reviewed by Michael Potts
Two healthy septuagenarians, my wife and I often read to each other at tea time, on the principle that hours so spent enrich. At the risk of Too Much Information, may I amend that to chai time? Being Californians, ours never has been a conventional arrangement, and we do not mean it to become one.
A Frontline story on Atul Gawande and his book Being Mortal attracted our attention, and when I requisitioned the book at our library, I found myself number sixty-something in line … so I broke down and bought the Kindle version despite the fact that as a recovering book publisher I am offended that Macmillan charges 66% of the hardcover price for a product that costs nothing to produce. But I digress.
Now to the meat: Being Mortal is a stunning book. Its author writes with authority, heart, courage, and common sense about the nightmare that too often attends the ends of the lives of people we love. Dr Gawande practices general and endocrine surgery at Boston’s Brigham and Women’s Hospital, professes at Harvard, does health research, writes for The New Yorker (one sometimes wonders if these overachievers sleep or have lives) and so is eminently qualified to speak directly to us about the bumpy part of life right before the precipice.
In our youth-oriented culture, we do everything we can to deny age while staying young. We love our stories about 80-year-old tennis players, particularly if they are known to smoke, drink, and indulge in the activities we so enjoyed in that blessed decade after we survived our thirtieth birthday, thus outliving our own predictions. And while most of us will live into a ripe elderhood with relatively few health alarums, most of us will experience, right there at the end, a highly unpleasant, most likely painful, interlude, possibly only a few seconds long but sometimes spread out over an agonizingly slow year or more.
And here’s the crux: our medical establishment usually makes it worse. If our suffering is prolonged, especially if it involves the modern scourge of cancer, our doctors will most likely offer us knives and poisons instead of palliatives. This is precisely the topic of Dr Gawande’s inquiry: how are we, as the strategists of our own endgames, able to make good decisions about the moves we decide on? “Death, of course, is not a failure,” he writes. “Death is normal. Death may be the enemy, but it is also the natural order of things.” Big hint: the title of the book. We are mortal, and so we will die.
At some length (hard to tell with a Kindle book, but the hardcover is 304 pages) Dr Gawande examines, through stories about the deaths of friends, patients, and his own father, the difficulty we have asking the important questions when we face a harsh prognosis. “The purpose of medical schooling,” he writes in the Introduction, “ [is] to teach how to save lives, not how to tend to their demise.” And so, quite naturally, doctors guide us toward prolongation at all costs when a timely and graceful exit would be more satisfactory for all concerned.
Before offering some considerations for improving the manner of our departure, Being Mortal takes us through a leisurely, thorough examination of how death has changed in recent years, and why we still die. “The story of aging is the story of our parts. Consider the teeth… By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia… Hair grows gray … simply because we run out of the pigment cells that give hair its color … This is not an appealing prospect.”
Explaining why geriatrics is a waning discipline despite the increasing demographic load of elders on our society, a colleague advises that “mainstream doctors … do not have the faculties to cope with the Old Crock. The Old Crock is deaf. The Old Crock has poor vision. The Old Crock’s memory might be somewhat impaired. With the Old Crock you have to slow down, because he asks you to repeat what you are saying or asking. And the Old Crock doesn’t just have a chief complaint – the Old Crock has fifteen chief complaints… You’re overwhelmed.” Another colleague enunciates her understanding of a physician’s true role: “to support quality of life … as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world.”
Some months after finishing the book, the Author’s Message that sticks with me (Spoiler Alert) is that when confronted with the inevitability of our own demise, we must ask a very few simple questions about any proposed treatment, questions that most doctors are not trained to answer. What do we need to finish? Acknowledging that we will not be able to regain youthful vigor and recognizing that death will ultimately take us, what course of treatment is likeliest to allow us to get that done? Every person’s answers will differ, and unless we give this some thought prior to necessity, our nearest and dearest will not be able to help us.
I invite you to cogitate on this. If you need encouragement, read the book.
A pair of personal observations. First: much of what’s bad in the culture I see around me appears to be traceable to greed, and our willingness to accede to, and our doctor’s quickness to propose, costly, painful, marginally effective “remedies” can easily be seen to be the long-term result of an increasingly interventional, chemically dependent, disease-focused health establishment. For-profit hospitals and insurance schemes, Big Pharma, the medical schools they finance, and even the practitioners they train, are more interested in corporate profitability rather than corporeal wellness. In our classless culture, noblesse (in the form of literate, critically thinking people with time on their hands to read clear to the end of this piece) obliges us to seek more humane ways for ourselves and our friends. This death business isn’t a comfortable conversational topic, but it’s surely an important one. Reading, and then discussing this book, has helped me to be clearer about how I want to shuffle off.
Second: reading a book on a Kindle is a delight. Atul is very good about defining technical vocabulary, but resting my finger on a word I’m not sure of and getting a dictionary definition and an offer to look up the Wikipedia citation is a welcome amenity. As my sight dims, I will be able to brighten the page and enlarge the type. We are living, and getting ready to leave, a world where many old delights (including ourselves) persist …and some of the new stuff is delightful, too.
Michael Potts observes the planet from Caspar, California. He is one of the founders of The Public Press.