaos is a common experience for patients and families when dying and death eradicate the illusion of linear progress. The events of serious illness and the reactions to those events are often complex and unpredictable, notwithstanding even comprehensive efforts toward ACP. Acute illness brings multiple attempts to rescue, diagnose, and treat with a momentum that has a life of its own, and chronic illness brings exacerbations that take one by surprise. The hoped-for orderly trajectory seems not to play out in reality. At these moments self-reliance fails. Advocates for hospice and palliative care are familiar with strategies of interdependence and resilience. Linking arms, connecting with spirituality, and riding out
FIGURE 19.3 Complexity Science Offers an Alternative View of U.S. Health Care.
the storm with supports in place are more likely to bring everyone safely to the other side than fighting the good fight.
It is not necessary to abandon technology and its hope of progress, but in view of a chaotic reality, humans are compelled to find a broader base for creative management. Complexity science and palliative care both recognize human interdependence, and both exploit untapped resources in what is small and close at hand. These approaches challenge the reductionist emphasis on rescue in favor of more abundant perspectives demonstrating that chaos itself generates resourceful solutions. Those who are comfortable with dying and death understand the creativity engendered by chaos.
Using chaos theory and complexity science rather than progressivism to ground a national worldview provides an opportunity to bring underappreciated American values into the spotlight. Rescuing an individual from collapse demonstrates one portion of a social contract, the tacit agreement between a people and its government with regard to protection from untimely death. Emergency services (911) and the surprisingly unsafe health care “safety net” (Becker, 2004) are supposed to make rescue universally available, whereas public access to other areas of health care in the United States is less straightforward. William F. May (May, 2011) argues that the contractual understanding of the role of government in the United States is inadequate. It does not reflect the intentions of the founding fathers, who envisioned a wider role for government than that of being a party to the social contract. May claims that the founders saw government as a necessary refuge from the storms of less civilized influences. This view of government as a covenant with the people, rather than a contract, allows a more nuanced role in keeping with the needs of a pluralistic society.