Being Mortal: Medicine and What Matters in the End

Being Mortal: Medicine and What Matters in the End Atul Gawande Metropolitan Books, 2014Atul Gawande's three earlier best-selling books1 have offered an incisive critique of medical practice in the United States, applying statistics and commonsense organizational theory to the delivery of medical services. They interest readers precisely because such practicalities bear so directly on everyone's well-being. With Being Mortal, Gawande has taken on an issue that is simultaneously broader and yet more specific: how the medical community and American society deal, and potentially can deal better, with the complicated processes of aging and dying. Since it is a truism that "we all die," there are few if any subjects that touch us so intimately.Gawande's record gives reason to perk up and pay attention. He is both an accomplished doctor and a clear and intelligent writer. He is a surgeon at Brigham and Women's Hospital in Boston, a professor at the Harvard Medical School and the Harvard School of Public Health, a director of a center for health systems innovation, and chairman of an NGO working to improve surgery worldwide. His energy must be prodigious, since amidst all this he is able to write prolifically as a staffwriter for The New Yorker and most preeminently as the author of his four books.The speakers at the recent "White Coat Ceremony" for first-year students at the University of Massachusetts Medical School focused on one theme: the importance of kindness in medical practice. One way of seeing Being Mortal is that Gawande explores just how kindness can best be brought to bear on aging and dying, not just by the medical profession but by American culture at large. As we will see, this is not an easy sub- ject. There are many difficult intersections between "doing everything conceivable to keep a patient alive," which is the medical profession's historic ethic and perceived task, and making the end of life a fulfilling, self-actualizing experience. Kindness in the abstract may be the aspiration but the abstraction doesn't tell us much about how the trade-offs are best handled. It is no wonder Gawande, though feeling strongly, foreswears dogmatism: "I have found it unclear what the answers should be, or even whether any adequate ones are possible." As readers come to realize how open the subjects of aging and dying are, they find that Being Mortal is a book of provocative consciousness-raising, not a manual of final answers.Gawande discusses the variety of ways the experience of aging and dying have been softened in the United States, but an understanding of the book requires us first to see how he perceives the mixed humanity and inhumanity of hard-charging medical treatment. When he tells us that "people are living longer and better than at any other time in history" and that there has arguably been "no better time in history to be old," he acknowledges a fact that deserves a prominent place in any discussion of the subject. As recently as 1965, he says, there was little that could be done about heart disease. By contrast, medicine now has an "awesome arsenal of technology." His recital of just some of the developments since World War II - sulfa, penicillin, many other antibiotics, drugs for blood pressure and hormonal imbalances, artificial respirators, and kidney transplants - is, we all know, just scratching the surface.In light of these things, it is ironic when he says the treatment "of sickness, aging, and mortality as medical concerns... has failed." This condemnatory hyperbole becomes understandable only when we come to know the context in which he says it. He compares the harshness of "treatments that addle our brains and sap our bodies for a sliver's chance of benefit" with the kinder, gentler medicine he considers possible. He knows not only that much medical practice carries treatments to excruciating extremes, but also that patients often lose privacy and control, are leftto live alone or in impersonal facilities, and have doctors who in the rush of their activity never sit down with their patients to discuss end-oflife care. …