An All-Too-Brief Review of Being Mortal

Being Mortal, which is subtitled “Medicine and What Matters in the End,” is about aging and frailty, decline and death, and dealing with those as well as possible.  It’s not really a book about medical ethics or even about medicine as much as about our latter days.  It’s full of stories about the loss of independence, assisted living, nursing homes, intensive care at the end of life, hospice, and finally having “difficult conversations” and “letting go” (those are two of the chapter titles). 

The point of these stories is to plead for better, whole-person-driven palliative care throughout the practice of medicine.

I found it deeply about human dignity and autonomy, in the best sense of that word.  As the author, Atul Gawande, M.D., puts it in his epilogue, “We’ve 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.”

For me, the book’s key graph is on page 128:

“The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant.  The problem is that they have had almost no view at all.  Medicine’s focus is narrow.  Medical professionals concentrate on repair of health, not sustenance of the soul.  Yet—and this is the painful paradox—we have decided that they should be the ones who largely define how we live in our waning days.  For more than a half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns.  It’s been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs.

                “This experiment has failed.”

How to correct this failure?  Provide more, and better, palliative care; in some settings, hospice prolongs survival over intensive treatment, and Aetna—Aetna, for heaven’s sake—ran a pilot program that found that good palliative care can reduce costs and improve patients’ well-being.  Dr. Gawande describes these.

And, more fundamentally, doctors need to talk with their patients and their families, earlier and more thoughtfully than they often do now, about what matters to them—How do they understand their condition?  What fears do they have?  What would be their goals—that is, what would they want to be able to do—if their condition worsens?  (One person described in the book, a university professor and not a notorious sports fan, said he’d be happy if he could eat chocolate ice cream and watch football on TV.)  What trade-offs would they be willing to accept to achieve those goals?

When the author speaks of “well-being” and the reasons for living, one wonders what he thinks of physician-assisted suicide (PAS).  Here, he waivers.  He offers that the line between withholding treatment or providing palliative treatments with double effect, on the one hand, and acting more affirmatively to end life, is blurry.  “Given the opportunity, I would support laws [to allow PAS as in Oregon].”  (A Harvard surgeon, he doesn’t say whether or how he voted when it was brought to the Massachusetts ballot, and narrowly defeated, in 2012.)  But he gives the sense of being dragged into this position.  He emphasizes that life and good care, not hastening death, is the proper role of medicine:

“The fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success.  It is a measure of failure.  Our ultimate goal, after all, is not a good death but a good life to the very end.  The Dutch have been slower than others to develop palliative care programs that might provide for it…we damage entire societies if we let providing this capability [for PAS] divert us from improving the lives of the ill.  Assisted living is far harder than assisted death, but its possibilities are far greater, as well.”

Space limits me from trying to write a fuller “review essay” here, but frankly, the world doesn’t need more from me about this book.  It is warm, personal—“moving” and “affecting,” as the blurbs on the dust jacket say—and written by a surgeon, no less.   (Surgeons are so often, well, not exactly warm and cuddly.)  Dr. Gawande writes in a clean, direct style, reflectively, even humbly, without the least hint of putting on airs. 

I think Being Mortal deserves a wide readership, and I highly recommend it.

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