D. S. Rao
Being Mortal by Atul Gawande. New York, Henry Holt and Company, Metropolitan Books. 2014. Pages, 283, $ 26.
‘Grow old along with me! / The best is yet to be, / the last of life, for which the first was made,’ sang Robert Browning in the 19th century, when life expectancy in England was forty-seven. In the 20th century, when it rose to sixty, T.S. Eliot wrote, ‘An aged man is but a paltry thing, / a tattered coat upon a stick.’ Both poets lived to be seventy-seven. In the 21st century, with increasing economic wellbeing and phenomenal advances in science and technology, life expectancy has touched eighty in most countries. But medicine has its limitations. It can prolong life, delay death, but, asks Dr. Atul Gawande, is it always a good thing to do so?
The writer-physician begins his book by recalling his medical school seminar discussion on Tolstoy’s classic, The Death of Ivan Ilyich, about the suffering of Ivan, who is bedridden from a fall and suffers intense pain, for which the doctors cannot find cure or relief. ‘He lives in mounting anguish and fear of death. But death is not a subject that his doctors, friends, or family can countenance’ (2). That is the most painful part, the paradigm, not the inevitable end. Tolstoy recognized this. ‘As Ivan Ilyich’s health fades and he realizes that his time is limited, his ambition and vanity disappear. He simply wants comfort and companionship. But almost no one understands – not his family, his friends, or the stream of eminent physicians whom his wife pays to examine him. Tolstoy saw the chasm of perspective between those who have to contend with life’s fragility and those who don’t’ (99). The farm boy Gerasim understands his master better and does his little bit to help. The American medical students saw ‘the failure of those around Ivan Ilyich to offer comfort or acknowledge what is happening to him was a failure of character and culture. The late nineteenth century Russia of Tolstoy’s story seemed harsh and primitive’ (2).
Later, Dr. Gawande recalls from his days as a junior surgical resident the story of a patient in his sixties, suffering from a cancer, incurable but treatable, with only two options: ‘comfort care or surgery’. The patient chose surgery. ‘The operation posed a threat of both worsening and shortening his life.’ The surgery was a ‘technical success’, but he died within two weeks. ‘If he was pursuing a delusion, so were we… We did little better than Ivan Ilyich’s primitive nineteenth century doctors – worse, actually, given the new forms of physical torture we’d inflicted on our patient. It is enough to make you wonder, who are the primitive ones,’ the nineteenth century Russian doctors or the twentieth century American physicians? (3-6).
The contrast between the two cases, separated by a century of medical advances, reinforces the adage: knowledge comes but wisdom lingers.
Dr. Gawande explores the finitude of life and medicine, the delicate line separating the duty of a doctor to save life and the obligation to ensure its quality. He has ‘the writer’s and scientist’s faith… by pulling back the veil and peering in close, a person can make sense of what is most confusing or strange or disturbing’ (9). And he does this poignantly, provocatively, and preeminently.
Changing family structures and increasing commercialization of medical care have raised the stress on the natural process of ageing and the inexorable end. There used to be a time when family tended the old and the infirm, and most deaths occurred at home. Atul’s grandfather Sitaram Gawande, a farmer in India, respected and venerated by his family, married thrice, outlived his wives, raised thirteen children, lived up to a hundred and ten years, and died with the loved ones around. But times have changed. Children have begun to move away in pursuit of higher education or career prospects, striking roots in far-off lands, while parents preferred familiar places and their own freedom, to moving with children. Even when children are in the same city or country and not too far, independent living of the old is becoming the new norm, but increasingly difficult, giving rise to old age resorts, nursing homes, hospices and assisted living facilities. Globalization has compounded the problems, when ageing parents and their children are in different hemispheres. Both the generations cherish their freedoms to the extent of leaving the end-life decisions to medicine, insurance, technology and total strangers.
Dr. Gawande notes that in the United States, twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months that is of little apparent benefit.
The author records, ‘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.’ As Felix says, ‘Old age is a continuous series of losses.’ Philip Roth puts it more bitterly in his novel Everyman: ‘Old age is not a battle. Old age is a massacre.’ Things fall apart – words from W. B. Yeats’ ‘Second Coming’ – words so apt that Dr. Gawande uses them as heading for his second chapter; earlier, Chinua Achebe has adopted them for the title of his celebrated novel! Things fall apart. Death occurs not due to any single disease but a mix of multiple biological failures.
Dr. Gawande cites a colleague: we want autonomy for ourselves, and safety for those we love. That remains the main problem and paradox for the aged. ‘Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self’ (106). Some old age homes do not allow the inmates even to play with pets, or take a walk outside, lest they fall and hurt themselves.
Call it concern or crookedness, clinical care or cleverness, families cling to the last straw or play games for whatever reasons; and doctors earnestly think their diagnosis and treatment will work, or, worse, give false hopes, impoverish people, and enrich hospitals. ‘We know the dance moves. You agree to become a patient, and I, the clinician, agree to try to fix you, whatever the improbability, the misery, the damage, or the cost. With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life, with its loyalties and individuality, we are plodding novices.’ Novices indeed in these final calls, if the doctors are sincere; or blood suckers and death dealers, if they are not. Either way, it turns out to be ‘a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run – and when we imagine ourselves to have much more time than we do – our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register’ (173).
There are three types of doctors: Paternalist, Informative, and Interpretive. The Paternalist Doctor decides what is best for you. The Informative Doctor provides alternatives and asks you to make up your mind. The Interpretive Doctor goes for shared decision-making and asks: ‘What is most important to you? What are your worries?’ and leads you to the decision that most helps achieve your priorities.
In a telling battle simile, Dr. Gawande observes: ‘Medicine exists to fight death. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war you cannot win … you want a general who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end’ (187).
Patients with terminal illnesses move from hospitals to nursing homes, to boredom, loneliness and helplessness. In the absence of a family they could count on, ‘the elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about’ (109). In the name of safety, some nursing homes do not permit the inmates liberties even small children are allowed.
Dr. Gawande rightly cites, ‘culture is the sum total of shared habits and expectations… culture has tremendous inertia. That’s why it is culture. It works because it lasts. Culture strangles innovation in the crib.’ However, some facilities have come up with new ideas. Bill Thomas helped usher into Chase Memorial Nursing Home, a program he called the Eden Alternative, introducing cats, dogs, birds and children, to care for or play with, ‘an opportunity for the inmates to grab on to something beyond mere existence. And they took it hungrily’ (127). But such bold ventures are rare, and remain so. Even the best of homes for old tend to degenerate. Dr. Gawande aptly notes: ‘Nothing that takes off becomes quite what the creator wants it to be. Like a child, it grows, not always in the expected direction.’
According to health professionals, the basic requirements for physical independence are eight activities of daily living: ability to use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk. To live safely on one’s own, eight more capabilities are required: shopping, cooking, housekeeping, doing laundry, managing medications, phone calls, travel and finances. Paradoxically, we ‘live longer’ only when we ‘stop trying to live longer.’
This is the first non-fiction work I have found hard to put away, partly because of my own age and partly because of the issues the book deals with, issues most people avoid even a mention, though almost everyone faces them some time in life. Dr. Atul Gawande was a participant in the agonizing final years of his father, himself a surgeon. Mother too being a doctor, the family has had cumulative practice of over a century in medicine (123). The scientist-writer’s clinical approach is tempered with genuine warmth; his extensive research does not make the book unduly academic; and his transparent concern for life and death makes the book a compelling read for all.
Being Mortal is a deeply moving, disturbing and haunting book by a practicing physician.
The Publishers, however, would have done better, if they had added a select bibliography and an index.