Reviewed by Jane Tompkins
If you are interested in the problems of aging and death, for yourself and the people you love, this is a book you should read. Atul Gawande, an Amaerican surgeon of East Indian descent (both his parents were doctors), brings to his subject a perspective that is not what we expect from the professionals we go to for our care. The book is an indictment of the medical establishment’s attitude toward death and the way nursing homes and “assisted living” facilities care for the aged. Even more remarkable, though the author is aware of the tragedy he describes, he is not angry or self-righteous. Gawande writes out of deep compassion for both patients and doctors and from a comprehensive understanding of the circumstances that have led us to where we are. He views the terrible shortcomings of the system that trained him with wryness rather than outrage: “I learned a lot of things in medical school,” he writes, “but mortality wasn’t one of them. …Our textbooks had almost nothing on aging or frailty or dying. …The purpose of medical schooling was to teach how to save lives, not how to tend to their demise.”
Though Being Mortal documents the inability of medicine to deal with our mortality, it is not an unwelcome or an unpleasant read. Quite the reverse. I felt grateful that finally someone from within the system had come forward to acknowledge and explain what is wrong. Gawande tells the story of Joseph L., a man with incurable metastatic cancer, partial paralysis, organs filled with fluid, and no bowel control, who demands an eight-hour operation which has little chance of prolonging his life, none of saving it, and a very good chance of causing lethal complications. “He was pursuing little more than a fantasy at the risk of a prolonged and terrible death—which was precisely what he got.”
How did such a situation come to be? “We all avoided talking honestly about the choice before him.” No one wanted to take responsibility for facing the prospect of death—not the patient, not his family, and least of all the doctors, whose competence and sense of identity depend on their being able to make people well. Faced with death, people busy themselves weighing the pros and cons of this or that procedure; no one is willing to look at the larger picture, admit what is really happening and help the patient to cope with it. The final chapter of the book, titled “Hard Conversations,” is devoted to this point.
The problem of how we treat people at the end of life is only the final stage in a process of dehumanization that, in this country, has already started when a person can no longer care for himself or herself. Gawande contrasts the death of his grandfather, who lived to be a hundred and ten in a small village in rural India, surrounded and cared for by his extended family, to that of many, perhaps most, people in the United States, who are left “alone or isolated in a series of anonymous facilities, their last conscious moments spent with nurses and doctors who barely know their names.” His brief but brilliant historical analysis suggests how these circumstances came about—changes in life expectancy, medical technology, nutrition, family size, gender roles, transportation, economic arrangements, and, ultimately, our understanding of how people deserve to live.
The forms of living that have evolved in the wake of these changes are driven, he affirms, by the ideal of the independent self. Both generations–young and old–now strive for a way of life that allows maximum liberty and control, “including the liberty to be less beholden to other generations.” Gawande observes that people living in extended families all over the world have left home as soon as they had the chance, and that by and large their parents have not been sorry to see them go. But, he adds, the trouble is “our reverence for independence takes no account of what happens in life: sooner or later, independence will become impossible.”
Instead of the extended family we have nursing homes which, the author suggests, are founded on the same principles as correctional facilities where everyone does the same thing at the same time (wake up, wash, dress, eat breakfast, etc.). And, we have what is euphemistically called “assisted living.” Conceived by a nurse who saw the need to provide elderly people who needed help with as much autonomy as possible, assisted living originally provided habitation for a small number of elders who lived as if they were at home, doing what they wanted when they wanted, with help for the things they could not do by themselves—a world away from the regimented, joyless facilities that now bear the same name.
But although he makes us aware of the agony people undergo because of the brutality of our current arrangements, Gawande refuses to get up on his high horse. He does not scold or preach but humbly and patiently explains. As I read, I felt comforted by his wisdom in the face of suffering and human imperfection. The book is enlightening, and healing in itself.~