Gawande's Being Mortal

by Stefani Daniels, Managing Partner
Published on Oct 23, 2015

This is a brilliant reflection on the nature of aging and the process of dying. Dr Atul Gawande has done his research and talked to over 200 people to get right to the core of a most unpleasant subject, one which most of us would rather avoid. It deals with the key question of when efforts to stay alive should be halted in favor of efforts to make the end of life bearable and dignified.

Of all the sayings about life, one in particular holds truth: no one gets out alive. Author and practicing Boston surgeon Atul Gawande tackles this very concept in his latest book, Being Mortal: Medicine and What Matters in the End. “Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone” says Gawande. “We have been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.”

I’ve been reading Gawande’s writings since I first encountered his 2009 article in the New Yorker about the cost of healthcare in McAllen Texas which was double that of the average national Medicare spending. Atul Gawande is a bright and gifted writer and what separates him from most other physician/writers is his willingness to see both sides of a controversy. He has a firm commitment to data. And, unlike many doctors who diagnosis healthcare problems without taking the risk of proposing solutions, Gawande offers actual “boots on the ground” suggestions for useful change. He recognizes that often change must occur incrementally, one common-sense step at a time. His books stand testament that policy makers are swayed far more effectively by a reasoned and elegantly crafted prose than loud polemics.

In this book, Gawande brutally confronts the aging process but it is also deeply moving.  He describes the failure of healthcare professionals to accept the reality of mortality and accordingly make it a focal point in the way they treat the frail elderly, the terminally ill and the dying.  In the Introduction he says that the only thing he remembers in medical school that came close to the subject of managing terminally ill patients, was the discussion on Leo Tolstoy’s classic The Death of Ivan Ilyich.  Gawande quotes Tolstoy “What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo treatment and something very good would result.” Gawande reports that as medical students saw it, the failure of those around Ivan Ilyich to offer comfort or to acknowledge what is happening to him, was a failure of character and culture. He admits that within a few years of completing his surgical training and beginning his practice, he encountered patients forced to confront the realities of decline and mortality and that he was unready to help them.

The first half of the book pulls no punches.  I admit, it was disturbing.  It lays bare the reality of aging and increasing dependence. In the chapter ‘Dependence’ Gawande says “It is not death that the very old tell me they fear. It is what happens short of death – losing their hearing, their memory, their best friends, their way of life.” He says we do not think about the eventuality that most of us will spend significant periods of our lives too reduced and debilitated to live independently. As a result, most of us are unprepared for it.   

Gawande, argues that quality of life is the desired goal for patients and families. He describes some socially fulfilling care models for assisting the frail and dependent elderly and details the efforts by many individuals to find ways and means of improving their quality of life.  Several of the anecdotes are from his colleages own experiences of tending to an aged parent or a spouse.  It is in this context that he acknowledges his new respect for the work of palliative care professionals who are committed to ensure that a person's last weeks or months are as rich and dignified as is feasible. 

Referring to a book The Philosophy of Loyalty written by a Harvard Philosopher Josiah Royce, Gawande says that Royce wanted to understand why simply existing – why being merely housed and fed and safe and alive – seems empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile? The answer he believed is that we all seek a cause beyond ourselves. This was to him, an intrinsic human need. The cause could be large (family, country, principle) or small project or the care of a pet. The important thing was that in ascribing value to the cause and seeing it as worth making sacrifices for, we give meaning to our lives.

At the beginning of the book Gawande talks about his grandfather who lived till the age of a hundred and ten years and ultimately passed away surrounded by his large family in India in the midst of the people he loved and in his own home. He says “My father’s father had the kind of traditional old age that from a Western perspective, seems idyllic.” “But in my grandfather’s world," he continues,  "how he wanted to live was his choice, and the family’s role was to make it possible."  The second half of the book is Dr.Gawande’s account of his father's battle against brain cancer. In describing the family's struggle with his father's tumor, the reader might be surprised to learn that three doctors--the author and his parents--cannot parse the options presented by the oncologist....the informative physician.  "How could we--mere mortals--make a decision."

Dr Gawande’s book is a call to action to rethink how we approach end of life management. Our focus must be on maximizing well-being, not life span. "Interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person's life". Atul Gawande is a fantastic writer and has your attention till the end. More importantly he has touched on a subject that is the final anxiety of our existence.