American Health Care’s Temporal Order0

(January 26, 2014) The world of contemporary health care is not based upon absolutes, but rather an ever-evolving system of beliefs influenced at any given time by a confluence of advances in science, popular culture, current events and religion.  As these and other components shape that which we as a nation accept as truth, some historical notions transition away from their previously influential roles in society, to be replaced by ideologies that better conform to modern standards.  Given enough time and perspective, these erstwhile canons can even transcend into the realm of mythology and folklore. As with the idea that the mentally ill were once widely believed to be victims of demonic possession, what was once considered an immutable medical truth is now viewed as a quaint theory of an immature age.

Historically, the science of medicine presents a wealth of examples to show how fleeting truth can be, even within the context of life and death. As popular beliefs evolve over time and yesterday’s miracles mutate into miraculous medical advances, such as was the case when Jonas Salk introduced the first polio vaccine, so too are our perceptions concerning the bridge between life and death forced to recalibrate over time. The factors that distinguish animate from inanimate life forms have also come under renewed scrutiny, as definitions for each evolve and expand from both a scientific and ethical viewpoint, complicated by the ways in which we express and understand the morality of our times. Though individuals may clash upon the exact moment when life begins, it is difficult to find dissenters who refuse to acknowledge basic pregnancy when presented with a picture of an ultrasound. On the opposite end of this spectrum, however, the chasm across which society defines death has in the past begun to widen. Overshadowed by the debate surrounding euthanasia, quality of life and personal autonomy, the absence of any definitive measurement for “death” is often overlooked, with the exception of a few high profile tragedies, such as the recent case of 13-year old Jahi McMath in California, Marlise Munoz in Texas, and the 15-year saga of Theresa Schiavo in Florida.

In this modern age, the confusion and controversy relating to the definition of brain death is inextricably connected to advances in life-support, and in particular the miraculous yet mechanical ways in which the heart and lungs can now survive against all odds. Brain death generally includes the cessation of brain and brain stem functionality, at which point in time only ethical intervention can fend off an actual pronouncement of death.  California defines death by “determining that the individual has suffered an irreversible cessation of all functions of the entire brain, including the brain stem.”  (Cal. Health & Safety Code § 7182.)  Though this is widely viewed as an objective benchmark within the medical community, nevertheless families of those who sadly fall within this description can, and often do, take issue with the subjective understanding of a term such as “irreversible.” The science of a situation can be qualified, whereas hope cannot.

The modern day flow of information from around the globe compounds this enigma with Internet stories of miraculous recoveries following brain death, although in many instances a closer review often questions the accuracy or even existence of the initial death-determination. To be sure, rare and often unexplainable instances of the so-called Lazarus phenomenon, or the “delayed return of spontaneous circulation after cessation of cardiopulmonary resuscitation” [Vedamurthy Adhiyaman, et al., The Lazarus Phenomenon, J.R. Soc. Med., 100 (12); 552 (Dec. 2007)], undermine that which is the determinate factor in understanding irreversibility.

No matter how the practice of medicine changes over time, there continues to be no shortage of individuals who seek to improve upon their health, nor is there a dearth of physicians who pledge to heal.  While both patients and providers may take issue with the infrastructure upon which their relationship is based, there is little vacillation in the roles each is obliged to play.  Indeed, since its initial entry into the British-ruled Province of New York in 1736, the American hospital has seen, and survived everything from warfare both global and domestic, the rise and fall of the Federalist and (Jeffersonian) Republican Parties, the absence of running water, automobiles, the invention of light bulbs, the lobotomy, Bayer Heroin, Medicare, and most recently the Affordable Care Act. For an individual who must rely upon a hospital and its delivery of medicine in matters of life and death, genuine confusion and the need for a positive outcome greatly overshadow concern for partisan politics.

History tends to judge a society by the value it places on its individual members. The theories taking center stage in today’s transition to modern American health care are transient at best, and any early complications on America’s road to reform should not be viewed as deliberate architectural bumps designed to bring the delivery of medicine to a halt. Without question, the crux of the Affordable Care Act represents a complicated ideology, and thus far many of its casualties are the result of reform-based intricacies turned friendly fire, the price of necessary change.  However small the number of Congress people who have processed the tens of thousands of regulatory pages that bring actual meaning to the 2010 law, we are past the point of finding typographically errors or fault from technicalities. The legacy of what we now call “Obamacare” has only just begun, but we as a nation cannot yet objectively state that health care in the United States has suffered an irreversible cessation of functionality.  As hindsight has taught us, the present condition of reform is probably “fair,” or even “guarded,” and any progression to “good” or regression to “serious” appears unlikely in the near future.

In times such as these it is important to remember the temporal influence that has historically shaped our nation’s health care. After all, when in 2012 the United States Supreme Court was poised to weigh in on the Constitutionality of reform with the Electoral College waiting on deck, many thought it would be a miracle if the Affordable Care Act survived the year. Yet here we are in 2014, shifting through the wreckage caused by partisan debate, reassessing the foundations that form the building blocks of our new system, and looking toward the future. As was the case with other dramatic health care changes, eventually our focus will shift from the needs of the system to those of the patient, and, like its contentious predecessor the Medicare Act, today’s polarizing Affordable Care Act will settle in as the prevailing health care system for the United States.  Like any form of evolution, the shape must change as an entity matures so as to adapt to new challenges and address new needs.  Should it find itself unwilling or unable to do so, the ACA runs the definite risk of extinction before its true worth can be accurately judged.

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